Breast Surgery

The Breast Center provides state-of-the-art diagnostic and surgical care, strictly adhering to the latest international protocols. With a focus on early and accurate diagnosis, as well as tailored, patient-centered treatment, the Center covers the full spectrum of breast disease management.

Services:

• Fine Needle Aspiration (FNA) biopsy
• Core needle biopsy (with or without ultrasound guidance)
• Lumpectomy/Quadrantectomy combined with oncoplastic techniques
• Sentinel lymph node biopsy
• Skin-sparing mastectomy, with or without preservation of the nipple–areola complex
• Immediate reconstruction (using autologous tissue, expanders, or implants)

Preoperative Diagnosis

Preoperative diagnosis is essential for optimal treatment planning, as it ensures accuracy before surgery. In cases of suspicious findings, histological confirmation using a core biopsy is recommended. This approach, standard across international Breast Units, guarantees maximum diagnostic precision and supports safe preoperative planning.

Depending on lesion characteristics, preoperative diagnosis can be achieved through four methods:

• Palpable lesion: Percutaneous core needle biopsy
• Ultrasound-visible, non-palpable lesion: Ultrasound-guided core needle biopsy
• Mammography-only lesion: Stereotactic vacuum-assisted biopsy, particularly valuable for small lesions and microcalcifications
• MRI-only lesion: MRI-guided biopsy, available at Metropolitan Hospital, allowing highly accurate tissue sampling. Several such procedures have already detected early cancers as small as 1–2 mm

At our Breast Center, under the guidance of Dr. V. Venizelos, all these diagnostic methods are performed with exceptional accuracy, ensuring the best possible preoperative assessment. Clinical results have demonstrated diagnostic accuracy of up to 98%, as presented at the Hellenic Breast Surgery Society Congress (2010) and the European Breast Congress (2013).

All procedures are minimally invasive, performed under local anesthesia, through tiny incisions, and take only a few minutes.

In leading international Breast Centers, intraoperative frozen-section biopsy is now performed only in very limited cases.

Diagnosis should always be established before surgery, ensuring that the patient is fully informed from the outset about both the nature of the condition and the treatment plan. This approach also allows the patient, in many cases, to actively participate in decision-making.

Preoperative Diagnosis with Core Needle Biopsy for Histological Confirmation

Until a few years ago, fine needle aspiration (FNA) was the standard method for establishing a cytological diagnosis of a breast lump. While FNA has a relatively high sensitivity, it can still produce false-negative results.

In recent years, including in Greece, FNA has largely been replaced by image-guided core needle biopsy (Core Biopsy).

This method allows for the extraction of small tissue samples rather than just individual cells, enabling highly reliable histological confirmation of the lesion.

This approach offers several important advantages:

• By analyzing the tumor’s molecular profile and all its characteristics, clinicians can safely determine preoperatively the appropriate management of the axillary lymph nodes—whether a full lymph node dissection is necessary or not. Specific criteria, such as those established in the Z0011 study, indicate that even if some lymph nodes are positive for metastasis, radical axillary dissection may be unnecessary. The Z0011 study demonstrated that postoperative radiation of the corresponding axilla does not affect survival but significantly reduces morbidity and the incidence of lymphedema.
• If the lesion is benign, confirmed through complete histological analysis, surgical intervention can often be avoided.
• In certain patients, depending on the tumor’s characteristics, preoperative (neoadjuvant) chemotherapy may be more beneficial. After completing this therapy, surgery can be performed with improved safety and outcomes. The tumor characteristics that guide this decision are determined from the histological analysis of the tissue samples obtained via core needle biopsy.

Sentinel Lymph Node Biopsy

Ιn patients with a preoperative diagnosis of breast malignancy established through one of the methods described above, and who do not have palpable or pathological lymph nodes in the corresponding axilla, a sentinel lymph node biopsy (SLNB) should be performed. This procedure is now considered the gold standard and is included in all international guidelines for axillary management in early-stage breast cancer.

At the Nuclear Medicine Department, a few hours before surgery, the sentinel lymph node(s) are localized through the injection of a very small amount of radiotracer into the breast lymphatic channels, followed by lymphoscintigraphy to record the precise location. After anesthesia, a small amount of blue dye is injected to further delineate the sentinel node(s).

The identified lymph node(s)—typically 1 to 4—are then surgically removed and sent for rapid intraoperative pathological examination. If the nodes are negative for metastatic involvement, a full axillary lymph node dissection is not required.

This approach significantly reduces the risk of lymphedema, minimizes pain, allows early mobilization of the upper limb, and enables a rapid recovery. In many cases, patients can even be discharged on the same day.

