The Surgical Treatment of Breast Cancer
When breast cancer is first diagnosed it is important to evaluate the extent of the problem both in the breast and elsewhere. This is called "staging". It involves the assessment of the disease in the three general areas, which represent steps in the progression of breast cancer.
Step 1 = where the cancer started in the breast. Staging includes an assessment of how advanced this primary site is. In staging terminology this is abbreviated "T" for Tumour.
Step 2 = the lymph nodes in the armpit (termed axilla), Staging aims to measure whether or not the cancer has spread here. Abbreviated "N" for Nodes.
Step 3 = the rest of the body. Breast cancer can spread to any other areas but the usual places are the bones, lungs and the liver. Abbreviated "M" for metastatic spread.
Following staging it is possible to summarise the cancer in terms of the T, N & M categories and these form the basis of decisions on future treatment and prognosis.
Surgical Treatment of Breast Cancer
Surgery remains the most effective way of getting rid of primary breast cancer quickly and completely. For most patients therefore, the first part of the treatment for primary breast cancer is an operation. The aim of the surgery is to remove all of the cancer cells from the breast and from the lymph nodes in the armpit (axilla), and by doing this to prevent the cancer coming back in either of these areas. Not only does this treat the primary site of the cancer but the tissue that is removed can be examined in the laboratory to give important information on the size, type and behaviour of the cancer cells. This information is the most important guide in determining which additional treatments maybe used following surgery. In particular the presence or absence of cancer cells in the removed lymph nodes shows how readily the cancer is able to spread in that particular individual.
Modified Radical Mastectomy
A modified radical mastectomy is an operation to remove the whole of the breast and all of the lymph nodes in the armpit that serve the breast. This type of surgery effectively and reliably removes all of the primary breast cancer and any cancer cells that may have spread to the lymph nodes. Even in cases where the cancer is particularly big, or in more complicated situations where there is more than one area of cancer in the breast, a modified radical mastectomy succeeds in achieving the first aim of breast cancer treatment by removing all of the cancerous tissue. For this reason modified radical mastectomy is one of the operations that is considered in any patient who has a new diagnosis of primary breast cancer. Most patients want to avoid the loss of the whole breast and opt for other equally effective operations, but modified radical mastectomy remains a very good way of treating breast cancer and in some women has significant advantages over other types of surgery.
Breast Conserving Surgery - Wide Local Excision of Tumour
A wide local excision of the breast tumour and axillary clearance to remove the lymph nodes is the alternative to mastectomy, and because the breast is not removed it is described as breast conserving surgery. The aim of the wide local excision is to remove all of primary cancer lump from the breast. It is necessary for a narrow rim of normal tissue surrounding the lump, to be included in the wide local excision. This provides a margin of safety that helps to ensure that no cancer cells are left behind in the conserved breast. Experience has, however, shown that even if the tumour is removed with an adequate margin small numbers of cancer cells often remain and radiotherapy is therefore required to complete the treatment.
Breast conserving surgery is therefore made-up of three essential parts namely; wide local excision, axillary clearance (removal of lymph nodes) and post-operative radiotherapy. As long as all these three parts are included, breast conserving treatment is just as good as a mastectomy at achieving a cure in cases of breast cancer.
Surgery to the Axillary Lymph Nodes
There are two important reasons why women with breast cancer require surgery to remove or sample the lymph nodes in the armpit (axilla). Firstly, if breast cancer starts to spread the first place that it spreads to is usually the armpit and if the lymph nodes are not removed, or treated with radiation therapy, there is a high chance of the cancer coming back under the arm. Removal of the axillary lymph nodes is a very effective way of preventing this happening and it is very rare to get further breast cancer recurrence in the armpit after this type of surgery.
Sentinel Node Biopsy
Sentinel node biopsy is a radically new way of overcoming the problem of breast cancer lymph node surgery. This technique results in the removal of a few axillary lymph nodes which when analysed give an accurate representation of whether all the lymph nodes are free from cancer or whether there is lymph node involvement and further surgery is required.
Side Effects of Breast Surgery;
The main problem that often occurs in the few weeks following surgery to remove the lymph nodes is an accumulation of fluid (lymph) in the wound. Any wound produces a little fluid but there is much more accumulation following surgical removal of the lymph nodes. For this reason many surgeons use small tube drains to remove the worst of the fluid over the first few days following surgery. The amount of lymph fluid produced each day gradually decreases and the wound drain can be removed after a few days. Some lymph fluid still accumulates and patients can become aware of swelling of the wound under the arm. There may be a visible swelling, however accumulation of fluid is harmless and cannot lead to any serious problems. If the fluid accumulation becomes uncomfortable it is a simple procedure to remove the build up of fluid with a needle. The skin around the wound is usually numb and this does not hurt.
A few days after surgery some women notice a tight, uncomfortable cord underneath the skin of the arm. This cord is caused by thrombosis of a small vein and extends from the armpit down the inner surface of the upper arm to the elbow and sometimes even into the forearm. This is a temporary side effect and generally the cord softens and disappears after about 6 weeks. Gentle stretching exercises may help to relieve the discomfort.
Numbness in the arm
During surgery to remove the axillary lymph nodes two skin nerves called the third and second intercostals brachial nerves are encountered. These nerves supply the skin of the inner surface of the upper arm. During surgery it may not be possible to avoid cutting one or other of these nerves. Even if the nerves are not cut they are always bruised, therefore, following surgery most women will notice that there is some numbness in the armpit and down the inside of the arm. The nerves take a long time to repair themselves and the skin numbness will always take some months to fade. In about 25% of patients the numbness disappears entirely but in most patients (50%) sensation never returns entirely to normal. In the remaining 25% of women the nerves do not seem to repair at all.
During surgery, there are no tendons, muscles or nerves to muscles that are cut and the inevitable restriction in arm movement is only due to the discomfort of having recent surgery to the armpit. If not used, the shoulder joint can stiffen very rapidly and it is very important, therefore, to perform regular arm exercises to regain fully shoulder movement. Most hospitals will arrange for the physiotherapist to visit prior to leaving hospital.
Lymphoedema of the Arm
For most women, removing all of the lymph nodes from under the arm makes no difference to the arm at all. In around 10% of women, however, fluid drainage from the arm is affected and the arm swells as a result. This swelling is never very severe but is enough to make the arm feel heavier and the forearm and hand may be puffy. This swelling is termed lymphoedema.
Infection of the Arm or Breast
Infections of the arm or breast are not a common occurance, but can start rapidly with the appearance of a red patch of skin which is sore and warm. This type of infection is called cellulitis and may be associated with a fever and other flu like symptoms. Often the infection in the arm starts with an injury, perhaps a dirty cut or graze, to the hand. Breast cellulitis mainly occurs in a few months following surgery and probably starts off in the surgical wound. Cellulitis in the arm or breast is treated with the correct antibiotics. Infection usually responds rapidly to antibiotic tablets and it is sensible to start a course of these at the earliest signs of infection.
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