Breast Cancer Surgery

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 complete 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 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.

Injection of blue dye for sentinel node biosy
blue sentinel node identified in the armpit
The scar of SNB

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 or Her2 proteins?

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 .

Breast cancer stage Meaning Survival at 5 years
0 Non-invasive tumour (e.g. DCIS type) 95%
1 Confined to the breast and less than 2 cm wide 85%
2 Local spread and less than 5 cm wide 70%
3 Local spread and more than 5 cm wide 50%
4 Advanced disease and spread to other organs 15%

When is it Advisable to Have a Mastectomy Rather than a Lumpectomy?

In certain situations, your breast specialist may advise you to have complete removal of the breast (mastectomy), rather than removal of the cancer lump (lumpectomy). Such situations include the following:

  • If the tumour lies in a central location behind or close to the nipple.
  • If there is more than one cancer in the same breast.
  • If the cancer is very large in relation to the size of the breast (more than 4 cm wide).
  • If the patient specifically requests a mastectomy.

Breast Reconstruction

Approximately 1 in 5 patients with breast cancer will require a mastectomy rather than a lumpectomy. As mastectomy results in the distortion of the body image, it is natural for some patients to seek reconstructive surgery. However, some women are just relieved to have had the cancer removed and are not keen on having breast reconstruction. Although an external implant is available that can be put inside the brassiere, it may be adequate for some women. Other women will require surgical breast reconstruction to give them a satisfactory appearance. All patients undergoing mastectomy should be offered the possibility of breast reconstruction, either performed immediately at the time of mastectomy, or as a later procedure. Mastectomy combined with immediate reconstruction is preferred and seems to cost less than mastectomy with subsequent delayed reconstruction. There is no evidence that immediate reconstruction at the time of mastectomy worsens the breast cancer outlook. Frail patients with other medical problems are not advised to undergo breast reconstruction surgery as they have an increased risk of complications.

There are various methods of reconstruction and the choice should be made after discussion with the breast surgeon, specialist breast nurse and other patients who have had breast reconstruction. You should request pictures showing the outcome of the various methods. The choice of reconstruction depends upon the woman's build, shape and size of her breasts, previous scars, and her own preferences. The author prefers the type of mastectomy that preserves most of the natural skin envelope of the breast (called a skin-sparing mastectomy) when performing immediate breast reconstruction in view of the superior cosmetic result:

Steps of standard skin-saving mastectomy (SSM)

Breast Reconstruction
Breast Reconstruction

The various methods of reconstruction include:

A. Breast implants (saline-filled tissue expanders or silicone implants),
B. Flap reconstruction (from back, tummy or buttocks)

The LD flap (back) reconstruction:

Breast Reconstruction
This photo shows the LD flap
Breast Reconstruction
The flap is placed into the skin envelope

The long-term cosmetic result of SSM (right) plus LD flap reconstruction:

This 52 year old lady had right skin-saving mastectomy and immediate breast reconstruction using a skin and muscle flap from the back for early breast cancer. She also had nipple reconstruction and enlargement of the opposite breast in order to achieve symmetry. (The procedure was performed by the author KM in 2003)

LD flap ReconstructionLD flap Reconstruction

LD flap ReconstructionLD flap Reconstruction

This doctor had left SSM and LD flap for early breast cancer. She also had nipple reconstruction and enlargement of the opposite breast in order to achieve symmetry

Reconstruction Left skin reconstruction Left SSM

Reconstruction Side View

\

This 49 year old lady had left skin-saving mastectomy and immediate breast reconstruction using a skin and muscle flap from the back for early breast cancer. She also had nipple reconstruction and tattooing.

Breast Reduction

Breast Implants

An implant is inserted under a muscle in the chest wall at the mastectomy site. Implant reconstruction can be performed immediately at the time of skin-sparing mastectomy or as a delayed procedure through the original mastectomy scar. There has been a recent concern regarding the safety of silicone implants. In fact, there is no evidence that silicone implants increase the incidence of breast cancer or other diseases, such as arthritis. The main problems with implants are infection (occurring in 2% of patients) and scarring around the implant. Scarring makes the breast feel hard and painful, and it is more common if the prosthesis is very smooth.

