Breast-conserving surgery - Wide Local Excision
Breast-Conserving Surgery (Lumpectomy, Wide Local Excision)
This procedure aims to remove a cancer from the breast with a wide margin whilst maintaining the shape and appearance of the breast as much as possible. A wide variety of surgical techniques and scar placements are possible to try and best achieve these aims. To be suitable for this operation the cancer needs to be small enough relative to the size of the breast to allow a wide margin of normal tissue to be excised around the cancer.
Whilst you are asleep under anaesthetic, an X-ray is taken of the tissue removed to try and ensure that a good margin has been achieved. However, this margin of tissue has to be normal under the microscope and the results from looking at this tissue under the microscope are not available until 1 - 3 weeks later. If the margin is clear under the microscope, radiotherapy is given to the rest of the breast tissue on that side. If the margins are not clear (10 -15% of cases), the options are either to go back and remove a bit more tissue or perform a mastectomy.
Sometimes, combining wide local excision with a breast reduction or breast lift can make the operation possible for some ladies in whom it would otherwise not be (see Oncoplastic breast-conserving surgery). Such procedures can allow a wider excision of the cancer with a greater chance of complete removal at the first operation. They can also make the appearance of the breast after surgery better in some cases. An operation that combines breast reduction or breast lift with wide local excision is called Therapeutic mammaplasty. Occasionally, it may be an option to replace tissue removed from the breast during wide local excision with tissue from the back or the side of the chest. These operations are called LICAP flap, or TDAP flap.
Admission and Aftercare
You are generally admitted on the day of surgery, occasionally the day before. You will be re-examined and the site of the scar drawn on the breast. If your cancer was detected by mammography and cannot be felt then the radiologists will place a wire or a tiny bit of radiation in the breast so that the correct area can be identified and removed at surgery. The operation takes about 40 minutes to one and a half hours depending on the extent of surgery required. Dissolvable stitches are used and a waterproof dressing of special glue is applied. This dressing can be left alone and the glue flakes off after 2 or 3 weeks. Sometimes a support dressing is used for 24 hrs and you may be advised to wear a supportive bra day and night for a couple of weeks.
A day case operation is possible for many women; some prefer or are recommended to stay overnight. This often depends upon the type of surgery that is performed under the arm (axilla), as well as your general fitness and the degree to which you can be looked after at home
Wide local excision is an operation that is not associated with a lot of pain. Most of the discomfort after the operation is related to the surgery performed to remove nodes under the arm, in the axilla, which usually settles after a few days. Most women are able to perform normal activities within a few days of this operation. Overall recovery and return to work will depend upon a variety of factors including the extent of surgery and what after-treatment is necessary.
Appearance of the Breast after Wide Local Excision and Radiotherapy
The operation involves removing tissue from the breast. The affected breast may therefore be slightly smaller after surgery. The overall cosmetic appearance of the breast after surgery (and radiotherapy) is something that some women attach more importance to than others but it is usually possible to achieve a very good cosmetic result in most women with minimal scarring, relatively straightforward surgery and (realistically) a small indentation to the breast.
There are many surgical tricks that can be used to minimise the deformity caused by surgery, some of them involving additional scarring and/or additional surgery, but many of them very simple. Some surgical techniques can also minimise the adverse effects of radiotherapy. Often, indentation or slight breast deformity develops after radiotherapy. Radiotherapy is one of the "unknowns" in terms of cosmetic result from wide local excision. It never enhances cosmesis and whilst some women have no lasting effects of radiotherapy, others (unpredictably) have obvious signs that radiotherapy has been given.
Complications - What can go wrong?
Any operation can be associated with infection or bleeding. Wound healing can be particularly affected by infection and smoking. Any operation can be associated with anaesthetic problems (nausea in particular), venous thrombosis (although precautions are taken routinely) and allergic reaction to drugs or dressings. Every effort is made to avoid these problems.
Very ocasionally when the breast tissue is rearranged to fill a defect where a cancer has been removed by wide local excision, the blood supply to a part of the breast fails. This can produce a lumpy area in the breast and is called fat necrosis. It gradually resolves although can take up to 2 years to settle. Lesser degrees of lumpiness at the site of surgery are common after radiotherapy and may be permanent.
Q. Would it ever be the case that if I chose wide local excision, I might wake-up from the operation to find that a mastectomy was necessary and had been performed?
Answer - No. This would never be the case. A mastectomy would never be performed without your written permission after a full discussion of the options.
Q. Why might I not be suitable for wide local excision?
Answer - You might not be suitable for wide local excision if: 1. The proportion of the breast that needs to be removed is so large that the residual breast would be very deformed and likely to be quite uncomfortable. The proportion of the breast that can be removed also depends upon exactly which part of the breast needs to be removed. 2. The nature of the breast cancer. If there are multiple cancers in the breast or if the cancer seems to have several islands of cancer around it, it is not usually suitable for wide local excision.
Q. Would it be safer if I had a mastectomy?
Answer - A wide local excision treats the cancer just as well as a mastectomy if 3 criteria are fulfilled: 1. The wide margin of tissue that is removed around the cancer is normal under the microscope, 2. Radiotherapy is given to the rest of the breast, and 3. A satisfactory cosmetic result is achieved. Thus, women who are suitable for wide local excision have a genuine choice between this operation and a mastectomy. However, breast conserving surgery involves much less surgery and recovery time than a mastectomy and breast reconstruction and the cosmetic result is usually much better.
Q. Can my cancer recur in the breast?
Answer - Yes, this is possible, although very unlikely. Within 10 years of surgery, this will happen to less than 5 in every 100 women.
Q. Is there anything I can do to help myself?
Answer - Keep generally healthy. If you smoke, try and stop or smoke as little as possible. This will minimise the risk of surgical complication.