Anatomy and topographic anatomy of the breast:

The mammary gland covers the anterolateral side of the chest, especially the pectoralis major. The gland is located between the muscular chest wall and the skin and is the basis for an organ called the breast (mama). The main physiological function of the breast is breastfeeding, so it is significantly more developed in women than in men.

The glandular parenchyma consists of lobes that open through about 20 main milk ducts into the nipple located in the areola. The nipple with the areola is called the nipple-areola complex (NAC). Montgomery glands with a lubricating function are located in the skin of the areola. The orientation of the lobes and mammary gland outlets is not regularly radial. They are not arranged like pieces of sliced ​​cake. They can be chaotic, and the boundaries between them are not macroscopically very obvious. The glandular parenchyma itself is enveloped by connective-adipose tissue. The amount of fat is variable, and fat is mainly responsible for the breast's size, shape, and consistency. The mammary gland is separated from the surrounding tissue by a more or less pronounced fascia with fibrous bands (Cooper's ligament). The caudal edge of the breast is the basis for a structure called the submammary groove. It is important to realise that the structures of the mammary gland can exceed the anatomically visible limits of the breast. As a result, about 90-99% of the glandular parenchyma can be surgically removed by mastectomy. A dense network of collateral characterises the vascular supply. The innervation is mainly segmental.

We clinically recognise imaginary quadrants on the breast - the upper-outer (UOQ), lower-outer(LOQ), upper-inner(UIQ), and lower-inner quadrant(LIQ). It is also possible to define the central segment, including the middle part of the breast with NAC. In the area of the upper-outer quadrant, the gland more or less extends towards the armpit. This part of the breast is sometimes called the Tail of Spence. It is important to know that the areas described above serve only for a rough description and that there are no precise anatomical boundaries between them. The approximate location of the lesion in the breast can also be described using a clock position, the distance from the NAC or depth (for example, the lesion located at No. 3, 4 cm from the NAC, basally on the chest wall).

The axilla area is functionally related to the breast. It is an anatomical space in the shape of an approximately quadrilateral pyramid, which contains an individually variable number of axillary lymph nodes (10 - 40) entrapped in the fat body of the axilla. An important anatomical structure in the axilla is the axillary vein, the long thoracic nerve innervating the serratus anterior muscle (fan-shaped muscle), and the thoracodorsal neurovascular bundle. From the surgical point of view, there are traditionally three levels of the axilla; the boundaries between the levels are defined by the lateral and medial edge of the pectoralis minor muscle.

Diagnosis of breast gland diseases: 

History and clinical examination:

The first step is always taking a history and clinical examination. When taking a history, we ask mainly about changes in the breast in the past period, possible bulging of the lump, or even breast pain. However, this is very often a non-specific symptom. A possible indication of a spontaneous nipple discharge and its colour may also be important. We perform a clinical examination on a woman undressed from the waist up. We first examine with an inspection. We look at possible asymmetries in the basic position. We look for changes in the surface during uplifting arms, such as skin or nipple retraction or asymmetrical arching. Followed by careful palpation, we look for palpable lesions. Some women's breasts can also have a physiologically glandular structure ("cobblestone texture"), so it is more difficult to orientate palpably. An integral part of the breast examination is the palpation of the axillary and supraclavicular nodes; the most suitable attitude of the patient for this examination is with her hands on her hips. 

Breast imaging assessment: 

Of the paraclinical examinations, the most important is the imaging assessment, which can be divided into basic and supplementary.

Routine breast imaging assessment:

The imaging method of choice is usually Ultrasound Scan (USS) for women under 40 years of age and mammography (MMG) for women over 40. It is related to the gradual involution of the mammary gland, loss of the parenchyma and later predominance of adipose tissue. Generally speaking, young women's breasts are better assessed by USS, while MMG better assesses the breasts gland in involution. However, this is not always true, so we always use both tests when breast cancer is suspected, which often complement each other. 

However, we have to be cautious as the breast may not be captured completely in the mammogram. In particular, tumours in its periphery may not be shown on the MMG images. That is why a clinical examination is irreplaceable. 

Additional imaging examination:

Magnetic Resonance Imaging (MRI) is of the greatest importance for additional imaging examination of the breast. Due to its high sensitivity, it is essential for the diagnosis of breast cancer as MRI often detects lesions that are not visible on USS or MMG. The disadvantage of the examination is the low specificity. Therefore MRI is used only in carefully indicated cases.

Biopsy

When a breast lesion is assessed on imaging assessment, it is rarely possible to clearly distinguish insignificant or benign changes from breast cancer. Therefore, a puncture tissue biopsy (tru-cut, core-cut) is always taken from a focal lesion. The method of the first choice for targeting (navigation) biopsy is Ultrasound Scan (USS guided biopsy), usually performed at the radiology department. Lesions visible only on MMG must be biopsied under MMG using stereotactic (STX) navigation, which requires special instrumentation. Biopsy under MRI is also possible, although this is only available in a limited number of hospitals in the Czech Republic. Further management depends on the biopsy results.

In case tru-cut biopsy is unsuccessful, there is a possibility to remove a larger amount of tissue using Vacuum-Assisted Biopsy (VAB), but there is a higher risk of complications, particularly hematoma, so it is not the method of choice. On the other hand, Fine-Needle Aspiration Biopsy (FNAB) is used less frequently in practice due to the difficult evaluation of a cytological preparation, usually with a non-conclusive result.

Some breast diseases affect mainly the skin, even cancer! If suspicious skin changes occur, a probatory incisional (surgical) biopsy from the affected area is recommended. This procedure involves excision of a piece of skin (up to 1 cm) with a scalpel under local anaesthesia, suture of the wound and subsequent histological examination of the specimen.

Other paraclinical examinations

Other paraclinical examinations can be considered less significant and indicated only selectively. 

Elevation of inflammatory markers (leukocytes, CRP) can support the diagnosis of inflammatory disease. Also, bacteriological examination of the smear or puncture can then detect the etiological agent. 

