Traditionally, breast cancer in advanced stages was treated with radical surgery, completely removing the breast and the axillary nodes, or it was treated with chemotherapy and later, provided that the patient was not metastatic, also subjected to radical mastectomy.
Currently, advances in diagnosis and treatment have made it possible to perform conservative treatments in both breast and axillary surgery.
Advances in surgical treatment
The marking of the lesion in the breast will be done by expert breast radiologists, who will place the marker in the center of the lesion. In this way, either in complete radiological response or partial response, the marker will be used for subsequent breast-conserving surgery.
In the event that the patient may benefit from neoadjuvant treatment, the Multidisciplinary Tumor Committee must decide in which cases a Selective Sentinel Lymph Node Biopsy (SLNB) will be performed. These cases will require axillary lymph node marking prior to neoadjuvant treatment to allow accurate follow-up of the initially affected lymph nodes.
Neoadjuvant systemic therapy allows the reduction and even complete disappearance of the tumor.
The criteria for performing SLNB after neoadjuvant therapy are as follows:
- Number of metastatic lymph nodes at the time of diagnosis: maximum 3 nodes.
- Complete axillary radiological response evidenced by ultrasound after the administration of the last cycle of neoadjuvant chemotherapy, regardless of the response of the primary tumor.
The marking method can be performed by using radioactive seeds of I-125 or by placing a radiological marker.
After finishing the chemotherapy treatment, the case will be re-evaluated with mammography, breast and axillary ultrasound and bilateral MRI with breast contrast.
After the radiological study we may find these scenarios:
- Absence of radiological response in the breast. If the breast tumor has not disappeared or the response is not sufficient to perform conservative surgery, the patient will undergo mastectomy. If there was no response in the axilla, axillary lymphadenectomy will be performed, and if the lymph nodes have been marked with seeds with I-125, it will be ensured that these marked nodes are removed to recover the seeds.
- Complete radiological response in breast and axilla. Breast-conserving surgery will be performed, and with regard to the axilla, if there were initially 1 or 2 marked nodes, the BSGC technique will be performed and the nodes initially marked with seeds or with radiological marker (whether or not they are sentinel nodes) will be removed. If there were 3 marked nodes, only those nodes will be removed and no SLNB will be performed, since it is understood that there are enough nodes to make a decision after their intraoperative anatomopathological study.
- Partial response in the axilla. Independently of the response in the breast, if the response in the axilla of the nodes is not complete, even if it has been partial, the patient will undergo axillary lymphadenectomy, as it is understood that there is residual disease in the axilla.
In summary, the knowledge of the different molecular subtypes of breast cancer and the advances in radiodiagnosis, as well as in nuclear medicine (BSGC) and breast surgery, allow us today to treat these patients with advanced stage tumors and axillary involvement in a conservative manner, thanks to the individualization of treatments.