Quadrantectomy is a surgical procedure in which a "quadrant" (approximately one-fourth) of the breast, including tissue surrounding a cancerous tumor, is removed. It is also called a partial or segmental mastectomy.
Purpose
Quadrantectomy is a type of breast-conserving surgery used as a treatment for breast cancer. Prior to the advent of breast-conserving surgeries, total mastectomy (complete removal of the breast) was considered the standard surgical treatment for breast cancer. Procedures such as quadrantectomy and lumpectomy (removing the tissue directly surrounding the tumor) have allowed doctors to treat cancer without sacrificing the entire affected breast.
Demographics
The American Cancer Society estimates that approximately 211,300 new cases of breast cancer are diagnosed annually in the United States, and 39,800 women die as a result of the disease. Approximately one in eight women will develop breast cancer at some point in her life. The risk of developing breast cancer increases with age: women ages 30–40 have a one in 252 chance, ages 40–50 a one in 68 chance, ages 50–60 a one in 35 chance, and ages 60–70 a one in 27 chance.
In the 1990s, the incidence of breast cancer was higher among Caucasian women (113.1 cases per 100,000 women) than African American women (100.3 per 100,000). The death rate associated with breast cancer, however, was higher among African American women (29.6 per 100,000) than Caucasian women (22.2 per 100,000). Rates were lower among Hispanic women (14.2 per 100,000), American Indian women (12.0), and Asian women (11.2 per 100,000).
Description
The patient is usually placed under general anesthesia for the duration of the procedure. In some instances, a local anesthetic may be administered with sedation to help the patient relax.
During quadrantectomy, a margin of normal breast tissue, skin, and muscle lining is removed around the periphery of the tumor. This decreases the risk of any abnormal cells being left behind and spreading locally or to other parts of the body (a process called metastasis). The amount removed is generally about one-fourth of the size of the breast (hence, the "quadrant" in quadrantectomy). The remaining tissue is then reconstructed to minimize any cosmetic defects, and then sutured closed. Temporary drains may be placed through the skin to remove excess fluid from the surgical site.
Some patients may have the lymph nodes removed from under the arm (called the axillary lymph nodes) on the same side as the tumor. Lymph nodes are small, oval- or bean-shaped masses found throughout the body that act as filters against foreign materials and cancer cells. If cancer cells break away from their primary site of growth, they can travel to and begin to grow in the lymph nodes first, before traveling to other parts of the body. Removal of the lymph nodes is therefore a method of determining if a cancer has begun to spread. To remove the nodes, a second incision is made in the area of the armpit and the fat pad that contains the lymph nodes is removed. The tissue is then sent to a pathologist, who extracts the lymph nodes from the fatty tissue and examines them for the presence of cancer cells.
Diagnosis/Preparation
Breast tumors may be found during self-examination or an examination by a health care professional. In other cases, they are visualized during a routine mammogram. Symptoms such as breast pain, changes in breast size or shape, redness, dimpling, or irritation may be an indication that medical attention is warranted.
Prior to surgery, the patient is instructed to refrain from eating or drinking after midnight on the night before the operation. The physician will tell the patient what will take place during and after surgery, as well as expected outcomes and potential complications of the procedure.
Aftercare
The patient may return home the same day or remain in the hospital for one to two days after the procedure. Discharge instructions will include how to care for the incision and drains, what activities to restrict (i.e., driving and heavy lifting), and how to manage postoperative pain. Patients are often instructed to wear a well-fitting support bra for at least a week following surgery. A follow-up appointment to remove stitches and drains is usually scheduled 10–14 days after surgery.
If lymph nodes are removed, specific steps should be taken to minimize the risk of developing lymphedema of the arm, a condition in which excess fluid is not properly drained from body tissues, resulting in chronic swelling. This swelling can sometimes become severe enough to interfere with daily activity. Prior to being discharged, the patient will learn how to care for the arm, and how to avoid infection. She will also be told to avoid sunburn, refrain from heavy lifting, and to be careful not to wear tight jewelry and elastic bands.
