Disclosures about surgery

Patients with breast cancer who must undergo breast surgery are now already eligible for breast-conserving surgery with a chance of at least 2 in 3. A complete amputation is still necessary if, for example, the tumor in the breast is widely spread, or the volume to be removed is quite large in relation to the total breast volume. "We can already remove up to a fourth of the breast with still an aesthetically acceptable result," says Jan Lamote. "We owe this mainly to the development over the past 15 years of oncoplasty: the combination of oncological and plastic surgery techniques, which allows us to better preserve the anatomical shape of the breast during breast-conserving surgery. But fortunately, the volumes to be removed are also getting smaller and smaller. We can better visualize, localize and demarcate tumors, as well as destroy remaining tumor cells more effectively with radiotherapy. Moreover, we can reduce the size of many tumors with chemotherapy even before the operation.

Breast cancer surgery: doomed ?

Especially aggressive tumors often shrink significantly with preoperative chemo. Sometimes they even appear to have completely disappeared on imaging. Nevertheless, breast surgery is then still performed to cut away some mammary gland tissue around the clip used to mark the tumor before chemo. Because only microscopic examination can tell whether the tumor is completely gone. "Of course, we would prefer to be able to verify that without cutting. Like through biopsies or 'punctures' in the region of that clip. Only, how many of those do you have to do to miss - with high certainty - no tumor cells? A study by The University of Texas MD Anderson Cancer Center will determine whether 12 such biopsies are sufficient."
At the same time, this study, the results of which are expected by 2028, will also shed light on another point of improvement. Today, during breast surgery, it is standard practice to check which lymph nodes drain lymph fluid from the tumor first. These "sentinel nodes" - 1 to a few per breast - are removed for microscopic examination. If tumor cells are found in up to 2 sentinel nodes, the other axillary nodes are left alone. Radiotherapy is then just as effective and has a significantly lower risk of side effects, such as lymphedema or 'a fat arm' (see also book*).

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So the decision whether or not to do a complete axillary gland excision falls only at the time of breast surgery. "Unless during the breast cancer diagnosis suspicious axillary glands are already noticed, prodded, and found to be affected after microscopic examination," says Jan Lamote. "Then we decide - at that point already - to do a complete axillary gland excision later, during breast surgery, anyway. So without waiting for the effect of the preoperative chemo. In contrast, in that American study, they mark the glands that are already affected at diagnosis. And when later, during breast surgery, it then turns out that only sentinel glands are marked, one can use the sentinel gland procedure to check whether a complete axillary gland excision is still necessary! In the best case, the patient retains not only the entire breast, but also all the axillary glands except the sentinel glands. All these new developments will allow us to fight breast cancer more and more effectively and with less cutting."

Reconstruction with prosthesis or own tissue

So hopeful news, but for now most breast cancer patients undergo breast surgery. About a fifth of them opt for breast reconstruction. Choosing reconstruction - again a surgical procedure - is obviously not a light decision and requires a good informative conversation about the options. And this even before the oncological surgery, because the reconstruction can sometimes take place simultaneously. Jan Lamote: "In about half of the reconstructions the classical reconstruction with a prosthesis, in the cavity behind the pectoral muscle, is still chosen. Usually a temporary 'expander prosthesis', which is regularly topped up with fluid, is placed first in order to gradually stretch the pectoral muscle and skin. Several months later, when radiotherapy is also over, the definitive prosthesis, filled with silicone or physiological water, then follows. But gradually more patients have begun to opt for reconstruction with their own tissue. This involves excising skin, fatty tissue and a few blood vessels from a donor site - usually the lower abdomen.

To then place the "free flap" on the chest wall and reconnect the blood vessels to blood vessels of the breast. It is quite possible that we may even evolve to a reconstruction technique in which stem cells from one's own fat are injected into the operated breast. And doing so together with a supporting structure, which helps them survive and stimulates them to become fat cells, grow and divide." Reconstruction with one's own tissue easily takes several hours and is surgically much more complex than this one with a prosthesis. "The reimbursed fee has since been adjusted accordingly," Jan Lamote says. "But as always, it is wise to ask for a price estimate for the procedure and your own contribution as a patient."

Weighing and weighing

In order to make a well-considered choice for one of the reconstruction techniques - if both are an option - one must of course also be aware of the possible complications. "How often these occur is not easy to express in a few figures, because they are related to the technique as well as to personal factors," notes Jan Lamote. "Talk to your plastic surgeon about this, but in general we can give you this. A prosthesis is foreign material, which increases the risk of infection and fluid accumulation just after the procedure. Sooner or later the scar tissue around the prosthesis will thicken, harden and contract to a greater or lesser extent, which can cause deformations and pain. Wear and tear can also cause the prosthesis to leak or tear, and after about 7 to 10 years it must be replaced anyway. A reconstruction with your own tissue feels and looks more natural and lasts a lifetime, but you have to recover longer from the procedure and add scars at the donor site. Just after the procedure, there is more risk of thrombosis, especially where blood vessels were connected. In rare cases, the blood supply then cannot be restored and the transplanted tissue is lost."

Preventive amputation

For now, breast surgery and reconstruction remain procedures that are not free of complications. "We therefore consider preventive amputation - of both breasts or of the healthy breast after breast cancer in the other breast - only in women with an increased breast cancer risk," Jan Lamote concludes. "Such as in women who are carriers of an abnormality in the BRCA1 or BRCA2 gene, or who are not carriers but have a high familial risk."

Written by An Swerts