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Revlon/UCLA Breast Center: Westwood Location, 200 UCLA Medical Plaza, Los Angeles

Breast Cancer Management

In this section, we will discuss the statistics and the most common types of breast cancer, diagnosis, staging of breast cancer and the concept of multidisciplinary treatment in breast cancer. The role of surgery in breast cancer treatment and breast reconstruction are the focus of this update. Breast cancer is the most serious breast disease and also the most common female cancer. When found early, the chance of being cured after conventional treatment is excellent. This section is devoted to help women understand what breast cancer is and how to seek treatment after the diagnosis of breast cancer. In the next several updates, we will continue the discussion on topics of breast cancer staging and its implication in treatment.


  • What is the incidence (number of new cases) of invasive breast cancer in American women and men in 2007? What is the annual incidence of DCIS (ductal carcinoma in situ) in American women in recent years?
    In 2007, it was estimated that 178,480 new cases of invasive breast cancer were diagnosed among women, and an additional 2,030 cases were diagnosed in men. The number of new cases of invasive breast cancer is lower than that of 2005. The small decrease may result from a real drop in breast cancer.

    In contrast to invasive breast cancer being a real cancer, ductal carcinoma in situ (DCIS) is a precancerous condition. The incidence of DCIS increased significantly in the 80s and 90s in the United States. The increased number of DCIS cases is attributed largely to the routine use of screening mammography. Although the increase is across all age groups, the incidence rates in women age 50 or older have been stable since 2000. This may be due to a declined use of screening mammography in recent years.

    Approximately 80% of all in situ carcinomas found between 2000 and 2004 were of ductal type. The majority of these were found by mammography alone, before reaching the size that can be felt by breast examination.

    The current lifetime risk of developing breast cancer in the American woman is approximately 1 in every 8 (12.3%) compared to 1 in 11 in the 1970s. The reasons for increased incidence are multifactorial; longer life expectancy, postmenopausal hormonal replacement therapy and obesity after menopause may all contribute to the observed increase of breast cancer cases.

  • Does age affect one's chance of getting breast cancer?
    Second to being a female, aging increases one's risk for breast cancer development. Available data between 2000 and 2004 shows that incidence and death rates of breast cancer increase with age with 95% of all new cases and 97% of breast cancer deaths occurring in women aged 40 and older. Women aged 20-24 rarely develop breast cancer and women of 75-79 years of age have the highest incidence. After age 80, the incidence decreases, which may reflect fewer receiving screening.

    Among women younger than 50 years of age, the incidence rates have not changed much. Among older women, the incidence rates started to rise in the early 1980s and continued at a slower rate between 1986 and 2001 and have decreased in recent years.

  • Diagnostic studies for early breast cancer
    Breast cancer is most frequently detected by screening mammography or found on the breast examination. They are frequently confirmed by targeted breast ultrasound and, sometimes, breast MRI. The ultimate confirmation of breast cancer diagnosis for the suspicious findings is tissue-proven cancer either obtained by core needle or open surgical procedure. Ideally, a core biopsy for diagnosis before the surgery is preferred so the cancer surgery can be planned and discussed with the patient, including the extent of breast tissue that needs to be removed and the axillary lymph node surgery.

  • What are the studies used today for breast cancer diagnosis and staging?
    Whenever there is diagnosis of invasive cancer, it is necessary to measure the extent of the cancer, which is called staging. There are studies that are used for this purpose. The breast cancer stage is based on three parameters: the size of the tumor in the breast, the number of lymph nodes involved by the cancer and if there is disease present elsewhere in the body (distant metastasis). For staging breast cancer, some of the tests discussed may be indicated for your case. In some cases, all of the tests may be required. They may be done prior to surgery or after the operation, when more information about the size of the tumor and lymph node involvement becomes available. Patients diagnosed with large breast tumors and/or presenting with more than three positive lymph nodes or cancer invasion into the skin and chest wall or inflammatory breast cancer (even without other significant symptoms) should consider the scans mentioned below for proper staging. Sometimes one or more studies will be considered in patients with an early stage disease. This will be triggered by patient's complaint or abnormal blood laboratory tests. The most common sites of metastatic (spread) breast cancer are the bones, lungs, liver and brain, in an isolated form or multiple sites. Other sites such as adrenal, intestines, pleura and soft tissues may also be involved.

