The evolution of the conservative approach to breast cancer

The profound revolution that surgical treatment of breast cancer has undergone during the past 30 years has led to the progressive reduction of the extent of surgery, with less mutilation. As a consequence, quality of life has improved and women are now more motivated to follow screening programs for early diagnosis of the disease. Since conservative surgery is as effective as radical surgery, research is now focused on reducing radiotherapy. Overall, survival after breast cancer is not affected by reducing the extent of surgery, which, together with less invasive diagnostic procedures, has a good effect on patients' quality of life. For this reason in our Institute we are now evaluating the feasibility of a reduction of the radiation field and the sensibility and sensitivity of new diagnostic approaches for axillary staging.     

Surgical treatment of early breast cancer in day surgery

Quadrantectomy and associated sentinel lymph node biopsy (SLNB) is currently employed in most breast surgery centres as the gold standard in the treatment of early breast cancer. This approach has a modest morbidity and can usually be performed in a day-surgery regimen, leading to best acceptance by the patients. This reports outlines the experience of our Breast Unit with quadrantectomy and SLNB in day surgery for early breast cancer. One hundred patients presenting to our institution with primary invasive breast cancer measuring less than 3 cm and clinically negative axillary nodes underwent quadrantectomy and SLNB in day surgery. For 60 women with breast cancer the sentinel node was negative, so the only definitive surgical treatment was performed in the day-surgery regimen; 40 patients with positive sentinel nodes were hospitalised a second time for axillary dissection. In these patients that needed clearance of the axilla, SLNB was performed on the only positive node in 22 cases (55%). None of the patients admitted for quadrantectomy and SLNB in day surgery required re-hospitalisation after discharge. All patients proved to be fully satisfied with early discharge from hospital when questioned on the occasion of subsequent monitoring. Short-stay surgical programs in early invasive breast cancer treatment are feasible today owing to the availability of less invasive approaches such as quadrantectomy and SLNB. There are two main pointers to a distinct advantage for this kind of approach, i.e. recovery and psychological adjustment. Recovery from surgery is faster and the patient tends to play down the seriousness of the operation and to have a better mental attitude to neoplastic disease. Moreover, when performing quadrantectomy with SLNB in day surgery fewer than 50% of breast cancer patients (40% in our experience) require another surgical treatment, concluding the surgery in a single session.     

年轻乳腺癌患者保乳术后是否有更高的局部复发率的Meta分析

目的研究年轻乳腺癌患者接受保乳手术后是否比非年轻乳腺癌患者有更高的局部复发率。 方法计算机检索PubMed、EMBASE、中国知网、维普数据库、Google 学术、万方数据库深圳市卫生健康电子文献共享平台等数据库,比较年轻乳腺癌患者（小于35~45岁）与非年轻乳腺癌患者（大于35~45岁）保乳术后局部复发率的临床对照研究。采用STATA 12.0软件对纳入研究进行Meta分析,对汇总后的相对危险系数（RR）及95%可信区间（CI）进行分析,并对纳入文献的发表偏倚进行分析。 结果共纳入23项研究（共18775例患者）。总体分析,RR=2.639,95%CI：2.338~2.979,说明年轻乳腺癌组较非年轻乳腺癌组有更高的局部复发率,且结论差异有统计学意义;而对接受手术时的所在年份（以该时间段的最晚年份进行分组）进行亚组分析时发现,在2010年至2020年期间接受手术的患者,RR=1.348,95%CI：0.653~2.780,说明该时期的年轻组乳腺癌患者比非年轻组乳腺癌患者有更高的局部复发率,但差异无统计学意义。 结论在近10年接受保乳手术的年轻乳腺癌患者,其术后局部复发率与非年轻乳腺癌患者相比差异无统计学意义,局部复发情况得到明显控制,治疗效果得到显著改善。故在目前的诊疗规范指导下,年龄较低并不增加乳腺癌患者保乳术后复发的风险,具有保乳指征的年轻乳腺癌患者,同样可以通过保乳手术,得到有效的治疗。     

