The 16th Annual American Breast Surgeons Conference, held in the United States from April 29 to May 3, 2015, gave the latest information on how to treat benign and malignant breast disease. Boughey, M.D., from the Mayo Clinic in Rochester, R.I., and others have compiled five important advances in breast surgery over the past decade, which are described below.
1. Nipple-preserving mastectomy (NSM)
The number of NSM performed has increased greatly in the last decade, and by 2015, NSM is widely performed as a prophylactic and curative procedure in patients with breast cancer. Compared to mastectomy alone and skin-preserving mastectomy, there is a lower rate of tumor recurrence and no difference in survival after performing NSM in the nipple-areolar region. Currently, the procedure can be used for larger tumors, larger breasts, and the limitation of lesion-to-nipple distance is gradually being reduced.
NSM can better control the biological behavior of the tumor and is more aesthetically pleasing. Therefore, for suitable patients, preserving the skin and nipple is not a desirable treatment modality and can be received with good results.
2. Contralateral prophylactic mastectomy (CPM)
For breast cancer patients without family history or BRCA mutation, the possibility of contralateral breast malignancy decreases every year, therefore, the survival advantage of performing CPM is no longer obvious, and only young patients with triple negative breast cancer can benefit. Nevertheless, patients are more willing to perform CPM because of the increasing concern for breast symmetry and the poor aesthetics of unilateral mastectomy, which has led to the increasing rate of CPM.
3. Axillary surgery
Due to advances in radiology, the extent of axillary management after mastectomy is decreasing. The results of the Z0011 trial have dramatically changed the surgical management of the axilla, and patients in stage T1C2 N0 with breast-conserving surgery and radiotherapy may be managed without axillary lymph node dissection if only one or two invaded lymph nodes are found.
Previously, patients with invasive axillary lymph nodes required axillary lymph node dissection after chemotherapy, but now, for patients treated with targeted drugs, massive axillary lymph node dissection is not necessary.
Studies have shown that for breast cancer patients with invasive lymph nodes and surgery after chemotherapy, the false-negative rate in the anterior lymph nodes is 8C14%, and false-negatives can be reduced by taking multiple anterior lymph nodes, using dual tracers, using immunohistochemical techniques, and accurately removing the invaded lymph nodes. For breast cancer patients with invasive lymph nodes, the effect of neoadjuvant therapy can be evaluated by testing the sentinel lymph nodes.
4. Changes in the incision margin of breast-conserving surgery
Studies have shown that breast-conserving treatment and mastectomy have similar effects on the treatment of breast tumors, but the condition of the incision margin after breast-conserving surgery has received attention from scholars. Currently, there is a consensus that the incision margin at the unstained ink is safe for invasive tumors through multidisciplinary treatment.
Dr. Morrow suggested through his research that the biological subtype of the tumor affects its recurrence rate, but with systematic treatment and radiation therapy, recurrence can be effectively reduced, and there is no evidence that increasing the cut margin reduces the risk of tumor recurrence.
This consensus has reduced the reoperation rate and treatment cost, and is now widely used in clinical practice.
5.Gene testing
The population for genetic testing is now expanding to include patients with a suspected family history of breast or ovarian tumors, patients diagnosed with triple negative breast cancer before age 60, premenopausal (<50 years) breast cancer patients, and patients with a family history of more than three specific tumors (including pancreas, prostate, sarcoma, adrenal cortex, stomach, brain, endometrium, thyroid, and kidney). The range of genes tested is also expanding and goes beyond testing for BRCA1/2.
Genetic testing can contribute greatly not only to diagnostic treatment, but also to providing good counseling services to patients. Thereafter, clinicians will rely on large-scale gene pools and comprehensive family relationships to determine the significance of genes, and the role of genetic testing will continue to increase.
6. Summary
Breast surgery is based on breast-conserving treatment, mastectomy and axillary condition assessment, with a focus on more optimal and personalized treatment.
Next, clinicians need to apply their strength to the blade, continue to challenge the inherent thinking, and constantly update the level of understanding of tumor biology, targeted systemic therapy, and multidisciplinary personalized gene therapy to promote the development of breast surgery.