As part of breast cancer diagnosis, we examine distant organs (liver, lungs, bones), for example, using USS, X-rays, Bone scan, Computed Tomography (CT) scan, and possibly also Positron Emission Tomography - Computed Tomography (PET-CT) scan.

Breast disease:

Developmental defects:

Developmental breast defects are not so common, but they can cause differential diagnostic problems. Surgical treatment is also used in their possible adjustment, so they are briefly mentioned here.

- Breast asymmetry: A minor difference in size is normal as completely symmetrical breasts are the exception. However, surgical correction (breast modelling, breast reduction) can be considered in cases with proportionate deferences.

- Aberrant gland: It can occur anywhere in the breast, but its most common location is the area of ​​the axillary protrusion of the breast to the axilla. If it causes difficulties or diagnostic embarrassment, its surgical removal (resection) is recommended.

- Breast hypertension (gigantomastia): it can have different definitions. In specific forms, it causes subjective difficulties (back pain, obstacle to body movement). It can be surgically treated with reduction mammoplasty.

- Poland syndrome: is a rare disorder in which affected individuals are born with missing or underdeveloped muscles on one side of the body, resulting in abnormalities that can affect the chest, shoulder, arm, and hand. It may require surgical correction.

- Gynecomastia: is a relatively common disease of men manifesting breast hypertrophy in men, both bilaterally or unilaterally. The basis is the proliferation of the periductal ligament. In some cases, this may be a side effect of some medicines. The surgical treatment option is a simple resection of gynecomastia or a more complex correction using plastic surgery techniques.

- Congenital deformities of the thorax: are also manifested in the area of ​​the breasts, especially the inverted chest (pectus excavatum) or the bird's chest (pectus carinatum).

Inflammatory diseases

The most common inflammatory disease of the breast is puerperal mastitis, which is usually treated by a gynaecologist and usually does not require surgical treatment.

From a surgical point of view, two types of inflammatory diseases are worth mentioning:

- Chronic recurrent periareolar mastitis (Zuska's disease). It typically manifests as redness or painful swelling of the breast in the periareolar region, often progressing to the formation of an abscess, which can even spontaneously perforate in the form of a fistula. They can also be associated with symptoms like temperature, shivering. The disease occurs mainly in smokers and can often recur. In the acute phase, the incision of the abscess is often required, and in the interphase, resection of the residual infiltrate can be performed. However, this surgery does not deliver the expected effect. Ductal anomalies are probably the cause of the disease. Bacteriological examination of possible secretion is in place, but the secretion is sterile, in which case the normal skin microflora will be cultivated. In case of general symptoms, antibiotic treatment is appropriate. In their absence, the importance of antibiotics is questionable. They are usually without effect and can cause side effects. Differential diagnosis must always rule out breast cancer, often by tissue puncture biopsy.

- Granulomatous mastitis: is a rare disease of not very clear aetiology, which usually manifests itself as a solid lesion, often with skin redness and abscess, which may resemble cancer. Biopsy and histological findings are crucial and mandatory. Treatment is difficult. Resection of the tumour can lead to cosmetic deformities and is often burdened with recurrences. Sometimes anti-inflammatory therapy (non-steroidal anti-inflammatory drugs) can be used favourably.

Breast cancer

Breast cancer usually presents as a painless lesion visible on imaging methods. In addition to clinical examination, MMG and USS, biopsy and histological examination of the nature of the tumour are decisive in the diagnosis. 

It is the most common tumour in the female population and the tumour with the highest prevalence worldwide. It can also occur in men but is relatively rare (less than 1% of patients). Most cancers arise sporadically. However, in about 5 - 10% of women, cancer development is linked to hereditary predisposition, mainly based on BRCA1 and BRCA2 gene mutation. Mutations in other known genes (e.g. CHEK2) may also be associated with an increased risk of breast cancer. External risk factors - do not play a significant role. The excessive long-term use (5, often more years) of hormone replacement therapy (HRT) in menopause is worth mentioning. 

Prevention 

- primary prevention measures: the elimination of risk factors are not very effective. Thus, except for bilateral prophylactic mastectomy in healthy carriers, the BRCA gene mutation can be considered individually. 

- Secondary prevention measures: mammographic screening with the main aim of early detection of cancer is essential. In the Czech Republic, mammographic screening was introduced in 2002 and consisted of a regular mammographic assessment (MMG) of asymptomatic women from 45 years of age at two-year intervals. Women should be referred for screening by a general practitioner or a registered gynaecologist. In the Czech Republic, mammographic screening is relatively successful and more than half of the women participate. A significant proportion of women currently being treated for breast cancer are asymptomatic when the tumour was diagnosed before its clinical manifestation. Early diagnosis of breast cancer treatment increases the chance of cure, and mammographic screening is a proven tool to reduce breast cancer mortality in the population. 

Clinical symptoms 

Many treated women have no clinical signs, and the disease is detected before clinical manifestation in mammographic screening. In the case of clinical symptoms, it is most often a painless lesion, which may be associated with skin or nipple retraction or visible arching. Retraction is usually caused by peritumoral retraction of the ligament. In more advanced stages, cancer manifests with venous drawing, swelling, or even redness. A special diagnosis is "inflammatory cancer", which presents itself as a red or livid discolouration of most breast skin, similar to inflammation. The condition is caused by tumour cells' diffuse infiltration of cutaneous lymphatic vessels, which is the worst prognostically favourable form of breast cancer. Inflammatory cancer may or may not be associated with a focal lesion in the parenchyma on imaging methods. Inflammatory cancer always requires primary systemic treatment, and it must not be treated surgically first! The presence of mediators associated with wound healing would likely promote the growth of left tumour cells, the "complete" surgical removal of which is impossible in diffuse lesions. 

Another specific clinical unit is Paget's carcinoma, which is characterised by the presence of Paget's tumour cells in the epidermis of the family or even the areola. This is a pre-invasive stage (carcinoma in situ), which is usually associated with the presence of pre-invasive or invasive carcinoma deeper in the breast parenchyma. 