Breast Implant An example of Anatomically

Modern implants consist of an outer silicone shell (roughened or textured) and an inner compartment that can be filled with saline (salt water) instead of silicone gel. Implants having a similar shape to the natural breast have recently been introduced. Your breast surgeon will explain the pros and cons of the various types of implant available to you.

The cosmetic outcome of SSM and implant-based reconstruction

This 46 year old lady had right skin-saving mastectomy and immediate reconstruction using an implant alone

Right SSM ana implant reconstruction
Right SSM ana implant reconstruction

Flap Reconstruction

A portion of the patient’s skin and underlying fat and/or muscle (with blood supply), called a flap, is moved to the mastectomy site in order to build a new breast. Two types of flap are commonly used in breast reconstruction: in the first method, the flap is taken from the back; the second uses a flap taken from the abdomen (tummy tuck). It is also possible to rebuild the breast using a flap from the buttock. The flap choice depends upon the breast size and shape and the woman’s build. The LD flap (from the back) is the simplest and most robust method of flap-based reconstruction. The steps and final result of the procedure are demonstrated on the previous page. The other flap commonly used is called DIEP (deep inferior epigastric perforator) flap and allows simultaneous tummy-tuck procedure. However this type of reconstruction takes several hours and can be performed in a selected group of patients only.

This lady had right SSM and LD flap reconstruction

Skin Sparing

The back scar resulting from the use of LD flap

Back Scar of LD Flap

Below:

This 41 year old lady had right skin-sparing mastectomy and immediate reconstruction using a tissue flap from the back (LD flap) combined with the sentinel node biopsy for 3 small cancers in the right breast. The procedure was performed by the author Kefah Mokbel in 2003. The patient remains free from disease.

Right Skin Sparing

Nipple Reconstruction

It is also possible to reconstruct the nipple using local skin, a portion form the opposite nipple, or a skin graft taken from the groin (Figure 9). The new nipple can be tattooed to make it a similar to that of the opposite nipple. A disposable tattooing instrument is used to minimise the risk of disease transmission.

Nipple Reconstruction

Nipple Preservation

In selected cases the nipple can be preserved during skin-saving mastectomy and reconstruction in order to achieve a superior cosmetic result. The photo below shows the excellent cosmetic result from bilateral nipple-saving mastectomy and reconstruction in a 40 year old diagnosed with breast cancer:

This 42 year old lady had bilateral nipple-preserving SSM and implant reconstruction

The Result of Bilateral Nipple
Bilateral NP SSM plus implant Reconstruction
Bilateral NP SSM plus Implant Reconstruction

Treatment of Non-invasive Breast Cancer

In non-invasive breast cancer, the cancer cells remain confined to the ducts or lobules. The medical name for non-invasive breast cancer is ductal carcinoma in situ (DCIS) if it occurs in the milk gland ducts (tubes), or lobular carcinoma in situ (LCIS) if it occurs in the gland lobules.

LCIS is not considered cancer as such. The presence of this abnormality in a breast biopsy means that the patient has an increased risk of developing breast cancer. The risk means that about 1 in 3 women with LCIS will develop breast cancer within 30 years of being diagnosed with the original condition.

DCIS usually appears as small white spots on the mammogram, called micro-calcifications (Figure 10). Occasionally, it shows as a lump in the breast or as a blood stained nipple discharge. However, this type of cancer does not usually spread beyond the breast. It is a relatively commonly finding in women participating in the screening programme. The likelihood of non-invasive cancer/DCIS spreading to the lymph glands in the armpit is approximately 1 in 200 cases. This small number is why armpit surgery (axillary dissection) is not routinely performed for DCIS, unlike the invasive type of breast cancer.

Non Invasive Breast cancer

Figure 10. A mammogram showing white spots of calcium (micro-calcifications) suggestive of non-invasive breast cancer (DCIS)

Like invasive breast cancer, DCIS is graded as low, intermediate or high. High-grade DCIS is relatively aggressive, especially if associated with cell death, and is thought to be more likely to progress into invasive cancer.

The London Breast Care Centre Ltd is registered in England Reg. Number 06896654
Registered office: 91 Addison Road, Holland Park, London W14 8DB UK