Removing larger malignant tumors can be performed in different ways; either the breast is removed completely (mastectomy) or only the affected part is widely excised (breast-conserving surgery).
Whether or not breast-conserving surgery is possible depends on several factors. Recent studies demonstrate however that even with a sufficient tumor-free margin, breast-conserving surgery combined with radiotherapy, may result in a slight increased risk for local recurrence compared to a mastectomy. Long-term survival was similar in both groups.
The skin incision is performed over the tumor and the tumor is removed with a cuff of surrounding healthy breast tissue. Certainly with larger tumors, there is always a small chance that the tumor has not been completely removed. The excised part is therefore analyzed by a histopathologist. This doctor fixes the tissue, cuts it into thin slices, stains it and studies the specimens under a microscope to check if the tissue edges are tumor free. This process usually takes at least one week.
A second procedure may be needed if the tumor is not completely removed. Once the tumor has been completely excised, the remaining breast needs to be irradiated. This is done to eradicate any undiscoverable microscopic satellite lesions that could possibly be growing in the remaining breast gland tissue. The combination of surgery and radiotherapy can result into variable degrees of deformation of the remaining breast according to the sensitivity of each person to irradiation.
Figure 1: Breast conservative surgery: examples of breast deformation after segmentectomy and variable reactions to post-operative radiation therapy.
If the lesion is large or if the breast is small then the amount of tissue that needs to be removed may be relatively large in comparison to the volume of the breast. In this case we will use the terms segmentectomy (removing a segment of the breast, fig. 1) or quadrantectomy (removing one quarter of the breast, fig. 2) . In such instances, corrective surgery should be considered in a later phase as the defect can leave some important irregularities in the shape of the breast, specially when combined with radiotherapy (which almost always will be the case).
Figure 2: Breast conservative surgery: examples of breast deformation after quadrantectomy and variable reactions to post-operative radiation therapy.
Reconstructive options should be offered and discussed before performing ablative surgery, preferably with a plastic surgeon specialized in reconstructive breast surgery. The different methods of breast reconstruction are discussed in other areas of this website. Depending on the relative proportion of breast that has been removed, in general, different reconstructive options are proposed. The table with the algorithm below summarizes the general approach of defects of the breast. Be aware that other or different decisions may be taken for every individual, depending on local tissue conditions. Options need to be discussed with your reconstructive surgeon.
|Relative amount of breast gland removal||Reconstructive technique|
|< 1/8 of the total breast volume||Re-arrangement of the remaining gland|
|> 1/8 and < 3/8 of the total breast volume||Loco-regional pedicled skin flaps|
|> 3/8 of the total breast volume||Removal of the remaining gland|
|Full breast reconstruction with free flaps or implants if no radiation is involved|
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