Breast Surgery Treatment Options
Greater than 22% of newly diagnosed breast cancer patients are at risk of harboring BRCA mutations. BRCA mutations dramatically increase the risk of breast cancer, contralateral breast cancer and ovarian cancer.
Features that indicate a risk for BRCA mutations include
- Early onset of breast cancer ( less than 50 years of age when diagnosed);
- Two breast primaries (you have 2 cancers on one side or a cancer in each breast)
- A family history of early onset of breast cancer
- Male breast cancer
- Personal or family history of ovarian cancer
- Ashkenazi (Eastern European) Jewish heritage
- A previously identified BRCA1 or BRCA2 mutation in the family
Women with breast cancer who have a BRCA mutation
- if tested before surgery will often opt for mastectomy with contralateral prophylactic mastectomy (removing other breast) and breast reconstruction.
- if tested after breast conservation surgery often opt for further surgery such as bilateral mastectomy with reconstruction before radiation
- can take tamoxifen which reduces contralateral breast cancer risk by at least 50% and is independent of ER or PR hormone receptor status of the primary cancer
- prophylactic oophrectomy (removal of ovaries) reduces the risk of ovarian cancer by 96%
Women without breast cancer who have a BRCA mutation
- Can start with intensive breast surveillance including MRI at age 25
- Prophylactic bilateral mastectomy (removal of both breasts even though they do not have breast cancer). This reduces breast cancer risk by greater than 90%
- Prophylactic oophrectomy. This reduces the ovarian risk by 96%. It reduces the breast cancer risk by up to 68%.
Testing involves providing a saliva sample which is then sent away for analysis.
Stereotactic Breast Biopsy
A stereotactic breast biopsy is performed on an outpatient basis in a facility with a mammography unit. You will lie face down on an examination table with the affected breast positioned through an opening in the table. The table is then raised and the procedure performed below. The breast is compressed and held in position throughout the procedure.
A local anesthetic is injected into the breast to numb the area. Several x ray pictures of the positioned breast are taken. The surgeon and the radiologist will discuss the correct positioning of the needle tip after reviewing the x-ray pictures of the compressed breast. A small nick is made in the skin at the site where the biopsy needle will be inserted. The surgeon will then insert the needle and advance it to the location of the abnormality using x-ray co-ordinates. X –ray images are again obtained to confirm the correct positioning of the needle tip.
Tissue samples are then taken by firing the biopsy needle. The needle will take multiple samples and they will be analysed for the presence of calcifications if required by x-ray of the specimens. Non calcified breast samples are sent direct to pathology. After the sampling is complete a final set of images is taken. A small marker is placed at the site of the biopsy for reference in future imaging.
The biopsy incision site is cleaned and dried and steristrips (paper strips) applied. A check mammogram of the biopsied breast is then performed in the main department.
Because the vacuum-assisted breast biopsy needle removes larger pieces of tissue there is risk of bleeding and forming a blood clot (hematoma) in the breast. A hematoma can occur in 1 out of 100 patients who undergo this type of biopsy. If the bleeding is significant the hematoma may have to be drained in the operating room under a general anesthetic. This risk is more common in patients with a history of bleeding tendency or those taking blood thinner medications.
There is a risk of infection in 1 out of 1000 breast biopsies performed. This risk is more common in diabetics and heavy smokers.
Lung injury is a rare but known complication of breast biopsies. If the breast abnormality is close to the chest wall the needle may pass through the chest wall and injury the lung.
Excisional Breast Biopsy
An excisional breast biopsy is a surgical procedure performed in an operating room under general anesthesia to remove a breast mass (lump). Sometimes a superficial breast lump can be removed in the office under local anesthesia.
An excisional breast biopsy may be done if you have:
- A benign mass that is increasing in size
- A benign breast mass that is causing symptoms such as pain
- A core biopsy that reveals atypical cells
In an excisional biopsy of the breast, the surgeon makes an incision in the skin and removes all of the abnormal tissue for examination under a microscope. Unlike needle biopsies, a surgical biopsy leaves a visible scar on the breast and sometimes causes a noticeable change in the breast’s shape. Surgical biopsies take about an hour, and the recovery period is less than two hours.
