Breast Cancer Surgery
“What are the surgery options for breast cancer?”
“Should I Conserve my breast or remove?”
“Do I need Chemoport?”
Breast Cancer Surgery
Breast Cancer Surgery
Surgery is the main component of breast cancer treatment that involves removing the cancer with an operation. Together, we will decide which surgery is best for you.
Breast cancer Surgery may be used in combination with other treatments, such as chemotherapy, hormone therapy, targeted therapy and radiation therapy.
Your treatment is tailored according to:
- Your type of breast cancer (the biology of the tumor)
- The stage of the breast cancer
- Your overall health, age and other medical issues.
- Your personal preferences.
A breast cancer surgery, has two parts to be tackled:
1. The Tumour in Breast
2. The Nodes in the Armpit (Axilla)
Breast Conservation Surgery (BCS)
BCS or Lumpectomy involves the removal of the lump along with a margin of the healthy breast tissue. The rest of the breast remains intact. Breast conservation surgery will also address axilla with sentinel lymph node biopsy or removal of nodes in the armpit. After BCS, we compulsorily give Radiation to the breast which will reduce chances of cancer coming back ‘locally’.
Breast Conservation Surgery (BCS) is absolutely SAFE!
Who is a candidate for a BCS?
BCS can be done in almost all women with newly diagnosed, early-stage breast cancers. For Large tumours – We give chemotherapy first, to shrink the tumour and make BCS possible. If it doesn’t shrink, then the breast will have to be removed.
Other factors that determine whether you are a good candidate, if:
• your tumor is small relative to your breast size
• your tumor is in one area of your breast
• you’re able to receive radiation treatments after lumpectomy.
Modified Radical Mastectomy (MRM)
MRM means removal of the entire breast, most of the skin and most of the lymph nodes in armpit. The remaining skin is sewn together to close the wound.
We do MRM in the following situations:
• Multicentric tumour – There is more than one tumour in the breast, seen on mammography
• Large single tumours not shrinking by chemotherapy
• BRCA 1/2 Mutation positive patients
• Patient choice – sometimes, even when conservation is possible, patients opt for a mastectomy.
Patients stay in hospital overnight and go home the next day. Two drains are placed and can usually be removed in 10 to 14 days. Recovery is about 2 weeks.
“Should I Conserve my breast or Remove?”
Clinical trials published in the 1980s taught us that in women with early stage breast cancer that had lumpectomy together with breast radiation therapy had the same survival rate as women who underwent a mastectomy.
Oncoplastic surgery is usually done at the same time as lumpectomy to fill up the defect and preserve and restore the natural appearance of the breast.
In my practice, oncoplastic surgery is offered to all women who have breast conserving surgery so they can have better cosmesis and have good quality of life.
Oncoplastic surgery also refers to surgery on the noncancerous (contralateral) breast. It is done to obtain symmetry and can also be done at the same time as the lumpectomy.
We know from experience that even small lumpectomies can result in significant deformity and pain. Often the immediate cosmetic outcome after a lumpectomy and radiation is good but over time, due to ongoing radiation changes and scarring, the breast can shrink, dimple and pucker.
With oncoplastic techniques, even large lumpectomies are do-able and the breasts often look better that they did before the patient had cancer.
Breast Reconstruction Surgery
This is about creation of a new breast shape, after removal of a whole breast (mastectomy) or part of the breast (breast-conserving surgery).
To reconstruct or not to reconstruct?
My all patients are made aware prior to surgery for the possibility of breast reconstruction. Reconstruction is not necessary to “cure” breast cancer but it is often necessary for a patient’s sense of well-being.
No Reconstruction / Post mastectomy Bra and Prosthesis.
If a woman chooses not to undergo reconstruction, she can be fitted with a post mastectomy bra and artificial breast prosthesis. This is usually done about 6 weeks after surgery, once the incisions have healed.
Breast prostheses are available in different materials (silicone gel, foam, and fiberfill) and textures (firm, medium, and soft). Sizes, shapes, and skin tones vary widely.
We can place prostheses in a special pocket of a bra or bathing suit. When properly fitted and weighted, prostheses allow you to have correct posture. Custom-made prostheses are also available.
Considering Reconstruction. What are the Options?
Immediate / Delayed
Implants / Autologous tissues
The When & How Of Breast Reconstruction:
WHEN: The breast can be reconstructed at the same time breast is removed (immediate reconstruction) or later in a separate operation (delayed reconstruction). The initial timing of reconstruction often depends on whether or not the patient is having radiation after mastectomy.
HOW: Following the complete mastectomy, a new breast can be formed with an implant (implant-based reconstruction) or the patient’s own tissue (autologous reconstruction) or a combination of the two.
