1344 Breast cancer surgery in practice (today)

Introduction/Background HISTORY OF BREAST SURGERY: 3rd century BC (Egypt): Breast removal/Cautery -1894: Halsted= Radical mastectomy -1948: Patey= Modified Radical Mastectomy/MT -1958: Creation of the National Surgical Adjuvant Breast and Bowel Project (NSABP) -1968NSABP-B01: Adjuvant chemotherapy (5FU) -1970NSABP-B02: EBRT after Radical Mastectomy -1975 -1985NASABP-B04: MR(Halsted) vs MT -1981–1989 NSABP-B06: Tumorectomy + RTE vs MT -2006–2011 NASABP-B32: GSvs LA -2017: ACOSOGZ0011: Systematic LA discontinued if GS+ Methodology Surgery in practice 'today What are the objectives of surgery? ONCOLOGICAL ISSUES = SURVIVAL: Local/regional disease control Increase recurrence-free survival Increase overall survival FUNCTIONAL ISSUES = QUALITY OF LIFE : Limit post-therapeutic sequelae Aesthetic issues What are the selection criteria? Tumor characteristics (T, N, Hist, G, RH, Her2, Ki, emboli, pCR...) Objective patient characteristics (Age, PS, Breast Volume, Atcd) Informed' patient choices (good or not so good...?) Importance of collegial decision-making (RCP+++) Results LOCAL: CONSERVATIVE TREATMENT :In practice: If palpable : Tumorectomy around the nodule If not palpable : Zonectomy around the harpoon +/- 'quadrantectomy' if large resection (obsolete term) Intraoperative analysis recommended: Measurement of margins/Room X-ray/Room ultrasound Main principles : - Exceresis between the skin surface and the aponeurosis in depth - NEVER SURFACE OR DEEP RECOUPE in theory - Safety' margin around the lesion (>5 10mm?) - Orient the part (Cork++/Threads/Ink/Clip...) - Always leave Clips at end of procedure (Invasive or In situ) - Allows BOOST in RTE if necessary - Facilitates recuts - Indication of recuts - Intraoperative 'limit' margins Conclusion Understanding breast surgery is inseparable from its history! It was born 120 years ago with Halsted (late 19th c.). Since then, it has evolved considerably thanks to : The advent of radiotherapy (thanks Marie Curie!) Then other adjuvant treatments The introduction of international randomized trials The description of oncoplastic surgery and reconstruction Ever more conservative Radical mastectomy →Mastectomy→ Tumorectomy Systematic curage →GS Disclosures None.