When a breast mass or an area of calcification cannot be felt, the surgeon may choose to use a procedure called wire localization to help identify the tissue. After applying a local anesthetic, the radiologist/surgeon inserts a hollow needle into the breast and, guided by ultrasound or mammography, places the tip of the needle in the suspicious area. A thin wire with a hook on the end is passed through the hollow needle and into the breast alongside the suspicious area. The doctor then removes the needle, leaving the wire in place to serve as a guide to help find the area of breast tissue at time of surgical excision.
Breast cancer is usually treated with a breast lumpectomy (partial mastectomy) or mastectomy and nodal surgery.
A partial mastectomy involves removal of a part of the breast tissue and additional margins. It is an outpatient procedure and usually takes about 1 hour. The procedure usually does not involve any great volume loss to the breast and the cosmetic appearance remains largely unchanged. The nipple remains intact during the procedure. The incision site may be located around the nipple or overlying the abnormal breast lesion.
The procedure can involve localizing the breast lesion;
- With an ultrasound and placing a wire directly through the mass or
- With the surgeon removing an easily visible and palpable mass without any imaging assistance.
A simple or total mastectomy involves removal of all the breast tissue. The procedure is carried out under general anesthetic . Most mastectomies involve removal of the nipple and the surrounding areolar tissue. In some instances the nipple can be left after a mastectomy, especially if a breast is being removed that does not have cancer. Breast reconstruction can be performed in many cases post mastectomy.
Sentinel Lymph Node Biopsy
Breast cancer is a disease which can spread to the lymph nodes under your arm. The breast surgeon performs a sentinel biopsy to identify those patients who have cancer in their nodes and distinguish them from patients who do not have cancer in their nodes
Complete removal of all the nodes (axillary dissection) is performed in patients with a positive sentinel node biopsy. Axillary dissection can carry a 10 % chance of developing swelling of the arm (lymphedema) which can be very severe in some cases.
Nodal disease is essential in planning treatment such as chemotherapy and radiotherapy. Node positive patients can be treated differently from those who are node negative. It is also useful to know if a patient has cancer in the nodes prior to considering breast reconstruction after mastectomy.
The sentinel node procedure involves injecting blue dye and a radioactive tracer close to the nipple region at the time of surgery. The dye and tracer will then travel from the nipple region to the axilla and mimic the path of cancer cells to particular nodes. At the time of surgery the surgeon will make a horizontal incision under the axilla. After careful dissection the area of the axilla containing the nodes is reached. A probe is used to detect the tracer in any nodes and inspection is carried out to see if any blue nodes are found. All hot and blue nodes are removed and sent to pathology.
Axillary Lymph Node Dissection
Breast cancer can spread to the lymph nodes under the arm. This may be visible on imaging such as a mammogram, ultrasound, MRI or a PET scan. All abnormal nodes on imaging are biopsied if possible by either fine needle aspirate or a core biopsy under local anesthesia to confirm the diagnosis. Nodes can appear normal on imaging but actually contain disease so all breast cancer patients with invasive disease will have a nodal procedure at time of surgery.
If your breast cancer has spread to the nodes it is important that you have adequate treatment for this area which may involve surgery, chemotherapy and radiotherapy.
An axillary dissection is the surgical treatment for node positive disease. Patients vary in their total number of nodes in the axilla, but all are removed. An axillary dissection usually involves a separate incision under the arm. After the nodes are removed a drain is placed in the cavity.
Post procedure there can be side effects after the complete removal of all the axillary nodes. Less than 10 % of women who have this procedure develop arm swelling to some degree. Of the 10% that do get arm swelling only about 1% will get extreme arm swelling. As a result 1 out of 100 women who have an axillary dissection will have significant arm swelling (lymphedema).
