Overview of Breast Cancer Surgery

Breast cancer is the most common cancer in women living in the United States. As of 2018, 1 in 8 women in the US are likely to be diagnosed with invasive breast cancer during their lifetime. Luckily, survival rates are getting better with time. This could be due to more personalized treatment and early detection. Surgery has always been a key part of breast cancer treatment, especially in the early stages.

Over the years, research has helped us use less aggressive surgical options. A key milestone was moving away from radical mastectomies, which involve removing the whole breast, to breast-conserving surgery (BCS). BCS saves as much healthy breast tissue as possible.

A key study aiding this transition was the national B-04 study. This study compared radical mastectomy with total mastectomy (where the entire breast is removed but not the muscles underneath). It showed that there was no difference in survival between the two types of surgery. This led doctors to favor less invasive surgery.

Then, the B-06 study looked at women with smaller tumors. This study compared mastectomy with lumpectomy, a type of BCS where only the tumor and a small rim of normal tissue are removed. The results showed that survival wasn’t affected by the type of surgery. But, it did show a significant decrease in local recurrence when lumpectomy was combined with radiation therapy. This study pushed the shift from mastectomy to BCS further.

However, the rate of mastectomies has been recently going back up. This might be because younger women, genetic testing, more knowledge about individual risks and benefits, and better breast reconstruction options are influencing this decision.

There’s also interest in using MRI to image the breast. This can be helpful in women with dense breasts, a family history of breast cancer, or unclear findings on a regular mammogram (x-ray of the breast). But, it’s worth noting that while using MRI might lead to more mastectomies being done, it doesn’t seem to improve survival rates.

Anatomy and Physiology of Breast Cancer Surgery

The breast is found on the front of the chest and is made up of skin, fat, and breast tissue. Most of the breast is atop a muscle called the pectoralis major, with the rest resting on a different muscle, the serratus anterior, and a portion of the oblique. The breast is covered in two layers of fascia, a type of connective tissue. One layer is underneath the skin and another layer is in front of the muscle fascia. These structures are crucial in breast removal surgery, where the surgeon aims to remove all the breast tissue along with a portion of the muscle fascia for a complete removal.

The boundaries of the breast are defined by the second to sixth ribs and the lateral border of the sternum (breastbone) to the middle of the armpit. The breast tissue sometimes extends into the armpit area, known as the “axillary tail of Spence”.

The breast is supplied with blood from three primary arteries. One of these arteries supplies about 60% of the blood to the breast, while the other two supply the rest. The health of a specific artery, the internal thoracic artery, is vital to the wellbeing of the nipple-areolar complex as due to its numerous branch arteries. Similarly, the veins that drain the blood from the breast follow the pattern of the arteries. The blood drains towards the armpit through three main veins.

The breast gets its feeling from nerves that branch out from the second to the sixth ribs. An additional nerve gives feeling to the inner side of the upper arm and is often dealt with during armpit surgery. A particular nerve to note is the thoracodorsal nerve, which can cause a condition known as “winged scapula” if accidentally cut during surgery.

Most of the breast drains to the lymph nodes in the axilla, or armpit area, for liquid waste removal while the rest of it following a line of lymphatics that travel along a particular branches of the artery. In breast surgery, three levels of lymph nodes are identified for surgical removal, based on their location in relation to a muscle called the pectoralis minor.

Why do People Need Breast Cancer Surgery

Over the past years, treatment of breast cancer has shifted from radical surgeries to more safe and conservative procedures. One of these procedures is lumpectomy, which is a surgery to remove the cancer or other abnormal tissue from your breast. Depending on the size and stage of the cancer, doctors often combine lumpectomy with adjuvant or neoadjuvant therapy. This may include hormonal therapy, chemotherapy, and/or radiation therapy to ensure the complete treatment of the disease.

A study floated the idea of treating certain stage 1 or 2 breast cancers using lumpectomy alone without radiation. However, it found that while survival rates remained consistent for all patients, there was a higher chance of cancer returning in those who had just the lumpectomy. Since then, standard treatment has been to combine lumpectomy with radiation. This approach is usually considered for small tumors that can be removed completely without disfiguring the breast. Additionally, tumor size should be considered relative to the size of the breast, making the decision for lumpectomy very individual to each patient.