Axillary dissection in the context of the biology of lymph node metastases

BACKGROUND: Modern breast surgery, as the primary treatment of invasive breast carcinoma, has been evolving over the last century. Aggressive radical surgery, which included chest wall resection, complete axillary clearance and internal mammary node dissection, has slowly changed to a less aggressive approach. This has been based on an improved understanding of the biology of the disease. Over the years, randomized prospective trials, performed at centers all over the world, have demonstrated that axillary dissection does not impact on the overall survival while it helps with loco-regional control of breast cancer. Its major role, at the present time, is limited to staging and prognostication; functions that are equally well served by the limited approach of a sentinel node biopsy. SOURCES: This review is based on the available medical literature involving the biology and organ specificity of the metastatic process, not only in breast cancer but also in other malignancies. In addition, studies pertaining to clinical breast cancer, and the role of surgery in its treatment, were reviewed. The ongoing trials on the role of sentinel node biopsy in the management of the clinically node negative patients are discussed. CONCLUSIONS: This review covers the history, pathophysiology, and clinical basis of the current role of axillary dissection for invasive breast cancer. From the data presented we hope that the medical community will agree that there is no therapeutic role for extended axillary dissection at the current time.     

Review of the development of letrozole and its use in advanced breast cancer and in the neoadjuvant setting

Five years of adjuvant endocrine therapy with the antiestrogen tamoxifen has been shown to significantly reduce the risk of recurrence in women with early breast cancer and has thus been the standard of adjuvant therapy for this malignancy over the last two decades. Tamoxifen has also been used for the first-line treatment of advanced or metastatic breast cancer, and it was studied in the neoadjuvant setting to promote breast-conserving surgery in those patients who may be otherwise ineligible. However, comparative clinical trials involving the more recently approved third-generation aromatase inhibitor drugs (anastrozole, letrozole, and exemestane) have challenged tamoxifen as first-line therapy in advanced/metastatic breast cancer as well as in the neoadjuvant setting. Although trials with other AIs have shown improved efficacy and better tolerability over tamoxifen, letrozole has consistently demonstrated superiority over tamoxifen when used as first-line treatment for advanced/metastatic breast cancer or as neoadjuvant therapy. The efficacy of letrozole in the neoadjuvant setting further extends to those tumors with positive human epidermal growth factor receptor (HER1) and/or HER2 expression, which are often less responsive to tamoxifen. The encouraging results of such trials identify letrozole as a better alternative to tamoxifen in improving responses rates in the treatment of advanced breast cancer and as neoadjuvant therapy, which allows breast-conserving surgery in women with inoperable breast cancer or who were not candidates for breast-conserving surgery.     

BREAST CANCER: CURRENT ISSUES IN DIAGNOSIS AND TREATMENT

The diagnosis and treatment of breast cancer in Australia has changed in response to new technologies and cultural influences which have emphasized the importance of psychological and social aspects of breast cancer. In this review article, recent developments are examined in relation to current surgical practice. Changes in the incidence of breast cancer, the effect of mammographic screening on the outcome of treatment, the increasing use of breast-conserving surgery, the timing of surgery in relation to the menstrual cycle and the importance of risk factors for breast cancer are all considered. Breast cancer is a potentially curable disease. Early detection and conservative surgery provide a framework for disease control.     

整形技术在乳腺癌乳房再造治疗中的应用

乳腺癌作为多发的恶性肿瘤疾病之一,临床常采用手术方式进行治疗。近年来,国内的医学诊 断和治疗技术不断得到提高,乳腺癌的手术诊疗手段也有很大的进展。但由于部分患者切除了病变乳房, 生理及精神均受到不同程度的创伤。因此,整形外科诊疗技术在乳腺癌治疗中被广泛使用,在解决患者癌 症病灶的同时能够兼顾患者的生理形态美,保证患者生活质量。基于此,本文就乳房再造术、乳房重建手 术类型及其辅助技术作一综述,旨在为乳腺癌患者的相关手术治疗提供参考     

Endoscopic surgery for breast diseases: the present state of art and outlook for the future

