Wide Excision

Surgery to the breast:

There are several equally effective ways of removing the cancer from the breast. We realise that being given a choice of what to do can be difficult, but we encourage you to discuss all the options available to you with your surgeon, your Breast Care Nurse, family, friends and relatives, particularly if any of them are medical themselves or have had to make the same decision in the past.

Please DO NOT feel you are being pressured into making an instant decision. You will have several days to think about it and you are free to request as many appointments as you need to get further information, advice or clarification, either with your nurse or surgeon.

There are a few principles you should understand that will make your decision easier:

1. You will only be offered the treatment which gives you the best chance of a cure and you will only be offered a choice of treatments if your surgeon is confident that there is more than one effectively way of removing your cancer.

2. Whilst effective treatment of the cancer is the first priority, your surgeon will be very aware that most women also consider a reasonable cosmetic result important.

From this four important facts drop out:

  1. If cosmetics is of NO importance to you whatever, then a mastectomy is the simplest procedure. (It ensures that only one operation on the breast will be needed, that radiotherapy treatment after mastectomy can often be avoided, and with less breast tissue remaining the risk of a future new cancer developing is reduced.)
  2. The best cosmetic result is usually obtained by removing as small an amount of breast tissue as safe and, therefore, reconstruction is reserved for women who have to have a mastectomy as the only way of effectively removing the cancer.
  3. The cost of retaining the major part of the affected breast is that radiotherapy WILL be required afterwards. (Except in case of pure low grade ductal carcinoma in situ.)
  4. The second potential cost of retaining the major part of the affected breast is the small risk that a second operation may be required. About 1 in 5 of women treated this way need a second operation. The reason for this is explained below. (Link to Wide local excision – risk of second surgery.)

Wide Local Excision (Lumpectomy or quadrantectomy):

This is removal of the cancer with a rim of normal tissue around it.

For most women with an early small cancer, this is the treatment of choice. It is likely to give a good cosmetic result and removes a minimum amount of breast tissue much of which is replaced by the body in the first few weeks after surgery. It leaves a scar but this soon fades. Although the surgery requires a general anaesthetic (asleep), it is common for the woman to be able to go home the next day.

The surgeon aims to remove a margin of normal breast issue around the cancer. We will check very carefully by what we see, what we feel and we will X-ray the tissue we have removed to be as certain as possible all the affected tissue has been taken. However, it is very important to check under the microscope that there is normal tissue in all directions around the cancer, and this takes about 5 working days to complete. If this is not the case, then further surgery to the breast will be needed.  This means a second operation about 4 weeks after the first.

The problem your surgeon will have is that some changes of cancer (particularly lobular cancer or carcinoma in situ) will not be seen by the naked eye, felt or show on the tissue X-ray and can only be seen at 60 times magnification under the microscope.

Wide local excision is ONLY acceptable as a treatment provided:

1. The microscopic examination confirms that some normal breast tissue has been removed from ALL around the cancer and/or any carcinoma in situ.
2. That radiotherapy is then given to the remaining breast tissue on the affected side, (except in the rare case of pure low grade carcinoma in situ.)

Mastectomy:

This is removal of the whole breast, the nipple and some skin and leaves an oblique scar across the flat chest.

It is necessary in women with larger cancers, multiple cancers within the one breast or widespread pre-cancer (carcinoma in situ).

It is also suitable for women who consider a good cosmetic outcome as unimportant, or who are confident that to wear an external prosthesis (false breast) in their bra will give them an acceptable result.  It is also the best choice for women who want to guarantee have their cancer removed at one operation.

The disadvantages of mastectomy over wide local excision, apart from the cosmetic, are that it is a bigger operation, it is common to have to leave a surgical drain (tube coming out from the skin) which may take up to a week before it can be removed and the surgery is a little longer and therefore it takes a bit longer to recover. It is usual to be in hospital for 2 days or more after the surgery.

Reconstruction:

Breast reconstruction is only suitable for women who have to have a mastectomy or who have a poor cosmetic result after a wide local excision (which is relatively rare now that internal rotation flaps are available).

The best cosmetic results and the least risk is to leave a woman’s own breast tissue in place if it is safe to do so.

If you are considering reconstruction it is very important that you discuss the matter fully with one of our senior reconstructive breast or plastic surgeons (of which we have 2 attached to our unit) and your breast care nurse. We will need to assess your needs individually and making a decision on which technique is suitable in your case depends on many factors which experience only can provide. The following information is for guidance only.

Internal rotation flaps:

In this surgery the cancer is removed like a slice of cake with the overlying skin. The breast issue is then freed up on the inside and rotated to fill in the missing segment. This usually involves a small cut about the nipple which is moved a short distance to compensate for the skin loss, and there is a second scar around the outside of the breast extending into the under arm area.

Suitable for:

Women with larger cancers in normal or large breasts or moderate sized cancers in a small breast.

Inner half (particularly upper inner – the cleavage area) cancers.

Advantages:

It gives a good cosmetic result and retains the shape of the breast even though the volume be reduced by about one cup size. (Up to one cup size discrepancy is common and rarely noticeable – most women who have never had breast surgery are uneven one side to the other if they look carefully).

Disadvantage:

There is additional scaring of the breast even though the scars tend to be hidden in the normal folds and skin lines of the breast.

It takes about 40 minutes longer for the surgery over simple wide local excision, but to go home the following day is still normal.

Tissue expander reconstruction: