The plastic surgeon provides reconstructive services in oncology. Surgeries for breast cancer or melanoma are often jointly teamed with oncologists during surgery. Both surgeons can simultaneously work during surgical mastectomy; carrying out an immediate reconstruction … This procedure is ideal for the patient as both aesthetic result and the psychological well-being. These procedures are performed by the Board of Quebec Medicare since diagnosis of cancer is involved.
Breast cancer is the most unfortunately common cancer in women. It affects one in eight women during their lives. This is an uncontrolled multiplication of abnormal cells in the mammary gland. We distinguish invasive cancer and carcinoma in situ, the latter being confined to the milk ducts. The invasive cancer is one that is the most common and that puts the patient at risk for lymph node metastasis and can affect distant organs such as the liver, lungs, bones or brain.
What increases the risk?
The exact cause of the occurrence of breast cancer remains unknown. There are several factors that contribute to its development, alone or in combination. Among these factors which increase risks are:
• alcohol consumption;
• Early onset of menstruation;
• late onset of menopause;
• the absence of pregnancy;
• first pregnancy beyond 30 years;
• taking hormones replacement after menopause;
• the presence of atypia on breast biopsy;
• breast cancer in a first-degree relative;
• the presence of a gene predisposing to breast cancer, such as BRCA1 and BRCA2.
It is to be noted that the risk factors are not direct causes of breast cancer, but cause a statistical increased risk of developing cancer in patients. Many women with breast cancer have none of these factors.
Finally, note that the three factors of the most important risks are often overlooked by the public: the fact of being a woman, getting older and heredity.
The newest technique in imaging of the breast
Early diagnosis by mammography screening has helped reduce mortality from breast cancer. Note that there has been much progress in the ways of diagnosing breast cancer. In 2012, progress is mainly due to four fields in radiology:
- The most accurate digital mammography;
- the expertise of radiologists in breast ultrasound;
- improved biopsy techniques for breast imaging;
- the advent of magnetic resonance imaging of the breast.
The Newest technique in Surgery
Resection of the tumor
Surgery of breast cancer has changed significantly in recent decades due to the deeper knowledge that one has breast cancer. Until the 1970s, the surgery most frequently used was the Halsted radical mastectomy, a mutilating technique where we had to remove the whole breast, lymph nodes and muscles of the chest wall, leaving the skin directly-over the ribs.
Subsequently, there have been modified radical mastectomy, were the surgeon preserved the muscles of the chest wall. Finally, the notion of preservation for nearly 25 years: the most common techniques nowadays are partial mastectomy or lumpectomy. The breast is preserved and only the tumor is removed with safety margins around. This was possible thanks to the radiation given to the breast after surgery.
Immediate breast reconstruction
The other major development in the evolution of breast cancer has been progress in the techniques of breast reconstruction, especially the acceptance by the medical community of the immediate reconstruction. This means breast reconstruction by a plastic surgeon during the same surgery and the same anesthesia.
When necessary, the surgical oncologist performs the complete removal of the breast, and in the vast majority of situations, it is therefore possible to perform breast reconstruction at the same time. This has greatly contributed to the reduction of psychological shock of the loss of the female breast.
Oncoplastic: what is it?
In recent years also appeared techniques of Oncoplastic breast surgery. First available especially in Europe, and more recently in the United States, these techniques are now used by surgical oncologists at the CHUM. This is to give the best possible shape during partial mastectomy. This new technique requires more knowledge and skill from the surgical oncologist as to give the best possible shape to the breast following removal of the tumor to leave the smallest possible distortion.
The nodes in the armpit: what do we do in 2012?
We cannot ignore the enormous progress made in terms of the management of axillary lymph nodes. Recall that the standard was to proceed, until fifteen years ago, to a hollowing out of the nodes in the armpit for any patient with invasive breast cancer. Since then, things have changed. The first step was the appearance of the sentinel lymph node. By definition, the sentinel node is the first node that is at risk of being hit by cancer cells. If this node can be found and analyzed, only patients with cancer in it must undergo a recess of the nodes in the armpit.
With this technique, more than half of the patients with invasive breast cancer are now avoiding the recess of the nodes in the armpit. The technique involves the injection of a radioactive substance with or without a blue colored substance in the breast. This substance is found in the sentinel lymph node under the arm, and then it is taken and sent for final analysis.
The second step is much more recent, less than a year. It leaves many puzzled in the medical community because there is no consensus on its application. The controversy began with what is called the study ACOSOG Z011. Briefly, the recommendations are ‘no longer proceeded with the recess of the nodes in the armpit if not more than one or two sentinel nodes contain cancer cells.
No change in recurrence or patient survival was noted. The medical community remains divided on these findings, but the overall trend is to follow these recommendations with some modifications or criteria. Surgical Oncologists at the CHUM follow this trend nothing exceptions after case study of each patient they treat. There is certainly a trend in oncology to perform the least invasive procedure for the same effectiveness with the least possible complications.
Radiotherapy is given to any patient who had a partial mastectomy and even some patients who have had a complete mastectomy. Its aim is to reduce the local recurrence within regional lymph nodes. It is given after chemotherapy treatments for a variable period of up to 25 days. The new radiotherapy follows the same trend in surgery to attempt shorter invasive treatments. Several techniques of partial radiation and smaller duration of treatment and even early implementation phase are being studied.
Since the start of chemotherapy more than 40 years ago, many changes have been made. First, there are three kinds of chemotherapy:
• adjuvant treatment (after surgery in prevention the of recurrence);
• neo-adjuvant therapy (before surgery to reduce the larger breast tumors);
• palliative treatment (where there are already metastases to vital organs).
The first revolution in chemotherapy has been the discovery of Herceptin less than 10 years ago. This is the first targeted therapy against the HER 2 receptor which, when amplified (the equivalent of a hyper) produces very aggressive tumors. 15 to 20% of breast cancers fall into this category. Herceptin has helped to greatly improve the survival of these patients.
The second revolution that we are witnessing is the era of the biology of breast cancer, where we use genomics to predict the risk of recurrence or tumor aggressiveness. The prototype is the use of the Oncotype DX test for the majority of tumors larger than 1 cm hormone to determine the need to give adjuvant chemotherapy. This step was carried out until very recently by eye or approximately by the physician or surgeon oncologist.
The anti-hormone therapy
The anti-hormone therapy benefits patient with breast cancer to the same extent as chemotherapy. Tamoxifen was used in the early 1970s. We are now using of aromatase inhibitors (anastrozole, letrozole and exemestane). They can be used only in postmenopausal women.
Here are some sites selected by the team of Clinic Agatha for you to refer to:
PLEASE ADD THE LINKS TO THE WEBSITES I GAVE YOU AT OUR LAST MEETING
Here are some sites selected by the team of Clinic Agatha for you to refer to:
Voici quelques liens sélectionnés par l’équipe de la Clinique Agatha pour vous :
PLASTIC SURGERY AND MEDICINE (UNINSURED SERVICES)
- Breast augmentations
- Redrapages breast
- Injectables (Botox and Juviderm)
- Tummy tuck and liposuction
INJECTABLES (BOTOX & JUVEDERM)
IPL LASER HAIR REMOVAL & PHOTO-REJUVENATING
We offer now the service of photo hair-removal with the laser IPL as well as the photo-rejuvenating treatment right here available at Agatha Clinic.