Surgery is usually the first form of treatment for breast cancer. One of the most important decisions a woman newly diagnosed with breast cancer faces is deciding what type of surgical treatment to have. Surgical treatment options of the breast include lumpectomy and mastectomy. Oncoplastic surgery or breast reconstruction may be utilized. The two intertwined goals of definitive breast cancer surgery are:
- To remove the cancer completely in order to minimize the chance of cancer recurring in the local area (breast, chest wall or regional lymph nodes) and to improve survival.
- To perform the surgery in the best possible cosmetic way to preserve a womans body image, self esteem and psychosocial well-being.
Although breast-conserving treatment (lumpectomy and radiation) is often the procedure of choice for women with early stage breast cancer, many women are either not candidates for breast conserving treatment, or may choose mastectomy for personal reasons.
Lumpectomy | Mastectomy | Breast Reconstruction | Implant Reconstruction
Flap Reconstruction | Oncoplastic Surgery | Breast Prosthesis
Lumpectomy technically means to remove a lump, but it is typically used to indicate the removal of a breast cancer with negative margins (rim of normal surrounding tissue). This term can be misleading because many breast cancers do not form lumps but are detected in asymptomatic women on routine mammograms. Alternative terms include wide local excision, which signals the intention to remove a breast cancer with negative margins. Partial mastectomy is less specific and includes lumpectomies as well as quadrantectomies, indicating that a portion but not the entire breast has been removed.
If a breast cancer cannot be felt, a wire localization procedure is performed to identify the site of the cancer in preparation for lumpectomy. If the cancer or biopsy marking clip are visible on ultrasound, the breast surgeon can use ultrasound guidance to localize the cancer intraoperatively while the patient is under anesthesia in the operating room. The cancer is visualized on ultrasound, and a fine wire is inserted through or next to the cancer. The breast tissue surrounding the localizing wire is removed with the lumpectomy. An ultrasound is performed of the specimen to be sure the cancer has been removed and to assess the margin of tissue surrounding it. If the cancer cannot be seen on ultrasound, a radiologist can use mammography to localize the cancer preoperatively. Local anesthesia and an oral sedative can be used to make this procedure more comfortable. The cancer is visualized on a mammogram, a fine wire is inserted through or next to the cancer and a mammogram is done to demonstrate the location of the wire to the cancer or biopsy marking clip. The patient is taken back to the operating room and the lumpectomy is performed. A specimen x-ray is performed to be sure the cancer has been removed.
A breast cancer can extend microscopically in the surrounding tissue beyond its apparent borders on breast exam or imaging studies, so the margin status is not known until the pathologist looks at the lumpectomy specimen under the microscope. Sometimes additional surgery, a re-excision, is necessary to remove a clear margin of normal tissue around the cancer. Intraoperative breast ultrasound can be used by the breast surgeon to increase the chances of removing the cancer with a negative margin with the initial lumpectomy.
It is important to consider breast exam findings and the potential effects of a biopsy on subsequent definitive breast cancer surgery. Handling, imaging and orientation of both breast biopsy and lumpectomy specimens is critical. It is important for the surgeon to consider aesthetic issues such as placement, orientation and length of incisions, oncoplastic techniques, and cosmetic closure of incisions to achieve the best possible cosmetic result.
The advantage oflumpectomy is to effectively treat breastcancer while preserving a breast that looksand feels normal. The amount of anesthesia,extent of surgery, hospital stay, andpost-operative recuperation are less withlumpectomy than mastectomy. Most women withearly stage breast cancer are excellentcandidates for lumpectomy followed by breastradiation. Numerous scientifically rigorous,prospective randomized studies with long-term follow- up of 10-20 years havedemonstrated that the combination oflumpectomy and radiation is equivalent tomastectomy in terms of survival andmortality. Local recurrence rates (thechance of the breast cancer coming back inthe breast or on the chest wall) are similarwith these approaches, assuming certaincriteria are met, but local recurrence ratesare lower with mastectomy, 10% versus 15% at15 years after treatment. The majority oflocal recurrences after lumpectomy andradiation can be treated with mastectomy,and the outcome appears to depend more onthe underlying tumor biology rather thanwhether the initial treatment waslumpectomy/ radiation or mastectomy.