                 a) Blood work: the blood tests will give information about liver function and bones as well as tumor burden, which may 
                     then lead to targeted imaging studies.

                 b) Chest X-ray: is a standard radiological study to evaluate lungs before any major surgery and to rule out cancer
                     spread to the lungs.

                 c) Chest, abdomen and pelvis computed tomography (CT scan): this type of test is a quite sophisticated x-ray 
                     that studies the body in great detail by a sequence of many pictures. Ideally, intravenous contrast is injected 
                     to better visualize the potential tumor mass elsewhere in the body. Sometimes, patients might be asked to
                     also swallow a contrast solution if the abdomen and pelvis are included in the study. When used to stage breast
                     cancer, the areas of major interests are the lungs and liver, but other visualized areas such as ribs, spine, pelvic
                     bones, lymph nodes in the chest, abdomen, adrenal glands are also reviewed. When a suspicious finding is in
                     question, further tests such as a dedicated MRI, focusing on the area in question, or biopsy may be necessary
                     to assess the nature of it.

                d) Positron emission tomography (PET): this scan is performed with the injection of a radioactive tracer labeled
                    sugar (glucose). An increase of the uptake at any area in the body indicates cells that are metabolically active
                    and consuming a large amount of glucose. The combination of PET/CT allows assessing the functional
                    abnormality and the precise anatomical location as well as the size of the abnormality all at the same time, which
                    improves interpretation and the accuracy prediction. This test is especially useful when the chance of having 
                    metastasis is high. However, the PET/CT scan does not adequately evaluate the primary tumor in the breast
                    or the lymph nodes in the axilla. For this reason, mammography, breast ultrasound and MRI remain to be 
                    the gold standard breast imaging tests.

                e) Bone scan: bone is the most common site of breast cancer spread. In cases of advanced stages or when there are
                    symptoms suggestive of  metastatic bone disease, a bone scan can specifically review the entire skeleton. To do
                    this test, a radioactive material is injected through a vein which preferentially accumulates in areas with bone
                    destruction and new bone formation. Other conditions such as arthritis, injuries or infection may also cause an
                    abnormal bone scan. When the finding is equivocal it might be necessary to add other studies such as x-ray,
                    MRI or even a biopsy to further clarify the finding.

                f) Brains scans: when brain involvement by the breast cancer is suspected, which is usually prompted by symptoms, 
                   brain evaluation by CT or MRI are helpful. These tests are performed similarly as for the analysis of other
                   anatomical sites and can be very helpful for making diagnosis and planning for treatment as well as for follow-up
                   of brain metastases.

  • How to choose specialists in breast cancer care?
    There are many specialists involved in advising women about their breast cancer treatment and care. They include a breast surgeon, plastic surgeon, medical oncologist, radiation oncologist, cancer geneticist, psychosocial counselor and integrative medicine professional. Once a patient is diagnosed with breast cancer, she is likely to see a team of specialists to determine the best treatment for her. Each of the specialists will be focusing on a different aspect of the treatment.

    For most, the first step is to see a surgeon who specializes in breast diseases. The patient should always have her imaging films, slides and reports available, at the time of their consultation. A thorough history and physical examination are important parts of the consultation as not all the critical information is included in the tests reports. It is at this visit that the findings will be reviewed, discussed, the therapeutic goal will be discussed and the course of action will be determined. This includes any other tests that may be necessary for treatment planning, the options of different types of surgery and what the following treatments may be. While each case is unique, the usual order of the treatment is:

                   1) surgery,
                   2) meeting with the medical oncologist to discuss the need for chemotherapy,
                   3) meeting with the radiation oncologist to discuss the need for radiation,
                   4) hormonal therapy after the radiation if the tumor is hormone receptor positive.

    While most will receive all of the above treatments, some patients will only need certain types of treatment. In the cases of large breast cancer, chemotherapy may be recommended before surgery. In these situations, the medical oncologist is involved at the beginning of the treatment planning. The medical oncologists are the doctors who discuss different chemotherapy regimens and recommend the appropriate drugs, including hormonal therapy. If mastectomy with immediate reconstruction is being considered, meeting a plastic surgeon at the beginning of the treatment planning is recommended. The plastic surgeon will discuss reconstruction options, optimal timing of reconstruction and make a recommendation regarding the reconstruction. Radiation commonly happens after surgery and chemotherapy if chemotherapy is needed or after surgery when chemotherapy is not needed. Patients who had a mastectomy frequently do not require radiation if the tumor was smaller than 5 cm, without skin and/or chest wall involvement, margins are clear and lymph nodes are not involved. If the tumor was hormone receptor positive, additional hormone therapy is frequently advised. The appropriate drugs such as tamoxifen, aromatase inhibitors (AI) medications and others will be discussed and recommended by a medical oncologist.