Hidden Scar Breast Surgery
We practice this advanced approach for removing breast cancer or benign breast lump.
Hidden Scar Surgery is a type of breast surgery where the incision sites are hidden, and scars are not visible when the incision heals. The Hidden Scar approach can be performed for both nipple sparing mastectomy or lumpectomy procedures. The goal of the procedure is to leave little trace of the surgery after the incision site heals.
We hide the incision in one of three locations:
- the natural crease under your breast (called the inframammary fold)
- around your nipple areolar complex
- in a skin crease in your armpit (called the axilla).
You may be a candidate for a Hidden Scar breast surgery if your:
- Tumor is small compared to the size of your breast
- Tumor is confined to a specific area of the breast
- Tumor is small enough where your surgeon can completely remove the tumor as well as some margin of normal tissue around it
- Cancerous cells have not spread to the nipple.
Wire Localisation Excisional Biopsy
In some cases very small cancers are picked up on mammogram. These can be so small that you cannot feel a lump at all. In these cases, in order to remove the cancer it needs to be “localised” to make sure the right area is removed.
We use a “guidewire” to localise a small cancer. Using local anaesthetic a fine wire is placed into the breast so that the tip of the wire lies next to the cancer or suspicious area. This can be done either with ultrasound or mammogram, depending on which shows the cancer best.
Then, under general anaesthesia, the area of the breast with the wire in it is removed. In all cases of wide local excision, the area that has been removed will be x-rayed to make sure the cancer has been removed and then the specimen will be sent away to be analysed by a pathologist.
Simple mastectomy, total mastectomy and complete mastectomy all refer to the same operation.
With this operation the entire breast, most of the skin and the nipple-areolar complex are removed.
Axillary lymphnodes are spared.
Skin and Nipple Sparing Mastectomy
This involves removal of the entire breast, usually through an incision along the fold below a woman’s breast (inframammary fold) with preservation of all the skin and the nipple-areolar complex.
As with the skin sparing mastectomy, this operation is done in combination with reconstruction, either implant based or autologous (tissue taken from the patient’s body).
Skin and nipple sparing mastectomy is an option for women who are considering prophylactic (preventative) mastectomy because they are at high risk for developing breast cancer such as those with a BRCA mutation.
Some patients with early stage breast cancer (stage 0, 1 and 2) who are not candidates for breast conservation may be considered for skin and nipple sparing mastectomy.
How can you tell if breast cancer has spread to the axillary lymph nodes?
Axillary lymph nodes evaluated before surgery with imaging (Ultrasound or MRI). If a lymph node looks abnormal on imaging, it can be biopsied with a needle. Even if the lymph nodes look normal on imaging, it’s still necessary to go the extra step and remove the whole lymph node and look at it under the microscope to determine whether or not it contains cancer.
So, along with either a Mastectomy or a Lumpectomy axillary assessment/treatment is carried out during surgery with either of the two procedures:
1.Sentinel Lymph Node Biopsy
2.Axillary Lymph Node Dissection
What is sentinel lymph node biopsy (SLNB)?
A SLNB is a procedure in which the first draining lymph node is identified, removed, and examined to determine whether cancer cells are present.
In this procedure, a radioactive and/or blue dye is injected subdermal/peritumor area that travels along the lymphatics and drain tumor. These nodes are then sent for pathology examination by a technique called frozen section. The results are usually available within 30 minutes. If they are found to contain tumour cells then the rest of the axillary nodes may be removed. If sentinel lymph nodes do not have cancers cells, then no further removal of axillary lymph nodes is required.
What are the benefits of SLNB?
SLNB avoids more extensive lymph node surgery and reduces the incidence of arm swelling (Lymphedema) and Shoulder dysfunction.
What is Axillary Lymph node dissection?
An axillary node dissection is more extensive procedure, involving more lymph nodes, and is more common for larger tumours. The complications of extensive lymph node surgery are:-
- Lymphedema or swelling of the arm
- Seroma or the buildup of fluid at the site of the surgery
- Numbness, tingling, or pain of the arm
- Shoulder weakness
A Chemoport is a device which is implanted into the body by a surgery and is used to administer I.V. Chemotherapy. This placement provides safe, easy and reliable I.V. access to your blood stream. This is a common procedure in patients requiring long term I.V. access.
A port placement surgery is an out patient procedure and usually done under local anesthesia.
• Chemoports lower the risks of damage caused to your peripheral veins and tissues.
• It provides multiple access to the veins of your body.
• Chemoport can be kept for almost 2 years or even more.
• The silicon of chemoport can withstand 2000 needle pricks!
• Chemoport allows us to frequently collect blood samples without injecting a needle each time.
I strongly advise using a chemoport for chemotherapy. The quality of life becomes much better.