Breast Cancer Surgery

Many women are candidates for incision via the inframmamary fold (the bra line). I had mine done this way and one can hardly tell that I had a mastectomy. This is often available for small and medium breasted women, less so for women with large breasts. Be sure to discuss this option with your doctor to see if you are a candidate. Many do not offer this option, so be sure that you determine if you are not a candidate or if your surgeon simply does not offer the procedure.

Generally lumpectomy is offered for unifocal (one site of disease), and the patient is willing to undergo radiation. If the tumor is large relative to the breast size, neo-
adjuvant (up-front) treatment may be given to shrink the cancer before lumpectomy.

Questions to ask would be:
How large is the cancer? Can clear margins be obtained? Should I receive chemotherapy or endocrine therapy prior to surgery to shrink the tumor? How will the incision lines be placed? Will oncoplastic techniques be used? How much deformity will there be? Is there a reason not to preserve the breast?

Sentinel node biopsy involves mapping the breast (or skin in the case of melanoma) to determine which 1-4 (average 2) lymph nodes drain the breast. This allows precise removal of the lymph nodes most likely to harbor metastases form the breast cancer. A standard axillary biopsy is a removal of 1 or more lymph nodes that are abnormal - usually by size criteria. A standard axillary lymph node dissection is the removal of all the lymph nodes in a certain anatomic area (the 3 dimensiaonl triangle between the lateral border of the pectoralis major muscle (anterior border), the axillary vein (superior border), and the lateral border of the lattisimus dorsi muscle (posterior border). There are typically 10-15 lymph nodes under each arm but like most things in biology the number is a bell shaped curve with some people having a few (6 or less) and some people having a lot (30 or more).

My treatment included 10 breast cancer surgeries, 8 rounds of chemo and 5 years on Arimidex. The worst surgery was the DIEP Flap procedure mainly because I used my "good arm" to pull me up out of bed or a chair. As a result, a rib on that side flipped up over my collarbone, trapping a bundle of nerves between the bones. The pain was off the charts for six weeks, and I can't take many pain meds. I saw a pain management specialist who wanted to keep me on Valium... I DON'T THINK SO!!! I eventually saw a physical therapist who figured it out, manually flipped the rib back into place. Problem solved.

Arimidex was a witch!! If you're taking aromatase inhibitors then you know what I mean. Every day I felt like I was 110 years old. The only thing that got me through was daily exercise, walking yoga, weights. When I stopped the Arimidex, I began to feel better in about 3 or 4 days. While I understand it's no fun, I urge you to continue with your aromatase therapy because it does lessen risk of recurrence.

There is nothing better to assess axillary lymph node status than sentinel lymph node biopsy. PET scanning has been tried. This involves radioactive glucose injected into the patient's venous system. This radioactive glucose is taken up by cancer more readily than non-cancerous tissue and therefore becomes slightly radioactive. This radioactivity can then be detected by scanning the axilla or the entire patient. However PET scanning cannot detect small amounts of cancer in the lymph node (anything <5 mm).

However, a better question might be - Why do we need to know the status of the axillary lymph nodes in breast cancer? Removing the lymph nodes in breast cancer has always been thought of as prognostic (helping determine how well a patient will do and how much chemotherapy to give) but not therapeutic (helping to improve survival). We are now able to determine the prognosis of the patient by looking at the biology of their cancer with newer advanced pathologic tests such as MammaPrint, OncotypeDX, MammaStrat and others. I believe we will stop doing sentinel node biopsy and axillary surgery in general (outside of removing bulky lymph nodes) in the very near future.

Reverse Axillary Mapping is a brilliant idea (in a string of brilliant ideas) from Dr. Suzanne Klimberg - a professor of surgery at the University of Arkansas in Little Rock. In addition to mapping the breast to find the sentinel nodes that drain the breast, she thought 'Why don't we map the arm lymphatics at the same time and avoid injuring them?' This decreases the chance of getting lymphedema of the arm (swelling caused by extra fluid in the arm because the outflow has been disturbed). In her series of patients, she has a very low incidence of arm swelling.

The technique involves injecting a small amount of blue dye in the upper inner aspect of the arm. The blue lymphatics that drain the arm can then be identified and avoided at the time of sentinel lymph node biopsy (unless clinically full of cancer). The breast sentinel nodes are identified by injecting the breast with a radioactive dye that drains and makes the sentinel nodes slightly radioactive. These radioactive lymph nodes are identified with a gamma radiation detector and removed at the time of surgery.

The vast majority of women with breast cancer should be getting no more than a sentinel lymph node biopsy. The exceptions are patients that have large (clinically positive) lymph nodes at the time of their diagnosis that have undergone a biopsy of their lymph node that shows cancer(fine needle aspiration or needle core biopsy typically). Women undergoing lumpectomy who have 1-2 sentinel nodes with cancer in them can now forego a completion dissection based on the recent ACOSOG study - Z0011 that was published in JAMA in February. The caveat is that they have to have whole breast irradiation (not partial breast irradiation). Also this does not apply to patients having a mastectomy (with or without reconstruction). If they have a positive sentinel node, they should have a completion dissection.

oncoplastic breast cancer surgery refers to breast cancer surgery that is done in a way that not only makes sure the breast cancer is properly removed, but also that the surgery is done thinking about the cosmetic outcome of the breast.
for mastectomy, this might mean leaving as much skin as possible if an immediate reconstruction is preformed. for lumpectomy, this might mean doing the lumpectomy in a way that leaves the breast looking cosmetically acceptable, with the least possible change in shape or size.