Breast cancer

02 December 2008

Treating breast cancer with surgery

The management of breast cancer is almost identical in men and women, with the exception of breast reconstruction.

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  • Diagnosing breast cancer
  • The aims of surgery in breast cancer
  • Surgery for breast cancer – lumpectomy
  • Surgery for breast cancer – mastectomy
  • How is a mastectomy carried out?
  • Sentinal lymph node biopsy
  • Complications of breast surgery
  • Complications of axillary dissection
  • Surgery and the outcome of breast cancer

Breast cancer is a common cancer in women. It also occurs in men, but is not as common. Of all breast cancers, 1:100 cases occurs in men. The management of breast cancer is almost identical in men and women, with the exception of breast reconstruction.

There are three ways of considering the management of breast cancer:

  • systemic management – which means treatment of the whole body (usually chemotherapy or hormonal treatment)
  • treatment of the primary tumour (surgery, radiotherapy or occasionally systemic treatment)
  • treatment of the lymph nodes

We are going to look at treating breast cancer using surgery. Each type of surgery available will be discussed.

These are:

  • Wide local excision – popularly called “lumpectomy” in which only the lump is removed – as well as radiotherapy (treatment with radiation)
  • Mastectomy in which the whole breast is removed

How is breast cancer diagnosed?

Normally the primary (main) tumour has been found before surgery. Sometimes though a patient may have only enlarged lymph nodes, which have been felt under the arm.

If the primary tumour has been identified (as either a lump or on x-ray mammography or ultrasound) it will usually be treated with surgery. Surgery is not used if the cancer has already spread around the body. In this case the woman is treated with drugs.

The triple test

The diagnosis is usually made using the "triple" test. This involves:

  • a clinical assessment by the treating doctor – this means that the doctor has carried out a detailed examination of the woman as well as discussing her past medical history and that of her family
  • a mammogram or ultrasound
  • a needle biopsy

That will tell the doctor and the patient that the lump is or is not a cancer and how far it has spread.

Based on this information, a decision about surgery and in particular, what type of surgery is made.

This should be a joint decision between the surgeon and the patient.

Breast cancer is not an emergency and there is no reason to rush into surgery. Once the diagnosis has been made the woman and her doctor need to discuss the condition thoroughly so that she understands exactly what procedure needs to be carried out and why. Only then should the surgery be done.

The aims of surgery

The aims of surgery in breast cancer are:

  • to treat the cancer adequately and get the least chance of a recurrence
  • to get the best cosmetic result
  • to do surgery on a patient who understands the procedure and why that procedure is the best option
  • to let the patient return to a fully functional life as soon as possible which means that the patient should be well psychologically

Surgery for breast cancer - lumpectomy

Wide local excision

This is also called breast saving surgery. It is suitable for some patients and some types of breast cancer.

If the patient and the tumour are "suitable" then the outcome is the same as a patient who has a mastectomy. However, this is only the case in certain circumstances.

Who is suitable?

The surgeon needs to remove both the tumour and enough tissue around it to make sure that the tumour is gone. So if the woman has small breasts or a large tumour, then too much tissue may need to be removed along with the tumour. This will leave a badly scarred breast, in which case a mastectomy will give a better cosmetic outcome.

Tumours bigger than five centimetres are rarely suitable for this type of treatment. These tumours may be treated with drugs first to shrink them. A mastectomy may be better in the case of a larger tumour.

Some tumours have more than one group of malignant cells – effectively acting like several small tumours. There are also situations in which there may be areas of potentially precancerous cells in the surrounding breast tissue. In these circumstances, it is usually advisable to remove all the breast tissue, as there may be other areas in the remaining breast with similar changes.

Under the right conditions, the long-term outcome of “lumpectomy” is as good as that of mastectomy. But to ensure this, the woman must have radiotherapy. This means that if there is a reason why radiotherapy cannot be used (such as pregnancy) then this form of treatment is not suitable.

How is a wide local excision carried out?

The patient is usually given a general anaesthetic (rarely it can be done under local anaesthetic). The tumour is marked before the operation. A cut is made through the skin and down to the tumour. The tumour is then removed with normal breast tissue around it. At least one centimetre of normal tissue should be taken out around the tumour. The skin is sewn up. Dissolving stitches or stitches to be removed can be used. A drain may be placed in the wound. (This depends on where the tumour is and how deep the resection is). The patient may stay in hospital overnight or may go home the same day.

