Breast Cancer Surgery

 

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(also called local excision or wide local excision) and mastectomy. Oncoplastic surgery or breast reconstruction may be utilized. The two intertwined goals of definitive breast cancer surgery are:

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• 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 woman’s body image, self esteem and psycho-social well-being.

 

Fortunately, breast- conserving treatment (lumpectomy usually followed by breast radiation) is the procedure of choice for most women with breast cancer. However, some women are either not candidates for breast conserving treatment or may choose mastectomy for personal reasons.

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Lumpectomy (Local Excision, Breast-conserving Surgery)

 

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 local excision, wide local excision, or breast-conserving surgery, all of which signal the intention to remove a breast cancer with negative margins, without removing the entire breast. 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 of lumpectomy is to effectively treat breast cancer while preserving a breast that looks and feels normal. The amount of anesthesia, extent of surgery, and post-operative recuperation are less with lumpectomy than mastectomy. Most women with early stage breast cancer are excellent candidates for lumpectomy followed by breast radiation. Numerous scientifically rigorous, prospective randomized studies with long- term follow- up of 10-20 years have demonstrated that the combination of lumpectomy and radiation is equivalent to mastectomy in terms of survival and mortality. Local recurrence rates (the chance of the breast cancer coming back in the breast or on the chest wall) are similar with these approaches, assuming certain criteria are met, but local recurrence rates are lower with mastectomy, 10% versus 15% at 15 years after treatment. The majority of local recurrences after lumpectomy and radiation can be treated with mastectomy, and the outcome appears to depend more on the underlying tumor biology rather than whether the initial treatment was lumpectomy/ radiation or mastectomy.

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For women over 65-70 years of age, with breast cancers which are smaller than 2 cm, hormone receptor positive, without cancer in axillary lymph nodes, breast radiation after lumpectomy could potentially be omitted, with the same likelihood of survival. The chance of having the cancer recur in the breast or axilla is low in either case, but increases from 2% to 10% if radiation is not done.

 

There are certain situations in which mastectomy would be a better treatment than breast-conserving 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 significant associated ductal carcinoma in-situ. However, multiple 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 may 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 misconception 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

 

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. This can be done with or without immediate breast reconstruction.

 

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 by the pathologist; this specimen must be benign in order to have 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 Paget’s 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; they usually occur elsewhere on the chest wall.

 

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.This can be done with or without immediate breast reconstruction.

 

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. 

 

A prophylactic mastectomy is a mastectomy which is used to prevent breast cancer in women who have very high risk for developing breast cancer. Nipple-sparing and skin- sparing mastectomies with immediate reconstruction are often used as prophylactic mastectomies.

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Breast Reconstruction

 

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 don’t 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 one’s 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 cancer-treatment 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.

 

Implant Reconstruction

 

Tissue expanders

The most common technique used for breast reconstruction is the placement of a tissue expander followed by subsequent placement of a permanent implant. A tissue expander is a temporary implant which is inserted either in front of (prepectoral) or behind (subpectoral) 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 interim option for women who need to defer definitive breast reconstruction, for example, because of the need for post-mastectomy radiation. 

 

Permanent implants

Less commonly, a permanent implant can be placed without using a tissue expander first, as a single- stage breast reconstruction.

 

Flap reconstruction

 

TRAM flap

 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.

 

DIEP flap

 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.

 

Latissimus dorsi flap

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.

 

TUG flap

 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 at the donor site is well- hidden. This is a good option for women with small breasts, especially if they don’t want to use an implant.

 

GAP flap

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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Oncoplastic Surgery

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. Another option is placement of a BioZorb form within the lumpectomy cavity. This is a spherical coil made from the same material as some sutures. The coil itself dissolves in 1-2 years, but it also has titanium clips attached to it; these guide the delivery of radiation boosts to the lumpectomy site.  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.

 

Breast prosthesis

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.