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Home Treatment Options Surgery Surgical Options for the Treatment of Breast Cancer

Surgical Options for the Treatment of Breast Cancer

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SURGICAL OPTIONS FOR THE TREATMENT OF BREAST CANCER

 

 

There are several surgical options available for the treatment of breast cancer, depending on the characteristics of the patient’s disease. Once the presence of breast cancer is determined by biopsy, the patient undergoes a series of tests to establish the tumor stage. A variety of factors including tumor size and location, spread to other areas of the body, genetics and patient preference will determine the extent of surgical treatment. Most cases of breast cancer seen today require some form of surgery to remove affected tissue. Studies have shown that survival rates for breast conservation (lumpectomy/partial mastectomy) and total mastectomy are equal. The breast itself and the area under the arm, the axilla, can be considered separately when determining the type of surgery necessary at each location. Reconstructive surgery is an option that can be considered at the same time as the cancer operation, or at a later date. A discussion with your doctor will help to determine which type of procedure is best for you, but this article will hopefully provide some insight into the reasoning for choosing one type of surgery or another.

 

THE BREAST

Conservation- Lumpectomy/Partial Mastectomy

The most conservative form of surgical treatment for breast cancer is lumpectomy, also called partial mastectomy or wide local excision. A lumpectomy consists of removing only the breast tumor and a small area of the surrounding normal breast tissue on all sides. A single incision is usually made directly over the lump or the location of the tumor as seen on imaging. The size of the scar and the defect created in the breast will depend on the size of the tumor. The removed tissue will then be sent to a pathologist to make sure that the edges of the sample contain no tumor cells. Studies have shown that recurrence rates of breast cancer are significantly reduced when there is no tumor at the edge of the normal tissue excised with lumpectomy. Ordinarily, lumpectomy is performed to remove breast tumors that are small enough relative to the size of the entire breast that removal will leave an acceptable cosmetic result. Obviously, this will depend on the individual patient and location as well as the size of the tumor.

 

Two procedures that accompany lumpectomy are radiation therapy and axillary staging. In current treatment of breast cancer, lumpectomy is followed by radiation therapy to the breast when the tumor is shown to be malignant. Most often radiation is delivered to the entire breast, often with a boost to the area of the tumor. There are also studies underway in which women with less advanced disease can receive radiation only to the area of the breast in which the tumor is found. With current criteria, cancer recurrence rates after lumpectomy and radiation therapy are now less than 5% at 10 years. There are some contraindications to radiation treatment, which include previous radiation and autoimmune diseases such as lupus. Pregnancy is a relative contraindication. Often the pregnancy can be carried to term and then the radiation treatment can be given. Axillary staging involves removing one or more lymph nodes from the axilla to analyze them for the presence of cancer cells. It is usually done at the same time as a lumpectomy when the tumor is suspected or known to be malignant. It will be further discussed later in this section. Although additional surgical procedures may be required if a recurrence occurs, the overall survival rates for lumpectomy compared to mastectomy are equal.

 

Mastectomy

There are certain conditions that prohibit lumpectomy and are considered indications for a total removal of the breast, called a mastectomy. These indications include a tumor that is large relative to the size of the patient’s breast, many areas of calcification throughout the breast seen on mammography and patients who are unable to receive radiation treatment. Patient preferences for mastectomy over lumpectomy or to avoid radiation therapy are also valid indications for mastectomy.

 

Currently, two main types of mastectomy are performed for the surgical treatment of breast cancer: simple mastectomy and modified radical mastectomy. A simple or total mastectomy consists of the removal of all of the breast tissue as well as the nipple and areola, the dark skin surrounding the nipple. All breast tissue down to the covering of the pectoralis muscle (the “pec”) is removed. The nipple and areola generally need to be removed for disease that requires a mastectomy because of the close association with the rest of the breast tissue. Rates of invasion into the nipple and areola can be as high as 10% in mastectomy samples. A sentinel node biopsy can also be done through a second incision under the arm. A modified radical mastectomy also consists of the removal of all breast tissue including the nipple and areola with the addition of the removal of the axillary lymph nodes and surrounding fat. Similar incisions are made as in a simple mastectomy but must also allow for the removal of the lymph nodes.

 

There are also adaptations to the mastectomy that are used in the treatment of breast cancer. A procedure called a skin sparing mastectomy can be done when immediate reconstructive surgery is planned. It involves only removing the skin of the nipple and areola in order to provide as much skin as possible for reconstructive surgery. In rare cases the nipple and/or areola can be spared depending on the characteristics of an individual tumor. However, skin sparing can not be used when the tumor is very close to the skin or the skin is already involved. Oncoplastic surgery is another option. In this procedure, a partial mastectomy is combined with a plastic reconstruction to achieve adequate removal with a good cosmetic result in cases of larger tumors or poor location. Finally, chemotherapy can be given prior to surgery (neoadjuvant). In some cases, this can lead to enough shrinkage of a large tumor to allow breast conservation. Radiation therapy may also be required following a mastectomy for patients with more advanced disease. However, radiation is not required for patients with early stage disease following a mastectomy.

 

THE AXILLA

Another important aspect of the treatment of breast cancer is to assess for spread of the cancer to the nearby lymph nodes under the armpit, also known as the axillary nodes, and to treat them is tumor spread is present.  Because the axillary lymph nodes drain most of the breast tissue, they are the most common place of early spread of cancer. The presence of cancer cells in the lymph nodes indicates the need for more aggressive medical treatments. A physician can check with physical exam for lymph nodes that seem abnormal such as those that feel hard or immobile. Diagnosis of the lymph node that feels abnormal can be made using aspiration cytology, in which the cells from the lymph node are extracted with a needle and examined under a microscope. Nodes can also be diagnosed based on radiology findings like a CT scan. However, to examine nodes that appear to be normal based on exam and imaging, two different surgical procedures can be done, often at the same time as the lumpectomy or mastectomy: sentinel node biopsy and axillary dissection.

 

The more commonly used procedure is sentinel lymph node biopsy. A separate incision is made under the arm to locate the nodes. This procedure is done by injecting blue or radioactive dye into the breast. Then, the first lymph node that drains the affected breast is located based upon the appearance of blue dye or radioactivity using a detector. Only stained or palpably abnormal lymph nodes are removed and sent to pathology to look for the presence of tumor cells. If the nodes are clear, no further axillary procedures are required; if the nodes are cancerous, then a full node dissection can be done. Sentinel biopsy can be done as a same day procedure and does not usually cause the problems with swelling and mobility found with full dissection. Also, studies have shown that the sentinel node biopsy is an accurate diagnostic tool to predict the presence of spread cancer.

 

Axillary dissection consists of removing the lymph nodes and the surrounding fat from the area under the arm. Dissection is effective in removing potentially cancerous lymph nodes, however, it can produce many undesirable side effects. It may increase the pain following the procedure. It also can cause long-term problems. Decreased range of motion of the arm can occur but should be very rare in the presence of postoperative physical therapy. Numbness and even permanent swelling of the arm due to the blockage of the lymph channels can occur. However, most instances of swelling (lymphedema) do not interfere with the full use of the arm. Due to the side effects, axillary dissection is usually performed when abnormal nodes are felt on physical exam prior to surgery or after lymph nodes are found to be positive for cancer by biopsy, although it can be done as a combined staging and therapeutic procedure.

 

 

RECONSTRUCTIVE SURGERY

Reconstructive surgery is not required following mastectomy, but many women prefer to have at least the shape of the breast reconstructed. In general, patients who are younger and have less advanced disease are better candidates for reconstructive surgery. Also, patients with factors such as obesity, advanced age, smoking and psychological/emotional difficulties are poor candidates for reconstruction. The type of reconstruction is determined by the size of the opposite breast, the amount of skin left by the mastectomy and the need for radiation and chemotherapy. For example, implants are often not placed prior to radiation because it can lead to contraction of the tissue around the implant. Reconstructive surgery can often be initiated immediately, during the same surgery as the mastectomy, or at a later date. However, reconstructive surgery is being done more often immediately because studies have shown that there is no change in cancer recurrence and survival when reconstruction is performed right away. Also, because the skin has not yet retracted, better cosmetic and more symmetric results are often achieved when reconstruction is performed immediately. When reconstruction is postponed to a later date, the tissue and skin can be gradually stretched using something called a tissue expander. Once the skin has stretched, the reconstructive procedure can be done. Reconstruction is a process that can require multiple surgeries depending on individual patient factors and the type of surgery chosen. Also, in spite of adequate reconstruction, techniques are limited in the amount of symmetry they can achieve. Therefore, a procedure on the unaffected breast may be necessary to achieve symmetry.

 

One option for breast reconstruction is the use of implants. Most often when implants are chosen, the final implant is not inserted at the time of the original operation. A tissue expander is usually placed. Over time, the skin is stretched to the final size. The expander is later changed to the final implant (either saline or silicone), with the timing dependent on coordination with chemotherapy and/or radiation. Complications that can occur with implants include contraction of the tissue around the implant, infection and tissue death around the implant due to decreased blood supply.

 

Another option for reconstruction involves using a flap of muscle, fat and skin from the back, abdomen or buttock and inserting it at the location of the breast to mimic the original shape. These flaps are often taken from an area where the patient has excess tissue so a good cosmetic result can be achieved. The two most common procedures that involve this technique are called the latissimus dorsi myocutaneous flap (using a muscle of the back) and the transverse rectus abdominus myocutaneous flap, also called a TRAM flap (using a muscle from the belly). Because tissue is taken from another area on the patient’s body, complications can arise either at that site or at the reconstructed breast. Complications that occur in the area that tissue was harvested from include laxity, or loss of tone, and tissue death due to loss of blood supply. Complications in the breast include infection and tissue death due to low blood supply.

 

The nipple and areola can also be reconstructed, but physicians most often like to wait until the breast is fully healed to determine the symmetry of the breast reconstruction and the proper location for nipple placement. A nipple can be constructed by using a flap of skin from the reconstructed breast and folding it upon itself to form a nipple. Later the nipple can be tattooed along with the area of the areola to mimic the look of the original breast. A nipple and areola can also be constructed from a flap of skin taken from elsewhere on the patient’s body where they have darker skin pigmentation, such as a scar or skin creases. However, this is currently done less often.

 

With all these techniques, plastic procedures on the contralateral breast are often required and done when the final size and appearance of the reconstructed breast are achieved. Obviously, this does not apply to cases of bilateral total mastectomy with reconstruction

 

Megan Walker, Michael Warso MD

 

Resources

www.breastcancer.org

 

www.breastreconstruction.org

 

Sabiston textbook of surgery: the biological basis of modern surgical practice.—18th ed./editors, Courtney M. Townsend Jr.…[et al.]. SAUNDERS ELSEVIER, Philadelphia, PA 2007

 

D'Souza N, Darmanin G, Fedorowicz Z. Immediate versus delayed reconstruction following surgery for breast cancer (Protocol). Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD008674. DOI: 10.1002/14651858.CD008674.

Curr Opin Obstet Gynecol. 2002 Feb;14(1):45-52.Current surgical management of breast cancer. Cody HS 3rd. The Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, and Cornell University Medical College, New York