The surgical management of breast cancer

Most treatment plans for breast cancer involve some form of surgery. This falls into two main categories: breast-conserving surgery, which includes wide local excision, or mastectomy, which involves removal of all the breast tissue. While breast conservation is not always appropriate, the evidence shows that women who have it do just as well as those who have a full mastectomy (Sampson and Fenlon, 2000).

The clinical and pathological features of breast cancer that influence the type of surgery used include the position and size of the cancer; the size of the breast; an incomplete initial excision; a young age (under 35); extensive in situ component; lymphovascular invasion; and histological grade (Sainsbury et al, 1995).

Types of breast surgery

Wide local excision/lumpectomy

The lump is removed, plus about 1cm of surrounding normal tissue to ensure clear margins of excision.

The nipple is usually unaffected and, providing the milk ducts have not been damaged by radiotherapy, breastfeeding may still be possible (Baum et al, 1994).

Quadrantectomy/segmentectory

This involves removal of a quadrant (quarter) of the breast and underlying tissue.

Mastectomy

All the breast tissue is removed, along with the axillary tail. The nipple and some of the skin is also removed, leaving a scar across the chest wall. A seroma may occur post-mastectomy. This is a temporary build-up of serum that may need to be removed using a needle and syringe, or it may resolve itself with time.

Part of the role of the hospital breast care nurse is to fit such patients with soft-foam breast forms before discharge. Advice on choosing a suitable bra is also given. Patients are then seen eight weeks later, once any swelling has reduced, to be fitted for a more permanent breast prosthesis.

Axillary lymph node surgery

It is highly likely that any breast surgery will include surgery to the axillary lymph nodes. There are about 20-30 lymph nodes in the armpit. They form part of the lymphatic system and drain fluid and infection from the breast.

These nodes are checked for cancer cells before surgery as this is the most common area for breast cancer cells to spread to. The status of the nodes is the best single prognostic factor on which to base treatment decisions (Dixon and Sainsbury, 1998).

Axillary node clearance (ANC)

This involves the removal of all of the lymph nodes in the axilla up to the apex. However, this can increase the possibility of long-term damage such as numbness in the upper arm, restricted arm movement, cording (when cords of fibrous tissue form due to inflamed lymphatics) and/or swelling of the arm (lymphoedema).

To prevent lymphoedema, patients should be advised against carrying heavy bags with the affected arm or having blood taken from, or blood pressure measured in, that arm. They also should be advised to wear gloves for gardening or washing up to minimise risk of infection of the lymphatic system.

Axillary node sampling (ANS)

This may be performed when four or more nodes are removed. This gives information about whether or not the cancer cells have spread to the axilla, but does not reveal the extent of this.

Sentinel node sampling

Another practice is to identify the sentinel node - the first node in the armpit that receives lymph from the region of the affected breast - and to take a biopsy during the operation. To find the node the surgeon will inject a radioactive isotope and/or blue dye before surgery. During the operation, the surgeon should be able to locate it either by using a radioactivity counter or looking for the 'hot' blue-stained lymph node.

Sentinel node biopsy is not yet a proven and established method for staging or treating the axilla in the UK, and should be combined with some other form of staging procedure until the results of an ongoing multicentre trial are available.

Breast reconstruction

There are three ways to reconstruct the breast following a mastectomy:

- Using an implant or tissue expander;

- Using a latissimus dorsi (LD) flap;

- Using a transverse rectus abdominus myocutaneous (TRAM) flap.

Breast reconstruction can be carried out at the same time as the mastectomy or at a later stage. Immediate reconstruction results in one operation only, but can take a lot longer and lead to complications associated with lengthy surgery. Care therefore needs to be taken to ensure the patient is suitable for the type of surgery performed.

Using an implant or tissue expander

Silicone implants are the most commonly used implants after breast surgery. Associated health concerns are that they can cause cancer, arthritis and interfere with the immune system (Sampson and Fenlon, 2000). However, the Department of Health has stated that there is insufficient evidence to support such claims.

Saline implants are an alternative, and have the advantage of being closer in type to the body's own fluids. However, they have a tendency to wrinkle or ripple and feel slightly less like natural breasts.

Tissue expanders can be used for women with larger breasts. These implants are a mixture of silicone with an empty 'bag' inside attached to a port. The port is hidden and tunnelled under the arm, and can be inflated through weekly injections of saline (about 50ml at a time). Once the desired breast size has been reached, a second operation may take place to replace the tissue expander with a permanent silicone implant.

Implants and expanders are inserted under the muscles of the chest wall. Because they are foreign bodies, the body can occasionally form a hardened capsule around the implant and infections can occur. The implant can also shift position.

Mammograms to detect signs of recurrence can still be performed following insertion of a breast implant but may be more difficult to read. Patients should alert the radiologist to their recent surgery.

LD flap reconstruction

This is when an area of skin and fat from the back and the latissimus dorsi muscle are pivoted around to form the breast shape. The muscle is tunnelled under the arm, leaving it attached to its blood supply, and it may be shaped around a silicone implant if the breast size demands it.

TRAM flap reconstruction

This is when the flap of rectus muscle and skin are tunnelled, with their blood supply, to the breast area. If necessary, more fat and tissue can be used with this method, so implants are rarely used. With flap reconstruction, the greatest problem is flap necrosis.

Research has shown that this occurs in 5% of patients opting for the LD flap reconstruction and 10% of patients opting for the TRAM flap reconstruction (Watson et al, 1995).

Seromas or haematomas may also occur where the muscle and fat are removed. These tend to be temporary, but can be aspirated or drained.

Nipple reconstruction

If nipples need to be removed, prosthetic replacements can be attached using a water-soluble adhesive. Some hospital surgical appliance departments can take a cast of the nipple on the unaffected breast and make a copy. Other options include a nipple being tattooed onto the reconstructed breast, or the use of tissue from the remaining nipple to reconstruct another.

General nursing care

As with any surgery, the wound should be checked regularly for signs of bleeding or infection. The patient will usually have two suction drains in place: one in the breast and one in the axilla. These should also be checked and removed as per hospital protocol. The patient should never be forced to look at their wound - they are undergoing an alteration in body image and need sensitive and careful care.

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