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Links to other sub topics in this section:
Breast Conservation Surgery includes the following two procedures:
Wide Excision Lumpectomy: The lump in the breast is excised along with a margin of normal tissue of 1 cm. This means that the lump that we romove will be surrounded on all sides by normal breast tissue of 1 cm thickness.
Axillary Dissection or sampling: Breast cancer spreads by 'lymphatics' to the lymh nodes in the axilla. On palpation of axilla, if the nodes are enlarged, then a complete removal of all the axillary fibro fatty lymphatic tissue is a must. In those patients, in whom the tumour is small and there are no clinically enlarged nodes, a conservative approach called as Sentinel Lymph Node biopsy can be done. See the section on lymph node dissection for further details.
For a patient to undergo BCS, certain conditions need to be fulfilled. They are as follows:
Post operative Radiotherapy: In a BCS, though we remove the tumour along with a one cm margin on normal tissue all around the tumour, there is still a significant chance (in the range of 25 to 40%) that cancer will again arise from the remnant breast tissue of the same side. To decrease this cancer developing again in the same breast, radiotherapy is a MUST for any patient undergoing a BCS, and post operative radiotherapy after BCS decreases the chances of disease coming back to a bare 3% (This is very significant). This point has to be understood by the patient, and only if the patient is agreeing for a post operative radiotherapy, can a surgeon go ahead with a breast conservation surgery.
Disease in one location only (Unicentric disease): To understand this, consider division of the breast into four quadrants. A BCS can be done only if the disease is localized to one quadrant or in one area. If there is disease in two (or more) separate quadrants or areas (called as Multicentric Disease ), then a BCS cannot be done. A pre operative mammogram gives an idea of the disease distribution in a majority of cases, and is a must for any BCS.
Cosmesis: The size of the tumour relative to the size of the breast is an important factor to consider. If the breast is large and tumour is small, there is no problem. But if the breast is smaller and tumour is larger, then BCS will result in a cosmetically unacceptable result. So either a mastectomy may be done, or BCS can be done with some form of plastic surgical reconstruction.
Patient desire: Some patients may be too apprehensive about a BCS and do not want any breast tissue remaining back. After counselling, a mastectomy may be done.
The answer very well lies in the above points.
Multicentric Disease: As explained above, if the disease in the breast lies in two or more separate areas or quadrants, a BCS cannot be done.
Patient not ready for post operative radiation therapy Post operative radiation therapy is an integral component of BCS and if any patient is unwilling to undergo a radiation therapy, then a BCS cannot be done.
Cancer of the breast arises due to 'induced' genetic changes in the glandular and ductal cells of the breast, whatever be the 'inducing' agent, be it the female hormone estrogen, or be it anything else. These changes may be in a single cell, which ultimately replicate and form the tumour; or may be a part of a more generalized process, where all the cells have some form of changes which may ultimately culminate into a cancer. In a BCS, we remove the tumour with a surrounding normal margin of about 1 cm of so. But even ensuring a margin of 1 cm, what is the guarantee that no more cancer cells are remaining behind? And also, there will definitely be some chances atleast, that since a cancer has arisen in that breast, it can do so again from the remaining cells in that breast.
It was seen that if a wide excision lumpectomy was done, and if post operative rasiation therapy was not given, the chances of a cancer coming back in that breast were in the range of almost 25% to 40%, which is definitely very high and unacceptable. For this purpose, post operative radiation therapy was evaluated and it was found that after a post operative radiation therapy, the chances of recurrence come down to a mere 3% to 10%. Hence, post operative radiation therapy is an integral component of a BCS.
When the size of a tumour is large (but still operable), and the size of the breast is not relatively large, then BCS is a problem, since it will result in an unacceptable cosmetic result. In this situation, a Neo Adjuvant Chemo Therapy (NACT), can be given, which will reduce the size of the tumour, and then a BCS may be feasible. A majority of patients respond very well to NACT and will ultimately become feasible for BCS. If the size of the tumour doesn't shrink with NACT and the patient still desires breast conservation, then she must be counselled about other forms of reconstruction.
After a BCS with post operative radiotherapy, the chances of a 'local recurrence', meaning the chances of disease coming back in the same breast range from 3% to 14%. Though these chances of local recurrence are more than in a mastectomy, they do not affect the overall survival. So one should not be worried about this fact, and not go for mastectomy, just because chances of disease coming back are slightly higher.