14 April, 2021

Surgical Management of Breast Cancer

Breast cancer is a cancer that occurs in the breast cells and it is the most common cancer in women over the age of 50 but can also occur in younger women. The cancer typically forms in the ducts or lobules of the breast. If breast cancer is diagnosed at an early stage, there is a good chance of a cure. The more advanced the cancer, the less chance that treatment will be curative.

Most of the women suffering from breast cancer have some type of surgery as part of their treatment. Depending on the situation, breast cancer surgery may be performed to:

• Remove the cancer as much as possible (breast-conserving surgery or mastectomy)
• Detect the cancer spread to lymph nodes under the arm (sentinel lymph node biopsy or axillary lymph node dissection)
• Restore the shape of the breast after the removal of cancer (breast reconstruction)
• Relieve symptoms of advanced cancer

Treatment options for breast cancer include surgery, chemotherapy, hormone therapy and radiotherapy. A combination of two or more of those treatments is often used. The treatment modalities used depend on: the cancer itself-its size and stage (whether it has spread), the grade of the cancer cells and whether it is receptive to hormones or contains HER2 receptors. Alongside, causes and risk factors are also taken into consideration before suggesting the treatment option for breast cancer.

Surgeries used to treat breast cancer include:

• Removing the breast cancer (lumpectomy)
• Removing the entire breast (mastectomy)
• Removing a limited number of lymph nodes (sentinel node biopsy)
• Removing several lymph nodes (axillary lymph node dissection)
• Removing both breasts

Why is it done?

The purpose of breast cancer surgery is to remove cancer cells from the breast. A procedure for inserting breast implants or reconstructing a breast from the patient’s own tissue (flap surgery) can be performed at the same time or later for those who prefer breast reconstruction.

Breast cancer surgery is used to treat most of the breast cancer stages, including:

• High risk of breast cancer: Patients with a high risk of breast cancer based on a strong family history of the disease, as a result of certain noncancerous breast biopsy or a gene mutation can opt for preventive (prophylactic) mastectomy with or without immediate breast reconstruction to prevent breast cancer
• Noninvasive or In-situ breast cancer: Patients diagnosed with in situ ductal carcinoma (DCIS) may undergo lumpectomy which may be accompanied by radiation therapy, while mastectomy with or without breast reconstruction can also be an option
• Early-stage breast cancer: Lumpectomy or mastectomy can be used to treat small breast cancers with or without breast reconstruction accompanied by radiation along with chemotherapy, hormone therapy or targeted therapy
• Larger breast cancers: Larger cancers can be treated with mastectomy, while chemotherapy, hormone therapy or targeted therapy are often used before surgery to allow a lumpectomy to be performed.
• Locally advanced breast cancers: Large breast cancers or the one that have spread to several lymph nodes are treated with chemotherapy, hormone therapy or targeted therapy initially to shrink the tumor and so as to make the surgery more successful. These cancers may be removed using mastectomy or lumpectomy, followed by radiation therapy.
• Metastatic breast cancer: Breast cancer that spread to other parts of the body can be treated by mastectomy
• Recurrent breast cancer: Breast cancer that returns after initial treatment may be removed with additional surgery.

Surgical Treatment of Breast Cancer

There are two main types of surgery to remove breast cancer:

• Breast-conserving surgery (BCS) also referred to as a lumpectomy, partial mastectomy or segmental mastectomy, quadrantectomy, is procedure which is performed to remove the part of the breast containing the cancer. This surgery is done to remove the cancer and some of the normal tissue around it. The amount of breast removed depends on where the tumor is and how large it is, and on other factors.
• Mastectomy is a surgery to remove the entire breast including all of the breast tissue and sometimes other tissues in the vicinity. There are various forms of mastectomy. Some of the women can also have double mastectomy, in which both the breasts are removed.

Breast-Conserving Surgery or Mastectomy: What to choose?

Most women with early-stage cancers have the option to choose between BCS and mastectomy. The significant advantage of BCS is that a woman can have most of her breast as only the part of the tissue with cancer cells will be removed, yet she still needs radiation in most cases. Women who undergo mastectomy are less likely to get chemotherapy for early stage cancers.

Mastectomy could be a better and safer option for many women because of the breast cancer type, tumor size, prior radiation treatment, or other factors. Many women may be concerned about the possibility of cancer recurrence from a less extensive surgery. Over the past 20 years, studies show that the survival rate for the people having BCS with radiation is equivalent to undergo mastectomy.

Surgery to Remove Nearby Lymph Nodes

To assess the spread of breast cancer to axillary lymph nodes, one or more of these lymph nodes will be removed and observed in the laboratory. This is an important aspect to find out the cancer stage. Lymph nodes can either be removed as part of breast cancer surgery or as a separate operation.

