CANCER SURGERY

A lumpectomy (also known as wide local excision) involves removal of a breast lump. This is often recommended for small cancers. If the lump is not easily felt, Michelle may ask our Consultant Radiologist to identify the abnormal area to be removed by either placing a skin mark on the overlying skin or placing a wire or SCOUT device into the area in question so Michelle knows which part of the breast tissue to remove at the time of surgery.

For women with moderate to large sized breasts, Michelle may be able to remove the breast cancer (therapeutic) and the reshape the breast by removing skin and breast tissue (mammoplasty) to try and preserve a normal breast shape which will usually be smaller and more uplifted. If there is a significant difference between the 2 breasts afterwards, the breast on the other side may also need to be reduced to give a better match in size and shape if so desired. This is known as symmetrisation surgery and will be performed at a later date.

Michelle will be able to tell you if you are suitable to have this sort of surgery, and explain in detail about the pros and cons of therapeutic mammoplasty.

A mastectomy is removal of the entire breast with or without the overlying skin and nipple. There are many types of mastectomy including a simple mastectomy, skin sparing mastectomy, nipple or areolar preserving mastectomy and skin reducing mastectomy.

Postoperatively, most women recover well from a simple mastectomy. If you have a simple mastectomy, you are left with a flat chest wall and have the ability to wear a soft form shaped like a breast (called a “softie”) placed in the bra soon after surgery. Then at a later date a prosthesis is fitted which slips into a pocket in a post-surgery bra. Ladies can live a full and active life after a simple mastectomy. The Spire Breast Care Nurses will sort out the softies and prosthesis fittings, as well as chat to you about suitable bras.

Postoperative problems can include pain, numbness, and tingling to the wound. Other sensations such as a phantom breast or phantom breast pain are unusual.

Breast Reconstruction is discussed with all women having a mastectomy. The aim of breast reconstruction is to restore a breast shape which is acceptable to you. Your reconstructed breast will look and feel different to your natural breast. Your breasts will not look identical, but hopefully the reconstruction will be similar in terms of size, shape and position to your remaining breast. Available options include use of an implant or your own tissue (for example from your tummy).

In an immediate reconstruction, Michelle will need to consider what anti-cancer therapies may be recommended following surgery. This may involve radiotherapy which can damage a breast reconstruction.

Reconstruction of your breast following mastectomy can be done either at the same time as cancer surgery (immediate reconstruction) or later (delayed reconstruction). Each option has pros and cons, which Michelle will discuss with you. For immediate reconstruction, Michelle will need to consider any additional treatments, like radiotherapy, that might be needed after surgery, as these could affect the reconstruction. Michelle works closely with her plastic surgical colleagues for women who wish to have a DIEP reconstruction (using the abdominal “tummy” tissue for the reconstruction).

Michelle will explain the possible complications of any breast reconstruction and let you know that it is often a process that may require several surgeries to achieve the desired result. Not every type of reconstruction is suitable for every patient.

FURTHER INFORMATION CAN BE FOUND BELOW:

Types of Breast Reconstruction

Types of breast reconstruction | Cancer Research UK

Breast Reconstruction Using Implants

https://www.cancerresearchuk.org/about-cancer/breast-cancer/treatment/surgery/breast-reconstruction/using-implants

Breast Reconstruction Using your Own Tissue

https://www.cancerresearchuk.org/about-cancer/breast-cancer/treatment/surgery/breast-reconstruction/using-body-tissue

Breast reconstruction using body tissue | Cancer Research UK

If you have invasive breast cancer, you will usually need an operation to the axillary lymph nodes (the lymph glands in the armpit) at the same time as your breast operation. Evidence is now emerging that some patients are able to avoid lymph node surgery if they are over a certain age, and their breast cancer is very small and slow growing. Michelle will let you know if your cancer means you do not need to have an axillary operation.

