BREAST SURGERY

Most abnormalities of the breast are diagnosed by screening mammography (mammogram: a specialized x ray or the breast) or ultrasound (a procedure that uses sound waves to locate lumps in the breast which is similar to the sonar that ships use to detect objects underwater). Often, however, the patient or primary doctor feels a lump in the breast on physical exam, this is called a palpable lesion and may or may not show up on mammography or ultrasound.

Breast Biopsy

The first step in the diagnosis of a breast abnormality is to determine the risk that the lesion may be a malignancy, a breast cancer. Features of the abnormality (size, location, firmness, regularity) and the patient (age, family history, number of pregnancies) help determine this risk. If there is a chance the abnormality could be a cancer, a biopsy of the lesion is recommended. Generally a small needle is guided into the lesion with mammography or ultrasound to assure that the needle cuts out a small (less than a millimeter) piece of tissue from the lesion. The skin is anesthetized prior to the biopsy; however, breast tissue is very sensitive and the procedure is somewhat uncomfortable and the area of the biopsy is sore for several days. In some cases, an open biopsy is indicated and a small surgical incision is made on the breast and the entire lump is removed. This can be done with a wide area of the breast anesthetized with local anesthetic, or the patient can be put to sleep with a general anesthetic for the procedure. With either technique, the biopsy is done in the operating room as an outpatient procedure.

Carcinoma In Situ, Precancerous Lesions

If the lesion is a precancerous lesion, the lesion and surrounding normal breast tissue must be removed, this is called a segmental mastectomy or lumpectomy. This procedure is similar to the open breast biopsy. In the lesion is non-palpable, cannot be felt, a special wire must be placed in the breast at the site of the lesion with mammographic or ultrasound guidance immediately prior to the surgery to allow the surgeon to remove the proper tissue.

Breast Cancer

If the lesion is proven to be a breast cancer, the patient has many options. The goal of treating a patient with breast cancer is to maximize the chance of cure; however, many of the treatment pathways arrive at the same point with very different effects and side effects on the patient. It is important that the patient is involved in the decision making process and tell the doctors what factors are most important to her to help tailor the most appropriate therapy.

Neo-adjuvant Therapy

Most women will get surgery and chemotherapy. Generally, surgery is first with chemotherapy afterward based on the findings at surgery. Sometimes, chemotherapy and even radiation therapy is recommended prior to surgery, this is termed neo-adjuvant therapy. A woman should be aware of the risks, benefits and side effects of these two treatment pathways and be involved in the decision process since the different pathways may have very different challenges to her lifestyle.

Breast Conserving Therapy vs. Total Mastectomy

There are also two different types of surgery that offer similar cure rates. One is to remove only the cancer and a small amount of surrounding tissue (the margin) and then follow surgery with 4-6 weeks of radiation treatments to the breast. This breast conserving therapy, segmental mastectomy and radiation therapy, is equivalent to surgically removing the entire breast, total mastectomy, as far as the chances for curing the cancer. The choice of operations really depends on the personal preferences of the woman and both operations are still performed regularly. After removal of the whole breast there are many options for immediate or delayed reconstruction of the breast in conjunction with a plastic surgeon. This may involve breast implants or using extra skin, fat and muscle from the abdomen to recreate a breast using the woman’s own body tissues.

Axillary Lymph Nodes

The next step in the management of breast cancer is to assess the lymph nodes under the arm (axilla) on the same side as the breast cancer as this is the first place the cancer generally spreads. If the lymph nodes are obviously enlarged, the entire mass of lymph nodes will be removed at the time the breast cancer is removed. An axillary lymph node dissection is done in addition to the segmental mastectomy for breast conserving surgery, or the lymph nodes are removed with the entire breast and the procedure is called a modified radical mastectomy.

If the cancer is small and the axillary lymph nodes are not likely obviously enlarged, a special procedure may be done to remove only 1-3 lymph nodes to make sure there is no cancer in them and spare the patient the risks involved with removing all the lymph nodes. This procedure is called sentinel lymph node biopsy and uses a blue dye and a short acting radioactive tracer to identify the lymph nodes most likely to have cancer in them so only they are removed and examined. If the sentinel lymph nodes do have cancer in then, all the axillary lymph nodes should be removed or receive radiation therapy to prevent recurrence of cancer in the axilla (the underarm). The spread of cancer to the lymph nodes also changes the prognosis (chance for cure) and changes the types of chemotherapy that may be offered.

The treatment of breast disease and breast cancer has many different options, many of which are equally effective. There is no “one size fits all” treatment, and many of the treatments have very different effects on the appearance and independence of the patient. At Coast Surgical Group, we encourage women to become informed as to the risks, benefits, procedures and side effects of the various treatment options and help us make the most appropriate treatment plans to suit their individual needs.