Why it's done?

A mastectomy is used to remove all breast tissue if you have breast cancer or are at very high risk of developing it. You may have a mastectomy to remove one breast (unilateral mastectomy) or both breasts (bilateral mastectomy).

Mastectomy for breast cancer treatment

A mastectomy may be a treatment option for many types of breast cancer, including:

• Ductal carcinoma in situ (DCIS), or noninvasive breast cancer
• Stages I and II (early-stage) breast cancer
• Stage III (locally advanced) breast cancer — after chemotherapy
• Inflammatory breast cancer — after chemotherapy
• Paget's disease of the breast
• Locally recurrent breast cancer

Your doctor may recommend a mastectomy instead of a lumpectomy plus radiation if:

• You have two or more tumors in separate areas of the breast.
• You have widespread or malignant-appearing calcium deposits (microcalcifications) throughout the breast that have been determined to be cancer after a breast biopsy.
• You've previously had radiation treatment to the breast region and the breast cancer has recurred in the breast.
• You're pregnant and radiation creates an unacceptable risk to your unborn child.
• You've had a lumpectomy, but cancer is still present at the edges (margin) of the operated area and there is concern about cancer extending to elsewhere in the breast.
• You carry a gene mutation that gives you a high risk of developing a second cancer in your breast.
• You have a large tumor relative to the overall size of your breast. You may not have enough healthy tissue left after a lumpectomy to achieve an acceptable cosmetic result.
• You have a connective tissue disease, such as scleroderma or lupus, and may not tolerate the side effects of radiation to the skin.

Mastectomy to prevent breast cancer

You might also consider a mastectomy if you don't have breast cancer, but have a very high risk of developing the disease. A preventive (prophylactic) or risk-reducing mastectomy involves removing both of your breasts and significantly reduces your risk of developing breast cancer in the future. A prophylactic mastectomy is reserved for those with a very high risk of breast cancer, which is determined by a strong family history of breast cancer or the presence of certain genetic mutations that increase the risk of breast cancer.

Who can have breast-conserving surgery?

Breast-conserving surgery (BCS) is a good option for many women with early-stage cancers. The main advantage is that a woman keeps most of her breast. However, most women will also need radiation therapy, given by a radiation oncologist (a doctor who specializes in radiation).

BCS might be a good option if you:

• Are concerned about losing a breast
• Are willing to have radiation therapy and are able to get to the appointments (if you need help getting to and from your appointments see Road to Recovery).
• Have not already had that breast treated with radiation therapy or BCS
• Have only one area of cancer in the breast, or multiple areas in one quadrant (multifocal) that are close enough to be removed together without changing the look of the breast too much
• Have a tumor smaller than 5 cm (2 inches), that is also small relative to the size of the breast
• Are not pregnant or, if pregnant, will not need radiation therapy immediately (to avoid risking harm to the fetus)
• Do not have a gene mutation (change) such as a BRCA or ATM mutation, which might increase your chance of a second breast cancer
• Do not have certain serious connective tissue diseases such as scleroderma or Sjögren's syndrome, which may make you very sensitive to the side effects of radiation therapy
• Do not have inflammatory breast cancer
• Do not have positive margins

Possible side effects of breast-conserving surgery

As with all operations, bleeding and infection at the surgery site are possible. Other side effects of breast-conserving surgery can include:

• Pain or tenderness or a "tugging" sensation in the breast
• Temporary swelling of the breast
• Hard scar tissue and/or a dimple that forms at the surgical site
• Swelling of the breast from a collection of fluid (seroma) that might need to be drained
• Change in the shape of the breast
• Neuropathic (nerve) pain (sometimes described as burning or shooting pain) in the chest wall, armpit, and/or arm that doesn’t go away over time. This can also happen in mastectomy patients and is called post-mastectomy pain syndrome or PMPS.
• If axillary lymph nodes are also removed, other side effects such as lymphedema may occur.

Was all the cancer removed?

