The treatment is planned multidisciplinary
Specialists of general surgery, radiology, pathology, medical oncology and radiation oncology are working together and in cooperation using a multidisciplinary approach in the planning of treatment of breast cancer. The specialist who evaluates the patient first is usually a surgeon. It is also important that psychologists and psychiatrists evaluate the patient before and after the treatment.
In which situations is surgery performed?
The first choice in breast cancers caught at the early stage is surgery. In the surgical method, cancerous tumor is excised either from the breast tissue or around it clearly or the whole breast is taken. Also to understand whether the tumor spread to the armpit or not, some lymph nodes are excised. By performing surgical interventions, first the stage of disease is detected and the patient’s additional therapy requirements (radiation, hormone, chemotherapy) are determined.
Today, excellent results in a lot of patients can be obtained through developments in surgical treatment and improvements in additional treatments.
Breast protective surgery
Patients with breast cancer are being lost due to systemic recurrence, or in other words spread (metastasis), not recurrences in the breast. In this context, removing tissue with a tumor by way of breast protective surgery in suitable cases with single tumor focus is being preferred instead of taking of whole breast. Tumor tissue is excised with about 1-2 cm normal breast tissue around the tumor in breast protective surgery (large excision, tumorectomy, lumpectomy).
Other techniques based on larger excisions of that region in the breast are called “quadrantectomy” or “partial mastectomy”.
As for lumps being thought as non-palpable and malign and marked by wire through mammography or ultrasound are filmed after excision by wire guided or ROLL (Radionuclide-Guided Occult Lesion Localisation) techniques and are controlled whether they are excised or not.
Operations in which the whole breast is taken (Mastectomy)
Mastectomy is a method applied in situations that breast protective surgery is not suitable. While it was common in the past, today mastectomy is preferred for patients with tumor unsuitable for the breast protective surgery, with a large diameter and/or showing spread distribution in the breast (multi focal tumors). Again, according to patient’s situation modified radical mastectomy, or in other words excising the whole breast and a big part of the axillary lymph nodes can be considered in this case. Due to excision of a big part of the axillary lymph nodes some complaints like swelling in the arm, numbness, tingling may be seen in some patients.
- B) Surgical interventions to evaluate axillary lymph nodes
Breast cancer spreads mostly to axillary lymph nodes. In the past, excision of the whole axillary lymph nodes was preferred to detect the stage of disease, to determine the involvement in axillary lymph nodes and provide local control (axillary disection). But researchers focused on the pursuit of another method because of complaints of side effects like swelling in arms (lymphedema), shoulder restriction and deformation, low strength and numbness in arms. In recent years, “Sentinel Lymph Node Biopsy Technique”, a method of excision of the most possible lymph nodes was improved due to being able to find single tumor cells.
How is Sentinal Lymph Node Biopsy Technique performed?
In this technique, a radioactive substance like 99mTc is injected into the breast with the tumor before surgery. The lymph node or nodes (sentinel lymph node) are excised by a radioactive substance detector or counter tool called gamma probe after lymphoscintigraphy, monitored either in the afternoon one day before the operation or in the morning of operation day and sent to pathology to be analyzed during surgery. A blue stain injection can also be into administered into the breast with the tumor during the operation. In this case, blue colored lymph nodes can be excised as sentinel lymph node by finding the blue colored lymph duct. It is then sent to pathology during the operation. If the sentinel lymph node are involved, all axillary lymph nodes will be excised. If it is found negative during operation, it is left as is. Thus, side effects like lymph edema, shoulder restriction or numbness in arm are seen in fewer patients compared to just sentinel lymph node biopsy. These sentinel lymph nodes are treated by special processes and sections of negative patients are subject to special stains. Thus, if a minimal involvement is determined in the lymph nodes, the patient should be operated a second time as required and supplemental axillary dissection is performed, in other words, whole lymph nodes are excised.
Breast restoration (Breast reconstruction)
Breast restoration is performed to restore the natural form of the breast after cancer. In this context breast restoration is not a cosmetic surgery but a restoration (reconstruction), in other words, it should be seen as replacement of a lost limb due to disease. Through new improvements in medical science, surgeons can now generate a lifelike breast. Plastic and reconstructive surgery specialists are also found in the treatment team of breast cancer. These specialists perform operations to transform the breast naturally if required.
What are the benefits of breast reconstruction?
Psychologically, breast loss influences a lot of women negatively. The result of a breast reconstruction operation can be like a new life for most patients. The sexual and familial lives of these patients gets better. Furthermore, a stronger spiritual state can help patients to cope with the disease.
Which stages are there in breast reconstruction?
Breast reconstruction has 3 basic stages. These are; generation of breast tissue, reconstruction of nipple and areola, creating symmetry between breasts.
I – Regeneration of Breast Tissue
Regeneration of removed breasts can be done in two ways:
1- Breast prostheses,
2- Patient’s own tissue (autogenous tissue).
A lot of factors like patient’s general health, age, body features, characteristics of mastectomy operation, whether radiotherapy was administered or not, status of the other breast, patient’s preferences, surgical experience and skills of plastic surgeon play a role in the choice of the operation method and reconstruction time.
1 – Breast prostheses
Breast prostheses come in two types: gel-filled or serum physiologic-filled (salt water). In both prostheses the exterior surface consists of a silicon wall. According to patient’s status, reconstruction can be done by placing the prosthesis directly, or with help of a balloon called “tissue expander”, by placing it to expand soft tissue in the chest wall and then removing it so that the permanent breast prosthesis can be put in place. This method is preferred especially in late reconstructions.
2 – Breast reconstruction by patient’s own tissues (autogenous tissues).
Breast reconstructions by autogenous tissue are more complex and require surgical operations by experienced specialists.
Skin and subcutaneous fat tissue is split completely from the abdomen, dorsum or hip region where they are connected by feeder veins. The plastic surgeon has to be experienced in microsurgery for this operation because stitching of thin veins is only possible under a microscope.
II – Reconstruction of nipple and areola
Sometimes a few operations may be required to obtain a natural breast image. The first operation, to regenerate tissue is the most difficult one. Secondary operations such as regeneration of the nipple and areola (area around the nipple) are easier and these are done using local anesthesia. Nipple is made from tissue taken from the area. Skin taken from the other nipple or groin may be used to cover up the areola.