Update on the surgical management of breast cancer

The surgical management of breast cancer has undergone continuous and profound changes over the last three decades. For patients with early stage breast cancer, breast-conserving surgery followed by radiation therapy has been definitively validated as a safe alternative to radical mastectomy, with similar survival rates, better cosmetic outcomes and acceptable rates of local recurrence. Thanks to the improvements in diagnostic work-up, as well as the wider diffusion of screening programs and efforts in patient and physician education, tumors are more often detected at an early stage, furtherly facilitating the widespread use of breast conserving techniques. Breast-conserving surgery has been introduced also in the treatment of patients with locally advanced tumors after tumor downsizing with preoperative chemotherapy, with acceptable rates of ipsilateral breast tumor recurrence. When performing breast-conserving surgery all efforts should be made to ensure negative surgical margins in order minimize the risk of ipsilateral breast tumor recurrence as they are associated with worse distant-disease-free and breast cancer- specific survival rates. The recent introduction of "oncoplastic techniques", that may allow more extensive excisions of the breast without compromising the cosmetic results, has furtherly increased the use of breast-conserving procedures. Mastectomy remains a valid surgical alternative in selected cases and is usually associated with immediate reconstructive procedures. Staging of the axilla has also gradually evolved toward less aggressive approaches with the adoption of sentinel node biopsy, but several controversies still remain about completion of axillary lymph node dissection in patients with a pathologic positivity in sentinel lymph node biopsy. The present work will highlight the benefits and unresolved issues of the different surgical treatment options in breast cancer and axillary treatment.