The first lymph node in your armpit is called a sentinel node or guardian lymph node. Prior to your cancer operation, you will have had an ultrasound of the armpit (axilla). If no cancer is seen in any of the lymph nodes, Michelle will recommend a Sentinel Node Biopsy.

In order to find the sentinel lymph node, 2 procedures are required to localise these nodes. You will be required to undergo a nuclear medicine injection at Southmead Hospital with technetium-99m. This will usually be performed on the day of the operation.

A small injection of colloid particles labelled will be injected into the nipple on the day of surgery. This injection does produce some stinging and discomfort at the site of injection, however, is rapidly resolves after approximately 30 seconds. The technetium is transported through the lymph gland channels to the first lymph nodes that drain the breast in the armpit.

When you arrive in the operating theatre, you will have a general anaesthetic for your operation. Michelle then injects 2ml of patent blue dye into the breast in order to further localise the sentinel lymph node. These nodes will be coloured blue and therefore Michelle will be able to find the “blue and the hot nodes”. A gamma probe will be used in the operating theatre to detect the hot nodes. These are the nodes that will contain the technetium-99m.

The blue dye will cause the nipple and areola to have some blue discolouration which will resolve and the patients will experience a colour change to their urine (blue urine) and faeces.

Some patients may have an allergy to the blue dye however this is unusual. The allergic reaction can range from a blue hue to the skin, blue hives, or in the more serious and rare circumstances anaphylaxis.

The benefits of sentinel lymph node biopsy are that only a few lymph nodes are removed and therefore the complications that can occur with a full axillary lymph node dissection such as lymphoedema, shoulder stiffness, pain, and sensory changes to the arm and thoracic wall are significantly reduced.

Surgery for breast cancer always involves removal of the cancer and an operation to the axillary lymph nodes (the lymph nodes under the arm).

In the situation where the lymph nodes are shown to contain cancer cells before the operation (positive axillary lymph nodes), Michelle will recommend an axillary lymph node clearance at the time of surgery to remove the breast cancer. An axillary lymph node clearance (ANC) is performed in order to adequately stage the breast cancer.

The number of nodes involved will impact on what additional treatment is required postoperatively. The results of the ANC will have implications for whether or not chemotherapy or radiotherapy is required and the type and duration of the chemotherapy regime and the site and duration of the radiotherapy. The number of lymph nodes removed can vary between women, but usually it is between 10-20 nodes.

Complications of an Axillary Lymph Node Dissection

It can be associated with lymphoedema (swelling of the arm). This may be a temporary or permanent problem. There may be also some loss of sensation to the side wall of the chest or to the upper limb. If you develop post-operative lymphoedema you may be required to wear a pressure garment or have some therapeutic massage.

There may be some restriction in arm and shoulder range of motion and you will see a physiotherapist before you leave hospital.

There is a risk of post operative infection and bleeding. If necessary, you will be given antibiotics, and may need to return to theatre if there is ongoing bleeding.

There are also specific nerves in the axilla which can affect movement of the upper limb and shoulder and every attempt is made to ensure that they are not damaged during the ANC.

Patients that have an ANC will usually have a drain tube inserted at the time of surgery which will be removed a few days after the operation. You can go home with your drain in place.

If you are found to have cancer in your armpit at the time of your diagnosis, Michelle may recommend that a marker clip is inserted into one of the affected lymph nodes. This procedure is done by the Radiologist in the X-ray department, under ultrasound guidance, with some local anaesthetic. It usually takes around 10 minutes to insert the clip.

Some of her patients then have upfront chemotherapy (“neo-adjuvant chemotherapy”). If the lymph nodes return to normal during the neo-adjuvant chemotherapy, you may be offered a TAD procedure, where a few lymph nodes are removed from your armpit at the time of the breast surgery, rather than a full clearance. The surgery will be guided by blue dye and Technetium 99, as well as a wire that has been inserted into the clipped lymph node. The wire is placed into your armpit a few hours before surgery in the X-ray department by the radiologist, using the ultrasound machine.