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[Local Medical]New technology to preserve the appearance of the breast and remove the tumor combined with intraoperative radiotherapy

[Local Medical]New technology to preserve the appearance of the breast and remove the tumor combined with intraoperative radiotherapy

Text: Chen Qiulei Compiled by: Liang Yingxiu

(Kuala Lumpur News) Breast cancer is a malignant tumor that occurs in breast tissue. Cancer cells originate from breast ducts or lobules and spread within breast tissue or organs. In severe cases, they may even metastasize to other parts of the body.

Clinically, breast cancer can be divided into Ductal Carcinoma In Situ (DCIS); Stage I, the mass is less than 2 cm; Stage II, the mass is between 2 and 5 cm; Stage III, the mass is greater than 5 cm; Stage IV , metastatic breast cancer, in which cancer cells have spread to other parts of the body.

Breast cancer is one of the most common cancers in women. However, with the advancement of medical technology, the treatment methods of breast cancer have been greatly improved.

Traditional treatment procedures surgery first

Dr Saladina Jaszle, consultant breast and endocrine surgeon, pointed out that generally, there are five main standard treatments for breast cancer, namely surgery, radiotherapy, hormonal therapy, chemotherapy and targeted therapy. In the past, traditional treatment procedures generally started with surgery, followed by chemotherapy, radiotherapy or hormonal therapy. However, with the advancement of medical technology today, as long as certain conditions are met, most patients tend to undergo chemotherapy and targeted therapy first. Just performed surgery.

“In surgery, there are two main types, namely mastectomy and lumpectomy, or breast-conserving surgery. In a mastectomy, the doctor removes the patient’s entire breast, including The skin above the nipple and tumor. This treatment method can be performed immediately at the same time as breast reconstruction surgery, and is suitable for patients with multifocal breast cancer. The treatment effect is safe and beautiful.”

She said that when performing a mastectomy, in order to ensure the health of the breast skin, minimize intraoperative blood loss, and ensure the safety of the patient, the surgeon only removes a layer of subcutaneous tissue as thin as a tissue between the cortex and the fat layer. Surgery on the avascular surface does not remove 100% of the breast tissue (about 98 or 99% of the tissue is removed), so there is still a recurrence rate of 3 to 6%. No radiation therapy is required after this surgery unless the cancer has spread to the lymph glands.

“Modern women pay attention to appearance, and I usually recommend that patients undergoing mastectomy surgery use implants or tissue from other parts of the body, such as the Latissimus Dorsi Flap (LD Flap), rectus abdominis muscle, etc. Transverse rectus abdominis myocutaneous (TRAM Flap) breast reconstruction surgery allows patients to reshape complete breasts and regain their beauty and confidence.”

“The best time for breast reconstruction is after surgery (immediate reconstruction), or after completion of other auxiliary treatments and recovery (delayed reconstruction).”

Breast reconstruction not recommended for smokers

She said that in some cases, such as those who are in poor physical condition, suffer from other diseases such as kidney disease, heart disease, diabetes, etc.; or are smokers and like to drink, breast reconstruction surgery is not recommended because of its The implanted tissue is affected by the above-mentioned adverse factors, which will greatly reduce the chance of tissue survival and is not conducive to the postoperative curative effect. On the contrary, even if the patient is over 70 years old, but is in good health, as long as the patient is willing to , the operation should be performed.

She said that some patients with early-stage disease can undergo lumpectomy surgery, which is also called wide local excision surgery.

This surgery removes the tumor in the breast and about 1 centimeter of surrounding tissue from the outer edge of the tumor. Compared with the earlier “cut as much as possible” (the incision distance is 2 cm), this method is more conducive to reducing scars.

This surgery is often performed at the same time as sentinel lymph node biopsy (Sentinel Lymph Node Biopsy, SLNB) or axillary lymph node dissection (Axillary lymph node dissection). After the surgery, the wound is healed and then 3 weeks of radiotherapy are performed to remove occult tumors in the breast. and reduce the chance of recurrence.

“In some cases, such as younger patients, tumors larger than 2 centimeters, triple-negative breast cancer, and HER2+ breast cancer, chemotherapy is required first and then radiotherapy. Older patients can also undergo chemotherapy if their health conditions permit.”

