Breast Cancer Surgery

Breast cancer surgery has always been the first line of treatment for this disease, and remains so today, even though is the most invasive one. Surgery is the tool with which we can remove the bulk of the tumor most easily. The good thing about surgery is that it removes the whole mass, whenever possible. A problem with it is that it requires a target. We have to know where the tumor is. This is often the case with breast cancer surgery.

Also, surgery is very invasive and we don’t get control of the microscopic margins. When we take out a cancer, it is very important that we leave no tumor cells behind at the edges. The way we do this is trying to go in and take normal tissue around the tumor as much as we can without causing destruction. In certain areas this is going to be easier than in others. For example, in breast cancer surgery we can usually take an area of normal breast tissue around the tumor, whereas in the brain everything you take will lead to destruction.

In breast cancer we have three operations we use to do. William Halsted, a very famous professor of surgery at John Hopkins, is considered the father of modern surgery. He invented rubber gloves for his girlfriend, who was a nurse allergic to disinfectants. He invented the radical mastectomy for breast cancer. With this, the entire breast was removed, and also all the pectoral muscles were removed, because he thought cancer spread through the pectoral muscles. We now know this isn’t often the case.

Around the 1960’s, doctors decided that that was too much surgery. We started removing the entire breast but leaving the pectoral muscles. After that, we moved into what is now called lumpectomy, where the tumor is removed with a little margin of normal tissue. Then, through a separate incision, we use to take out lymph nodes and do what is called a sentinel node biopsy. We inject either dye or radioactive material before the operation that will be picked up by the lymphatics and deposited in these lymph nodes. Then, we open up the axilla and we look for the dye. We take out the lymph nodes and we see if it contains metastasis. It is unusual for metastases to skip lymph nodes, so if it is clean, we consider that the tumor has not metastasized.

In order to see if this really works, surgical protocols were started about three decades ago. With many studies we found that lumpectomy with axillary dissection worked as well as the modified radical mastectomy, which worked also as well as Halsted’s radical mastectomy. Now, the lumpectomy with axillary dissection is the gold standard.

What we try to achieve surgery is to do less and less to patients in a surgical way, as it is so invasive. So far, however, we still have the need to do breast cancer surgery in a lot of cases.

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