Endoscopic breast surgery (EBS) is still not in common use today, mainly because of the lack of intracavitary operative maneuvers in breast surgery. It has been shown, however, that in experienced hands, the therapeutic benefits of EBS include not only improved natural esthetic outcomes but also less morbidity with faster recovery. Endoscopic partial/total mastectomy, axillary dissection, and breast reconstruction can be performed through an axillary incision with an additional periareolar incision depending on the situation, as safe alternatives to conventional operative procedures for early breast cancer. Furthermore, EBS is particularly effective when performing axillary dissection and mobilizing tissue flaps for immediate reconstruction. Since EBS requires the creation of a dissecting working passage and space, which tends to increase operative invasiveness, operating time, and blood loss, in less experienced hands an initial period of learning curve adjustment appears to be mandatory. Safety in terms of adequate local control must be further evaluated and long-term results need to be followed up before EBS can be applied in more advanced-stage breast cancer. Instead of being regarded as a competing technology. EBS should be welcomed and accepted in combination with conventional methods to nurture and further improve the technical aspects of breast cancer surgery. EBS is expected to become an indispensable and integral part of breast surgery in the near future, especially in an era when informed consent is sought with broader patient choice and empowerment models.     

How to treat male breast cancer

The prevalence for breast cancer in males in Europe is estimated to be 1 or less per 100,000. Male breast cancer has a peak incidence at the age of 71 years. There are no randomized data giving information on the optimal therapy for male breast cancer patients, thereby limiting firmer conclusions. The preferred primary surgical therapy is modified radical/simple mastectomy, but breast-conserving surgery has also been used in males. Post-operative radiotherapy should be used on a more routine basis; as males have shorter breast-anatomical distances and males are diagnosed at a later stage compared with females. The so far preferred adjuvant therapy modality has been tamoxifen for patients with endocrine responsive disease. The use of aromatase inhibitors in males is more controversial, since they may not deplete the estradiol levels sufficiently. Different chemotherapy regimens have been used in the adjuvant and metastatic setting. The use of adjuvant therapy has in institutional and review comparisons been demonstrated to result in an improved outcome.     

The impact of mastectomy, breast-conserving treatment and immediate breast reconstruction on the quality of life of Chinese women

Background : The psychosocial impact of breast surgery has been extensively studied in the Western population. There is a relative paucity of comparable data in Oriental women who are increasingly affected by cancer of the breast. The present study investigates the effects that different types of breast surgery have on the quality of life of Chinese women. Methods : Forty‐nine Chinese women with early breast cancer were interviewed at 6 months–2 years following their primary surgery (breast‐conserving treatment (BCT; 17 patients), mastectomy (15 patients) and mastectomy with immediate breast reconstruction (17 patients)). Aspects of quality of life measured included general psychological well‐being, body image, sexual functioning and social functioning. Results : Patients who received BCT had significantly better body image scores compared to mastectomy patients. They were less worried about their appearance, had more freedom in the choice of clothing, felt less upset by the change in their body and felt more accepted by their partners. The three groups did not differ significantly in the other aspects of quality of life measured. Conclusions : Compared to mastectomy or mastectomy and immediate breast reconstruction, the most significant benefit of BCT is the preservation of a better body image.     

Late follow-up of a randomized trial of surgery plus tamoxifen versus tamoxifen alone in women aged over 70 years with operable breast cancer

BACKGROUND: Breast cancer has been considered a more indolent disease in the elderly, who are less tolerant of aggressive therapy. This trial tested the hypothesis that tamoxifen without surgery would provide adequate control of breast cancer for the remainder of life in elderly women, thereby sparing them surgery. METHOD: Women aged over 70 years with operable, invasive breast cancer were randomized to receive either tamoxifen alone or surgery plus tamoxifen. Time to treatment failure (TTF), indicating initial primary treatment failure, was the primary endpoint. Overall mortality, and death from breast cancer were also compared between the two groups. RESULTS: Between 1984 and 1991, 455 patients were included in the trial. The analysis was based on a median follow-up of 12.7 years. The TTF was significantly shorter in the tamoxifen alone group: hazard ratio (HR) 4.41 (95 per cent confidence interval (c.i.) 3.31 to 5.88). Ninety-three (40.4 per cent) of 230 patients randomized to tamoxifen alone underwent surgery for the management of their disease. Both overall mortality and mortality from breast cancer were significantly increased in the tamoxifen alone group, although the survival curves did not diverge for the first 3 three years: HR 1.29 (95 per cent c.i. 1.04 to 1.59) and 1.68 (95 per cent c.i. 1.15 to 2.47) respectively. CONCLUSION: Omission of primary surgery in unselected elderly women with operable breast cancer who were fit for the procedure resulted in an increased rate of progression, therapeutic intervention and mortality.     