In contrast to lumpectomy, mastectomy involves the complete removal of breast tissue. Doctors might recommend mastectomy for patients where the tumor is larger than 5 cm, there is more than one tumor in different parts of the breast, the chest wall is affected, or for a type of breast cancer called inflammatory breast cancer. It may also be suggested for patients with a type of cancer affecting the nipple, called Paget’s disease. Mastectomy might also be considered if cancer continues to be present along the edges of the tissue removed in a lumpectomy or if a patient has already had a lumpectomy with radiation and the cancer has returned.

Prophylactic mastectomies, which are preventive surgeries, have become more common. This surgery is often recommended for patients who have a high lifetime risk of breast cancer. For instance, if they have tested positive for specific gene mutations like BRCA1 or BRCA2, have a strong family history of breast cancer, or have a particularly aggressive type of breast disease. There are also skin-sparing mastectomies, where most of the skin over the breast is saved. This approach is suitable for patients when it’s possible to get a clean margin or edge of healthy tissue around the cancer, and can be particularly beneficial if the patient is considering reconstructive surgery.

Another important part of breast cancer surgery is the management of the lymph nodes under the arm, known as the axilla. Sometimes, these lymph nodes can be removed to determine the stage and prognosis of the cancer. Guidelines have been changing to avoid removing more lymph nodes than necessary, as it can lead to complications such as lymphedema, a condition that causes swelling in the arm. In many cases, only the sentinel lymph node—the first lymph node cancer is likely to spread to—is removed.

However, full removal of the axillary lymph nodes might be necessary in specific circumstances. For example, in cases of advanced or inflammatory breast cancer, cancer with no obvious primary tumor but presence in the axilla, recurrence of cancer in the axilla after previous treatment, or when lymph nodes remain positive for cancer after chemotherapy. It is also recommended in any clinically node-positive patients—meaning those where there is proven spread to the lymph nodes in the armpit and chemotherapy is not part of the treatment plan.

When a Person Should Avoid Breast Cancer Surgery

There are certain situations where performing a lumpectomy, which is a surgery to remove a lump in the breast, isn’t safe or recommended. These include:

– If the patient has already received radiation therapy to the area.
– If the patient is pregnant.
– If there are tumors present in different sections of the breast, also known as multicentric tumors.
– If it’s not possible to get ‘clear margins’ – this means fully removing the tumor without leaving any cells behind, either because the tumor is large or has spread to nearby areas.
– If the patient can’t tolerate radiation therapy due to physical issues.

There also a few situations where lumpectomy is generally not recommended, but may still be possible. These include:
– When there are multiple tumors in the breast (multifocal tumors).
– If the patient has a connective tissue disease.
– When the tumor is extremely large in comparison to the size of the breast.

If breast cancer returns or develops in a breast that previously received radiation treatment, the management usually involves a mastectomy, which is the removal of the entire breast.

There are a few situations, however, where it’s not advised to perform a mastectomy:
– If the patient has metastatic disease, which means the cancer has spread to other parts of the body.
– If the patient can’t tolerate general anesthesia due to poor physical health.
– If the patient has advanced local disease that needs to be treated and shrunk down (neoadjuvant treatment) before undergoing surgical resection.

Equipment used for Breast Cancer Surgery

When a doctor is treating breast cancer and chooses to save as much of the breast as possible, it’s really important to figure out exactly where the cancer is located. This makes the surgery more successful. The cancer doctor and the x-ray doctor have to work very closely to make sure they get the best result. There are lots of different ways to pinpoint the cancer before the surgery. The most common way is to use a wire needle.

The wire needle is inserted into the breast, using either a mammogram or an ultrasound to guide it. It’s usually done on the same day as the surgery. If the cancer is bigger than 2 cm, more than one wire might be needed. But there are some drawbacks to this method. It can be difficult to coordinate the schedules of the cancer doctor and the x-ray doctor. Sometimes, the wire can move around and cause problems like a collapsed lung, bleeding, or a puncture in a breast implant. And if the wire is accidentally cut during the procedure, pieces can get left behind.

