Types of surgery for DCIS

Surgery is the main treatment for DCIS. Most women have an operation called a wide local excision (WLE, also called a lumpectomy). This removes the DCIS and some surrounding normal tissue (a clear margin). Usually, you have radiotherapy after a WLE to prevent the DCIS coming back or becoming an invasive cancer. If the DCIS is very small and low-grade, you may not need radiotherapy.

In some situations, such as when DCIS covers a wide area, women may be advised to have the whole breast removed (mastectomy). Sometimes a woman chooses to have a mastectomy instead of WLE because it means they won’t have the worry of DCIS coming back.

Breast reconstruction (making a new breast shape) can often be done at the same time as the mastectomy, or at a later time.

During mastectomy the surgeon may remove a small number of lymph nodes in your armpit (called a sentinel lymph node biopsy). A pathologist checks the lymph nodes for cancer cells.

When deciding about surgery, it’s important to take your time and have the information you need to make the right decision for you.

Surgery for DCIS

Surgery is the main treatment for DCIS. The operation you have depends on the size and position of the DCIS and your own preference. Your surgeon and breast care nurse will talk to you about your options.

Your surgeon will usually recommend surgery that keeps as much of the breast and its shape as possible. This surgery is called a wide local excision (WLE).

In some situations, the surgeon may recommend having the whole breast removed (mastectomy). The surgeon may take a sentinel lymph node biopsy (SLNB) during the mastectomy operation. This is to make sure that there is no small invasive cancer present which has spread to the lymph nodes.

You can usually choose to have breast reconstruction (making a new breast shape) at the same time as the mastectomy or later. Some women may decide not to have breast reconstruction at all.


Wide local excision (WLE)

The surgeon removes the DCIS and some of the normal-looking tissue around it (a clear margin). This is called a wide local excision. It may also be referred to as a lumpectomy. You will usually have a fine wire inserted to mark the area so the surgeon can find it more easily. This is called wire localisation.

After WLE, most women are advised to have radiotherapy to reduce the risk of DCIS returning or of an invasive cancer developing. If the area of DCIS was very small and low or intermediate-grade, WLE may be the only treatment you need.


Clear margins

After surgery, the pathologist examines the tissue in the edges of the tissue (margin) around the DCIS. If there are any cancer cells at or close to the margin (a positive margin), you will need another operation to remove more tissue. Making sure the margins are clear reduces the risk of the cancer coming back in the breast.

If your surgeon thinks a second operation is unlikely to clear all the DCIS cells, you may be advised to have a mastectomy.


Mastectomy (removing the breast)

Breast surgeons will usually try to conserve a woman’s breast whenever possible. But sometimes they may recommend a mastectomy. This may be when the DCIS:

  • covers a wide area
  • is in more than one part of the breast and the affected areas are not small.

Before the operation your surgeon will talk to you about sentinel lymph node biopsies and options for breast reconstruction.


Making decisions about surgery

It can be difficult to make treatment decisions. You may be offered the choice of a wide local excision or a mastectomy. Surgery to your breast can affect your feelings of femininity, your sex life and relationships. When deciding about surgery, it’s important to take your time and to have all the information you need to make the right decision for you.

Both wide local excision and mastectomy have the same long-term results in terms of treating DCIS. It’s helpful to think about the possible advantages and disadvantages of each before making a decision.

Wide local excision

Advantages

  • It keeps the appearance and sensation of the breast.
  • Recovery is shorter and easier than with a mastectomy.
  • It may be less likely to affect your sex life and relationships.

Disadvantages

  • You may need more than one operation to get clear margins.
  • You will usually need radiotherapy after the surgery.
  • Radiotherapy has short-term side effects, and some women may have long-term side effects.
  • You may still worry about the cancer coming back somewhere else in the breast.

Mastectomy

Advantages

  • You may not need radiotherapy.
  • You may feel less anxious as all the breast tissue has been removed.

Disadvantages

  • You lose your breast permanently.
  • It takes longer to recover after having a mastectomy.
  • It changes your appearance which may affect your confidence, sex life and relationships.
  • You will need a longer operation and possibly further surgery if you want breast reconstruction afterwards. However, reconstruction may help to reduce disadvantages for some women.

Your doctors and breast care nurse can answer any questions you may have and tell you what to expect. They may have photographs of other women who’ve had surgery, which they can show you.

Talking to other women who’ve already had surgery can also help – you can contact them through Breast Cancer Care. Your breast care nurse may know of a local cancer support group where you can talk to someone who’s had a similar operation.


Sentinel lymph node biopsy (SLNB)

During surgery, your surgeon may remove a few lymph nodes from the armpit to see if they contain cancer cells. Women who have a mastectomy usually have an SLNB done during the operation. Women having a wide local excision do not usually have an SLNB, unless the surgeon thinks there may be an invasive cancer present.

A sentinel lymph node biopsy is a way of checking the smallest possible number of lymph nodes (usually 1–3) in the armpit. The sentinel nodes are the first ones that lymph fluid drains to from the breast, so they are the most likely nodes to contain any cancer cells. If the sentinel nodes don’t contain cancer cells, you won’t need surgery to remove any more lymph nodes.

Removing the smallest possible number of lymph nodes reduces the risk of side effects that can occur after lymph node surgery. These include swelling of the arm, known as lymphoedema and stiffness of the arm.

How an SLNB is done

A doctor or hospital technician injects a tiny amount of radioactive liquid, which is harmless, into your breast. This is usually around the nipple. You have this done on the day of surgery or sometimes the day before.

The surgeon may also inject a blue dye into your breast, which stains the lymph nodes blue. The sentinel lymph nodes absorb the radioactivity or become blue first. The surgeon uses a small hand-held instrument to find the lymph nodes that have picked up the radioactivity. They only remove the blue or radioactive nodes (sentinel nodes), which are tested to see if they contain cancer cells.

The nodes that are removed are examined by the pathologist to make sure there are no cancer cells. If the sentinel lymph nodes contain cancer cells, it means there is an invasive cancer in the breast and not only DCIS.


Breast reconstruction

If you are having a mastectomy, your surgeon will usually ask if you want a new breast shape made at the same time (immediate breast reconstruction). Some women prefer to leave reconstruction until a later time, and others may decide not to have it done at all. It depends on what’s right for you.

If you’re not having immediate reconstruction but think you might want to have breast reconstruction in the future, it’s a good idea to mention this before you have a mastectomy. You don’t have to make a final decision at this stage, but it will help the surgeon to plan your operation.

Breast reconstruction is specialised surgery. It is done by a plastic surgeon or an oncoplastic surgeon (experts in breast cancer surgery and reconstruction). There are different methods of reconstruction. A new breast shape can be made using a silicone implant or with fat, and sometimes with muscle from your back or tummy.

Occasionally, women with bigger areas of DCIS and larger breasts can have the DCIS removed and both breasts reshaped. The treated breast will be smaller than before, so the other breast is reduced in size to leave you with a symmetrical appearance. This is called a therapeutic mammoplasty. There is a higher risk of short-term complications following this operation, but often only one operation is needed and the results are usually good.

Your breast surgeon and breast care nurse will tell you more about the types of breast reconstruction that are suitable for you.

I had surgery to remove the cancerous cells and reconstruct my breast from my abdominal muscles. It’s a bigger operation than having implants, but it gives a natural breast shape.

Bronwen

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