Wide Local Excision

What is Wide Local Excision?

Wide Local Excision (WLE), also known as lumpectomy or breast-conserving surgery, is a surgical procedure aimed at removing cancerous tissue from the breast along with a margin of healthy tissue around it. This procedure allows for the preservation of much of the breast tissue, contrasting with a mastectomy, where the entire breast is removed. It is primarily used in the treatment of early-stage breast cancer.

Who is Suitable for Wide Local Excision?

Wide Local Excision is suitable for patients with certain criteria:

Early-Stage Cancer: It is most effective for patients with early-stage breast cancer where the tumour is small and localised.
Single Tumour: Ideal candidates typically have only one tumour in the breast. However, recent advances allow some patients with more than one tumour in the same quadrant of the breast to still undergo this procedure.
Good Cosmetic Outcome: Patients likely to have a good cosmetic outcome post-surgery, where removing the tumour does not significantly alter the breast's appearance, may prefer this option.
Patient Preference: Some patients opt for WLE over mastectomy for personal reasons, including the desire to preserve their breasts.
Availability of Radiation Therapy: Radiation therapy is usually required post-surgery to treat any remaining microscopic cancer cells. Patients need to be willing and able to undergo radiation therapy following WLE.
No Previous Radiation Therapy to the Breast: Patients who have not had previous radiation therapy to the breast area are better candidates for WLE.
Overall Health: Suitable candidates should be healthy for surgery and subsequent treatments.

Benefits of Wide Local Excision

Breast Conservation: One of the most significant benefits is the ability to preserve most of the breast tissue, which is important for many patients from a psychological and cosmetic perspective.
Effective Cancer Control: When combined with radiation therapy, WLE offers a level of cancer control comparable to that of a mastectomy for early-stage breast cancer.
Shorter Recovery Time: The procedure generally involves a shorter recovery period than a mastectomy, allowing patients to return to their normal activities more quickly.
Less Invasive: Since the surgery is less extensive, it often results in fewer complications and less pain during recovery.
Better Cosmetic Outcomes: Preserving the breast may improve patients' satisfaction with their body image and quality of life post-surgery.
Localised Treatment: WLE targets and removes the tumour and a small margin of surrounding healthy tissue, minimising the impact on the rest of the breast.

Types of Wide Local Excision

The types of Wide Local Excision can vary depending on the specifics of the cancer and the approach deemed most suitable by the surgical team:

Standard Wide Local Excision: This is the typical form of WLE, in which the surgeon removes the cancerous tumour along with a margin of surrounding healthy tissue to ensure no cancer cells are left behind.
Oncoplastic Wide Local Excision: In cases where a larger amount of tissue needs to be removed, oncoplastic surgery combines cancer surgery and plastic surgery techniques in one procedure. This approach not only removes the cancer but also reshapes the breast at the same time, sometimes involving surgery to the opposite breast to ensure symmetry.
Segmental Resection or Quadrantectomy: In this type of excision, more extensive than a standard WLE, up to a quarter of the breast tissue is removed, including the tumour. Depending on the tumour's size and location, this approach might be necessary but requires a more significant reconstruction effort.

Preparation Before a Wide Local Excision

Preparation for a Wide Local Excision involves several steps to ensure the surgery goes smoothly and to optimise outcomes:

Medical Evaluation: Undergo a thorough medical evaluation, including blood tests, a mammogram, and possibly an MRI, to assess the size and location of the tumour. This helps in surgical planning.
Consultation with Surgeon: Discuss the details of the procedure, potential risks, and post-operative care with your surgeon.
Medication Review: Inform your medical team about any medications you are taking. Some, especially blood thinners, may need to be stopped before surgery.
Preoperative Imaging: Sometimes, a wire localisation procedure is performed before surgery to mark the tumour's exact location if it's not easily palpable.
Fasting: You will likely need to fast (not eat or drink) for several hours before the surgery, usually starting at midnight the night before.
Arranging Support: Plan for someone to drive you home after the surgery and help out at home as you recover.

Wide Local Excision Procedure

The procedure typically proceeds as follows:

Anaesthesia: General anaesthesia is commonly used, though local anaesthesia with sedation might sometimes be an option.
Incision: The surgeon makes an incision over or near the tumour site.
Tumour Removal: The tumour and a margin of healthy tissue around it are excised. The amount of tissue removed depends on the tumour's size and location.
Sentinel Node Biopsy: A sentinel lymph node biopsy is sometimes performed during the same procedure to check if cancer has spread to the lymph nodes.
Tissue Marking: The surgeon may place small metal clips inside the breast to mark the area of tissue removal for radiation therapy.
Closure: The incision is closed with sutures, and a dressing is applied.

Wide Local Excision Recovery Plan

Rest: Ensure you get plenty of rest and gradually increase your activities as your surgeon recommends.
Physical Therapy: Engage in gentle exercises to restore movement and strength once approved.
Emotional Support: Consider speaking with a counsellor or support group if you feel overwhelmed.
Radiation Therapy: Most patients will start radiation therapy a few weeks after surgery to eliminate any remaining cancer cells, depending on the pathology report.
Regular Check-Ups: Ongoing monitoring for breast health and any potential recurrence is critical.

Wide Local Excision Prognosis

The prognosis following a WLE is generally very favourable, especially for patients diagnosed with early-stage breast cancer. Depending on the specific case, the outcomes are often excellent when combined with appropriate adjuvant therapies such as radiation, hormonal therapy, or chemotherapy. The five-year survival rate for patients with early-stage breast cancer who undergo lumpectomy and radiation therapy is comparable to those who opt for mastectomy. The key to a favourable prognosis is completely removing the cancerous tissue with clear margins, significantly reducing the risk of recurrence.

Wide Local Excision Risks

Infection: Any surgical procedure can lead to infections, but proper wound care can mitigate this risk.
Bleeding: There may be some bleeding during or after surgery, which usually can be controlled during the procedure.
Scarring: The surgery will leave a scar, which can vary in size and appearance. Techniques such as oncoplastic surgery aim to minimise and improve the cosmetic outcome.
Changes in Breast Sensation: Some patients experience changes in sensation in the breast or nipple due to nerve damage during surgery.
Asymmetry of the Breasts: The breast that undergoes surgery may differ in size or shape compared to the other breast.
Lymphedema: If lymph nodes are removed or damaged during surgery, it can lead to lymphedema, a condition characterised by swelling in the arm or chest area on the side of the surgery.
Incomplete Removal of Cancer: There is a risk that not all cancerous tissue is removed, which might necessitate further surgery or alternative treatments.

What if Wide Local Excision is Delayed?

Delaying a Wide Local Excision can have several implications:

Progression of Cancer: The most significant risk is the potential for cancer to grow and spread, making it less amenable to breast-conserving approaches and potentially requiring more extensive treatment like mastectomy or systemic therapies.
Higher Stage at Diagnosis: A delay could lead to diagnosing the cancer at a more advanced stage, which can negatively impact the prognosis and treatment options.
Increased Anxiety and Stress: For many patients, delaying surgery can lead to increased psychological stress and anxiety about the progression of their cancer.

Patients need to discuss the timing of the surgery and any potential delays with their surgeon to understand the risks and benefits in their specific context. Decisions should be made based on the size and characteristics of the tumour, overall health, and the patient's circumstances, always aiming to optimise both the oncological and psychological outcomes.