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.     

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??Centennial review and enlightenment of breast cancer surgery DUAN Xue-ning.Breast Disease Center,Peking University First Hospital,Beijing 100034,China
Abstract The treatment of breast cancer is mainly based on local therapy since its record. In particular, since 1894 Halsted pioneered radical mastectomy, surgery has always been at the heart of breast cancer treatment. From the attempt of extended radical resection to the advent of modified radical mastectomy, all patients were treated on the basis of tumor free resection, with the prognosis of patients who did not deteriorate. After the Fisher team put forward the concept of breast cancer as a systemic disease, local treatment of breast cancer is developing towards a narrower operation. Local excision and radiotherapy for breast conserving became feasible. Depending on status of sentinel lymph node to determine whether to carry out axillary clearance has also been recognized in this century. Over the past hundred years, surgical treatment has not significantly improved the prognosis of breast cancer, but has improved the quality of life. With the rapid development of systemic therapy, the trend of breast cancer treatment has been reversed. The importance of operation to local control seems to be shaken. The enhancement of endocrine therapy and target therapy, the further optimization of cytotoxic drugs make the prognosis of breast cancer more dependent on the whole body treatment, and the progress of radiotherapy also affects the status of the partial operation control, especially the presence of positive axillary nodes. In the age of group medical treatment to individualized medical treatment and the pursuit of precision medical treatment, molecular subtypes guidance systematic therapy is feasible, and the guidance of surgical treatment has not been supported by evidence. Therefore, the idea of tumor free resection cannot be changed. It is necessary to recommend the best way of operation to improve survival, and to find a better combination of surgery and systematic therapy.     

Patient and Tumor Characteristics Associated with Primary Tumor Resection in Women with Stage IV Breast Cancer: Analysis of 1988–2003 SEER Data

Abstract: Surgery is the cornerstone of treatment for women with nonmetastatic breast cancer. In contrast, standard treatment for patients with Stage IV disease includes chemotherapy and radiation, with surgery usually reserved for local tumor‐related complications. Little is known about the predictive factors associated with primary tumor resection for Stage IV breast cancer. We conducted a retrospective, population‐based, case–control study using the 1988–2003 Surveillance Epidemiology and End Results (SEER) data. Using multiple logistic regression, we identified patient and tumor characteristics from among SEER region, age at diagnosis, year of diagnosis, marital status, race, Hispanic ethnicity, tumor grade, and size that were associated with surgical resection of the primary breast tumor (compared with no surgical resection) among women with stage IV breast cancer. Adjusted odds ratios and 95% confidence intervals are reported. Of 10,017 patients, 4,836 (48%) underwent surgical resection of the primary breast tumor. Patients in the Northeast and Midwest and patients presenting with two or more primary breast tumors were more likely to have surgical resection. Patients who were older, diagnosed after 1992, unmarried, black, and whose tumors were >5 cm, inflammatory, of unknown size, indeterminate grade, or unknown progesterone status were less likely to have had surgical resection of the primary tumor. Several patient and tumor characteristics were significantly associated with surgical resection of the primary breast tumor in Stage IV disease. Further study of the surgery decision‐making process is recommended.     

Unresolved, atraumatic breast hematoma: post-irradiation or secondary breast angiosarcoma

Post-irradiation or secondary angiosarcoma of the breast was first described in the 1980s in patients treated with breast conserving therapy for cancer. The primary management of radiation-induced breast angiosarcoma has focused on surgical resection with an emphasis on achieving negative tumor margins. While surgery remains a key component of treatment, novel therapeutic approaches have surfaced. Despite such advances in treatment, prognosis remains poor.     

Conservative oncoplastic surgery in breast cancer. Indications and limitations to its application

Conservative surgery is the technique of choice in the surgical treatment of women with breast cancer. The conflict between the extent of resection and the final cosmetic result can lead to asymmetries and deformities that are intensified after adjuvant treatment. The introduction of oncoplastic techniques in the conservative management of breast cancer have allowed the indication for breast conservation to be increased and have improved cosmetic results, increasing the technical alternatives available to general surgeons specialized in breast cancer. The present article aims to review the indications and limitations of these conservative oncoplastic techniques in the surgical management of women with breast cancer.     

