viernes, 19 de octubre de 2018

What Does a Quadrantectomy Involve?

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By Afsaneh Khetrapal, BScReviewed by Liji Thomas, MD

Following a diagnosis of breast cancer, the majority of women are likely to undergo some form of surgical procedure. The options usually offered are as follows:

Mastectomy – removal of the whole breast.
Lumpectomy (wide local excision) – removal of the tumour mass and a narrow rim of surrounding healthy tissue.
Quadrantectomy (partial or segmental mastectomy) – removal of approximately a quarter of the breast tissue, with 2-3 cm of healthy tissue surrounding the tumour, a wide excision of the overlying skin, and of the underlying connective tissue (fascia).

A quadrantectomy is not a common procedure. It is classed as a breast-conserving technique which is considered to have curative intent, unlike a “lumpectomy” or “tumorectomy,” both of which primarily aim to remove the tumor mass alone.

The quadrantectomy technique was established to remove a specific segment of breast tissue, including the duct-lobular system. The technique has the advantage of greater surgical curative capability than other breast-conserving techniques in patients whose tumors show ductal spread. This is because breast cancer which originates in the terminal duct very often spreads in the duct-lobular system.

In a quadrantectomy the surgeon actually removes one-quarter of the breast in addition to a 2-3 cm rim of surrounding breast tissue. This is considered a necessary precaution to ensure that the margins around the growth are clear of tumor cells. The overlying skin is also removed, in addition to some of the muscle of the chest wall, located beneath the tumor. For good measure, the lymph nodes that are closest to the tumor are also removed and tested for cancer cells. The excised tumor, skin and the surrounding tissue are all sent for histopathologic examination. In most cases, this type of wide resection should include complete axillary lymph node dissection, and it should be followed by radiotherapy should be done to remove any metastatic nodes and provide complete prognostic information.

Unfortunately, a quadrantectomy results in some cosmetic problems due to the large volume of breast tissue excised. It leads to a change of breast size and shape. For this reason, it is not uncommon for the patient to undergo plastic surgery following recovery. This is often to balance the size of the two breasts by breast reduction on the healthy side. In addition to the aesthetic benefit to the patient, this would also balance the weight of the breasts on the chest and back muscles.

Other patients may opt for a breast reconstruction to be carried out, to rebuild the area removed. It is suggested that such remodeling of the breast be done before starting any further cancer therapy (radiation or chemotherapy). This is because radiation will change the texture of the skin in the surgery area. During chemotherapy, the body’s ability to heal from surgical incisions and dissections is compromised. With such factors to consider, it becomes appropriate to determine the surgical technique that balances cancer curability and cosmetic outcomes.

Perhaps part of the reason that quadrantectomy is not commonly performed is that it has failed to show better results in local recurrence rates, compared with wide resection. Therefore, it seems that quadrantectomy should be limited to breast cancer cases characterised by segmental and wide ductal spread.

In a 2002 study published in the New England Journal of Medicine, the results of a comparison made between quadrantectomy and radical mastectomy, followed by radiation therapy in both cases, was reported. It appeared the overall survival of each cohort was the same at the end of the follow-up period (75%) whilst the likelihood of recurrence was higher for women undergoing quadrantectomy (9%) than radical mastectomy (2%).

On the other hand, a 2005 study in the World Journal of Surgery did not determine a significant difference in ipsilateral breast tumor recurrence following breast-conserving therapy (quadrantectomy) compared to lumpectomy provided sufficiently wide surgical excision could be achieved.