Breast Surgery

The diagnosis of breast cancer is made using a combination of Clinical Examination (where a palpable lump is assessed by experienced medical personnel), 

a Radiological Examination (any combination of ultrasound, mammography, or MRI), and a Histological Assessment (where a biopsy is studied under a microscope).

• In the early stages, breast cancer gives no symptoms and can only be detected by radiological assessment.
• As the disease progresses, a lump may be felt - when the lump grows it may produce skin changes such as redness or dimpling.
• As cancer grows, it will start to spread. The most common ‘first station’ is the lymph nodes of the armpit (axilla), and from there it can spread to distant locations (most commonly the liver, bones, and lungs).

• A very large breast lump can ulcerate, bleed, or discharge fluid.
• Nipple discharge can occasionally be an indicator of breast cancer.
• Although a common complaint, breast pain is not a common presenting symptom of breast cancer.

• Treatment for breast cancer depends on size, spread, previous history, and individual factors such as co-morbidities. Breast cancer treatment is often a combination of surgery, radiotherapy, chemotherapy, and hormonal therapy.
• The treating specialist will form a plan by assessing each patient. Sometimes, this requires a discussion at a Multi-Disciplinary Team Meeting (MDT Meeting), where multiple specialists determine the most appropriate course of action.
• Depending on the individual, other supporting specialists may be involved, including an occupational therapist, a physiotherapist, and a psychotherapist.
• Most people start their treatment with surgery, then progress to other therapies dependant on the characteristics and status of the cancer.

Wide Excision

Wide Excision is the removal of cancer with a safety margin (where a small amount of tissue is taken around the tumour to ensure none is remaining in the body) and is followed by radiotherapy to eliminate any remaining cells. 
Patients who are good candidates for this surgery are those where the cancer was discovered in its early stages and is still small, and where the surgery can leave good cosmetic results.

Mastectomy

Mastectomy is the removal of the whole breast. This approach is usually used if the cancer is too big for a wide excision, if there are multiple tumours, or if the patient has a preference for this approach. The likelihood of requiring radiotherapy is usually lessened following this more radical surgery. 
The patient will have a flat chest on the side of operation with a horizontal scar across the chest. Drains are inserted during this operation which the patient takes home, and these are removed by the district nurses when the drainage is minimal (usually around 1-3 weeks).

This is a technique used to identify an abnormal area in the breast that can be seen on ultrasound or mammogram, but cannot be felt on clinical examination, and is required to be removed surgically. A tiny wire is placed in the breast under local anaesthesia, before the operation. The wire guides Mr Haddawi to the area of concern and will be removed during the operation.

A radiologist places the wire a few hours before the operation. To do so, an injection of local anaesthetic will be given to numb the area, and the wire (within a needle) is inserted under the guidance of a mammogram or ultrasound. Once the wire is placed, the needle will be removed. A mammogram might be performed after the wire is inserted. This checks the wire’s position and helps the surgeon plan the operation. A dressing is applied, and you will be asked not to move the arm adjacent to the wire. Most patients do not have any pain once the wire is placed

In some cases, more than one wire may need to be placed. This is done in large areas of micro-calcification or if there’s more than one area needing to be removed.

After the wire is inserted, you will be directed to the operating theatre waiting room to check in for your operation. Under anaesthesia, Mr Haddawi will remove the piece of tissue around the tip of the wire. The wire will be included in the specimen to be removed, and the entire specimen is sent to the lab for a full histology report.

With all surgical procedures, there are some risks and potential complications. Fortunately, these risks are rare and Hookwire Localisation of the breast usually proceeds without any problems. In about 2% of cases, the abnormal area is not found in the piece of tissue removed during the operation. There are several technical reasons why this can happen. The operation may need to be performed again if the expected abnormalities aren’t present when the pathologist tests the specimen. In another 2-3% of cases, the wire might move after insertion. If this happens and is detected before the operation, the wire will be removed and another appointment is arranged for a repeat procedure. Your doctor will advise you if this is necessary, and discuss your results including what further action may be required accordingly.

Radiotherapy is the treatment of specific body areas with carefully measured and administered radiation for cancer treatment. 

In breast cancer, radiation is delivered to the breast and axilla region for local control of cancer or could be administered to areas of metastasis for symptomatic control.

Radiation therapy is provided in special centres; Palmerston North is the closest centre to Taranaki. Planning is done in the centre, followed by administering the radiation over 1-3 weeks, with a 15-20 minute session each day, excluding the weekends and holidays. 

Indications in Breast Cancer:

Radiotherapy is described in the following situations:

1. Treatment of the remaining breast after Breast Conservative Surgery to reduce local recurrence.
2. After the removal of the whole breast, if the cancer is large, close to, or involves the margins.
3. In cases where there is the involvement of lymph nodes.

Side effects of Radiation Therapy:

Radiation therapy can be associated with specific side effects. The patient may or may not develop some of the following:

1. Feeling tired; usually starts midway through the treatment and lasts for a few weeks. Patients recover entirely from this side effect.
2. Skin reaction to the radiation field; presents as redness, itchiness and occasionally skin breakdown. This side effect reaches its maximum a few days after the last treatment session. The radiation oncologist provides you with an ointment to help control the symptoms; the irritation usually settles down after 2-4 weeks. It may leave behind a light brown patch in the area.
3. Breast changes and swelling during the treatment phase can be noticed, while the breast becomes slightly firmer and smaller after the treatment.
4. Swelling of the arm: This is related to scarring of the lymphatics that drain the upper arm on the side of cancer. The incidence increases if radiotherapy is administered after removing the lymph nodes from the armpit (axillary Dissection). An incidence of 5-10% is reported in the literature. Physiotherapy and special compression stockings are required occasionally.
5. Scarring of the lung: this is due to the lung being within the radiation field. The radiation planning and the new radiation machines (Linear Accelerators) that move around the patient ensure that the lung and heart get the very minimum radiation dose. Thus this complication is not significant with the current technology and mostly has no clinical significance.
6. Effect on the heart: when radiation involves the left chest wall. Radiation therapy can increase the chances of heart disease in the long term. With the new generation Linear Accelerators, this side effect is minimised significantly.