Clinical Practice Guidelines for Endoscopic Breast Surgery 2021

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Clinical Practice Guidelines for Endoscopic Breast Surgery in Patients with Early-Stage Breast Cancer: Chinese Society of Breast Surgery (CSBrS) Practice Guidelines 2021

Endoscopic breast surgery has emerged as a transformative approach in the management of early-stage breast cancer, offering minimally invasive alternatives to conventional open procedures. The Chinese Society of Breast Surgery (CSBrS) developed the 2021 practice guidelines to standardize the application of endoscopic techniques, addressing indications, contraindications, operative methods, and complication management. These guidelines were formulated through rigorous literature review, expert consensus, and evaluation using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system.

Level of Evidence and Recommendation Strength

The guidelines classify evidence quality into four levels (I–IV) and recommendations into two categories (A and B). Level I evidence includes high-quality randomized controlled trials (RCTs), while Level II encompasses well-designed cohort or case-control studies. Strength A recommendations are supported by robust evidence, whereas Strength B reflects moderate evidence or expert consensus. A multidisciplinary panel of 76 experts, including breast surgeons (82.9%), oncologists (5.3%), radiologists (5.3%), pathologists (2.6%), radiotherapists (1.3%), and epidemiologists (2.6%), contributed to the voting process, ensuring comprehensive clinical and methodological validity.

Indications for Endoscopic Breast Surgery

Endoscopic techniques in breast cancer encompass nipple-sparing mastectomy ± immediate implant-based reconstruction, axillary or internal mammary lymph node dissection (ALND/IMLND), and sentinel lymph node biopsy (SLNB).

  1. Nipple-Sparing Mastectomy (NSM)

    • Indication: Tumors not invading the nipple, areola, or subcutaneous tissue, with a ≥2 cm margin between the tumor and areola edge (Level II evidence, Strength A). Preoperative imaging must confirm the absence of involvement.
    • Axillary Lymph Node Dissection: Recommended for clinically node-negative (cN0) or limited node-positive (cN1) disease (Level I evidence, Strength A).
    • Internal Mammary Lymph Node Biopsy/Dissection: Indicated when internal mammary nodal involvement is suspected (Level II evidence, Strength A).

  2. Breast-Conserving Surgery

    • Endoscopic techniques enable precise tumor resection under intraoperative ultrasound or dye-guided localization, achieving optimal margins and cosmetic outcomes. Studies report comparable oncological safety to open surgery, with superior aesthetic results.

Contraindications

Endoscopic surgery is unsuitable for:

  1. Severe Breast Ptosis (Level II evidence, Strength A): Anatomical challenges in maintaining the operative space.
  2. Breast Volume >500 mL (Level II evidence, Strength A): Technical limitations in managing large breast tissue endoscopically.
  3. Prior Axillary Surgery (Level I evidence, Strength A): Altered anatomy increases procedural complexity.
  4. Inflammatory Breast Cancer (Level II evidence, Strength A): Aggressive tumor biology and diffuse involvement contraindicate minimally invasive approaches.

Operative Techniques and Space Establishment

Creating and maintaining a stable operative cavity is critical. Two primary methods are endorsed:

  1. Liposuction-Assisted Technique: Fat removal precedes CO₂ insufflation or mechanical suspension to stabilize the cavity (Level II evidence, Strength A). This method reduces operative time and enhances visualization.
  2. Non-Liposuction Technique: Direct CO₂ insufflation or suspension without prior liposuction (Level II evidence, Strength A). Suitable for patients with minimal subcutaneous fat.

Intraoperative Monitoring
Continuous endoscopic visualization and hemodynamic monitoring are mandated to detect complications like hypercapnia. Positive end-expiratory pressure (PEEP) ventilation mitigates CO₂ absorption-related hypercapnia (Level II evidence, Strength A).

Complication Management

  1. Intraoperative Hemorrhage: Immediate conversion to open surgery is advised if bleeding sources are unidentified (Level II evidence, Strength A).
  2. Postoperative Bleeding: Endoscopic exploration or open hemostasis is recommended for active bleeding (Level II evidence, Strength A).

Clinical Outcomes and Advantages

  1. Oncological Safety: Endoscopic ALND demonstrates equivalent nodal yield and recurrence rates to open surgery. High-definition optics improve identification of axillary neurovascular structures, reducing lymphedema and sensory deficits.
  2. Aesthetic Outcomes: Smaller, concealed incisions and preserved nipple-areola complex enhance cosmesis. Endoscopic reconstruction with implants or autologous flaps (e.g., latissimus dorsi, omentum) achieves natural breast contour with lower complication rates (e.g., seroma, infection).
  3. Internal Mammary Lymph Node Dissection: Thoracoscopic approaches avoid costal cartilage resection, minimizing morbidity while enabling thorough nodal evaluation.

Challenges and Future Directions

Despite advancements, endoscopic breast surgery faces barriers:

  1. Technical Standardization: Variability in procedural expertise across institutions necessitates centralized training programs.
  2. Evidence Gaps: Most studies are single-center with small cohorts. Multicenter RCTs are needed to validate long-term oncological outcomes.
  3. Breast-Conserving Adoption: In China, breast-conserving rates remain low. Endoscopic techniques, combined with precise localization tools, could expand eligibility for breast conservation.

Training and Implementation

The CSBrS emphasizes structured training for surgeons, including mastery of endoscopic instrumentation, cavity maintenance, and complication management. The 2019 consensus guidelines outline stepwise skill acquisition to prevent technical failures.

Ethical and Legal Considerations

These guidelines serve as a clinical reference, not a legal benchmark. The CSBrS disclaims liability for non-adherence-related disputes and retains exclusive rights to updates and interpretations.

Conclusion

The 2021 CSBrS guidelines establish endoscopic breast surgery as a safe, effective option for early-stage breast cancer, prioritizing oncological rigor and patient-centered outcomes. By harmonizing innovation with evidence-based practice, these recommendations aim to elevate the standard of breast surgical care in China and inspire global collaboration.

doi.org/10.1097/CM9.0000000000001592

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