Description
Contemporary breast surgery has evolved significantly with the integration of sentinel lymph node biopsy (SLNB) and oncoplastic techniques, enabling effective cancer control while preserving breast aesthetics and function. Sentinel node mapping has largely replaced routine axillary lymph node dissection in early breast cancer, reducing surgical morbidity such as lymphedema and shoulder dysfunction. At the same time, oncoplastic surgery combines oncologic resection with plastic surgical principles, allowing wider tumor excision without compromising cosmetic outcomes. This shift reflects a broader philosophy in modern breast cancer care—achieving oncological safety while prioritizing quality of life and body image for patients. Together, these approaches represent a major step toward more personalized and less invasive breast cancer surgery.
Summary Listen
- Breast cancer is a significant health concern in India, with a notable difference in patient demographics compared to the Western world, as nearly half of the cases occur in women under 40. Diagnosis in India relies on a combination of clinical examination, mammography, sonography (often integrated), and core needle biopsy, which has replaced cytology due to its improved reliability.
- Core needle biopsy is the standard of care because it is reliable, reviewable, and allows for disease grading and additional immunohistochemical tests like estrogen receptor, progesterone receptor, HER2 receptor, and Ki-67. For small, suspicious lesions detected during follow-up, wire-guided excision or vacuum-assisted biopsy are employed when core needle biopsy is not feasible or yields negative results.
- Surgical management of breast cancer involves addressing both the primary tumor and the axillary lymph nodes, which are critical for determining prognosis and guiding adjuvant treatment. Axillary lymph node dissection (ALND), while essential for staging, carries significant morbidity risks, including lymphedema, shoulder dysfunction, and sensory loss.
- Sentinel lymph node biopsy (SLNB) has emerged as a less invasive alternative to ALND in clinically node-negative patients. It involves identifying and removing the first lymph node(s) draining the breast, allowing for accurate assessment of axillary metastasis with reduced morbidity. Negative SLNB results often eliminate the need for further axillary surgery.
- SLNB is performed by injecting dye (radioactive technetium 99, methylene blue, or indocyanine green) into the breast's lymphatic channels, allowing surgeons to locate and remove the sentinel lymph node(s) for pathological examination. Indocyanine green, which glows in an infrared light, requires a special camera for visualization during the procedure.
- Breast cancer treatment has evolved to recognize distinct subtypes (hormone receptor-positive, HER2-positive, and triple-negative), each requiring tailored therapeutic approaches. While historically, a fixed sequence of surgery, chemotherapy, and hormone therapy was standard, modern treatment often involves neoadjuvant chemotherapy to shrink tumors and improve breast conservation rates.
- Modified radical mastectomy, involving removal of the breast and axillary contents, remains a standard surgical approach. However, breast-conserving surgery (lumpectomy) followed by radiation therapy offers comparable survival outcomes. Oncoplasty, combining oncological surgery with plastic surgery techniques, aims to improve cosmetic outcomes in breast-conserving procedures.
- Oncoplasty allows for larger excisions with better margins while preserving breast shape and size. It involves various techniques, including volume displacement, local flaps, and contralateral breast surgery, to achieve optimal cosmetic results. In cases requiring mastectomy, breast reconstruction with saline/silicone implants or microvascular flaps (e.g., DIEP flap) can restore breast volume and shape.
- For patients undergoing axillary lymph node dissection, lymphaticovenular anastomosis (LVA) is a promising technique to reduce the risk of lymphedema. LVA involves connecting lymphatic vessels to veins to improve lymphatic drainage and minimize fluid accumulation in the arm. Overall, advancements in surgical techniques and adjuvant therapies have significantly improved survival, function, and cosmesis for breast cancer patients.
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About the Speakers
Dr. Tarang Patel
Senior Consultant, Breast and Cancer Surgeon, EPIC Multispeciality Hospital, Ahmedabad
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