BREAST CANCER SURGERY

INTRODUCTION

Surgery remains the mainstay of treatment for breast cancer despite recent and continuing advances in medical treatment.

Breast cancer usually presents as a lump. Other less common ways that it can present are nipple distortion, skin dimpling or other changes in the skin, unilateral (one-sided) breast pain, breast asymmetry or nipple discharge. Breast cancer may also be detected by mammographic screening.

Once a diagnosis is made, a treatment plan is formulated for each individual patient. The multidisciplinary approach for breast cancer is used in planning treatment and all available options are considered in order to optimise cancer control. This may involve surgery, endocrine therapy, chemotherapy and radiotherapy. Adjuvant therapies are usually offered after surgery but can sometimes be given beforehand when it is termed neoadjuvant.

Surgical treatment is aimed at removal of the whole tumour with clear margins. Breast conserving operations remove the tumour with a rim of surrounding normal tissue and leave behind the rest of the breast tissue. Mastectomy is recommended for large tumours, widespread, multifocal or advanced local disease. Removal of lymph nodes from the axilla (armpit) on the side of the tumour is used to determine further treatment and prognosis.

Reconstruction of the partial defect after wide local excision or mastectomy is possible. The most common operations offered for breast cancer are:

• Breast conserving procedures:
  • Wide local excision
  • Lumpectomy
  • Quadrantectomy or Segmentectomy
• Mastectomy
• Reconstruction of the defect after cancer excision
• Axillary lymph node removal

Prophylactic bilateral mastectomy (removal of both breasts to prevent cancer) is sometimes offered to women who have a high risk of developing breast cancer because they carry (or have a high probability of carrying) a gene that predisposes to breast cancer, for example BRCA1 or BRCA2 genes. In women who are truly at risk, the risk reduction with prophylactic mastectomy is thought to be as high as 90%. Immediate breast reconstruction is possible for most women. All women considering this procedure should consult with a geneticist and specialist breast surgeon.

BREAST CONSERVING PROCEDURES

Breast conservation is offered when the size of the tumour in relation to the breast allows enough breast tissue to remain after tumour excision, and provide a satisfactory cosmetic result.

Wide Local Excision / Lumpectomy / Quadrantectomy

The breast cancer is removed with a rim of normal breast tissue in order to obtain clear margins.

Reconstruction of the defect after cancer excision

The extent of reconstructive surgery required depends on the size of the tumour and the amount of breast tissue that remains after the tumour is removed. There are various oncoplastic techniques that can be used for remodelling the remaining breast tissue.

The remaining healthy breast tissue can be moved into the defect using ‘oncoplastic simple volume displacement’ techniques so that the area in which the tumour was located does not end up as a depression and the scar stuck down onto the chest wall.

For larger tumours or when the tumour is situated in a position in the breast where these simple methods are not suitable, ‘oncoplastic mammaplasty volume displacement’ techniques can be used to refashion the remaining breast tissue and relocate the nipple-areola into a better position. The result is a normal shaped but smaller breast. Surgery to alter the opposite healthy breast can provide symmetry between the breasts.

When removal of a large tumour does not allow a satisfactory cosmetic result to be achieved with the remaining breast tissue, the options are to preserve the breast and replace the missing volume using ‘oncoplastic volume replacement’ techniques or, to perform a mastectomy with or without immediate breast reconstruction.

The advantage of the oncoplastic volume replacement option over mastectomy is that the donor site scar is shorter. In addition, a smaller amount of tissue is required for transfer into the defect. However, radiotherapy will be required to treat the remaining breast tissue.

On the other hand, the advantage of having a mastectomy over breast conserving surgery is that the risk of a recurrent cancer in that breast is minimised. Another advantage of a mastectomy is that radiotherapy to the chest wall may not be required. There are different options available for complete breast reconstruction. These include implants or expanders, flaps or a combination of these methods. Reconstruction after a mastectomy can be done at the time of the mastectomy (immediate) or at a later date (delayed).

The disadvantage of a mastectomy over breast conserving surgery is that more tissue will have to be imported for complete breast reconstruction if this is desired.

MASTECTOMY

Mastectomy involves removal of all of the breast tissue. Mastectomy is advised when disease is widespread, multifocal (more than one tumour), the tumour is large in relation to breast size or there is residual disease after attempted wide local excision. Some women opt for mastectomy in the first instance in order to have the least chance of residual disease or to avoid radiotherapy to the remaining breast tissue.

Breast reconstruction after mastectomy

If mastectomy is necessary, the complete range of ‘techniques for breast reconstruction’ appropriate to the individual woman should be discussed either as an immediate or delayed procedure, to fit in with the overall treatment plan for the breast cancer.

LYMPH NODE REMOVAL

Removal of lymph nodes from the axilla (armpit) gives information about whether or not breast cancer cells have spread outside the breast. The state of the lymph nodes is an important indicator of prognosis because there is a direct relationship between the number of lymph nodes involved with cancer cells and the risk of the breast cancer recurring. Adjuvant therapy can be tailored to each woman on this basis. There are different procedures for the removal of axillary lymph nodes and they include axillary clearance (levels 1-3), axillary sampling and sentinel node biopsy. They vary in the number of nodes removed and how the nodes are identified for removal. In general, the smaller the number of nodes removed, the less likely is the chance of lymphoedema (swelling of the arm). Lymphoedema may occur from months to years after the operation or radiotherapy. Radiotherapy in addition to axillary lymph node clearance gives the highest rate of lymphoedema and this combination is best avoided if at all possible.

More and better options for treatment, preservation and reconstruction of the breast are now available for women diagnosed with breast cancer. Understanding what is available will empower women to play an active role in their care.