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Surgery
Published: Thursday, May 03, 2007
1. Indications for mastectomy versus breast conserving surgery
It is important to obtain negative resection margins at the time of surgery (tumour > 2 mm from an inked margin) for all patients with invasive disease or DCIS.2 Invasive or in situ disease at the margin is treated in the same manner. A positive margin is defined as tumour touching ink and (or transected tumour), a close margin is margin < 2 mm and anything in-between (Table 1). Even with pathologically negative margins, 25% to 40% of women treated with partial mastectomy alone (without radiation) will recur in the breast within five to ten years of follow up.2
Table content sourced with permission from www. 3. Guidelines for re-excision and boost following breast conserving surgery Re-excision to obtain negative margins is recommended for patients with close or positive margins. If a margin is <2 mm and re-excision is declined or inappropriate, a radiation boost to the tumour bed is recommended. Re-excision should be more strongly recommended where the risk of ipsilateral breast tumour recurrence (IBTR) is high and systemic risk is low3, for example: Margin <2 mm and:3
When the deep margin is positive, and the surgeon has dissected down to fascia, then a boost should be given. Patients with close or positive margins who decline re-excision should be advised that the risk of IBTR is increased. The relative risks/ benefits of re-excision vs. boost in the context of local control and cosmesis should be discussed.3 4. Recommendations for axillary dissection for breast cancer surgery
Table content sourced with permission from www. Sentinel lymph node biopsy is a diagnostic procedure used to determine whether a breast cancer has metastasized to axillary lymph nodes. A sentinel lymph node biopsy requires the removal of only one to three lymph nodes. If the sentinel nodes do not contain cancer cells, this may eliminate the need to remove additional axillary lymph nodes. The sentinel lymph node procedure entails the injection of a small dose of a low-level radioactive tracer called technetium-99 into the breast in the region of the patient’s tumour at least two hours before surgery. At the time of surgery, a blue dye is also injected to help visually track the location of the sentinel node during the operation. After injection of the blue dye, the surgeon uses a hand held gamma ray counter to detect the radioactive tracer and locate the sentinel node. Once the area has been pinpointed, the surgeon will make a small incision (usually one-half inch) and remove the sentinel node(s) for a pathologist to examine under a microscope. The blue dye provides additional visual confirmation of the sentinel node’s location during surgical removal.5 Sometimes, lymphoscintigraphy will be used after injecting the technetium-99 before surgery. Since the uptake of the technetium-99 by cancerous lymph nodes is sometimes different than the uptake by normal lymph nodes, these nuclear medicine images may also help show which lymph nodes are cancerous.5 In facilities that offer intraoperative consultation and imprint histology, the pathologist performs a quick touch prep H&E test to provide preliminary information regarding sentinel node metastases. If this test comes back positive, the surgeon will proceed with axillary dissection. If the touch prep H&E test comes back negative, the surgeon will proceed as per established guidelines as previously discussed with the patient. A complete sentinel node assessment will be performed post-surgery to provide complete pathology of the nodes.5
Table content sourced with permission from www. 6. Recommendations for sentinel lymph node biopsy
7. Types of breast reconstruction
The reconstruction may include the breast mound alone or also the nipple-areola complex. It is also possible for women to have delayed reconstruction following mastectomy with a combination of implant and tissue reconstruction or for women with significant cosmetic deficit following breast conserving surgery to have delayed reconstruction with implant and/or tissue reconstruction. For immediate reconstruction, the general surgeon performs the mastectomy at the same time the plastic surgeon reconstructs the breast. For delayed reconstruction, the plastic surgeon should be in close contact with the general surgeon who performed the original mastectomy for details of the patient's previous treatment and prognosis. Reduction mammoplasty of the other breast may be considered to retain symmetry. The remaining breast is at increased risk for malignancy with the risk probably greatest for patients who have lobular carcinoma or a significant family history. Some patients may be candidates for, or may choose to have, contralateral total mastectomy with bilateral reconstruction rather than simple reduction mammoplasty on the contralateral side.7
Table content sourced with permission from www.
Table content sourced with permission from www.
Table content sourced with permission from www.
