Breast cancer is commonly diagnosed worldwide and it is the second most common cause of cancer death in female. One in 9 female suffers from breast cancer. Incidence and risk of breast cancer increases with age. Risk factors for breast cancer includes 1) family history of breast cancer and genetic predisposition, 2) excessive alcohol consumption (>2S.D/day), 3) early menarche, 4) late menopause 4) nulliparous after age 30, 5) obesity, 6) age, 7) previous diagnosis of breast cancer 8) dense breast 9) age>50.
With development of breast screening and advancement in breast cancer management, 5 year survival of breast cancer sufferer had improved markedly. Breast cancer is diagnosed via triple assessment which includes 1) history and examination 2) diagnostic imaging (mammography/ultrasound+/- MRI) 3) tissue diagnosis (fine needle aspirate (FNA)/ Core biopsy/VABB).
Breast surgery remained the mainstay treatment for early breast cancer but other therapy (chemotherapy/radiotherapy/endocrine therapy) are available to complement the treatment for breast cancer.
The types of surgery for malignant breast disease includes:
Breast conserving surgery- Lumpectomy/ wide local excision
Complete excision of disease with good margins of normal tissue around to ensure complete resection and preserving the rest of the breast. If disease is not palpable, hookwire localization under mammographic or ultrasound guidance to target lesion will be required. Specimen assess with specimen x-ray and will be marked and sent to histopathology for assessment. If margins are inadequate, further re-excision will be required in a separate setting.
Mastectomy +/- reconstruction
Complete excision of breast with or without breast reconstruction. This procedure does not remove 100% of breast tissue as there maybe some under skin. Reconstructive surgery is performed in conjunction with a plastic surgeon either as a immediate setting (during mastectomy) or delated setting (after treatment of breast cancer). Reconstruction can be either with a prothesis of native tissue.
Sentinel node biopsy
Removal of the first tier lymph node(usually in the armpit) for assessment. This is performed with help of radioactive dye and blue dye injected around the breast in order to locate the first few nodes draining from the breast. If negative, chances of the other lymph node being positive is <5%. This procedure has a lower complication rate compared to axillary clearance.
Removal of majority of the armpit lymph node for assessment. This is usually done in the setting of positive nodes within the armpit either diagnosed before surgery or after sentinel node biopsy. There are certain circumstances that axillary radiotherapy is used instead of axillary clearance. Case will be assessed in a case by case setting.
Oncoplastic breast surgery/ perforator flaps
With breast conserving surgery, oncology clearance is of utmost importance but an adequate cosmetic outcome is also important for the patients’ wellbeing. Many plastic surgical techniques have been adopted and modify to help reshape the breast after breast conserving surgery. Apart from breast reduction techniques, flaps created from the chest wall or abdominal wall are used to replace breast volume after excision to allow symmetry.
Berry et al. Oncoplastic breast surgery: a review and systematic approach. Journal of plastic, reconstructive and aesthetic surgery 2010:63(8): 1233-1243
Meybodi F, Cocco AM, Messer D et al., The Modified Lateral Intercostal Artery Perforator Flap. Plast Reconstr Surg Glob Open. 2019 Feb 5;7(2):e2066. doi: 10.1097/GOX.0000000000002066. PMID: 30881825; PMCID: PMC6416140.