Breast cancer is a complex disease that we know today that encompasses different subtypes, with more and better prognosis and differential treatment.
A multidisciplinary team of specialists in Gynaecology and Obstetrics involved involved in the various aspects of treatment should first make a diagnosis as accurate as possible later to help the patient to make the best decision, since each case must be treated individually. In fact, the most important factor ahead of the results in the medium and long term is to develop from the beginning a treatment plan adjusted as possible to each individual circumstance, to make appropriate sequence in the best possible treatments. Add unnecessary treatments, skip treatments needed or to abortions improper order decrease the chances that the patient is disease-free medium to long term.
To choose the most appropriate treatment in each case, the key points are:
- Personalised study of each patient
- Clinical, pathological and imaging
- Valuation Multidisciplinary Committee, with all the specialists involved
- Final decision with the patient after adequately inform them of the various options in this case more than one
According to each case, one treatment or another is done. The following outlines each.
Surgery for breast cancer has two main objectives. On one hand, removing all diseased tissue, with minimal removal of healthy tissue around. On the other hand, after making the removal, should reshape the breast leaving a cosmetically acceptable breast for women.
When these two objectives can not be carried out, it is better to opt for mastectomy, which involves removing the entire breast and breast tissue. Oncoplastic surgery is a technical device that allows the number of conservative surgeries and cosmetic results are leveraging techniques of plastic surgery. In almost all cases, mastectomy can be done with immediate reconstruction which in some patients can make saving skin and even the areola and nipple.
Patients breast conserving radiotherapy should be treated, at least in the tumor bed, which can be done during surgery due to intraoperative radiotherapy. Some patients also need radiation therapy to the chest or nodal areas.
• Intraoperative ultrasound: In this type of surgery intraoperative ultrasound is used during the operation in order to locate non palpable lesions and achieve optimal margins palpable lesions (lower reoperation rate by removing the minimum required volume of tissue removed). Intra-operative radiotherapy: This technique can reduce the duration of treatment of external radiotherapy in breast-conserving surgery. In some selected cases with good prognosis tumors patients, this treatment obviates the subsequent external radiotherapy.
In patients with breast cancer it is very important to know if there is disease in the regional lymph nodes, usually the armpit. Years ago it was necessary to remove all nodes to check that none of them was affected by the tumor. However, since the late 90s, in tumors with low likelihood of disease in the axilla it is possible to omit unnecessary axillary dissection by using the technique of sentinel node.
This technique involves injecting into the tumor or at its periphery, a substance that emits a signal that can be detected (radioisotope). The lymphatic system captures this substance, which follows the same path that would follow if the tumor cells to leave the tumor via the lymphatic. When this material reaches the first node that is on its way (we call sentinel) accumulates in it. This allows you to locate where you are and identify during surgery to remove it and study. If the sentinel node is not sick (not minimally, according to the newest data), it is not necessary to remove the rest; so the disadvantages are avoided axillary clearance. The OSNA system currently allows to know exactly their status during surgery, which avoids having to re-intervene in patients with disease in the sentinel node is not detected during surgery with conventional methods.
At present, as many patients receiving chemotherapy or other treatments before surgery, we are performing this technique after treatment, reducing the number of patients who are ultimately subjected to axillary dissection. In these cases they should study three lymph minimum for optimal validity. Even in patients with limited disease armpit, if we mark the patient so that it can locate node, the sentinel node biopsy is planteable if good response to chemotherapy.
Surgery combined with plastic surgeon
If the treatment is carried out in collaboration with a specialist in Plastic Surgery can be offered three types of specific treatments.
• Oncoplastic surgery with remodeling contra-lateral breast: when you need a lift or reduction of the healthy breast to achieve better symmetry, we prefer to operate with the plastic surgeon to optimize results.
• Immediate and Delayed Reconstruction: immediately after removal of the breast and in the course of the surgery, breast reconstruction, which can be either with own tissue as prosthesis-expander is done. The technique to perform is valued individually.
• Surgery of lymphedema: micro-lymphatic-venous anastomosis and transfer of inguinal lymph nodes of donor surface area to the armpit. Performed by highly specialized reconstructive surgeon.
Risk reduction surgery
Women at high risk of developing proven breast cancer, either genetic or due to alterations in the breast and proven by biopsy, may be risk reduction surgery. This surgery may combine the presence of a laparoscopic surgeon, a breast surgeon and a plastic surgeon. It involves removing the ovaries and fallopian tubes, along with a mastectomy with immediate reconstruction. This surgery can be done with preservation of the skin and even aerola-areola complex in some cases.
Placing resevorio port-a-cath
In cases of patients who should receive chemotherapy after surgery, the device is placed reservoir port-a-cath. This device allows you to manage without damaging chemotherapy arm veins.
Chemotherapy, Hormone anti-target (anti-estrogen treatments), treatments, new treatments being validated. The current trend is increasingly treat the tumor prior to surgery with the idea of demonstrating their sensitivity to treatment of the tumor to the profile is suitable start. Depending on the degree of response, not only it allows the tumor to know very relevant biological information, but gives prognostic information and may allow less invasive surgery if there is a significant reduction of tumor. It is crucial to perfect coordination between the medical oncologist, a radiation oncologist and the surgical team.
A resource increasingly used in patients receiving treatment before surgery is to place an intra-tumoral marker, which identifies the piece of tissue that must be removed if the tumor's response to treatment is very important and not it is easily visible by imaging tests.
The study of gene expression in each tumor can help us improve the prognostic information of each individual case, and we already have tests that allow choosing the best treatment in each particular case, so that the patients who are suitable will support us them to better customize treatment.
Local treatment of breast, armpit lymph node regions and neighboring radiotherapy is a cornerstone of modern therapy to breast cancer. It is imperative for conserving surgery. More and more evidence that its role is not only relevant face to local control, but has a significant impact on the overall course of the disease there. It is for this reason it is very important to administer properly, with the best available technology at the right time. There is now the possibility of part of radiotherapy (the intended surgical bed) during surgery, which is called intraoperative radiotherapy. This intraoperative dose is required in all cases, there are patients in which only localized this dose is sufficient and in other conventional external radiation therapy is performed after surgery, that its duration will be reduced by intraoperative dose (7-5 weeks), and if there is indication for treatment hypofractionated can reach reduced to 3 weeks.