Breast pain is a non-specific symptom. Usually, it has a non-tumour background, but the symptom cannot be disregarded. Even breast cancer can rarely manifest itself first in emotional discomfort or pain. 

Examination for suspected breast cancer consists of medical history, clinical examination, and imaging assessment (ultrasound and mammogram +/- magnetic resonance). In the case of a finding of the solid lesion, a puncture biopsy is needed. In case of suspected skin changes, e.g. inflammatory carcinoma, Paget's carcinoma, incisional skin biopsy with histological examination is indicated. 

Biopsy findings 

For clinical purposes, biopsy findings can be divided into: 

- invasive cancer 

- carcinoma in situ 

- precancerous lesions - risk lesions for cancer 

- other tumour types (than cancer) - benign, insignificant changes

Invasive breast cancer

In the case of invasive breast cancer, the "pre-treatment assessment" must first be completed. It stands on the following main pillars: 

1) Specification of the histological finding and the determination of the "phenotype" of the tumour. The most common histological type is invasive carcinoma without further specification (No Special Type - NST, formerly ductal carcinoma). The second most common histological type is lobular carcinoma (approximately 15% of cases). Other histological types are less common. Phenotype, grading, expression of steroid receptors (Estrogen Receptors - ER, Progesterone Receptors - PR) and Human Epidermal growth factor Receptor 2 - HER-2 receptors are essential for treatment. Knowledge of the phenotype before treatment is essential in terms of determining the treatment strategy respectively. It can help decide whether to treat primarily surgically (first surgery, then other modalities) or start with systemic, neoadjuvant treatment before surgery.

2) Determining the clinical extent of the disease (staging). It is necessary to determine the extent of the primary tumour in the breast (clinical examination, MMG, USS), the condition of the axillary lymph nodes (palpation, USS, possibly puncture biopsy) and distant organs predisposed to distant metastases: lung - X-ray, liver - USS, skeleton - scintigraphy, in patients with locally more advanced tumours. A CT of the chest and abdomen is also advisable. The TNM classification of malignancies is standardly used to describe the extent of the disease.

The treatment balance is subsequently based on the extent of the disease, the phenotype and the patient's overall condition.

The role of surgery in the treatment of breast cancer

The treatment of breast cancer is typically multimodal, usually combining local methods (surgical treatment and radiotherapy) with general, systemic methods (chemotherapy, hormone therapy and targeted treatment with modern drugs, "biological treatment"). The vast majority of breast cancers are detected in the stage of the localised disease, i.e. without signs of distant metastases, which corresponds to clinical stages I - III according to the TNM classification. In localised diseases, the role of surgery is crucial. In that case, surgery is usually scheduled first, followed by systemic therapy +/- radiotherapy. In locally more advanced stages (clinical stages II and III) and tumours of suitable phenotype, neoadjuvant systemic treatment is considered first, which can reduce the clinical extent of the tumour and create more favourable conditions for later surgery.

Basic surgical procedures

Surgery for breast cancer usually consists of surgery on the breast and surgery on the regional lymph nodes.

Breast surgery 

Breast-conserving surgery (BCS)

The most common operation on the breast is the wide local excision (WLE). It consists in removing the primary tumour with the margin of the surrounding unaffected tissue. Opinions on the minimum width of the safety margin have evolved in the past. In the case of a positive resection margin (after receiving the result of histological examination), it is appropriate to increase the radicality of the operation, either by resection of margins (still maintaining the breast) or by mastectomy (removal of the entire breast). The edges of the post-resection cavity are usually marked preoperatively with permanent marks in the form of titanium clips, which allow for a more targeted focus of adjuvant radiotherapy on the "bed" of the tumour. The removed resection must always be marked so that the pathologist can reliably orient it sideways, i.e. identify which side of the resected specimen is cranial, which is caudal, etc. The marking methods may be different (stitches, clips), but in any case, must be agreed with the investigating department of pathology. It is also important that the surgeon does not interfere with the resection in any way, cut it, etc. If the surgeon "sees'' the tumour during the operation, it is wrong. Typically, after receiving the resection, the pathologist marks its surfaces with a coloured substance (ink) and then cuts through. The positive resection margin in the microscopic specimen represents the site where the tumour cells are in contact with the dye (tumour on ink). Therefore, the surgeon should avoid any artificial interventions in the resection. If such inappropriate tampering occurs, the pathologist must be informed. 

A BCS can always be performed where it is technically possible to achieve at least an acceptable cosmetic result. Therefore, it is not possible, particularly in large tumours occupying a large part of the breast (e.g. unfavourable tumour/breast size ratio), or in the presence of multiple tumour lesions in multicentric carcinoma. Postoperative (adjuvant) radiotherapy to the breast area must be a necessary therapeutic adjunct to BCS. More detailed studies found that tumour cells tend to remain in the breast even at a considerable distance from the "visible" tumour, and radiotherapy aims to eliminate them. BCS alone without adjuvant radiotherapy carries a high risk of local recurrence. An acceptable rate of local recurrence is considered to be 1% per year. In BCS, we usually remove the breast gland at the tumour site in its entire thickness, i.e. from the subcutaneous tissue to the muscular base. The extent of the removed tissue is always individual with an effort for a negative margin and usually does not respect the border of the mammary lobes (these are not visible) or the imaginary border between the quadrants. Nowadays, it is not very relevant to call it "lumpectomy (removal of a lesion with a minimal margin)," segmentectomy "(removal of an unspecified and anatomically non-existent segment), or" quadrantectomy "(removal of an imaginary quadrant whose boundaries can be perceived differently). Preoperative localisation of intangible tumours is an indispensable part of breast-conserving surgery. As already mentioned, a large proportion of patients are operated on for intangible cancer. However, the surgeon must know which part of the breast to remove. It is, therefore, necessary to use some of the methods of preoperative localisation. There are many of these, and each has its advantages and disadvantages. The simplest is to draw a projection on a cross on the skin during the USS assessment, and this method is simple but inaccurate. The traditional method is to insert a locating wire under the USS or MMG, the wire is anchored in the area of ​​the tumour, and the skin is led out. The surgeon then proceeds according to the wire. The method is already in decline due to its obvious disadvantages. Currently, special seeds are used for localisation, either radioactive or magnetic, which can be detected through the tissues by special probes (gamma-probe or magnetic probe). These methods are relatively accurate but somewhat expensive. In any case, knowledge and availability of some of the localisation methods is a necessary prerequisite in every workplace of breast surgery. Poor preoperative localisation leads to poor targeting of the operation, which results in insufficient, inadequate resection. In the extreme case, the resection can completely miss the tumour, or cause the removal of an unnecessarily large volume of tissue with adverse cosmetic consequences, or both. Perioperative use of an ultrasound scan by a breast surgeon is theoretically possible, but in practice, it is not very widespread for the resulting perioperative discomfort and also for the relatively high professional demands of quality interpretation of breast ultrasonographic imaging. 

