Breast cancer has still the highest incidence in female tumors and this disease seems also to occur in earlier age of woman’s life than in the past. The diagnostic-therapeutic approach is today multi-interdisciplinary in highly specialized structures (“Breast Unit” or “Woman Department”), which has led to important improvements both in 10-years overall survival rates (64% of patients treated in Italy in the final Eighties) and in the quality of life. In a previous paper (Leadership Medica, 2:22-28, 1997) the authors reported their 15-years experience in the treatment of breast cancer patients at the Senology and Surgical Prevention Unit of the Oncology Institute in Bari, Italy. This previous study aimed at comparing conservative surgery to invasive surgery in terms of disease control - both locoregional and distant - and of aesthetic results. Over the last years, conservative surgery has become more complex because of the different clinical aspects of the disease, because of the more and more frequent detection of minimal not-palpable lesions, because of the imprescriptibility of chemotherapy and radiation therapy, because of the need of the support of the molecular biological laboratory and of experts in epidemiology and healthcare statistics. In the present paper, the author reports about the further cases who underwent surgery from January 1996 to September 2001, together with his personal experience.

The development of new diagnostic techniques and of the molecular biology together with a better self-awareness of the women, thanks to the press campaigns for early diagnosis, have led to the possibility of performing conservative surgery, which is nevertheless radical from an oncologic point of view and acceptable from an aesthetic point of view.

This results in great psychological and physical benefits for the patients. The biological aggressiveness of breast cancer is today considered to be related more to the biological characteristics of the neoplasm rather than to tumor burden.

However, tumor burden, histology and the morphologic characteristics of the involved organ play an important role in the decision making process of the surgeon when he has to choose between conservative and invasive surgery, after having, of course, discussed the matter with the patient.

More and more cases treated at the Oncology Institute of Bari from January 1996 to September 2001 showed the presence of occult or minimal lesions, detected during a spontaneous screening. On the contrary the incidence of inflammatory cancer and of tumors with axillary lymphonodes involvement (N+) remained the same.

Considering all new cases (more than 2000) of breast cancer treated over the last six years, we observed an increase in the percentage of conservative surgery. However, conservative surgery is still not always performed because of cultural, geographical, organization and sanitary reasons.

In the next future it will be however possible to plan a surgical strategy even more conservative. After the consolidated success of the QUART and of the principles at the basis of it (breast cancer as systemic disease, for which surgery must only guarantee a radical and less invasive treatment, locoregional control, exact prognostic indication together with a better quality of life), the development of new conservative surgery techniques has become fundamental especially in the treatment of the axilla and for the indications to radiation therapy.

Recently, the extension of the breast surgical operation and the opportunity to perform a partial or total axillary dissection have been discussed. Axillary dissection may result - even if in a small number of cases - in various complications for the patient and in immunological problems. It is well known that the natural history of breast cancer is characterized, in many patients (51-54% in our cases), by the early metastatic involvement of locoregional lymphonodes, apparently related to the phase of the increase of the tumor burden. It is however certain that in case of clinical axillary positivity, dissection must be complete, removing the three classic levels.

Also because, the number of the involved lymphonodes and their level are not only important prognostic factors, but also therapeutic. In case of clinical axillary negativity, it is now custom to think that removing systematically axillary lymphonodes to find that they are not involved is no longer a good clinical practice. The knowledge of the locoregional lymphonodes status is however always considered the most important prognostic factor in patients with operable breast cancer. This is why the histological evaluation, after having removed axillary lymphonodes, is today indispensable. Indeed, the other possible diagnostic methods (echography, lymphangiography, lymphoscintigraphy, Mx, PET, NMR) are not able to detect the metastatisation process (presence and extension) of the locoregional lymphonodes. The scientific community has therefore considered the possibility of a selective dissection to verify the locoregional lymphonodal involvement in those patients who resulted clinical negative after axillary palpation. On account of the past experience with cutaneous melanoma (Morton et al., 1992), in Italy (Van der Veen et al., 1994; Albertini et al., 1996; Veronesi et al., 1997) the technique of the “sentinel lymphonode” has recently been adopted. This technique consists in the ablation of the first axillary lymphonode, which is considered predictive of axillary lymphonodal involvement. Indeed, the lymphonodes status is today considered a factor to define the stage of disease rather than a site to be treated with surgery. Also the inner mammary lymphatic chain represents an interesting variable to control breast cancer, which can therefore be the subject of further studies together with the role and the feasibility of radiation therapy.

Translated by Interpres sas

Francesco Schittulli
Direttore “Dipartimento Donna”
Primario Senologo Chirurgo Istituto Scientifico Oncologico Bari (Italia)