Surgical Options for Breast Cancer and Reconstructive Surgery

An Article by Gregory M. Senofsky, M.D., F.A.C.S.

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Surgical options for breast cancer have changed and evolved considerably during the past five years. In the 1980's women were given the option of modified radical mastectomy versus lumpectomy, formal axillary node dissection and radiotherapy.  Women now have additional options for surgical treatment including skinsparing quadrantectomy (removal of 25% of the breast) with flap advancement closure, J-wire placement for mammographically-directed wide excision or quadrantectomy, and sentinel node mapping for more accurate and less invasive axillary node dissection. This article will explain these surgical treatment options. 

Lumpectomy, an terms used in the 1970's and 1980's to remove the abnormal lump from a women's breast, has given way to either wide excision or quadrantectomy. Now, more than ever, the margins of clearance of breast cancer have come to play a major role in the treatment and survival of breast cancer patients. Larger and more directed resections of breast tissue are necessary to obtain healthy clearance of the malignant cells in order to minimize recurrence. In many cases, the tumor cannot be felt by hand and it is necessary to place several J-wires around the abnormal area prior to surgery. These wires are placed through the skin of the breast utilizing mammographic procedures. The J- wires help to accurately locate the tumor so that it can be removed completely. 

Sometimes following larger resections, it is desirable to rebuild the remaining breast so that it has a natural and healthy appearance. Flap advancement closure is a technique which is particularly effective in this regard. It is performed immediately after the surgery is completed and the pathologist confirmed that the cancer has been removed along with a health rim of normal tissue. Flap advancement refers to the technique of gently separating the remaining back of the breast from the muscle beneath it and bringing the back edges of the remaining breast together in the most pleasing visual manner. This technique requires a thoughtful approach so that the final result is a smooth and well shaped breast. 

The extent of axillary lymph node dissection necessary is an area of controversy. In the recent past, aggressive axillary node dissections were performed removing as many nodes as possible in order to see if the cancer had spread to them. Over the past five years, a method called sentinel node mapping has evolved. This allows the surgeon to seek out the specific lymph nodes that the cancer would spread to if it could. These lymph nodes, as well as some surrounding nodes, are removed through a small incision hidden in the edge of the hairline under the arm. The new method of sentinel node mapping minimizes the risks and still gives physicians the important staging information that is needed. When the sentinel nodes have cancer in them, a full axillary node dissection is performed at the same time in order to identify patients who need more aggressive treatment. 

A minority of patients have breast cancer too extensive to treat with wide excision or quadrantectomy, and for these patients a modified radical mastectomy may be recommended. Breast reconstruction following mastectomy is readily performed using the patients own abdominal wall tissue instead of the use of implants. The reconstruction is performed at the same time as the mastectomy in most cases. The mastectomy is performed with the skin-sparing technique, and the skin, fat and a portion of the abdominal wall muscle is brought up to replace the breast. The flap of abdominal tissue is placed behind the skin flaps of the mastectomy. Using a microscope, the tiny arteries and the veins are connected to sustain the new breast. This reconstruction, commonly known as the free microvascular TRAM flap, incorporates an automatic tummy tuck and has lifelong durability, with no implant complications. 

In conclusion, surgery for breast cancer has evolved tremendously toward a more accurate and complete excision of the tumor with the creation of a attractive remaining breast, and improvement in the quality of the woman's life. 
 

Written by: Gregory M. Senofsky
Copyright--Surgery of the Breast: Principles and Art.
edited by Scott L. Spear 
Lippincott-Raven Publishers, Philadelphia © 1998