Breast Cancer Surgery
Breast Mass (or lump)
A breast mass may be felt while performing a self breast exam or by a radiologic test, such as a mammogram, an ultrasound, or even an MRI. Thankfully, almost 80% of breast masses (or lumps) are not cancerous. Nevertheless, careful evaluation is needed since almost 1 in 6 American women live into their late 70”s (normal life expectancy of about 78) will develop breast cancer at some point in their life
The word biopsy means simply taking some cells, or a piece of tissue, or even an entire mass (or lump) for examination by a pathologist. The pathologist is trained to diagnose whether or not the tissue is malignant (cancerous) or benign (non-cancerous). There are different methods available to biopsy the breast.
- Fine Needle Aspiration (FNA): Involves putting a needle into the mass or lump by palpitation (feeling) or ultrasound guidance in the surgeon’s office.
- Stereotactic Breast Biopsy: Is done in the x-ray suite using a large-bore needle and x-ray with 3-D guidance on an outpatient basis. This technique is often used to biopsy lesions seen on a mammogram which are too small to feel.
- Core Needle Biopsy: Is an office-based technique using a larger biopsy needle to remove a small “core” or tissue from a mass one can feel. For lesions detectable by breast ultrasound, an ultrasound guided core needle biopsy may be performed in the office setting under local anesthesia.
- Incisional Biopsy: Usually occurs in the outpatient surgery suite under intravenous sedation. The surgeon makes a small incision and cuts out a piece of the tumor/mass and sends it to the pathologist.
- Excisional Biopsy: Is the entire mass-lump is surgically removed for pathologic examination. Like the incisional breast biopsy, this is usually an outpatient surgical procedure performed with the patient sedated by the anesthesia service.
Breast Cancer Diagnosis
Breast cancer is when the pathologist examines biopsy tissue under the microscope and diagnoses cancer. They will normally analyze the tumor for the following characteristics:
- The presence or absence of estrogen and progesterone receptors
- The presence or absence of HER-2-neu receptors
- The tumor grade (1-4)
- The specific breast tissue type the cancer started from
- Test to attempt to predict how rapidly the cancer is growing
Wide Local Excision (Lumpectomy)
This is the resection of the cancer, plus a margin of normal breast tissue. This is a cancer operation and is more extensive than a routine excisional breast biopsy. This generally requires a general anesthetic. This provides equivalent survival outcomes to a mastectomy, provided:
- It is accompanied by radiation therapy
- The cancer is not large (usually < 4cm)
- The cancer is not multi-centric (not scattered throughout the breast)
- The cancer is not a result of a genetic mutation (BRCA1 & 2 gene mutation)
- The patient is not young (<35)
Approximately, 20% of patients will need a re-operation to excise additional tissue for + margins.
Ultimately, it is the patient’s choice with guidance from her surgeon whether to do a lumpectomy or mastectomy
Sentinel Lymph Node Biopsy
This is a sampling of 1 or 2 lymph nodes in the axilla (armpit) to determine whether the cancer has spread to the lymph nodes. This for the most part has replaced the complete removal of all the lymph nodes in the axilla as part of the staging evaluation for breast cancer. The sentinel node is the first lymph node to receive lymphatic drainage and therefore the node most likely to contain metastatic disease. This node is localized by injecting a blue dye and/ or a radioactive particle in the breast just before surgery and then removing that lymph node(s) that is either blue or radioactive. If the cancer has spread to greater than 3 lymph nodes, then it is generally advisable to remove additional lymph nodes (completion axillary dissection)
This is the removal of the cancer in the most cosmetically acceptable fashion. The cosmetic outcome is generally as important to the surgeon as the patient, as long as it does not compromise cure. Paradoxically, with this approach, the incision may occasionally be slightly larger, in order to advance adjacent tissue to preserve breast contour.
This is the removal of the entire breast. Candidates for this include patients not suitable for breast conservation (lumpectomy/ wide local excision). Despite equivalent survival for Stage I and II disease, there has been a trend for more patients to choose this option. If this option is chosen, breast reconstruction should be a standard component to this therapy. Reconstruction performed by the plastic surgeon may involve the patients own tissue (autologous), synthetic implants, or both. The reconstruction may be done at the time of the mastectomy or delayed.
Breast Cancer Radiation
This is the medical use of ionizing radiation to control or kill malignant cells. It is a critical adjunct in ideally all patients who receive breast conservation. Occasionally it may be necessary to also employ this in patients who have a mastectomy, especially if the cancer is large or multiple lymph nodes are positive. This may interfere with reconstruction from the plastic surgeon. The types of radiation include:
- external beam radiation over approximately 6 weeks (the most commonly used)
- brachytherapy with in-dwelling catheters (Mammosite or Contura) twice daily for 5 days
- single dose radiation at the time of the lumpectomy
Breast Cancer Chemotherapy
This is a group of chemicals given to kill rapidly dividing cells. Whereas, surgery and radiation are used to control cancer cells in the breast and lymph nodes, chemotherapy reaches vulnerable areas that can’t be reached by surgery or radiation (bone, brain, lungs, liver, etc.). Determinants of who should get chemotherapy include patient age, tumor size, lymph node status, hormonal status and the biological aggressiveness of the cancer. Depending on the hormonal status of the cancer, anti-estrogen hormonal therapy may be used.
Preparing For Breast Cancer Surgery
- You quite possibly will likely have met with the radiation therapist and possibly the plastic surgeon pre-op.
- For Stage I and Stage II patients, a chest x-ray and liver chemistries are sufficient for staging.
- Patients with more advanced disease may need a CT scan, PET scan, or bone scan.
- Do not take blood thinners 5 days before surgery.
- Do not eat and drink within 6 hours of surgery.
- If you have had prior Staph infections, please let your surgeon know.
Post Operative Care
- You should be discharged with pain medicine and possibly an antibiotic.
- It is okay to shower the day after your surgery.
- If you have drains, make sure you know how to empty these and record the output.
- The incisions themselves need no special care.
- The drain site can be covered with a Band-Aid and antibiotic ointment.
- Call the office about 4-5 days after your surgery to set up a 2 week follow up appointment and to get a preliminary report on your pathology.