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Breast-Conserving Surgery (BCS) Breast-conserving surgery (BCS) involves "lumpectomy" (the surgical removal of a tumor and the surrounding clean margin of normal tissue) followed by radiation therapy. Breast-conserving surgery (also called breast-preserving) and radiation therapy is referred to as "breast-conserving therapy".The goal of this treatment is to excise the tumor, while maintaining a cosmetically acceptable breast. It should be pointed out that while many women believe a lumpectomy will not alter the appearance of the breast, this is not always true. In fact, some physicians believe that if the breast is very small and the tumor is large, or the cancer involves the nipple, BCS may not be an option because the surgery could create a form to the breast that might be unacceptable to the woman. Frequently physicians will not feel it appropriate to do breast conserving surgery if the nipple must be removed, while the patient would rather retain any amount of the breast even if it means loosing the nipple. In some cases, a large portion of the breast and the lining over the chest muscle beneath the tumor are removed (this is called a "partial mastectomy" or "segmental mastectomy"), and sometimes as much as one quarter of the breast tissue is excised in what is called a "quandrantectomy." But because all of these techniques leave some breast tissue behind, they are considered breast-conserving. BCS has proven to be effective for early-stage breast cancers (cancers that have not spread to other areas). BCS is not an option for women in the early stages of pregnancy because the adjuvant radiation therapy might be harmful to the developing fetus. BCS, with the exception of some re-excision procedures, is also not possible if breast cancer has recurred following radiation therapy. Women with large, pendulous breasts may not be able to have BCS because of the technical difficulties in targeting the radiation beam. Many advances have been made, however, in the technological tools of radiation to help get around this obstacle. The decision to have BCS is individualized to the patient, and the radiation oncology doctor will provide the appropriate recommendation. Women with collagen vascular diseases, such as lupus erythematosus or scleroderma, may be advised against BCS as it is thought that these conditions may be made worse by radiation.
An important aspect of BCS is assuring that the margin of normal tissue surrounding the tumor is free and clear of cancer cells. When the tumor is first removed by the surgeon, it will be sent to the pathologist who will determine whether it is cancer or not and whether the margins are positive (meaning there are cancer cells in the margin of normal tissue that was removed with the tumor) or negative (meaning that the margin of normal tissue surrounding the tumor was clear of cancer cells). If the margins of the removed tumor specimen show any cancer, the woman will need to have a "re-excision" (more normal tissue removed from the tumor bed area) of the area to assure that all cancer cells have been removed. Mastectomy A "mastectomy," the surgical removal of the breast, can be accomplished in several different ways depending on the size of the tumor and the extent of the disease. When only the breast, nipple, and areola (the tan or brown-colored area surrounding the nipple) are removed but the axillary (armpit) lymph nodes remain intact, the operation is called a "simple mastectomy" or "total mastectomy." A "modified radical mastectomy" is the removal of the entire breast, the lining over the chest muscle, and some axillary lymph nodes. A "radical mastectomy" is the most extensive surgery, involving the removal of the muscles beneath the breast and nearly all of the axillary lymph nodes. Because mastectomy requires more extensive surgery than does a lumpectomy, greater discomfort occurs, and there is the possibility of a longer hospital stay and a greater risk of complications. In some cases, the surgeon will place one or two soft, pliable, plastic drains in the wound left by the surgery. These drains will remain in place after the person goes home from the hospital to allow the yellow, and possibly red-tinged, fluid to continue to drain from the breast area and to reduce the possibility of swelling. Bright red bleeding is a sign of hemorrhage and must be reported to the doctor immediately. The drains are an annoying presence but shouldn't be especially painful. Before leaving the hospital, the patient is taught how to empty the drains and is instructed on specific exercises to move the shoulder through a complete range of motion. This encourages the return of mobility to the arm on the side with the surgery. These drains typically are removed at the first post-operative check-up, which occurs five to seven days after the surgery. If the drains fail to remove all the fluid and swelling occurs over the chest wall, the physician can drain the discharge using a needle that is inserted into the breast. Any sign of infection, a fever, yellow-green drainage from the breast or underarm incision, redness along the incision lines, unusual tenderness or warm skin should be reported to the surgeon immediately. Lymph Node Surgery  The surgeon