Breast Conservation Surgery - Wide Local Excision, Lumpectomy
The type of surgery performed on your breast for breast cancer treatment can largely be broken into two categories:
- Breast conservation surgery (wide local excision, lumpectomy).
What is breast conservation surgery?
Breast conservation surgery has a number of different names. You may hear it being referred to as a Lumpectomy or a Wide Local Excision.
Many cancers in Australia are diagnosed whilst they are still very small and often unable to be felt. This is often the case with women who have had a breast cancer diagnosed through Breastscreen.
Small cancers like these are suitable for breast conservation surgery. This is where the cancer is removed with a small margin of normal breast tissue surrounding it leaving the majority of the breast untouched.
This results in a breast that still looks similar to what it did before surgery (maybe a bit smaller and with a scar).
Women undergoing a lumpectomy need to have the rest of the breast that is untouched treated with radiotherapy (XRT) to decrease the chance of the cancer recurring (coming back).
Approximately 70-80% 0f women are suitable for breast conservation surgery.
Why do I have to have radiotherapy (XRT) with BCS?
Breast radiotherapy (XRT) is x-ray therapy to treat the remaining breast tissue left behind after BCS.
Breast XRT is usually a 4-6 week program (Monday-Friday) where you will need to present to the radiation oncology center to undergo treatment.
BCS was designed to avoid patients needing a mastectomy for treatment of small breast cancers. Instead of removing the entire breast only the cancer is removed with a margin of normal breast tissue around it. Studies have shown that the remaining breast tissue left behind is at a particularly high risk of developing a cancer within it if left untreated. Breast radiotherapy (XRT) is aimed to treat the remaining breast tissue that is left behind after BCS to decrease the chance of developing a recurrence (the cancer coming back).
The long-term results of BCS with breast XRT are comparable to having a mastectomy. On average the 5-year risk of your breast cancer recurring with BCS +XRT are only slightly higher than having a mastectomy whilst maintaining a good cosmetic result.
BCS alone without XRT usually results in a very high chance of the tumour coming back. Therefore, when choosing to undergo BCS you need to be willing and able to undergo breast XRT.
5-year recurrence rates for Mastectomy and BCS
2 - 5%
BCS + XRT
5 - 7.5%
15 - 25%
Why might I need more surgery to get a bigger margin?
The aim of BCS is to remove the breast cancer with a margin of healthy normal breast tissue surrounding it. When perform BCS we aim to remove as little normal breast tissue as possible. The more normal breast tissue that is removed, the more likely a poor cosmetic result will occur. We aim to remove the cancer with the smallest possible margin of surrounding normal breast tissue.
The final pathology will inform us on the extent of the margin. The result will either be adequately cleared, Close margin or involved margins.
An involved margin means that there is cancer identifiable right to the area where the lump of breast tissue was removed. This may mean that the cancer is bigger than first believed. It will nearly always be necessary for another operation to be performed in this circumstance to take an additional margin or normal tissue. This is called a ‘Cavity Re-excision’.
A close margin is very debatable. This occurs in up to 20% of all BCS. There is much debate about what is the minimum margin that is acceptable. The concern is a ‘too closer margin’ will result in a higher recurrence rate. However, with good radiotherapy to the breast smaller margins are now tolerated and acceptable. I will discuss with you your specific margins and discuss the need to return for further surgery. In general terms, a margin greater than 1mm for a breast cancer and 2mm for pre-cancerous DCIS is acceptable (these are rough guides and every case is individual).
Will I definitely avoid a mastectomy?
Unfortunately it is not possible to guarantee that you will not need a mastectomy if undergoing BCS. Although it is uncommon for a patient who begins with BCS to final require a mastectomy.
This may occur if your cancer turns out to be larger than is expected from your mammogram and ultrasound. If this is the case, the initial surgery will have close or involved margins and require further surgery. Depending on your breast size this may or may not be possible. If you have small breasts there taking further tissue may result in a poor cosmetic result and require a mastectomy +/- reconstruction. Similarly, if after a few attempts to obtain clear margins there is still cancer present then a mastectomy will be indicated. Dr. Green will discuss this with you in detail if this was to occur.
What is involved in the surgery?
A lumpectomy is performed under a general anesthetic. You will come into hospital on the day of your operation.
If the breast cancer is unable to be felt a wire (hookwwire) will be placed into the breast to locate the tumour prior to your surgery. You will have this done by a breast radiologist.
Once you have completed the hospitals admitting paperwork you may head to the radiology suite for a hookwire to be placed if the breast cancer is not easily felt (dr. Green will have discussed this with you at your consultation). Similarly, if you are having a sentinel node biopsy you will head to the nuclear medicine department to have the radioisotope tracer injected into your breast – read more about axillary surgery.
Once all the pre-op preparation is completed will head the operating suite where Dr. Ben and the anesthetist will meet you.
Once you are off to sleep the operation will take round 30-60 minutes. It will be longer if any axillary surgery is being performed.
The operation involves an incision over the tumour and a lump of breast tissue is removed. The breast tissue will contain the breast cancer with a margin of normal breast tissue around it. If a hookwire has been used the lump will be sent to radiology for an x-ray to confirm the cancer has been removed. The procedure may be combined with surgery to your lymph nodes (Sentinel Node biopsy, Axillary Lymph node Clearance). The breast will then be repaired so as not to leave a defect and the skin will be closed with a dissolving stitch and covered with a waterproof dressing.
Once in recovery you will be attached to several monitors that are keeping a close eye on you. Once the recovery nurses are happy you will be transferred to your ward.
What is a hookwire?
Many breast cancers are detected on screening mammograms and not because a lump is felt. In this case Dr. Green will require a guide wire to locate the cancer within the breast. This wire is called a hookwire and is placed on the morning of your operation in the radiology department.
The hookwire enables Dr. Green to pinpoint the exact location of the cancer and remove it with the smallest possible margin of normal breast tissue so as to maintain a good cosmetic result.
What happens after my operation?
You will be in hospital usually for one night. See the breast conservation surgery post-op advice page for further details.
Once you are recovered you will return in a week to the rooms for a discussion about your pathology, any further treatments that may be required and to remove your dressings.
Possible complications of breast conservation surgery
A wide excision will also involve a sentinel node biopsy +/- Axillary clearance if the surgery is being performed for a breast cancer. The following information relates to the Breast lumpectomy / wide excision component. For further information regarding sentinel node surgery and axillary surgery please see the operation details for those components of your surgery.
Wide Excision and Sentinel Node Biopsy is a common operation performed by Dr. Green for which he has been well trained. The vast majority of patients will follow the “usual” path of recovery and be discharged from hospital feeling well 1 or 2 days after their operation.
Despite this things may not always go according to plan and a small number of patients may experience a significant complication.
The information below will help you understand some of the possible problems that can result from having a lumpectomy. “Complications” are listed below. Some are common and others are less common but very important if they happen. While the following list is a guide, it is not comprehensive.
If you would like more information after your consultation and reading this page please feel free to discuss any issues with Dr Green.
|COMMON (up to 10% of cases)||Uncommon (up to 5% of cases)||Rare but important (less than 1% of cases)|