Newer methods don’t use a wire, which avoids some of these problems. For example, the timing can be more flexible, the surgery day isn’t as long, and the method can be used no matter how the surgeon approaches the operation. These non-wire methods can be put in anywhere from five days to a month before the surgery. This makes scheduling more flexible for the doctors involved.

The non-wire methods are either radioactive or not. The radioactive method involves a small seed-like object that gives off radiation. It’s put into the breast similarly to how a biopsy clip is placed. It can be inserted up to five days before surgery. Then during the surgery, the doctor uses a tool that detects the gamma rays from the seed to locate and remove it, along with the cancer. Since this method has been shown to be safe and to reduce the chance of needing another operation to remove more cancer, more and more surgeons are starting to use it.

Methods that aren’t radioactive include the SCOUT RADAR device, MAGSEED, and RFIL. One advantage of these non-radioactive methods over the radioactive one is that, since they don’t use radiation, they can be placed in the patient at a separate facility if needed. They can also be inserted up to thirty days before the surgery. During the surgery, the doctor uses a tool that emits infrared light to find the device and remove the cancerous area.

Who is needed to perform Breast Cancer Surgery?

Treating breast cancer with surgery requires the teamwork of a group of medical professionals specialized in different areas. One such professional is a radiologist who works with the schedule of the surgeon. The radiologist’s job is to confirm that any markers used for a biopsy (a test to check if you have cancer), like clips, seeds, or wires, are included in the tissue that has been removed during the surgery. This step is important to make sure that the targeted cancerous area has been completely removed.

Some surgeons also choose to check the edges of the removed tissue (also called ‘margins’) while the surgery is still happening. This is done to ensure all cancerous cells have been removed and you’re getting the most comprehensive care possible.

Preparing for Breast Cancer Surgery

If doctors find something unusual during a medical examination or through medical imaging tests, they will commonly ask a patient to get a core needle biopsy. This is a type of test where a small sample of tissue is removed from the body for testing. During this biopsy, a small marker (or clip) will also be put in place near the area being tested. This is especially helpful for patients who will later receive chemotherapy treatment because it can help doctors find the exact spot they need to keep an eye on, which can become difficult to locate after treatment.

After the biopsy, patients may need to have more testing based on what the doctors find. These tests could include an ultrasound of the armpit area, a CT scan of the chest, stomach, and lower body, a specialised breast scan known as an MRI, a complete blood test, a comprehensive metabolic panel test (which looks at different chemicals in the body), and/or a PET/CT scan, which provides 3D images of how tissues and organs are functioning.

Additional tests or follow-up treatments may be considered if a patient is experiencing specific symptoms. Depending upon the stage and type of cancer, the patient may meet with different specialists including radiation oncologists (doctors who use radiation to treat cancer), medical oncologists (doctors who treat cancer with medicine or chemotherapy), genetic counselors (health professionals trained in genetic diseases and conditions), and/or plastic surgeons. The patient’s case may also need to be discussed at a tumor board, which is a meeting of different doctors and health professionals who work together to figure out the best treatment plan for cancer patients.

How is Breast Cancer Surgery performed

Lumpectomy is a surgery to remove a breast tumor and some of the normal tissue that surrounds it. It’s also called breast-conserving surgery because the goal is to save as much of your healthy breast as possible. This type of surgery is less invasive and leaves a smaller scar than a mastectomy, which removes the whole breast.

If the tumor isn’t obvious by touch, the doctor will use a picture of your breast to guide the surgery. The surgeon will keep a safe distance (usually about 1 cm) from the tumor to make sure they get the entire thing without taking too much breast tissue. After the tumor is removed, the doctor will send it for an image scan to confirm all suspect tissues were removed. To help keep track of it, your surgeon will attach tiny clips to the empty place where your tumor was to guide future treatment like radiation.