During BCS, the surgeon will try to remove all the cancer, plus some surrounding normal tissue. This can sometimes be difficult depending on where the cancer is located in your breast. During (sometimes) and after surgery, a doctor, called a pathologist, will look closely at the tissue that was removed in the lab. If the pathologist finds no invasive cancer cells at any of the edges of the removed tissue, it is said to have negative or clear margins. For women with DCIS, at least 2mm (0.08 inches) of normal tissue between the cancer and the edge of the removed tissue is preferred. If DCIS cancer cells are found near the edges of the tissue (within the 2mm), it is said to have a close margin. If cancer (invasive or DCIS) cells are found at the edge of the tissue, it is said to have a positive margin. Having a positive margin means that some cancer cells may still be in the breast after surgery, so the surgeon often needs to go back and remove more tissue. This operation is called a re-excision. If cancer cells are still found at the edges of the removed tissue after the second surgery, a mastectomy might be needed

Oncoplastic surgery of the breast is an innovative approach to the treatment of breast cancer. The word ‘oncoplastic’ is derived from the Greek words ‘onco’ (tumour) and ‘plastic’ (to mould). The concept encompasses the use of plastic surgical techniques in order to reshape the remaining breast or reconstruct the breast after appropriate wide excision of the breast cancer. The result is “seamless” specialist breast cancer surgery in which removal of the cancer is merged with reconstruction. This obviously requires very careful planning, and the delicate balancing of oncological needs with aesthetic aims.

What is a Breast Hookwire Localisation?

Mammography, ultrasound and magnetic resonance imaging (MRI) scan images or pictures sometimes show abnormalities in the breast that cannot be felt by a doctor. If the abnormality is to be surgically removed, it is necessary to place a fine wire, called a hookwire, in the breast with its tip at the site of the abnormality. This acts as a marker during surgery and enables the surgeon to remove the correct area of breast tissue. The hookwire is inserted to guide the removal of both benign (non-cancerous) and malignant (cancerous) abnormalities. The wire is called a hookwire because there is a tiny hook at the end, which keeps it in position. Breast Hookwire Localisation is done using local anaesthetic to numb the breast in the area where the hookwire is to be inserted.

Indications

Hook wire guided wide local excision is usually performed on breast lesions that cannot be clinically detected or felt but are identified on imaging studies.

Procedure

The method of imaging such as mammography, ultrasound or MRI is first selected depending on which one shows the lesion clearly and is ideal for you. The identified region of the breast is sterilized and numbed with local anesthetic. Under image guidance, a fine needle is inserted into the breast tissue to reach the region of the abnormality. The hook wire is then passed through the needle until its tip is within the tumor. The needle is then removed leaving the wire in place. Further imaging is obtained to verify the position of the tip of the wire. The external part of the wire is then taped to the skin. Later a wide local excision is carried out using the hook wire as reference and the lesion is removed along with the wire. Localization of the tumor and placement of the hook wire takes approximately 30-45 minutes.

Post-Procedure Care

Following the procedure, you may have some soreness for which pain medication is prescribed. The scar produced is usually small. A well-fitted, comfortable bra must be worn for support. Exercises are recommended to avoid stiffness of the shoulder and back muscles. Your doctor may suggest a course of radiotherapy or chemotherapy to destroy any unseen cancer cells.

Risks and complications

• Shifting or dislodgement of the wire.
• Breakage of the wire leaving fragments in the breast after surgery.
• Reaction to anesthetic or contrast agent used during imaging.
• General complications such as bleeding, swelling, infection and nerve injury.

Hook wire guided wide local excision helps identify and remove suspicious lesions in the breast that are unable to be felt. The excised tissue is examined in the laboratory and your doctor will inform you of the results.

ALND may be needed

• If a previous SLNB has shown 3 or more of the underarm lymph nodes have cancer cells
• If swollen underarm or collarbone lymph nodes can be felt before surgery or seen on imaging tests and a FNA or core needle biopsy shows cancer
• If the cancer has grown large enough to extend outside the lymph node(s)
• If the SLNB is positive for cancer cells after chemotherapy was given to shrink the tumor before surgery

Lymphedema

A possible long-term effect of lymph node surgery is swelling in the arm or chest called lymphedema. Because any excess fluid in the arms normally travels back into the bloodstream through the lymph system, removing the lymph nodes sometimes blocks drainage from the arm, causing this fluid to build up.

