Treatments

Coordination between the surgeon, oncologist, oncologist - radiotherapist and pathologist is necessary to treat a patient with breast cancer. Within an approved center, multidisciplinary care can include:

1 - surgical treatment:

The surgeon performs an excision of the tumor and an area of ​​healthy tissue surrounding it.
We can perform a conservative treatment that preserves the breast (partial mastectomy) or removal of the breast (total mastectomy). The decision is made taking into account the histological type, the size and the number of lesions located in the breast; as well as breast volume and a possible contraindication to radiotherapy. Patient preference is an important part of the decision.

For non-palpable lesions (in case of conservative treatment), a preoperative location is necessary in order to guide the surgeon to the lesion. This location can be done by a metal wire (called "harpoon") placed with radiological guidance; or by an innovative method of radioisotopic detection allowing the surgeon to locate the lesion.
In case of conservative treatment, oncoplasty techniques can be used. These techniques make it possible to carry out a conservative treatment while preserving the esthetics of the breast, for lesions located in quadrants difficult to operate or in the event of a relatively large lesion.
During the intervention, metal markers (clips) are placed which will guide post-operative radiotherapy. These clips will then be visible on the monitoring and follow-up radiological examinations. They're safe.

After mastectomy, an immediate (at the same time as the mastectomy) or secondary (remote) breast reconstruction can be performed. The technique can use an implant (prosthesis), a flap (muscle + skin). Complementary techniques are generally necessary (reconstruction of the areola, lipofilling (filling of a defect by autograft of fatty tissue), etc.).

The reconstruction by prosthesis:
A prosthesis is placed behind the pectoral muscle. This technique imposes skin flexibility that can possibly be acquired by means of expanders (temporary prostheses).

Tattered reconstruction :
- The musculocutaneous flap of the dorsal muscle: this muscle located in the back, as well as the skin and the fat facing it are brought in place of the mastectomy. This flap remains vascularized by its original vascular pedicle.
- The musculocutaneous flap of the rectus abdominis muscle or T.R.A.M. (Transverse Rectus Abdominis Myocutaneous flap): this muscle located at the level of the abdomen, the skin and the fat next to it are transposed at the level of the mastectomy. This flap also remains vascularized by its original vascular pedicle. This technique is little used today.
- The flap of the lower epigastric perforators or D.I.E.P. (Deep Inferior Epigastric Perforator flap): we take a sample of fatty tissue and the skin next to the abdomen. This graft is then connected by microsurgery to the mastectomy area.

The choice of technique depends in part on the quality of the skin tissue, smoking habits and the patient's wishes.

Any technique involves several stages: a reconstruction of the breast (shape and volume), the result of which is judged a few months later. Adjustments can be proposed according to the wishes of the patient. Finally the areola and the nipple can be reconstructed in a second step.

The removal of axillary nodes is also part of the intervention. The objective is to diagnose lymph node metastases, in order to adapt the adjuvant treatment.
Today, the removal of sentinel lymph nodes is the most common technique. It consists of removing the first lymph nodes that drain the breast and preserving the other lymph nodes in the armpit. A radioactive tracer is injected into the breast a few hours before the operation and the migration of the tracer into the lymph nodes is detected to identify them. You can also use a dye (Patent Blue, and more recently a fluorescent molecule, indocyanine green). The sentinel node technique has been used for over 20 years. It makes it possible to make the diagnosis of lymph node extension with the same reliability as with an axillary dissection (removal of a dozen lymph nodes). It significantly reduces the risk of complications induced by cleaning, in particular pain and lymphedema of the arm (large arm).
When the sentinel node technique is not possible, especially if at least one axillary node has been diagnosed by clinical examination, imaging +/- a puncture, axillary dissection should be performed. This gesture aims to remove a dozen lymph nodes between universal anatomical landmarks, under the xillary vein. Besides the risk of long-term complications, cleaning most often requires the installation of a transient drain, to limit the risk of lymphocele.

Simple interventions such as partial mastectomies, with or without oncoplasty, total mastectomies are today most often performed in outpatient hospitalization or during a short hospitalization of 24 to 48 hours, followed by hospitalization at home. >

2 - radiotherapy:

Its objective is to reduce the risk of local recurrence. It may include radiation from the breast, chest wall, lymph node areas.
It most often consists of a daily session for 4 to 6 weeks. Alternative techniques can be proposed such as partial breast irradiation or hypo-fractionated irradiation which reduces the number of sessions. Post-operative radiotherapy is almost systematic after conservative surgery.

3 - chemotherapy:

Depending on the type of cancer, patients may receive chemotherapy in order to treat lesions from a distance or to reduce their risk of occurrence. It is administered by a device called an implantable chamber which can be placed under local or general anesthesia. Many protocols are available, most often they are spread out over 5 months at the rate of 6 to 8 cures every 3-4 weeks. Many variations are possible.

4 - targeted therapies:

Currently 20% of breast cancers are accessible to targeted treatment with monoclonal antibodies: trastuzumab. This treatment is indicated for tumors overexpressing HER2.

5 - hormone therapy:

This treatment is indicated for tumors expressing estrogen and / or progesterone receptors. It reduces the risk of local recurrence, distant recurrence (metastasis) and cancer in the other breast.
Tamoxifene is used in postmenopausal women and aromatase inhibitors or Tamoxifene is used in postmenopausal women.
Treatment is prescribed 5 years in most cases and 10 years in the event of a poor prognosis.

The choice of these different treatments and their order depend on many factors, in particular the stage of the disease and the biological characteristics of the tumor.
For example, the treatment of small luminal A tumors most often begins with surgery, followed by radiation therapy and then hormone therapy. Conversely, the treatment of basal cancers most often begins with chemotherapy.
The treatment of breast cancer is therefore increasingly personalized. The choice is made during a meeting of all the specialists involved in the treatment: radiologists, pathologists, surgeons, medical oncologists, radiotherapists, etc. Proposals are based on national benchmarks and the experience of the team.