Surgical Management of Breast Cancer

 By Consultant Surgeon Prof. G. Sivakumar

Breast cancer afflicts women of all ages. The crux of treatment is in the early diagnosis and appropriate treatment. Stage I and II are treated by curative surgery. Curative surgery in early breast cancer removes all cancer-bearing tissues.

Stage III and IV are a fairly advanced stage of the disease. Palliative treatment is done for stage III and IV cancers. Women seek surgical help late. The goal in cancer management is early identification. Breast cancer screening programmes identify cancer even before it is palpable. High-risk patients need annual mammography, annual physical examination and monthly breast self-examination.

The primary treatment of breast cancer is Surgery. Micrometastasis after the primary curative surgery is treated with adjuvant chemotherapy. Adjuvant surgical procedures like removing hormone secreting ovaries in selected premenopausal women with cancer breast are also useful. In advanced breast cancers, surgical debulking is done. In women with bone fractures due to secondaries in the bone surgery is done to fix the bone.

Surgery for non- palpable tumours:

Tumors that are not felt during a clinical examination are called non-palpable tumours. Non-palpable tumours are diagnosed by mammography and sono mammography. The suspicious lesions are localized by stereotactic methods and marked by hook wires.

 The tissues around the suspicious area are excised and sent for radiological and pathological confirmation. Mastectomy is not done. Newer methods can achieve removal through a special type of needles called Mammotome.

The five-year survival rate of these patients is about 95 %. Adjuvant radiation and removal of axillary glands are done. Like any curative surgery, adjuvant chemotherapy is given to all these patients.

Also read: What women need to know about breast cancer 

Surgery for Stage I and II

During the early twentieth century, a radical surgical treatment was advised. ‘Radical Mastectomy’ was practised by Halted of Johns Hopkins hospital, Baltimore and this was the standard treatment for over sixty years. More radical treatment methods were gradually abandoned because of increased surgical morbidity.

 Radical mastectomy includes removal of the breast, axillary nodes and the pectoral muscles. Removal of pectoral muscle does produce a significant cosmetic loss. Modified procedures that preserve muscles are found to be very effective and are practised now.

Axillary gland removal is important. Involvement of these glands indicates a poor prognosis. Sentinel node biopsy is a new technique that helps in identifying the involved axillary glands. Hence axillary dissection is avoided in situations when sentinel biopsy is negative for cancer cells.

Breast conservation is possible in this group of patients.

Only the tissue around the cancerous lump is excised and radiation is given to rest of the breast. Significant advances in adjuvant chemotherapy and hormonal therapy has helped in achieving very good disease-free period.

Surgical removal of both ovaries along with breast surgery is a useful adjuvant that is done in selected premenopausal patients with hormone-responsive tumours.

Also read: Basic facts on Breast cancer

Surgery for Stage III and IV

Neoadjuvant therapy is usually given for this group of patients. First chemotherapy is given and patients are downstaged. Surgery is done to remove the tumour. Postoperatively radiation and chemotherapy is given. This protocol achieves good long-term survival. Big ulcerated masses in the breast are removed to improve the quality of life.

Surgical debulking helps in reducing the tumour cells and it is also called cytoreductive surgery. Metastasis to the bone produces severe pain and fractures can occur in the weight-bearing bones. Surgery is done to internally fix these fractures. Metastasis to lung produces pleural effusion. A minor surgical procedure may be required to aspirate this effusion.

Pic courtesy: NPR