Award Lecture: "What’s new in breast cancer surgery: a tailored approach"

It is now clear that breast cancer may be more or less aggressive and that several prognostic and predictive factors may play a major role in the choice of the most appropriate therapy and in the final results. Modern imaging, morphological and biological characterisation of the lesion (besides many other factors such as age, fitness and attitude of the patient towards the diagnosis of cancer), require a more flexible attitude from the surgeon.

The study of the primary tumour and of its pathological features together with a molecular portrait based on the gene expression patterns and modern technology in examining sentinel node (reverse transcriptase-polymerase chain reaction (RT-PCR)) will undoubtedly lead to a better understanding of breast cancers.

Moreover, the surgeon should never forget that correct treatment nowadays is the result of the correct blending of the surgical, radiotherapeutical and pharmacological techniques that are available. This obviously means that the surgeon is no longer alone when faced with the tumour. However, this demands great knowledge of the problems and the ability to face different situations and to evaluate each single situation in its entirety.

Surgical treatment may cure a high percentage of cases nowadays and this is due to early diagnosis. However, early diagnosis does not mean underestimating the risks and problems connected with breast cancer.

Conservative surgery is now the usual therapy for small in situ or invasive tumours, but many problems must be solved.

Practically, one can either be a maximalist, doing the upmost independently of the histology and biology of the tumour, carrying out as large an excision as possible, or a minimalist, guided by global evaluation of the situation and therefore highly personalised. Certainly the former is easier, more traditional and more easily repeatable in terms of respecting guidelines. The second is more eclectic, requires a deep knowledge of the problem and therefore patient management becomes more complex and difficult.

However, in the near future there will certainly be quality improvement in the diagnosis and treatment of breast cancer and keener attention to individual situations. In particular, everything should be codified, registered and subject to quality control. Every phase of the surgical procedure must be accurately recorded to favour quality control, to ensure completeness of excision, to avoid overtreatment of women with favourable lesions, to ensure that all necessary data are obtained for making decisions on adjuvant radiotherapy or adjuvant systemic therapy.