Diagnosis and Treatment of Non-Palpable Legions of the Breast

Audio/Video Link *requires RealPlayer free download Dr. Jos Aristodemo Pinotti: "My presentation is related to the kind of strategy that we have been using during the last twelve years in doing histological and cytological monitoring during surgery with the objective to reduce local recurrence in conservative treatment of breast cancer. As you know, in the last forty years one of the most important achievements of treating breast cancer was conservative surgery, and there was and there is a very important enthusiasm with conservative surgery. Nevertheless, we learned with our experience in this last decade that one of the important problems of conservative breast cancer is local recurrence. We have 7, 8, or 9 times more local recurrence in conservative treatment than in radical treatment. In the beginning, even Veronesi who introduced this conservative treatment in an organized way, believed that local recurrence had no relation with the prognosis of breast cancer but immediately after not only Veronesi but a lot of other authors demonstrated that local recurrence is a very important marker of metastasis and metastasis is a very important marker of prognosis. So one of the most important concerns of the mastologists all around the world is with local recurrence in conservative treatment of breast cancer. As you can see, different authors have different frequency of local recurrence but all of them have high frequencies of breast cancer recurrence. Since the beginning when we have involving margins, the incidence of recurrence is larger than the incidence of recurrence when the margins are free but this is an observation after the surgery not during the surgery. This is the statistics, I mention Veronesi demonstrated that the relative risk of metastasis is four times more when he has a local recurrence, as Chowdhury three times more, and we demonstrated in our case three times more as well so there is no doubt that local recurrence is a very important marker for prognosis. Some authors and some statistics demonstrated that local recurrence occurs less in radical mastectomy, a little more in quadrantectomy, a little more in tumorectomy, and even more in quadrantectomy without irradiation. This paper of Holland's is a very important paper because he demonstrated not exactly dealing with local recurrence but with residual cancer focus in the breast that when you have margins of 1 cm you have more than 50%, 2 cm more than 40%, 3 or 4 cm 10%, but the most important conclusion of this paper is that even when you take almost all the breast, and all of you who are mastologists know when we take out a tumor with 4 cm of margins in a medium size breast, you almost take all the breast out. Even in that case, there is the presence of residual focus. So the solution is not only a question of extension of the margins, our conclusion in that moment was that we should try to individualize the case during the surgery, and that's our proposition. What do we do? We do the quadrantectomy and during the quadrantectomy if we have a known non-palpable lesion, we should be sure that the known non-palpable lesion was taken out using radiology and other forms that you already know. During the quadrantectomy, the pathologist is with us in the surgical theater and we put some markers in the different faces of the surgical specimen in order to be sure, together with the pathologist, who would identify the margins correctly. The pathologists do the scraping of the surgical margins in order to have a cytological examination. The cytological examination guides the histological examination, immediately after the margins are inked so they will be recognized in the histological frozen examination. The specimen is lanced and the histological examination is done in different parts of the surgical margins. We give a lot of importance to the margin that looks to the areola because of the epidermotropic characteristic of the cancer progression, and it's possible to detect during the examination if the tumor is near the margin because the margins are inked. Immediately after, the pathologist informs the surgeon about the margins and we decide together if