WHAT YOU NEED TO KNOW NOW
Surgical management of your breast cancer requires treatment of the primary tumour within the breast by removing the known tumour with clear margins. Surgical options for tumour removal include a lumpectomy (partial mastectomy), total mastectomy or mastectomy with reconstruction.
A lumpectomy or partial mastectomy involves the removal of the tumour along with a rim of normal or unaffected breast tissue. This process aims for negative margins. Post-operatively, radiation will be given to the area to reduce the risk of recurrence within the breast and/or lymph nodes.
If a tumour cannot be felt, you will require a wire-localization by the radiologist on the day of surgery. This is when a thin wire is placed under image guidance through the site of the cancer. This procedure is similar to the biopsy but less painful and less time consuming.
A simple mastectomy without reconstruction removes all of the breast tissue including the nipple and areola. Post-operatively you will have a horizontal scar across a flat chest. Various external prostheses are available to obtain symmetry in clothing.
When a mastectomy is completed in conjunction with immediate breast reconstruction, an envelope of skin, with or without the nipple areola complex, is left for immediate insertion of a tissue expander or breast implant.
Skin-sparing and Nipple-sparing mastectomy
There are many options for breast reconstruction, but your breast surgeon in conjunction with your plastic surgeon would discuss what is best suited for you. This is determined by your own preferences as well as your body type and health history. In general, the breast can be reconstructed by flaps of your own tissue or prosthesis (tissue expanders and implants). This video will provide an overview of what to expect with mastectomy and implant-based reconstruction.
Assessment of lymph nodes is also required at the time of surgery. Depending on your stage and extent of disease, this can be completed with either a sentinel lymph node biopsy (SLNB) or an axillary lymph node dissection (ALND).
What is an SLNB?
This is done at the same time as your breast surgery and involves removing the first few lymph nodes from under the arm that drain the breast. This is on average two to four nodes. In order to find those first nodes, you will have an injection of a radioactive dye (called Technecium 99) and often a blue dye. Both of these dyes travel to the nodes and allow your surgeon to find the sentinel nodes. The radioactive dye can be injected up to 24 hours before the surgery; the blue dye is put into the breast once you are asleep at the time of surgery.
A SLNB has very little risk but will result in very mild swelling under the arm where the nodes were removed (called a "seroma"). This is normal and will usually resolve within a week or so; if not, then it can be drained with a needle in the clinic. It is very uncommon to have a long-term side effect such as arm swelling (lymphedema) with only a SLNB performed. It is very rare, but allergic reactions to the blue dye have been reported and would be treated at the time of surgery if it develops.
What is an ALND?
This involves removing the whole group of lymph nodes under the arm (called the level I and II nodes). This is done if there is disease in lymph nodes that can be felt (they are clinically enlarged) and in situations where the nodes have not responded to chemotherapy beforehand. It is also done if there is a significant amount of tumour cells found in the sentinel nodes.
After this surgery, there is a more significant risk of lymphedema (15 to 30 per cent), so you would also need a drainage tube to be left in place until the discharge of fluid decreases under 30cc over 24 hours for two consecutive days (on average it remains about seven to 10 days).