Conservative treatments

Following the work of Pr. Veronesi of the European Cancer Institute of Milan, published in 1981 and since then confirmed by the updating of its initial findings by numerous other studies, it has been clearly demonstrated that long-term survival of a patient treated for breast cancer is the same whether the initial surgical treatment is conservative or not (when there is a choice). Even taking into account local recurrences that may occur in the preserved breast (risk of 5 % after 5 years and 10% in 10 years).

Contrary to popular belief, breast preservation is not related to the severity of the lesion. Some lesions represent a very low risk but are extended (in situ cancer for instance), hence requiring a full mastectomy even though their prognosis is excellent. On the contrary, some small aggressive tumors have a more moderate prognosis but can be treated conservatively.

The limits of conservative treatment are not related to the size of the tumor, but to the quality of the result after the resection of the tumor. This usually depends on the ration between the tumor’s volume and the breast’s volume. As a matter of fact, result of conservative treatment can be excellent, even when the tumor reaches 4cm, for women with breasts of large volume (C-cup or more).

After conservative treatment and radiotherapy of an upper-external breast cancer of 4cm

The result might be less good after resection of a 1 cm tumor in the case of a patient with smaller breasts (A-cup). 

After conservative treatment and radiotherapy
of a cancer smaller than 1 cm

A good result of full mastectomy with reconstruction is better than a bad result of conservative treatment.

From Left to Right :
After mastectomy and expander
After opposite breast augmentation

In very specific cases, a subcutaneous mastectomy with areola preservation can be considered as the optimal surgical treatment. This applies to patients with breasts of small or average size, where the tumor is distant from the areola with no lymph node damage.  

From Left to Right :
Left breast external cancer
After subcutaneous mastectomy and introduction of an expander
Final result after prosthesis exchange of left breast and right breast augmentation

In some indications, the limits of breast conservation can be widened through the use of pre-operative chemotherapy.  Chemotherapy, when necessary, can sometimes be suggested before surgery (neoadjuvant chemotherapy, or NAC) rather than after surgery (adjuvant chemotherapy) in order to diminish the tumor size

From Left to Right :
24mm on the MRI before NAC
9mm on th eMRI after NAC

and make it available to a conservative treatment that couldn’t have been done in the first place.

From Left to Right :
Result after surgery
Final result after radiotherapy

From Left to Right :
30mm tumor before NAC
Lesion reduction and result after conservative treatment

Final result after radiotherapy

In the 1990s appeared oncoplastic (the use of mammoplasty techniques in the breast cancer surgery). This enables in some cases the improvement of conservative treatment through indirect incisions with glandular flaps. It also permits to widen breast preservation possibilities, especially when resorted to after CNA chemotherapy for lesions that were initially of large volume.

Direct incisions are most of the time used in the upper external region of the breast (50% of breast cancers locations)

From Left to Right :
Result after conservative treatment of a right external cancer of 20 mm
Inconspicuous scar without esthetic sequels on the breast

Direct incisions are not indicated when breasts have too much fat (due to the risk of fat necrosis). When the breast is glandular, they are very useful to avoid apparent scars on the neckline.

From Left to Right :
25mm upper-internal lesion on the neckline
Result after surgery and a peri-areolar incision

From Left to Right :
20mm upper-medial lesion on the neckline
Unconspicuous result after surgery and peri-areolar incision

They also permit, through Round Block technique, to resect tumors in any location with optimal result. This technique however requires quite large areolas.  

From Left to Right :
Upper-internal cancer on both breasts
Result after Round Block

From Left to Right :
Final result after radiotherapy from the left side
Final result after radiotherapy from the right side

 The tumor’s location can sometimes be an obstacle to breast preservation, as it is the case for lower-internal tumors.  A direct incision might leave sequels, even in the case of small tumors.

Lower-internal location, important sequels of conservative treatment without oncoplastic

Oncoplastic techniques have helped to expand conservative treatments possibilities in that location.

From Left to Right :
Lower-internal location: resection with infra mammary incision permitting a flap
Result after dermal flap with Round Block

From Left to Right :
Lower-internal cancer before surgery
After surgery and radiotherapy
Unconspicuous scar even with arms raised

As the treatment of a lower-medial lesion might leave sequels without associated oncoplastic, in particular on ptosed breasts. 

Inferior location: important sequels of conservative treatment without oncoplastic

In that situation, the realization of a mammoplasty at the same time is ideal, as it enables a very large resection and an excellent final result.

From Left to Right :
Lower-medial cancer

Aspect before surgery
Final result after radiotherapy

In the case of a retro-areolar tumor, resorting to a plasty with cutaneous plug may allow breast preservation.  The breast needs to be large enough,

From Left to Right :
Retro-areolar tumor before surgery
After surgery and radiotherapy

or ptosed,

From Left to Right :
Retro-areolar tumor before surgery
After surgery and radiotherapy

taking into account a possible asymmetry.

From Left to Right :
Retro-areolar tumor before surgery
Result after surgery

From Left to Right :
After surgery and radiotherapy
After areola and nipple reconstruction

In the case of breast hypertrophy, basic conservative treatment associating a resection without oncoplastic followed by radiotherapy can often lead to a post-treatment inflammation with rash, edema and pain that might become chronic and disabling for the patient.  

From Left to Right :
Upper-external cancer post-treatment inflammation Frontal view 2 years after treatment
Associated axilar sequels view from the side

A reduction associated with the tumor resection has a triple advantage. It enables to improve the functional and esthetic result of the surgery, ease the radiotherapy and diminish the post-radiation sequels. Realized using a superior pedicle, it is perfectly adapted to lower location tumors.

From Left to Right :
Lower-external cancer

Aspect before surgery
Result 15 days after surgery

Reduction through this superior pedicle technique can be done wherever the tumor location is found, as long as there is no skin adhesion.

From Left to Right :
Upper-medial cancer on both breasts
Result after 1 month

From Left to Right :
Internal cancer
Result after 6 weeks

The reduction is to be offered systematically at the time of the cancer treatment, especially since it would be very difficult to achieve after radiotherapy (major risk of post-operative complications after reduction of an irradiated breast).