Breast-Conserving Surgery

Breast-conserving surgery takes out the tumour with a margin, a layer of normal tissue around it, so that no cancer cells are left at the cut edges. The removed tissue is examined under the microscope, and the report describes the type and size of the cancer, its grade, its receptors and whether the margins are clear. The definition of a clear margin differs between invasive cancer and DCIS and between guidelines, and your team explains which standard they use. Radiotherapy to the remaining breast then lowers the chance of the cancer returning in the breast. Oncoplastic surgery combines removal with reshaping. At a simple level the remaining tissue is moved to fill the gap; at a more extensive level the breast is reshaped like a breast reduction or lift, called a therapeutic mammaplasty, or the space is filled with nearby tissue from the side of the chest. The other breast may be adjusted for symmetry at the same time or later.

Breast-conserving surgery is recommended for most early breast cancers and for DCIS when the area can be removed with clear margins and an acceptable breast shape. The key factor is the size of the tumour in relation to the size of the breast: a 3 centimetre tumour may be suitable in a large breast but not in a small one, and oncoplastic techniques widen the options. Tumours that are large at diagnosis can often be shrunk first with chemotherapy, hormone therapy or targeted therapy, so that conserving surgery becomes possible. Mastectomy is usually advised instead when cancer is present in several separate areas of the breast, when suspicious calcifications are widespread, when margins remain involved after re-excision, or when radiotherapy cannot be given safely, for example after previous chest radiotherapy or during early pregnancy. Some people with a high-risk gene mutation choose mastectomy for future risk, and others choose it for personal reasons, which is a valid choice.

Many cancers found on screening cannot be felt, so the area is marked before surgery. A radiologist places a fine wire, a tiny radioactive seed, a magnetic seed or a radar reflector into the tumour under ultrasound or mammogram guidance, either on the day or some days before. A tracer for the sentinel node biopsy is also injected into the breast. Under general anaesthesia the surgeon makes an incision, often placed around the areola or in a natural skin line, and removes the tumour with its margin, guided by the marker. The specimen is X-rayed in the theatre to confirm that the target and the marker clip are inside it, and further thin layers can be taken from the cavity walls if needed. Small metal clips may be left in the cavity to guide the radiotherapy. The sentinel nodes are removed through a small armpit incision. The tissue is then closed in layers, with oncoplastic reshaping when planned. The operation usually takes about 1 to 1.5 hours.

Candidates have a biopsy-confirmed cancer or DCIS, imaging of both breasts and an assessment of the armpit nodes. MRI is used in selected cases, for example in dense breasts or lobular cancer, to make sure there is no other disease in the breast. The plan is agreed by a multidisciplinary team, including whether chemotherapy or hormone therapy should come first. You also need to be able to have radiotherapy, which means attending a short course of daily treatments in the weeks after surgery. Preparation includes blood tests, an anaesthetic assessment and a review of medicines, especially blood thinners, which are paused on medical advice. Smoking slows healing and should be stopped well before surgery. A good supportive bra is useful afterwards. International patients can usually send biopsy reports, pathology slides and scans in advance, so that the marker placement, surgery and sentinel node biopsy can be arranged over a few days after arrival.

Most people go home the same day or after one night, usually without drains. Discomfort is generally mild to moderate and settles with simple painkillers. Gentle arm and shoulder movement is encouraged from the start, and most people return to light work and everyday activities within one to three weeks. The tissue report usually arrives in about one to two weeks. Staying near the hospital for about a week allows a wound check and a face-to-face discussion of the report, including any need for re-excision. Radiotherapy normally starts about three to six weeks after surgery, or after chemotherapy if that is given, and the whole-breast course is now commonly given over about one to three weeks, sometimes with a boost to the tumour bed. You can either return for radiotherapy or have it near home, using the surgical report, clip positions and a written plan. Hormone therapy, if needed, continues at home for years.

Breast-conserving surgery is a common operation with a low rate of serious complications. Bruising, a collection of fluid in the cavity (seroma) and minor wound infection are the most frequent problems and usually settle with simple treatment. Bleeding needing a return to theatre is uncommon. The main specific issue is an involved or close margin, which can mean a second operation to remove more tissue; this happens in a minority of patients. Numbness around the scar and changes in breast sensation are common. Lymphoedema of the arm is uncommon after sentinel node biopsy alone. The breast may become smaller, firmer or slightly different in shape, especially after radiotherapy, and oncoplastic techniques aim to reduce this. Radiotherapy itself can cause skin redness, tiredness and later firmness of the breast. After treatment you have regular follow-up and yearly mammograms. For suitable cancers, breast-conserving surgery with radiotherapy offers a cancer outcome similar to mastectomy while keeping the breast.