Breast Cancer Surgery | Dr. Wu Jiong (Breast Surgery) | CMCS Shanghai

About Dr. Wu Jiong

Dr. Wu Jiong is Director of Breast Surgery at Fudan University Shanghai Cancer Center — China's foremost oncology institution and one of the highest-volume breast cancer surgical centres in the world. She is a nationally recognised leader in breast cancer surgery, oncoplastic reconstruction, and sentinel lymph node procedures, with particular expertise in neoadjuvant therapy-guided breast conservation, volume displacement oncoplasty, and fluorescence-guided sentinel lymph node navigation. Dr. Wu's practice is defined by the philosophy that breast cancer surgery must achieve two simultaneous goals: oncological cure and preservation of the patient's body image, psychological wellbeing, and quality of life. Her team at Fudan University Shanghai Cancer Center has pioneered the integration of dual-tracer sentinel lymph node navigation, Level II oncoplastic techniques, and contralateral symmetrisation into a single operative workflow for young patients with locally advanced breast cancer.

Case Overview

Ms. Sophie Martin, a 35-year-old French university lecturer based in Shanghai, unmarried and nulliparous with strong wishes to preserve fertility and breast appearance, presented with a three-month history of a progressively enlarging left breast mass. Examination revealed a 4 cm × 3 cm firm, poorly mobile mass in the upper outer quadrant with an enlarged left axillary lymph node. Core biopsy confirmed invasive ductal carcinoma Grade II, ER-negative, PR-negative, HER2 3+, Ki-67 40% — HER2-positive subtype, Stage cT2N1M0 (IIB). BRCA1/2 testing was negative. The multidisciplinary team elected neoadjuvant TCbHP chemotherapy (docetaxel, carboplatin, trastuzumab, pertuzumab) for four cycles to downstage the tumour and create conditions for breast conservation. After four cycles, the tumour reduced to 1.2 cm × 0.8 cm on MRI. Dr. Wu Jiong performed oncoplastic breast-conserving surgery using volume displacement with an inferior pedicle glandular flap, dual-tracer ICG fluorescence plus methylene blue sentinel lymph node biopsy, and simultaneous contralateral reduction mammoplasty for symmetry. Three sentinel lymph nodes were identified; one showed micrometastasis (<2 mm); axillary lymph node dissection was omitted per ACOSOG Z0011 criteria. Final pathology: tumour 1.0 cm, clear margins (>2 mm), Miller-Payne Grade 5 (near-complete pathological response). The patient was discharged at 24 hours with excellent aesthetic outcome and returned to lecturing at six weeks.

Patient Background

• Name / Nationality: Ms. Sophie Martin (pseudonym) — French; university lecturer based in Shanghai
• Age / Sex: 35-year-old female; unmarried; nulliparous; strong fertility and breast preservation priorities
• Chief Complaint: Left breast mass for 3 months, progressively enlarging
• Examination: Left upper outer quadrant mass 4 cm × 3 cm; firm; poorly mobile; ill-defined margins; left axillary lymph node enlarged approximately 1.5 cm; right breast and axilla normal
• Imaging: Mammography and ultrasound — irregular high-density mass with microcalcifications; BI-RADS 5; axillary lymph node cortical thickening with loss of fatty hilum
• Pathology: Invasive ductal carcinoma Grade II; ER(-), PR(-), HER2(3+), Ki-67 40%
• Stage: cT2N1M0 — Stage IIB; HER2-positive subtype
• Genetics: BRCA1/2 negative

Neoadjuvant Therapy and Surgical Planning

Rationale for Neoadjuvant Approach

Direct surgery for a 4 cm HER2-positive tumour with axillary nodal involvement would have required total mastectomy and axillary lymph node dissection — a devastating outcome for a 35-year-old patient with strong body image priorities. HER2-positive breast cancer is among the most chemotherapy-sensitive subtypes, with pathological complete response rates of 40–60% with dual HER2 blockade. Neoadjuvant therapy serves two purposes: tumour downstaging to enable breast conservation; and in vivo chemosensitivity testing — the pathological response at surgery predicts long-term prognosis and guides adjuvant therapy selection.

Neoadjuvant Regimen: TCbHP

• Regimen: Docetaxel + carboplatin + trastuzumab + pertuzumab (TCbHP) — four cycles
• Rationale: Dual HER2 blockade (trastuzumab + pertuzumab) with platinum-based chemotherapy — the standard neoadjuvant regimen for HER2-positive breast cancer per NEOSPHERE and TRYPHAENA trial evidence
• Tolerability: Manageable toxicity; no dose reductions required; fertility preservation counselling and oocyte cryopreservation completed before chemotherapy initiation

Response Assessment

• Clinical examination: Tumour reduced to approximately 1.5 cm; softened; axillary lymph node no longer palpable
• Breast MRI: Residual tumour 1.2 cm × 0.8 cm in upper outer quadrant deep parenchyma; no satellite lesions; axillary nodes radiologically negative
• Response classification: Partial response (PR); R0 resection with breast conservation feasible

Dr. Wu's pre-operative assessment: The MRI tells us the tumour has responded beautifully — from 4 centimetres to just over 1 centimetre. But the location is the challenge. The upper outer quadrant is the most visible part of the breast. A standard lumpectomy here leaves a concavity that is immediately apparent in any clothing. We need to remove the tumour with adequate margins and simultaneously reconstruct the defect with the patient's own tissue — so that when she looks in the mirror, she sees a breast, not a scar. That is what oncoplastic surgery gives us.

