Treating breast cancer depends on the characteristics and diameter of the tumor and includes surgery (surgical therapy) and oncological therapy, which may include radiations, chemotherapy, anti-hormonal treatment and biological treatments. The integration of the therapeutic options will be determined according to the tumor characteristics and in most cases, only after receiving the final results of the surgery.
In any case, the treatment will be adapted to the patient according to the tumor characteristics, lymph nodes involvement and operation, and also considering her personal preferences.
What is the objective of the surgical treatment?
The objective of the surgical treatment in breast cancer is to take out the entire tumor, including the healthy tissue in its margins and examine the lymph nodes of the armpits.
Sometimes the mastectomy is partial, and sometimes the situation requires a full mastectomy, but in both cases these are relatively small surgeries, that last about an hour and are conducted under general anesthesia. Because this is a superficial surgery, that does not include opening body cavities (like the thorax or the abdominal cavity), mostly you can discharge from the hospital on the following day, and regain full function quickly, within a week – 10 days. After a breast conserving surgery (partial mastectomy or Lumpectomy, there is mostly a requirement for complimentary radiation therapy. After a complete mastectomy only some cases require radiation.
Breast Conserving Surgery (Lumpectomy): as its name infers, this is a surgery aiming to conserve the breast in its original shape as much as possible. In small tumors, it is enough to extract the tumor, and therefore the shape of the breast is usually preserved, apart from the scar, which is usually a gentle stripe.
When the tumor is large or when the breast is small, sometimes we need to use plastic surgery techniques to achieve the optimal aesthetic result, in a process called “oncoplastic reconstruction”. A surgery including an oncoplastic reconstruction is considered larger, and sometimes it requires an additional surgery to match for the other breast.
In cases that the tumor is not palpable but only observed in imaging, we should mark the suspicious finding before the surgery, by inserting a thin wire into the tumor and guide the surgeon. The marking is done under local anesthesia (much like a biopsy), and is oriented by an ultrasound or a mammography a day before the surgery or in the morning of the surgery.
Complete mastectomy: In cases that the tumor has expanded, or when you want to avoid complementary radiation treatments, there is a need to perform a complete mastectomy. In most cases, it is possible to preserve the breast envelope, i.e., the skin and the nipple, and perform an immediate reconstruction. The most common and simple reconstruction is using a silicone draft and a biological sheet (ADM), done by a plastic surgeon in the same procedure, immediately after the mastectomy.
Sometimes there is need for complementary radiation therapy also after a complete mastectomy, and there is not always a way to know this before the surgery.
Surgical treatment of the armpit lymph nodes: Within the breast cancer surgery (and sometimes when it is a pre-cancerous tumor) there is a need to examine the sentinel lymph nodes. These are the first lymph nodes in the chain, and their role is to drain the breast. They are usually located in the armpit. Sometimes, there is more than a single sentinel lymph node. To identify suspicious nodes, we mark them using a small dosage of radioactive substance (isotope) injected around the tumor between one day and one hour before the surgery and/or by injecting a small dosage of blue color around the tumor during the surgery. Through a small armpit incision it is possible to identify and remove the affected sentinel lymph node and send it to be examined under the microscope and see whether cancerous cells have spread to it. Today, it is accustomed to only remove the infected node(s) without touching the other nodes, even if we find cancerous cells in the nodes. This is the place to point out that the reception of a material in the sentinel nodes does not testify of their involvement, but only directs the surgeon about the lymph nodes to be removed and tested.
In cases that the lymph nodes’ involvement is known before the surgery, there is no need in sentinel biopsy, and it is recommended to extract the armpit lymph nodes in a procedure called “axillary dissection”. This is done through an armpit incision and requires the extraction of the armpit fat in distinct anatomic boundaries. This is due to the fact it is very hard to discern between healthy and infected lymph nodes using the naked eye. Such a surgery usually removes 10 to 20 lymph nodes, and inserts a drain to drain the fluid for a few days. Axillary dissection entails increased risk to develop lymphedema, a lymphatic edema and chronic swelling of the arm, especially if after the surgery there is another radiation treatment for the armpit. There are guidelines to decrease the risk for lymphedema, and it is important to remember that less than 10% of the women that undergo axillary dissection will develop significant lymphedema in the future.
Inter-surgical radiation: In women over 55, with tumors smaller than 2 cm, and no lymph involvement, it is possible to provide inter-surgical radiation. In Israel, this treatment is done using a device called intrabeam, which generates radiation that is passed through a special applicator inserted into the cavity left after dissecting the tumor. The radiation prolongs the surgery in about an hour, but in most cases, it saves the need for daily radiation therapies for a few weeks. (In about 10-15% of the cases, it is discovered, after the surgery that this treatment is not enough, for various reasons, and then there is a need to add external radiation therapy).
Who Treats Breast Cancer?
Treating breast cancer is multi-disciplinary and involves radiologists, imaging specialists, surgeons, pathologists and oncologists, every one of them an expert in his own field, but in this kind of treatment they are required to work in constant cooperation and consultation. In most cases, radiologists are involved in the primary diagnosis stages, and perform most of the biopsies. In the next stage, after there is a breast cancer diagnosis, the first doctor is usually the surgeon, who determines the fitting surgical options, and if necessary, there is an oncologist involved, to determine the need for complementary therapy based on the final answers from surgery, that include all the tumor characteristics and the involvement of the lymph nodes. In certain cases, it is recommended to prescribe a preliminary oncological treatment, before the surgery, in order to decrease the tumor. Such a preliminary therapy (called Neoadjuvant therapy) can be either chemotherapy or hormonal.
In addition, we involve nurses to adapt breasts, and genetic consultants, psychologists and social workers, if they are required.