All patients who have an axillary dissection will be referred to a lymphedema specialist to help prevent or alleviate symptoms.
Following an axillary dissection it is important that precautions are taken to avoid an infection in the affected arm. This involves not having procedures or injections on this side.
The lymphedema specialist will provide all the information and exercises needed post axillary dissection to help with any problems that may develop. Lymphedema can develop days, weeks, months or even years after surgery.
A medical oncologist is an internal medicine physician who specializes in cancer treatment.
The medical oncologist is responsible for administering chemotherapy or oral anti-hormone drugs.
If a cancer is made up solely of non- invasive cancer ie DCIS then the patient will not require chemotherapy. DCIS does not escape the ducts or travel to the nodes or around the body and therefore no systemic treatment is necessary. If a breast cancer has an invasive component then the patient may require chemotherapy.
Chemotherapy is not given in all cases of breast cancer. Many factors are taken into consideration before chemotherapy is recommended. Large, aggressive and metastatic breast cancers are usually treated with chemotherapy in addition to other treatments.
In some cases, chemotherapy can be given before surgery in order to shrink the size of the tumor to make breast conserving surgery more straightforward. All patients with Herceptin positive invasive cancers will be recommended to take the Herceptin drug. This is always given in combination with a chemotherapy regime.
The majority of breast cancers are hormone sensitive. This means that they will grow if stimulated by estrogen. Part of the treatment of hormone sensitive breast cancers is to block circulating estrogen in the body. Tamoxifen and the aromatase inhibitors are drugs used for this purpose. All patients with DCIS and invasive cancers are recommended to take anti- hormone blocking pills for 5 years if their cancer is found to be hormone sensitive.
The course of oral anti-hormonal drugs is usually 5 years although the benefits can last for many years after.
Oncotype Dx is a diagnostic test that helps identify which women with early stage, estrogen receptor-positive (ER+) and lymph node negative breast cancer are more likely to benefit from adding chemotherapy to their hormonal treatment. The test also assesses the likelihood that a woman’s breast cancer will return. If the pathology from a core biopsy or surgery reveals that node positive disease or carry amplification of the Herceptin Receptor then this test is not performed as it is likely that your medical oncologist will advocate chemotherapy anyway.
The Oncotype DX test results also provide additional information, such as the activity levels of the estrogen, progesterone and HER 2 receptors in your tumor, to help guide your treatment.
What the test measures
The Oncotype DX test measures the activity of different genes in a woman’s breast tumor tissue
How the test is performed
Oncotype DX is performed on a small amount of tumor tissue that was removed during your surgery.
What you will learn
The report contains the Recurrence Score result, which is a number between 0 and 100.
- women with lower Recurrence Scores have a lower risk that their cancer will return. These women also have a cancer that is less likely to benefit from chemotherapy. It is important to note that a lower Recurrence Score does not mean that there is no chance that a woman’s breast cancer will return.
- women with a higher Recurrence Score have a stronger chance that their breast cancer will return. At the same time, these women may also gain a large benefit from chemotherapy. A higher Recurrence Score does not mean that a woman’s breast cancer will definitely return.
Radiation is a special type of energy carried by waves or a stream of particles. It can come from radioactive substances and special machines. There are many different levels of radiation energy, such as radiation from the sun or radiation used to make a chest x ray or a mammogram. When radiation energy is used at high levels it can treat cancer and other illnesses. The use of high energy rays or particles to treat a disease is called radiation therapy.
Cancer is a tumor or an overgrowth of abnormal cells. Their ability to multiply without limits, grow quickly and invade surrounding normal tissues making cancer cells different from normal cells. Radiation, used at high doses, causes changes in the cancer cell that stops the cell’s ability to multiply and eventually kills the cancer cell.
After lumpectomy radiation is always recommended. After mastectomy there are certain indications for recommending radiotherapy (cancers greater than 5cm, node positive and or chest wall involvement).