There are certain situations in which mastectomy would be a better treatment. If the cancer is too large in relation to the size of the breast such that it can’t be removed with negative margins the patient may be at a higher risk for a local recurrence with breast- conserving treatment. If the cancer can’t be removed with a cosmetically acceptable result, there is no advantage to breast- conserving treatment. Fortunately chemotherapy or even hormonal therapy can be used to shrink large breast cancers so that a lumpectomy can often be successfully performed in such cases. In other cases, if a wide area of tissue is resected or a quadrantectomy is necessary, oncoplastic techniques can be utilized to obtain excellent cosmetic results.
Multicentric breast cancers, in which breast cancer is present in more than one quadrant of the breast, have a higher risk for local recurrence with lumpectomy and radiation if there is associated ductal carcinoma in-situ. However, two small invasive cancers or a solitary invasive cancer with an extensive intraductal component can be treated successfully with lumpectomy and radiation as long as negative margins are obtained. Inflammatory breast cancers are not amenable to breast-conserving surgery because of the high risk for local recurrence.
Some patients can’t be safely treated with radiation or have a high risk of complications related to radiation , such as women with collagen vascular disorders especially active scleroderma or lupus (SLE), women in the first trimester of pregnancy, women who have been previously treated with mantle irradiation for Hodgkin’s Disease or prior radiation therapy to the same breast. A woman with a breast implant in place for augmentation has a 35-65% risk for complications if radiation is performed with the implant in place beneath the breast.
Breast cancers directly behind the nipple require resection of the nipple areolar complex. Breast conserving treatment, often with nipple areolar reconstruction, can be performed in such cases, but if a nipple areolar resection is required in a woman with small breasts, mastectomy and reconstruction may be preferable cosmetically, depending on the extent of the resection.
Women with BRCA mutations who are diagnosed with cancer in one breast may chose to have bilateral mastectomies because of concerns about an increased risk of developing a second primary cancer in the same breast over time and a high risk for developing cancer in the opposite breast.
Women with cancer in axillary nodes or in both breasts, young women and women with triple negative breast cancers can expect equivalent treatment outcomes with either breast- conserving therapy or mastectomy.
For some women, their breasts are not an important part of their body image, so preserving their breasts isn’t a priority. Some women do not want to undergo breast radiation. A mastectomy is a very effective treatment for breast cancer and would be a reasonable choice under such circumstances.
However, it is critical for a woman to be fully informed of the indications, risks and benefits of breast- conserving treatment versus mastectomy so she can make an informed decision for the right reasons, based on the best available information. A joint study of the American College of Radiology and the American College of Surgeons found that high mastectomy rates in the United States are the result of inappropriate use of medical selection factors and geographical location, with mastectomies performed more frequently in women who are candidates for breast
conserving therapy in certain parts of the country. A common misperception is that since mastectomy is a more aggressive surgical treatment, it is a better treatment. For the majority of women with early stage breast cancer, lumpectomy/ radiation and mastectomy are equivalent options.
“The Office of Medical Applications of Research of the NIH and the National Cancer Institute convened a consensus development conference on the treatment of early-stage breast cancer in June 1990. The panel concluded that “breast conservation treatment is an appropriate method of primary therapy for the majority of women with stage I and II breast cancer and is preferable to mastectomy because it provides survival rates equivalent to those of total mastectomy and axillary dissection while preserving the breast.” The validity of this statement has been upheld by long-term data from prospective randomized trials. The rate of BCT for eligible breast cancer patients has risen steadily since the consensus conference statement.”
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Mastectomy is a surgical procedure in which the entire breast is removed. There are different types of mastectomies.