    Depending on the identified patient's risk factors, particularly in the presence of a strong family history for breast and/or ovarian cancer and young age, meeting with a cancer geneticist should also be part of the initial evaluation. A blood test called BRCA gene test may be recommended as a result of this meeting. If a BRCA gene mutation is found, this may change one's decision regarding the type of breast cancer surgery and in managing the unaffected breast and ovaries. It also provides valuable information to other family members for their risk of developing breast cancer.

    After treatment is complete, the patient will be followed by her treating physicians periodically. Each specialist may have his or her own protocol, but frequently, women will be followed by her breast surgeon, the radiation oncologist and the medical oncologist. Patient will require a diagnostic mammography every six months during the first 2-3 years after the lumpectomy surgery and once-a-year mammography for the unaffected breast. If there is no new abnormality detected, she will then resume yearly mammography follow-up of both breasts.

    At any time after a cancer diagnosis, not only patients but family and/or care givers might need some form of psychosocial support. Specialized centers, such as the Revlon/UCLA Breast Center, offer a team of specialists (including internal medicine doctors with focus on nutrition, life style, complementary medicine, psychologists), patient support groups, volunteers, and a variety of activities which can help patients to cope and better manage many aspects of life that are affected by breast cancer diagnosis and treatment.

  • Why and when to get a second opinion
    There are reasons why a patient may want to seek a second opinion. The diagnosis of cancer is serious and the patient needs to feel fully confident about the treatment plan. A second opinion meeting may help patients to gain a deeper understanding of the problem and make a better choice in selecting their treatment. While the second opinion may agree with the first one, it may boost the patient's confidence in making the decision. Patients need to also prepare to hear and deal with conflicting opinions. Furthermore, breast cancer treatment involves not only dealing with the cancer growing in the breast but also with the cosmetic appearance of the breast after treatment, the chances of disease spreading to elsewhere in the body, the genetic contribution of family history to one's breast cancer development, the overall health and emotional state of the patient and her family members. Centers, such as the Revlon/UCLA Breast Center, have programs involving a team of specialists evaluating breast cancer patients during the same second opinion consultation. This specific second opinion program is called Multidisciplinary Clinic, where a thorough assessment of each patient's case is performed by a team of experts, including a breast surgeon, a plastic surgeon, a medical oncologist, a radiation oncologist, a breast radiologist, a pathologist and a member of the psychosocial support team as well as a cancer geneticist. Similar programs are available in different centers. The goal is to provide the patient with a complete evaluation of all their studies and formulate a comprehensive treatment plan by a panel of experts from all specialties. Too many second opinions can create confusion and delay the needed treatment.

  • Choosing the right surgical treatment for an operable breast cancer
    Decision in regards to what kind of surgical treatment is the most appropriate one for any given patient is influenced by a variety of factors including size of the tumor in the breast, type of breast cancer, relationship between size of the tumor and the involved breast, patient's own preference, and history of radiation in the past. The most common options are lumpectomy versus mastectomy with or without reconstruction and lymph node staging procedure, either sentinel lymph node biopsy or axillary lymph node dissection.