From a technical point of view, BCS can be performed in the usual manner with linear sutures or using oncoplastic techniques. Oncoplastic methods were originally developed in plastic surgery to model or reduce the breast and cover the resulting defect - the resection cavity with a local dermoglandular lobe. Additionally, the breast is "rearranged" so that the cosmetic result is as good as possible. This includes procedures such as "round block" resection, "vertical mammoplasty", "horizontal mammoplasty", etc. Their detailed knowledge goes beyond general surgery. From a surgical point of view, the need for careful hemostasis is essential, as the resection area can be relatively large, and the possibility of postoperative pressure compression (e.g. bandage with a bandage) is very limited in the soft tissues of the breast. An unpleasant postoperative complication can be a hematoma, which sometimes forces a surgical revision. We usually drain the wound with a drain taken between the sutures (Tygon, glove drain, etc.), which we usually extract on the 1st postoperative day. It is possible to leave the wound completely without drainage. We use vacuum drainage (Redon's drain) only if the post-resection cavity has been covered with tissue from the surroundings. Otherwise, the vacuum would collapse the cavity and the early adhesion of their edges, which is often cosmetically unfavourable. A regular accompanying phenomenon after BCS is seroma, i.e. filling the cavity with serous fluid. As a rule, it gradually absorbs itself within a few days or weeks, the healing of the post-resection cavity is slower, and the cavity is naturally filled with soft tissues from the surroundings. In case of significant pressure or arching, it is appropriate to puncture the seroma with a thicker needle (pink). Sometimes repeated punctures are needed.

Another possible complication is an early infection, the incidence of which is slightly higher in breast surgery compared to "pure" aseptic procedures, as mammary ducts may be colonised by microflora. The wound infection shows typical signs of inflammation (redness, pain, bowing, in more severe cases, even general symptoms such as fever or chills). The release of infected secretion (purulent seroma) with a swab for bacteriological examination and antibiotic treatment, first empirically, later targeted. Even in breast surgery, the rule "Ubi pus, ibi evacua" applies, either by puncture or by dissolving one or more sutures. However, it is usually necessary to warn against the extensive dissolution of the entire wound, which would significantly prolong healing and lead to mostly poor cosmetic results. Evacuation of infected contents in a more conservative way is fully sufficient. The need for wide wound opening and, for example, a vacuum-assisted closure system is exceptional and is limited to the most serious complications. The frequency of early infections can be reduced by prophylactic perioperative administration of antibiotics. However, there are no clear opinions on the possible use of antibiotic prophylaxis in breast surgery due to possible side effects and increased costs. 

Mastectomy 

Mastectomy means the removal of the entire mammary gland with the surrounding soft tissues, although knowing that 100% of the glandular parenchyma may not be removed, as mentioned above. The indication can be therapeutic wherever a conservation procedure (BCS) cannot be used for breast cancer, either for tumour size, multicentricity, inability to adjuvant radiotherapy, or if the patient chooses to remove the entire breast as an alternative. Mastectomy can also be used prophylactically, usually in healthy carriers of BRCA gene mutations, where it is usually bilateral and usually associated with immediate breast reconstruction. Depending on the extent of the skin cover tissue that is removed during mastectomy, the following procedures can be distinguished: 

1) Simple mastectomy - NAC and such a part of the surrounding skin are removed so that the resulting defect can be sutured linearly under moderate tension, if possible without unpleasant skin excess, which is a problem usually at the edges of the wound (medially or laterally). The intention is a flat, smooth chest, on which it will be possible to apply a breast epithelium without any problems, i.e. a correction aid inserted into a special bra with an epithet. The resected skin usually has a spindle-shaped shape and, depending on the course of the long axis of the wound, an oblique or transverse mastectomy can be recognised. Orientation is chosen individually with regard to a favourable cosmetic result. It is rarely necessary to consider the location of the tumour if it grows into the skin. Vertical mastectomy has not been used for many decades. 

2) Skin-sparing mastectomy (SSMx) - NAC is usually removed with a variable part of the skin in its vicinity. The essence is to preserve a larger part of the skin cover than with simple mastectomy. The purpose is to maintain more favourable conditions for breast reconstruction. This procedure is particularly important if it is associated with immediate breast reconstruction. Otherwise, the left skin has annoying skin excesses, which are scarred and often cannot be meaningfully used in later breast reconstruction. The disadvantage of skin examination may also be a worse surgical approach and the resulting higher risk of complications with the possibility of skin necrosis caused by ischemia left by a larger skin lobe. 