Integrating anatomy,radiology, pathology,and surgery: An alternative approach in resecting multifocal and multicentric breast carcinoma

The sick lobe hypothesis provides the basis for a lobar approach in radiology, pathology, and surgical treatment of breast cancer. This approach aims to remove the tumor together with the surrounding field of genetic aberrations. Detailed preoperative lobar imaging that properly maps the disease and assesses its extent guides the parenchymal resection. Integration of our knowledge of breast anatomy and pathology with the results of preoperative radiological mapping is critical in assessing the eligibility of patients with multifocal and/or multicentric breast cancer for breast conservation treatment. Through an appropriately selected incision, a multisegment resection of the diseased lobe(s) is performed, which leaves the residual parenchyma in a formation that allows dovetailing of one part into the other, like the way pieces of a jigsaw puzzle fit together. Detailed pathologic analysis of the surgical specimen provides valuable feedback to the radiologist, establishes the completeness of surgical intervention, and generates predictive information for therapeutic decisions. Our approach is a step in continuous search for ideal tailored therapy to avoid under or over‐treatment of breast cancer patients.     

乳腺癌手术治疗百年历史回顾与启示

自有记载以来,乳腺癌的治疗就是以局部治疗为主,特别是自1894年Halsted首创乳腺癌根治术后,该手术一直是乳腺癌治疗的核心术式,之后从扩大根治术到改良根治术,临床医生均遵循在无瘤切除的基础上以未恶化为标准的操作。Fisher团队提出乳腺癌为全身性疾病的概念后,乳腺癌的局部治疗向更小的操作范围发展,保留乳房的肿瘤局部切除加放疗成为可能,并延续至今。目前,以前哨淋巴结活检来判定是否行腋窝淋巴清扫的方法亦获得业内认可。经历百余年的发展,虽然乳腺外科手术治疗仍未能明显改善乳腺癌病人的预后,但对改善病人生活质量意义重大。随着全身系统治疗的迅速发展,乳腺癌的治疗趋势出现逆转。手术对局部控制的重要地位似乎被动摇,内分泌治疗与靶向治疗的强化,细胞毒药物的进一步优化,使乳腺癌的预后更依赖于全身治疗,放疗的进展亦影响手术的局部控制,特别是对腋窝淋巴结阳性的病人。在群体化医疗向个体化医疗转化,追求精准医疗的时代,分子分型指导系统治疗成为可能,然而其指导手术治疗尚未获得证据支持。因此,无瘤切除的理念尚不能改变,推荐最优生存结果的手术方式,发掘更优化的手术与系统治疗的组合势在必行。     

术前针刺活检与手术标本分类的一致性对早期乳腺癌治疗的影响

目的探讨术前针刺活检与手术标本分类的一致性对早期乳腺癌治疗的影响。方法以我院48例接受手术的乳腺肿瘤患者作研究对象,上述患者均接受穿刺活检和手术切除活检,以手术切除活检为标准,分析穿刺组织ER、PR、HER2和Ki-67免疫组化检测结果。结果手术切除确诊42例阳性,6例阴性,穿刺组织ER、PR、HER2和Ki-67的,阳性预测值97.44%、93.75%、89.65%和92.59%,阴性预测值55.56%、25%、15.79%和19.05%,敏感度92.86%、71.43%、61.91%和47.62%,特异度75%、33.33%、27.27%和21.43%。结论穿刺活检ER、PR、HER2和Ki-67免疫组化联合检测比较准确反映乳腺癌组织病理情况,为该病的治疗提供参考。     