performing the lumpectomy or mastectomy will also remove 6 to 15 of the 30 to 60 lymph nodes from under the arm (armpit or axillary) for the pathologist to examine for any spread of cancer cells. This procedure is almost always done for breast cancers that are "invasive" or "infiltrating," meaning they have broken through the inner lining of the breast duct with possible spread to other areas of the breast or elsewhere. Full node dissection includes levels I, II, and III, and all three levels are done with a Halsted radical mastectomy. Removing level I and II or just level I is a limited node dissection. Lymph node sampling usually involves removing anything that looks suspicious and some additional tissue in level I. Lymphadenectomy is a 'generic term' and could include any of these. Knowing whether the lymph nodes, and how many, are positive for cancer is very important information for treatment planning and prognosis. Lymph node dissection is almost never done, however, if the primary tumor is an "in situ lesion" (noninvasive, noninfiltrating) as these early cancers rarely spread to the lymph nodes, and the potential complications of lymph node dissection therefore can be avoided. Lymph node dissection is done primarily as a way to accurately stage the disease and is not considered a treatment procedure. Women who have had lumpectomies and mastectomies often say that the postoperative discomfort from the lymph node dissection was greater than the breast surgery itself. This is due in part to the fact that the incision is made in the underarm or armpit, and any movement in that area strains the wound. Also, nerves under the arm may be damaged during surgery. In the hospital, no invasive procedures -- blood tests, injections, intravenous fluid administration -- will be done on that arm. The nurses will even avoid taking the person's blood pressure on the affected arm. The numbness in the fingers and hand of the affected arm that occasionally occurs following surgery may linger for years and could lead to injuries, so care must be taken when cooking, sewing, or using any tools with that hand. Infection also is a risk, so any sign of swelling, redness, warmth of the skin, or fever should be reported to the doctor. Great care must be taken to protect the arm, especially until the wound has healed and the numbness has lessened or disappeared. The most common problem resulting from lymph node dissection, affecting about one out of ten women, is "lymphedema" or swelling of the arm due to cutting of the lymphatic vessels during treatment for breast cancer. The arm and hand can become quite distended and uncomfortable. Exercise to facilitate drainage of fluids and to prevent lymph fluid and blood from collecting in the lower part of the arm and hand is helpful in preventing swelling. A specially designed compression sleeve may help prevent this fluid accumulation. It is not known why, but lymph edema may not appear until years after the surgery has taken place. In some cases, women are advised to avoid wearing binding jewelry (bracelets, cuffs, watches, and rings) on the arm and fingers of the arm that had lymph node dissection, because this can interfere with the flow of blood and lymph fluid to and from the hand. In recent years, a technique called "lymphatic mapping" has been developed for locating the main, or "sentinel lymph node," which is the first node to receive fluid from the lymphatic vessels going from the breast to the armpit. Either a radioactive material or blue dye is injected into tissue surrounding the tumor, or into the tumor bed when it has been removed, and is tracked as it enters the pathway of vessels to the sentinel node. If a dye is used, the surgeon will be able to see the sentinel node by tracing the path of the dye. If a radioactive material is used, a hand-held Geiger counter is used to pinpoint the sentinel node. Once the sentinel node is identified, the surgeon can remove it for immediate pathologic analysis, a test that is called a "sentinel-node biopsy." If that node is free of cancer cells, it is highly probable that no other lymph nodes are involved, and lymph node dissection or sampling therefore is not necessary. This lymphatic mapping technique represents a major advance over previous tests because it can be carried out by making a tiny incision, therefore avoiding the side effects that may occur with more extensive surgery when multiple nodes are removed. Lymphatic mapping must be done by specially trained surgeons and pathologists who have special training and experience with this procedure. Due to the level of experience necessary, this procedure may not be available at all hospitals. The patient should ask the surgeon about the extent of his/her experience with this procedure. Radiation Radiation therapy (also called radiotherapy, irradiation, and x-ray therapy) is the use of high-energy waves (x-rays or gamma rays) or streams of particles (electrons, protons, neutrons, alpha particles, and beta particles). Radiation therapy is one of the oldest, cost effective cancer therapies. Advances in technology and a better understanding of how radiation works in the body have made radiation therapy a significant part of cancer treatment. It is estimated that 50-60% of all patients with cancer