She emphasized that surgery and radiotherapy are a “matching package” for the treatment of breast cancer. If surgery alone is used, the recurrence rate is as high as 30%. If combined with radiotherapy, the recurrence rate drops to 15%. With the current new medical technology, the recurrence rate is only 8%. This is quite close to the 3 to 6% recurrence rate for mastectomy surgery.

As mentioned previously, the standard surgical treatment procedures are lumpectomy and radiation therapy. The standard radiotherapy procedure is 15 times plus 5 booster doses, which takes about 3 weeks. If necessary, chemotherapy may be added before radiotherapy. However, more than 10 years ago, intraoperative radiotherapy (IORT) was introduced in the medical field, allowing patients to save time and avoid the hardship of traveling.

Reduce radiation reaction and reduce recurrence rate

She pointed out that IORT is a new technology of radiotherapy. The tumor is first removed during surgery, and then radiotherapy is immediately carried out around the tumor cavity to kill the remaining cancer cells. The treatment only needs one time, allowing surgery and radiotherapy to be completed at one time. , significantly reducing the radiation response and dose to surrounding normal tissues such as the heart and lungs, while retaining a more beautiful appearance of the breast.

In short, patients can undergo IORT directly after surgery, eliminating the need for postoperative radiotherapy. IORT must meet specific conditions. It is mainly suitable for low-risk patients, whose tumors are no larger than 3 cm, who are older than 45 years old, that is, hormone receptor-positive, HER2- breast cancer patients, and more ideally, those with negative lymph nodes.

When IORT is performed under the above conditions, the risk of recurrence is low. It is worth mentioning that for eligible patients, IORT treatment has the same efficacy as a 3-week course of radiotherapy.

“In addition, if the patient is 35 years old and has a tumor larger than 3 cm, which makes him a high-risk group, he must undergo another 3 weeks of radiotherapy after IORT. IORT replaces 5 boosters in radiotherapy.”

Breast cancer gene expression patterns are mainly divided into three types. The first type is hormone receptor positive (HR+), that is, estrogen receptor positive (ER+) or progesterone receptor positive (PR+); the second type is human epidermal growth factor receptor Positive (HER2+); triple negative breast cancer tested for all 3 receptors.

Before treating patients, Sharadi said that it is necessary to distinguish the types of breast cancer and clarify the gene cell expression morphology, the pathological characteristics of the tumor, the size of the tumor, and the metastasis of lymph glands in order to prescribe the right medicine.

Other factors are also important considerations in formulating a treatment plan, including age, breast size, and physical condition. These factors will affect treatment planning and prognosis.

Consultant Breast and Endocrine Surgery:
Dr Saladina Jaszle

Remove less than 30% of breast tissue

In addition to considering the patient’s own health condition, what are the conditions for breast lumpectomy?

During lumpectomy surgery,

No more than 30% of the breast tissue should be removed,

Some doctors are even more strict,

Its requirement is 20 to 25% lower.

The maximum limit of her principle is 30%.

Otherwise it will affect the postoperative effect.

In addition to the unsatisfactory appearance, it will also bring unnecessary trouble to subsequent re-examinations.

Then there is no point in doing this surgery.

“Take a patient with an A-cup breast and a 5-centimeter tumor as an example. More than 50% of the tissue needs to be removed, and the appearance of the breast is affected. She can choose to undergo mini-breast reconstruction, but calcification may occur thereafter. , This will cause unnecessary trouble in subsequent review and supervision. I think it is not appropriate to perform lumpectomy surgery in situations like this, and neoadjuvant chemotherapy should be considered to shrink the tumor.”

She said that in another example, the patient was also an A cup and the tumor was 3.5 centimeters. Based on the criterion of removing the tumor and about 1 centimeter of surrounding tissue from the outer edge of the tumor, that means the range of removal was 5.5 centimeters, which is almost half. of breast tissue. The doctor may recommend that the patient undergo 6 rounds of chemotherapy first to shrink the tumor to 1 to 1.5 cm, at which point breast-conserving surgery can be performed. This is neo-adjuvant chemotherapy (neo-adjuvant chemotherapy) that has become popular in the past 10 years.

