Breast Cancer Surgeries

Conventional Surgery For Breast Cancer

Surgery is a must for curing breast cancer. The type of surgery selected depends on the stage of cancer. Radical mastectomy and modified radical mastectomy are the two conventional procedures that are offered to patients with breast cancer.

  • Radical mastectomy The removal of the breast, chest muscles and all of the lymph nodes under the armpit. Though this was a standard procedure 80 years ago, presently it is used only when the tumor has spread to the chest muscles. This is a rare occurrence in the present day as patients tend to come early. Radical Mastectomy surgery has many side effects and research has proven that this breast cancer surgery does not benefit the patient. So,this procedure is rarely required.
  • Modified radical mastectomy (MRM) This has been standard of care for breast cancer for many years. This procedure is less traumatic than radical mastectomy. This involves the removal of the breast, many of the lymph nodes under the arm (not all) and the lining over the chest muscles (not the muscles). This reduces the discomforts to the patient at the same time providing adequate cure. Today even this procedure has become obsolete. Today even this is considered overtreatment. This surgery is performed only when it is not possible to save the breast by breast conservation therapy or lumpectomy. However, in those patients who need mastectomy, breast can be reconstructed in the same sitting or after completion of all treatments.

Advanced Breast Cancer Surgeries

Minimally Invasive Breast Surgery (MIBS): Over the past 25-30 years the trend towards saving normal natural breast has increased supported by robust research. It has been proven that saving breast DOES NOT affect the cure rate (oncological outcome). Today increasing numbers of patients are able to undergo one of the types of minimally invasive breast cancer surgery and save their natural breast, improving the cosmetic outcome and quality of life for women undergoing breast cancer surgery.
  • Breast Conservation Surgery or lumpectomy with Oncoplastic surgery. This involves removal of the cancer lump or tissue in the breast as well as some of the normal breast tissue around it and the lining over the chest muscles below clearing all the cancer bearing tissue. Usually some of the lymph nodes under the arm are taken out (through a separate incision) and tested for possible spread of cancer. Oncolplastic surgery technique helps in giving normal contour (shape) to the breast after adequate removal of cancer tissue. The surgical options may include local tissues rotation (rotation mammoplasty) or a tissue transfer from a distant area of your body (Latissimus Myocutaneous Flap) or silicone prosthesis. At the end of this patient gets almost a normal appearance of breast.

  • Skin Sparing Mastectomy and Reconstruction. Some situations require for the removal of entire breast tissue along with nipple. This happens in cases of large size breast cancers or multiple cancer in same breast. The skin over breast is softer and replaced skin from other parts of the body cannot match that skin.  Retaining natural skin over the breast gives the best cosmetic results compared to any other form of reconstruction (tissue transfers). The breast can be completely reconstructed through the same incision or wound to restore the normal shape and contour in the same sitting. Nipple can be reconstructed using tattooing. There are few specific flaps that are commonly used for reconstruction of breast. These are TRAM flap, LD flap or DIEP flap. The use depends on various situations.

  • Nipple Areola Skin Sparing Mastectomy and Reconstruction Some situations require for the removal of entire breast tissue without need to remove nipple (extensive changes on mammography, multicentric cancer or prophylactic mastectomy for high genetic risks like BRCA mutation families). Skin-sparing and nipple-sparing mastectomy is routinely performed through one or two short incisions placed over the breast. The breast can be completely reconstructed through the same wound to restore the normal shape and contour in the same sitting using one of the tissue flaps (from the back or belly). This gives almost normal looks to the breast.

  • Robotic Breast Surgery: This is the most advanced form of breast surgery being performed at very few centers and very selectively. This is especially performed for the patients who are eligible for nipple areola skin sparing mastectomy (extensive changes on mammography, multicentric cancer or prophylactic mastectomy for high genetic risks). The entire surgery including flap reconstruction can performed with very tiny wounds with least possible pain and scaring. The role of robotic surgery is predominantly in reconstruction in these cases. The technique has not yet picked peace.

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    Armpit (Axillary) Lymph Nodes:

    Sentinel Node Biopsy (SNB):

    Sentinel node biopsy is the procedure of choice for managing the armpit lymph nodes  almost all breast cancers today. This basically means that the only the nodes that drain the breast are selectively removed avoiding the nodes draining the arm. This way the risk of arm swelling up in the future comes down to less than 2% from 40% when all armpit nodes are removed. This is a big difference for the patient. We perform this procedure using double dye technique so that nodes are not missed. We use methylene blue and indocyanine green (ICG). There are centers that perform this by using a radioactive substance. However, we have been able to effectively avoid using it.

    Axillary Lymph Node Dissection (ALND):

    Every breast cancer surgery involves removal of the lump and removal of the draining lymph nodes in the armpit or axilla. The nodes in the axilla are divided into 3 levels and at least 2 of these levels are removed while performing ALND surgery. The unfortunate part of this surgery is that about 40% of the patients develop swelling of their hand in their lifetime as the lymph nodes responsible for arm and breast are in the axilla. This is a very high number.  This was a standard of care till about 15 years back for all breast cancers. Even today ALND is required for some the patients who come to us with involved nodes.

    Axillary Reverse Mapping (ARM):

    Every patient is not fortunate enough to reach us in early stage. There are times when patients have involved lymph nodes in the arm pit. Traditionally all these patients have to undergo ALND and have a very high lifetime risk of arm swelling up. We have devised a technique called axillary reverse mapping that would try to identify the lymphatic ducts coming from the arm and preserve those, removing all the lymph nodes. By doing this we may be able to reduce the risk of arm edema or swelling.

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