Breast Cancer surgery
The primary treatment for invasive breast cancers is by surgical removal of the tumor, and quite often this is followed by radiation therapy to help prevent a local recurrence of the breast cancer. The first issue in which the surgeon participates is to ‘stage‘ the breast cancer. This involves determining the size of the tumor, whether or not cancer cells have invaded beyond the breast duct walls, and if there is metastasis to the lymph nodes.
I just want to let you know that I have created a newer version of this page with more up-to-date information on Breast Cancer Surgeries. However, this page is still very useful, and I would still use it as well.
The type of breast cancer and nuclear grade of the actual cells are also important staging and grading factors, but those considerations are generally determined by the pathologist and not the surgeon.
If an excisional (large sample) biopsy is required, this will be performed by a surgeon. The surgeon is naturally called upon to perform the lumpectomy (tumorectomy), or breast mastectomy, and will They also perform axillary node dissections and sentinel lymph node biopsies as required.
The surgeon may need to remove additional axillary lymph nodes
If the breast cancer is indeed classified as ‘invasive‘, then the status of the lymph nodes has to be determined. This is usually first accomplished by a sentinel node biopsy, which is also performed by the surgeon. A few of the sentinel lymph nodes have to be located and then surgically removed. If these are found to be free of cancer cells upon microscopic evaluation, no additional lymph nodes need to be removed. Generally one hopes to avoid extensive axillary lymph node dissection, especially in situations where all other indicators suggest they are highly likely to be negative for cancer cells. In some cases, radiation therapy might be applied to the region as a preventative measure, instead of surgical exploration or removal.
The surgeon needs to know the location, size, and orientation of the breast tumor
The main concerns for the surgeon removing the breast tumor are first to remove all of the tumor, and secondly to leave reasonably wide ‘margins‘. A margin is a certain width of normal tissue surrounding the cancer tumor. A wide ‘negative‘ margin, which means a band of tissue with no trace of cancer cells around the site of the removed tumor, is essential to help prevent local recurrence.
The surgeon will try to plan the surgery with a view to leaving this wide surgical margin, but it’s not always easy. Sometimes the breast tumor develops in locations where a wide margin is not easily achieved and surgery might interfere with other vital functions.
The radiologist and the surgeon work together to plan breast cancer treatment
The surgeon and the radiologist will normally meet before the operation to discuss the X-ray and ultrasound images of the tumor. Specifically, the surgeon will want to know exactly where the tumor is, and whether there are any unusual features of the tumor. A decision has to be made in terms of whether or not the breast can be conserved.
Generally speaking, all reasonable efforts are made to conserve the breast. But if the pathological and radiology reports indicate an aggressive or higher grade breast cancer, of if the extent of the tumor is large and uncertain, then the decision to perform mastectomy will have to be made.
Breast cancer surgery is not always the best option
Not all women with breast cancers are good candidates for lumpectomy or mastecomy. If first has to be determined to the best extent, the size of the tumor, the type of breast cancer, the stage and grade of the tumor, and of critical importance, whether there is metastasis to the lymph nodes or not. All of these factors will influence the decision as to the degree of surgical treatment required.
If the cancer has clearly already metastasized to the lymph nodes or elsewhere, then primary breast cancer treatment may involve chemotherapy instead. The overall health and age of the patient can also weigh into the decision to perform breast cancer surgical treatments. In some cases chemotherapy is actually used prior to surgery to reduce the tumor size, but this approach is not yet widely used, and usually only done in specific cases.
The tumor should be removed for local control
In a ‘systemic‘ context it may seem as though there is little point in removing the tumor surgically, but there are still important reasons to remove the tumor, even if it is not curative. “Local control” of the tumor is still an issue.
If a large breast tumor is left in place, it may continue to grow larger and larger. Growing tumors eventually bulge out and erode the skin, and may become infected. Also, any positive lymph nodes in the axilla region left in place may also continue to grow larger and larger, eventually making the arm itself unusable. Surgical removal of the breast tumor or positive axillary nodes is still important to prevent out-of-control tumor growth and for overall patient comfort.
Total, modified, radical, mastecomy
Sometimes the terminology used to discuss the breast surgery can be confusing. The term ‘breast conserving surgery‘ is a bit of an overarching term, which means the tumor was small enough to be removed, along with a small amount of surrounding tissue, but the breast remains, albeit slightly reduced in size and appearance. There are generally a few options to consider regarding the extent of the tumor removal or ‘resection‘, which will depend mostly upon the size and grade of the cancer, but also on the location in the breast and to a certain extent upon the size of the breast.
A total (or ‘simple’) mastecomy is, like the name implies, the complete surgical removal of the affected breast. However, the lymph nodes and surrounding chest muscles are left intact.
A modified mastecomy describes a situation in which the entire breast is removed, along with the lymph nodes under the arm. Chest muscles are not touched, but the lining over these muscles are removed.
A radical mastecomy involves the removal not only of the breast, but also the lymph nodes, the muscles beneath the breast, and some of the fatty tissue surrounding the breast. Radical mastectomy are the least common mastecomy, and are usually only in the cases of extensive breast tumors, or if the cancer cells appear to have invaded the chest wall.
A partial mastecomy indicates that in addition to the tumor, quite a large amount of breast tissue and also some skin are surgically removed. The lining over the chest muscles below the tumor is also removed, and sometimes some lymph nodes are surgically excised as well. A partial mastecomy might be recommended for stage I and II breast tumors only.
