Seventy percent of all women who are treated for early breast cancer will undergo a procedure to excise the breast cancer from the breast and conserve the breast. The procedure is often termed a lumpectomy. It involves removing the breast cancer with a surrounding margin of normal breast tissue (wide local excision).
Women that undergo breast conserving surgery will be required to have radiotherapy postoperatively.
The benefits of breast conservation are that the cancer can be removed and the breasts can be maintained. The breasts, however, postoperatively may appear slightly smaller.
A variety of techniques can be employed to improve the cosmetic outcome post wide local excision (see oncoplastic breast surgery).
Radiotherapy is given postoperatively to reduce the chance of a cancer coming back in the breast in the future.
The main advantage of breast conservation is that it is a procedure that allows a patient to maintain their breasts and keep the natural shape of the breasts. Patients are usually advised to stay overnight in hospital after the wide local excision and although the breast will look and feel different after radiotherapy and surgery, the appearance of the breasts can be maintained.
Radiotherapy will be commenced once the operative wound has healed ( usually approximately 3 weeks post surgery). Daily trips to the radiation centre are required from Monday to Friday for a 3 to 5-week period. This can have a significant impact on women who do not live close to a radiotherapy department. Dr Thornton’s team, however, can arrange accommodation for country patients during their radiotherapy treatment . It is also usually possible to schedule convenient radiotherapy appointment times to assist in particular women who have returned to work or have family committments.
As the breast is maintained, the patient will be required to have annual imaging and there is a small risk of local recurrence if the breast is maintained. This is approximately 0.5% to 1% per year. This can cause some anxiety in women. There is always the chance that further surgery may be required.
A hookwire placed under ultrasound or mammogram may be required to be preoperatively in order to guide the surgeon to the cancer. This is especially common when it is an impalpable cancer (it cannot be felt) or it is DCIS (carcinoma in situ associated with microcalcification).
Treatment for invasive breast cancer will usually also include a separate procedure to the axilla. This will be to remove some of the glands from the armpit to help determine what further cancer treatment is required post operatively This will be undertaken at the time of the excision of the breast cancer.
If the lymph glands are shown to be malignant (contain cancer cells) preoperatively an axillary lymph node dissection will be undertaken at the time of wide local excision. If there is no abnormality to the lymph glands of the armpit preoperatively (clinically with imaging or with a fine needle aspiration), a sentinel lymph node biopsy will be undertaken. This procedure involves removing the first lymph glands that drain from the breast to the axilla (see sentinel lymph node biospy).
Complications of wide local excision includes infection, bleeding, haematoma (occasionally requiring return to the operating theatre), seroma ( a collection of fluid which the body produces which fills the space where the cancer has been removed and occasionally needs to be aspirated with a syringe and needle postoperatively). Changes in sensation to the nipple if the procedure is performed close to the nipple, loss ability to breastfeed if a central excision is undertaken ( a central excision involves removal of the nipple and areolar complex and or excising the breast tissue from behind the nipple and areola. It is performed for cancers which lie directly behind the nipple and areola or for Paget disease of the nipple). Cosmetic changes/cosmetic deformity to the breasts, sensory changes, and numbness over the scarring.
Patients need to be aware that there is always the chance that a return to the operating theatre to remove more breast tissue may be required if the margins are not clear at the time of lumpectomy. A xray of the breast specimen is usually undertaken during the surgery to assist in ensuring that enough tissue has been removed around the cancer. However the final decision regarding the margins is made by the specialist breast pathologist when the specimen is formally examined under the microscope, as some breast cancer s can not be felt in the specimen by the surgeon and may also not be seen on the specimen xray.
Absorbable sutures are used and a waterproof dressing is applied. The patient is usually discharged the day after the operation and is followed up within 48 hours with the final pathology.
The procedure is suitable for ladies that have small breast cancers. Multifocal breast cancer, wide spread DCIS (with or without malignant microcalcification) or large breast cancers are usually not suitable for breast conserving surgery and will require mastectomy with or without immediate reconstruction.