Breast Lump Wide Excision and Axillary Sampling

Before you agree to have your breast surgery it is important to know all you can about it. The information here is a guide to common medical practice. Each hospital and doctor will have slightly different ways of doing things, so you should follow their guidance where it is different from the information given here. Because all patients, conditions and treatments vary it cannot cover everything. Use this information when making your breast surgery treatment choices with your doctors. You should mention any worries you have. Remember that you can ask for more information at any time.

What is the problem?

There may be one of two problems:

• There is something in part of your breast, such as a solid lump or a cyst. We need to take it out to prevent it getting bigger or troublesome. This is called a lumpectomy or breast lump excision.
• There is something in the breast, which is not quite normal. We need to take it out for examination under the microscope. This is called an excision biopsy.

What has gone wrong?

The breast is made up of millions of tiny glands, called lobules, which make milk and tiny tubes, called ducts that carry the milk to the nipple. There are other tissues, such as fat, blood vessels, fibrous tissue and lymph glands.

What is the problem?

Your tests suggest that there is either:

• a very small carcinoma in your breast
• breast tissue that may turn malignant if left untreated
• tissue that may prove to be a non–malignant condition.

There is no sign of spread of cancer to any other part of the body. There is no sign of any other tumour in either breast.

What has gone wrong?

The breast is made up of millions of tiny glands, called lobules, which make milk and tiny tubes, called ducts that carry the milk to the nipple.

The cells that line the ducts or, more rarely, the lobules, can start growing and spreading in an uncontrolled way; this is called malignant change. The cells look malignant under the microscope and may have spread outside their normal limits. At first, they stay inside the ducts or lobules for a time, called in-situ carcinoma. At some later date, they spread through the walls of the ducts or lobules into the breast tissue. They can spread into the lymph nodes and other parts of the body. This is called invasive carcinoma.

Sometimes, the appearance of the lining cells simply suggests that they may start turning malignant at some stage in the future; this is called premalignant change.

The breast tumour cells have special receptors, called oestrogen receptors, which female sex hormones, such as oestrogen stick to. A special microscope stain on the removed tissue is used to detect these sites. Future treatment partly depends on how many of these sites are found.

The aims

The first aim is to find out exactly what abnormal tissue is in the breast. We do this by removing the diseased part of the breast with a clear rim of healthy breast. This is called wide excision. This can also be a good initial treatment for a small invasive breast cancer treated conservatively.

The second aim is to find out whether there are malignant cells in the rest of the body. A good guide is whether there are malignant cells in the lymph nodes in the armpit. To do this, we will take out four or more glands from your axilla at the operation. We call this axillary sampling.

We send the breast lump and lymph nodes to the laboratory. It takes about a week to prepare the tissue, examine it under the microscope and prepare a report.

The benefits

The operation will make clear what is happening to the tissue in your breast. If there is breast cancer, the operation should start you on the path towards the best treatment for it. The swelling or problem area will no longer be in your breast. The tissue that we remove will help us to plan your future treatment. For most patients, no more surgery is needed. The breast is still there, which would not be the case after a mastectomy.

If there is in-situ cancer, or premalignant change, any further steps can be planned with certainty.

Are there any alternatives?

If you definitely have an invasive breast cancer, having the whole breast removed in a mastectomy is an alternative to a wide excision. This needs serious thought and discussion with your breast specialist and breast nurses. You would have the same life expectations, but with a smaller chance of the disease coming back in the same area. You would lose the breast, but for some this is not a major factor. You would avoid radiotherapy to the breast.

There are good ways of rebuilding the breast following a mastectomy. Sometimes a small breast may become very deformed by a wide excision and can be difficult to rebuild. You need to spend some time with the breast specialist and the breast nurses discussing this whole matter. There is no rush to decide.

Radiotherapy on its own, without surgery, would not be as good in your case. Neither would drug treatment on its own. The same applies to alternative therapies, such as aromatherapy and reflexology.

What if you do nothing?

If you do nothing, your breast problem will get steadily worse. You could lose out on important treatment. It is not a good idea to start any treatment, if it is not clear what is wrong.

Author: Mr Michael Edwards FRCSEng FRCSEd. Consultant general surgeon.

© Dumas Ltd 2006

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