Breast cancer surgery has drastically changed over the past few decades and has become one of the most rapidly evolving and fascinating subspecialties in surgery. The majority of patients will require surgery at some point of their breast cancer treatment. Traditionally, all patients with breast cancer had a mastectomy and removal of the lymph nodes under the arm.
Fortunately, there are many more options available today and the international trend is to minimizie the extent of surgery for the breast and under the arm and to reduce the risks and negative effects of surgery without compromising safety.
The type of surgery that may be recommended depends on various factors which include the extent, location and stage of the cancer, the tumour biology (type and behaviour of the cancer) and patient preferences.
A mastectomy is the traditional and oldest surgical therapy for breast cancer and involves the removal of the entire breast. More modern mastectomy techniques may preserve skin and even the nipple in selected patients who wish to have reconstruction.
Some patients decide to remove the other breast at the same time. It is important to discuss of all options and offer a realistic assessment of risk of developing a cancer in the other breast, which is generally very low.
Breast Conserving Surgery
This involves the removal of the cancer with a margin of healthy tissue around it while preserving the rest of the breast. There are many surgical options available ranging from simple lumpectomies to oncoplastic procedures in which the cancer resection is combined with a plastic surgical technique. Breast conserving surgery offers many advantages such as improved cosmesis and sensation and is equal to mastectomy with regards to survival. It is therefore the internationally accepted standard of care for patients with early-stage breast cancer. It is important to note that all patients treated with breast conserving surgery will need radiation.
Sentinel Lymph Node Biopsy
This procedure is carried out on patients with no sign of spread to the glands under the arm on imaging or examination. It is often done at the same time of the surgery to the breast but can also be done as a stand-alone procedure before any other treatment is started. The first guarding “sentinel” lymph node is identified during surgery - with the help of radio-colloid and blue dye- and removed. If cancer is found in the sentinel node this can change further treatment, the sequence of treatments and options for reconstruction.
Axillary Lymph Node Dissection
This procedure is carried out when the cancer has spread to the glands under the arm. All lymph nodes within a certain area then need to be removed. This operation carries a higher risk of shoulder problems, pain and swelling of the arm (lymphoedema). The operation is generally performed at the same time as the breast operation. There are few selected patients who will not need a full axillary lymph node dissection even when their sentinel node biopsy is positive. These decisions are individualized and should always be discussed within the multi-disciplinary team.