Breast Cancer Surgery
If you are in the unfortunate position to be facing a breast cancer diagnosis it is likely that you will be seeing a breast surgeon first. The role of the surgeon during your initial consultation is very important, as your cancer treatment will usually start with an operation.
I believe that some of my other key roles as your cancer surgeon are:
- to provide you with clear information so you can understand fully the details of your cancer diagnosis
- to discuss your particular needs and expectations
- to agree with you to a personalised treatment plan
- and to support you along the way with the help of our team of nurses and cancer specialists
Breast Conserving Surgery
The aim of breast cancer surgery is to remove the cancer from your breast completely, with clear margins, that is with no cancer cells present at the edge of the removed breast tissue. This can be achieved by removing only a portion of your breast, and the term used for this procedure is “Complete Local Excision” or “Wide Local Excision”. A great proportion of breast cancers can be removed safely this way, without the need to perform a mastectomy. Most women, and surgeons, would prefer breast conserving surgery to mastectomy, if feasible, as it involves less surgical intervention, less risks of complications, better aesthetic result, and improved quality of life.
Usually a Wide Local Excision is followed with a moderate dose of radiation therapy to the breast a few weeks later. The goal of breast cancer surgery is that you remain free of breast cancer – a Wide Local Excision followed by breast radiotherapy gives you as good a chance to achieve this as a mastectomy would do, although with less extensive surgery than if you had mastectomy and with preservation of your remaining natural breast.
Some breast cancers are just a bit too large for a simple Wide Local Excision to result in a normal looking breast after the operation. In this situation some surgeons perform a mastectomy rather than risk cosmetically unacceptable results after a breast conserving operation. An alternative to a mastectomy is sometimes available, and this consists of using oncoplastic techniques of breast conserving surgery.
Oncoplastic Breast Surgery
Oncoplastic breast surgery involves a range of advanced techniques that achieve adequate resection of the cancer while preserving the breast shape. The two main categories of oncoplastic techniques can be described as:
- Volume displacement techniques – Complex internal mobilisations of breast tissue are carried out, in combination with cancer removal, to re-arrange the breast into a normal shape. Mammoplasty techniques and breast reductions are examples of procedures in this category, and often result in somewhat smaller breasts.
- Volume replacement techniques – In yet smaller breasts, when there is insufficient breast volume for a mammoplasty or breast reduction, there are techniques to fill the breast defect after a Wide Local Excision. Local chest wall perforator flaps are the most useful techniques in this category. These consist of islands of skin and fat located just outside the breast, beneath the armpit, which can be mobilised and rotated into the breast to replace the volume excised after a Wide Local Excision. This is routinely done through incisions in the lateral (outer) edge of the breast or at the lower skin fold of the breast, leaving inconspicuous or invisible scars.
Oncoplastic techniques make possible the resection of larger cancers, sometimes in very small breasts, giving the option of breast conserving surgery to many women with cancer who would otherwise have required a mastectomy.
A mastectomy is still sometimes necessary to safely remove very large breast cancers, especially in very small breasts where other breast conserving techniques are not possible, or to remove multiple cancers in the same breast. A mastectomy removes the whole breast, and when required this can often be performed with preservation of most of the breast skin and/or nipple and simultaneous breast reconstruction.
Sentinel Node Biopsy
Breast cancer can spread to the lymph nodes (glands) in the axilla (armpit). This occurs in around 25-30% of women presenting with a breast cancer diagnosis. Knowing whether the lymph nodes are affected by cancer or not is obviously very important, and essential to plan other treatments after removing the cancer.
We call sentinel node the first node in the axilla that breast cancer cells would reach if they spread outside the breast. A procedure called Sentinel Node Biopsy is usually carried out during the same operation as the breast cancer procedure and consists of removing this sentinel node, or nodes (usually 1 to 3), so that these can be analysed for cancer cells by the pathologist. To identify the sentinel node(s) their location is mapped prior to surgery. The mapping is achieved by injecting a fluid substance into the breast that gives a small amount of radioactive signal; blue dye fluid is also injected at the time of surgery. Both the radioactive substance and blue dye travel through the lymphatic channels to the sentinel node in the axilla and their radioactive signal and blue colour can be identified respectively by the surgeon, who can then remove the mapped sentinel node(s).
Axillary Node Clearance
Axillary clearance, also called axillary dissection, involves removing all lymph nodes in the axilla – the number of nodes being very variable from one person to another. This procedure is necessary after a sentinel node biopsy procedure has shown node(s) containing cancer, and also if it is clear at the time of breast cancer diagnosis that it has spread to the axilla, i.e. enlarged node(s) with cancer cells on biopsy. In these situations, it is important to know how many lymph nodes in the axilla are affected by cancer to help planning with other treatments.
An axillary clearance procedure has several known potential complications, including chronic arm lymphoedema (arm swelling), shoulder stiffness, and diminished sensation of the upper inner arm. A sentinel node biopsy has much less chance of producing these complications, and therefore it is a preferred option when cancer spread to the axilla is not known yet.