New mastecomy techniques attempt to preserve as much breast skin as possible
A skin sparing mastectomy is a relatively new technique in which the surgeon makes a much smaller excision circling the areola (nipple). Sometimes this is called a ‘key hole‘ incision. The use of this technique will largely depend upon the location of the tumor, and the size. But if the surgeon can access and remove the tumor from this approach, about 90% of the skin is preserved and with negligible scarring.
Reconstruction by a plastic surgeon is performed during the same operation. A ‘subcutaneous mastecomy‘ describes a particular procedure in which the tumor and quite a bit of breast tissue are removed, not the overlying skin and the nipple. By leaving the nipple and most of the skin intact, reconstruction is much easier. However, the concern is that some cancer cells may still remain.
Breast conserving surgery and mastecomy have about the same overall survival rates
At the present time, close to 90% of surgical breast cancer treatment is accomplished by breast conservation surgery and not mastectomy. The combination of successful early detection breast cancer screening programs, as well as advances in radiation and systemic breast cancer therapies has significantly reduced the need for treatment by mastectomy. Recent studies have demonstrated that the cure rate following breast conserving surgery is really about the same as the risk following mastectomy.
To put that another way, the risk of local recurrence is in fact slightly higher when only breast conserving surgery is performed, but radiation therapy following breast conserving surgery reduces this risk, and local recurrences are typically found during follow-up and successfully removed. So when breast cancer survival over a 10 year span in measured, there is no statistically significant difference between women who undergo breast conserving surgery vs. those who have a mastecomy.
Of course, once a breast cancer has reached a stage III or higher and is clearly or significantly invasive, then mastecomy is in most cases the only reasonable option.
Pain and other complications following breast cancer surgery
Pain is naturally an unfortunate consequence of breast cancer surgery. Women who are of a younger age, have had more extensive axillary surgery, and who have also been treated with radiation therapy are more likely to experience a more persistent postoperative pain. Post operative infection, lymphedema, and seroma are other common after-effects following breast cancer surgery. Breast seroma is particularly common following a modified radical mastectomy.
A seroma is a ‘pocket‘ of clear yellow fluid that can develop following surgery, caused by blood plasma leaking through ruptured blood vessels. They are harmless but can cause alarm because they can sometimes ‘look‘ like a mass on a follow-up mammogram. A lymphedema is a situation where swelling and fluid retention is caused by complications to the lymphatic system, which can often lead to infection. Lymphedema is more common following surgical excision of axillary lymph nodes, so it has to be carefully monitored.
In most settings, breast surgeries are performed by a general surgeon
Not all breast cancers are performed by ‘breast cancer‘ surgeons, but even a general surgeon will usually still have quite a bit of experience with breast surgeries. Breast cancer surgery is one of the most common operations encountered in a general surgical practice.
Breast reconstruction surgery is often part of breast treatment surgery
Increasingly, women who have undergone a breast-altering surgery to remove a breast cancer will also have breast-reconstruction surgery, done by a plastic surgeon. When this is known to be the case, the surgeon performing the treatment operation will work closely with the reconstructing surgeon, not only to plan the two procedures, but sometimes both processes actually take place during the same operation.
Not all women who undergo mastecomy will be candidates for reconstructive breast plastic surgery. Sometimes the breast can be surgically reconstructed using either implants or tissue flap procedures, but not all women will have enough spare tissue to engage in a breast reconstruction procedure.
Breast reconstruction is often performed at the same time as breast tumor removal
In many cases the breast reconstruction surgery is done at the same time as the tumor removal, though likely performed by a plastic surgeon and not the surgical oncologist or general surgeon. But some women choose, when given a choice, to wait for chemotherapy and radiation treatments to finish before considering breast reconstruction.
During breast reconstruction an ‘expandable implant‘ is placed in the breast, and over time it is injected with more and more fluid through a special ‘port‘ on the implant surface which allows needles to pass through. This way, the size of the implant can be increased gradually, allowing time for the skin to stretch and adjust in small increments. This process can take several months.
Breast implants can hide recurrent breast cancers
But there is a downside to breast reconstruction. Breast implants make it harder to use palpation to feel for any new little lumps of tumor recurrence. When little lumps are detected on the chest wall during follow up examinations, they can be quickly treated and surgically removed with no impact on survival. But, when these local recurrences go undetected because of a breast implant, they can grow to a large size before they are eventually found and removed, and this can unfortunately have a negative impact on overall survival.
The surgeon’s role after surgery is limited
Following the actual surgical removal of the breast cancer, the surgeon is generally no longer involved. Subsequent therapies may be undertaken by the oncologist (chemotherapy) or radiation oncologist (radiation treatment). The patient will certainly undergo follow-up mammograms in the following months and years to determine whether or not there is local recurrence or the breast cancer, or regional metastasis.
Often a biopsy sample is taken at the margins of the primary tumor surgical site. If there are cancer cells found in the margins, a small additional surgery may be required to remove some of this tissue. Follow-up investigations will also keep a close watch on the status of the previously unaffected breast. A surgeon with breast cancer experience may also have useful recommendations to the multidisciplinary team regarding prudent follow-up measures after the initial breast cancer treatment. Having seen many previous breast tumors, they can often express confidence in the extent of removal of cancerous tissues, or advise as to which regions should be monitored with particular care.
For further reading, I suggest you visit this page on a multidisciplinary team approach to breast cancer treatment.
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