Breast Conservation Surgeries in the Setting of Breast Cancer
The majority of breast cancers diagnosed in the United States are treated with Breast Conservation as most women prefer to avoid mastectomy if deemed safe for their unique situation.
When you elect to proceed with Breast Conservation, you likely have been diagnosed with breast cancer based on a fine needle aspiration of a palpable breast mass or core needle biopsy as guided by ultra sound, mammogram or MRI. Once the cancer diagnosis is made from a small biopsy, the larger abnormal area of the breast is then surgically removed and defined as a lumpectomy while the healthy regions of the breast are left unharmed. The breast tissue removed during lumpectomy is evaluated by our board-certified Pathologists to evaluate the type of cancer that may be present. The margins of the lumpectomy are examined to ensure that all of the cancer has been removed. You may additionally undergo removal of several lymph nodes at the time of your lumpectomy to determine if cancer has moved into the lymph nodes under your arm. Only a small number of lymph nodes are removed as a means to reduce your risk of lymphedema or swelling of the arm and hand after surgery. This limited removal of lymph nodes is known as a sentinel lymph node biopsy and is guided by an injected radioactive isotope and/or blue dye. Special testing is performed on the breast tissue and lymph nodes removed in the operating room to understand the unique nature of a given cancer. Some test results return within days of surgery while others may require up to 3 weeks (OncotypeTM, MammoprintTM). Once the lumpectomy tissue and lymph node testing have been reviewed, further treatment options for chemotherapy and/or hormonal therapy can be explored by your cancer care team.
If cancer cells are identified at the cut edge of the lumpectomy (“ink on tumor”), the margin is referred to as a “positive”. Cancer cells identified in excised lymph nodes are additionally referred to as “positive” and are reported as the number of positive nodes relative to the number of negative nodes. Should review of your lumpectomy margins or lymph nodes return “positive”, you may require additional surgery to ensure that the cancer can be more completely removed.
Patients electing to proceed with breast conservation undergo whole breast radiation therapy to complete their cancer care after lumpectomy. Whole breast radiation is given to lumpectomy patients to reduce the chances that cancer will recur in the preserved breast or in the remaining lymph nodes under your arm. Whole breast radiation therapy most commonly occurs after chemotherapy if required. Radiation is delivered over 6 weeks under the direction of a Radiation Oncologist from your local medical community. You will be offered education regarding skin care and proactive lymphedema care at our center throughout all of your ongoing cancer care after lumpectomy.
A few patients with DCIS (non-invasive breast cancer) with advanced age may be candidates for lumpectomy without whole breast radiation. Cases as these do require careful review and execution as acquired breast deformities as these are not candidates for reconstruction with fat grafting.
Some patients with large breasts may elect to proceed with simultaneous breast reduction in the setting of breast conservation. Others benefit from the involvement from a board-certified plastic surgeon to ensure a superior level of onco-plastic care after lumpectomy and before starting whole breast radiation therapy. Large lumpectomy defects not addressed by an experienced breast reconstructive surgeon before radiation therapy may limit your final cosmetic outcome. You may require a contralateral balancing breast reduction or breast lift to attain symmetry of your breasts after cancer care. We will be able to provide you with this information at the time of your initial consultation.
Contra-lateral surgical procedures for breast symmetry are protected by the Women’s Health and Cancer Rights Act (WHCRA) of 1998 (www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/whcra_factsheet.html).
Patients diagnosed with breast cancer may have undergone prior cosmetic breast augmentation. Most experts agree, radiation of breast implants has been associated with an increased risk of capsular contracture, infection, asymmetry and pain. Dr. Marga will be able to advise you as to your personal risk of an implant related complication in the setting of breast conservation at the time of your initial consultation.
Historically, patients with larger breast cancers have not been offered breast conservation therapy. The definition of “larger” now relates to the size of the defined radiographic area of concern relative to the size of the involved breast. Location of the tumor may also affect treatment recommendations as skin or chest wall involvement may necessitate a more extensive surgical procedure. Patients may be treated with chemotherapy before surgery to shrink the size of the tumor therefore making more patients candidates for breast conservation. Chemotherapy given before definitive breast cancer surgery is referred to as neo-adjuvant whereby chemotherapy given after the surgical removal of a cancer is simply adjuvant. Neo-adjuvant chemotherapy patients are followed by serial ultra sound examinations and repeat MRI just prior to surgery. All neo-adjuvant patients are offered education related to all onco-plastic procedures for lumpectomy in addition to all forms of breast reconstruction should they require mastectomy to treat their cancer safely.
Dr. Marga is pleased to evaluate your unique breast concerns to include your radiographic evaluations and physical examination to define the most appropriate onco-plastic surgical outcome with a focus on oncologic safety and superior cosmesis after cancer care.