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Surgery

Introduction

Breast cancer develops from the uncontrolled growth of various cells that make up the breast tissue. It can occur with or without an inherited genetic abnormality. As in the development of cancers in other tissue, both genetic and environmental influences probably play a part. Certainly, smoking and obesity are associated with an increased risk of developing breast cancer.

Breast cancer generally begins in lobules (milk-producing glands) or ducts (milk-draining passages extending from the lobules to the nipple). Breast cancer can sometimes occur in the fatty and fibrous breast tissues. If left untreated, the tumour cells may invade the nearby healthy breast tissues and into the lymph nodes, particularly in the armpit or spread to other parts of the body.

Diagnosis

Self-breast examinations, breast examination by doctors, ultrasound or mammograms can detect breast lumps or cancers. Following this a “triple test” should be completed before definitive treatment. The “triple test” (history, examination, mammogram plus or minus ultrasound, and tissue diagnosis from a biopsy) has been shown to be very accurate in determining whether a breast abnormality is a cancer or not.

Surgical procedures

Breast cancer is generally treated with a combination of surgery, hormone therapy (blocks some hormones), radiation therapy (use of high-energy rays) if required, chemotherapy (use of certain drugs). Deciding on the appropriate type of surgery for you will depend on the stage of cancer, type of cancer and the long term benefits of other treatment.

The two main types of breast cancer surgeries include:

  • Wide local excision (WLE) of the breast cancer (breast-conserving surgery): This involves the removal of only the tumour along with a small margin of the surrounding breast tissue.
  • Mastectomy: involves removal of the whole breast (with or without breast reconstruction).

The various types of mastectomy procedures include:

  • Simple or Total Mastectomy: The surgeon will remove the entire breast, with or without some or all of the lymph nodes from the armpit. At the time of surgery a drain is left place to drain any tissue fluid that may accumulate. This is usually removed after some days.
  • Skin-Sparing Mastectomy: This is most often done via an incision around the nipple and areola to remove the breast tissue. Most of the breast skin is preserved with this technique, which is generally lost in traditional mastectomy. It offers the advantage of negligible scarring and provides the best option for immediate breast reconstruction.
  • Nipple-Sparing Mastectomy: The surgeon will make an incision in the fold of skin under or to the side the breast or around the areola, where the cut cannot be easily seen after healing and will spare the nipple.
  • Preventive/prophylactic or risk-reduction mastectomy: If you are genetically predisposed and have a high risk of developing breast cancer, you may choose to have a risk reducing procedure. A mastectomy or nipple-sparing mastectomy can be performed with or without a breast reconstruction.
  • Radical or halsted mastectomy: The surgeon will remove the entire breast along with the underlying chest wall muscles and lymph nodes. It is rarely performed but may be necessary to treat locally advanced breast cancer. It is the most disfiguring of all the mastectomies.

In some cases the patient can decide between a mastectomy and wide local excision. With a small breast cancer that can be removed with a clear margin of healthy tissue and leave a cosmetically satisfactory result a wide local excision and adjuvant, (post surgery), radiation therapy is as effective as mastectomy in local control of breast cancer.

Lymph node dissection: The removal of the lymph nodes is an important step in breast cancer surgery to help doctors and patients decide on what further treatment is beneficial. If breast cancer spreads it usually spreads first of all to lymph node in the axilla (arm pit). Checking for lymph node spread is part of staging breast cancer disease. It can be done by removing the sentinel lymph node which is the first lymph node, or nodes to which the cancer cells spread (sentinel lymph node biopsy) or removing all the lymph nodes in the axilla so the pathologist can check them for cancer cells.

Breast and nipple reconstruction

Following the removal of breast tissue, the breasts can be reconstructed to achieve a similar shape and size of the original breast/s. The surgeon may perform reconstruction either during the surgical procedure or a few months after the procedure. Breast reconstruction can be performed with either an implant technique or patient tissue technique.

  • Saline or silicone implants can be used to replace the breast tissue. This can be done at the time of surgery, or if a mastectomy has been done at some time previously, a tissue expander may first need to be placed to stretch up the skin so that a breast implant can be used.
  • Replacing the breast tissue with tissue transplanted from your stomach, buttocks, back or thigh.

The nipple can also be reconstructed using skin over where the breast was, tissue transplanted from another part of the body or a skin substitute, or by having a nipple tattooed on the reconstructed breast.

Related surgical techniquesRisk reducing surgery to remove the ovaries may be necessary in inherited forms of breast cancer to lower oestrogen levels in the body and so reduce the chance of triggering the development of breast cancer.

Post-operative care

Mastectomy, wide local excision and lymph node surgery are done under a general anaesthetic. The patient is completely asleep and feels no pain. The length of stay usually depends on the extent of surgery and the patients need to be in hospital. Just because a patient has a drain in tissue after surgery doesn’t mean they have to stay in hospital. Breast care nurses are wonderful at following patients throughout their whole treatment and can monitor and remove drains from patients in their own homes.

Pain relieving medication is an important part of post operative care. The surgeon and anaesthetist will usually, as a team, make sure patients have a comprehensive pain management plan. Wound dressings are water proof to allow patients to shower and can be removed according to the surgeon’s instructions. Sterile dressings can be left in place for days without any risk to wounds. A special surgical bra can be used to hold the bandages in place and may help to relieve discomfort. Patients may experience tingling, numbness or discomfort in the armpit if lymph node surgery has been performed. Any bruising usually settles after a few days. After surgery, physiotherapists usually play an important role in supervising exercises to help prevent arm stiffness and loss of mobility if a patient has had lymph node surgery. These exercises can be continued at home.

Patients can usually resume normal activities a few weeks after mastectomy, but may require only a few days of rest after a wide local excision.

Risks and complications

As with any surgery, breast cancer surgery involves potential risks and complications. Apart from anaesthetic risks they may include:

  • Haematoma (accumulation of blood in wound) and seroma (accumulation of fluid in wound). These may, very occasionally require drainage by needle aspiration or surgery.
  • Excessive bleeding
  • Lymphoedema (accumulation of lymph fluid in the arm)
  • Wound infection
  • Nerve pain
  • Scar formation in the armpit

Other Treatments Lists

  • FRACS
  • Breast Surgeons of Australia and New Zealand
  • Health Central Coast
  • Health Hunter New England Local Health District
  • Gosford Private Hospital
  • Lake Macquarie Private Hospital
  • Maitland Private Hospital
  • Brisbane Water Private Hospital
  • Berkeley Vale Private Hospital