will receive radiation at some time during their cancer treatment. Radiation therapy works by damaging the cells genetic material, the DNA in cells. DNA is the part of the cell that carries the genetic code responsible for the division and growth of the cells. Radiation is more effective on cells that are actively reproducing and on those that divide more rapidly. It is less effective on cells that are in the resting phase or divide slowly. Radiosensitivity is a term used to reflect how susceptible a cell, cancerous or healthy, is to radiation induced damage. Cells that divide frequently tend to be radiosensitive and are more affected by radiation. Although radiation therapy attacks reproducing cells, it does not distinguish between cancer cells and cells of normal tissues. The damage to normal cells can result in side effects. Thus, each time radiation therapy is given it involves a balance between destroying the cancer cells (in order to cure or control the disease) and sparing the normal cells (to minimize undesirable side effects). This is why radiation treatment is given in small doses or fractions over several weeks and allows the optimal dose to kill the cancer with less damage to normal tissues. Radiation therapy (RT) typically is used as an adjuvant treatment (treatment given in addition to the primary treatment, which is usually surgery). RT is given about one month after a lumpectomy or mastectomy to destroy malignant cells that may remain undetected in the breast region, meaning the breast, chest wall or armpit. With RT, the intention is to kill any stray cancer cells and thereby prevent recurrence. RT is a local therapy (a therapy confined to one area of the body), therefore it may be supplemented by chemotherapy, a systemic therapy (therapy that goes throughout the entire body). The two treatments, however, are not usually given at the same time. Radiation therapy may be given before or after chemotherapy, and in some situations it may be administered between chemotherapy treatments. Radiation therapy after mastectomy typically involves a shorter course of treatment (about five weeks) than the six to seven weeks of therapy that follow a lumpectomy. RT occasionally is used before surgery to shrink a large tumor so that the tumor can be surgically removed. It also is used as a "palliative treatment," which means it is given to relieve symptoms such as pain and bleeding when the cancer has spread. Therapies used as a palliative treatment are not referred to as adjuvant. Radiation therapy is indicated in the following situations:
External Beam Radiation Therapy (EBRT) When the source of the radiation (usually a high-energy radiation machine called a linear accelerator) comes from outside the body, the treatment is called "external beam radiation therapy" (EBRT). The total dose of radiation needed to destroy the tumor is divided into a series of smaller daily doses or fractions, which are administered five days a week for six to seven weeks until the total, or cumulative dose, is achieved. Treatment is given Monday through Friday with no treatment on weekends or holidays. A "booster dose" of radiation usually is given upon completion of external beam therapy to deliver a final, intense dose of radiation to the tumor bed area and hopefully destroy any remaining cancer cells. There are several ways to deliver the booster dose. Internal Radiation Therapy or Brachytherapy With "internal radiation therapy"--also known as interstitial radiation, implant therapy, or brachytherapy (meaning short-distance therapy)--the radiation is directed to the breast region from within the tissue. Multiple small, narrow needles or tubes (these being the implant) are placed within the tumor bed area or cavity of the breast tissue and are filled with small seeds (about the size of a grain of rice) of radioactive material. While the implant (needles with the radioactive seeds) is in place, the breast tissue surrounding it will be continually bombarded with radiation. The implant procedure requires a short hospitalization, usually two to three days, and the patient is in radiation isolation (the patient is radioactive while the radioactive seeds are in place) during that time. After the cumulative radiation dose is achieved, the implant is removed, radiation isolation is discontinued, and the patient is no longer radioactive. This is a well-tolerated procedure with only mild to moderate discomfort. The treated area may be sore or sensitive for a while after therapy. The advantage of brachytherapy is the ability to deliver a high dose of radiation to a small area. It is useful in situations that require a high dose of radiation or a dose that would be more than the normal tissues could tolerate. The other method of delivering a booster dose is by "electron beam therapy." This type of radiation therapy is delivered by the same machine (linear accelerator) used to give the external beam therapy but uses a different type of radiation beam. The electron beam boost is done as an outpatient procedure, the same as the initial radiation, and adds another two weeks or ten treatments to the entire radiation therapy treatment. Before radiation therapy begins, the physician who specializes in treating cancer with radiation, called a "radiation