3) Subcutaneous mastectomy (nipple-sparing mastectomy, NSMx) - the entire skin cover, including NAC, is preserved here. The relationship of the gland and outlets to the skin in the NAC area is very close, so it is rather the rule that a certain part of the gland remains left in the form of a retro-areolar "target" of the tissue if we do not want to face complicating postoperative necrosis. Thus, NSMx is used primarily as a prophylactic procedure in healthy carriers of BRCA gene mutations, which is usually associated with immediate breast reconstruction. It can also be used in a therapeutic indication for smaller tumours farther from the family, but with caution and awareness of possible lower radicality. Also, during mastectomy, it is necessary to pay attention to consistent hemostasis, and it is advisable to drain the wound with one or two Redon drains, which are usually left until the secretion drops to below 30 ml/day, which can take several days but also several weeks. If drains are left longer, there is an increased risk of ascending bacterial contamination of the wound, resulting in a clinically manifest early infection. Thus, the spectrum of possible complications is principally similar to that after BCS. In a mastectomy, the already mentioned cutaneous ischemic necrosis is more common. There is a risk of clinically significant perioperative loss in exceptional cases due to a large wound area, inconsistent perioperative hemostasis, and sometimes inappropriate surgical approach. Especially after bilateral mastectomy, blood transfusions may sometimes be necessary, but this situation should be exceptional in practice. Sometimes, as a result of mastectomy, episodic as well as persistent pain in the operated area, called "postmastectomy algic syndrome," may persist. Its healing effect is usually very difficult. Note: The current era of breast surgery dates back to the end of the 19th century when the American William Halsted (read Hölsted) introduced radical mastectomy. In addition to removing the breast, it also included resection of both pectoral muscles and the descending lymph nodes. Since then, breast surgery has undergone constant development in reducing the radicality of surgical intervention. This is related to the understanding of breast cancer as a systemic disease and, of course, the development of non-surgical treatment modalities. Today, the term "radical modified mastectomy" can be found. This was described in the first half of the twentieth century and represented a combination of simple mastectomy with axillary dissection. It still finds therapeutic use. 

Breast reconstruction

As already mentioned, the cosmetic defect after mastectomy can be adjusted in the simplest way using special bra pads (breast epithesis). In the first weeks after surgery, a soft foam postoperative epithesis is used. Later, after the wound has healed, the patient receives "definitive" silicone epithesis with a special washable cover and bra. Nowadays, these corrective aids are at such a level that it is not usual for a dressed woman to notice that her breast has been removed.

A more demanding option for correcting breast loss is breast reconstruction. It is a surgical procedure that restores the shape and looks of the breast using plastic surgery techniques. It is usually a challenging surgical procedure, which might be performed in one or several sessions, i.e. several surgeries are necessary to achieve the final result.

According to the timing, we distinguish between "Immediate" breast reconstruction, when the reconstruction begins already at the time of mastectomy (during one operation), or "delayed" breast reconstruction when the reconstruction is performed many weeks, months, or years after a mastectomy. Both procedures have their advantages and disadvantages, including indicated adjuvant radiotherapy, the local and time availability of reconstruction at the time of mastectomy, and mental, technical factors, etc.

The mistaken idea is that breast reconstruction threatens the oncological safety of cancer treatment and can be indicated once the patient is cured, is fixed in the public consciousness, including the medical professionals. However, it must be acknowledged that this argument is often an excuse only. In our country, the main reason for not needing immediate reconstruction is its local unavailability. In the Czech Republic, breast reconstruction is reserved for plastic surgery and is a demanding operation, limited by a large number of complicated and often requiring long discussions with the patient in order to achieve realistic expectations. In general, there are not enough plastic surgeons in the Czech Republic who would cover the demand of patients for reconstructions.

Of course, sometimes, there can be real adverse effects on cancer treatment and reconstruction procedures. 

Especially, it should be mentioned that the best possible cosmetic outcome may have a poor effect on the oncological radicality of surgery, and reversely, the more radically resected the mastectomy is, the more difficult it is to reconstruct the breast. 

In addition, reconstructions and radiotherapy interfere - radiotherapy always has a particularly negative effect on the reconstruction. Other possibilities are a possible delay of the resection operation within the "waiting" for the availability of a plastic surgeon or possible delay of the adjuvant oncological treatment, e.g. administration of chemotherapy, due to the ongoing complications of breast reconstruction. It is clear that the oncological aspect always has priority in the case of interference with oncological and reconstructive procedures!

From a technical point of view, the missing breast volume cannot be returned either by foreign material (alloplastic reconstruction) or by the tissue itself, autologous reconstruction. In some cases, it is possible or appropriate to combine both methods.

During alloplastic reconstruction, the basis of the volume of the reconstructed breast is a breast implant, which, however, cannot be inserted directly under the skin of the mastectomy lobe. Its coverage would be insufficient, the cosmetic effect bad and the risk of complications high. Therefore, it is necessary to support the coverage of the implant with a local skin lobe or special materials (e.g. acellular dermal matrix - ADM). Another option is to place the implant completely under the muscle layer, which usually requires tissue expansion using a submuscular breast tissue expander in the two-stage method. The disadvantage of implant reconstruction is mainly in the presence of foreign material in the body and the somewhat unnatural appearance of the breast. Unfortunately, the reality is also the general deterioration of the cosmetic result in time caused by the thickening of the fibrous capsule around the implant (capsular contracture).

The gold standard of autologous reconstruction is now flap reconstructions from the lower abdomen. The main volume of the lobe consists of the skin and subcutaneous tissue of the caudal part of the abdomen between the navel and pubic hair. The resulting defect at the abdominal donor site can be sutured linearly with transposition of the navel, which remains attached in the muscle-fascial abdominal wall in place in the linea alba. Of course, the procedure is not possible in thinner patients. The first to be described in the 1980s was a transverse rectus abdominis muscle (TRAM) flap. Its pedicle represents the cranial part of the rectus abdominal muscle on the upper epigastric vessels. Later, a free TRAM flap more certainly supplied by the lower epigastric vessels was introduced into practice as a free flap. However, this requires implementing microsurgical anastomosis of the artery and vein, usually on the internal thoracic vessels. To access these vessels, it is necessary to arrange access by resection of the parasternal part of the cartilage, usually III. ribs. Currently, the gold standard is the deep inferior epigastric perforators (DIEP) flap, supplied by one or more perforators of the deep inferior epigastric vessels. Its advantage is the possibility of complete preservation of the abdominal muscles and thus less weakening of the abdominal wall due to surgery. The disadvantage is a complex and time-consuming procedure. The pedicle flap with the latissimus dorsi muscle (LD flap) is also used in breast reconstruction. However, it is usually not the method of the first choice, but rather it is used when other reconstruction procedures fail. A more recent reconstruction method is lipofilling (lipografting, lipotransfer, fat transfer), consisting of harvesting the patient's fat tissue by liposuction and subsequent insertion of the cell fraction simply with a syringe and needle into the target site. The disadvantage is the limited volume of tissue transferred, and it is difficult to predict the level of absorption. The method usually needs to be implemented in more sessions, and despite that, it is necessary to presume that the reconstructed breast will be rather smaller. The advantage is the relative simplicity of the procedure and the absence of foreign material in the body.

