Depending on the size of the tumour, the removal of only one lymph node (called a sentinel node) may suffice, or all of the lymph nodes may have to be removed (axillary curettage).
Tumorectomy (conservative surgery)
In this type of operation, only the tumour is removed, along with a safety margin, i.e. an area of healthy tissue around the malignant lesion, to ensure that no malignant cells remain in the breast. If the tumour is not palpable by clinical means, the radiologist will in advance of the operation insert a harpoon, a type of needle, into the tumour in order to guide the surgeon during the surgical operation.
In a conservative operation, the aim is to completely eliminate the tumour while producing a cosmetically correct result. If necessary, a plastic surgeon will be called in to perform immediate remodelling of the breast with the option of corrective surgery on the other breast.
Mastectomy (or mammectomy)
This operation involves complete ablation of the affected breast. Depending on the final results of the operation on the tumour and the sentinel node/axillary curettage, the mastectomy may be followed up by other treatments (radiotherapy, chemotherapy, hormone therapy).
In the latter case, the superjacent skin and the nipple are also removed. Since the mammary gland extends to the armpit, the result is a flat area in place of the breast.
Breast reconstruction after a mastectomy is a personal choice. Each surgical solution must be adapted according to the possibilities on a local level and each person’s self-motivation.
The patient is presented with three reconstruction options:
- Reconstruction by prosthesis
- Volume restoration by a muscle and skin flap from the back
- Volume restoration by a muscle and skin flap from the abdomen
Technique for detecting lymph node metastasis via the sentinel node
A technique currently used has been developed to demonstrate the presence or absence of metastasis in axillary lymph nodes. This technique involves making a small incision to remove a sample of the first ganglionic relay (functional lymph node) in the tumour’s lymph network: the sentinel node. Only in cases where the sentinel node has been invaded by cancerous cells will axillary lymph node curettage be performed.
The sentinel node technique has the advantages of considerably reducing the duration of the operation and of hospital stay as well as the number of post-surgical complications. Shoulder function is more easily restored and the risk of oedema in the arm is virtually non-existent. The risk of non-detection of microscopic lymph node metastases is minimal, as shown by various scientific studies.
What is the procedure ?
On the eve or morning of the day of surgery, you will be expected in the nuclear medicine department. A mildly radioactive and completely harmless product is injected around the breast tumour. Next, several images are taken. During the operation, the sentinel node is easily located by means of a probe detecting the radioactivity, and removed. This node is immediately analysed under the microscope. If it is a healthy sentinel node, the operation ends at this point.
If the node has been invaded by cancerous cells, the operation will obviously continue with complete excision of the lymph nodes from the armpit (axillary lymph node curettage). The surgeon sometimes uses a blue colouring agent to view the pathways and the lymph nodes by another method. Traces of the blue colouring agent may be evident after the operation; this is natural and has nothing to do with radioactivity, which disappears within 24 hours.
Axillary lymph node curettage
Microscopic examination of the lymph nodes is important to be able to decide on the course of treatment to be pursued. Where complete excision of the lymphatic region is performed, the number of lymph nodes excised differs from patient to patient.
After the operation, a drain (a small plastic tube) will be put in place to take away blood and serous fluid from the armpit. The period for keeping the drainage in place will vary according to the patient, but she will not have to be hospitalised for longer as a result. The home-care nurse will change the drainage container every day and will attend to the wound.
The surgeon will examine the patient twice a week to ascertain whether or not the drain can be removed.
After lymph node excision, some nerves in the skin may have been cut, and this may produce a sensation of sedation or pins-and-needles in the skin near the armpit, the inner arm and the armpit itself.
Physiotherapy is required to restore full mobility to the shoulder and arm. The physiotherapist will visit you on the day after your operation.