OFFICE NUMBER

305-271-3300

 

 

 

Surgical Treatment Options Breast Cancer

Surgery is considered the primary treatment for breast cancer. The goal is to remove the tumor and normal surrounding breast tissue to obtain clear margins. The options include removal of the breast versus removal of the tumor, while preserving the breast. One or several lymph nodes are removed to find out whether or not they are involved with cancer cell. The information obtained in surgery will help to stage the breast cancer and guide the surgeon to determine if further additional treatment (chemotherapy, radiation therapy, hormonal therapy) is needed.

Management of the Breast

Breast Conservative Surgery (Lumpectomy):
With this type of surgery, the tumor is removed with a rim of normal surrounding breast tissue. The goal is to remove the tumor while at the same time retaining a cosmetically acceptable breast.

 

 
     
Lumpectomy is also known as wide excision or partial mastectomy. The tumor and surrounding breast tissue are removed while preserving the breast.   The local treatment of breast cancer when preserving the breast also includes radiation therapy. The most common modalities are external radiation and accelerated partial breast irradiation.

 

Total or Simple Mastectomy:
This involves the removal of the breast tissue including the nipple-areolar complex.

 

 
     
The breast tissue and nipple-areolar complex are removed in a total or simple mastectomy. The axillary lymph nodes are left intact.   This picture depicts the final result of either a total mastectomy or modified radical mastectomy without immediate reconstruction.

 

Modified Radical Mastectomy:
This is the same as a total or simple mastectomy, in addition to the removal of the lymph nodes under the arm. The number of lymph nodes removed varies from patient to patient.

 

A modified radical mastectomy is by definition the removal of the breast plus the axillary lymph nodes. The axillary lymph nodes are removed if cancer cells have spread to them. The pathologist will inform us of the number of lymph nodes affected with cancer. This information will be used to dictate the need of further systemic adjuvant therapy.

 

Radical Mastectomy:
The breast tissue, nipple-areolar complex, axillary lymph nodes and chest wall muscles (pectoralis major and minor) are removed. This operation is rarely performed today. It is only reserved for a minority of cases where there is gross invasion of the chest wall muscles, despite primary treatment with chemotherapy or radiation therapy.

Skin Sparing Mastectomy:
This refers to the removal of the breast tissue and nipple-areolar complex with preservation of the skin envelope of the breast. The cosmetic outcome of the breast reconstruction has markedly improved by keeping the native breast skin envelope and shape. The oncology principles always take priority and should never be compromised.

 

The skin envelope of the native breast is preserved. This surgical technique provides a superior cosmetic outcome. The breast is reconstructed in stages with either tissue expanders, TRAM flap, or Lattissimus dorsi flap. The nipple-areolar complex will be reconstructed at a later time.

 

Nipple Sparing Mastectomy:
The breast tissue is removed leaving the native breast skin envelope and preserving the nipple-areolar complex.

Immediate Breast Reconstruction:
This surgery will restore the breast. The breast can be reconstructed at the same time of the mastectomy (immediate reconstruction) or at a later time (delayed reconstruction). The breast cancer patient should be evaluated by the plastic surgical team to discuss all options of reconstruction. Options of reconstruction include breast implants (tissue expanders) versus using tissue from other parts of the body (Tram flap, Diep flap, Latissimus dorsi flap, Fat transfer).

 

Prophylactic Mastectomy

Prophylactic mastectomy is the removal of a healthy breast in order to reduce the risks of developing breast cancer. Recent studies have shown that women have been increasingly opting for prophylactic contralateral mastectomies in the United States. This includes women with either invasive breast cancer or DCIS (preinvasive cancer). The second clinical scenario applies to those women who are considered high risk but do not have a diagnosis of breast cancer. As breast surgeons, it is our responsibility to inform patients of the risks, benefits, and indications for prophylactic mastectomy. The patients can make a sound decision based on the facts, rather than a decision based on misconceptions. In most scenarios this is a patient driven surgery and patient preference plays a major role in the choice of surgery. For some patients it is not even the medical issue; it is the anxiety of the decision. Patients do not want to worry about getting cancer in the second breast in the future. Greater social acceptance of double mastectomies and improved cosmetic surgery techniques are reasons for this increase in prophylactic mastectomies. The patients should know this is a risk reducing surgery rather than risk eliminating. The reason for the reduction in risk rather than total elimination of the risk is because the breast tissue fades out in the overlying subcutaneous tissue and into the underlying muscles. Even the most meticulous mastectomy technique may fail to clear all the breast glandular tissue. These tissue elements that can be left behind remain a risk for developing breast cancer. This is something that the patient must come to terms with. Prophylactic surgery of this nature is not 100% effective. However, it is the most effective prophylaxis available today and can reduce the risk by up to 90% to 95%.

 

Prophylactic mastectomy is the removal of a healthy breast. It reduces the risk of developing breast cancer by approximately 90% to 95%. This is a risk reducing surgery rather than risk eliminating.

Invasive Breast Carcinoma:
Despite being able to dramatically lower the chances of future breast cancers from developing, prophylactic breast removal has not been shown to decrease a woman's chance of dying from breast cancer. The threat to her life comes from the cancer she already has. It is important to assess the risk of the index tumor and how it spreads distally. If this risk of spreading far outweighs the risk of a contralateral mastectomy, the surgery should not be recommended. Occult malignant tumor is present in the contralateral breast in 3% to 5% of patients. The five year incidence of developing breast cancer in the unaffected contralateral breast is approximately 4%. The annual rate of getting a new contralateral breast cancer is approximately 1% per year.

Ductal Carcinoma in Situ (DCIS):
The 10 year survival rate for women with DCIS is 98% to 99%. Therefore, removal of the normal contralateral breast will not improve survival rates for this group of women. However, patients with DCIS do have an increased risk for contralateral breast cancer. The annual rate of getting a new cancer in the 2nd breast is approximately 0.6% per year and this is considered quite low. The cumulative risk for contralateral breast cancer in patients with DCIS will increase over time, from 3.3% at 5 years to 10.6% at 20 years.

BRCA Gene Mutation:
The best candidate for prophylactic removal of the breasts is a BRCA-positive woman who also has a strong family history of the disease. The lifetime risk of developing breast cancer is 85%. There is a 50% incidence of getting the first breast cancer by the age of 50. The lifetime risk of getting a second contralateral breast cancer is approximately 50%.