Breast-conserving surgery: quadrantectomy

The surgical techniques and clinical results of quadrantectomy as a form of breast-conserving surgery are described. A quadrantectomy is a breast-conserving technique including wide resection and tumorectomy. A quadrantectomy is designed to remove an anatomic segment of breast tissue (duct-lobular system). It has the advantage of greater surgical curability than other conserving techniques in cases with ductal spread, because breast cancer arising in the terminal duct often spreads in the duct-lobular system. However, quadrantectomy poses some cosmetic problems due to the large volume of breast tissue excised. Additionally, quadrantectomy has failed to show better results in local recurrence rates compared with wide resection. Therefore quadrantectomy should be limited to breast cancer with segmental and wide ductal spread. It is important to determine the surgical technique that compromises between local curability and cosmetic results for each patient with breast cancer.     

A surgeon's look at the treatment of cancer

Radical resection of cancer, such as radical mastectomy and abdominoperineal rectal resection, was developed in the last century. Wide‐field resection and lymph node dissection formed the basic tenets of these operations. Oesophagectomy, hepatectomy, pancreatectomy and other major resections followed. These surgical endeavours led to some spectacular cures, but also frequent postoperative deaths and complications. Advances in surgical technique and medical science have reduced the risk of surgery to an acceptable level. The last two decades have seen patients presenting with earlier and smaller cancers, prompting re‐examination of the basic tenets of oncological resection. Radiotherapy as an adjunct to surgery has reduced the need for wide radical resection of cancer of the breast, rectum and many other sites. Prospective randomized clinical trials have validated the safety of lesser scopes of surgical resection for breast cancer and cutaneous melanoma. The classical radical mastectomy is now seldom carried out. Simple wedge excision (so‐called ‘lumpectomy’) is now the most common operation for breast cancer. Wide radical resection continues to be advocated for cancer of the lung, oesophagus, stomach, and pancreas, but its benefit needs to be confirmed by similar controlled trials. Adjuvant chemotherapy given after resection of breast and colon cancer has proven survival benefit. Chemotherapy can also shrink some bulky, unresectable cancers, making them resectable. Advances in molecular biology have recently allowed the introduction of novel therapeutic agents which can abrogate the growth and progression of some cancers at the molecular level. Technological advances have enabled the development of minimally invasive cancer treatment techniques. Procedures such as radiosurgery, radiofrequency ablation, and video‐assisted endoscopic resections can achieve cancer control with minimized risk and morbidity. The new millennium will see continued evolution in the role of surgery in the treatment of cancer.      

乳腺导管扩张症和浆细胞性乳腺炎差异的探讨

目的：分析乳腺导管扩张症和浆细胞性乳腺炎临床上的差异。提出各自独立诊断的论据。方法：结合24例乳腺导管扩张症和28例浆细胞性乳腺炎对两病的临床症状、鉴别诊断、手术治疗、病理结果进行比较分析。结果：乳腺导管扩张症临床表现为乳头溢液和乳腺肿物，主要与乳腺肿物和早期乳腺癌鉴别诊断，手术以局部切除多见，病理表现为导管扩张及导管周围明显炎性改变。浆细胞性乳腺炎临床表现为乳腺肿物和炎性改变，主要与晚期乳腺癌和炎性乳腺癌鉴别诊断，手术切除的范围较大。病理变化以乳腺组织的炎性反应和多发性脓肿为主。结论：乳腺导管扩张症和浆细胞性乳腺炎有明显的差异，应作为这两种疾病独立诊断。     

Cases of sternal metastasis except from breast cancer]

Surgical resection is the option for sternal metastasis from breast cancer. But surgical treatment is the subject of controversy for sternal metastasis except from breast cancer. Four cases of secondary malignant tumors of the sternum except from breast cancer were reported. Primary lesions included thyroid cancer, gastric cancer, malignant fibrous histiocytoma of the chest wall and multiple myeloma. In 3 cases, operation were done and they survived 11 months, 13 months and 3 years respectively. In case of secondary malignant tumor of the sternum except from breast cancer, surgical treatment should be considered.     

