The breast is an organ consisting of adipose and glandular tissue (mammary gland). It is one of the two prominences found on the anterior thoracic wall and is a feature specific to mammals. Its role is vital during lactation as it produces and secretes milk while being a symbol of femininity and motherhood. Early diagnosis and prevention of breast conditions help reducing morbidity and mortality. Breast surgery should ensure optimal oncologic results and the best possible esthetic results (oncoplastic surgery).
There are numerous benign breast conditions. In any case, potential malignancies should be excluded since symptoms are similar. As a result, a benign lesion may appear as a palpable mass, pain, nipple secretion, galactorrhea, inflammation, etc.
Fibrocystic lesions form a wide spectrum of lesions of benign biological behavior. Such lesions are due to fibrosis, cystic lesions, papillomatosis, sclerosing adenosis, atypical hyperplasia of the ducts, etc. However, in the case of concurrent cellular atypia (as in the case of atypical proliferative disease of the ducts) there is higher relative risk to develop malignancy.
Other benign conditions are ductal carcinoma, ductal ectasia, cysts, abscesses, hematoma, cystic liponecrosis, gynecomastia in men, gigantomastia, inflammations (mastitis, abscesses, fistulas, and Mondor disease – superficial thrombophlebitis) and benign conditions (fibroadenoma, phyllodes tumor, hamartoma, hemangioma, lipoma).
Fibroadenoma is the most frequent benign tumor of the breast. It often affects young women consulting breast specialists. It is solitary most of the times; however, it can be multiple occurring in one or in both breasts. Fibroadenoma is a benign condition which is not considered a predisposing factor for malignancy. However, very rarely malignancy has been reported to occur in the circumference of a fibroadenoma while more rare tumors appear in medical imaging to be similar to fibroadenomas but demonstrate a malignant behavior (e.g. phyllodes cysteosarcoma). It is therefore recommended to surgically remove it in cases of women over 25 or if it is rapidly growing and increasing in size within healthy margins.
Malignant breast tumors are mainly carcinomas while tumors of mesenchymatic origin are usually less frequent.
Breast cancer is the most common malignant tumor in female population and is the second cause of death from cancer. Early menarche, late menopause, childlessness, age of first pregnancy >35 years, positive family history, history of cancer on the other breast, environmental factors (eating habits, obesity, alcohol consumption, radiation).
Diagnosing cancer is of utmost importance, since its early diagnosis and management is truly a life saver. It is made after considering the medical history, the clinical examination, the mammogram and the other medical imaging methods (ultrasonography, digital mammogram, magnetic mammogram), puncture-cytological examination (FNA) and the harvesting of a specimen for histologic examination using core biopsy. A series of other diagnostic examinations contribute to the staging (complete blood count, biochemistry, CA15-3 cancer indices, chest X-rays or CT scan, bone scintigraphy, liver ultrasound). Staging takes place using the TNM system (T-tumor, N-nodes, M-metastasis).
It is recommended for all women for early diagnosis:
- Reference mammogram at 35 years;
- Self-examination once a month;
- Mammogram once a year after 40 years of age (ultrasound in case of dense breasts);
- Clinical examination by an expert surgeon once a year after 40 years of age;
There are numerous histologic types of cancer. By general rule, there are two main histologic types, depending on the origin of malignant cells, ductal and lobular cancer. Depending on the presence of infiltration or not, there is the infiltrative and non-infiltrative cancer (in-situ). Infiltrative ductal carcinoma is the most common type. The expression or not of specific estrogen or progesterone receptors are significant predisposing factors and are taken into account to select the most adequate treatment. Specific microscopic morphology characteristics result in the characterization of various forms of cancer as inflammatory, metaplastic, adenoid cystic, papillary, tubular, mucous, comedo, medullar, Paget’s disease of the nipple, etc. Tumors of mesenchymal origin (sarcomas), lymphomas, melanomas, etc. are rare forms of cancer.
Cancer should be treated surgically most of the time. Radiotherapy, chemotherapy and hormonal treatment have a complementary role to play.
It is should be mentioned that various techniques have been developed to treat small non-palpable lesions of the breast. These aim at the identification, the stereotactic definition and removal (with a wire guide) using a vacuum-assisted breast biopsy-mammotome or transdermal removal – tumor necrosis Radiofrequency ablation, Laser, Cryosurgery).
Surgical interventions are distinguished into simple biopsy, wide local resection, quadrantectomy, partial mastectomy, simple (radical) mastectomy, extended radical mastectomy, modified radical mastectomy, skin-sparing mastectomy, subcutaneous mastectomy. Surgical procedures on the breast are combined with lymph node curettage of the ipsilateral axilla. The indications and the selection of the most adequate procedure are subject to strictly defined protocols based on many factors including the tumor size, the size of the breast, the location of the tumor in relation to the nipple, the imaging findings, the rest of the medical history, the patient’s wishes, etc. Surgeons should be well-experienced and the patient fully informed of the advantages and disadvantages or the potential complications of each procedure.
In eligible cases of small size tumors (T1, T2) it is possible to perform conservative surgery (wide local resection or quadrantectomy) to achieve good esthetic results. In such cases, treatment may be combined with radiotherapy and axillary curettage.
In order to improve the esthetic result, the surgeon should perform incisions along the Langer’s lines, sparing the underlying tissues and mammary gland structures. Oncoplastic breast surgery consists of techniques aiming at achieving the best cosmetic results. Reconstructive surgery is also possible in collaboration with a plastic surgeon. It consists of the placement of special silicone implants, the use of tissue dilator or the creation of flaps for cosmetic restoration. The restoration surgery can be performed concurrently or at a later time (delayed) when best results are usually achieved, after potential chemotherapy and radiotherapy have taken place and the wound is better healed. Breast surgery should aim at the best oncologic and aesthetic result possible, to improve patient survival and psychological state as well as their quality of life.