Breast Surgery
Surgery – What are the Surgical Options?
Each patient should play an active role in selecting the appropriate surgical treatment with the specialist.
Studies have shown that removal of the whole breast (mastectomy) does not prolong life when compared with removal of the cancer lump alone (lumpectomy). As lumpectomy preserves more of the breast, it is associated with a better body image compared with total mastectomy.
If you have a successful lumpectomy i.e. the lump was completely excised with clear margins, then radiotherapy to the whole breast is usually required. In some cases (approximately one third) mastectomy is the preferred treatment option.
It is also advisable to remove some lymph glands from the armpit (this is called axillary dissection – axilla means ‘armpit’) if the cancer is invasive. If the lymph glands do not contain cancer, then the outlook for the patient is very good.
However, the more lymph glands that contain cancer and the bigger the cancer is, the greater the chances are that the cancer may come back after treatment. This helps the specialist to predict the behaviour of the breast cancer, and to know if more aggressive treatments, such as chemotherapy, are needed.
Removal of the lymph glands increases the chances of arm swelling (lymphedema), arm stiffness and pain. Therefore it is preferable to remove the minimum number of glands. The Sentinel Node Biopsy technique allows accurate sampling of the glands.
Patients with invasive breast cancer who do not have enlarged glands in the armpit on clinical examination are suitable for this technique. It involves the removal of approximately two glands using a blue dye and/or a radioactive isotope tracer) through a small cosmetic scar.
The sentinel glands (blue and/or hot) can be examined by the pathologist while the patient is under anesthesia. If these sentinel glands are clear then no further armpit surgery is needed and the patient can be spared the potential adverse effects of complete glands clearance which occur in 10% of patients. However if the sentinel glands contain cancer cells then all the armpits glands should be removed. This is usually needed in 25% of patients with invasive breast cancer. This technique is a new standard of care for the management of the armpit and requires that the surgeon is familiar with the technique and the armpit glands are not enlarged on clinical examination.
The author prefers the technique of sentinel node biopsy combined with glands sampling to axillary gland clearance in patients with tumours smaller than 2 cm. This is because most patients in this category have clear glands and that clearance has a 10% chance of causing problems with the arm (stiffness, swelling and/or pain). However, if the sentinal node or the sample contains cancer cells, then all of the armpit glands should be removed.
Once the breast cancer and the armpit lymph glands have been removed, they are then examined under the microscope by a specialist called a pathologist. The pathologist will determine the following:
• Exactly what type of breast cancer it is?
• How big is the cancer?
• Has the cancer been completely removed?
• Do the lymph glands contain cancer?
• Does the cancer have hormone receptors?
The pathologist will also decide the severity of the cancer according to its appearance under the microscope and how much it has spread. In practice, the cancer is assessed (or staged) on a scale of 0 to 4 (Table 6).