oncologist," examines the area to be treated and determines, with the help of a radiation physicist, precisely how the beam will target the breast and the lymph nodes (if they need treatment). The physician will also determine the size of the area to be treated and both the daily dose and cumulative dose of radiation needed. The amount of radiation will be decided based on the size of the tumor, how sensitive the tumor is to radiation and by the ability of the normal tissue to tolerate the radiation. As a guide for the radiation, the "radiation therapist" (who actually performs the treatment) draws a map (outline) directly on the person's body with a temporary dye or with tiny semi-permanent tattoos that look like dark freckles or dots, from the collarbone to the bra line and from the breastbone across the involved side of the chest to the armpit. To ensure that the person being treated is in the correct position and remains motionless for each treatment, a mold is made to fit the upper body. This treatment planning process is called "simulation" and is done to achieve the most accurate and precise dose of radiation to target the cancer and spare the surrounding normal, healthy tissue. The simulation process may take several hours because of all the necessary measurements, calculations, and markings, but the subsequent radiation treatments only take a few minutes. One discomfort with external beam radiation therapy is having to remain motionless in the same position during the treatment. Some people are concerned that receiving radiation makes them radioactive, but this is not true. Because the radiation beam passes through the skin, however, temporary local side effects may occur in the body area being treated. As treatment progresses, the skin tends to become red, dry, and irritated. It may itch and there may be some oozing of fluid from the skin, particularly in women with large breasts. The dryness and itching may be relieved with special skin creams or ointments prescribed by the radiation oncologist or oncology nurse. In some cases the irritation may progress to one or a number of blisters on the breast. Surprisingly, these blisters are not particularly painful. When they occur, the radiotherapist may stop the daily radiation doses for a few days or a week to allow the blistering to resolve. An antiperspirant should not be used during the course of therapy (on the treatment-side underarm only; using it on the opposite underarm is fine), and skincare products should not be used on the affected skin during treatment without the approval of the radiation oncology doctor or nurse. Over-the-counter products can contain chemicals that are irritating to radiated skin; the radiation oncology doctor and nurse will know what products are safe to use. It is important to protect the skin of the chest from the sun, as it is highly prone to sunburn following radiation therapy. Other treatments that might be damaging to sensitive skin, such as using an ice pack or a heating pad, should be avoided as well. Many women notice breast soreness and swelling of the breast. Lymphedema (swelling of the arm) may be present if the armpit is also targeted by radiation. Fatigue and loss of appetite also can occur during therapy, but exhaustion is not an expected side effect; many women find they can continue with their jobs and daily activities without much difficulty. After a course of radiation therapy, future mammograms (breast x-rays) on the affected side of the body may be more difficult to read due to changes in the normal breast tissue after radiation. This is why most physicians obtain a new 'baseline' mammogram to use for future comparisons 3 - 6 months after radiation is complete rather than waiting for the next annual mammogram. Long-term side effects that may appear but are not common include lung inflammation, which can cause a dry cough and shortness of breath, and brachial plexopathy, which is an irritation of the nerves in the collarbone area and shoulder. Brachial plexopathy causes discomfort in the shoulder and tingling and weakness in the affected arm and hand. Soft tissue changes, rib fractures, and irritation of the heart also may occur, but these are not common. A more serious long-term complication is the development of a second cancer due to the radiation - such as a new breast cancer in the opposite breast, lung cancer, leukemia, or cancer of soft tissues or bone. If a second cancer were to develop, it may occur within a few years of radiation exposure (for leukemia) or not until 10-15 years after exposure (for solid tumors or cancers other than leukemia). Although these secondary cancers are possible, the actual incidence is rare. Other possible side effects following treatment are aching or shooting pains, which are experienced by a small percentage of people. In addition, the skin may appear darker than normal, as if tanned, for a period ranging from months to years. Hair loss under the arm and around the nipple usually is permanent, and the sweat glands may not regain their normal function. When radiation therapy follows lumpectomy, the breast may become smaller and firmer than it was before the treatment.  This content is reviewed regularly. Last Updated 6/6/2007
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