Dr. Tsvetan Popov, MD
Clinical case
We present the case of a 46-year-old woman with histologically proven Luminal type B HER2-overexpressing invasive ductal carcinoma of the left breast. Local excision of the approximately 3 cm (cT2 cNx) tumor was performed five months ago at another institution, followed by systemic drug therapy.
On the basis of aggressive tumor biology, history and relatively young age, the patient was considered high risk. An informed decision was made to pursue an oncoplastic approach by performing a bilateral (bilateral) subcutaneous mastectomy with preservation of the areola-mammary complex, with a one-stage breast reconstruction (with implant) and mastopexy (lift) (Images A and B). In the absence of clinical and imaging evidence of enlarged and metastatic axillary lymph nodes, a sentinel lymph node biopsy (SLNB) was performed in the left axilla for staging. An indocyanine green dye method was applied for fluorescence imaging and identification of the sentinel lymph node.
Results
- Absence of tumor infiltration into the surgical margins (oncologic radical surgery)
- Absence of metastases in the sentinel lymph node
- Smooth postoperative period without complications
- Good cosmetic result (Image C)
- High levels of quality of life at follow-up
- Patient satisfaction
What is the oncoplastic approach to breast cancer (BC)?
- Improved prognosis in patients with CG also places emphasis on the cosmetic aspect of surgical treatment
- Oncoplastic surgery (OS) is a modern philosophy in the surgical treatment of CG, combining the principles of surgical oncology with those of plastic reconstructive surgery
- A number of studies have reported lower rates of positive resection lines (tumor infiltration into the surgical margin) and local recurrence after subcutaneous mastectomy compared with other techniques
- OPH incorporates two basic principles of breast remodeling: 1) tissue/volume displacement - mobilizing adjacent tissue flaps, and 2) tissue/volume replacement - using implants or autologous (own) tissue distant from the breast
- Reported higher levels of quality of life (reduced psychological distress from surgical treatment, improved functional, oncological and aesthetic outcomes) compared to standard approaches
General recommendations and critical remarks
- Performing a colon biopsy („gold standard“) in high-risk breast tumors with priority over excisional biopsy - an opportunity for individualized therapeutic approach and improved prognosis
- Performance of BSLV in certain indications - a well-established and minimally invasive surgical approach for axillary staging, associated with improved quality of life and reduced incidence of postoperative complications compared to standard axillary lymph node dissection
- An individualized approach and the selection of the optimal surgical technique are critical to improving clinical and aesthetic outcomes in breast cancer
Images: A - preoperatively; В - 1st postoperative day (POD); С - 7th SOD; Д - Sentinel lymph node.