Breast Cancer surgery
The primary treatment for invasive breast cancers is by surgical removal of the tumor. Quite often, depending on the tumor type, radiation therapy will follow to help prevent a local recurrence of the breast cancer.
The first task of the surgeon is to ‘stage‘ the breast cancer. This involves determining the size of the tumor, whether or not the cancer cells invade beyond the breast duct walls and if there is metastasis to the lymph nodes.
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The type of breast cancer and nuclear grade of the actual cells are also important staging and grading factors. However it is generally a pathologist who looks at staging and grading factors and not the surgeon.
A surgeon will perform an excisional (large sample) biopsy if necessary. So, surgeons obviously perform a lumpectomy (tumorectomy) and a breast mastectomy.
In addition surgeons will also perform axillary node dissections and sentinel lymph node biopsies as necessary.
The surgeon may need to remove additional axillary lymph nodes
If a specialist classifies the breast cancer as ‘invasive’, then it is important to also evaluate the status of the lymph nodes. The first procedure to determine if there is also lymph node involvement is a sentinel node biopsy.
So, the surgeon will firstly locate a few of the sentinel lymph nodes and then surgically remove them for analysis. If the lymph nodes are free of cancer cells under microscopic evaluation, the surgeon will not remove any additional lymph nodes.
Generally, one hopes to avoid extensive axillary lymph node dissection. This is especially true in situations whereby all the other indicators suggest that the lymph nodes are highly likely to be negative for cancer cells. In some cases, medics may apply radiation therapy 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 a breast tumor are firstly 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, means that the surgeon leaves a band of tissue, with no trace of cancer cells, around the site of the removed tumor. This is essential to help prevent local recurrence.
The surgeon will try to plan breast cancer surgery with a view to leaving this wide surgical margin, but it is not always easy. Sometimes the breast tumor develops in a location whereby a wide margin is not easily achievable and surgery may 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.
The surgeon and radiologist will have to ultimately make the decision in terms of whether or not the breast can be conserved.
Generally speaking, the medical team will make all reasonable efforts to conserve the breast. But if the pathological and radiology reports indicate an aggressive or higher grade breast cancer then a mastectomy may be the best treatment option. In addition, if the extent of the tumor is large and uncertain, then the surgeon and patient will have to make the decision to perform a mastectomy.
Breast cancer surgery is not always the best option
Not all women with breast cancers are good candidates for lumpectomy or mastecomy. So, the most important factors regarding this decision are:-
- The size of the tumor
- Type of breast cancer
- The stage and grade of the tumor
- Whether there is metastasis to the lymph nodes or not.
All of the above factors will influence the decision as to the degree of surgical treatment that is necessary.
If there is already metastasis to the lymph nodes, or elsewhere the primary breast cancer treatment may involve chemotherapy. The overall health and age of the patient can also weigh into the decision to perform breast cancer surgical treatments.
In some cases surgeons may actually prescribe chemotherapy prior to surgery to reduce the tumor size. However, this approach is not yet widely in use and medics tend to reserve it for special cases.
Removal of the Tumor helps with Local Control
In a ‘systemic’ context it may seem as though there is little point in removing the tumor surgically. However, even if removing the tumor is not curative there are still important reasons for surgical removal. Indeed, ‘local control’ of the tumor is still an issue.
If a surgeon leaves a large breast tumor in place, it may continue to grow larger and larger. Growing tumors eventually bulge out and erode the skin. Also infection of the tumor may also become an issue.
In addition, 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 and Radical Mastecomy
Sometimes the terminology that medics use to discuss breast cancer surgery can be a little confusing. The term ‘breast conserving surgery’ is a bit of an overarching term.
Breast conserving surgery
Means the tumor was small enough for surgeons to completely remove. Together with the tumor, surgeons will remove a small amount of surrounding tissue. However, 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’. Theses factors depend upon:-
- The size and grade of the cancer,
- Location in the breast
- The size of the breast in the first place
A Total (or ‘Simple’) Mastectomy
A total mastectomy is like the name implies, the complete surgical removal of the affected breast. However, surgeons leave the lymph nodes and surrounding chest muscles intact.
A Modified Mastecomy
This type of mastectomy describes a situation in which there is entire removal of the breast. In this operation there is also removal of the lymph nodes under the arm. Although surgeons do not remove the chest muscles, the lining over these muscles is also removed.
