Surgery remains the first line treatment for early breast cancer. Surgical therapy has two components:
- The breast
- Draining lymph nodes (in the arm pit)
In our unit, 60% of cases undergo breast-conserving surgery. The principle is to remove the tumour with a surrounding rim of normal breast tissue, while at the same time, achieving an acceptable cosmetic result. Sometimes, a second small operation is required to obtain a clear surgical margin. Postoperative radiotherapy is almost always required after breast conserving surgery.
Some women still require a complete mastectomy because of the pathological nature of the tumour or because the size of the tumour in relationship to the size of the breast would result in an unacceptable cosmetic outcome. A number of women elect to have a mastectomy, most commonly because radiotherapy can often be avoided after total removal of the breast. All women who have mastectomy are offered breast reconstruction by one of our plastic surgeons.
Draining Lymph Nodes
Invasive breast cancer will spread to the lymph glands in 40% of cases. It is therefore very important to know if this has happened in order to plan optimal further management such as chemotherapy or hormonal therapy.
The lymph node status is assessed by removing the Sentinel Lymph Node (SLN). The SLN is the first lymph node that a breast cancer will spread to (if it spreads). It is usually situated in the Axilla (armpit), and is occasionally found in other places such as the lymph nodes behind the sternum (breast bone).
The SLN is identified by pre-operative mapping of the draining lymph nodes by lymphoscintigraphy or the use of blue dye at the time of operation. A radioactive substance, blue dye, or both is injected near the tumour to locate the position of the sentinel lymph node. The surgeon then uses a device (gamma probe) that detects radioactivity to find the sentinel node or looks for lymph nodes that are stained with the blue dye. Once the sentinel lymph node is located, the surgeon makes a small incision (about 3-4 cm) in the overlying skin and removes the node.
If the SLN has significant tumour involvement, removal of more lymph nodes (axillary dissection) may be necessary.
Axillary dissection may lead to shoulder stiffness and restriction of movement. It may also cause numbness down the inside of the upper arm and in 10-15% of cases, it may result in long term swelling of the arm known as lymphoedema. These side effects are very uncommon following SLN biopsy.
Most breast cancer surgery requires a short hospital stay (Day Only or “24 hour” admission). Patients who have a mastectomy or axillary dissection will usually have a drain left in after surgery which may need to remain in place for a week or more. A specialist breast nurse will help with its management at home.
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