The surgical management of early breast cancer

Definitive surgical treatment should never be undertaken without a histological confirmation of the diagnosis. For operable disease primary treatment is normally breast-conserving surgery or mastectomy, in association with axillary surgery. Patients with larger technically operable tumours may be treated with primary chemotherapy to try to shrink the tumour so that less radical surgery can be undertaken. The objective of surgery is clearance of local and regional disease with a margin of clear tissue, and to achieve an acceptable cosmetic outcome. Clinical assessment of the axilla is unreliable and because of the prognostic significance of the axillary nodal status this has to be determined histologically. Patients with single tumours < or = 4 cm are suitable for conservation therapy but this will depend on breast size. After excision with clear margins and subsequent radiotherapy the breast recurrence rate should not exceed 5-10% at 10 years. Patients will require mastectomy because of disease extent, breast size, or for personal reasons. The usual operation is a total mastectomy with axillary clearance but small islands of breast tissue may persist subcutaneously as potential sites for future disease. Good breast-conserving surgery is invariably better than reconstruction but, in the event of a mastectomy, reconstruction is offered either as an immediate or a delayed procedure. Complications of any form of surgery include haematoma, wound sepsis and wound flap necrosis. Specific complications are collections of serous fluid in the axilla or in the wound itself (seroma), shoulder stiffness and cording caused by distal thrombosis of lymphatics or veins after axillary dissection. The intercostobrachial nerve is often divided during surgery, causing numbness of the inner upper arm. Some degree of lymphoedema of the arm occurs in 10-15% of patients treated with axillary surgery. It is usually mild and may become rare as more patients have sentinel node biopsies.