Breast cancer is the most common cancer affecting females. Almost 1/4th of all cancers diagnosed in our country are breast cancer. The incidence of breast cancer is more than 150,000 cases a year, and majority of those cancers diagnosed in our country are in advanced stages III and IV. Surgery is the most important part of multidisciplinary treatment of breast cancer.
Surgery for breast cancer is known as MRM (Modified Radical Mastectomy). The term originates from the Greek word mastos, meaning woman's breast, and the Latin term ectomia, which signifies excision. mastectomy requires complete removal of breast along with axillary lymph nodes from a almost elliptical transverse incision of breast surrounding the nipple areolar complex. The other options or surgical technique for breast cancer surgery is Breast Conservation Surgery.
BCS is technically wide local excision with adequate margins with axillary lymph node dissection. This is a surgical technique which helps to the patient to have organ (breast) conservation with good surgical margins with good cosmesis. Whenever patient is advised Mastectomy she should also be counselled about the options of breast conservation with or without reconstruction. Breast reconstruction can be done in the same sitting and have a very positive and profound positive effect on her psychology. Whether the patient undergoes Breast conservation surgery or Mastectomy the survival figures are same in both surgical techniques.
Mastectomy is mandatory in few cases where in multi centric or multifocal disease is there, in patients with advanced loco regional disease. MRM is required in patients of Paget’s disease, inflammatory breast cancer and in patients with poor response of Neo adjuvant chemotherapy and also in those where in the breast mass to tumour ratio is unfavourable. Mastectomy surgery can lead to various early and late side effects and complications. Most notable complications are seroma formation, haemotoma, skin flap necrosis, wound infection and lymphedema.
Pre operative preparation to the surgery for breast cancer involves complete diagnostic and metastatic work up including investigations like PET CT among others. Normally the site and side is marked and it is advised not to take blood samples, place IV cannulations and give IV medicines on the diseased side. Patient usually requires admission for two or three days, most commonly the patient is discharged in two days with a romovac suction drain for lymphatic fluid.
Post operatively patient is started with pain killers, antibiotic and other supportive medications for at least 01 week. Drain is removed after the 24 hour lymphatic drain is less then 30ml or so for two consecutive days. Normally the operative wound is dressed every 3 days or so and the clips or sutures are removed after 02 weeks. The final histopath and immune histochemistry receptor status which give final stage and receptor status of the disease would be available in one week after surgery. This report helps us to plan further adjuvant chemotherapy and targeted therapy including radiation therapy for the patient.
Arm paraesthesia and numbness are other complications which patients suffer in post operative period. Of all the compilations arm lymphedema is the most frustrating to treat and mange in long term. Best treatment is to prevent development of lymphedema by good surgical techniques and active post operative physiotherapy and occupational therapy management. The incidence of arm lymphedema in almost 15-18% cases of mastectomy and the incidence has fallen after use of surgical technique of Selective Sentinel lymph node biopsy.
To sum up, Mastectomy is the gold standard in surgical techniques for management of breast cancer. Both Mastectomy and Breast conservation surgery have similar survival figures and have low morbidity and are very safe procedures. All cases in which mastectomy is being planned should be considered for Breast conservation surgery if possible. Finally, the prevention of arm lymphedema is better and avoided with use of Sentinel lymph node sampling wherever feasible.
(Author: Dr. Naveen Sanchety, Director - Surgical Oncology, Sarvodaya Hospital, Sector-8, Faridabad)
