Welcome back to an introduction to breast cancer, I'm Dr. Anees Chagpar. I'm so glad that you chose to join us today, because we're going to talk about one of my favorite topics in terms of breast cancer, and that's surgical management. How do we actually take care of cancer, so that we can get it out of patients, and into a bucket, so that our pathologists can look at it under the microscope? Let's get started. You'll remember in a previous session when we talked about staging. One of the most important things about staging, was helping us to understand, what kind of treatment would be optimal for patients at different stages. And for the most part, surgery is always part of the curative management of a patient with breast cancer, except if they have stage four disease, or distant metastatic spread. Now when we think about surgical management, there are two main objectives. The first objective is to get the cancer that's in the breast out of the breast, making patients cancer free. The second objective is to check the lymph nodes. Remember back to when we talked about staging? We said that one of the important things was to check the lymph nodes. Because that's where breast cancer would spread first if it was going to spread anywhere. And because tissue is the issue, we need to check those lymph nodes surgically, and send them to the pathologist so that they can look at them under the microscope. Today, we're going to focus on the first issue. How do we actually get this cancer out of patients and into a bucket? Well, there are a number of ways that we can do this. But the primary objective or goal is to actually remove the cancer with a rim of tissue all the way around the cancer. That's called a margin. The margin is the distance between the cancer itself, and where the cut is. So if we go to the drawing pad here. If we think about a cancer, and we resect it. The distance between the cancer itself and the edge of the specimen is called a margin. Now, there are a number of ways that we can actually take out a cancer and still get a margin. Can you think about ways that we could potentially do that? Well, there are two main options. The first option is what I often call a partial mastectomy. This is where we remove part of the breast. Which part? The part that has the cancer in it. Plus that rim of normal tissue all the way around. Now, partial mastectomies are also called by different names. Some of you may have heard this referred to as a lumpectomy. I rarely use that term. Because most patients these days, particularly in the developed world, present without a lump. They've had a screening mammogram, and without us being able to feel the cancer, they still have a cancer there. This can also be called breast conserving surgery. Now, some of you might be wondering, how do you take out a cancer if you can't feel it? Well, often times when the radiologist does a mammogram, and does a biopsy of an area of suspicion, they'll leave a little marker there, or a clip. And then, at the time of surgery, what they can do is, they can either put in a fine little wire, some places use a radioactive seed. Some sort of localizing marker, such that we can follow that marker and take out that area. We'll often call this a needle localized partial mastectomy. Or sometimes it's called a radio-occult lesion localization, if they've left a little radioactive seed. No matter how you slice it. This is still taking out just part of the breast. What's the other option? The other option is to remove the whole breast, or do a total mastectomy. That's another way that we can get rid of this cancer with a rim of tissue all the way around. Now, many of you might be asking the question, who does better? Which one makes patients live longer? And the answer, you might be surprised, is that they are exactly the same. Don't believe me? Let's look at the data. Here you can see 20 year survival data. We're comparing total mastectomy, that's the line with boxes, or lumpectomy, that's the line with the triangles. And you can see that over 20 years, whether you look at disease free survival, distance disease free survival, overall survival, the curves are super impossible. So there's absolutely no difference between whether you take out part of the breast or whether you take out the whole breast. Now, what about the chances of the cancer coming back in the same breast? Well, that's different, if you remove the whole breast, the chances of the cancer coming back on that side. Nope, it's not zero because it's impossible to remove every single solitary cell, but it's pretty low, less than 5% because essentially, you've removed all of the breast tissue. So, the chances of cancer coming back in the residual chest is very low. Now, what do you think the rate is of getting cancer back in the breast if you've just remove the part of the breast? Over 20 years, that number is 39.2%. Well, nobody likes that number compared to that number. So, how can we make these two options equal? The answer is, we add radiation. Here's some data from one of the largest clinical trials that actually looked at these two options. If we look here, this is the NSABP B-06 trial, which really randomized patients to either have a partial mastectomy or a total mastectomy. And as you can see from the bottom two lines of this table. Disease-free survival and overall survival were exactly the same. The difference was in local regional recurrence rates, with a lumpectomy 39.2%, with a mastectomy, 5%. But look at the column in the middle. When they added radiation, that rate went down to 14.3%. And I would argue that these days with advances in radiation therapy, we'll talk more about that in that session. This number actually gets down to more like 5 to 6%. So it's looking a lot more like the total mastectomy category. Now, when we think about these different options. You have to think under the total mastectomy category. There are more options. Two main options. The first is what I call a conventional mastectomy. This is where the breast is removed. And you're left flat. After that, you can either wear a prosthesis, which is like a fake breast that you wear in your bra. Or you can have delayed reconstruction sometime down the line. The other option is what's called a skin sparing mastectomy with immediate reconstruction. Let's look at how that works. If we think about the breast, and the nipple-areolar complex, what we can do, is we can make a tiny incision just around the nipple-areolar complex, and we can remove all of the breast tissue. So that you're left with an empty envelope of skin, and a hole in the middle. What you've removed is essentially all of that breast tissue plus the nipple-areolar complex. Why might we want to remove that nippel-areolar complex? Remember back to when we talked about what the breast looks like? Remember of how the breast is made up of ducts and lobules and most breast cancers come from the ducts? Well all of those ducts go to the nipple, so in a skin sparing mastectomy, because we want to remove all of that ductal tissue, we take out the nipple areolar complex. Well, if you're left just with an empty envelope of skin and a hole in the middle, that's not very cosmetically appealing but the plastic surgeons right at the same time can take tissue either from your tummy, giving you a tummy tuck or tissue from your back or an implant of any size you want, and they can reconstruct the breast right at the same time. So at the end of the day what you're left with is an empty envelope of skin. Which they've now filled, and later on they can make a nipple and tattoo on the areola. We'll look at some pictures and you'll see that the cosmetic result is very good. Let's take a look at these three options in greater detail. But first, think about if there are any things that would sway you to go one way or the other. Let's go back to this diagram. If all of these are equal in terms of survival, and with radiation they're equal in terms of local recurrence, can you think of some reasons why you might do one over another? Well, certainly if you can't have radiation. This isn't a very good option because nobody likes this 39.2%. So, what's radiation like? Radiation is given five days a week, oftentimes for three to six weeks, so if you're in an area of the world where radiation therapy isn't something that's commonplace, it might be very difficult to have breast conserving surgery. Similarly, if you've had radiation previously, maybe you've had a previous breast cancer, or you had Hodgkin's Lymphoma, and you had radiation therapy to the chest, you can't have radiation again for the most part. And so again, this is not a good option. Collagen vascular disorders, things like rheumatoid arthritis or lupus, these are relative contraindications, so you'd want to talk to your radiation oncologist about whether that would be a sufficient reason for you to opt for a mastectomy or whether you could still have breast conserving surgery. There are some tumor characteristics as well that would sway you one way or another. And we'll talk more about these in later sessions. Things like inflammatory cancer, that we talked about a little bit when we talked about tumor types. That red, podorange that gets into the skin. Well, if it's in the skin of the breast and involves the whole breast, a skin sparing mastectomy isn't a good option and neither is a partial mastectomy. Multicentricity, this is where a little bit of a vocabulary lesson might come in handy. Multicentricity is when you have more than one cancer in more than one quadrant of the breast. That's different than multifocality, which is where you have more than one tumor, but both are in the same quadrant of the breast. If all of the disease is limited to one area of the breast, you can still often have a partial mastectomy. Sometimes, tumor size is also an issue. When we talk about chemotherapy in the later session, we'll talk about timing. And you'll see that tumor size is one of these questionable areas. Because sometimes patients can have chemotherapy in advance of surgery. So that if you have a big cancer, that can often shrink it to be a smaller cancer, so that patients who otherwise couldn't have a partial mastectomy, now can. But for a lot of the decision making that we do, because all of these options are equal, it comes down to patient preference. With a needle localized, partial mastectomy, this is often a day surgery. You come in the morning of the surgery, you have your surgery, you go home the same day. It's beautiful! You have the same breast that you had to begin with, minus a cancer, plus a little scar. The disadvantage of this option for many patients is that they need radiation. What about a total mastectomy? Well, under the conventional arm you come in the morning of surgery, you have your surgery, you're often in the hospital only over night. You will have a drainage tube. But you go home the next day, often times you wont need radiation. We'll talk about radiation in another session as well but the disadvantage with the conventional mastectomy is that you're flat, so what about the skin-sparing mastectomy. Well again, you come in the morning of surgery, you have your surgery, the issue here is it's a bigger surgery. So you're often in hospital two to five days, you're not flat, you likely won't need radiation. But it is a big operation and so for many patients post operative pain is an issue. So weighing the risks and benefits, the advantages and disadvantages of each of each option, really comes down to patient preference when other medical contra indications don't play a role. Let's take a look at what these three options look like. So here's a patient who had breast conserving surgery. I would bet that you can't even tell where her cancer was. Her scar is nicely hidden right here right around that nipple areola complex and often times we can use what's called onco plastic procedures, techniques that we can use plastic surgery techniques to make the oncologic resection much nicer. These two patients have both had mastectomies. The patient on the left had a conventional mastectomy so she's flat. The patient on the right had a skin sparing mastectomy with immediate reconstruction. As you can see her cosmetic result is quite good. Here, she's had, she actually had a tummy tuck reconstruction. And we'll talk more about reconstruction in a later talk. She's had her nipple reconstructed and the areola tattooed. Pretty nice, I think. Many patients ask if they can keep their nipple. What about a nipple-sparing mastectomy? This is actually a procedure that we can do. I'm always a little hesitant however. Because remember all of those ducts go to the nipple. So you want to think about both cosmetic reasons and oncologic reasons to do this or not. Now on the oncologic side you need to think about extent of disease. If there's a lot of disease, especially ductal carcinoma in situ, where it's inside the pipe, inside those ducts, and all of those ducts go to the nipple, you might not want to keep the nipple there. Another thing is if you have a cancer that's very close to the nipple. Again, you might not want to leave the nipple there if you're worried about cancer involving the nipple. We'll talk about Paget's disease when we talk about special types of cancer. That's another one where you really don't want to leave the nipple, because, in Paget's disease, the nipple itself is involved. But aside from the oncologic reasons, there are also cosmetic reasons why leaving the nipple there might not be such a great option. For example, some patients have very large and pendulous breasts, so the nipple might not be positioned where you would want it. Many patients will use the opportunity to have breast cancer surgery as an opportunity to actually get a little bit more perky if you will. So the nipple can be relocated to a more optimal position. If it's not in the right position, you might not want to keep it in that position. You might want to have the plastic surgeons make a new nipple that they can place at a correct position. It's also important to remember that if you keep the nipple there, although it looks very natural because it is your own nipple, it wont be responsive to cold or sexual stimulus. And it will be insensate, that is to say you wont be able to feel the same as you do with your normal natural nipple once you have your breast removed. These are important considerations. What about removing the other breast? We've talked about mastectomy and reconstruction, and for a lot of women, this is a great option for them. But many women who are faced with breast cancer say well what about the other breast? When we talked about genetics, we remember that that increases your risk of developing cancer. So certainly, if you carry a genetic mutation and you've got cancer in one breast, you might be thinking do I really want to keep the other breast. Well, even without a genetic mutation, if you have a cancer in one breast, you have to remember that your risk of developing cancer in the other breast, is half to one to percent per year cumulative over your lifetime. So let's think about that. Let's suppose you're thirty years old and normal life expectancy let's say is 80 years old. That's a fifty year life span. And over those 50 years, regardless of your genetic risk, if you have cancer in one breast, your risk of developing cancer in the other breast would be estimated to be 25 to 50%. So some women would say, hmm, 50, 50 shot at getting cancer again? No thank you. And we'll remove the other breast in a prophylactic way. That is to say, to prevent breast cancer from coming into that breast. We know that contralateral prophylactic mastectomy you can reduce the chances of you getting cancer in that breast by 95%. So you take that 25% to 50% number and you bring it down to 1.25 to 2.5% which is much more acceptable. Other considerations are symmetry. So, removing both breasts and making them look equal, kind of like this lady here. She had cancer in one breast, and decided to remove them both. And I would argue it's hard to tell which breast had the cancer and which breast didn't. She's had a wonderful cosmetic result. It also can ease follow ups. So instead of having a mammogram every year or an MRI every year, If you've had bilateral mastectomies, you really don't need any kind of special imaging for follow up. You're followed with physical exam because any recurrence would occur right underneath the skin and show up like a pimple which is easy to find with your fingers. Now, for many patients, the reason to do this is really piece of mind. But, you need to understand that the data are still out with regards to whether this actually conveys a survival benefit. We've talked a lot about surgical options today on how to remove this cancer. In upcoming lectures, we're going to talk about how we can reconstruct the breast. I hope you'll join me. Until next time. I'm Dr. Anish Shagpar