“The advantages of this new concept treatment method are that, firstly, it can shrink the tumor before surgery and reduce the circumference of the tissue to be removed; secondly, after chemotherapy, we can directly understand the efficacy of the chemotherapy drugs used on the patient.”

Traditional surgery leaves obvious scars

On the other hand, in terms of current technology, surgical models have improved, and the shift to oncoplastic breast conserving surgery began as early as 10 years ago. This surgical model includes breast cancer removal (onco-) and breast plastic surgery (plastic surgery). By using advanced local technology, we can achieve curative effect while also reducing the deformation of breast appearance, which brings good news to patients.

She said that in the past, when performing lumpectomy surgery, the traditional method was to make an incision directly on the lesion, remove the tumor and then sew, leaving a linear scar there after the operation, which affected the appearance of the breast.

However, with plastic breast-conserving surgery, the surgeon makes an incision from around the areola, lifts up the outer layer of skin, and then performs the tumor removal procedure. Postoperative scars are limited to the areola. This is her more commonly used periareolar mammoplasty or round block technique. For patients with C-cup tumors located on the surface, this technique is more suitable; for patients with large tumors and close to muscles, traditional resection techniques are suitable.

Central resection is suitable for patients with small tumors

“Another breast-conserving surgery, central lumpectomy, mostly uses the Grisotti flap technique. That is to say, the cancer cells are located under the nipple. After the tumor is removed, it moves back to the local area. Or the lower half of the breast can make up for the removed defect. This method is suitable for patients with small tumors and large breasts.”

She suggested that patients with the same lesions and cup A or B breasts could undergo skin-sparing mastectomy and immediate latissimus dorsi flap breast reconstruction surgery.

In addition to the techniques mentioned above, there are other options for plastic breast preservation surgery, such as batwing mastopexy lumpectomy, reduction mastopexy lumpectomy or J-plasty, etc.

Analyze the pros, cons and efficacy and determine the order of surgery according to the condition

When a patient comes for treatment, as a doctor, Sharadi feels it is his responsibility to give her the most detailed explanation.

She will begin with an initial consultation and breast examination, followed by appropriate breast imaging (mammography and ultrasound) to analyze the size and stage of the tumor.

Once a core needle biopsy of a breast mass is performed and cancer is diagnosed, doctors will perform a computed tomography (CT) scan to evaluate the patient’s breast cancer stage. It is necessary to obtain all necessary information through the biopsy results.

Don’t trust alternative therapies

Sharady said she will be honest about all treatment options, their pros and cons, and work out a treatment plan that’s best for them. “During this entire discussion, I will decide the order of chemotherapy and surgery based on the patient’s condition, and analyze the applicability, advantages, disadvantages, and efficacy of the relevant surgeries one by one.”

Many patients readily accept the doctor’s advice and receive treatment; however, some patients use inappropriate alternative therapies. She will try her best to persuade them, saying that these alternative therapies have no clinical medical proof and are ineffective in treating the disease, but they still choose these therapies. . The condition was upgraded from stage I to stage II and III due to repeated delays.

Cancer cells develop very quickly. She advises everyone if they are diagnosed with cancer not to take the risk of believing in alternative treatments that have no medical basis. Please seek medical treatment as soon as possible. The sooner you start corresponding treatment, the higher the chance of controlling the condition and improving it. The longer it is delayed, the longer the treatment process will take once it worsens, and it will be more difficult to improve the condition.

Stage IV cancer is not the end of the world

With the advancement of medicine, even if cancer has reached stage IV, it is not the end of the world. As long as an appropriate treatment plan is given and the patient follows the doctor’s instructions, changes his lifestyle, gets rid of bad habits, and maintains a healthy lifestyle and diet, he can live as long as 10 years.

“For some patients who are not suitable for lumpectomy surgery, please do not feel discouraged. As mentioned above, we can perform chemotherapy first to shrink the tumor before surgery; otherwise, we can choose mastectomy surgery combined with breast reconstruction surgery.”

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