Table content sourced with permission from www. 8. Potential contraindications to breast reconstruction
9. Advantages of breast reconstruction In terms of body image and emotional state, the advantages of immediate breast reconstruction are well documented. However, there are many patients who have no interest in breast reconstruction, but it is reasonable for the surgeon or the oncologist to discuss its availability with all women. Any patient contemplating reconstruction should recognize that the goal of reconstruction is for a good body image while fully clothed. A reconstructed breast will not look like or feel like a natural breast.7 To learn more about breast reconstruction options, decision-making, pre- and post-op care and follow-up, review the material on the UBC Breast Reconstruction Program. 10. Recommendations for adjuvant cancer treatments following immediate breast reconstruction Breast reconstruction following mastectomy for cancer does not adversely affect the prognosis or the physician's ability to follow the patient for metastatic disease.7 There is no documented increase in local or regional recurrence associated with immediate reconstruction nor is there a delay in the recognition of local or regional recurrence when it does develop. As well, no survival difference can be identified in patients who have undergone immediate reconstruction. Hence, in terms of tumour control, there are no patients in whom the procedure is specifically contraindicated.7 Post-operative radiotherapy, when indicated, may be given in the usual way. There may be some adverse effects in terms of capsular fibrosis around implants. Tissue flaps should not be adversely affected.7 It is possible that post-operative complications may be increased if extensive tissue transfer is carried out and this in turn may delay the start of adjuvant chemotherapy. A review of the literature does not suggest that this is a significant problem in centres where this type of procedure is done frequently. The complication rate does not appear to be higher than that for mastectomy alone.7 Generally, there does not appear to be any contraindication to immediate reconstruction in terms of adjuvant treatment and patient outcomes. However, operating time for autologous reconstruction is significantly longer than for regular breast surgery. This, combined with challenges in coordinating both a general surgeon and plastic surgeon's operating schedules, can add to the surgical wait time.7 11. Breast prosthesis and how to help a patient obtain one Not all women are interested in breast reconstruction following mastectomy. Some choose to wear an external breast prosthesis in their bra or bathing suit to give the appearance of a natural breast. There are many types and levels of quality of breast prostheses on the market. Prostheses can be made of light, fluffy cotton, foam, or silicone gel. Temporary “fluffy” breast forms are available free of charge for women who have had a mastectomy or for women with significant deficit after breast conserving surgery. These can be worn immediately after surgery, if desired, to fill out their clothing. Temporary forms can be obtained through most hospitals, local Canadian Cancer Society offices or by calling the Cancer Information Service line at 1.888.939.3333. Permanent external breast forms can be fitted four to six weeks after mastectomy, when the incision line is healed, there is no infection, and swelling has dissipated. A woman should also be emotionally ready for a fitting. A physician prescription is required for financial reimbursement if a woman purchases a breast form and mastectomy bra. Wearing a permanent prosthesis can help with posture changes and back issues that can result from having a breast removed. Partial breast shapers are available for women who have had breast conserving surgeries and can be placed in the bra to replace lost tissue and balance the figure. Permanent external breast forms can be purchased through specialty stores who often have trained fitters. Financial assistance toward the purchase of permanent breast prosthesis is available through a variety of sources. Patients should contact the appropriate source to see what is covered by their plan.
The Canadian Cancer Society has a Breast Prosthesis Bank (BPB) that offers gently used or end of the line bras and prosthesis free of charge to women with limited financial means. Patients should call the Cancer Information Service at 1.888.939.3333 to find a Breast Prosthesis Bank in their community or to arrange for prosthesis to be mailed to them. References: 1. Clinical practice guidelines for the care and treatment of breast cancer, Guideline 3: Mastectomy or lumpectomy? The choice of operation for clinical stages I and II breast cancer, Rev. July 23, 2002, © 2006 CMA Media Inc. or its licensors. 2. BC Cancer Agency (http://www.bccancer.). Vancouver (BC): 2006. (cited Sep 22, 2006). Available from: BC Cancer Agency's Cancer Management Guidelines -> Breast -> Management 3. BC Cancer Agency (http://www.bccancer.). Vancouver (BC): 2006. (cited Sep 22, 2006). Available from: BC Cancer Agency's Cancer Management Guidelines -> Breast -> Management 4. Clinical practice guidelines for the care and treatment of breast cancer, Guideline 4: Axillary dissection (2001 decision: no update required) © 2006 CMA Media Inc. or its licensors. 5. BC Cancer Agency (http://www.bccancer.). Vancouver (BC): 2006. (cited Sep 22, 2006). Available from: http://www.bccancer./NR/rdonlyres/169A6C64-24C3-4D5E-9828-BB3F4FBC2BC7/17503/BreastSLNGuidelineFeb2006.pdf 7. BC Cancer Agency (http://www.bccancer.). Vancouver (BC): 2006. (cited Sep 22, 2006). Available from: BC Cancer Agency's Cancer Management Guidelines -> Breast -> Management |
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