    • Lumpectomy - also called partial mastectomy or wide excision, is aimed at removing the cancer lump with some grossly uninvolved surrounding tissue to warrant the removal of the cancer with clear margins. This type of procedure is also known as breast conservation surgery. The clear margins of the removed tumor need to be confirmed by microscopic examination by the pathologist. Lumpectomy is frequently used to treat isolated ductal carcinoma in situ (DCIS) and invasive cancers that are small in relation to the size of the breast. Sometimes, lumpectomy is not suitable for a patient with DCIS or invasive cancers if the size is too large for the involved breast dimensions or there is more than one cancer in the breast or cancer returns to the same breast after the initial treatment, patient is pregnant or patient's reluctance for the particular type of surgery. When lumpectomy is the chosen surgery, with very few exceptions, radiation therapy is part of the breast treatment.
    • Mastectomy - is a surgery to remove the breast. It has several varieties which define the extent of the removal. The subcutaneous mastectomy describes the procedure that removes all the breast tissue except the nipple areolar complex. To preserve the nipple areolar complex, some breast tissue is being preserved. As a result, subcutaneous mastectomy is not recommended for treating breast cancer. Simple mastectomy is the type of mastectomy that removes all breast tissue, including the excessive skin and nipple areolar complex. When this is done at the same time as the immediate reconstruction, the skin envelope is preserved, which is called skin sparing simple mastectomy. The simple mastectomy can be done in conjunction with sentinel lymph node biopsy. When the mastectomy is extended to include the removal of the armpit lymph nodes, the operation is called modified radical mastectomy (MRM). Rarely, the removal of the muscle behind the breast (pectoralis major) is necessary. When the pectoralis major muscle is removed in conjunction with the removal of the breast and the armpit lymph nodes, the surgery is called radical mastectomy (RM). Mastectomy and total lymph node removal are far less common operations today as the diagnosis of breast cancer is made earlier, allowing for breast conservation and lymph node biopsy in the majority of these women. Also, chemotherapy can be given before surgery to shrink the large tumor, allowing lumpectomy in some, even if it is not feasible at the beginning.
    • Sentinel lymph node biopsy (SLNB) - The main lymphatic drainage of the breast occurs in the axilla (armpit). When it spreads, the breast cancer travels to the axillary nodes. For patients who have no clinically suspicious nodes, removing the first station of the lymph nodes will enable the doctors to stage the lymph nodes and recommend the appropriate axillary treatment. This form of lymph node removal is called sentinel lymph node biopsy (SLNB). SLNB is typically recommended for patients with invasive breast cancer smaller than 5 cm (about 2 inches) in size without skin or chest wall involvement and the axilla is free of enlarged lymph nodes on the physical examination or suspicious lymph nodes on PET/CT scan or other imaging studies. This procedure has largely replaced the axillary lymph node dissection in properly selected patients because of fewer side effects with high accuracy to stage the nodal involvement. SLNB is not usually recommended in women with DCIS unless patient is undergoing mastectomy or there is a high likelihood of finding an invasive cancer based on imaging studies (mammography, ultrasound, MRI) or clinical breast examination. SLNB after neoadjuvant chemotherapy in women with T3 or T4 breast cancer, women with multicentric cancer, pregnant women and women with recurrent breast cancer after previous SLNB is not clear. There are two general approaches to identify the otherwise undistinguishable lymph nodes. The first one is to inject a small amount of radioisotope tagged tracer in the breast around the target cancer or under the nipple areolar complex, or in the overlying skin. The lymph nodes that contain the radioactive tracer are SLN and they can be found by a gamma probe during the surgery. A preoperative lymphoscintigraphy is also useful in gathering the information of the sites of SLN (i.e. in the axilla of the same side, along the internal mammary chain or in the other axilla). The second method used is the blue dye method and the dye is injected immediately before the surgery. The SLNs are blue in color and can be detected visually. Some surgeons will use one of the two methods for SLN mapping. Others will use both methods to remove both radioactive lymph nodes and blue lymph nodes. The number of SLNs varies from patient to patient with an average of approximately three for each procedure. In rare cases, the SLN is not detected even when both methods are used for SLN identification. Both blue dye and radioactive tracer are eliminated through the urinary and gastrointestinal tracts. During the first 24 hours after the surgery, the urine would be bluish-greenish in color and bowel movements tend to be greenish as well. The elimination of the radioisotope is not noticeable. One may develop an allergic reaction to the dye used with hives seen soon after the blue dye injection. Anaphylaxis to the dye is a more serious form of allergy but it occurs rarely. 
    • Axillary lymph node dissection (ALND) - this procedure refers to the surgery to remove the lymph nodes in the axilla. It is a surgery that is only recommended when: 1) breast tumor is > 5 cm or skin and/or chest wall are involved by cancer; 2) there are enlarged lymph nodes in the axilla on physical examination or suspicious lymph nodes seen on PET scan; 3) lymph node involvement proven by needle biopsy or SLN biopsy and 4) breast cancer recurs after previous SLN biopsy.

 

  • Types of reconstruction and timing
    Breast reconstruction is the surgery that rebuilds the breast after mastectomy. The specialist who does breast reconstruction is the plastic surgeon. As most women are interested in some type of reconstruction after the mastectomy surgery, meeting a plastic surgeon should be part of the treatment planning when mastectomy is being considered. A patient may elect to have either immediate or delayed reconstruction or not to have any reconstruction at all. A good symmetry of both breasts can be achieved with wearing a bra and most regular clothing, but the reconstructed breast will not have sensation.

