Treatment of breast cancer requires a multidisciplinary approach. Although surgical treatment is the first step in many patients, one, several or all of radiotherapy, chemotherapy and hormone therapy are applied in a certain order, depending on the results of post-operative pathological examination. While surgical treatment and radiotherapy are more important in providing local control of the tumor, chemotherapy and hormonotherapy help in systemic control.
When deciding on the treatment for breast cancer, treatment options should be discussed with the patient after detailed information is given to the patient about her condition.
Surgical Treatment
Treatment of early stage breast cancer often begins with surgery. Today, there are two main applications preferred for this purpose:
- Breast-conserving surgery
- Mastectomy ± breast reconstruction
Breast-conserving surgery: It refers to the removal of the tumor along with some healthy breast tissue around it. As part of this treatment, radiotherapy (radiation therapy) must be applied to the remaining breast tissue. Situations in which breast-conserving surgery cannot be applied are as follows:
- Cases with tumors in more than one focus in the same breast (Multicentric tumor)
- Patients whose tumor is very large or whose tumor/breast size ratio is not appropriate
- Those who have previously received radiotherapy to the same body area
- Those who have active connective tissue disease (since radiotherapy cannot be performed in these people).
- Early pregnancy (since radiotherapy cannot be performed)
If the tumor recurs in the breast where preventive treatment was applied, the recommended treatment is to remove the entire breast, that is, mastectomy. Local recurrence of the tumor does not have a negative impact on survival time, as long as it is caught early with appropriate follow-up.
Mastectomy ± breast reconstruction: Mastectomy is the removal of breast tissue. is to be taken in its entirety. It is the classical surgical treatment method of breast cancer. Provides good local control; The risk of tumor recurrence is low. However, the loss of the breast affects women negatively psychologically. For this reason, breast reconstruction (breast reconstruction) is recommended for patients who will undergo mastectomy as a surgical treatment. Information should be given about whether there is a chance of a breast implant procedure) and possible reconstruction options. Its direction is largely towards the armpit lymph nodes. For this reason, cancer cells that gain the ability to spread usually first go to the armpit lymph nodes. Knowing the status of the axillary lymph nodes in breast cancer patients is important in diagnosis, treatment and follow-up.
The removal of the axillary lymph nodes is valid for invasive tumors. Since in-situ cancers (limited within the milk ducts) theoretically do not go to the lymph nodes, there is no need to clean the armpit. Removal of the armpit lymph nodes (axillary lymph node dissection) has 3 purposes:
- Accurate staging of the disease.
- To guide concomitant treatments.
- Lymph. To ensure local tumor control in patients with gland involvement.
While the removal of the lymph nodes related to the breast meets the above-mentioned objectives, it does not increase the risk of unwanted side effects such as swelling in the arm (lymphedema). also increases. In order to prevent these risks, some precautions are taken, such as protecting the patient's hand and arm from injuries.
With standard axilla dissection, an average of 20-30 lymph nodes are removed. Studies conducted in recent years have shown that at least 10 lymph nodes must be removed in order to sample the armpit correctly.
Thanks to the impact of breast cancer screening programs and women being more aware of breast cancer, most breast cancer cases can now be detected at an early stage. . Today, we know that approximately 60% of all breast cancers and an average of 75% of early stage breast cancers do not involve the axillary lymph nodes at the time of diagnosis. If it can be shown that there is no lymph node involvement in these patients, there is no need to clean the axillary lymph nodes. For this reason, the sentinel (sentinel) lymph node sampling technique has been developed in the last 10-15 years.
Sentinel lymph node biopsy: Sentinel lymph node biopsy in patients with no clinically enlarged axillary lymph node detected. By applying sampling, information is obtained about whether there is axillary lymph node involvement. There is no need to clean the axillary lymph nodes in patients with negative sentinel lymph nodes.
It is performed with the help of blue dye (isosulfan blue, methylene blue, etc.) or a radioactive substance (individually or both combined). In recent years, periareolar injection has become more preferred. The number of sentinel lymph nodes may be more than one. These lymph nodes are removed and it is investigated whether they contain tumor cells. If no tumor cells are seen, the procedure is terminated; There is no need to remove other lymph nodes under the armpit. If cancer cells are found in these lymph nodes, the part of the axillary lymph nodes related to the breast must be removed.
The reliability of sentinel lymph node sampling in detecting axillary lymph node involvement has been proven in many studies. It requires a certain learning process, but when done correctly, it is a safe method and side effects such as swelling in the arm are eliminated.
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