A simple or total mastectomy removes all the glandular breast tissue along with the nipple-areolar complex.
A skin-sparing mastectomy is a simple mastectomy in which a limited amount of breast skin is removed, often preserving all the breast skin except for the nipple areolar complex. This is combined with immediate breast reconstruction and gives a better cosmetic result than traditional simple mastectomy, without adversely affecting local recurrence rates.
A nipple-sparing mastectomy removes all the glandular breast tissue but preserves a very thin flap of the nipple-areolar complex. No skin is removed with this surgery. This results in a superior cosmetic result. It also means that there is tiny amount of ductal tissue preserved in the intact nipple. A sample of tissue is excised from directly beneath the nipple and evaluated with a frozen section during the surgery; this specimen must be benign in order to proceed with a nipple-sparing mastectomy. Nipple-sparing mastectomy can be considered in cases with
tumors < 3 cm, > 2 cm away from the nipple, without an extensive intraductal component, with negative margins, with clinically negative axillary lymph nodes, no skin involvement, and no inflammatory breast cancer or Pagets disease of the nipple. It is not ideal for women with very large, pendulous breasts. A preoperative breast MRI should be performed. It is combined with immediate breast reconstruction. Local recurrence rates are low in appropriately selected patients, and recurrences in the retained nipple are rare.
A modified radical mastectomy is a combination of simple mastectomy plus axillary node dissection (surgery to remove all the lymph nodes within certain anatomic boundaries in the underarm). A variable amount of skin is removed along with the nipple-areolar complex. No muscles are removed.
A radical mastectomy removed all the glandular breast tissue, a large swath of overlying skin along with the nipple-areolar complex, both pectoralis major and minor muscles and the axillary lymph nodes. It is rarely used currently because of studies, particularly those of the NSABP, which showed that modified radical mastectomy was as effective as radical mastectomy. Radical mastectomy was the most common breast cancer surgery performed for the majority of the twentieth century, and was often performed at the same time as a diagnostic breast biopsy, while the woman was under general anesthesia. As we have learned more about the biology of breast cancer it has become apparent that such extensive surgical procedures are not necessary, and that women can safely consider treatment options in a timely fashion before undergoing definitive breast cancer surgery. For women with locally advanced breast cancer who may have needed a radical mastectomy in the past, chemotherapy and sometimes radiation therapy can be used to shrink large breast cancers prior to surgery.
A prophylactic mastectomy is a mastectomy which is used to prevent breast cancer in women who have very high risk for developing breast cancer. Skin-sparing and nipple- sparing mastectomies are often used as prophylactic mastectomies.
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Breast reconstruction can be performed to recreate the appearance of the breast after mastectomy. It is safe and does not affect local recurrence risk or survival. For some women who dont have reconstruction, the asymmetry from the absence of the breast can cause back pain or make it difficult to find appropriately- fitting clothes. Breast reconstruction can be performed at the same time as the mastectomy, immediate reconstruction. Delayed reconstruction can be performed at any time, even years after mastectomy, if a woman chooses to do so. There are some situations in which it might be preferable to delay reconstruction. In general, immediate reconstruction results in a better cosmetic result because more breast skin can be preserved as it can be combined with skin-sparing or nipple- sparing mastectomies. It reduces psychological distress by combining the mastectomy with the breast reconstruction in one surgery. Breast reconstruction is performed by a
plastic surgeon. At the time of the plastic surgery consultation, the plastic surgeon will discuss reconstructive goals and expectations, and make recommendations about various types of breast reconstruction based on ones particular case. The plastic surgeon and breast surgeon work together to be sure combined procedures are done in the best possible way from both the oncologic and aesthetic perspectives. Breast reconstruction usually requires a series of operations to complete the process, including reconstruction of the nipple and tattooing to achieve the appearance and coloration of the nipple- areolar complex. There are two main types of breast reconstruction: implant reconstructions and flap reconstructions. In general, implant reconstructions are simpler and less time-consuming, but flap reconstructions create a reconstructed breast with a more natural appearance and texture.
