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Breast Conserving Surgery (Lumpectomy)

Breast conserving surgery (BCS), also known as a “lumpectomy” or “partial mastectomy”, is a surgical technique used to treat breast cancer by removing the tumour while preserving as much of the breast tissue as possible. This approach aims to provide effective cancer treatment while maintaining the breast’s appearance and minimising the psychological and emotional impact on patients.

BCS is often preferred over mastectomy for eligible patients because it offers the advantage of retaining most of the breast tissue, which can have positive implications for a patient’s body image and quality of life.

The exact cause of breast cancer is not fully understood, but it is believed to result from genetic mutations in breast cells. Several factors can increase the risk of developing breast cancer:

  • Genetic Factors: Inherited mutations in genes such as BRCA1 and BRCA2 significantly increase the risk.
  • Hormonal Factors: Long-term exposure to oestrogen and progesterone, such as from early menstruation, late menopause, or hormone replacement therapy, can increase the risk.
  • Environmental and Lifestyle Factors: Factors such as alcohol consumption, obesity, lack of physical activity, and exposure to radiation can contribute to the risk.

Symptoms of breast cancer can vary widely, and some individuals may not experience any symptoms. Common signs and symptoms include:

  • A Lump in the Breast or Underarm: Often the first noticeable symptom, a lump may be painless or tender.
  • Changes in Breast Shape or Size: Swelling, dimpling, or changes in the shape or size of the breast.
  • Nipple Changes: Inversion, discharge (especially bloody), or changes in the appearance of the nipple.
  • Skin Changes: Redness, scaling, or thickening of the breast skin or nipple.
  • Pain: Persistent pain in the breast or nipple area.

Several risk factors increase the likelihood of developing breast cancer. While some factors cannot be changed, such as age and genetics, others can be managed through lifestyle choices:

  • Age: The risk of breast cancer increases with age, with most cases diagnosed in women over 50.
  • Family History: A family history of breast cancer, especially in a mother, sister, or daughter, increases the risk.
  • Genetic Mutations: Inherited mutations in BRCA1, BRCA2, and other genes.
  • Hormonal Factors: Early menstruation (before age 12), late menopause (after age 55), and hormone replacement therapy.
  • Reproductive History: Having no children or having the first child after age 30.
  • Lifestyle Factors: Alcohol consumption, obesity, physical inactivity, and a diet high in saturated fats.

Lumpectomy Surgical Technique

A thorough preoperative assessment is essential for planning BCS. This includes:

  • Imaging Studies: Mammograms, ultrasound, and MRI scans are used to determine the size, location, and extent of the tumour.
  • Biopsy: A biopsy confirms the diagnosis of breast cancer and determines its characteristics, such as hormone receptor status and HER2 status.
  • Patient Evaluation: Assessment of the patient’s overall health, medical history, and personal preferences is crucial for surgical planning.
  • Anaesthesia: BCS is typically performed under general anaesthesia, although local anaesthesia with sedation may be used in some cases.
  • Incision Planning: The surgeon plans the incision to ensure optimal removal of the tumour and minimal impact on the breast’s appearance. The incision is usually made around the areola or along natural skin folds to minimise scarring.
  • Tumour Removal: The surgeon excises the tumour along with a margin of healthy tissue to ensure complete removal. The size of the margin depends on the tumour’s characteristics and location. In some cases, wire localisation or radioactive seed localisation may be used to guide the surgeon to the precise location of the tumour.
  • Intraoperative Assessment: During the surgery, the excised tissue is often sent to the pathology lab for a frozen section analysis to ensure clear margins (no cancer cells at the edges of the removed tissue). If cancer cells are found at the margins, additional tissue may be removed.
  • Lymph Node Evaluation: Sentinel lymph node biopsy or axillary lymph node dissection may be performed to check for the spread of cancer to the lymph nodes. The sentinel lymph node is the first node to which cancer cells are likely to spread from the primary tumour.
  • Reconstruction: If necessary, the surgeon may perform oncoplastic techniques to reshape the breast and maintain symmetry. This can involve rearranging the remaining breast tissue or using tissue from another part of the body.
  • Closure: The incision is closed with sutures, and a drain may be placed to prevent fluid accumulation. The surgical site is then covered with a sterile dressing.

Proper postoperative care is crucial for successful recovery after BCS. It includes:

  • Pain Management: Prescribed pain medications to manage postoperative pain.
  • Wound Care: Instructions on keeping the incision site clean and dry, and recognising signs of infection.
  • Activity Restrictions: Guidelines on limiting physical activity to allow proper healing.
  • Follow-Up Appointments: Regular follow-up visits to monitor recovery and discuss further treatment.

After BCS, additional treatments are often recommended to reduce the risk of cancer recurrence. These may include:

  • Radiation Therapy: Most patients will need radiation therapy to destroy any remaining cancer cells in the breast. It usually starts a few weeks after surgery and continues for several weeks.
  • Chemotherapy: Depending on the cancer’s stage and characteristics, chemotherapy may be recommended to target cancer cells throughout the body.
  • Hormone Therapy: For hormone receptor-positive cancers, hormone therapy (such as tamoxifen or aromatase inhibitors) can help reduce the risk of recurrence by blocking the effects of oestrogen.
  • Targeted Therapy: For HER2-positive cancers, targeted therapies like trastuzumab (Herceptin) may be used to block the growth-promoting effects of the HER2 protein.

Advantages and Considerations of BCS

BCS offers several advantages over mastectomy, including:

  • Preservation of Breast Appearance: BCS maintains the breast’s natural shape and appearance, which can have significant psychological and emotional benefits.
  • Shorter Recovery Time: BCS generally involves a shorter recovery period compared to mastectomy.
  • Less Invasive: The surgery is less extensive, leading to fewer complications and a quicker return to normal activities.

However, BCS is not suitable for all patients. Considerations include:

  • Tumour Size and Location: Large tumours or those located in difficult-to-reach areas may not be suitable for BCS.
  • Multiple Tumours: The presence of multiple tumours in different parts of the breast may require more extensive surgery.
  • Previous Radiation Therapy: Patients who have previously received radiation therapy to the breast may not be suitable candidates for BCS.

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