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Breast Conserving Surgery for Cancer


The lump in your breast has been identified to contain cancer cells. As the lump is small, it is suitable to be treated by breast conservation surgery. Breast conservation surgery is also known as a ‘wide local excision’. If the resection needs to be larger, it is also sometimes called a ‘segmental mastectomy’ or a ‘quadrant resection’ (quadrantectomy).

What does the operation involve?

A surgical incision is chosen that will give the best cosmetic result. Often this is at the circumference of the areola to mask the scar (figure 1). If the incision has to be made on the skin of the breast because of the position of the lump, it usually follows a natural skin crease which is circumferential around the breast (figure 2). In the lower and sometimes outer part of the breast, a radial incision is chosen to prevent deforming the position of the nipple when the defect is repaired (figure 3).

It is important to remove the breast cancer surrounded by a cuff of normal tissue. A good analogy is the Malteser chocolate candy. If the tumour were to be the hard crunchy middle, normal breast tissue is represented by the chocolate. The clear margins (chocolate in the analogy) need to be sufficiently thick to reduce the risk of the cancer coming back within the breast. Shavings of the cavity once occupied by the surgical resection, are also taken, in order to reduce the need to return for further surgery, should the width of excision be close (figure 4).

The bigger the tumour and/or the greater the width of the excision, the larger the amount of breast tissue that will require to be resected at operation. The greater the volume of this resection, the more likely the resulting visible volume defect will be if no attempt is made to fill the space created by tumour removal. At the time of your surgery, the adjacent breast tissue will be used to repair the defect created in what is called an ‘oncoplastic procedure’. This form of primary repair often avoids the need for a drain in the breast by drawing together breast tissue without leaving a space. By not allowing a blood clot or fluid collection to form within the potential breast space, this technique will also give you better long term results of breast shape and contour.

What dressings will I have?

The surgical incision is closed using stitches that dissolve. On top of this, there will be Steri Strips, which is like human sellotape that holds the wound together, preventing it stretching and reducing hypertrophy. Over this, there will be a small strip of gauze covered by a plastic dressing, just like a small piece of clingfilm. This dressing is waterproof, which means that you can wash, shower or bath in the usual way, without worrying about getting it wet. You may sometimes see spots of condensation underneath the dressing, which is fine. If water is getting underneath the dressing, you need to report this by contacting my office.

Are there any complications from the breast conservation surgery?

The surgical incision and scar as adverse effects have already been mentioned. Volume loss in the breast, as a result of removing the lump can be hidden by adjusting the adjacent tissue and repairing the defect, with very good long term results. With larger lumps, sometimes the volume loss may be noticeable.

Early complications soon after surgery include bruising and bleeding. Bruising normally occurs into tissue planes, and resolves without any intervention. A bleed can occur into the cavity from which the benign lump was excised. Should that happen, there is sometimes a need to return to the operating theatre for the blood clot to be evacuated. This is, fortunately, rare and occurs in 2% or less of such operations.

Most surgical incisions heal as a faint line that is flush with the skin. Sometimes, the incision stretches or is raised in what is called a ‘hypertrophic scar’. Hypertrophic scars can sometimes be pink and itchy. Keloid scarring is rare. It is more common in women who have darker, pigmented skin. Sometimes, such scars need treatment and further advice could be offered, should this be necessary. Fortunately, these adverse affects of wound healing are rare.

Surgical incisions on or around the breast sometimes result in altered sensation of the overlying skin or nipple, if this is in close proximity. Altered sensation in the breast can either be a reduction in sensation or sometimes over-sensitivity. The small nerves that supply the skin are microscopic structures, not visible to the naked eye. These small nerves are cut as the skin is excised and the lump removed at the time of surgery. Sensation returns as the skin is reinnervated.

You may need to have radiotherapy after your breast conserving surgery. If so, radiotherapy may induce redness and swelling of the breast. This may take some time to settle after the radiotherapy is completed. Occasionally, the skin may become moist towards the end of your radiotherapy course. Recovery is usually swift with simple treatment. Very occasionally long term contracture of the breast occurs after radiation therapy. The combined effect of surgery and radiotherapy may affect the final cosmesis of the breast on completion of treatment.

The axillary operation

Surgery of the axilla under arm is necessary in breast cancer to stage the tumour. This means that we need to know if the breast cancer has spread to the glands under the arm. This can be achieved by a specialised technique to sample specific glands in the underarm or by a formal dissection to take the block of nodes that drains the breast.

A sentinel lymph node biopsy (SLNB)

Sentinel lymph node biopsy is a modern way to evaluate the axilla, using a minimally invasive surgical approach. The principles of this procedure are as follows. A tracer material is used to map which of the lymph glands in the underarm are most likely to drain the region of the breast that the tumour is located in. The tracer materials most commonly used are a blue dye called ‘Patent Blue V’ and/or a radioisotope consisting of technetium colloid. This is injected into the breast at the time of surgery, in the case of the dye, or the day before, when the radioisotope is used. The radioisotope contains a small amount of radioactivity which is a fraction of the amount used in a standard x-ray. The tracer material is taken up by the lymphatic channels in the same way that tumour cells might utilise these natural structures to arrive in the lymph glands under the arm. The dye stains the sentinel nodes blue, which allows its visualisation at the time of surgery. The isotope is measured by a special counter (like a modified Geiger counter) that allows the same node or nodes to be targeted at the time of your operation. A positive sentinel node, identified by the blue dye or isotope, is not necessarily one that is involved with cancer but is the first draining node of the region of the breast and therefore representative of the rest of the axillary lymph node basin. There is often more than one sentinel lymph node, and usually between one to four nodes are biopsied. Sentinel lymph node biopsy is a safe technique that allows the axilla to be staged (to determine whether the nodes are positive or negative) without major surgery. The advantages of this procedure are that there is a short recovery time, requiring only an overnight stay in hospital at most, with minimal effect on shoulder stiffness or function of the arm. The results of the sentinel lymph node biopsy are usually available a few days after the surgery. The disadvantage of the sentinel lymph node procedure is that if the nodes are found to be positive, you will require further treatment to the underarm. This is usually a formal axillary dissection (see below).