Surgical procedures on the regional lymph nodes

An integral part of the surgical treatment of breast cancer is the operation on the regional lymph nodes performed, with a few exceptions, simultaneously with the operation on the breast. Over time, it has become increasingly clear that its significance is not so much therapeutic as the substantial determination of the condition of the axillary nodes and the resulting indications for non-surgical treatment modalities. However, therapeutic significance can still be expected in the case of more severe nodal involvement.

Sentinel Lymph Node Biopsy (SLNB, SNB, sentinel biopsy)

It is the surgical method of the first choice in patients without obvious clinical involvement of the axillary nodes within the pre-treatment assessment. In principle, it is a matter of removing the first sentinel node for the tumour area. The breast can be considered as a single lymphatic basin for sentinel biopsy. The indicator is used to identify the sentinel node, a macromolecular substance that, after injection into the breast area, is transported by the lymphatics to the first regional node and then to other nodes. In practice, the sentinel node is not always exactly one. In some cases, the indicator can be transported to two or more nodes simultaneously and with similar intensity. In this case, we remove two or more sentinel nodes. Even for this reason, SLNB is a procedure usually performed under general anaesthesia.

Nowadays, radiocolloid most often serves as an indicator. It is usually a macromolecule of albumin labelled with the isotope Technecia 99Tc. During lymphoscintigraphy, the indicator has applied either peritumorally to the parenchyma of the mammary gland. Still, it is more reliable to apply it intradermally to the periareolar area, where a dense lymphatic knit, the Sappey's plexus, is located. After transport to the node, the accumulated isotope can be detected in the axilla using a gamma-probe. The availability of this procedure is an essential requirement for breast surgery in hospitals these days. The application of the radiocolloid takes place either on the day of the operation in the morning (one-day protocol) or the day before the operation (two-day protocol). The choice of protocol depends mostly on the availability of the nuclear medicine workplace. Some dyes with suitable characteristics can also be used as indicators, such as patent blue or methylene blue. In more surgically difficult cases, the administration of both types of an indicator can be combined (combined method of SLN detection). Rarely, other substances can be used as indicators, such as indocyanine green (detected on the principle of fluorescence) or a paramagnetic substance (detected by a special magnetic probe). However, their use requires special equipment and has not become very widespread in practice.

The harvested sentinel node is sent for histopathological examination. The surgeon performs careful hemostasis and wound closure. It is possible to use drainage, but this is not necessary. Potential complications are operations, hematoma, early infection, seroma.

Axillary dissection (axillary dissection, axillary exenteration)

For decades, this was a typical surgical procedure on the axillary nodes. However, it has a relatively high risk of permanent secondary lymphedema of the upper limb (approximately 30% of operated patients) and is currently indicated only in patients with more severe metastatic involvement of the axillary nodes and patients with inflammatory cancer.

Opinions are still evolving as to what level of metastatic involvement of the axillary nodes is already "significant enough" for axillary dissection to be performed. However, knowledge of current views goes beyond the subject of general surgery. For that reason, we will not discuss the indication criteria of axilla dissection in more detail here. However, we would like to emphasise that dissection of the axilla in a patient without proven metastatic involvement of the axillary nodes is a serious medical failure!

It is also appropriate to mention the possibility of perioperative histopathological examination (perioperative cryobiopsy, frozen incision). At the time of SLNB implementation, sending a sentinel node for the perioperative frozen section was common practice. If a metastasis was found, the performance immediately extended to axillary dissection. However, this procedure is no longer used frequently, as the indication criteria for axillary dissection are now more complex and require factors other than the presence or absence of tumour cells in the sentinel node. In current practice, a large group of patients with a "positive" sentinel node no longer have to undergo axillary dissection today. It can either be omitted altogether or "replaced" by radiotherapy. The decision on possible supplementation of axillary dissection today is usually made by MDT with a delay after surgery, after receiving the final result of histopathological examination, in the context of the possibilities of non-surgical treatment modalities and after discussion with the patient.

Technically, the axillary dissection procedure consists of the removal of the fat body of the axilla with lymph nodes in the range of Level I and Level II of the axilla. It is performed along the axillary vein approximately to the medial edge of the pectoralis minor muscle. Anatomical structures define the extent of surgery. It is only rarely individually affected by the extent of cancer. Access to the operation can be obtained either from a separate arcuate incision or via a wound after a simple mastectomy or wide local excision. The position of the patient can be modified. The most suitable is the supine position with the upper extremity outstretched and the inclination of the table plane to the contralateral side. During the operation, it is necessary to visualise and preserve the long thoracic nerve running in the axilla's medial part and the serratus anterior (a fan-shaped muscle). Its interruption would result in scapular winging" (a scapula alata). We also preserve the thoracodorsal bundle running on the dorsal wall of the axilla and nourishing the latissimus dorsi muscle. Visualisation and investigation of the axillary vein is a matter of course, although it is often duplicated to avoid its seemingly "fatal" interruption without any consequences. We avoid the area cranially from the vein where the axillary artery and the structures of the brachial plexus. Unusually, it is necessary to dissect Level III of the axilla if it is affected by cancer metastases. The procedure can be technically demanding and risky, as the subclavian vein area is only accessible to a limited extent, and the risk of bleeding is considerable. Only in exceptional cases is the tumour involvement in the axilla so significant that it occupies some of the described structures. Then it is a matter of individual consideration of which structure can be sacrificed within the resection and whether it will be associated with a positive effect from an oncological point of view. In contrast, the intercostobrachial nerve or nerves and the pectoral bundle wrapping around the edge of the small pectoral muscle can be resected without serious consequences. The axillary dissected tissue is sent to the pathology as a whole. However, sometimes it may happen that after the dissection is completed, there are some unremoved nodes in the axilla. These can be removed later and sent for examination separately.