In a mastectomy, the doctor removes all of the breast tissue. This is often done with an oval incision and careful separation of the skin layers. The doctor tries to remove all of the breast tissue while keeping the blood supply to the skin safe. In some cases, the doctor will keep the skin and the nipple to make reconstruction surgery easier. The removed breast tissue is then sent to a lab for further testing.

Sentinel Node Biopsy is a procedure that helps determine if the breast cancer has spread beyond the breast to the lymph nodes. In this procedure, a doctor injects a special radioactive substance and a blue dye around the tumor in the breast just before surgery. These substances create a pathway that travels to the first lymph nodes where the cancer cells may have spread; these are known as sentinel nodes. They are removed and checked for cancer cells.

Axillary Node Dissection is a procedure where several lymph nodes are removed from the armpit and checked for cancer. This is often done when a sentinel node biopsy shows cancer cells have spread to the lymph nodes. The doctor will make a curved incision, separate the skin and muscles in that area, and remove the lymph nodes. Afterwards, the area is thoroughly cleaned, and the cuts are closed with stitches.

Whether you have a lumpectomy or mastectomy will depend on many things, including the size and location of your tumor, the size of your breast, whether the cancer has spread to multiple parts of your breast or body, and your personal preference.

Possible Complications of Breast Cancer Surgery

In simple terms, breast cancer surgery is generally a safe procedure with a low risk. However, it’s possible for complications to arise from both types of surgeries: lumpectomy, where only the tumor and some surrounding tissue is removed, and mastectomy, where the whole breast is removed.

In a lumpectomy, there is a chance that not all cancerous cells are removed, which could require a further surgery or even a mastectomy. Both types of surgery could also result in a buildup of fluid in the surgical site known as a seroma, or blood pooling at the site called a hematoma. They might also cause infections or skin necrosis, where skin cells at the surgical site die.

Damage could occur to blood vessels around the operation site, including the axillary vein under the armpit. Nerves might be injured or cut during the procedure, which could lead to sensory or motor issues. Lymphedema, a condition that causes swelling in the arm or hand, might also occur, especially if all the lymph nodes under the arm are removed during surgery.

What Else Should I Know About Breast Cancer Surgery?

Breast cancer is a serious disease that often needs surgery as a part of its treatment. Whether the patient needs a mastectomy (removal of the whole breast) or breast conservation surgery (removal of cancer but not the whole breast) depends on the individual’s specific situation and the extent of the disease.

In some cases, you might need to go through chemotherapy and/or radiation treatment before surgery. This is done to shrink the tumor or the lymph nodes under the arm, especially in more aggressive types of breast cancer like inflammatory breast cancer.

However, in most early-stage breast cancers, surgery is usually the first step in treatment. After the operation, it’s highly recommended to go through radiation therapy if you underwent breast conservation surgery. This is to avoid the high risk of cancer coming back.

If your cancer tests positive for hormone receptors (for example, estrogen or progesterone), you’re advised to undergo hormone therapy for at least five years. This may also be recommended for high-risk women as a preventive measure.

Chemotherapy is also suggested for cancer cases that are more aggressive or in cases where the cancer doesn’t respond to estrogen, progesterone, and HER2neu receptors.

When treatment is over, it’s important to continue checking for any recurrence of breast cancer. You’ll need to get a mammogram (breast X-ray) at least once a year to check for cancer coming back or appearing in the other breast. This usually begins six months after you’ve finished radiation therapy. If you’ve been screened every six months, the recommendation is to go back to once-a-year checks after two years.

Frequently asked questions

1. What are the different surgical options available for my breast cancer treatment? 2. How will the choice of surgery impact my long-term survival rates? 3. What are the potential risks and complications associated with the surgery? 4. Will I need additional treatments such as radiation therapy or chemotherapy after the surgery? 5. How will the surgery affect the appearance and function of my breast?

Breast cancer surgery aims to remove the breast tissue along with a portion of the muscle fascia for complete removal. The surgery may involve removing lymph nodes in the axilla for liquid waste removal. There are risks involved, such as damage to nerves that can cause conditions like "winged scapula," and the surgery may affect the feeling in the breast and inner side of the upper arm.

