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.

Breast Biopsy

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:

  1. It is accompanied by radiation therapy
  2. The cancer is not large (usually < 4cm)
  3. The cancer is not multi-centric (not scattered throughout the breast)
  4. The cancer is not a result of a genetic mutation (BRCA1 & 2 gene mutation)
  5. 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)

Oncoplasty

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.

Mastectomy

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:

  1. external beam radiation over approximately 6 weeks (the most commonly used)
  2. brachytherapy with in-dwelling catheters (Mammosite or Contura) twice daily for 5 days
  3. 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.

Breast Cancer INTRABEAM Treatment

“For Stage I and II breast cancer, lumpectomy provides equivalent survival to a mastectomy, provided adjuvant radiation is employed.  According to the American College of Surgeons, greater than 25% of patients in the United States who need radiation following a lumpectomy did not undergo radiation. In Alabama, this number is greater than 40%. Traditionally, high-energy radiation is delivered externally 5 days a week for up to 7 weeks.

Within the past 10 years, it has become apparent that select patients can forgo extended whole breast radiation in favor of partial breast irradiation delivered twice a day through a percutaneous catheter that the patient would wear for about one and a half weeks to 2 weeks. The optimal patients are older than 45, have a tumor less than 3cm, have negative margins of excision, and ideally would be node negative. This is certainly more convenient than 6-7 weeks, but does add the discomfort of additional surgical procedures with catheter insertion, keeping the area dry for greater than a week, and having a medical device protruding from the breast for 1 to 2 weeks.

The most recent advance is a single dose of radiation delivered in the operating room while the patient is under anesthesia. The INTRBEAM system is a small portable electronic X-ray source that delivers radiation via a spherical applicator immediately after the lumpectomy following pathologic margin assessment. The duration of therapy depends on the volume of the applicator used, typically between 25 and 50 minutes. The lifestyle advantages are obvious. Daily radiation therapy for an employed patient is inconvenient at best, and for a more infirmed or rural patient may be completely untenable.

This exciting new therapy is supported by a  greater than 2000 patient  multicenter trial presented at the American Society of Clinical Oncology meeting in Chicago 3 years ago and published in the prestigious journal, The Lancet in July 2010. A follow up presentation at the December 2012 San Antonio Breast Conference showed no breast cancer 5 year  survival benefit to receiving 6 weeks of therapy compared to a single dose intraoperatively. In fact, there was a trend for improved overall survival in the INTRABEAM arm due to fewer non-breast cancer deaths.

Currently, Trinity Hospital is the only hospital in the state and one of about 40 facilities nationwide to use the INTRABEAM.  These hospitals include Georgetown, NYH-Cornell, Florida-Gainesville, and USC-Los Angeles. A clear impediment to wider state wide use has been reimbursement. Despite a willingness to pay thousands of dollars for catheter based therapy which has far weaker data, Blue Cross/Blue Shield of Alabama has refused to pay the several hundred dollars for the INTRABEAM. That deterrent however has not prevented Trinity surgeons and radiation therapists from delivering this treatment to Alabamians many who would not have had radiation therapy otherwise.    ”

– William A. Thompson, III, MD, FACS

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.

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