When dissecting the axilla, it is necessary to pay attention to consistent hemostasis and drain the wound with a drain. The drain is removed in lower daily secretion based on the principles stated for simple mastectomy.

The spectrum of early postoperative complications is similar to other procedures in breast surgery. However, as already described, axillary dissection carries a significant risk of long-term complications, especially secondary lymphedema. This arises as a result of irreversible interruption of the lymphatic system and thus a reduction in the transport capacity of the lymphatic system in the relevant basin (upper limb, chest wall). It is characterised by an increase in the volume of the upper limb, which is first reversible, later passes into an irreversible fibrotic stage. Whether or not lymphedema manifests itself depends on the individual capacity of the remaining lymphatic pathways. The incidence of lymphedema in operated patients is about 30%. Lymphedema can manifest clinically at varying intervals after surgery, often after several years. It is either permanent or appears only after increased load. The severity of subjective difficulties and objective symptoms may not always correlate with each other. Treatment of lymphedema is difficult and should take place in specialised clinics. It includes special exercises, bandages, arm sleeves, or special messages for lymphatic drainage. In principle, it is a mechanical aid to the outflow of tissue fluid so that lymphedema can only be corrected, not permanently cured. Pharmacotherapy has no convincing effect. There are reports of a beneficial effect of surgical treatment (lymphatic vessel anastomosis, lymph node transplantation). However, from a practical point of view, these methods do not play a crucial role. Therefore, lymphedema could be prevented by indicating axillary dissection only in strictly necessary cases. A common complication after axillary dissection is transient or permanent hyposensitivity of the inner or back of the arm caused by the interruption of sensitive nerves (intercostobrachial nerves). Rarely do permanent movement disorders occur. After dissection of the axilla, early rehabilitation (gradual and nonviolent warm-up) of the unilateral limb is always in place.

Less typical procedures in the axilla

Some less typical procedures have also been described in the field of axillary nodes, guided entirely by the effort to eliminate the need for axillary dissection, which can still be used today. We will mention them only briefly:

Axillary sampling is an untargeted removal of about 4 nodes from the axilla area.

Nowadays, the dissection of the level I of the axilla now basically has no legitimate place in breast cancer treatment.

Targeted Axillary Dissection (TAD) is a surgical procedure described in 2016 and reserved for patients with originally metastatic nodes who regress after neoadjuvant chemotherapy. The most severely affected node is histologically verified by core-biopsy or FNAB before treatment. Also, this node should be marked by one of the localisation methods of unpalpable lesions, usually by introducing a special clip or grain under USS navigation. The following operation is then performed similarly to the SLNB, with the difference that if the marked node is not among the sentinel nodes, it has to be also removed. It is not really appropriate to try to prepare individual nodes but rather to resect the area with sentinel nodes and the marked node. In some hospitals around the world, this performance is already the standard in carefully indicated cases. If the removed nodes are oncologically negative, the procedure is definitive. If metastases persist in any of the nodes, axillary dissection is in place after receiving histopathological results.

The role of surgery in the multimodal management of breast cancer

The most important in breast surgery is the knowledge or skill of individual surgical procedures, particularly their indications. The surgeon should primarily know the indication criteria for "his" operations and the outcome he is responsible for. The surgeon should not see themselves as just the "performer" of the operation that someone else commands. In the case of breast cancers, interdisciplinary meetings are preferably used, of which the surgical oncologist is also a member.

As mentioned above, surgical treatment of breast cancer is reserved for localised diseases without signs of distant metastases. In contrast, in metastatic diseases, mainly systemic treatment is indicated. However, surgery can rarely be used in patients with distant metastases, especially in two situations:

1) Salvage surgery (Rescue surgery) - these are situations where, regardless of the overall prognosis, it is appropriate to remove the tumour as it causes the patient significant local problems. Typically, these are large ulcerated tumours in the breast area with an intense odour and a risk of bleeding. Even "modern" conservative methods of wound healing tend to be powerless in this case. In such a case, it is possible to consider a surgical procedure, typically "salvage mastectomy", which can eliminate this biggest threat and significantly improve the patient's quality of life. The indication of these procedures must be assessed individually, and before the operation, the penetration of the tumour to the chest wall or other anatomically important structures should be clarified.

2) Resection of distant metastases - the indication of these operations is not fixed. In general, procedures can be considered for oligometastatic metastatic disease limited to one organ. Thus, typically solitary metastases of the lung, liver, and bone. Particularly if it responds favourably to systemic treatment or does not show the excessive size or numerical progression over time. In addition, these procedures must be performed by a surgeon experienced with the surgical procedures in a particular anatomical site.

In the case of localised disease, surgical treatment is applied either primarily or after neoadjuvant systemic treatment, usually chemotherapy. The patient should be discussed in MDT. In a favourable case, Neoadjuvant treatment can reduce the primary tumour and the affected nodes and thus create better starting conditions for surgery. These are typically situations with an unfavourable breast and tumour size ratio, where tumour shrinkage may allow for a BCS with better cosmetic results. In addition, clinical regression of nodal metastases may save the patient from axillary dissection. However, a necessary precondition for using neoadjuvant treatment is a relevant tumour phenotype, in which a response to systemic treatment can be expected. In general, paradoxically, these are rather "more aggressive" phenotypes, but they can show a significant response to systemic treatment. Achieving complete clinical remission after neoadjuvant treatment is a prognostically favourable parameter. However, it is still necessary to proceed with surgery in such a situation, as clinical regression may not correlate with complete histopathological regression.

The disadvantage of neoadjuvant treatment is that it makes it more difficult to determine the necessary extent of surgical resection because the tumours do not have to shrink concentrically, and likely, the cells may be "diluted" in a given volume. Furthermore, it is not entirely clear how to proceed in some situations in the area of ​​the axillary nodes, and examination of the resection is more difficult for the pathologist. Finally, systemic treatment may, in rare cases, be completely ineffective as the tumour grows, and its resection is delayed, which is unacceptable.