Only in cases where the sentinel lymph node shows macrometastatic involvement (not micrometastases or isolated tumor cells) is a full axillary lymph node dissection considered necessary—and even then, recent studies show that in some cases with 1–2 positive sentinel nodes, complete dissection can be safely avoided under specific criteria. The importance of preoperative diagnosis is critical here: knowing the tumor’s molecular profile allows oncologists to safely decide whether complete removal of axillary lymph nodes is required if the sentinel node contains enough cancer cells to be classified as a macrometastasis.

Dr. Vasilis Venizelos, Director of the Breast Center, was among the first in Greece to implement the sentinel lymph node biopsy technique, beginning in the early 2000s.

Oncoplastic Breast Surgery

A key offering of the Breast Center, when a preoperative diagnosis of malignancy has been established, is the careful planning of the upcoming surgery. This is often done in collaboration with plastic surgeons for more complex or demanding procedures. Patients therefore have access to oncoplastic surgery or immediate reconstruction following mastectomy whenever deemed necessary.

Oncoplastic techniques are now a standard part of modern breast cancer surgery, providing:

• Oncological safety
• Significantly improved aesthetic outcomes for the operated breast
• Lumpectomy -the removal of the breast lesion with safe, “clean” surgical margins- is recommended in all cases of early-stage breast cancer. Successful application of oncoplastic techniques requires specialized training. In leading international centers, breast surgeons perform these procedures without implants, instead using the repositioning of internal tissue flaps to fill the defect left by tumor excision

Requirements for Oncoplastic Surgery

• Preoperative diagnosis (Core biopsy, FNA, Mammotome)
• Accurate imaging of the lesion to avoid reoperation (e.g., breast MRI)
• Preoperative staging, detailed medical history, clinical examination, and surgical planning, including incision design
• Comprehensive patient counseling with active involvement in the final decision
• Collaboration with a plastic surgeon where necessary

Advantages of Oncoplastic Techniques

• Reduces the need for reoperation due to positive margins
• Supports local disease control and reduces the risk of recurrence
• Preserves or even improves aesthetic outcomes, achieving symmetry with the contralateral breast
• Decreases the overall number of mastectomies performed
• Significantly enhances quality of life and psychological well-being for patients

Neoadjuvant Chemotherapy

The administration of chemotherapy prior to surgery—known as neoadjuvant chemotherapy—is increasingly utilized, following strict criteria in carefully selected patients. It is particularly beneficial for two patient groups: patients with triple-negative tumors, meaning tumors that lack estrogen receptors, progesterone receptors, and HER2 (c-erb B2) expression and patients with HER2-positive tumors (3+), which overexpress the HER2 protein.

Another group includes patients with large tumors, where standard mastectomy may not safely achieve complete tumor removal or may be technically challenging due to extensive skin involvement or tumor adherence to the chest wall. In these cases, preoperative chemotherapy is recommended to shrink the tumor (downstaging), transforming an initially inoperable tumor into one that can be safely and effectively removed. When the tumor responds well to treatment, it may even allow for lumpectomy instead of full mastectomy, preserving more of the breast while ensuring oncologic safety.

Oncological Board

At the Breast Surgery Clinic, a weekly multidisciplinary tumor board is held, as is standard in modern breast centers worldwide. In collaboration with medical oncologists and radiation oncologists, treatment decisions are made for each patient with breast cancer, ensuring a coordinated, evidence-based approach tailored to the individual.

Genetic Counseling Clinic

The Breast Clinic also operates a high-risk monitoring program for individuals with a positive family history of breast cancer. A comprehensive personal and family history is taken, and, in collaboration with a specialist biologist-geneticist, personalized recommendations are made according to international guidelines.

Psychological Support

Patients at the Breast Center, before or after surgery, receive support from a dedicated psychologist when needed. Additionally, there is close collaboration with the NGO “Alma Zois”, whose trained volunteers connect with patients seeking discussion and support from women with similar experiences.

The Breast Center at Metropolitan Hospital actively participates in all protocols of the Hellenic Surgical Society of Breast Surgery and regularly contributes to conferences in Greece. Presentations focus primarily on oncoplastic breast surgery, outcomes from sentinel lymph node biopsy, and broader topics concerning breast diseases.

All services offered by Metropolitan Hospital in breast disease management and preventive screening are directed by Dr. Vasilis Venizelos, a breast surgeon with over 15 years of specialized training in the UK. The center is staffed by an excellent scientific team and collaborates with distinguished specialists across multiple disciplines, including radiologists, pathologists, nuclear medicine physicians, plastic surgeons, medical oncologists, radiation oncologists, and highly trained nursing staff.