11Part of the reason we fear cancer is the thought of a mastectomy - where we lose what to most is an essential part of our femininity.

The good news is that surgery is not always disfiguring, breast conservation and reconstruction now play a major role in management.

The type of surgery done depends on the size of the breast, the size and position of the tumour and the patient�s wishes. Surgery encompasses both excision of the breast cancer either by breast conservation or mastectomy, as well as surgery to the glands in the axilla. In Europe 75% of patients in good centres get breast conserving surgery or mastectomy and immediate reconstruction. The concept of an onco-plastic surgeon is well established. Extensive preoperative planning is done in conjunction with a plastic surgeon to obtain the best cancer and cosmetic result. No longer are breast cancer patients rushed to surgery on the day of the diagnosis, but extensive planning with the entire cancer team is undertaken to give the patient the best result. With increasing frequency preoperative chemotherapy and radiation therapy are being used so that breast cancer surgery can be achieved with good cosmetics.

Breast Conserving Surgery

This type of surgery encompasses a wide variety of terms: tyclectomy, lumpectomy, quadrantectomy, partial mastectomy. The important principle is that the diagnosis of breast cancer should be made prior to surgery. In less than 3% of patients is it necessary to do an open surgical biopsy. Today most patients will have a core needle biopsy done under ultrasound or mammogram guidance. The rules for breast conserving surgery or lumpectomy as it is commonly known revolves around ensuring the cancer is removed with 1 cm clear margins. Accurate assessment of is achieved tumour size by ultrasound, mammography and MRI. Certain cancers such as lobular cancer should be treated circumspectly as they tend to be multifocal and care should be taken before offering these patients breast conserving surgery. Once 15% of the breast tissue has been removed some form of reconstruction should be offered to ensure no defect is left. There are various options to approach breast conserving surgery. Once the cancer has been removed and clear margins have been achieved (with the use of intra-operative pathology), the defect can be closed by moving breast tissue around (a parenchymal flap) or by using a breast reduction pattern or by using tissue flaps. These flaps consist of taking tissue from the armpit, back (latissimus dorsi) or lower abdomen (TRAM, DIEP).

Prosthetic material should not be used in patients having breast conserving surgery as all patients require radiation therapy and radiation on prosthesis has high complication rates. All tumour beds should be clipped to guide the radiation therapist where to give a radiation boost.

Mastectomy and reconstruction

All patients going for a mastectomy should be counseled as to when a reconstruction can be scheduled. You don't have to be disfigured for life. The reconstructive process should be discussed with the patient prior to initial surgery. The psychological impact of losing a breast varies, but for most women it means some form of grieving. Breast reconstruction can alleviate the sense of deformity that may develop after a mastectomy. It is considered an integral part of the management of patients with breast cancer. Breast reconstruction can be done immediately after the mastectomy or it may be delayed for a few months. The benefits of having reconstructive surgery at the time of the mastectomy are obvious in that it helps to preserve body image. Indications for mastectomy are patient preference, medical contraindication to radiation therapy, pregnancy, anticipated poor cosmetic result from breast conserving surgery, diffuse or multifocal disease and extensive intraductal component. The commonest type of mastectomy done today is the skin sparing mastectomy, with the use of expander prostheses to reconstruct. The nipple must be removed in a mastectomy.

Surgery to the axilla

An axillary dissection must remove sufficient lymph tissue to allow the pathologist to give a definite answer about axillary involvement with tumour. Removing 8 or more lymph nodes tells us about the aggressiveness of the tumour. If only 3 nodes are removed and they are not involved with tumour an inadequate dissection took place. Sentinel node biopsy (Fig 7.4) Controversy has long existed as to the value of axillary node dissection. As for screening of breast cancer and earlier detection of smaller tumours occurs, there is a definite decrease in the number of axillary node metastases (fewer positive lymph nodes with cancer). More emphasis is now being placed on the biology of the tumour and often these tumour factors are what determine whether it is necessary to give chemotherapy or not. Finally the technical advance of the sentinel node biopsy has questioned the morbidity benefit of a full axillary dissection.

The injection around the tumour of blue dye and a radioactive sulphur colloid can be used to reliably detect (in over 95% of patients) the first lymph node to which the tumour initially migrates. This has resulted in the use of the sentinel node biopsy technique.

By injecting one or both materials around the tumour, the surgeon will be able to pinpoint and remove only the relevant axillary node (sentinel node): checking which node is stained by the dye or detectable with a gamma camera. This stained node is then sent to the pathologist. This reduces the extent of the axillary dissection, which thus decreases the morbidity (complications) of the procedure. The accuracy of this technique is determined, the timing of the dye injection and the timing of the surgery and the accurate interpretation of the axillary nodes harvested. Sentinel lymph node biopsy is only used in node negative (no clinically palpable nodes) axillae. If there is nodal involvement clinically a full axillary section is indicated.