Other tumour and non-tumour lesions

In addition to breast cancer, several conditions can occur in the breast, from completely benign to premalignant. Their list would be, for surgery, long and confusing, and we will mention only the most important of them here.

Carcinoma in situ

According to the TNM classification, a pre-invasive lesion is where the tumour cells do not penetrate the basement membrane of the duct or lobule and are therefore not able to metastasise. It is more of a philosophical question whether or not they should be considered "cancer". According to the TNM classification of breast cancer, it is called "Tis".

Ductal carcinoma in situ (DCIS) - is a direct precursor of invasive breast cancer. The cells of the lining of the milk ducts undergo a gradual malignant transformation, and they start growing uncontrollably. However, in some cases, they cannot yet invade through the basement membrane and is, therefore, spread through the ductal tree, often discontinuously. They can often be clinically silent for a long time. Typically, calcification occurs in a particular breast location. This lesion is visible only on mammography and presenting as malignant microcalcifications, often on a large area. Sometimes they can lead to significant fibre production in the environment, which is the basis for possible ultrasonographic "visibility" of the lesion and makes it palpable.

From a surgical point of view, DCIS always requires a surgical solution, depending on the extent of the lesion, either in the form of BCS (usually with adjuvant radiotherapy) and often in the form of simple mastectomy. Determination of the range of the tumour before surgery is often complicated. It leads to necessary radicalisation. An operation based on histological examination of the surgical resection might be a resection of margins or simple mastectomy. The importance of node performance (SLNB) is controversial. About 1/3 of lesions considered to be DCIS according to a preoperative puncture biopsy will prove to be an invasive carcinoma in the definitive histopathological findings (a puncture biopsy will, of course, detect only a fraction of the lesion in which the invasion may not be present). The fact that "pure" DCIS does not have lymphatic or hematogenous metastatic abilities speaks against a regular sentinel lymph node biopsy performance. However, particularly in mastectomy, it is not realistic for the pathologist to thoroughly examine the entire mastectomy resection microscopically. Thus, cases of regional or distant metastases development can be encountered without a finding of invasive breast cancer.

The incidence of DCIS increases with the development of mammographic screening, but the proportion of patients treated for "pure" DCIS among all breast cancers is approximately 10%. A common situation is an invasive carcinoma in the surrounding DCIS field, which is already detected in the pre-treatment assessment.

Lobular carcinoma in situ (LCIS) - unlike DCIS, it is not considered a direct precursor of invasive carcinoma, but as an indicator of an increased risk of breast cancer in the patient, not only in the locality, but everywhere, but also in the bilateral breast. It is rarely diagnosed on its own. Rather, it is an incidental finding in a biopsy specimen or (more commonly) in resection for invasive cancer or other lesions. Its interference with the resection margin is not an indication of another surgical resection of margins. The presence of LCIS does not need to be treated surgically, although bilateral prophylactic mastectomy may be considered individually. In most cases, however, the "watch and wait" strategy is chosen, i.e. slightly more intensive patient monitoring.

Atypical ductal hyperplasia (ADH) is very closely related to DCIS. The difference between these lesions is only quantitatively defined by histopathological findings, and it represents a recognised premalignant lesion and an indication for surgical resection.

Other precancerous or non-tumoral diseases

A number of changes can be described in histological findings from puncture biopsies, such as columnar hyperplasia, flat epithelial atypia, sclerosing lesions, cysts, Fibrocystic disease (FCD), etc. These women have often been followed for decades in breast clinics. The term FCD is not frequently used today, and changes are no longer considered precancerous. As a result, breast clinics treat fewer women with benign lesions as most of the described benign changes do not require surgery. Over the years, the number of patients who often underwent unnecessary surgery for these benign lesions has decreased significantly.

Other breast cancers

Breast cancer is by far the most common cancer. Rarely, however, other cancers may occur in the breast. It is mainly a malignant variant of the phylloid tumour, formerly known as "cystosarcoma phyllodes", or a rare but very aggressive angiosarcoma most often caused by a late side effect of radiotherapy. These tumours may require radical surgical treatment if appropriate. However, it must be said that the overall prognosis of this disease is unpredictable. Infrequently, we can also encounter metastases to the breast area, such as malignant melanoma, colorectal cancer, etc.

Benign breast tumours

Of the benign breast tumours, the fibroadenoma is the most common. Histologically, tumour containing epithelial and stromal components. It is typically a sharply demarcated spherical tumour found in girls and young women. Multiple occurrences and a tendency to recurrence are common. The potential dependence on hormonal changes (and the use of hormonal contraception) is not very predictable. When finding it, we prefer a puncture biopsy. Possible confusion for cancer is not common but not exceptional. Surgical extirpation is indicated if it is symptomatic or reaches larger dimensions (3 - 4 cm). The operation is better performed under general anaesthesia. It differs from BCS mainly because the fibroadenoma can be easier to resect if we reach the correct tissue layer.

The resection of larger fibroadenomas is appropriate primarily to rule out phylloid tumours, which is similar to this tumour type, with more cellular stroma and a smooth transition from benign to malignant ones. In those cases, assessment of the biological nature (benign/borderline/malignant) using a puncture biopsy is usually unreliable. In the case of a phylloid tumour, we always prefer resection, rather in the form of BCS with the achievement of a free resection margin, which is especially important in malignant forms. Its clinical behaviour is mostly benign, but the rarer malignant form can excel in locally aggressive growth (repeated local recurrences) or even the formation of distant metastases.

Of the other benign tumours, the papilloma is worth mentioning. However, we can not rule out its transformation into papillocarcinoma of the breast. In a solitary lesion, surgical resection (in the form of BCS) is required. However, multiple papillomatosis is relatively common, which is a risk situation in terms of cancer. The management of these patients is often difficult, and it is necessary to discuss their cases in MDT.