INTRODUCTION
Surgery remains the mainstay of treatment for breast cancer despite
recent and continuing advances in medical treatment.
Breast cancer usually presents as a lump. Other less common ways
that it can present are nipple distortion, skin dimpling or other
changes in the skin, unilateral (one-sided) breast pain, breast asymmetry
or nipple discharge. Breast cancer may also be detected by mammographic
screening.
Once a diagnosis is made, a treatment plan is formulated for each
individual patient. The multidisciplinary approach
for breast cancer is used in planning treatment and all available
options are considered
in order to optimise cancer control. This may involve surgery, endocrine
therapy, chemotherapy and radiotherapy.
Adjuvant therapies are usually offered after surgery but can sometimes
be given beforehand when
it is termed neoadjuvant.
Surgical treatment is aimed at removal of the whole tumour with
clear margins. Breast conserving operations remove the tumour with
a rim of surrounding normal tissue and leave behind the rest of the
breast tissue. Mastectomy is recommended for large tumours, widespread,
multifocal or advanced local disease. Removal of lymph nodes from
the axilla (armpit)
on the side of the tumour is used to determine further treatment
and prognosis.
Reconstruction of the partial defect after wide local excision or
mastectomy is possible. The most common operations offered for breast
cancer are:
Prophylactic bilateral mastectomy (removal of both breasts to prevent
cancer) is sometimes offered to women who have a high risk of developing
breast cancer because they carry (or have a high probability of
carrying) a gene that predisposes to breast cancer, for example
BRCA1 or BRCA2 genes. In women who are truly at risk, the risk
reduction with prophylactic mastectomy is thought to be as high
as 90%. Immediate
breast reconstruction is possible for most women. All women
considering this procedure should consult with a geneticist and
specialist breast surgeon.
BREAST CONSERVING PROCEDURES
Breast conservation is offered when the size of the tumour in relation
to the breast allows enough breast tissue to remain after tumour
excision, and provide a satisfactory cosmetic result.
Wide Local Excision / Lumpectomy / Quadrantectomy
The breast cancer is removed with a rim of normal breast tissue
in order to obtain clear margins.
Reconstruction of the defect after cancer excision
The extent of reconstructive surgery required depends on the size
of the tumour and the amount of breast tissue that remains after
the tumour is removed. There are various oncoplastic techniques that
can be used for remodelling the remaining breast tissue.
The remaining healthy breast tissue can be moved into the defect
using ‘oncoplastic
simple volume displacement’ techniques so
that the area in which the tumour was located does not end up as
a depression and the scar stuck down onto the chest wall.
For larger tumours or when the tumour is situated in a position
in the breast where these simple methods are not suitable, ‘oncoplastic
mammaplasty volume displacement' techniques can be used
to refashion the remaining breast tissue and relocate the nipple-areola
into a better
position. The result is a normal shaped but smaller breast. Surgery
to alter the opposite healthy breast can provide symmetry between
the breasts.
When removal of a large tumour does not allow
a satisfactory cosmetic result to be achieved with the remaining
breast tissue, the options
are to preserve the breast and replace the missing volume using ‘oncoplastic
volume replacement’ techniques
or, to perform a mastectomy with or without immediate breast reconstruction.
The advantage of the oncoplastic volume replacement option over
mastectomy is that the donor site scar is shorter. In addition, a
smaller amount of tissue is required for transfer into the defect.
However, radiotherapy will be required to treat the remaining breast
tissue.
On the other hand, the advantage of having a mastectomy over
breast conserving surgery is that the risk of a recurrent cancer
in that
breast is minimised. Another advantage of a mastectomy is
that radiotherapy
to the chest wall may not be required. There are different options
available for complete breast
reconstruction. These include implants
or expanders, flaps or
a combination of these methods. Reconstruction after a mastectomy can
be done at the time of the mastectomy (immediate)
or at a later date (delayed).
The disadvantage of a mastectomy over breast conserving surgery
is that more tissue will have to be imported for complete breast reconstruction if this is desired.
MASTECTOMY
Mastectomy involves removal of all of the breast tissue. Mastectomy
is advised when disease is widespread, multifocal (more than one
tumour), the tumour is large in relation to breast size or there
is residual disease after attempted wide local excision. Some women
opt for mastectomy in the first instance in order to have the least
chance of residual disease or to avoid radiotherapy to the remaining
breast tissue.
Breast reconstruction after mastectomy
If mastectomy is necessary, the complete range of 'techniques
for breast reconstruction' appropriate
to the individual woman should be discussed either as an immediate
or delayed procedure, to fit in with the overall treatment plan for
the breast cancer.
LYMPH NODE REMOVAL
Removal of lymph nodes from the axilla (armpit)
gives information about whether or not breast cancer cells have spread
outside the
breast. The state of the lymph nodes is an important indicator of
prognosis because
there is a direct relationship between the number of lymph nodes
involved with cancer cells and the risk of the breast
cancer recurring. Adjuvant
therapy can be tailored to each woman
on this basis. There are different procedures for the removal of
axillary
lymph nodes and
they include axillary
clearance (levels
1-3), axillary
sampling and
sentinel
node biopsy. They vary in the number of nodes removed and
how the nodes are identified for removal.
In general, the smaller the number of nodes removed, the less likely
is the chance of lymphoedema (swelling
of the arm). Lymphoedema may
occur from months to years after the operation or radiotherapy.
Radiotherapy
in addition to axillary lymph node clearance gives the highest rate
of lymphoedema and
this combination is best avoided if at all possible.
More and better options for treatment, preservation and reconstruction
of the breast are now available for women diagnosed with breast cancer.
Understanding what is available will empower women to play an active
role in their care.
LINKS
www.cancerhelp.org.uk
www.cancerbacup.org.uk
www.breastcancercare.org.uk
www.cancer.gov
www.macmillan.org.uk/cancerinformation
Top of page
|