Conservative treatment in cancer of the breast

Conservative treatment combining breast saving surgical procedures and radiotherapy, is considered as the best treatment for small breast cancers. The purpose of the study is to define the most appropriate surgical technique in order to reach both the complete resection of the primary and the best cosmetic result. Terms corresponding to the type of resection will be define in order to facilitate the comparison between the different studies on tumorectomies for breast cancer. Technical problems will be analyzed in the light of our experience of the conservative treatment especially in what concerns the cosmetic results.     

Pulmonary resection for metastatic breast cancer.

Thirty-three patients treated primarily with surgical excision of pulmonary metastases from breast cancer were compared with 30 patients treated primarily with systemic chemohormonal therapy. Treatment for patients in the surgical group included pulmonary resection alone in 20, resection plus adjuvant systemic therapy in nine, and resection plus adjuvant radiation therapy in four. Treatment for patients in the medical group included systemic therapy alone in 22 and systemic therapy plus local radiation therapy in eight. Mean survival in the surgical group was significantly longer than that in the medical group, even when only those patients who manifested single pulmonary nodules were compared (58 months vs 34 months). The overall 5-year survival rate after treatment of lung metastasis was significantly greater for the surgical group than for the medical group (36% vs 11%). The results of this study indicate that surgical resection should be considered in patients with breast cancer who develop operable pulmonary metastases without evidence for concomitant extrapulmonary disease. In selected patients, such therapy may result in a survival benefit.     

Subclavicular recurrence of breast cancer: Does surgery play a role?

Occasionally, breast cancer relapses in the subclavicular region. In patients with failed multimodal treatment, or in those who develop an isolated recurrence, surgical resection may be useful to remove all macroscopically evident diseases. However, the procedure may be technically demanding and there are no published data regarding its benefits. The aim of the present study was to evaluate the feasibility and safety of subclavicular resection in breast cancer and provide indications as to whether it can contribute to disease control. We used a transpectoral approach to surgically remove isolated breast cancer recurrence in the subclavicular region in seven consecutive patients presenting over 2 years; in the eighth case a transmanubrial approach was necessary. We found that the surgical approach proposed is feasible and safe, with a 75% rate of complete resection; however, the series was characterised by a high rate of local and distant relapse. We conclude that the technique may be useful, in selected cases, for palliation only.     

Oncoplastic surgery: the evolution of breast cancer treatment

Oncoplastic surgery is an establish approach that combines conserving treatment for breast cancer and plastic surgery techniques. It allows wide excisions and prevents breast deformities by immediate reconstruction of large resection defects. The procedures are mostly useful for resection of 20-40% of the breast - a group of patients normally treated by mastectomy in the past. Four features are integral to oncoplastic breast surgery: (i) Appropriate surgery for cancer excision. (ii) Partial reconstruction to correct wide excision defects. (iii) Immediate reconstruction with the full range of available techniques. (iv) Correction of volume and shape asymmetries relative to the contra-lateral healthy breast. There are two fundamentally different approaches: (i) volume-replacement procedures, which combine resection with immediate reconstruction by using local flaps (glandular, fasciocutaneous, and latissimus dorsi mini-flaps), and (ii) volume-displacement procedures, which combine resection with a variety of different breast reduction and reshaping techniques, according to the location of the tumor. Oncoplastic surgery increases the oncological safety of breast-conserving treatment because a much larger breast volume can be excised and wider surgical margins can be achieved. Moreover, a "surgical screening" of the contra-lateral breast allows the diagnosis of occult cancers. Among oncoplastic approaches, a very unique technique is the possibility of implant use (augmentation mammaplasty) in case of quadrantectomy and simultaneous delivery of intraoperative radiotherapy to the tumor bed.     

