Surgery can be divided into pre-operative preparation, intraoperative execution and post-operative treatment phases. Breast cancer patients preparing for breast-conserving surgery can learn about the entire process of breast-conserving surgery from these three aspects.
Preoperative preparation phase
Before breast-conserving treatment, a thorough preoperative workup is required, including mammogram, ultrasound, and, if available, magnetic resonance imaging (MRI) of the breast, which is often recommended to clarify the nature of the lesion and guide the treatment plan.
In addition to the breast-related tests mentioned above, patients should undergo a number of other preoperative tests, such as electrocardiograms and pulmonary function tests to rule out abnormal heart and lung function, chest CT and liver ultrasound to rule out distant metastases from breast cancer, and blood tests to determine whether there are abnormalities in blood count and liver and kidney function. In addition, the patient’s blood pressure and blood glucose should be controlled within the acceptable range for surgery, which is important for the patient’s life safety in the perioperative period.
Before undergoing surgery, the patient and family need to sign an informed consent form to understand the surgical plan, the procedure, the possible scenarios and what the surgeon will do in different situations, and the possible postoperative complications and their management, in order to make the most appropriate decision.
For some patients with small lesions that cannot be located by palpation, preoperative localization is also required, either under mammography, ultrasound, or MRI. General anesthesia is preferred for breast-conserving surgery for breast cancer.
Surgical implementation
The goal of breast-conserving surgery is to reduce the chance of local recurrence by complete removal of the tumor and to ensure a good breast appearance. Therefore, the surgeon will give full consideration to these two objectives during the surgical implementation, and if these two objectives cannot be achieved, breast-conserving surgery may not be successful. The following points can be understood about the implementation process of breast-conserving surgery.
- Selecting the surgical incision. Breast-conserving surgery for breast cancer includes an extended excision of the primary site of the breast and axillary lymph node surgery (either an axillary lymph node biopsy or axillary lymph node dissection). The surgeon will usually make an incision in each of the breast tumor site and the axilla, or may choose a surgical incision if the tumor is located in the outer upper region of the breast near the axilla. The direction and size of the incision will be designed according to the location and size of the tumor, and the postoperative cosmetic result will be taken into consideration. If the tumor is located deep in the breast and has not invaded the skin, the skin on the surface of the tumor may not need to be removed. If it has invaded the skin or has localized skin depression manifestation, the surgeon will remove part of the skin.
- The general procedure of the procedure. If an anterior lymph node biopsy is required, in principle the surgeon will prioritize the anterior lymph node biopsy, and if axillary lymph node dissection is required, it will be performed after removal of the primary breast lesion. The scope of resection of the primary breast lesion includes the tumor, a certain area of breast tissue around the tumor, a portion of the skin if the tumor invades the skin, and a portion of the pectoralis major muscle and fascia if the pectoral muscle is invaded.
- Tumor evaluation. For resected tumor lesions with clear preoperative pathologic histologic evidence, intraoperative frozen pathology may be dispensed with; conversely, the lesions should be sent for intraoperative rapid frozen pathology to clarify the diagnosis. At the same time, the surgeon will also evaluate the resected peritumor tissues (i.e. superior, inferior, internal, external, basal cut margins, etc.) and the anterior lymph nodes, which are usually evaluated by intraoperative rapid cryopathological examination as well. If the results are not abnormal, breast conservation is initially proven to be successful, but postoperative pathological histology is still required. If intraoperative evaluation reveals residual tumor lesions, the surgeon may choose to proceed with breast-conserving surgery or perform a total mastectomy after evaluation. When the malignant lesion is a calcified foci, the surgeon will perform another mammogram on the intraoperatively excised specimen to clarify whether the lesion was completely removed.
- Treatment of the post-excisional area. After breast-conserving surgery, the surgeon will perform a thorough hemostasis and cleaning of the surgical area. For most successful breast-conserving patients, the surgeon places a marker in the residual cavity after removal of the tumor, with a metal titanium clip being the choice for those providers who are able to do so. The purpose of the marker placement is to prepare the patient for postoperative radiation therapy, which will be communicated to the patient prior to surgery.
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The above is just a general procedure for breast-conserving surgery and is not set in stone and will be treated by the clinician on a case-by-case basis.
Postoperative treatment
Tissue specimens removed intraoperatively are subjected to postoperative pathological histology and immunohistochemistry to guide postoperative treatment. After surgery, the physician will develop a treatment plan based on the immunohistochemical results of the tumor, the condition of the lymph nodes, and the health of the body, usually followed by radiation therapy after chemotherapy. Radiation therapy after breast-conserving surgery can substantially reduce the rate of local recurrence. Those who are suitable for endocrine therapy may be treated with endocrine therapy along with radiotherapy.
Regular follow-up is required during and after adjuvant therapy. In addition to blood tests, this includes breast ultrasound (including breast, axillary lymph nodes, and supraclavicular lymph nodes), breast MRI, chest CT, and liver ultrasound to closely monitor for local recurrence and distant metastases, and for patients receiving endocrine therapy, regular examinations of both adnexa of the uterus are required.
In conclusion, breast-conserving treatment is a systematic treatment process, and after surgery, patients should actively receive adjuvant therapy and regular review, and stay in close contact with their clinicians to identify and manage any possible conditions that may arise.