ABSTRACT
Clinical T1, T2 less than 3 cm, N0 invasive breast cancers are treated by wide local excision (WLE) followed by radiotherapy with comparable local control rates to mastectomy, both combined with axillary surgery. The tumour site, size, histological type, grade and extent of in situ disease, as well as the size of the breast, all influence choice of treatment, as does consideration of the expected cosmetic result and patient preference. Radiotherapy is indicated for all patients after conservative surgery. As yet no ‘low risk’ group has been identified where surgery alone gives adequate local control, but ongoing trials are addressing this issue. Contraindications to conservative surgery include multifocal breast tumours, extensive DCIS, central tumours in a small breast and incomplete excision. Significant pre-existing cardiac or lung disease, scleroderma and limited shoulder mobility may prevent the use of radiotherapy. Patients with operable tumours which are 3-4 cm or more in diameter have a higher local recurrence rate with conservative surgery and radiotherapy, and may be offered primary systemic therapy. Long-term results of this strategy, which aims to downstage the tumour and avoid mastectomy in many patients, are awaited. After primary chemotherapy, indications for locoregional radiotherapy are determined by high risk factors at presentation and preoperative clinical staging rather than postoperative pathological staging.
