Breast Cancer Treatments & Surgery

Bedside ultrasound is used as an adjunct to clinical breast examination. A targeted ultrasound examination of the region of interest in the breast may reveal more information about the underlying breast tissue than clinical examination alone. Bedside ultrasound does not replace formal diagnostic breast ultrasound which is performed by highly trained breast sonographers, and interpreted by specialist radiologists with an interest in breast pathology. Bedside ultrasound is used to target fine needle and core biopsies performed in rooms.

Fine needle biopsies are performed in rooms either of palpable breast lumps or under ultrasound guidance of impalpable lesions. Local anaesthetic is not usually needed, but may be required for some patients. Small samples of breast tissue is obtained for cytological examination by specialist pathologists, to obtain information about the breast tissue. Fine needle biopsy is used to complete the "Triple Test", the gold standard in breast assessment. A result is available after 24 hours.

Core biopsies are performed in rooms under local anaesthetic. A small sample of the breast lesion is removed in the core sample for examination by specialist pathologists. Some minor bruising and swelling may follow a core biopsy, as it is a minor surgical procedure. Core biopsies are obtained of breast lesions in order to make a definitive histological diagnosis so that definitive management can be planned. A result is available after 48 hours.

Most simple breast cysts do not need to be aspirated. Complicated simple cysts may be aspirated to relieve symptoms. Complex cysts are aspirated in order to obtain material for examination by specialist cytopathologists to exclude breast cancer. Palpable cysts are aspirated simply without an ultrasound, but impalpable complex cysts are aspirated with fine needles using bedside ultrasound for accurate targeting. Local anaesthetic may be used if necessary. Results are available after 24 hours.

A total mastectomy is no longer always needed for breast cancer treatment. All patients with benign disease, and the majority of women with breast cancer, can be treated safely with breast conservation surgery. A range of surgical approaches are used to maximize the cosmetic result after breast conserving procedures. Radiotherapy is usually used to reduce the risk of recurrence in the remaining breast tissue after breast conserving surgery. Occasionally a second surgical procedure is necessary if breast conservation is not successful in removing all of the affected breast tissue.

A mastectomy is sometimes the best procedure to manage certain conditions. Breast reconstruction may be performed either simultaneously, or delayed, as the clinical situation requires. Women are encouraged to actively participate in planning the individual procedure that best suits their particular situation. All the breast tissue, and usually the nipple, is removed by mastectomy. Skin preserving (subcutaneous) procedures are used to maximize the cosmetic result if breast reconstruction is planned, and in some cases, the nipple and normal breast skin can be preserved and only the diseased tissue removed from beneath the skin, with an immediate breast reconstruction achieved with a variety of methods. The breast care nurse and breast unit psychologist are actively involved in the psychological support of patients considering any form of mastectomy.

Surgically removing all of the lymph nodes situated in the axilla (armpit) is sometimes a necessary part of breast cancer surgery if the breast cancer cells have spread to these nodes. An axillary clearance is usually performed if the sentinel node has been found to contain cancer. On average 20 - 30 nodes are removed, but this does not have an adverse effect on the immune system. Some (approximately 15%) patients develop arm swelling which is well managed by lymphatic drainage massage and a compression sleeve.

The sentinel lymph node is the first node breast cancer cells will reach if they spread beyond the breast. Identifying and testing the sentinel node is therefore very helpful for planning subsequent breast cancer treatment after surgery. 

A Microdochectomy is a targeted surgical procedure, whereby a single duct behind the nipple is removed for examination by the breast pathologist. 

The major breast ducts coalesce behind the nipple/areola complex. Suspicious discharge for the nipple may be the first indication of significant disease in the ducts, even in the absence of clinical or imaging findings. Subareolar duct excision removes all of the major ducts from behind the nipple, to stop the discharge, and to provide the pathologist with the duct tissue for examination. The nipple is preserved, but breastfeeding is not possible after a sub-areola duct excision. Usually the cause of the discharge is benign duct disease requiring no further treatment, but if breast cancer is found in the ducts then further surgery may be required.

Open surgical biopsy under anaesthetic has largely been replaced by fine needle and core biopsies (see above). There remains however the unusual situation where a lesion in the breast is atypical and needs to be fully removed for complete examination by the pathologist.