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??Hot issues of surgery for breast cancer in 2018 LIU Yin-hua, XIN Ling, XIANG Hong-yu.Breast Disease Center, Peking University First Hospital, Beijing 100034, China
Coresponding author: XIN Ling, E-mail:kfs_xl@126.com
Abstract Thanks to the improvement of multi-disciplinary treatment, patients with breast cancer have better prognosis than those in the past. The goal of tumor treatment is to achieve best oncological outcome and minimize harm, which has been widely recognized in clinical practice. Various of breast surgical techniques have been constantly standardized in breast surgery recent years. With the increasing application of surgical energy equipment, laparoscopic techniques get much attention from surgeons. Moreover, the widespread use of materials with good biocompatibility in surgery, gives rise to the thinking for both the indications and standardized procedures of breast reconstruction, which in a result promotes the process of multidisciplinary collaboration. However, breast surgeons should adhere to the principle of cancer treatment and not be obedient to new techniques unconditionally. En bloc resection is the priority of tumor surgeries that all surgeons should always keep in mind.     

Conservative treatment of breast cancer: Milan experience

Summary Background The conservative treatment of operable breast cancer has gradually become well-established during the last 20 years as it offers adequate loco-regional control of the disease and saves the brest. Moreover, larger, demolishing operations have not shown to decrease the risk of distant metastases. Methods Four prospective, randomized trials (Milan Trials I to IV) have been conducted at the Department of Surgical Oncology of the Istituto Nazionale Tumori Milan since 1973 comparing the radical Halsted approach in operable breast cancer to conservative treatments combining extensive breast resection and various radiotherapies. Results Data analysis lends force to the conservative treatment concept, showing that an extensive breast resection, defined as quadrantectomy, together with radiotherapy are a safe procedure that results in a long term survival comparable to that after Halsted's mastectomy. Furthermore, the studies reveal that too limited a resection (lumpectomy) and withdrawal of radiotherapy increase the risk of local recurrence. In women older than 55 years, however, quadrantectomy without radiotherapy yields good results. Young age and the presence of an extensive intraductal component are further, signficant and important risk factors of local recurrence. Conclusions If attention is paid to the defined risk factors and adjuvant therapeutic regimes the conservative surgical treatment of breast cancer yields excellent long term results.      

Extent of Primary Breast Cancer Surgery: Standards and Individualized Concepts

Surgery is still a main therapeutic option in breast cancer treatment. Nowadays, methods of resection and reconstruction vary according to different tumors and patients. This review presents and discusses standards of care and arising questions on how radical primary breast cancer surgery should be according to different clinical situations. In most early breast cancer patients, breast conservation is the method of choice. The discussion on resection margins is still controversial as different studies show conflicting results. Modified radical mastectomy is the standard in locally advanced breast cancer patients, although there are different promising approaches to spare skin or even the nipple-areola complex. A sentinel node biopsy is the standard of care in clinically node-negative invasive breast cancer patients, whereas the significance of axillary lymphonodectomy seems to be questioned through a number of different findings. Although there are interesting findings to modify surgical approaches in very young or elderly breast cancer patients, it will always be an individualized approach if we do not adhere to current guidelines. Up to date, there are no special surgical procedures in BRCA mutation carriers or patients of high-risk families.     

2018年乳腺癌外科治疗热点问题

伴随综合诊治水平的不断提高,乳腺癌总体预后得到改善,追求最大获益和最小伤害的宏观理念在临床获得广泛认同。在外科领域中,各种乳腺癌相关的手术技术正在不断得到规范;伴随能量外科手术设备普遍应用于临床实践,腔镜技术也正在受到乳腺外科医生的高度关注;同时,近年来不同材质、具有良好组织相容性的修复材料研发成功并进入临床,引发了乳腺肿瘤外科医生与整形科医生对乳腺癌术后乳房重建方式合理性与技术规范化的思考,促进和推动了多学科合作的进程。面对诸多全新的理念,乳腺外科医生应该避免盲从,科学理解乳腺癌诊治的宏观原则。努力将肿瘤安全性优先的肿瘤外科基本理念贯彻到临床实践。