Breast Cancer Treatment

October 2023

The different breast surgical treatment modalities are: 

• Breast conserving surgery 

Also called partial mastectomy or quadrantectomy, consisting in removing the tumor with safety margins while conserving the rest of the breast. It is always followed by post-mastectomy radiation therapy. 

In some cases (non palpable tumor), an ultrasound guided harpoon may be placed preoperatively in order to guide the surgeon with the excision. The specimen is sent to the lab in order to ascertain the negative margins. In case of positive margins, it is best to re-excise into safe margins.

• Total mastectomy

It consists in the total excision of breast tissue with varying amounts of skin conservation and with or without nipple/areola conservation (very specific indications depending on your biopsy, PET scan and tumor characteristics).

In addition to breast surgery, you may need:

• Sentinel Lymph Node Biopsy (SLNB)

The sentinel lymph node is the first relay in the lymphatic channels after draining the breast (and breast tumor). Therefore, if it does not contain breast cancer cells, the chances of it having spread to the other lymph nodes are slim to none. Before breast surgery, a slightly radioactive tracer (Technetium 99m) is injected near the areola (the day before or the same morning), and it is traced with a special sensor to the sentinel lymph node, which is excised (usually 2-3 lymph nodes) via a small 3 cm incision in the axilla and sent to the pathology to be examined. 

Some surgeons may use Patent Blue, which can color the lymphatic channels and lymph  nodes. This product may rarely cause some allergic reactions. If the SLNB does contain cancer cells, an axillary dissection (or excision of all lymph nodes) should be completed either directly or in an delayed fashion to better stage the breast cancer. 

• Chemotherapy

You may need chemotherapy in the preoperative setting (neoadjuvant chemotherapy) in order to downstage a tumor (6 months), or in the postoperative setting (adjuvant chemotherapy) in case of high-risk factors (tumor and patient characteristics). 

• Post-Mastectomy Radiation Therapy (PMRT)

You will need PMRT after breast conserving surgery in order to decrease local recurrence and improve survival. In cases of total mastectomy, PMRT may be used (6 weeks) on the axilla, in case of numerous cancerous lymph nodes, or bulky disease and on the chest wall in case of incomplete resection and based on tumor/patient characteristics.

• Endocrine (hormone) therapy

Tamoxifen or aromatase inhibitors are used in patients with positive estrogen and progesterone receptors for a total duration of 5 years after completion of chemotherapy, in order to reduce the risk of recurrence and improve survival.

Her2-Neu inhibitors (Trastuzumab) may be used in positive HER2-Neu breast cancers to reduce the risk of recurrence and improve survival.

• Immunotherapy

Used in some cases of recurrent, aggressive, advanced or metastatic breast cancer. These are highly advanced targeted therapies that only work in certain types of cancers. They have changed the way we look at advanced breast cancer in terms of survival. 

Breast cancer surgery undesirable effects

To be discussed with your breast and plastic surgeon:

• Inadequate surgical resection

• Arm/shoulder chronic pain

• Inner arm abnormal sensation

• Breast skin partial or total necrosis

• Wound dehiscence

• PMRT induced skin damage

• Lymphocele or seroma

• Arm Lymphedema

• Hematoma

• Surgical Site Infection

• Deep Vein Thrombosis or Pulmonary embolism