Minimally invasive biopsies allow preoperative diagnosis. Any breast lesion that is considered suspicious after taking into consideration the clinical examination, the imaging tests, the age as well as the family and personal history of a woman, must be identified histologically, before the woman is taken to the operating room.
EUSOMA (European Society of Mammology) recommends that 90% of women undergoing surgery for breast cancer have a preoperative histological diagnosis with minimally invasive biopsies. Knowledge of the biology of the tumor, as revealed by its histological examination, can modify therapeutic manipulations. One such case is a triple negative breast cancer or a cancer that overexpresses the Her2neu oncogene. In some women with this type of tumor histology, systemic therapy is recommended before surgery.
Micro-invasive biopsies (core biopsy) are performed with local anesthesia. This is achieved with the help and guidance of the mammographer, when the lesion is visible on the mammogram (stereotactic biopsy), of ultrasound, when the lesion is visible on the ultrasound, or with the guidance of the MRI, when it is visible only on the MRI. In this way we obtain a part of the lesion for histological diagnosis, without the woman undergoing surgery. Diagnostic surgery, i.e. with an open operating room, should only be done in case of inability or failure to obtain tissue with a minimally invasive technique.
With the preoperative diagnosis, the operation is better planned and the woman is fully informed about her treatment options before being taken to the operating room.
Breast cancer surgery
Breast cancer surgery has changed a lot in recent years. In most women with breast cancer, the breast can be saved and operations involve targeted removal of the tumor, often guided by guide wires placed using ultrasound, mammography or MRI. The oncological surgery to remove the tumor is combined with plastic surgery techniques, which allow us to remove it in wide healthy resection margins and at the same time achieve a good aesthetic result (oncoplasty).
For women who will need to undergo a mastectomy, we apply modern techniques that allow the preservation of the skin of the breast and the nipple and at the same time give the possibility of breast reconstruction in the same surgery.
Axillary lymph node surgery has also changed a lot. Extensive axillary lymph node dissection has given way to targeted lymph node dissection and sentinel lymph node biopsy.
60%-80% of women who previously underwent axillary lymph node dissection had negative lymph nodes. This resulted in patients having all the morbidity from removing the lymph nodes – lymphedema, i.e. swelling of the upper limb, without the oncological benefit.
The first conference on the application of the sentinel lymph node technique in breast cancer was held in Amsterdam in 1999. Today, 23 years later, this technique is now the standard of care in axillary staging in women with breast cancer and non-palpable axillary lymph nodes .
The sentinel lymph node is the first lymph node that drains lymph from the breast. So if this lymph node is located, removed and has no cancer cells, the probability that there will be no other infiltrated lymph nodes is 95-97%. In this case, the woman does not need to undergo lymph node cleansing of the armpit, because it does not offer better rates of local recurrence or overall survival.
Today even women with 1-2 positive axillary lymph nodes who will have breast conservation and radiation therapy can avoid complete lymph node cleansing because it will not offer them better rates of local recurrence, nor overall survival.
Oncoplasty of the breast
The breast is an organ with significant aesthetic and functional importance for the woman, therefore ideally the surgical treatment of breast cancer must be oncologically safe and aesthetically complete.
Oncoplasty is the use of principles of Oncology and Plastic Surgery with the aim of oncologically safe and aesthetically acceptable results.
Oncoplastic surgery allows the woman access to the oncological surgery for the removal of the tumor, but also to techniques for the restoration of large deficits with modern breast conservation. It also allows simultaneous or second time reconstruction of the other breast to achieve symmetry.
To recommend oncoplastic procedures, we must take into account individualized risk factors, such as smoking, high BMI (body mass index), diabetes, hypertension, history of deep vein thrombosis, and the fact that adjuvant treatments – such as radiation therapy – can adversely affect the aesthetic effect.
The team applying oncology and restorative techniques must ensure that:
• The woman has discussed her options, risks and benefits at length and has had enough time to process the information and make a decision.
• He had the opportunity to discuss pre-operatively with women who underwent a similar operation.
• To see photographic material from the results of similar operations.
• Be aware of the total number of interventions that may be needed to achieve the final desired aesthetic result.
She writes:
Eleni Faliakou
Breast Surgeon
Director of the Second MITERA Breast Clinic
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