You may need breast cancer surgery for several reasons. Some situations where surgery is necessary include: 1. If you have already received radiation therapy to the area, a lumpectomy may not be safe or recommended. 2. If you are pregnant, a lumpectomy may not be safe for you or your baby. 3. If there are tumors present in different sections of the breast (multicentric tumors), a lumpectomy may not be effective in removing all the cancer. 4. If it is not possible to fully remove the tumor without leaving any cells behind (clear margins), either because the tumor is large or has spread to nearby areas, a lumpectomy may not be sufficient. 5. If you cannot tolerate radiation therapy due to physical issues, a lumpectomy may not be recommended. There are also situations where a lumpectomy may still be possible, but generally not recommended. These include: 1. When there are multiple tumors in the breast (multifocal tumors). 2. If you have a connective tissue disease. 3. When the tumor is extremely large in comparison to the size of the breast. In cases where breast cancer returns or develops in a breast that previously received radiation treatment, a mastectomy (removal of the entire breast) is usually recommended. However, there are situations where a mastectomy may not be advised, such as: 1. If the cancer has spread to other parts of the body (metastatic disease). 2. If you cannot tolerate general anesthesia due to poor physical health. 3. If you have advanced local disease that needs to be treated and shrunk down before undergoing surgical resection (neoadjuvant treatment).

You should not get breast cancer surgery if you have already received radiation therapy to the area, if you are pregnant, if there are tumors present in different sections of the breast, if it's not possible to fully remove the tumor without leaving any cells behind, if you can't tolerate radiation therapy, if you have multiple tumors in the breast, if you have a connective tissue disease, or if the tumor is extremely large in comparison to the size of the breast. Additionally, if you have metastatic disease, can't tolerate general anesthesia due to poor physical health, or have advanced local disease that needs to be treated and shrunk down before surgery, a mastectomy may not be advised.

The text does not provide specific information about the recovery time for breast cancer surgery.

To prepare for breast cancer surgery, it is important to work closely with your medical team, including your surgeon, radiologist, and other specialists. They will guide you through the necessary tests and procedures, such as biopsies and imaging scans, to determine the extent of the cancer and plan the surgery. You may also need to undergo additional tests and consultations with other specialists, such as radiation oncologists or genetic counselors. It is important to follow any pre-surgery instructions provided by your medical team, such as fasting before the surgery and stopping certain medications.

The complications of Breast Cancer Surgery include: - Not all cancerous cells being removed, requiring further surgery or a mastectomy - Buildup of fluid in the surgical site (seroma) - Blood pooling at the site (hematoma) - Infections - Skin necrosis (death of skin cells at the surgical site) - Damage to blood vessels around the operation site - Injury or cutting of nerves, leading to sensory or motor issues - Lymphedema (swelling in the arm or hand) if all lymph nodes under the arm are removed during surgery.

The text does not provide information about the symptoms that require breast cancer surgery. It mainly focuses on different types of breast cancer surgeries and the factors that doctors consider when recommending them.

Breast cancer surgery is generally not recommended during pregnancy. The safety of surgery during pregnancy depends on several factors, including the stage of the cancer, the trimester of pregnancy, and the specific surgical procedure being considered. In the early stages of pregnancy, surgery may be delayed until after delivery to avoid potential harm to the developing fetus. However, if the cancer is advanced or causing significant symptoms, surgery may be necessary even during pregnancy. The type of surgery performed will also depend on the stage and location of the cancer. Lumpectomy, which removes the tumor and some surrounding tissue, may be an option in certain cases. However, mastectomy, which involves the complete removal of the breast, may be recommended if the cancer is more advanced or if there are concerns about the effectiveness of radiation therapy during pregnancy. It is important for pregnant women with breast cancer to work closely with a multidisciplinary team of healthcare professionals, including oncologists, surgeons, and obstetricians, to determine the best treatment approach that balances the needs of both the mother and the fetus. The risks and benefits of surgery during pregnancy should be carefully considered and discussed with the healthcare team.

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