The blue dye from the sentinel lymph node stains the skin and takes some weeks, sometimes months, before it fades. There have been cases where a faint blue staining has persisted for several months, and on occasion over a year. The first time that you pass urine after the operation, you are likely to find that this is stained blue or green. This is usually gone by the second passage of urine. Sometimes the bowel motion is also discoloured in this way. There are no long-term sequelae of this. The radioisotope has a short half life and there are no long term effects. It should not be used in pregnancy.

Sentinel lymph node biopsy is a sophisticated way of performing an axillary sample. Before sentinel node method became available, techniques described to sample the axilla were based on random methods, which have, in the main, been superseded.

Axillary dissection

Five or more years ago, the standard method of staging (to identify if lymph nodes were negative or positive) and treating the axilla was by removal of the block of lymph nodes that drain the axilla. Typically, there are around 20 lymph nodes. This number of lymph nodes is far from absolute and can range widely between individuals. The surgical dissection involves removing a block of tissue in the axilla (armpit) within the boundaries of blood vessels, nerves and muscles, that determine the extent of the surgical resection. The pathologist subsequently identifies lymph nodes from within this block of fat that are carefully assessed under a microscope. A pathology result is usually obtained several days after the surgery.

Axillary dissection or clearance is a much larger operation than sentinel lymph node biopsy, described above. After surgery, there will be a drain placed to remove any blood or fluid that can collect in the underarm in the few days after your surgery. This drain remains in place for approximately five days, until the volume of fluid falls to a minimum amount. You may go home from hospital with your drain in place, after the second day. If you wish to stay in hospital until the drain comes out, this is usually five days after your operation.

A seroma is a collection of fluid that may occur in the axilla after the drain is removed. It can present as a discomfort, stiffness or swelling. If it becomes full of fluid and tense, a needle and syringe may need to be used to aspirate the fluid. Sometimes, this may need to be repeated on more than one occasion.

Sentinel lymph node biopsy -v- axillary dissection

You will be recommended to have a sentinel lymph node biopsy if you have a relatively small tumour, and the likelihood of the lymph nodes being involved under your arm is small. In general terms, if you have a small breast lump there is approximately a two-third chance that the axillary lymph nodes are negative. If the nodes are negative and this is reliably shown by sentinel lymph node biopsy, you will need no further treatment to the underarm. If the lymph nodes are positive on sentinel lymph node biopsy, you will require an axillary dissection operation at a second procedure, usually one or two weeks after the first operation.

Sentinel lymph node biopsy, being a minimally invasive surgical technique, is associated with a smaller scar and very fewer adverse effects compared to axillary disection. Adverse effects in the early days include wound infection or blood clots at the site of surgery. These events are fortunately rare. Other later complications include stiffness of the shoulder, numbness near the scar or in the inner border of the upper arm, or hypersensitivity in these regions. Most of these symptoms are self-limiting.

Apart from the longer hospital stay associated with axillary lymph node dissection surgery, the risks of adverse effects following axillary clearance are higher. The scar in the axilla is longer. There is a higher risk of shoulder stiffness. To counteract this, you will be offered physiotherapy from an early stage whilst you are an in-patient in hospital. The risk of arm swelling (lymphoedema) with modern methods of surgery and selective use of radiotherapy affects 10% to 15% of patients in their lifetime. Most symptoms of arm swelling are transient and resolves on treatment with no long-term problems of arm use or function. After axillary surgery of this type, you will need to take great care of your skin and hands to avoid accidental injury that can precipitate episodes of infection and cellulitis, that predispose to lymphoedema and can become recurrent. After any axillary surgery, there can be local problems in the early days after surgery, such as wound infection and bleeding. This is more common after axillary lymph node dissection compared to sentinel lymph node biopsy. In addition, prolonged scar pain, anaesthesia and hypersensitivity are also more common after axillary lymph node dissection.

Sentinel lymph node biopsy is a sensible way of staging the axilla, thereby selecting women who need axillary dissection for treatment, only if they are node positive. If there is only a 30% chance that you are node positive, then the majority (about 70%) of patients do not need axillary dissection surgery. Sentinel lymph node biopsy is an efficient way of identifying those women who need the more major surgery of axillary dissection.

Post-operative care

After your axillary surgery, you will have a plastic dressing that allows you to wash and shower in the normal way. This will be removed when you attend out-patients at your post-operative visit. You will be offered physiotherapy whilst on the ward and a set of graded self-instructional exercises that you should do diligently as instructed by the physiotherapist. This reduces the incidence of shoulder stiffness and also helps tissue fluid drainage from the arm, reducing the risk of arm swelling.

The dressings will be removed when you attend out-patients. Dissolvable sutures are used inside and underneath the skin, so no stitches have to be removed.

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