Breast Cancer Surgery

The type of surgery for treatment of breast cancer depends on several factors which include tumour size and position as well as breast size. The choice is usually between Breast Conserving Surgery and a Total Mastectomy. This is usually combined with axillary nodal surgery (either sentinel node biopsy or axillary clearance) in the case of invasive cancer.

Breast conserving surgery (also known as Wide Local Excision or Lumpectomy) is possible if the tumour size allows for removal with adequate clear margins as well as a satisfactory aesthetic outcome (Note: The term” partial mastectomy” is an old-fashion term that has an alarming connotation and should be avoided). In the context of invasive breast cancer, Breast Conserving Surgery is routinely combined with radiotherapy. This has been shown in research to result in a similar long term outcome when compared with Total Mastectomy. In other words, the chances of developing a local recurrence and the overall long term survival are similar for either approach.

The term “Oncoplastic” breast cancer surgery is used to describe specialized techniques that allow removal of tumour while aiming for an optimal aesthetic result. The technique may involve mobilizing breast tissue to fill defects, using breast reduction techniques to remove large tumours or reconstructing a breast at the same time as a mastectomy. Oncoplastic breast cancer surgeons are specifically trained in these techniques so that the optimal surgical option can be offered to the individual patient.

In some cases, breast conserving surgery may not be possible or recommended. A Total Mastectomy may be the only viable option. The patient will be counselled regarding options of reconstruction as appropriate depending on tumour staging (breast reconstruction will be described in a different section). For some patients, particularly the older population, a straightforward total mastectomy may be the better option whereby radiotherapy is usually not required and the patient can avoid the need for further surgery.

The surgeon will discuss all surgical options in detail with the patient so that an informed decision can be made by the patient regarding the optimal treatment choice.

In cases of invasive cancer and some cases of extensive insitu cancer (DCIS), a sentinel node biopsy will be performed at the same time as the above surgery. If an invasive cancer is large (> 3 cm in diameter) or multifocal, it may be advisable to consider an Axillary Clearance instead. You surgeon will make a recommendation based on the clinical findings.  Sentinel Node Biopsy has been shown to be safe in cases of invasive cancer where the size is less than 3 cm. The Sentinel node is the first lymph node/s which receives drainage from lymphatics within a specific region. By removing the sentinel node, one can determine whether cancer cells have spread to the node itself. This will help with predicting long term outcome and will guide further management. The sentinel node can be located by injecting radioisotope into the breast prior to surgery. Thereafter, a lymphoscintiscan is often performed to map out the site/s and number of sentinel nodes which are usually found in the axilla (armpit). Blue dye may also be injected during surgery to assist with sentinel node identification. The sentinel node is then removed and sent to the laboratory for microscopic analysis to check on whether there are tumour cells present.

It is important that the sentinel node biopsy operation is performed by a surgeon who is specifically trained in the technique and regularly performs the procedure. This ensures the highest chance of success in finding and removing the true sentinel node/s.

If a sentinel node is involved with tumour cells, further surgery is often necessary to remove the rest of the lymph nodes in the axilla. This will ensure that any remaining tumour cells are adequately removed from that region. This operation is known as Axillary Node Dissection or Axillary Node Clearance. A drain is inserted after a nodal clearance to drain seroma fluid which is naturally produced by the body and secreted into the tissue space. This drain is removed once the drainage decreases and this can take up to 1 – 2 weeks after surgery (sometimes longer). Once the drain is removed, it is not uncommon for the body to continue to produce seroma fluid within the operative site. This is usually reabsorbed over time but if a large volume is produced, it may result in a visible swelling which can become uncomfortable. This usually requires needle aspiration which may be repeated as often as necessary until resolution of the collection.

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