Should We Schedule Breast Surgery Based on a Woman's Menstrual Cycle?

Abstract: The timing of surgery of breast cancer patients has been reported to impact recurrence and survival. It is well known that surgical manipulation of tumor induces micrometastasis. During the menstrual cycle, profound hormonal changes occur affecting the local environment of the breast and breast cancer. A significant amount of scientific research now suggests that estrogen may establish an environment more likely to produce micrometastasis, and an immune system less likely to manage micrometastasis. Progesterone may protect against the effects of estrogen, leading to improved disease-free and overall survival during the luteal phase. The studies examining this association are conflicting, but claim a 30% advantage for those patients undergoing surgery during progesterone predominance. A solid prospective study examining this possible benefit has yet to be performed. Until then, no harm can come from scheduling patients for surgery during the early luteal phase, and these patients may actually have a significant improved survival over those whose tumors are excised during the follicular phase.     

Breast education in general surgery residency

Breast cancer treatment has changed substantially with increased specialization. Overall, the number of cases performed by residents upon completion of residency has decreased and the introduction of sentinel lymph node biopsy has reduced the number of axillary lymph node dissections being performed. Our objective was to evaluate the breast surgery education being provided by general surgery residency programs. A survey was administered to applicants to the Roswell Park Cancer Institute surgical oncology fellowship program in the fall of 2009. This survey examined the type of training program, the breast surgery exposure, and applicant comfort with the medical and surgical aspects of breast cancer. The survey was completed by 29 of 35 applicants. Of the respondents, 83 per cent were chief residents. Overall, participants had comfort levels above 8 (of 10) with breast related cases. For modified radical mastectomies and axillary lymph node dissections the comfort level dropped below 8. Participants were least comfortable discussing the medical management of breast cancer. General surgery residents completing training were less comfortable operating in the axilla compared with the breast. The study suggests careful attention should be paid to assuring adequate breast education in surgical residency.     

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??Strategy and progress of surgical treatment for breast cancer CHEN Sheng, SHAO Zhi-min. Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai200032, China
Corresponding author: SHAO Zhi-min, E-mail: 0456177@fudan.edu.cn
Abstract Nowadays, the surgical treatment of breast cancer is based on a more conservative and individualized strategy. Standard breast conservation therapy needs to be promoted further, while the positive margin, recurrence and radiotherapy are key concerning issues influencing the choice of conservation surgery for patients and surgeons. Sentinel lymph node biopsy is the standard treatment strategy for lymph node negative breast cancer. The operation technique and indication of axillary nodes dissection are still controversial. The reconstruction surgery has provided opportunities for rebuilt of breast for patients who are not candidates for conservation therapy with consideration of both aesthetics and anti-cancer treatment efficacy. The cross link of imaging technique and surgery tends to be plural, and has achieved a great progress in the biopsy and minimally invasive treatment area. The biological subtype of breast cancer has played an important role in determining intrinsic property and treatment strategy for breast cancer??especially in neoadjuvant therapy.     

Oncoplastic Surgery: Pushing the Limits of Breast‐Conserving Surgery

In recent decades, the surgical management of breast cancer has steadily and considerably improved. Mutilating procedures have given way to more individualized surgical approaches aiming to preserve the breast as much as possible. For large tumors, preoperative chemotherapy is a major tool, but emerging oncoplastic surgery techniques are also a new approach in the armamentarium of breast cancer surgery, as a third option between conventional breast‐conserving surgery and mastectomy. As this new treatment modality allows wider margin excision, it reduces the need for re‐excision procedures and possibly increases breast conservation rates by extending the indications of breast‐conserving surgery. This review will provide an overview of current practices and clinical data available to date on oncoplastic surgery.     