Illustration showing an arm with lymphedema swelling, an unaffected arm and an arm with a compression garment used to help control lymphedema Lymphedema is less common after a sentinel lymph node biopsy (SLNB) than an axillary lymph node dissection (ALND). The risk is thought to be in the range of 5% to 17% in women who have a SLNB and around 20% to 30% in women who have an ALND. It may be more common if radiation is given after surgery or in women who are obese. Sometimes the swelling lasts for only a few weeks and then goes away. But in some women, it lasts a long time. If your arm is swollen, tight, or painful after lymph node surgery, be sure to tell someone on your cancer care team right away.

Limited arm and shoulder movement

You might also have limited movement in your arm and shoulder after surgery. This is more common after ALND than SLNB. Your doctor may advise exercises to help keep you from having long-lasting problems (a frozen shoulder). Some women notice a rope-like structure that begins under the arm and can extend down toward the elbow. This is sometimes called axillary web syndrome or lymphatic cording. It is more common after ALND than SLNB. Symptoms may not appear for weeks or even months after surgery. It can cause pain and limit movement of the arm and shoulder. This often goes away without treatment, although some women may find physical therapy helpful.

Numbness

Numbness of the skin on the upper, inner arm is a common side effect because the nerve that controls sensation (feeling) here travels through the lymph node area

The dye makes a map pattern of lymphatic fluid. The blue staining of the lymph tissue and the use of a special scanner identify the SLN. The SLN can be taken out and examine by a pathologist during surgery. If an SLN is tested negative for cancer cells, no further axillary lymph node dissection is done. Again, if an SLN is tested positive for cancer cells, an axillary clearance of lymph nodes or axillary irradiation (in some cases) will be carried out. If cancer is found in the sentinel node(s) later, the surgeon may recommend an ALND at a later time to check more nodes for cancer. Studies have shown, however, that in some cases it may be safe to leave the rest of the lymph nodes behind. This is based on certain factors, such as the size of the breast tumor, what type of surgery is used to remove the tumor, and what treatment is planned after surgery, among other things. Based on the studies that have looked at this, skipping the ALND may be an option for:

• Women with tumors 5 cm (2 inches) or smaller who have no more than 2 positive sentinel lymph nodes, are having breast-conserving surgery followed by radiation, and did not get any chemotherapy before surgery.
• Women who have lymph nodes with a very small amount of cancer (no more than 2.0mm) and are having a mastectomy

If there is no cancer in the sentinel node(s), it's very unlikely that the cancer has spread to other lymph nodes, so no further lymph node surgery will be needed.

After informed consent the patient will be placed under a general anaesthetic and a small probe/ wire will be passed into the discharging duct. An incision will be made around the areola and the single offending duct will be excised. The wound will be closed with absorbable sutures and a small waterproof dressing will be placed over the incision.

Possible complications

• Wound infection requiring antibiotics.
• Bleeding is uncommon, however bruising can occur.
• A reduction in nipple sensation and
• A change to the contour of the nipple and areolar complex.
• Loss of skin over the nipple (rarely).

The aim is to remove a single duct only. The duct that is excised will be sent to a specialist breast pathologist to determine if there is any cause ( eg- papilloma – a small growth, inside the duct) for the nipple discharge.

Indications

• Patients who have discharge from multiple ducts
• Inverted nipples
• Chronic infection beneath the nipples affecting the ducts
• Patients that have ongoing persisting nipple discharge post microdochectomy.

This procedure is usually performed as a day case. There are approximately 12-15 ducts opening onto the surface of the nipple and some diseases will affect all of the breast ducts.