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The most common technique used for breast reconstruction is the placement of tissue expanders followed by implants. A tissue expander is a temporary implant which is inserted behind the chest wall muscles. It is gradually filled with saline solution through a tiny valve under the skin until the overlying skin stretches enough so that the tissue expander can be exchanged for an appropriately sized permanent implant. The permanent implant has a more natural shape and texture. The permanent implant may be filled with saline (salt water) or silicone gel. Silicone implants are safe and have a more natural feel than saline- filled implants. The placement of a tissue expander can be a good immediate option for women who need to defer definitive breast reconstruction, for example, because of the
need for post-mastectomy radiation.
Less commonly, a permanent implant can be placed without using a tissue expander first, as a single- stage breast reconstruction.
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A TRAM (Transverse Rectus Abdominus Muscle) Flap takes skin, fatty tissue and muscle from the abdominal wall and shifts it up to the chest wall to create the shape of the breast. This results in a more natural looking and feeling reconstructed breast than an implant. The patient also gets a tummy tuck as a result of removing the excess abdominal tissue. A pedicle flap leaves the abdominal tissue flap attached to its original blood supply and tunnels it under the skin to the chest wall. With a free flap, the surgeon cuts the blood vessels to the flap and then attaches them to blood vessels in the chest using microsurgical techniques.
A DIEP (Deep Inferior Epigastric Artery Perforator) Flap is a free flap which uses skin and fatty tissue from the abdominal wall, like a TRAM flap, but preserves the abdominal muscle that the TRAM flap utilizes. This preserves abdominal wall strength, and therefore activities requiring abdominal wall muscles are easier to perform.
In this procedure, a flap of skin, fatty tissue, and muscle is taken from the back and transferred under the skin to the chest wall. In many cases, an implant is placed under the latissimus flap in order to create a reconstructed breast which is the same size as the opposite breast. For patients who have been previously treated with breast radiation, the latissimus flap is a way to cover the implant with healthy, flexible, non-radiated skin.
A TUG (transverse upper gracilis) Flap is a free flap which uses muscle and fatty tissue from the inner thigh to create the reconstructed breast. The scar atr the doner site is well- hidden. This is a good option for women with small breasts, especially if they dont want to use an implant.
A GAP (gluteal artery perforator) Flap is a free flap which uses tissue from the buttocks, including the gluteal muscle, to create the reconstructed breast. It is an option for women who are not candidates for a TRAM or DIEP flap.
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Breast conserving therapy with lumpectomy and radiation usually results in a good to excellent cosmetic result. However, for some patients more advanced surgical techniques are needed to improve cosmetic results. Oncoplastic surgery utilizes techniques to achieve optimal cosmetic results in conjunction with breast- conserving cancer surgery. For smaller defects, the breast surgeon or plastic surgeon can advance adjacent breast tissue flaps into the defect created by the lumpectomy. In larger-breasted patients who need wider areas of breast tissue or even a quadrantectomy in order to excise a cancer with negative margins, the treated breast can be reconfigured and a reduction can be performed on the opposite breast to achieve smaller but symmetric, nicely shaped breasts. For patients with ptotic (drooping) breasts, a lift or mastopexy can be combined
with the lumpectomy. For patients requiring a nipple-areolar resection, the nipple-areolar complex can be reconstructed,
and a reduction can be performed on the opposite breast to achieve symmetry. Oncoplastic surgery may be performed at the same time as breast-conserving cancer surgery or as a separate procedure.
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Some women decide not to have breast reconstruction. A breast prosthesis can be worn within a specially designed bra to recreate the look of the breast in clothing or bathing suits. For large-breasted women, the prosthesis can be heavy and uncomfortable. There are a variety of styles of breast prostheses, some of which adhere directly to the chest wall, others are light-weight and some are designed specifically to be worn in a bathing suit for swimming.
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