New advances in the surgical treatment of breast cancer

Latissimus dorsi mini-flap: a technique for extending breast conservation

The latissimus dorsi (LD) flap was first used in patients for breast reconstruction in 1896. More recently it has been used to fill defects after quadrantectomy or very wide excision. We have developed a two stage procedure for excision of large breast cancers which would otherwise require mastectomy. The first stage is a wide excision of the cancer without removal of the overlying skin. Thirty patients with large localized operable breast cancer underwent wide local excision followed 5 to 10 days later in 25 patients who had clear histological margins by an axillary dissection with transfer of the LD muscle and overlying fat into the defect in the breast (mini-flap). The cosmetic outcome of these 25 patients who underwent mini-flap were compared with age matched patients having a standard wide local excision and axillary node clearance or mastectomy and immediate breast reconstruction. The volume of tissue excised in patients having their defects filled by LD mini-flap was significantly greater than those women undergoing standard wide excision, p<0.001. Compared with patients who had a mastectomy and immediate breast reconstruction, patients who had mini-flaps reported a better treated breast shape, p=0.04, a greater resemblance to the opposite breast, less self consciousness and less change in attitude of their spouse, p=0.03 and they were more likely to choose the same operation in future compared with patients having immediate whole breast reconstruction, p=0.02. Results as rated by patients in the mini-flap group were similar to those women treated by standard wide local excision. Only one patient in the mini-flap group felt sexually inhibited. When wide local excision and LD mini-flap is performed as a two stage procedure, it is an oncologically safe technique and extends breast conservation to women with larger tumours. The cosmetic outcomes appear better than those following the alternative of mastectomy and immediate breast reconstruction.

Axillary surgery in breast cancer management--background, incidence and extent of nodal spread, extent of surgery and accurate axillary staging, surgical procedures

The prime objectives of axillary surgery in the management of breast cancer are 1) accurate staging, 2) treatment to cure and 3) quantitative information of metastatic lymph nodes for prognostic purposes and allocation to adjuvant protocols. It is generally agreed that axillary node status in potentially curable breast cancer is considered the single best predictor of outcome and the main determinant of allocation to adjuvant therapy. No physical examination, no imaging techniques, and no molecular biologic markers can today replace axillary surgery for staging purposes. The objectives of axillary surgery are best obtained by carrying out a complete axillary clearance. Nonetheless, less radical surgery is generally performed by carrying out a sampling procedure with a yield of about 4 nodes or a partial axillary dissection level I-II with at least 10 nodes recovered. Understaging the axilla is detrimental to outcome and, furthermore, locoregional tumor control is important for survival. Axillary surgery should therefore be conducted in accordance with high professional standards.

Recent trends in breast reconstruction

The rising popularity of breast reconstruction is closely linked to patient expectation, improved techniques and a better understanding of the risks and benefits of reconstructive procedures. Innovative new approaches can conceal the scars of mastectomy and extend the role of breast-conserving surgery, leading to improved outcomes.

The axilla: to clear or not to clear? That is the question!

The prime objectives for axillary dissection are staging and treatment to cure. No physical examination, no imaging techniques, and no tumor markers can replace axillary dissection for staging. Further, axillary node status in potentially curable breast carcinomas is still considered the single best predictor of outcome and the primary determinant of the use of systemic therapy. Finally, locoregional tumor control seems to improve survival, emphasizing meticulous axillary dissection. Today, the question to be asked is not whether or not to clear the axilla; rather, the question should go: How do we distinguish node-negative patients from those who are node-positive without clearing the axilla unnecessarily? No surgeon would advocate dissecting the axilla in node-negative patients if nodal status could be ascertained by a different technique. Ongoing trials addressing the reliability of the sentinel node technique seem promising, and this technique may perhaps in the near future solve the problem of distinguishing node-negative patients from those with axillary spread. For the time being, the necessity of determining axillary status and to treat for cure can hardly be questioned. Therefore, once axillary spread has been demonstrated in one way or another, an adequate and meticulous axillary dissection should be performed.