Operative Procedure

Phase 1 — Dual-Tracer Sentinel Lymph Node Biopsy

Tracers: Indocyanine green (ICG) fluorescence combined with methylene blue dye — injected peritumorally and subareolarly. Dual-tracer technique is mandatory after neoadjuvant therapy: neoadjuvant-induced axillary fibrosis increases the false-negative rate of single-tracer sentinel lymph node biopsy (SLNB) to 12–14%; dual-tracer reduces this to below 8%.

Fluorescence navigation: Near-infrared fluorescence imaging system used to visualise ICG-labelled lymphatic channels and sentinel nodes in real time — providing anatomical guidance that blue dye alone cannot achieve in a fibrotic post-neoadjuvant axilla.

Sentinel node harvest: Three sentinel lymph nodes identified (blue-stained and fluorescent): one in Level I, two in Level II. Intraoperative frozen section: one node with micrometastasis (<2 mm); two nodes negative.

Axillary management decision: Per ACOSOG Z0011 trial criteria — T1-2 primary tumour, 1–2 sentinel nodes with micrometastasis or macrometastasis, breast-conserving surgery with planned whole-breast radiotherapy — axillary lymph node dissection (ALND) omitted. ALND omission eliminates the primary cause of post-operative upper limb lymphoedema, which affects 20–30% of patients after full axillary dissection and is a lifelong morbidity.

Dr. Wu's operative note: The Z0011 data are unambiguous: for T1-2 patients with 1–2 positive sentinel nodes who receive whole-breast radiotherapy, axillary dissection adds no survival benefit and adds substantial morbidity. Lymphoedema is not a minor complication. It is a permanent, progressive condition that affects every aspect of daily life — dressing, exercise, professional activity. For a 35-year-old lecturer who uses her arms every day, avoiding lymphoedema is not a quality-of-life consideration. It is a clinical imperative.

Phase 2 — Oncoplastic Breast-Conserving Surgery

Incision design: Tennis racket incision along the areolar margin extending toward the upper outer quadrant — combining oncological access with aesthetic scar placement along the natural areolar border.

Tumour excision: Complete excision of residual tumour with 1 cm circumferential margin including deep fascia. Intraoperative frozen section of all six margins confirmed negative — R0 resection achieved before proceeding to reconstruction.

Volume displacement oncoplasty — inferior pedicle glandular flap: The glandular tissue of the lower breast pole was mobilised on its inferior vascular pedicle and rotated superolaterally to fill the upper outer quadrant defect created by tumour excision. This volume displacement technique uses the patient's own breast tissue — no implants, no donor site — to restore breast contour and eliminate the post-lumpectomy concavity that would otherwise result from upper outer quadrant resection.

Wound closure: Glandular layer closed with absorbable sutures to reshape the inframammary fold; skin closed with subcuticular suture for minimal scarring.

Dr. Wu's technical note: The inferior pedicle rotation is not a cosmetic procedure added to the cancer operation. It is the cancer operation done correctly. If we leave a concavity in the upper outer quadrant, the patient will need a second operation to correct it — or she will live with a deformity that reminds her of her cancer every time she dresses. We plan the reconstruction before we make the first incision. The oncological and aesthetic goals are designed together, not sequentially.

Phase 3 — Contralateral Symmetrisation

Simultaneous right reduction mammoplasty: To achieve bilateral symmetry, a reduction mammoplasty was performed on the right breast in the same anaesthetic session — removing equivalent tissue volume to match the post-oncoplasty left breast size and ptosis. Symmetrisation in the same operation avoids a second general anaesthetic, reduces the total recovery period, and ensures the patient wakes from surgery with matched breasts rather than experiencing an asymmetric interim period.

Operative data: Total operative time 3.5 hours (bilateral); blood loss approximately 50 mL; single left axillary negative-pressure drain placed.

