Breast Cancer

Paradigm shift in ablative surgery of breast cancer

From the evidence – based studies, most surgeons believe that breast cancer has become a systemic disease at time of diagnosis in a majority of cases, that any modalities of surgical treatment will not affect the overall survival and that the adequate local treatment can control the loco-regional disease and reduce the rate of local recurrence. In accordance with the better technology and public awareness, breast cancer can be detected in a more early stage with better prognosis and having a long term survival. Those survivors from breast cancer need a better quality of life and less morbidity incurring from the breast cancer treatment. As a consequence, the trend of surgical treatment of breast cancer is now shifting to more conservative with the objectives to do less but still maximize the loco-regional control, essential information and the quality of life of the patients.

Although breast cancers usually present as a single lump, multifocality and multicentricity of cacer are so frequent which occurs about 26-47% within the same breasts and up to 32% of subclinical nipple involvement. Therefore, the whole breast should be adequately treated.

Today, there are 2 surgical options for breast cancer which the patients could share the decision making. The first procedure is breast conservation therapy or BCT including adequate surgical removal of breast cancer and radiation therapy to the whole breast. This procedure can safe the breast but not all patients can be candidates especially those who are having a locally advanced breast cancer , pregnancy, some connective tissue diseases, previous breast irradiation, multiple breast cancer lumps, and positive breast cancer margins after surgery. BCT could be done without breast deformity even in those who have small breasts by using a soft tissue flap transfer, e.g. the latissimus dorsi flap, lateral chest wall flap, etc.

The second option is total mastectomy or surgical removal of the whole breast tissue including nipple-areola complex. This is a straight forward procedure without the need of radiation therapy but the breast needs to be sacrificed. With the increasing popularity in performing immediate breast reconstruction at the time of mastectomy, skin sparing incision was modified and widely accepted as an alternative technique for mastectomy. This more conservative approach to preserve more chest wall skin brings to a better cosmetic result after reconstruction without compromising the prognosis and recurrence.

A recent study at Department of Surgery, Faculty of Medicine Siriraj Hospital, showed that the incidence of subclinical nipple - areola involvement from breast cancer in Thai patients was 32% with an additional 5% of atypical ductal hyperplasia. The only areola involvement per se (negative nipple) was rare. Therefore, areola sparing mastectomy is technically possible without oncological compromise in some subgroup of patients. Nipple sparing mastectomy could also be performed in those who have small and peripheral lesion with negative subnipple tissue on frozen section.

For the axillary node management, Sentinel lymph-node biopsy (SLNB) is the most important advance in breast surgery since the development of reconstruction for a mastectomy. It is a more conservative procedure by pinpointing and removing only one or two key “sentinel” nodes at the axilla to which a tumor will first drain, we can find out whether or not the cancer has spread to the entire lymph-node system of 25 or so nodes. If the sentinel nodes are cancerous, the rest of the nodes must be removed. But if they're clean, studies have shown the rest of the nodes are also cancer-free and so can stay intact. Identification of the sentinel lymph-node can be done by injection of the radioactive material or the blue dye or both around the breast cancer , then the radioactive material or the blue dye will drain to the first node which will be stained as a radioactive hot spot or blue node. This procedure was claimed to be 96% accurate and could obviate the need of axillary dissection in about half of the patients. (Axillary dissection may cause arm lymphedema, shoulder dysfunction and paresthesia of the upper arm in some patients.)

Associate Prof. Dr.Supakorn Rojnanin, M.D.