Breast Cancer Surgery
Care of a patient with breast cancer is a team effort involving your breast surgeon, medical and radiation oncologists, the GP, breast care nurse, other specialists such as physiotherapists and a number of patient support services.
Your breast Surgeon provides a leading role in the team by providing the following care:
– Assesses and diagnose of breast cancer
– Performs surgery of breast and axilla (armpit)
– Provides long term follow up care of breast cancer patients
A/Prof. Edirimanne aims to provide surgery to maximize cancer control with best cosmetic and functional outcome which is tailored to patient wishes and expectations
This is one of the major historical advances in breast surgery and has been around for over three decades. Over that period there has been a number of clinical trials with long term follow up, which has shown BCS combined with radiotherapy to the breast has similar survival and local control rates to mastectomy. BCS has advantage of preserving ones own breast with all the functional, psychosocial advantages associated with it. There are two types of BCS.
Wide local excision or lumpectomy:
This is removal of breast cancer with a rim of normal breast tissue around it. If the cancer cannot be felt, your surgeon will organize a fine wire to be inserted to the lump by radiologist under local anesthetic prior to surgery known as Hook Wire Localization in order to precisely locate the cancer during the operation.
This allows removal of much larger cancers of the breast by combining plastic surgical techniques in patients who previously required mastectomy. For patients with smaller breasts partial breast reconstruction using local chest wall perforator flaps such as LICAP, AICAP flaps allowed breast conservation. For patients with larger breasts therapeutic mammoplasty techniques allowed breast conservation. These techniques are usually used in breast reductions and lifts. Depending on individual’s choice often these patients will require a similar reduction/lift in the other breast to match.
Despite the fact that a large proportion of patients are suitable for BCS there are still some patients who need to have the whole breast tissue removed due to extensive nature of their cancer. Recently, new mastectomy techniques such as skin sparing/reducing and nipple sparing has been accepted as safe techniques in selected group of suitable patients. These techniques are always combined with immediate breast reconstruction.
This involves removal of all breast tissue with nipple/areolar and part of the skin of the breast. If the cancer involves the skin or nipple and the patient is high risk for other techniques due to risk factors like smoking, simple mastectomy is offered.
Skin sparing/reducing mastectomy:
If the cancer involves nipple it is removed leaving the skin envelope. If the patient wishes to have smaller size reconstructed breasts part of the skin envelope can also be removed.
Nipple skin sparing mastectomy:
If the caner is well clear of nipple/areola as well as skin those patients are candidates for this procedure. This technique is also used in patients having risk-reducing mastectomy.
Every patient who requires a mastectomy is offered the full range of breast reconstruction options. Patient’s decision making to have reconstruction is a complex process, for which she takes a number of factors into consideration. The method of preferred reconstruction is also a decision taken by the patient after considering all the available options.
Immediate Breast Reconstruction (IBR):
This is when the reconstruction process is started at the time of the cancer operation. Depending on the technique the patient may get the final outcome after one operation or may require further operations to achieve that. Important factors such as patient features and risk factors, size and shape of the breasts, whether the patient likely need radiotherapy after mastectomy and/ or chemotherapy and most importantly the patient preferences are taken into consideration in selecting the most appropriate technique.
Implant (single or two stage):
Depending on number of factors this may be single stage or two stage. In single stage a final size implant with combine muscle and mesh (a synthetic or biological sheet) cover is performed. In two stage, firstly, a partly filled expander is inserted under the muscle which needs to be filled with saline over number of weeks at consultation rooms. It is then followed by second operation to replace the expander with the final implant. These types of immediate breast reconstructions are offered by your breast surgeon.
This technique uses patient’s own muscle/fat/skin either as a pedicle flap or free vascular flap to do the reconstruction. Commonly used flaps are latissimus dorsi (LD) and rectus abdominis (TRAM, DIEP etc.). These types of reconstructions are done by a plastic surgeon at the time of your breast cancer surgery.
This uses a combination of patient’s own tissue (usually LD) and expanders/implants.
Delayed breast reconstruction:
This is when a patient choses to have a simple mastectomy and often have other required treatment such as chemotherapy and post mastectomy chest wall radiotherapy first. Once recovered from cancer treatment patient undergoes the reconstruction procedure.
One of the ways that breast cancer spreads is via the lymph node channels. Cancer spreads commonly to the lymph nodes in the arm pit (axilla) and occasionally to the lymph nodes in between the ribs (internal mammary). Nowadays, as most of the breast cancers are diagnosed at an early stage most patients do not have their lymph nodes involved at the time of diagnosis.
Sentinel Lymph Node Biopsy:
This procedure has allowed those patients who do not have axillary lymph nodes involved by cancer to avoid unnecessary axillary surgery. Sentinel lymph nodes are the first group lymph nodes that the lymphatic channels of the breast are draining into. They can be identified by injecting a safe radioisotope dye as well as a blue colour dye to the breast. They are removed at the time of breast surgery and tested whether they have any cancer cells. If they are clear of cancer cells no further surgery is required.
This procedure involves removal of usually all the lymph nodes of the axilla. It is still required in some patients who have already proven cancer in the lymph nodes in axilla or those with high volume involved nodes found at or after the sentinel node biopsy procedure.
Targeted axillary dissection:
This procedure allows selected patients with involved axillary lymph nodes who had neoadjuvant chemotherapy and good response avoiding full axillary clearance and the morbidity associated with it.
chemo / hormonal
This is when chemotherapy or hormonal therapy is given to a patient before the surgery to reduce the size of cancer in the breast and/or lymph nodes. This can make some cancers that are too big to be operated operable and as well as increase the chances of avoiding a mastectomy and axillary clearance.
Long term care
of breast cancer
There are estimated 160,000 breast cancer survivors in Australia. The follow up of a breast cancer patient aims to address medical, psychological and social needs, identify and treat long term problems of treatments and identify potential cancer recurrence or new cancers early so that they can be treated effectively. This is a coordinated effort of your breast surgeon, oncologists, GP and breast and cancer care nurses. Clinical checks are supplemented by yearly mammograms and breast ultrasounds.