In recent years, with the increasing understanding of the biological behavior of breast cancer, the comprehensive treatment model of breast-conserving surgery plus radiotherapy has gradually become a new approach for the treatment of early-stage breast cancer. Data from foreign multicenter randomized studies showed that the difference between breast-conserving surgery and radical surgery was not significant in either recurrence-free survival or overall survival rate [1-4]. In our hospital, we performed breast-conserving surgery and comprehensive treatment for 15 cases of early breast cancer from May 2003 to August 2005, and achieved better results, which are reported below. Jia Haiquan, Department of General Surgery, Anyang Cancer Hospital 1. Clinical data 1.1 General data The whole group of 15 cases of breast cancer, all patients were female, and all were clearly diagnosed by pathological biopsy. The patients’ ages ranged from 30 to 50 years old, with a median age of 38 years old. The patients all had the voluntary request for breast preservation, and had the financial ability for the full treatment (radical radiotherapy) and the condition to receive lifelong follow-up. According to the 1997 UICC
Fourteen cases received 6 cycles of postoperative CAF chemotherapy and radiotherapy, and one case received only postoperative radiotherapy. One case received only postoperative radiotherapy. 6 to 38 months of postoperative follow-up, with a mean follow-up of 26.3 months. 1.2 Surgical method and postoperative treatment (1) Breast incision design: instead of a radial incision in the breast, a small shuttle incision was made at the tumor site, and part of the skin was excised, with a free flap of about 2 cm, and the incision margin was more than 2 cm from the tumor edge, including the gland where the mass was located, the surface skin and the subglandular pectoralis major muscle fascia, and the enlarged excision or quadrant excision of the breast tissue. For complete excision of the tumor, the gland and subcutaneous tissues can be properly sutured and the skin can be sutured in the case of enlarged mastectomy. For quadrant resection, the gland is not sutured, and the surrounding fat tissue is appropriately freed to fill the wound cavity, and the skin is finally sutured. (2) Treatment of cutting edge: The cutting edge should be ≥2cm from the tumor edge. After the enlarged excision of breast tissue, sutures should be marked at the inner, outer, upper and lower edges of the cutting edge and nipple direction and sent to freezing, and the cancer of each cutting edge must be negative. If the margins are positive for cancer, an extended excision should be performed until the cancer is negative. A separate incision is made in the axilla, except in the upper outer quadrant, and the Rotter lymph nodes between the pectoral muscles and the upper, middle and lower groups of axillary lymph nodes are completely removed. Three days after surgery, chemotherapy was administered with the CAF regimen for a total of 6 courses. After chemotherapy, radiation therapy was administered, including 50 Gy to the whole breast and 10 Gy to the tumor bed. 50 Gy to the ipsilateral clavicular area was added for axillary lymph node metastases. 20 mg/d of triamcinolone acetonide was administered to hormone receptor (ER, PR) positive patients at the end of chemotherapy for 3 to 5 years. The satisfaction survey of preserved breast was performed one year after surgery. Whether the breast shape was satisfactory; whether there was bilateral symmetry; whether there was nipple deviation; whether the breast elasticity was good; and whether the upper limb function recovered well. Postoperative follow-up was strictly carried out, mainly for mammogram X-ray and B ultrasound, and radical surgery for residual breast cancer could be performed for early detection. The median follow-up time was 26.3 months. There was no local recurrence or distant metastasis in 15 cases during the follow-up period. Evaluation of the cosmetic effect of breast-conserving surgery: The evaluation conditions included (1) breast shape; (2) bilateral symmetry; (3) nipple deviation; (4) breast elasticity; and (5) upper limb function. The evaluation criteria were classified as: satisfactory, basic satisfactory and unsatisfactory according to the above comprehensive conditions. For the whole group of cases, breast appearance was satisfactory in 9 cases, basic satisfactory in 5 cases, and unsatisfactory in 1 case. In the whole group of 15 cases, there was one case of nipple displacement and one case of local stiffness of the breast due to severe postoperative fibrosis of the subcutaneous tissue. With the development of biological immunology research, it was recognized that breast cancer is a systemic disease. Fisher et al. proposed through a lot of clinical and basic research that breast cancer metastasis is not a purely anatomical pattern from local to regional lymph nodes and then into the blood, but there is a phenomenon of jumping metastasis of breast malignant tumors, and blood flow diffusion is more important. This understanding has become the theoretical basis for breast-conserving surgery for breast cancer. The purpose of breast-conserving treatment is to (1)
(2) the postoperative recurrence rate is similar to that of mastectomy; (3) the preserved breast has certain cosmetic effects; (4) compared with radical surgery, breast-conserving surgery for breast cancer has a survival rate no less than radical surgery, significantly fewer complications, and significantly better function than radical surgery; (5) cosmetic and social mentality and family emotions are better than radical surgery; (6) patients, families and relatives are happy to accept this mode of treatment. (6) Patients, families and friends are willing to accept this treatment modality. The advantages of breast-conserving surgery include: (1) breast-conserving surgery for early-stage breast cancer is similar to radical surgery in terms of efficacy and survival rate; (2) breast-conserving surgery can preserve the shape of the breast, and the activity of the upper limbs is basically unrestricted after surgery, which improves the quality of life; (3) the operation time is short, the trauma is small, and the recovery is fast; (4) there are few postoperative complications, no skin necrosis or skin grafting, etc. Indications and contraindications of breast-conserving surgery: Breast-conserving surgery has no special restrictions on the pathological type of breast cancer. Although younger patients have a higher rate of postoperative local recurrence, age and axillary lymph node status, positive family history [5], etc. are no longer considered contraindications to breast-conserving surgery. Indications for breast-conserving surgery: (1) breast to mass ratio is appropriate, and breast shape can be well maintained after removal of the mass; (2) non-central tumor (>2 cm from the edge of the areola) far from the nipple and areola; (3) axillary lymph node metastasis N0 to N1; (4) mammogram and ultrasound confirm a single lesion; (5) patients with breast-conserving requirements and who can adhere to postoperative radiotherapy and follow-up. Absolute contraindications to breast-conserving surgery: (1) multiple lesions confirmed by mammography and ultrasound; (2) pre-pregnancy, breast cancer within 3 months; (3) breast cancer during lactation; (4) positive specimen margins, unable to reach negativity after extended resection; (5) collagen vascular disease; (6) patients who have received previous radiation therapy. Relative contraindications include large tumors with unclear borders, poor location (located in the center of the breast, <2 cm from the areola edge), difficult to guarantee the cut edge and poor cosmetic results after wide excision of the mass. The main cause of death from breast cancer is distant metastasis, and it has long been a consensus that breast cancer is a systemic disease. A number of evidence-based medical data show that breast-conserving surgery is not significantly different from total mastectomy in terms of disease-free survival or overall survival, except for a slightly higher rate of local recurrence [1-4]. Breast-conserving surgery for early-stage breast cancer can achieve similar therapeutic effects as radical surgery, and is an effective treatment alternative to radical surgery, and can obtain better cosmetic results, which not only reduces patients' psychological pressure but also improves their quality of life. Therefore, breast-conserving surgery for early-stage breast cancer will definitely become the preferred treatment method for early-stage breast cancer.