Breast conserving surgery

Fran is 44 years old. She has no family history of breast cancer and has not had any previous breast problems. Fran has 2 young children aged 6 an 8 years who were both breast-fed. Her husband Geoff noticed a lump in her right breast 1 week ago.

Clinical examination by the surgeon confirmed the presence of a 2 cm diameter non-tender lump at the 12 o clock position in her right breast.

Ultrasound examination showed an irregular hypo-echoic mass with posterior acoustic shadowing.

Mammography was performed and showed a mass in the right breast at the site of the palpable lump.

Ultrasound guided core biopsy was performed under local anaesthetic at the same consultation and a follow-up appointment was arranged for the next afternoon.

Ultrasound picture of cancer

Mammogram showing cancer

Fran and Geoff attended the next appointment together. The core biopsy revealed features of an invasive ductal cancer. This result was explained to them using a series of drawings to show how cancer develops.

Pre-operative tests consisted of a chest x-ray, full blood count and liver function tests and these were all normal.

A detailed discussion was held regarding treatment options. The tumour was considered suitable for breast conserving surgery due to its size and location in the breast..

Fran had a left partial mastectomy and sentinel node biopsy the following week.

The blue dye injected around the tumour in theatre showed 2 nodes low down in the axillary fat and these were removed as the sentinel nodes. They were examined immediately by the pathologist who reported that one contained cancer cells. A complete level 2 axillary dissection was therefore performed to remove any other lymph nodes that might also be affected.

The pathologist also examined the partial mastectomy specimen in theatre and reported that the medial margin was very narrow. An additional segment of breast tissue was excised to ensure adequate clearance.

The operation took 2 hours in theatre and there were no problems. Fran made a good recovery from surgery. She was discharged on day 3 after removal of her drains.

An appointment was made with the physiotherapist to assist with full mobilisation of her arm.

Histology was available on day 3. The detailed synoptic report is produced below.

Type: Infiltrating ductal cancer.

Size: 1.8 cm

Grade 2

Lympho-vascular invasion: Positive.

Oestrogen receptor: Negative.

Progesterone receptor: Negative.

HER 2: Negative

Margins: clear. Closest margin is at the medial surface. Wider excision medial margin all clear with 10mm margin.

EIC: Negative.

Sentinel node: 2 nodes examined. 1 positive. Level 2 axillary dissection showed a further 11 nodes of which one was positive. Final nodal status 2 / 13 nodes positive.

These results were presented at the multidisciplinary panel meeting the following Tuesday. The cancer is hormone receptor negative so treatment with hormonal medication such as Tamoxifen will not be effective. Chemotherapy will offer a significant survival benefit in a node positive premenopausal woman. This can be calculated by the medical oncologist using programmes such as Adjuvant Online.

In this situation it is estimated that a third generation chemotherapy regime including a Taxane can reduce mortality from 30% to 15%. This means that without chemotherapy 68 out of 100 patients will be alive at 10 years and with chemotherapy this is increased o 83. Fran decides to go ahead with treatment stating that she wants to do everything possible to be alive for her young children Chemotherapy starts 3 weeks after surgery and lasts for 4 months.

She was also referred for radiotherapy to the breast as this will decrease the risk of local recurrence of the cancer. Radiotherapy is given after chemotherapy to avoid added risk of cardiac damage if these treatments are given simultaneously.

Fran was advised to avoid falling pregnant while having treatment and has discussed appropriate contraception with her GP. We usually suggest avoiding pregnancy for at least 2 years following treatment. Specific advice in each situation will depend on the details of the specific tumour and treatment given.

Chemotherapy was completed in 4 months.

Radiotherapy was given as 20 treatments over 4 weeks. There was quite a marked skin reaction with reddening and blistering that settled down 4 weeks after completion of radiotherapy.

Follow- up visits were arranged 3 - monthly alternating between surgeon and oncologist.

Clinical exam and mammography at 12 months was normal. She has a full range of movement in the arm and has not had any trouble with swelling of her arm.

The breast still feels slightly heavy and sensitive after radiotherapy and this may take another 12 - 18 months to settle back to normal.

Fran is feeling well and is back at her part time job and playing tennis again. She will continue with regular follow-up.