A 48-year-old woman from Delhi presents with a 2 cm firm, mobile lump in the upper outer quadrant of the left breast discovered on self-examination 3 weeks ago. On clinical examination, the lump is non-tender, mobile, and there is no skin dimpling or nipple discharge. Axillary lymph nodes are not palpable. Mammography shows a dense mass with irregular margins and microcalcifications. Core needle biopsy confirms invasive ductal carcinoma (IDC). Staging investigations including chest X-ray, abdominal ultrasound, and bone scan are normal. The tumour is ER/PR positive and HER2 negative. What is the most appropriate surgical management for this patient?

Explanation

## Clinical Assessment This patient presents with: - T2 (2 cm), N0 (no palpable nodes), M0 (no distant metastases) → **Stage IIA breast cancer** - Invasive ductal carcinoma with hormone receptor positivity - No contraindications to breast conservation (single tumour, adequate breast size, patient motivation) ## Surgical Management Principles **Key Point:** For stage I–II breast cancer without contraindications, breast-conserving therapy (BCT) is equivalent in oncological outcomes to mastectomy when combined with appropriate radiotherapy [cite:Harrison 21e Ch 297]. **High-Yield:** BCT consists of: 1. Wide local excision (lumpectomy) with adequate margins (≥1 cm) 2. Axillary lymph node assessment (sentinel lymph node biopsy or dissection for staging) 3. Adjuvant radiotherapy to the breast (mandatory) ## Why BCT is Appropriate Here | Criterion | Status | Suitable for BCT? | |-----------|--------|-------------------| | Tumour size | 2 cm (T2) | Yes | | Single lesion | Yes | Yes | | No skin involvement | No dimpling/ulceration | Yes | | Adequate breast volume | Assumed adequate | Yes | | Patient age | 48 years | Yes | | Ability to receive radiotherapy | No contraindications stated | Yes | **Clinical Pearl:** Axillary lymph node dissection (ALND) is still indicated in this case because: - Clinical examination shows no palpable nodes, but sentinel lymph node biopsy (SLNB) or ALND is needed for accurate staging - Even with clinically N0 disease, 20–30% may have occult nodal metastases - Nodal status determines adjuvant systemic therapy decisions **Mnemonic: BCT Contraindications — "PRISM"** - **P**regnancy (relative) - **R**ecurrent disease in same breast - **I**nadequate margins (cannot achieve clear margins) - **S**kin involvement (T4b) - **M**ultiple lesions in different quadrants This patient has none of these contraindications. ## Radiotherapy Requirement **Key Point:** Adjuvant whole-breast radiotherapy is mandatory after BCT. Omission increases local recurrence risk from ~5% to 15–20% [cite:Robbins 10e Ch 22]. ## Systemic Therapy Considerations Adjuvant hormonal therapy (tamoxifen or aromatase inhibitor) is indicated due to ER/PR positivity. Chemotherapy eligibility depends on additional prognostic factors (grade, Ki-67, Oncotype DX if available).