Post-operative Course and Outcomes

• Recovery: Mobilised at 6 hours post-operatively; drain removed at 24 hours (output <30 mL); discharged day 1
• Wound: Primary healing; no seroma, no infection, no wound dehiscence
• Aesthetic outcome: Harvard Breast Cosmesis Scale: Excellent — bilateral symmetry, no visible deformity, natural breast contour preserved
• Patient satisfaction: Reported high satisfaction with breast appearance at 6-week follow-up; returned to full-time lecturing

Final Pathology

• Tumour size: 1.0 cm residual invasive carcinoma
• Margins: All margins clear (>2 mm) — R0 resection confirmed
• Lymph nodes: 1/3 sentinel nodes with micrometastasis (ypN1mi); no extranodal extension
• Miller-Payne Grade: G5 — near-complete pathological response; no residual invasive carcinoma in the primary tumour bed; only in situ component remaining

Adjuvant Treatment

• T-DM1 (trastuzumab emtansine) for residual disease per KATHERINE trial protocol — 14 cycles
• Whole-breast radiotherapy with tumour bed boost
• Ongoing fertility monitoring; oocyte cryopreservation completed pre-chemotherapy

Expert Commentary — Dr. Wu Jiong

1. Neoadjuvant Therapy as the Gateway to Breast Conservation

For HER2-positive and triple-negative breast cancer, neoadjuvant therapy is not merely a downstaging tool — it is an in vivo pharmacological test that reveals the tumour's biological sensitivity to treatment before the patient commits to a surgical plan. A tumour that achieves pathological complete response after neoadjuvant therapy has demonstrated that systemic therapy can eradicate microscopic disease — the most important prognostic information available. A tumour that does not respond identifies a patient who needs treatment intensification. In this case, the near-complete pathological response (Miller-Payne G5) confirmed that the dual HER2 blockade had eliminated virtually all invasive disease — transforming a mastectomy candidate into a breast conservation candidate with an excellent long-term prognosis.

2. Sentinel Lymph Node Navigation After Neoadjuvant Therapy

Sentinel lymph node biopsy after neoadjuvant therapy is technically more demanding than primary SLNB because neoadjuvant-induced axillary fibrosis disrupts the normal lymphatic architecture, increasing the false-negative rate of single-tracer techniques. The dual-tracer approach — ICG fluorescence combined with blue dye — addresses this by providing two independent detection mechanisms: the fluorescence system visualises lymphatic channels in real time under near-infrared light, guiding the surgeon to nodes that blue dye alone might miss in a fibrotic field. The Z0011 omission of axillary dissection for 1–2 positive sentinel nodes is one of the most important advances in breast cancer surgery of the past two decades. It eliminates the primary cause of post-operative lymphoedema without compromising survival — a trade that every eligible patient should be offered.

3. Oncoplastic Surgery: Integrating Oncology and Aesthetics

Oncoplastic breast-conserving surgery is not cosmetic surgery performed after cancer surgery. It is cancer surgery designed from the outset to achieve both oncological and aesthetic goals simultaneously. The volume displacement technique — rotating the patient's own glandular tissue to fill the resection defect — requires no implants, no donor site morbidity, and no second operation. It requires pre-operative planning that integrates tumour location, breast volume, skin envelope, and the patient's aesthetic priorities into a single surgical design. For upper outer quadrant tumours, which are the most common location for breast cancer and the most visible location for post-lumpectomy deformity, the inferior pedicle rotation is the standard oncoplastic solution. The result is a breast that looks and feels natural — not a breast that has been operated on.

4. Contralateral Symmetrisation: Completing the Holistic Outcome

Breast cancer surgery that leaves the patient with asymmetric breasts has not completed its job. For young patients with naturally full breasts, the asymmetry between an oncoplastically reconstructed breast and an untouched contralateral breast is immediately apparent and psychologically distressing. Contralateral reduction mammoplasty in the same operative session eliminates this asymmetry, reduces the contralateral breast's cancer risk (by reducing breast volume and density), and allows the patient to wake from surgery with a matched, aesthetically pleasing result. The additional operative time — approximately 45 minutes — is the most cost-effective investment in the patient's long-term psychological recovery that breast surgery can offer.

How CMCS Shanghai Coordinated This Case

CMCS Shanghai supported Ms. Martin from initial inquiry through adjuvant treatment completion, including: pre-consultation review of external mammography, ultrasound, and core biopsy pathology; specialist referral to Dr. Wu Jiong at Fudan University Shanghai Cancer Center's Breast Surgery Department; fertility preservation counselling coordination and oocyte cryopreservation scheduling before chemotherapy initiation; bilingual interpretation throughout all MDT discussions, neoadjuvant consent, and surgical planning sessions; coordination of breast MRI response assessment after four neoadjuvant cycles; real-time surgical updates to the patient's family in France; post-operative wound care and drain management instructions in English and French; six-week aesthetic outcome assessment coordination; T-DM1 adjuvant therapy scheduling and tolerability monitoring; radiotherapy planning coordination; and long-term surveillance protocol establishment with direct liaison between Dr. Wu's team and the patient's oncologist in Paris.

For international patients with breast cancer requiring expert surgical and oncological management in Shanghai, Dr. Wu Jiong's team at Fudan University Shanghai Cancer Center represents breast oncology expertise at the international frontier — combining neoadjuvant precision, sentinel lymph node navigation, and oncoplastic reconstruction to achieve cure without compromise. CMCS ensures that expertise is accessible: in the patient's language, with fertility and aesthetic priorities respected from the first consultation, and with overseas physicians informed at every treatment decision.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.