Most patients undergo radiation therapy as part of their complete treatment plan. The radiation usually begins immediately or soon after quadrantectomy, and involves a schedule of five days of treatment a week for five to six weeks. Other treatments, such as chemotherapy or hormone therapy, may also be prescribed depending on the size and stage of the patient's cancer.
Risks
Risks associated with the surgical removal of breast tissue include bleeding, infection, breast asymmetry, changes in sensation, reaction to the anesthesia, and unexpected scarring.
Some of the risks associated with removal of the lymph nodes include excessive bleeding, infection, pain, excessive swelling, and damage to nerves during surgery. Nerve damage may be temporary or permanent, and may result in weakness, numbness, tingling, and drooping. Lymphedema is also a risk whenever lymph nodes have been removed; it may occur immediately following surgery or months to years later.
Normal results
Most patients will not experience recurrences of the cancer following a treatment plan of quadrantectomy and radiation therapy. One study followed patients for a period of 20 years after breast-conserving surgery, and found that only 9% experienced recurrence of the cancer.
Morbidity and mortality rates
Following removal of the axillary lymph nodes, there is approximately a 10% risk of lymphedema and a 20% risk of abnormal skin sensations. Approximately 17% of women undergoing breast-conserving surgery have a poor cosmetic result (e.g., asymmetry or distortion of shape). The risk of complications associated with general anesthesia is less than 1%.
Alternatives
A full mastectomy, in which the entire affected breast is removed, is one alternative to quadrantectomy. A simple mastectomy removes the entire breast, while a radical mastectomy removes the entire breast plus parts of the chest muscle wall and the lymph nodes. In terms of recurrence and survival rates, breast-conserving surgery has been shown to be equally effective as mastectomy in treating breast cancer.
A new technique that may eliminate the need for removing many axillary lymph nodes is called sentinel node biopsy. When lymph fluid moves out of a region, the "sentinel" lymph node is the first node it reaches. The theory behind sentinel lymph node biopsy is that if cancer is not present in the sentinel node, it is unlikely to have spread to other nearby nodes. This procedure may allow individuals with early stage cancers to avoid the complications associated with partial or radical removal of lymph nodes if there is little or no chance that cancer has spread to them.
BOOKS
Iglehart, J. Dirk, and Carolyn M. Kaelin. "Diseases of the Breast" In Sabiston Textbook of Surgery. Philadelphia: W. B. Saunders Company, 2001.
PERIODICALS
Apantaku, Leila. "Breast-Conserving Surgery for Breast Cancer." American Family Physician 66, no. 12 (December 15, 2002): 2271-8.
Sainsbury, J. R., T. J. Anderson, and D. A. L. Morgan. "Breast Cancer." British Medical Journal 321 (September 23, 2000): 745-50.
Veronesi, U., N. Cascinelli, L. Mariani, et al. "More Long- Term Data for Breast-Conserving Surgery." New England Journal of Medicine 347, no. 16 (October 17, 2002): 1227-32.
ORGANIZATIONS
American Cancer Society. 1599 Clifton Rd. NE, Atlanta, GA 30329-4251. (800) 227-2345. <http://www.cancer.org>.
Society of Surgical Oncology. 85 W. Algonquin Rd., Suite 550, Arlington Heights, IL 60005. (847) 427-1400. <http://www.surgonc.org>.
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Quadrantectomy is usually performed by a general surgeon, breast surgeon, or surgical oncologist. Radiation therapy is administered by a radiation oncologist, and chemotherapy by a medical oncologist. The surgical procedure is frequently done in a hospital setting (especially if lymph nodes are to be removed at the same time), but specialized outpatient facilities are sometimes preferred.
QUESTIONS TO ASK THE DOCTOR
Why is quadrantectomy recommended?
What methods of anesthesia and pain relief will be used?
Where will the incision be located, and how much tissue will be removed?
