Surgical treatment for breast cancer has evolved over time to reduce the extent of surgery while minimizing physical and psychological damage. This is done without compromising the chances of recovery. The surgical treatment includes addressing the breast tumor while simultaneously examining and removing lymph nodes. Nowadays, "sentinel node surgery" is commonly performed without the need for complete removal. Also, the surgery to remove lymph nodes in the armpit can be minimized in most cases, reducing the risk of complications.
Types of Mastectomy:
- Total Mastectomy (Mastectomy): The treatment of choice may involve removing the entire breast, including most of the breast tissue, some skin, the nipple, and areola. Usually, the chest muscles are not removed. If desired, breast reconstruction can be performed by plastic surgeons during the same surgery or later. In Israel, breast reconstruction is considered part of the treatment and is covered by health insurance.
- Skin-Sparing Mastectomy: This approach involves removing the breast tissue through a limited incision while preserving the skin, followed by immediate breast reconstruction. This technique allows for a better cosmetic outcome compared to traditional mastectomy. The decision about the type of surgery depends on oncological considerations.
- Subcutaneous Mastectomy: This procedure involves removing the breast tissue while preserving the nipple and areola. Although it offers a better cosmetic result, it is a controversial technique as it involves leaving a significant amount of breast tissue. It is usually performed as a preventive measure in women with a particularly high risk of developing cancer, especially carriers of BRCA mutations.
Partial Mastectomy and Radiation Therapy:
Partial mastectomy involves removing the tumor and nearby tissue while preserving as much of the breast as possible. The two main techniques for partial mastectomy are "lumpectomy" (removal of a lump) and "quadrantectomy" (removal of a quarter of the breast). This approach is suitable when the tumor is localized and not widespread.
The decision for partial surgery depends on the appropriate ratio between the tumor size and the breast size. In certain cases, reducing the tumor size before surgery, known as neoadjuvant treatment, may make partial mastectomy possible. However, neoadjuvant treatment is not always effective, and sometimes a full mastectomy is still necessary.
Chances of Recovery:
The chances of recovery depend on the absence of the disease spreading to distant organs. Partial surgery does not significantly reduce the chances of recovery compared to a full mastectomy. In some specific cases, the chances of recovery after partial surgery may even be slightly better compared to a full mastectomy. However, partial surgery carries a higher risk of local recurrence of the tumor.
Possible Reoperation:
Partial surgery carries a risk of requiring additional surgery after evaluating the tissue samples in the lab (which is only available after surgery). This is often due to incomplete tumor removal with the tumor cells extending to the margins of the removed tissue. Approximately 20% of partial surgeries may require reoperation. Another reason for reoperation is the detection of a more extensive tumor than estimated before surgery, necessitating a complete removal.
Preparation for Neoadjuvant Treatment for Breast-Conserving Surgery:
Before initiating neoadjuvant treatment to reduce tumor size for breast-conserving surgery, it's essential to consider the possibility of a rapid response to the treatment. In such cases, accurate localization of the tumor after treatment may be challenging, even with manual examination or imaging. To aid in precise localization, small metal clips can be placed around the tumor before starting treatment.
Oncoplastic Surgery:
Oncoplastic surgery involves using plastic surgery techniques to improve the cosmetic appearance of the breast after removing tumors, ensuring both aesthetic and oncological outcomes. It may provide better results compared to conventional techniques. See the oncoplastic surgery section for more details.