Surgical management

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The first aim is to establish a definitive diagnosis to ensure that the patient has a single operative procedure. The roles of FNA and core biopsy will be considered. Cytology can be reported immediately, but core biopsy can establish a diagnosis of invasive cancer. Approximately 30% of patients with DCIS diagnosed on a core biopsy are shown to have invasive cancer at subsequent surgery. A lower percentage of patients are found to have invasive cancer when DCIS is diagnosed on a mammotome biopsy. The aim is to achieve complete excision at a single procedure and to minimise the amount of tissue removed. Studies have shown that, although there are significant differences in the amounts of tissue different surgeons remove when excising lesions of similar size within a single unit, the variations are small. Margins are the single most important factor affecting local recurrence. For impalpable cancers, there are a variety of different options for localising the lesion, including wire localisation, radioisotope injection and carbon marking. When wires are used for areas of microcalcification, consideration should be given to placing more than one wire in the breast to assist the surgeon. Intraoperative-orientated specimen X-ray is essential and can significantly increase the rates of complete excision. Not all screen detected breast cancers are small and some require more extensive resections or mastectomy. In both these groups of patients, consideration should be given to partial or total breast reconstruction.