Keeping Abreast

written by Dr Harjit Kaur on 20 July 2008

What you need to know about breast cancer surgery.

When a woman detects a lump or any abnormality in her breast, her whole world often comes to a standstill. A million things run through her mind, especially the possible loss of her breasts. As a result, we often hear women seeking all forms of alternative treatments before finally seeing a breast surgeon. Unfortunately, as a result of their unfounded fears and lack of awareness of the therapeutics options available, they usually end up with advanced disease.
 
Breast cancer is still the number one cause of cancer death in Malaysian women, with about 30-35% of women having advanced disease. In an era where technology and skills are constantly advancing, it is truly a sad picture.
 
The reason for this is multi-factorial, the most common being strong religious beliefs and taboos, the immense belief in faith healers, the lack of breast awareness and screening services as well as the lack of trained personnel to provide the necessary services.
 
There are many therapeutic options available to women when they detected with breast disease. About 80-85% of breast lumps are often benign or non-cancerous. In this group of women, treatment may be surgical or non-surgical. Surgery itself is often cosmetic defect and can be done as a day case.
 
In cases of malignant or cancerous breast lumps, the options are varied depending on many factors. Surgery may be breast-conserving or not. It is when mastectomy (the loss of the whole breast) is discussed as the best option to ensure a safe oncologic outcome that the woman often withdraws into her protective shell. 
 
Having to deal with the diagnosis of breast cancer and losing her breasts is often too much for many women to cope with. As a result, many default treatment.
 
Conventional surgeries in breast cancer
 
The most common surgeries is carried out in the management of breast cancer are the breast conserving surgery (BCS) and the mastectomy (removal of the entire affected breast). These surgeries may be associated with axillary clearance (removal of the axillary lymph nodes).
 
Although widely accepted as the standard surgical treatment, mastectomy and axillary clearance leaves a woman disfigured and at risk of lymphedema (swelling of the arm). When combined with radiotherapy, the skin changes over the already flattened chest add insult to injury. This in turn affects the women’s self-esteem and confidence.
 
In some cases, women suffer from troubling backaches due to imbalance suffered as a result of the loss of one breast.
 
Oncoplastic surgery as an option
 
Oncoplastic breast surgery is a concept of combining surgery for the cancer together with reconstructive surgery at the same time or as a delayed procedure. This option must be made available to any woman who is diagnosed with breast cancer that requires a mastectomy of significant tissue loss.
 
Immediate reconstruction after a mastectomy can be done using implants, tissue flaps or a combination of both depending on the suitability of the patient and the oncological criteria. With this technique, a woman will be able to have a reconstructed breast at the same sitting as the mastectomy. This has a tremendous positive impact on a patient’s self-esteem and self-image and is becoming more acceptable in general.
 
 
A technique called skin sparing mastectomy allows the patient’s skin to be preserved as much as possible. The entire breast tissue and in some instances even the axillary lymph nodes are removed via an incision around the nipple areolar complex. In this way the patient’s natural skin is preserved and reconstruction has a much better cosmetic outcome.
 
In some women, there may be a possibility of preserving the nipple areolar complex as well. This, however, is case sensitive and strict criteria must be followed.
 
 
Skin sparing mastectomy can also be combined with tissue flaps like the lattisimus dorsi (LD) flap (back muscle and tissue) and the TRAM flap (where abdominal tissue is used). The choice of reconstruction will very much depend on the best option and patients’ choice.
 
Implant reconstruction with or without the combination of a LD Flap is safe and short procedure with good outcome. Other tissue flap procedures may be more complicated and lengthy in surgical time and hospital stay.
 
 
Patients must be given explanations and all the possible options with the risks and complications addressed in detail. The patient finally makes the choice of the procedure with some guidance and advice from her doctor.
 
With the availability of oncoplastic breast surgery, patients have more options and this helps in decision-making about their treatment, thus preventing undue delays that may be detrimental to their prognosis.
 
It is important to highlight here that the oncology aspect of surgery takes precedence over the cosmetics. Hence, it is important for a patient to seek treatment from a doctor who is trained in the field because at no time should the oncological aspect of the surgery be compromised. A multidisciplinary approach in the patient’s management offers the best outcome.
 
 
Sentinel Node Biopsy (SNB)
 
In all aspects of surgery, we are moving towards minimally invasive procedures. In breast surgery, this is the direction we are heading as well.
 
Sentinel node biopsy is a minimally invasive technique of addressing the axillary lymph nodes and is practised all over the world, mainly in developed countries. SNB is most commonly associated with staging for breast cancer; however it can be used for malignant melanomas (skin cancer).
 
Sentinel is a term derived from the French word sentinelle, which means “to guard over” or “vigilance”. The sentinel node therefore acts as the first filter of malignant cells in the lymphatic system.
 
The technique of SNB is the identification of these sentinel lymph nodes (usually one to three nodes) with the assistance of radioisotopes and dye injections around the tumour. These sentinel nodes are then assessed intra-operatively with the help of frozen sections and is determined of its involvement of cancer cells.
 
If the sentinel lymph nodes are clear of cancer cells, it avoids the patient having a full axillary clearance and all the morbidly associated with it.
 
This procedure requires expertise and experience as well as competent team in a multidisciplinary setting. It involves a trained breast surgeon, radiologist and pathologist and nuclear medicine facilities. Surgeons who are experienced in SNB can identify the involved node in 85-98% of the patients. The false negative rate is usually less than 5%.
 
The risk of lymphedema (swelling of arm) is very much minimised with this technique. It can be done as a day case, compared to the traditional axillary clearance that involves a post-operative stay of at least three to four days.
 
 
There is more to breast surgery than meets the eye. The surgical techniques have improved, providing much better outcomes to women affected with breast diseases. Awareness of the availability and options will hopefully get more women to seek treatment early.