Types of mastectomy

There are three types of mastectomy, but the third type is now rarely carried out:

  • Local mastectomy: removal of the breast tissue and the fascia overlying the muscle underneath
  • Modified radical mastectomy: removal of the breast tissue, the fascia and the lymph nodes under the arm
  • Radical mastectomy: rarely done. Removal of the breast tissue, the lymph nodes and the underlying muscle and fascia

Fascia is connective tissue which forms membrane-type layers which are of differing thickness in all regions of the body. It surrounds the softer or more delicate organs and it is divided into superficial fascia (immediately beneath the skin) and deep fascia (which forms sheaths for the muscles). The fascia removed in a mastectomy is deep fascia surrounding the muscles underlying and around the breast.

How is a mastectomy carried out?

The type of incision into the skin depends on the size of the tumour, the type of tumour and whether or not breast reconstruction is going to be carried out immediately.

The breast tissue is pealed from the skin. The skin and underlying fat are preserved. The breast is then removed whole, with the covering of the muscle underneath. If a modified radical mastectomy is done then the lymph nodes are removed through the same incision.

What happens in the axilla (armpit)?

The lymph nodes in the axilla will nearly always have to be removed if they are felt to be enlarged when the woman is first examined. This is carried out using a technique called an axillary dissection.

What is an axillary dissection?

It is removal of some or all of the lymph nodes in the axilla:

The incision may be as part of the mastectomy incision or may be through a separate incision. It may be done at the same time as a wide local excision.

If there are no enlarged lymph nodes on examination then there are different approaches:

  • The lymph nodes may be left
  • A sentinel lymph node biopsy may be performed
  • A limited operation may be performed in which some of the lymph nodes are removed

What is a sentinel lymph node biopsy?

This involves sampling of the lymph nodes in the axilla. The object is to ascertain whether there is microscopic spread of the cancer to the lymph nodes. If there is, then the lymph nodes are usually removed.

The technique is designed to find out which is the first node that the lump would drain to. This node is sampled and the operation proceeds from there.

Sentinel lymph node biopsy, although relatively widely used, is still a controversial technique and is not used in all centres. It also needs to be carried out by a surgeon experienced in the technique who is monitoring all the women on whom the operation is performed. The monitoring is important since this tells the surgeon whether his or her technique is correct and allows an idea of the outcome in a number of patients over time.

Complications of mastectomy

Mastectomy without breast reconstruction is relatively painless and there are few complications. The complications are more likely to arise when breast reconstruction is carried out at the same time. This is because it is a longer operation with more movement of skin and other tissues.

When the breast is removed, there are flaps of skin left. Under normal circumstances the skin receives blood as part of the supply to the underlying breast. Once the breast is gone, this part of the blood supply also goes. This means that the edges of the skin flaps may lose some tissue as a consequence of this lack of blood flow.

A seroma may form. This is an accumulation of fluid under the skin, which is from the underlying surface of the muscle. It usually disappears on its own but may require drainage with a needle.

If the operation is done through the nipple then there is more chance of swelling of the skin or other complications.

Diabetic patients may occasionally get infections.

Complications of axillary dissection

  • Swelling of the arm - this depends on how many nodes are removed
  • Weakening of the shoulder muscles
  • Numbness in the armpit
  • A build up of lymph may occur since the lymph nodes are no longer available to drain the lymphatic fluid

Swelling of the arm after axillary dissection is a problem which concerns many women. It usually does not occur if only a few nodes are removed. It is more common if the high lymph nodes are removed and there is also radiotherapy to the area.

Many women think that it is better to opt for less axillary dissection at the time of mastectomy and take the chance of needing radiotherapy later. But the opposite is true. If there is evidence of disease involving the lymph nodes, the outcome is better if more extensive surgery is carried out at the time of mastectomy. The worst results occur with less extensive surgery followed by radiotherapy later.

Surgery and the outcome of breast cancer

Breast cancer can be cured if caught early enough. However, rather paradoxically, early breast cancer needs more, rather than less extensive surgery. In fact, the earlier the cancer is diagnosed, the more extensive the surgery will be in order to try to minimise the chances of recurrence as much as possible.

This is an important fact to realise when discussing the possible surgical procedures after a diagnosis of breast cancer.

 

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