A radical Mastectomy
As the name suggests, this type of breast cancer surgery involves
- the removal of the breast
- the lymph nodes
- also the muscles beneath the breast
- some of the fatty tissue surrounding the breast.
Radical mastectomy are the least common mastectomy and surgeons usually only perform them only in the cases of extensive breast tumors. Also, a surgeon will recommend a radical mastectomy if there is invasion of the cell wall by the cancer cells.
A partial Mastectomy
In a partial mastectomy, there is surgical removal of :-
- the tumor
- quite a large amount of breast tissue
- some skin
- the lining over the chest muscles
- surgical excision of some lymph nodes
Medics might recommend a partial mastectomy 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, surgeons call this type of surgery a ‘key hole’ incision.
The use of this technique will largely depend upon the location of the tumor and the size. However, if the surgeon can access and remove the tumor using this approach, about 90% of the skin is preserved and there is negligible scarring.
A plastic surgeon will usually perform reconstruction surgery during the same operation.
A ‘subcutaneous mastectomy’ describes a particular procedure in which the surgeon removes the tumor and quite a bit of breast tissue. However, the overlying skin and the nipple are left. So 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, breast conservation treatment accounts for around 90% of breast cancer surgery treatments.
The two main reasons for the reduction in mastectomy surgery are firstly, the successful early detection of breast cancer by screening programs. Secondly,the advances in radiation and systemic breast cancer therapies.
Recent studies demonstrate that the cure rate following breast conserving surgery is really about the same as that following mastectomy.
To put that another way, the risk of local recurrence is in fact slightly higher with breast conserving surgery. However, radiation therapy following breast conserving surgery significantly reduces this risk.
Furthermore, follow-up screening typically identifies local recurrences and surgeons successfully remove most of these.
So, when we measure breast cancer survival over a 10 year span, there is no statistically significant difference between women who undergo breast conserving surgery vs. those who have a mastectomy.
Of course, once a breast cancer is a stage III or higher, and is clearly or significantly invasive, then mastectomy 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 more likely to experience a more persistent postoperative pain tend to:-
- be of a younger age
- have more extensive axillary surgery
- have radiation therapy
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 breast cancer surgery. The cause of seroma is blood plasma leaking through ruptured blood vessels. Seromas 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 careful monitoring is necessary.
In most settings, breast surgeries a general surgeon performs breast cancer surgery
Breast cancer surgeons do not perform all breast cancer surgery. Indeed, sometimes a general surgeon will perform breast cancer surgery. A lot of general surgeons have quite a lot of experience with breast surgeries.
Breast cancer surgery is one of the most common operations performed 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 cancer will also have breast-reconstruction surgery 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 do the surgeons plan the two procedures, but sometimes both processes actually take place during the same operation.
Not all women who undergo mastectomy will be candidates for reconstructive breast plastic surgery. Sometimes, surgical reconstruction of the breast using either implants or tissue flap procedures is possible. However, 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. As mentioned, it is likely that a plastic surgeon performs the reconstruction, 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 the surgeon places an ‘expandable implant’ in the breast. Over time a medic injects the implant with more and more fluid. There is a special ‘port’ on the implant surface that allows a needle 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.
However, when follow-up screening detects little lumps on the chest wall, treatment with surgical removal is quick 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. Unfortunately, this can have a negative impact on overall survival.
The Surgeons role in Breast Cancer Treatment
The surgeons main role is the actual surgical removal of the breast cancer. After the breast cancer surgery, the care is handed over to other medical staff.
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. The reason for the follow-ups is to determine if there is local recurrence of 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 present in the margins, a small, additional surgery may be necessary 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.
A surgeon, having seen many previous breast tumors, can often express confidence in the extent of removal of cancerous tissues. Furthermore a surgeon can advise 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.
- Cady B, Falkenberry SS, Chung MA. (2000) The surgeon’s role in outcome in contemporary breast cancer. Surg Oncol Clin N Am 2000 , 9(1):119-132. https://www.ncbi.nlm.nih.gov/pubmed/10601528
- Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, Aguilar M, Marubini E. (2002) Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002, 347(16):1227-1232. https://www.ncbi.nlm.nih.gov/pubmed/12393819