    In regards to timing, the reconstruction can be done at the same time as the mastectomy (immediate reconstruction) or at a later date, after all treatment is completed (delayed reconstruction). This will largely depend on patient's choice and the goal of treatment. Becoming familiar with different types of reconstruction and being able to see pictures of the various forms of reconstructed breasts will help one's decision making. In the vast majority of the reconstruction cases, it involves more than one operation to achieve the optimal appearance. In some circumstances, surgery might be needed for the other breast to achieve the best symmetry of both breasts.

    The patient's overall health is very important when considering reconstruction as these operations are lengthy and require prolonged anesthesia time, particularly when involving a flap. Reconstructive surgeries increase the recovery time from a mastectomy and will differ greatly depending on the type of reconstructive surgery. Because of the complexity of reconstructive surgery and different considerations for the breast cancer treatment, some patients may be advised not to have breast reconstruction.

    Implants Saline and silicone are the two types of breast implants available for breast reconstruction. They come in different sizes and shapes. The plastic surgeons frequently show patients different types of implants and make recommendations. The silicone implants were avoided for some time as some suggested that certain immune system diseases might be caused by silicone implants. This has not been scientifically proven and the choice depends on patient's preference and doctor's considerations. The implants need to be monitored for ruptures especially when symptomatic. Micro-ruptures may not be obvious by most imaging studies and MRI may be the most sensitive technology for detection of this condition. While the salt water (saline) is absorbed by the body and eventually eliminated in case of rupture, the silicone leak can travel beyond the breast and be trapped in the lymph nodes or accumulate in the tissues elsewhere, causing inflammatory masses.

    In most cases, implant reconstruction starts with the placement of an expander behind the chest wall muscles (pectoralis and serratus muscles) and in front of the ribs. This device has different volume capacities to achieve different sizes of breasts and, over several weeks/months, the expander is inflated with saline, stretching the skin and creating a pocket under the muscle, until the desired volume is achieved. During a second procedure, the expanders are removed and replaced by an implant. Under certain circumstances, it is possible to place the implants immediately after the mastectomy. The last step of the reconstructive surgery is the nipple reconstruction which is followed by tattooing of the areola and reconstructed nipple.

    The implant reconstruction is a much simpler and shorter procedure, and it tends to heal quickly. The disadvantages are that the texture of the implants is different than the real breast and this is very noticeable to the patient, whose other breast does not have an implant. Another operation to replace the implants may be necessary as they expire. During the healing process, the body forms a thin layer of tissue around the implants and this can sometimes be hardened and contracted, producing discomfort and/or pain and excessively firm breasts. This process is also known as capsule contraction and is one of the main reasons why the breast implant is not recommended in patients who require breast radiation. Symptomatic capsule contraction may require surgery for correction.

    Flaps Tissue flap reconstruction refers to the use of patient's own tissues for breast reconstruction. The sources of the flaps include tummy, back, thighs or buttocks. The first two are the most common types which are going to be discussed here. Flap reconstruction is frequently chosen over the implant whenever radiation treatment is needed. Also flap provides a more natural looking, especially when the mastectomy is limited to one side.

    The TRAM flap (transverse rectus abdominis muscle) uses the tissue from the tummy to rebuild the breast. This is done with mobilization of skin, fat, blood vessels and the abdominal muscle to reach the breast site through a tunnel created underneath the skin. This technique is called pedicle TRAM flap. When blood vessels are divided from the lower abdomen and moved together with the flap to the breast site for reconstruction, they need to be reconnected to the blood vessels close to the breast to be rebuilt and this procedure is called free TRAM flap. The free flap requires an entire set of skills that involve the use of a microscope during the operation to connect the vessels attached to the flap to those in the breast area. The end result of the flap removal is a scar similar to a cesarean section, but much longer and a scar around the relocated belly button. The scar shape and extent of the reconstructed breast depend on the amount of skin that has to be removed during the mastectomy. Further procedures may be required to achieve symmetry between the two breasts. The breast contour is usually preserved and it is felt real because the tissue consistency is close to that of the breast.

