Chirurgie mammaire de la femme à haut risque : importance d'une stratégie multidisciplinaire thérapeutique en cas de cancer du sein

Breast surgery in high-risk patients is either prophylactic surgery if cancer is not yet present or therapeutic surgery if cancer is already present. For prophylactic surgery, a risk-reducing procedure based on a risk analysis can be considered if a program with risk-adapted monitoring is not feasible for the patient. This is generally preceded by genetic counseling and several tools are available for calculating the risk. If a bilateral salpingo-oophorectomy is necessary (BRCA1 or BRCA2 positivity), a combination of procedures may be considered. In such cases, it is almost always possible to perform primary reconstruction with autologous tissue or a silicone implant. If a therapeutic operation is performed because cancer is already present, several additional issues arise. In particular, a decision must be made as to whether it is more useful to operate first or administer primary chemotherapy. If the patient is young and chemotherapy is necessary, there is also the question of preserving fertility or harvesting eggs, which affects the schedule of surgical procedures. Occasionally primary chemotherapy is then begun only reluctantly because there is no time for fertility counseling and fertility-preserving measures. On the one hand, it is useful to know whether the patient has a relevant genetic predisposition because the breast surgery then more frequently results in a mastectomy. On the other hand, if the genetic predisposition is lower, a breast-preserving procedure can be used, followed by intensive tumor follow-up and high-risk monitoring. Genetic counseling and analysis of the BRCA gene take a few weeks, which also affects treatment planning. If radiotherapy of the chest wall and possibly of the lymph nodes is indicated, this also affects the method of reconstruction (complications in prostheses such as encapsulation and infection occur much more frequently after radiotherapy). These aspects underline the importance of multidisciplinary strategic planning in high-risk patients, which is why in all certified breast centers discussion of each new breast cancer case in a multidisciplinary conference prior to treatment is required for every patient.