Breast Cancer Surgery

Breast cancer and why screening matters

Breast cancer arises when cells in the breast begin to divide without the usual controls. It is not a single disease. Its subtypes behave very differently depending on the cell type involved, on whether the tumour expresses hormone receptors, and on its HER2 status. Two women can be given the same diagnosis in the same words and still need entirely different treatment.

Cancers found early leave more options open, and the breast can more often be conserved. That is the reason screening exists. The widely accepted approach is regular mammography from around the age of forty in women with no symptoms. Screening may begin earlier, and may need to be supplemented with ultrasound or breast MRI, in women with a family history of breast or ovarian cancer, a known genetic predisposition, or a previous breast biopsy. Self-examination does not replace screening, but knowing what your own breasts normally feel like — and coming forward promptly when something changes — matters.

• A newly noticed lump in the breast or armpit that feels firm and does not move freely
• Skin dimpling, an orange-peel texture, or redness that does not settle
• New inward pulling of the nipple, crusting, or spontaneous blood-stained discharge
• A change in the shape or size of part of the breast

How a breast lump is investigated: triple assessment

A breast finding is assessed on three legs: clinical examination, imaging, and — where indicated — biopsy. This is known internationally as triple assessment, and its purpose is to keep any single test from carrying the decision on its own, because no single test is reliable enough to do so.

Examination establishes where the lump is, how big it is, how it feels, whether it moves freely against the surrounding tissue and the skin, and whether the lymph nodes in the armpit are involved. Imaging is chosen according to age and breast density: mammography, breast ultrasound, or both together, with breast MRI reserved for selected situations. Imaging findings are reported using the BI-RADS system, a shared vocabulary that indicates how suspicious a finding is and whether further work-up is needed.

Diagnosis is confirmed by biopsy. In most cases this is a core (tru-cut) needle biopsy performed under local anaesthesia with ultrasound guidance. The tissue obtained is examined by a pathologist, who determines not only the type of cancer but also the features that steer treatment — hormone receptor status and HER2 status among them. A biopsy is not a step that rushes anyone towards the operating theatre; it is what makes it possible to plan the right operation, in the right order, alongside the right drug treatment. Not every lump is cancer. Fibroadenomas and cysts are common. But the way to tell the difference is assessment, not waiting.

Breast-conserving surgery or mastectomy?

There are two basic surgical routes. In breast-conserving surgery the tumour is removed together with a rim of healthy tissue around it, and the rest of the breast is left in place. In mastectomy the whole of the breast tissue is removed.

The choice is not a matter of which option feels safer to the patient. It depends on the size of the tumour relative to the size of the breast, whether the disease sits in one place or is spread through more than one part of the breast, how extensive any microcalcifications are, whether there is a known genetic predisposition, and whether radiotherapy after surgery is possible. Breast-conserving surgery is, by definition, half of a package that includes radiotherapy; if radiotherapy cannot be delivered, conservation may not be appropriate.

In some women, drug treatment given before surgery — neoadjuvant treatment — shrinks the tumour enough to make breast conservation possible where it would not have been at the outset. Where mastectomy is required, reconstruction can be discussed either at the same operation or later in the course of treatment. Which route suits you can only be determined once examination, imaging and pathology have been considered together. At İzmir Cerrahi Merkezi that conversation is held plainly: what each option involves, what it commits you to, and what follow-up it brings.

The axilla and sentinel lymph node biopsy

Breast cancer most often spreads first to the lymph nodes in the armpit, so assessing the axilla is part of the operation. For many years this meant clearing all of the nodes — axillary dissection — in every patient. That operation can leave lasting problems: lymphoedema of the arm, numbness, and restricted shoulder movement.

Sentinel lymph node biopsy was developed to avoid exactly that. A radioactive tracer, a dye, or both are injected into the breast and travel along the lymphatic channels to the first one or two nodes that drain the tumour. These sentinel nodes are removed and examined by a pathologist. If they are clear, the remaining nodes are left alone, and the patient is spared a dissection she did not need and its long-term consequences.

Sentinel biopsy is not suitable for every patient, and finding tumour in a sentinel node does not automatically mean a full dissection follows: in selected situations radiotherapy to the axilla is now preferred over further surgery. The decision about the armpit, like the decision about the breast, is individual and follows from the pre-operative work-up and the multidisciplinary plan.

• The aim is to stage the axilla accurately while avoiding unnecessary dissection
• If the sentinel nodes are clear, the remaining nodes are preserved
• Full axillary dissection is reserved for specific circumstances
• Arm exercises and lymphoedema advice are part of treatment, not an afterthought

Surgery is one part of treatment: the tumour board

Surgery is only one component of breast cancer treatment. Chemotherapy, endocrine (hormone) therapy, targeted agents and radiotherapy enter the picture for most patients. Which of these are used, in what order, and for how long depends on the stage and on the detail of the pathology. For some women drug treatment comes before the operation and for others afterwards — and that sequencing is itself a treatment decision with consequences.

For this reason the plan is not made by one doctor. It is set by a multidisciplinary tumour board, where a general surgeon, a medical oncologist, a radiation oncologist, a radiologist and a pathologist review the same information together. The surgeon's job is to carry out the surgical part of that plan correctly and at the right moment, and to guide the patient through the process. No stage of treatment proceeds on one person's judgement alone.

Patients seen at our centre with a breast cancer diagnosis, or in the middle of being investigated for one, are assessed on that basis. Which tests are needed, in what order, and which specialists will be involved is explained openly rather than left to unfold.

Recovery and follow-up

Breast cancer operations are performed under general anaesthesia. How long you stay in hospital depends on what is done: it is usually short after breast-conserving surgery and somewhat longer after mastectomy or axillary surgery. A drain may be placed to remove fluid collecting at the operative site and may need to stay in for a few days. These are averages and vary considerably from patient to patient.

Controlled arm and shoulder movement is encouraged early, and your team will show you which exercises to do and when. The pathology report on the removed tissue usually takes anywhere from a few days to a few weeks, and the definitive treatment plan is finalised at the tumour board once that report is available. Follow-up continues after treatment ends, with clinical examination and imaging at set intervals.

Contact your team without delay if you develop a fever, increasing swelling, redness or discharge at the operative site, or sudden swelling of the arm. If you have noticed a change in your breast, or you are holding an imaging or biopsy report and are not sure what happens next, you are welcome to be seen at our general surgery clinic so the options can be discussed properly.