Breast Conserving Surgery
Breast Conserving Surgery
Breast Conserving Surgery (BCS) is an umbrella term used to describe any surgical procedure to remove a (usually malignant) breast lesion without performing a mastectomy. The most basic breast conserving surgery is often referred to as a lumpectomy.
On hearing the diagnosis of breast cancer, the kneejerk reaction of a large proportion of patients is to request a mastectomy rather than have any form of lumpectomy (or more accurately, “breast conserving surgery”). On further enquiry, this is based on the (very reasonable) assumption that mastectomy will provide the best long-term prognosis in terms of either survival, cancer recurrence or both. However, there is an abundance of research that shows that this is not the case. In the 1980s, research demonstrated that breast cancer patients undergoing a mastectomy had no survival advantage over those having breast conserving surgery and furthermore, if patients undergoing breast conserving surgery then received a course of radiotherapy to the remaining breast tissue after their operation, the recurrence rate is similar to that of a mastectomy. There has been further research carried out more recently that suggests that patients undergoing breast conserving surgery and radiotherapy may actually have a lower risk of recurrence than those having a mastectomy.
Not all patients with a breast cancer can be treated with breast conserving surgery. Some patients still require a mastectomy. There are a number of possible reasons:
- Tumour size compared with breast size. Using advanced plastic surgery techniques, modern “oncoplastic” breast surgeons can remove larger tumours from smaller breasts without performing a mastectomy. Nonetheless, sometimes there are just no plastic surgery procedures that suit the situation and a mastectomy (with or without simultaneous reconstruction) is required.
- Genetics. Some patients have a genetic predisposition to developing breast cancers, such as patients with BRCA1, BRCA2, PALB2 and TP53 gene mutations. These patients often opt for a mastectomy to reduce the risk of future breast cancers, even when a lumpectomy might be a perfectly viable option for treating their current cancer.
- Patient choice. Despite their being no cancer treatment benefit to having a mastectomy when compared with a lumpectomy followed by radiotherapy, occasionally patients choose mastectomy. This is sometimes because of concerns regarding undergoing radiotherapy or worry about the potential of having multiple operations for positive margins (see below).
- Previous radiotherapy. Radiotherapy can only be given once to a specific part of a patients body in their lifetime. So if a patient has previously had breast cancer and undergone a lumpectomy and then radiotherapy, if they get another cancer in the same breast, they often need to undergo a mastectomy.
In some cases, the tumour can be felt (palpable) and so locating the area of breast that needs to be removed is straight forward. In other cases, the tumour cannot be felt (impalpable). This is usually due to the tumour being diagnosed on a screening mammogram rather than the patient coming to clinic with symptoms. In these cases, the tumour is localised by inserting a marker that can be detected during the operation and used to indicate the area to remove. Methods include using a wire, a radioactive seed, signal reflectors and radiofrequency tags.
There are two main downsides to breast conserving surgery compared to mastectomy:
- Further Surgery: After the block of tissue is removed, it is sent to the lab for microscopic assessment. In around 10-15% of cases, there are cancer cells seen extending to the edge of the specimen (i.e. a positive margin). In these cases, further surgery is required to take a shave of tissue from the breast cavity site.
- Radiotherapy: As described above, radiotherapy is required following breast conserving surgery (where it is much less likely to be required following mastectomy). Most patients tolerate radiotherapy very well, with minimal short or long term side effects. For some patients, radiotherapy is contraindicated (most commonly, previous radiotherapy to the same place or rarely Li Fraumeni Syndrome). In these patients, often a mastectomy must be performed since breast conserving surgery is only equivalent to mastectomy in terms of prognosis, if it is combined with post-operative radiotherapy.
There is a robust body of evidence demonstrating the benefits of breast conserving surgery compared to mastectomy, with regards to long term psychological morbidity. As a consequence, different techniques have been progressively developed in order to remove increasingly large areas of breast tissue without a mastectomy and still provide a good cosmetic result. This practice forms a large part of what is termed oncoplastic surgery.
Wide local excision (WLE)
A wide local excision is often simply referred to by patients as as a lumpectomy. This is the most basic and most frequently performed breast conserving surgery. It describes the simple excision of a block of breast tissue containing the malignant lesion along with a ‘margin’ of normal breast tissue surrounding the disease to ensure that the whole lesion is removed (hence ‘wide’ local excision). All other more complicated breast conserving procedures are essentially variations on a theme of wide local excision. If the area of breast tissue is less than around 20% of the total breast volume, then usually the surrounding breast tissue can be sutured together to close the cavity in the breast, so as to avoid any significant cosmetic defect without a more technical plastic surgery type of procedure being required. If the specimen is larger than 20% of the total breast size, then often a more complicated oncoplastic procedure is required, employing either a volume ‘displacement’ or a volume ‘replacement’ technique.
A mammoplasty is the medical term used to describe a breast reduction procedure. Prefixed by ‘therapeutic’, this describes a breast reduction procedure designed such that the tissue removed to reduce the breast size contains the wide local excision of the breast lesion. There are almost infinite variations on how to perform this procedure (Wise pattern, Batwing, vertical, Benelli…). The choice of method is based on a combination of factors including the breast size and shape, the tumour location in the breast, the patient’s risk factors for wound problems and the surgeon’s preference. Usually, the same procedure is performed on the other breast (usually simultaneously) for cosmetic symmetry. Some of the breast skin is also removed in most techniques to provide an uplift as well as breast volume reduction. Therapeutic mammoplasty is an example of a volume ‘displacement’ procedure, where the remaining native breast tissue is displaced or reshaped to form a new smaller breast. The procedure enables the removal of much larger tumours from usually a relatively large breast. But it is also used for smaller tumours in larger or droopy breasts, when the patient is keen to have a breast reduction or breast uplift procedure as part of their cancer excision, to improve their breast aesthetic whilst having their cancer removed.
Volume Replacement flaps
In patients with smaller breasts but a moderate or larger lesion, sometimes a mastectomy can be avoided by performing a simple wide local excision and then filling the cavity with a flap of tissue from somewhere adjacent to the breast. These are examples of pedicled flaps, where the tissue’s original blood supply is kept intact, as opposed to a free flap where the donor tissue is plumbed in (anastomosed) to the native vessels. These volume replacement flaps tend to be named after their blood vessels e.g. LTAP (lateral thoracic artery perforator), TDAP (thoracodorsal artery perforator), LICAP (lateral intercostal artery perforator), MICAP (medial intercostal artery perforator), etc.
It is important to make sure that you get your information from reputable sources when doing your own research on breast cancer and treatments.
For more detailed information about mastectomy surgery, here are some excellent resources: