Most patients diagnosed with a malignant breast tumour can be cured. In that case, the treatment consists of surgery (local treatment) and, often, a follow-up treatment (therapy). Some tumours are first treated with chemotherapy, after which surgery may follow.
An operation on the breast can be breast conserving (wide excision) or not (amputation or mastectomy). In principle, in addition to the 'breast surgery', there will also always be a surgery in the armpit and in this case, too, a less radical (sentinel or sentinel node procedure) and a more radical procedure (axillary lymph node dissection) are possible.
The proposed surgical treatment will always be tailor-madeit will take into account the volume of the breast, the size of the tumour, the patient's expectations and the history (e.g. previous surgery, radiotherapy...).
Each case is also always discussed at a multidisciplinary oncology consultation ("MOC") in the presence of several breast cancer specialists, both before and after surgery.
More explanations about the different surgical procedures are given below.
In case of a breast amputation or mastectomy, the entire mammary gland, most of the overlying skin and the nipple are removed. Where possible, this procedure is avoided, but if the tumour is too large in relation to the breast volume, a mastectomy is sometimes necessary.
In some cases, chemotherapy can be administered first, which can reduce the volume of the breast tumour so that a breast-conserving operation can be offered. This should be discussed with the doctor. In the case of multiple tumours in the same breast (multifocality or multicentricity), a mastectomy is also almost always suggested.
After the operation, all you see externally is a fine scar from the breastbone to the armpit. In very specific cases, a skin and nipple-sparing mastectomy may be offered; this is certainly not the standard.
Some women may also opt for breast reconstruction after consultation with their treating physician.
In a breast-conserving procedure (wide excision), we remove the area of the malignant tumour and aim for tumour-free margins (negative cutting surfaces) with an acceptable aesthetic result. Whether or not a breast-conserving procedure is possible should be decided on an individual basis.
The skin above the tumour is incised. The tumour is then loosened and removed from all sides. A mark is applied in the cavity where the tumour used to be, so the radiotherapist can locate the exact area (important for radiotherapy after the operation).
In non-sensitive breast cancers, the surgeon has a tool to localise the tumour. In this situation, a harpoon placed (tracker) that pinpoints the tumour.
In principle, a breast-conserving procedure always requires post-treatment with radiotherapy, as opposed to mastectomy, where it is not always necessary. Subsequently, a second skin incision will be made for the operation in the armpit (sentinel and/or axillary lymph node dissection).
The sentinel gland is the first lymph node (usually in the armpit) to which breast cancer cells can metastasise. It sometimes concerns one gland, sometimes several.
The theory of this procedure is based on stepwise progression: if the sentinel node is unaffected, there is a good chance that the other lymph nodes will also be unaffected.
The sentinel lymph node is detected during the operation by means of a nuclear tracer (injected before surgery) with or without blue dye (injected during surgery around the nipple).
Once the sentinel lymph node is removed from the body, it is examined during the operation. Only if malignant cells are found in the sentinel lymph node during this rapid assessment (frozen section), it may be decided to remove the remaining axillary lymph nodes (depending on the size of the affected area).
In some cases no malignant cells may be found by means of the rapid assessment, while a more extensive test in the following days may still reveal cancer cells. In this case, a second operation may be required to remove the remaining axillary lymph nodes.
Naturally, this technique is only offered to patients when the axillary lymph nodes are not suspected to be affected at the time of diagnosis. Both clinical examination and ultrasound examination of the axillary lymph nodes should be normal. If necessary, a puncture of the axillary lymph node(s) will take place before the operation.
Patients whose lymph nodes are affected will in principle undergo axillary lymph node dissection or clearance, although there are exceptions (to be discussed with your doctor).
On average, some 10-15 lymph nodes are removed.
The purpose of this procedure is to obtain a correct lymph node status: this is an important predictor of the likelihood of relapse and helps determine which subsequent treatment you should receive.
An axillary clearance performed with a wide excision is almost always performed through a separate incision, while a mastectomy is normally performed through a single incision.