There are two main types of surgery to remove lymph nodes including:

• Sentinel lymph node biopsy (SLNB): In this procedure, the surgeon removes only the lymph nodes under the arm where the cancer will possibly spread first. Removing only one or more lymph nodes decreases the risk of surgical side-effects such as swelling of the arm, also known as lymphedema.
• Axillary lymph node dissection (ALND): In this procedure, the surgeon removes many axillary lymph nodes (usually less than 20). ALND is not used much, but it can still be the best way to remove the lymph nodes in some situations.

Breast Reconstruction After Surgery

Many women who have breast cancer surgery can have the option of breast reconstruction. A woman having mastectomy prefers have the breast mound rebuilt after surgery to restore the appearance of the breast. A woman may consider in getting fat grafted into the affected breast in certain breast-conserving procedures to remove any dimples left from the surgery. The option of breast reconstruction depends on the medical situation and personal preferences of the woman. The patient can opt for breast reconstruction at the same time as the surgery (immediate reconstruction) or later (delayed reconstruction).

Patients may undergo breast reconstruction surgery at the same time or after mastectomy. A plastic surgeon with special training in reconstruction surgery performs this kind of procedure. The surgeon uses an implant or tissue from another any part of the body to create a breast-like shape that substitutes for the missing breast. The surgeon may even make a nipple outline and add a tattoo, which looks like the areola (the dark region around the nipple).

There are two main types of breast reconstruction surgery:

Breast implant: Breast reconstruction with an implant is performed in steps such as:

• The plastic surgeon places a balloon expander under the chest muscle which is the first step in the procedure, also called as tissue expansion.
• Saline is applied to the expander over weeks or months to stretch the chest muscle and the skin above it. This phase creates an implant pocket.
• When the pocket is the appropriate size, the surgeon removes the expander and inserts an implant in the pocket (filled with saline or silicone gel). This creates a new breast-like shape.
• Although it looks like a breast, since nerves were cut during the mastectomy, you will not have the same feeling as before.

Breast implants do not last a lifetime. If you want to have an implant, you will possibly need further surgery to remove it or repair it later on. Implants can cause issues such as breast hardness, pain and infection. An implant can break, move or change its position too. These problems can occur soon after the surgery in in later times.

Tissue flap: A reconstructive plastic surgeon with special training performs this surgery. He creates a new breast-like shape from the muscle, fat, and skin taken from other parts of the body (usually the belly or back) in tissue flap surgery. This new shape to the breast should last for lifetime. Women who are extremely underweight or obese, who smoke or who have severe health issues cannot undergo tissue flap surgery. Healing after this surgery sometimes takes longer than healing after surgery with the breast implant. You may have other issues, such as infection, low wound healing capacity and pain.

If you are thinking of getting reconstructive surgery, it is a good idea to explore it before your mastectomy or BCS with your breast surgeon and with the plastic surgeon. It gives the time for the surgical team to prepare the best treatment recovery plans for you, even if you opt for the reconstructive surgery later

Risks After Surgery

Breast cancer surgery is one of the safest surgeries, but it may sometimes carry few possible risks of complications, including:

• Bleeding
• Pain in the area of surgery performed
• Permanent scarring
• Arm swelling (lymphedema)
• Infection
• Wound healing problems
• Collection of fluid at the operative site (seroma)
• Loss of or altered sensation in the chest and reconstructed breasts
• Anesthesia related risks that may put a patient in a sleep-like state during surgery, such as confusion, muscle aches and vomiting

Radiation Therapy (RT) After Surgery

Many women who undergo a lumpectomy may have radiation treatment to the breast following surgery, and sometimes the underarm area. Likewise, some of the women who are under the treatment of mastectomy can have radiation therapy to chest along with the underarm area. Radiation therapy is given after the chemotherapy if the treatment plan includes chemotherapy.

Points to Remember for a Patient After Breast Cancer Surgery

Any patient who undergo breast cancer surgery can expect few after effects including:

• To be taken to a recovery room where blood pressure, pulse and breathing of the patient are monitored
• Can experience possible pain, numbness and a pinching sensation in the axillary area

It is important for a patient to follow certain set of measures to avoid any complications after the surgery. Doctor should give instructions to the patient on:

• How to care of themselves at home, including taking care of the incision and drains, identifying the signs of infection, and understanding activity restrictions
• When to resume wearing a bra or wearing a breast prosthesis
• Prescriptions for pain medication and antibiotics
• Instructions on regular diet and daily routine
• Patients who have breast reconstruction after mastectomy are advised to spend one night in the hospital. Those undergoing mastectomy without reconstruction or lumpectomy may leave the hospital the day of surgery with the proper instructions and guidance from the doctor for home care.

Author: (Dr. Ramakant Tayade)