The are many surgical treatments for breast disease ranging from open surgical biopsies, lumpectomy, mastectomy and sentinel lymph node biopsy. The appropriate preoperative evaluation is paramount to making the correct surgical choice.
Generally speaking there are two types of surgical treatments for breast cancer: lumpectomy or mastectomy. There are two goals related to breast cancer surgery: 1) remove/biopsy lymph nodes, and 2) remove the tumor with a clear surgical margin. A mastectomy removes ‘all’ of the breast tissue while with a lumpectomy (partial mastectomy) only the mass/lesion is removed .
Lumpectomy which typically will include adjuvant radiation therapy has been found equivalent to mastectomy in terms of long term survival. The procedure involved the removal of the abnormal tissue only. The need for a negative/clear peripheral margin is critical. Adjuvant radiation therapy is necessary in most cases where lumpectomy is the chosen surgical treatment. Radiation is given to the breast to address any potential microscopic disease is ‘left behind’. Local recurrence rates (the chance of the same cancer reoccurring in the breast) with lumpectomy AND radiation therapy is approximately 2-3% ; whereas the recurrence rate without radiation therapy is approximately 30%.
Utilizing surgical techniques (Oncoplastic), the defect created by a partial mastectomy can be repaired. Following lumpectomy and radiation the appearance of the breast should be relatively the same as preoperatively.
Mastectomy involves removal of all of the breast tissue. In reality however, there is a small amount of microscopic breast tissue that remains. Thus, the local recurrence rate (the chance of the same cancer reoccurring in the breast) is approximately 2-3%. This is as low a local recurrence rate that can be achieved. Most importantly however, the overall survival is no different than a lumpectomy.
There are different types of mastectomies: skin sparing mastectomies remove all the breast tissue, including the nipple and areola, leaving behind most, if not all of the native skin. These procedures are typically done in conjunction with reconstruction. Nipple/areolar reconstruction can be performed by a plastic surgeon, at a later date; nipple sparing mastectomies remove all of the breast tissue; the nipple/areolar complex is not removed and remains in place; areolar sparing mastectomies remove all of the breast tissue, including the nipple; the areola remains. The nipple is reconstructed by a plastic surgeon, at a later date.
The indications, risks, and benefits of each mastectomy option differs slightly, as does the indication to consider each.
Reconstruction. Immediate plastic surgical reconstruction, under most circumstances, can be performed at the same setting, if mastectomy chosen as the surgical approach. There are times, however, when a delayed reconstruction might be preferred or recommended. There are a number of different types of breast reconstruction, including placement of an implant, tissue transfer (TRAM Flap, etc) and free flaps (DIEP Flap, etc.). Reconstruction is typically initiated during the initial surgical intervention, but, can also be performed at a later date.
|Mastectomy||– Get all disease with only one surgery
– No more routine mammograms/US/MRI
– Usually no radiation (unless tumor >5cm or nodes positive)
– Lower risk for development of a new cancer (risk is not 0%)
|– You lose your breast
– Higher surgical complication rate with implant-based reconstruction
– Longer recovery period (4-6 wks, longer with autologous reconstruction)
– Loss of chest wall sensation, including nipple
– Usually requires surgery on the opposite breast for symmetry
– Overnight stay in hospital (can be done outpatient)
– Need annual imaging of your healthy breast
|– You get to keep your breast
– Easier recovery period (2 -4 wks)
– Lower risk of surgical complications
– Outpatient surgery
|– May have positive margins requiring a 2nd or 3rd surgery to remove all disease
– Nearly always requires radiation
– Need annual mammogram
– May require surgery on the opposite breast for symmetry
– Risk of a new cancer developing in healthy breast tissue is 0.5%/year
**The need for chemotherapy is based on tumor size, lymph node involvement and tumor biology (tumor DNA). The surgery you chose does not change the recommendation for/against chemotherapy. Said another way – CHOOSING A MASTECTOMY (when not recommended by your surgeon) DOES NOT DECREASE THE RISK OF DYING FROM BREAST CANCER. IT DOES NOT DECREASE THE RISK OF RECURRENCE OF YOUR BREAST CANCER AND IT DOES NOT DECREASE THE CHANCE YOU WILL NEED CHEMOTHERAPY.
In the past, to ‘stage’ breast cancer, a complete axillary lymph node dissection was performed. During this procedure, approximately 15-20 lymph nodes were removed, and, assess histologically (under a microscope). This allowed doctors to assess whether or not cancer cells had begun to spread. In women with clinically negative lymph nodes (those that were not abnormal to physical exam or x-rays), where less likely to have disease in the lymph nodes, so, ultimately negative or clear lymph nodes were removed, but, provided no benefit to the patient, only potential side effects. Thus, it was determined that a better mechanism must be found to evaluate lymph nodes for spread of disease.
The sentinel lymph node is the first lymph node(s) that would receive spread of disease, IF, the disease had begun the process of spreading. This lymph node was first utilized in patients who had skin cancer (melenoma); because in these patients the route that cancer spreads is very unpredictable.
To identify this particular lymph node (at times there may be more than one), the breast is injected with a radiotracer and/or a blue dye. These tracers are absorbed by the breast tissue, and, enter the lymphatic system of the breast, ultimately finding their way to the sentinel lymph node. A special probe is utilized intraoperatively, to identify which lymph nodes have the tracer, and, thus the sentinel lymph node(s). By analyzing these nodes, physicians can determine if cancer has begun the process of spreading.
The dye/tracer will drain to the lymph nodes, but, this does NOT mean that the cancer has spread. It is only by analyzing these nodes histologically, that this can be determined.
Research has validated the use of sentinel lymph node biopsy in staging breast cancer. In a trial involving 5,611 women with breast cancer and no clinical signs of axillary metastasis, researchers from the National Surgical Adjuvant Breast and Bowel Project (NSABP), which is a National Cancer Institute (NCI) clinical trials cooperative group, randomly assigned participants to receive SLNB alone or SLNB plus an axillary lymph node dissection (ALND).
The researchers found no differences in overall and disease free survival between the two groups of women. Based on these results, it was concluded that ALND might not be necessary for women with clinically negative axillary lymph nodes and a negative SLNB whose breast cancer is treated with surgery, adjuvant systemic therapy, and external-beam radiation therapy.
Breast biopsies are sometimes required to make a definitive diagnosis. If the lesion of concern is too small to appreciate by ‘feel’, a needle localization may be necessary. Needle localization, is done in the Breast Imaging Department. A mammogram or ultrasound (sometimes an MRI) is used to identify the lesion of concern, and, then to guide a wire, placed next to (adjacent) to this area of concern. This localizing wire, will assist surgically, in identifying the area of concern.
Subareolar dissection is a procedure that is sometimes performed in women who have unexplained nipple discharge. This is a procedure, whereby, the affected (draining) duct is isolated and a portion removed. Similar to a breast biopsy, the procedure sometimes requires a preoperative localization. Although most nipple discharge is from a benign (noncancerous) etiology, biopsy/subareolar dissection is at times required.
Many times, when chemotherapy is necessary, a port or vascular access catheter is placed. The catheter is placed in the operating room or Interventional Radiology. The port is attached to a catheter, which is placed in the venous system, just above the heart. An x-ray will be done to assure proper port placement.
How will the implant be accessed? A catheter is placed, through the skin, into the port (which has a rubber top). The medication can then be placed into the port, which will then feed into the catheter, and , via the catheter, into the patients venous system.
Will the port require care? No particular care is required, aside from normal good hygiene.
Once chemotherapy has been completed, the port can be removed, during a relatively short, outpatient, procedure.