The operation is performed under a general anaesthetic. A small incision around the areola (the line between the brown area of the nipple and the remaining skin of the breast) is made and all of the ducts are removed and sent for pathological assessment. The wound is closed with absorbable sutures. Approximately 1 in 3 patients after removal of the ducts from the nipple will have lost sensation to the nipple (numbness). This is more common in women who have had the procedure performed for infection. The symptom of nipple discharge will rarely recur. However, if the operation is performed for eversion (perhaps to correct an inverted nipple) about 10% of these patients will have recurrence of the inversion. Infection of the duct is common in smokers and continuation of smoking can contribute to recurrence of the problem. Breastfeeding is not possible after total duct excision. There are no concerns if a patient becomes pregnant post operatively. The breasts may feel slightly engorged but they will settle after delivery of the baby.

Complications

• Bleeding and bruising can occur post operatively. However, it is uncommon for patients to be returned to the operating theatre to drain a haematoma.
• Antibiotics will be given during the procedure and postoperatively to reduce the risk of infection. However, despite this a small number of women will get an infection postoperatively. The probability of this occurring is more common if the procedure is being performed for chronic nipple infection.
• Occasionally, patients can develop a seroma after the surgery. This is natural fluid secreted by the breast tissue in the cavity where the surgery has been performed and occasionally a needle and syringe will be required to aspirate the fluid postoperatively.
• There is always a probability of loss of skin over the nipple with nipple surgery as the blood supply to the nipple can be damaged at the time of surgery which can lead to loss of the nipple.
• A small scab will occasionally develop over the surface of the nipple and once it separates off the skin, new skin will grow under this.

Why do I need a "tissue marker" or "clip" inserted into my breast?

There are various reasons for marker insertion. When a biopsy is performed, a marker may be inserted if the area of concern is small and could possibly be fully removed during the biopsy. The marker will then be visible if further imaging or procedures are required in the future.

Sometimes a biopsy is performed with ultrasound and a marker is inserted. A mammogram is then performed to check if the abnormality visible on ultrasound can be seen with a mammogram. Alternatively, it will show where the ultrasound abnormality is if the mammogram appears normal.

When a marker clip is seen on subsequent mammograms it shows the radiologist where a biopsy has been previously performed and prevents repeated biopsies of the same abnormality.

Finally, some women with a diagnosed cancer are now having chemotherapy before surgery. In this instance, a marker is placed in the cancer or in an abnormal lymph node, as these may respond to the treatment and be too small to locate on imaging at a later date. Should the cancer largely disappear with chemotherapy, the marker will enable us to identify where it was with further imaging when the time comes to remove it surgically.

Marker placement is now very much standard practice when indicated.

Will I feel the marker?

Usually markers are not able to be felt, however, very rarely they may be felt if they are just beneath the skin surface.

Can the marker move?

The marker is designed to attach to the breast tissue to prevent it from moving and usually this works. When they are inserted under mammography there is a small chance they will move when the breast is released from the mammographic unit. This is a recognised complication known as the 'concertina effect'. The radiologist will review pre and post clip placement imaging and can address this issue if it occurs. The only other time the marker clip may appear to have moved is when the clip is in a large bruise (haematoma) which is liquid. As this is absorbed and resolves itself, the marker may appear to move. The marker will not travel to other parts of the body.

Can I have an MRI when I have a marker clip in my breast?

There is no problem with having an MRI of the breast or any other body part with a marker clip. In fact, markers can be inserted at the time a biopsy is performed in the MRI unit if required. The markers are all MRI compatible. You will be provided with the relevant details of your marker clip to give to your MRI technologist should you require other MRI scans.

How does the marker get removed?

There is generally no need to have the marker removed. If the biopsy sample proves to be benign (not cancerous) the clip can simply remain in the breast. If surgery is required to remove the abnormality the marker will also be removed. In some circumstances we may need to localise the abnormality and/or the marker clip with a hookwire prior to surgery.

A breast biopsy might be recommended if you have a suspicious area in your breast, such as a breast lump or other signs and symptoms of breast cancer. It can also be used to investigate unusual findings on a mammogram, ultrasound or other breast exam.

The results of a breast biopsy can show whether the area in question is breast cancer or if it's not cancerous. The pathology report from the breast biopsy can help your doctor determine whether you need additional surgery or other treatment.