Wide Local Excision / Lumpectomy

What is a lumpectomy?

A breast lump (which you can feel) or a breast lesion (which can only be seen on mammogram or ultrasound) may need to be surgically excised.
Traditionally, when this lump or lesion is benign, the procedure is called a lumpectomy.

For breast cancer and DCIS, the excision requires wider margins (more normal tissue surrounding the tumour to ensure it is completely removed). Therefore, the procedure is called a wide local excision (WLE).

Wire-guided excision

For lesions that cannot be felt, we use a wire-guided technique. This means placing a long needle into the lesion under imaging guidance. This is done under local anaesthetic one to two hours before your procedure. Once the needle is inserted, a “hook” is deployed at the end of the needle which fixes this wire in place until it is removed together with the lesion during the surgery. This is why it can also be called a “hookwire-guided excision”.

If a guidewire is used, once the lesion is removed, it is sent for an x-ray to ensure the lesion has been removed adequately.

The surgical incision

The position, size and shape of the scar will depend on the position and size of the tumour or lump as well as the size of the breast. The aims of surgery are:

  • Removing the tumour with adequate margins of normal tissue to reduce the chance of further surgery.
  • Closing the cavity created by removing the tumour. If only the skin is closed, fluid collects inside the cavity initially giving an impression of a good cosmetic result. However, following treatment with radiotherapy (which is required most of the time following WLE), the cavity shrinks giving a poor cosmetic outcome.
  • Maintaining breast shape – We try to maintain breast shape despite the volume loss caused by removing the tumour. This will result in as normal a breast shape as possible but a smaller breast size.
  • Avoiding obvious scars (such as in the cleavage area) – While this may not always be possible, we try to keep the scars in less obvious parts of the breast such as around the areola, below the breast or towards the arm pit. Another common incision is the so-called radial incision which is a line that radiates from the areola.
  • Symmetry – When possible, we try to match the opposite breast. However, this may require symmetrizing surgery to the other breast.

Most of the time, the tumour can be removed through a simple incision bringing the breast tissue back together to achieve the above-listed aims.

However, larger tumours require more complex techniques to achieve these aims. These techniques borrow from the plastic surgery techniques used in breast reduction (mammaplasty) and breast lift (mastopexy) techniques. These surgical techniques are called oncoplastic surgery (onco= related to cancer, plastics = plastic surgical techniques).

The likely surgical technique including final scar position and expected breast size will be discussed with you prior to surgery.

The tumour is sent to the laboratory for pathological analysis under the microscope. The details of the tumour will aid the decision regarding further surgery and adjuvant treatment.

What are the risks of surgery?

There is a small risk of bleeding which usually settles spontaneously.

There is also a small risk of infection which is further reduced by the administration of antibiotics at the time of surgery.

Up to 10% of patients may have a positive margin when examined under the microscope. This usually requires further surgery – either removing more tissue or sometimes a mastectomy.

Before surgery

Fast from midnight for a morning procedure OR from 7am for an afternoon procedure.

If your procedure includes a sentinel node biopsy, you will be booked for a lymphoscintigram – on the morning of surgery for an afternoon procedure, or the afternoon before for a morning procedure.

If you require placement of a guidewire, this will be done one to two hours before your procedure. It will be co-ordinated with your lymphoscintigram if you require both.

You will be informed of your admission time which will depend on the above procedures.

After surgery

Pain is usually minimal following a wide local excision but may be more significant after more extensive oncoplastic surgery.

You should take regular Panadol (as long as there are no medical reasons for you not to take it such as an allergic reaction or liver disease).

Non-steroidal anti-inflammatory medication such as Neurofen and Voltaren can also help with pain and inflammation but should be taken on a full stomach. Take these for the first 3-5 days as required.

Stronger pain killers such as opioid anaelgesics (Endone, Codeine) are usually not required and should be taken sparingly as they can cause constipation.

The wound is dressed with Dermabond glue which is waterproof. The glue feels hard which is normal. It sheds off over the 2-3 weeks.

Most wide local excisions do not require drainage. However, some patients may require placement of a drain tube following more extensive oncoplastic techniques such as a breast reduction.

You can usually go home the same day unless the technique used involved a breast reduction or symmetrizing surgery to the opposite breast. This may require you to stay overnight.

You will be followed up within 1-2 weeks of your surgery to review the wound and discuss your pathology results.

Your follow up appointment is usually made for you prior to discharge.