Progresses in the treatment of early breast cancer. A mini-review

The treatment of breast cancer has undergone continuous and profound changes over the last three decades; breast conservation therapy has been progressively validated as a safe alternative to radical mastectomy for patients with early stage breast cancer. Several large trials have shown that overall survival time of patients treated with conservative surgery and axillary dissection followed by radiation therapy is equivalent to that of patients treated with modified radical mastectomy, with better cosmetic outcomes and acceptable rates of local recurrence. Improvements in diagnostic work-up and the wider diffusion of screening programs have allowed the detection of smaller, often non palpable tumours, furtherly facilitating the widespread use of tumour localization and breast conserving techniques. Since the removal of negative lymph nodes is useless, eventually harmful and plays no therapeutic role in breast cancer patients, techniques for staging of the axilla have also gradually evolved toward less aggressive approaches, such as lymphatic mapping and sentinel node biopsy. The introduction of "onco-plastic techniques", that combine the concepts of oncological and plastic surgery of the breast, achieve the goal of allowing more extensive excisions while improving the aesthetic results, and eventually patient's quality of life. The present work will highlight potential benefits as well as unresolved issues of the above mentioned therapeutic options, with special emphasis on technical aspects of conservative surgery in the treatment of early breast cancers.     

Landmark Clinical Trials Influencing Surgical Management of Non‐invasive and Invasive Breast Cancer

The surgical management of breast cancer has changed considerably since the use of the Halstedian radical mastectomy early in the 20th century. Over the last 50 years, several landmark clinical trials from the USA and Europe have resulted in a paradigm shift in the management of breast cancer toward less radical forms of surgery with the combined use of multi‐modality treatments including systemic chemotherapy, endocrine therapy, and radiotherapy. Advances in such research have established a new worldwide standard of care for breast cancer surgical management and treatment, which has become more patient centric and which places a higher emphasis on cosmesis and improved patient quality of life. In this chapter, we review the landmark clinical trials that have influenced surgical management for non‐invasive and invasive breast cancer and that serve to guide current clinical practices to date.     

Cosmetic results in 242 patients treated by conservative surgery for breast cancer.

The surgery of breast cancer has changed lately in favour of breast conserving treatment, the main purpose of which is to provide good cosmetic results together with radical resection of the tumour. In this paper we describe the cosmetic results obtained in 242 patients treated by conservative surgery (226 quadrantectomies, 93%, and 16 lumpectomies, 7%) for low risk breast cancer. Several of these resections were combined with plastic surgical techniques for residual breast reshaping. The technique chosen depended on the site of tumour, width of resection, and breast volume. The cosmetic assessment was made by the patient and the physician. Our data suggest that better cosmetic results may be obtained when plastic surgical procedures are combined with conservative surgery for breast cancer.     

乳腺肿瘤外科治疗策略与进展

目前,乳腺癌外科治疗追求更保守的个体化治疗模式。保乳治疗的规范化有待于进一步推广。保乳术后复发及放疗是影响病人与外科医师选择保乳术式意愿的主要核心问题。前哨淋巴结活检已成为淋巴结阴性乳腺癌的标准治疗手段,其具体操作技术和活检后腋窝淋巴结清扫的指征仍缺乏一定的共识。应从美学和肿瘤治疗两个角度考虑乳房重建术,为没有机会保乳的女性提供重塑乳房的可能。近年来,影像学技术与外科的交叉应用逐渐趋于多元化,尤其在乳腺微创活检与病灶定位等方面的应用获得了很大的发展。乳腺癌分子分型已成为当下决定乳腺癌固有特性和治疗策略的重要系统,尤其在新辅助治疗策略的制定中发挥举足轻重的作用。     

保乳手术与改良根治术治疗乳腺癌的体会

【摘要】 目的 探讨保乳手术与改良根治术治疗乳腺癌的临床效果。方法 对我院从2005年1月到2007年6月期间乳腺癌治疗的临床资料进行回顾性分析。选择60名经手术治疗的乳腺癌患者,分为观察组和对照组,每组各30例,对照组给予改良根治术治疗,观察组给予保乳手术治疗,随访5年观察临床效果。 结果 观察组患者在手术时间、住院时间、术中出血量及并发症发生率方面明显优于对照组(P<0.05)。两组5年生存率比较差异无统计学意义(P>0.05)。结论 保乳手术治疗乳腺癌的效果确切,优点多,临床医师应根据患者的适应证合理应用。