Successful Lumpectomy in a Patient With Multicentric Breast Cancer

When there is extensive breast cancer, patients typically undergo mastectomy. However, lumpectomy may still be performed for patients who are motivated to avoid a mastectomy and understand the risk for positive margins requiring second surgery in unique cases. This report details the surgical management and clinical reasoning behind lumpectomy for a multicentric breast cancer spanning 5 cm. The lumpectomy was a success with negative margins on final pathology.


Introduction
Lumpectomy or mastectomy is the surgical management for breast cancer. The breast surgeon and the patient discuss the goals for each therapy and the risks and benefits associated with the decision. The arguments for lumpectomy are good cosmetic effects with minimal scar, avoidance of reconstructions and prosthesis, and minimal breast tissue excision. The arguments for mastectomy are lower recurrence rate, no need for radiation therapy, and no further surgery necessary [1].
The factors that favor lumpectomy include smaller, monocentric tumors; younger age; treatment carried out in specialized institutions; favorable physical factors; wire or radioactive seed localization of tumor; and patient compliance [1]. Typical contraindications for lumpectomy include locally widespread disease, multicentricity, diffuse (malignant) microcalcifications, first or second trimester of pregnancy, mutations in the BRCA1 and BRCA2 genes, and an already irradiated thoracic wall [2].

Case Presentation
The patient was a 55-year-old female who underwent screening mammogram and was found to have left breast 6 mm asymmetry in the upper region and a 10 mm focal asymmetry in the central breast (Figure 1). At the time of screening mammogram, the patient was asymptomatic with no palpable masses, changes in shape or volume of breast, or any nipple changes or discharge. Breast exam was unremarkable as well, with no dimpling, palpable masses, nipple retraction, or nipple discharge, and no cervical, supraclavicular, or axillary lymphadenopathy.    MRI of bilateral breasts was obtained to evaluate the extent of the disease and to help the patient and the surgeons determine whether it would be more appropriate to proceed with lumpectomy or mastectomy ( Figure 6). No further site of disease was identified. The patient's options for surgery were either mastectomy with a sentinel lymph node biopsy (SLNB) or lumpectomy with oncoplastic reconstruction and an SLNB. The patient understood the implications of having a lumpectomy versus mastectomy, including possible need for further surgery with a re-lumpectomy or a completion mastectomy, as well as the need for adjuvant radiation therapy, hormonal therapy for 5-10 years, and adjuvant biological therapy or chemotherapy based on final pathology.
The patient's ultimate decision was to undergo breast-conserving surgery with a left wire-guided partial mastectomy, an SLNB, and oncoplastic reconstruction. Three-wire mammogram-guided localization was performed targeting the three biopsy markers (Figure 7). Lumpectomy successfully removed the three sites of malignancy with surgical specimen containing all the biopsy markers ( Figure 8). Surgical pathology report confirmed negative surgical margins; SLNB detected metastases in three sentinel lymph nodes.

Discussion
Our case presented a 55-year-old female who underwent successful lumpectomy despite having multicentric breast cancer spanning 5 cm in greatest dimension. The case demonstrated that a distance of 5 cm between two clips does not warrant mastectomy in every case. If there are two lesions very far apart in different quadrants, separate lumpectomies could be performed with clear margins, followed by radiation [3]. Patients should be made aware of an approximately 30% chance of positive margins requiring margin re-excision; however, the chance of conversion to mastectomy due to positive margins is only around 7% [4]. This particular patient was highly motivated to avoid mastectomy. Furthermore, the institution had plastic and breast surgeons who had experience in performing oncoplastic surgery with reasonable success, allowing for a team approach with both surgeons performing their mutual skills for the patient. Following lumpectomy, patients will have tissue rearrangement and a smaller cup size; however, they generally prefer that to wearing a breast prosthesis on an insensate chest wall or reconstruction with no sensation on the breast envelope. In addition, the patient had an area in her cancer that was HER2 positive; if oncology considers upfront chemotherapy, that is further rationale to consider lumpectomy if she responds. Following the initial management of primary breast cancer, current clinical guidelines recommend annual follow-up with screening mammography. Screening ultrasound is not recommended for breast cancer surveillance by most guidelines, and further studies are required to determine which subgroup of patients would benefit most from surveillance with MRI [5]. Therefore, our patient was advised to undergo annual screening mammogram to monitor for recurrence of her breast cancer.
Surgical options for multicentric breast cancer have evolved in recent years. Historically, primary tumors in different quadrants of the same breast or tumors greater than 5 cm in size would be managed by total mastectomy. In recent years, however, there has been an encouraging upward trend in the use of breastconserving surgeries (i.e. lumpectomies); more women are being offered surgical options that were once considered to be contraindicated but are now found to provide equivalent breast cancer-specific survival rates as mastectomy [6].
In addition, the molecular phenotype with appropriate chemotherapy has become more important for patient survival than local control with surgery in recent years. Moreover, patients now receive radiation for much less time and toxicity for equal benefit in comparison to the previous protocol of six weeks of radiation. Therefore, recent advances in chemotherapy and the shortened courses of radiotherapy could motivate both surgeons and patients to consider lumpectomy for the management of multicentric breast cancers rather than mastectomy.

Conclusions
This case demonstrates a patient making an informed decision with her breast surgeon to undergo a lumpectomy rather than mastectomy in a case of extensive breast cancer spanning 5 cm. Breast-conserving surgery is still an option for extensive breast cancer when the patient is highly motivated to avoid mastectomy, the breast surgeon feels confident that there is a chance for negative surgical margins, and the plastic surgeon is able to perform oncoplastic surgery with reasonable success.

Additional Information Disclosures
Human subjects: Consent was obtained by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.