    DIEP flap (deep inferior epigastric artery perforator) is a newer technique and is a variation of the TRAM flap. It uses the same donor tissue and microvascular technique as the "free" TRAM flap with the differences being that the rectus muscle is removed from the abdomen and different blood vessels are being removed from the donor site. When using one's own tissue is being considered, the amount of tissue available for reconstruction of one or two breasts is an important factor for choosing the type of reconstruction. The other factors such as excessive weight, smoking and elderly age may be considered as contraindications for this procedure.

    The latissimus dorsi flap reconstruction uses skin and fatty tissue attached to a portion of the latissimus dorsi muscle (large back muscle) and blood vessels. All of these structures are mobilized from your upper back and the tissues are rotated through a tunnel created under the arm and eventually positioned at the mastectomy area. The amount of tissue obtained with this technique is usually not enough to rebuild the entire breast mound and is commonly used in combination with an implant. This operation is usually offered as an option when the TRAM flap is not recommended, such as in thin patients (particularly when they were never pregnant) or patients who had an abdominal surgery that could have compromised the vessels that supply the nutrition of the tummy flap. A straight horizontal scar at the back will be formed and can be hidden under the bra. The scars in the breast are those from the previous breast surgery and mastectomy procedure.

    The nipple reconstruction is the last step of the reconstruction. If desired by the patient, it is done when the breast is healed and the site and height of the nipple can be properly established. It is a very short procedure and it's done under local anesthesia. After the reconstructed nipple is healed, tattooing of the nipple areolar complex with the color matching the other breast finishes the entire reconstructive process. The reconstructed nipple has no sensation and does not react to stimulations such as temperature or touch.

    As mentioned above, breast reconstruction is a process where not only the mound of breast tissue needs to be replaced but also symmetric results need to be achieved. The vast majority of the reconstruction procedures are done in steps scheduled at different times. The type of reconstruction is tailored to each individual based on the medical consideration and patient's preference.

  • What are some of the possible side effects of breast surgery?
    Any surgery has potential complications and side effects. The most common ones associated with breast surgery are:

    • Infection: whenever there is a wound there is a risk for infection. The rate of infection after breast surgery is approximately 2% as reported to Centers for Disease Control and Prevention - from 1992 to 2004. If a patient develops a skin or incisional infection after surgery, the treatment usually consists of a course of antibiotics taken by mouth. Antibiotics given through the vein may be necessary when the infection does not respond to the antibiotics by mouth or it is more serious at onset. Rarely, another surgery is needed to drain the infected fluid collection. Conditions that predispose patients or make them vulnerable to the development of infection include: obesity, diabetes, chemotherapy, previously radiated breast, steroid intake, presence of infection at the time of the re-do surgery, surgery including mastectomy and/or axillary lymph node removal, and presence of implants, grafts or other artificial device. In these cases, prophylactic (preventative) antibiotic given through the vein before the skin incision, is advised. Very few patients will need to take antibiotics at home after the surgery.
    • Bleeding: breast surgery in general has minimal bleeding in patients with normal clotting ability. More extensive procedures, such as mastectomy with axillary dissection and immediate reconstruction are associated with some bleeding, but major bleeding is very rare. Major bleeding can occur during the operation or after surgery, forming a bloody collection in the wound, the so called hematoma. Some hematomas can be easily reabsorbed by the body. Expanding hematomas may need another surgery to remove the clot and to drain the wound. The need for blood transfusion for breast surgery is extremely rare. Some medical conditions which may predispose a patient to bleeding include: deficiency in clotting factors, low platelet counts, use of blood thinners and/or non-steroidal anti-inflammatory agents prior to surgery and shortly after (e.g. Coumadin, Aspirin, Advil, Motrin, ibuprofen), or extremely high blood pressure immediately after surgery. The use of some supplements, which contain large amounts of the following substances can also predispose to bleeding, such as ginkgo, ginseng, and garlic. Patients should discuss their medical conditions and use of medications with their surgeons, because some of them may cause bleeding, especially after surgery.
    • Wound healing problems: wound healing can be complicated by the tension on the wound closure, compromised blood supply to the tissue, infection, chemotherapy, bleeding, steroid use and radiation. Wound opening can occur shortly after or a long time after the operation. Some patients are prone to develop a prominent scar with darker pigmentation which is called keloid or a milder form. Up-to-date, there is not a single effective agent to prevent or treat keloid formation. Definitely, surgical removal alone is not effective. There is some evidence of benefit from occlusive (silicone and non-silicone-based) and pressure dressings, particularly used for patients who cannot tolerate invasive therapies. Some other available therapies include steroid injections, radiation, laser and injection of other medications which have been studied but have controversial results.
    • Pain: pain after surgery varies in intensity. Pain after breast surgery is mild. The breast itself can be sore after surgery and even the most intense episodes of pain can be well controlled by weak narcotics and good breast support. For some patients, Tylenol may be sufficient for pain control. Frequently, more pain is experienced by the patient with more extensive surgery or re-do surgery. The axilla surgery (armpit) is more painful than the breast surgery, particularly when axillary lymph node dissection is performed.
    • Seroma: this is defined as a collection of fluid in the space created by the tissue removal. Seroma usually presents as a fluid filled mass. When it is large or has not resolved on its own, the fluid can be aspirated through a needle. A drain may be necessary if the seroma does not resolve over time. When there is a large area of dissection (such as in mastectomies and axillary lymph node dissection), a drain is left for a few days until the space is gradually healed and the amount of the residual fluid is low enough to be absorbed by the body.
    • Deformity: even if the wound heals well without infection or openings, the scar tissue tends to contract overtime especially after radiation. A dimple, a concavity or asymmetrical appearance may occur in the breast after a large amount of tissue is removed as in some of the breast conservation cases (lumpectomy or partial mastectomy). For obvious reasons, mastectomy causes a major deformity which can be greatly minimized by reconstruction.
    • Re-do surgery: when discussing the breast surgery, issues of a possible cancer or "clear margins" for cancer surgery arise, because the cancer lesions are not well-capsulated and an involved margin indicates future recurrence. They usually have small "tentacles" of cancer cells extending beyond the main mass and it is impossible for the surgeon to determine if all cancerous cells are removed completely during the operation. Final proof for a clear margin comes from the microscopic examination of the cancer by the pathologist which occurs after the surgery. The re-do surgery, in case of breast conservation operation (lumpectomy), may involve certain margin(s) removal, another lumpectomy, or a mastectomy, depending on how much tissue has been removed from the first surgery, how much more tissue needs to be removed again, the size of the breast that is being treated and women's preference. Lastly, if the non-palpable microcalcifications are part of the cancer, a mammography after the lumpectomy before the second surgery or radiation is necessary to prove that they have been completely removed.

