The conservative intervention brought to the attention of the scientific world by Professor Umberto Veronesi (quadrantectomy and removal of axillary lymph nodes) is today the most practiced surgical procedure for cancer diagnosed at an early stage.
However, breast surgery has continued to develop the concept of “conservation” not only of the udder but also of the axillary lymph nodes.
In fact, the removal of axillary lymph nodes is not always necessary, especially if the tumour is diagnosed early, but because of the important protective action of the lymph nodes it is advisable to avoid the removal of all axillary lymph nodes unless before surgery, there is a clinical evidence of disease in the axillary site.
For information on the condition of clinically healthy axillary lymph nodes, the “sentinel lymph node” technique is used.
It is well known that tumor cells that become detached from the tumour, following the lymphatic pathways, migrate to the armpit passing from one or more lymph nodes that are placed “to sentinel” of the lymphatic system of the region.
If sentinel lymph node analysis is negative, it is highly probable that all other lymph nodes in the axillary cord are healthy and therefore do not need to be removed.
Recent studies also show that it’s possible to avoid the removal of all axillary lymph nodes even in case of limited disease in the sentinel lymph node (micrometastasis) and in some cases, treated with conservative surgery (quadrantectomy), and only one or two sentinel metastatic lymph nodes.
In MultiMedica, the histological examination of the sentinel lymph node is performed intraoperatively by an experienced pathologist, thus allowing the surgeon to remove the other axillary lymph nodes in the same surgical session if necessary.
The patient receives a complete and adequate treatment during a single operation, avoiding both the stress of waiting for the response to the sentinel lymph node histology and the discomfort of a second operation.
It is possible to reconstruct an udder both after a quadrantectomy and after a mastectomy.
Even if the quadrantectomy is a conservative intervention and therefore less demolitive, the resulting aesthetic damage can be important and the plastic surgeon can intervene at the same time as the breast surgeon with mastoplasty techniques typical of aesthetic surgery.
In case of mastectomy, the aesthetic damage is greater because the udder is completely removed with a part of skin, areola and nipple. In this case, the indication to the type of reconstruction depends on various factors such as, for example, the amount of skin tissue present, the state of the pectoral muscle, the volume and shape of the udder to be reconstructed.
Reconstruction can be done at the same time as mastectomy (immediate reconstruction) or at a later time (deferred reconstruction).
In selected cases, it is possible to perform both operations (oncological and plastic surgery) in one single surgical session, in others two separate operations must be programmed.
Often, contralateral breast surgery (mastoplasty and mastoplasty) is also required to improve symmetry of both breasts;
through a final outpatient intervention it is possible to reconstruct the areola and nipple.
It is possible that the disease may reoccur after surgery at local, regional and/or remote level and this depends mainly on the biological behaviour and characteristics of the patient’s cancer. Precautionary medication therapy reduces the risk of reappearance by eliminating any residual cancer cells after surgery, blocking their proliferation and/or spread.
Precautionary care available includes hormonal treatments, chemotherapy, biological therapies or a combination of the three modes.
Anti-hormonal treatments block the stimulation of cancer cells by female hormones, estrogens and progesterone (produced naturally by the body), thus inhibiting the proliferation of tumor cells themselves.
Chemotherapy instead has the ability to destroy tumour cells as they multiply.
Moreover, in recent years, the discovery of new ways of multiplying by certain types of cancer cells has made it possible to produce new drugs that have a targeted action, affecting only a few specific targets on cancer cells, with a mechanism very similar to the action of the patient’s immune system. These drugs are therefore called biological therapies.
Every therapy can be accompanied by side effects that depend on the medication administered and individual tolerance: many disorders can be avoided or improved with specific therapies or preventive measures. These side effects are explained to patients before starting therapy and it is now often possible to choose between different types of treatment in a personalised way to minimize disorders.
The choice of the best precautionary treatment and its duration is based today on different information about the patient (age, possible concomitant diseases) but above all on the individual characteristics of each tumour and takes into account the patient’s preferences, in order to package a therapeutic program as much as possible targeted/adapted to the individual clinical case.
In selected cases, patients may be offered the opportunity to participate in international and national research protocols aimed at improving healing possibilities or quality of life.
The rehabilitation process represents, from the moment of diagnosis, an integral part of the assistance to women with breast disease: the purpose of taking early care of the patient is to promote and encourage the restoration of a “normality” relational life, through the recovery and maintenance of physical and psychological wellbeing.
The repercussions on the body of a breast surgery are varied, often unknown or underestimated:
Rehabilitative care has, among other things, the aim of making the patient aware of how any intervention that modifies body integrity can have an impact on the body pattern itself, producing changes in posture and perception.
Through appropriate rehabilitation therapy, it is possible to improve motor dynamics modified by the surgical procedure, prevent pain and muscular contractures, improve breathing and ensure a good pelvic floor layout, as well as intervene on lymphoedema and problems directly related to the insertion of prostheses.
To this end, in our centers, the collaboration between the various professional figures has produced a programme designed specifically for women with breast disease and capable of adapting to their needs and the needs that intervene during the rehabilitation process itself, offering, in particular, individual and group therapies aimed at functional recovery, where necessary, also metacognitive rehabilitation sessions (learning an adequate perception of their own body pattern).
Radiotherapy and partial udder irradiation:”IORT” and hypofractionated treatments
Radiotherapy, after conservative surgery, is indicated in most cases and aims to reduce the risk of reappearance of the disease in both the udder and lymph node drainage areas.
The current irradiation techniques, made possible by the progressive technological evolution and an increasing knowledge of the natural history of the disease, guarantee, with equal effectiveness, less toxicity compared to traditional treatments; more and more often, when allowed by the clinical characteristics, radiotherapy is conducted by trying to minimize the overall duration of the treatment through an intensification of irradiation (hyperfractional radiotherapy).
In addition to these modalities, which involve several weeks of treatment, Intra-operative or “IORT” (Intra-Operative Radiation Therapy) radiotherapy is also available.
This method makes it possible to administer radiotherapy only on the site where the tumour lesion was present during surgery, using a dedicated device located inside the MultiMedica operating room.
The IORT can be, in selected situations, the only irradiation mode for the patient (Partial Mammary Irradiation); alternatively, it represents a part of the “standard” treatment, reducing in any case the overall duration of the post-operative therapy.
The IORT and more generally modern techniques of radiotherapy treatment therefore allow, in appropriate clinical situations:
- a reduction in the time taken to perform post-operative radiotherapy and a better integration with any adjuvant chemotherapy.
- an improvement in the effectiveness of the association between surgery and radiotherapy resulting from radiobiological knowledge.
- a reduction in side effects compared to conventional radiotherapy for the udder and neighbouring organs.
Also for radiotherapy, the knowledge available today, especially in the biological field, on breast cancer allows to diversify the treatments in an increasingly individualized way, with a wide multidisciplinary value and the active and conscious participation of the patient.
Checks will be performed over time depending on the patient’s personal needs to ensure specific surveillance by selecting the most appropriate diagnostic methods.
The oncologist will therefore provide a therapy appropriate to the type of tumour which could be a hormonal therapy, chemotherapy or radiotherapy.
Within our facility, multi-specialist disease management ensures that you receive the right therapy at the right time.
If you are in any doubt, therefore, please contact our Breast Care Center: timeliness is the first step towards an effective therapeutic path.