I. Mastering the new trend of breast-conserving surgery
The development of surgical treatment of breast cancer is basically divided into three stages.
1. traditional radical surgery, in which the large and small pectoral muscles, breast and axillary lymph nodes on the affected side are removed together.
2. Modified radical surgery: preserving the large and small pectoral muscles, removing only the breast and clearing the axillary lymph nodes.
3.Breast-conserving surgery.
4.Sentinel lymph node biopsy: fossa-preserving surgery.
Only resection of the tumor is performed accordingly. The above procedures have been scientifically analyzed by a large number of cases for a long time, and the results show that their 5-year survival rates are basically the same. Therefore, the three types of surgery have undergone great changes in some foreign countries: traditional radical surgery is basically eliminated, modified radical surgery accounts for 60%, and breast-conserving surgery accounts for 40%. Therefore, how to carry out breast-conserving surgery and fossa-conserving surgery in the new period is a great challenge for breast surgeons at present.
II. Mastering the indications of breast-conserving surgery
The international clinical summary of tens of thousands of breast-conserving surgery patients has been adopted, and the indications for breast-conserving surgery are generally as follows
① single lump.
②Lumps <2-3cm.
(iii) Excision of the lump should be 1 cm away from normal tissue and surrounded by negative margins.
④ negative axillary lymph nodes.
⑤ The mass should not be close to the nipple and the tumor should be ≥2 cm from the areola margin.
⑥The patient and family members understand and agree to breast-conserving surgery.
(7) Mammogram showed no extra-mass calcification foci.
Preoperative adjuvant examination confirmed no distant metastatic lesions; absolute contraindications included.
(i) Previous radiotherapy to the affected breast or chest wall.
(ii) Having active connective tissue disease, with particular attention to the risk of scleroderma and systemic lupus erythematosus.
③Patients who are pregnant or lactating.
④Multicentric, multifocal breast cancer.
⑤ Tumor with positive cut margins after extensive local excision, and negative pathological cut margins are still not guaranteed after re-excision.
Relative contraindications.
①Tumor located within the areola and the 2 cm circumference next to the areola, including nipple Paget’s disease.
②Tumor diameter >3 cm, but can also be considered with caution after preoperative neoadjuvant chemotherapy step-down.
③Mammography shows diffuse malignant or suspected malignant microcalcified foci.
3. Mastering surgical skills
The main technical procedures of breast-conserving surgery for breast cancer are
① Pre-operative estimation of whether the patient has an indication for surgery, if so, first explain the significance and problems of the operation to the patient and her family, and discuss with the pathologist about the collaboration of the operation.
(ii) Increase the extent of mass excision accordingly (1 to 2 cm from the outside of the mass).
③Send frozen sections to the pathology department intraoperatively, and if the diagnosis is malignant tumor, check whether the cut edge is negative at the same time.
If the diagnosis of malignant tumor is confirmed and the cut edge is negative, an anterior sentinel lymph node biopsy is performed and a small curved incision is made at the upper edge of the axilla to clear the axillary group of lymph nodes and send them for examination; if they are negative, the incision is closed and the breast-conserving surgery is completed.
IV. Comprehensive treatment after breast-conserving surgery
For patients with breast-conserving surgery, the next step of comprehensive treatment plan should be formulated according to the pathology after surgery. If chemotherapy is needed, it will be given every 3-4 weeks and 4-8 times. Radiotherapy must be administered once after chemotherapy. According to the immunohistochemistry, the decision of endocrine therapy, such as triamcinolone or phalloidin for 5-10 years orally, and the application of molecular targeted therapy according to Her-2 status and disease staging and typing. Patients were also taught about self-examination and regular follow-up, including liver ultrasound, chest X-ray, bilateral supraclavicular and axillary lymph nodes, and contralateral breast. Once local recurrence was suspected, a new biopsy could be performed, and for those with confirmed recurrence, modified radical surgery could be performed again.