 

  • What are some of the possible side effects of lumpectomy or mastectomy?
    Lumpectomy usually has the same scope of side effects as excisional biopsy. The most noticeable differences are the risk of deformity and of having to perform a new procedure to achieve clear margins. Depending on the size of the breast in relation to the amount of tissue that needs to be removed, the degree of deformity may vary from not noticeable to an obvious asymmetric looking. The asymmetry may not be immediately noticeable. As the swelling goes down and with the addition of radiation therapy, the unevenness may become prominent.

    Mastectomy is a relatively extensive procedure and some of the side effects associated with it are mainly related to the procedure itself, as discussed before. Probably the most important one is deformity, particularly obvious when there is no immediate reconstruction. Depending on how much tissue needs to be removed, which is basically related to the size and location of the tumor in conjunction with the breast size, tightness over the chest wall may be a complaint. This can potentially influence shoulder range of motion as the scar tissue contracts and creates tension of the skin and tissues overlying the chest wall. In the majority of the cases, there is no long-term noticeable disability. The shoulder range of motion exercises should be started shortly after drain removal to prevent long term sequelae. Occasionally, patients need to be referred to a physical therapist to improve the shoulder range of motion and to soften the scar tissue.

 

  • What are the possible side effects of sentinel lymph node biopsy (SLNB)?
    Sentinel lymph node biopsy is replacing axillary lymph node dissection in most breast cancer cases as this is a less invasive procedure with fewer associated side effects. As the sentinel lymph node biopsy involves only the removal of a few lymph nodes, the side effects tend to be minimal immediately after surgery and have almost no long-term side effect. Shoulder range of motion is usually not affected and several simple "do-it-your-self" exercises should help patients who may have some limitations at the beginning. Nerve damage is not common but short-lived tingling and sometimes sharp/shooting pain in the inner upper arm and in the armpit may occur. Long term dullness at the same area is rare. Because the risk of chronic arm swelling is minimal, long term lymphedema precaution protocol does not apply to patients with a few SLNs removed.

 

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