Suzanne Klimberg, MD

When a woman undergoes breast cancer surgery today at the University of Arkansas for Medical Sciences (UAMS) Medical Center in Little Rock, she could actually end up after surgery with a breast that looks as good—or in some cases, even better – than before the surgery.

UAMS breast cancer surgeons Suzanne Klimberg, MD, and Cristiano Boneti, MD, have pioneered a breast conservation surgical treatment for cancer that allows the skin of the nipple and areola to be preserved when removing the cancerous breast tissue. During this same operation, the breast can be reconstructed using a prosthesis.

Traditionally women have breast cancer surgery, and then later potentially three to five additional surgeries to reconstruct the breast. The new techniques allow all of it to be done during the first surgery.

“Now we are a one-stop shop,” Boneti said. “Women don’t have to go to the operating room again. There has been a very positive response from women in many ways. Women are just really, really happy with what we have been doing.

I was just speaking to a patient of mine, and she was already feeling debilitated from the cancer. Cancer was threatening to take away her whole life. She said it is hard to deal with cancer and being disfigured at the same time. In her mind a lot of her womanhood was related to her breasts. She would feel empty without her breasts.”

Other surgeons in the country have been using similar techniques, but the UAMS surgeons were the first to improve the techniques and demonstrate its safety with studies by following 300 patients representing 500 mastectomies. The study results showing that breast saving surgeries can be done without adversely impacting cancer recurrence rates was presented at the national meeting of the Southern Surgical Association in December 2010.

Some surgeons from other areas of the country are contacting or coming to visit UAMS to learn more.

“The word is spreading pretty fast, but we wish that more people across the country knew about this,” Boneti said.

Another recognition of the importance of the surgical improvements include Klimberg being elected president of two important national organizations, The American Society of Breast Surgeons and the Society of Surgical Oncology.

UAMS grades cosmetic results and over the past year or so, patients have also been asked to grade cosmetic results. Many women reported that their breasts looked better after reconstruction than before.

The improvements show just how much breast cancer treatment has changed in the past hundred years. In the late 1800s and early 1900s, it was considered improper to even say the word “breast” and women were afraid of talking about breast cancer. There was little awareness of the signs of breast cancer, and so it was often late in the disease when it was diagnosed.

Early in the 1900s the radical mastectomy was developed that involved

removing the breast, skin and muscles of the chest, leaving a disfiguring scar. That was a standard of care until the 1970 National Surgical Adjuvant Breast and Bowel Project published studies showing less aggressive surgery not removing as much muscle and tissue could be equal to a radical mastectomy in results preventing the recurrence of cancer.

“What they found was that you don’t need to cut everything out,” Boneti said. “A partial mastectomy without the disfiguring scar is as good as a radical mastectomy.”

The next step forward was learning that the skin of the breast can be safely saved without compromising care. But surgeons were still afraid of preserving the nipple areola because of fears it could spread cancer. 

In 2004 researchers showed that the glandular tissue and duct system that can spread cancer is 7 mm from the surface of the skin.

“So our idea is if you take all the glandular tissue and only leave behind the skin, there is no chance of the cancer coming back,” Boneti said. “That is what we did differently. We first described this technique in 2005. By doing a very strict operation following these precautions, we can save the entire skin off the breast including the nipple, pull out all the glandular material and fill the breast up with a prosthesis or a muscle flap taken from somewhere else in the body.  You have to be very careful how you do the surgery, but not be afraid of leaving breast tissue behind.”

One potential complication is nipple ischemia. Five percent of women may have some wound complications from that. If that is the case, Boneti said they remove the nipple areola, and later do breast construction the way it was done in the past.

“It is not desirable, but they don’t really lose anything,” he said. “Even if they lose the nipple, it is worth trying because 95 percent of women will do fine.” 

Never compromising oncological results for cosmetics, it is fortunate that breast conservation surgery is as safe as older techniques.

Not only is the operation less physically and mentally challenging for patients, it saves money for patients, insurance companies and government health plans. Insurance companies are required to cover mastectomies and reconstruction. One surgery is cheaper than four or five.

UAMS surgeons have also pioneered a new way to prevent lymphedema. Boneti said women who develop lymphedema after surgery can have their arm swell to three times it normal size, making it difficult to function.

“Fluid from cells needs to be drained back to the bloodstream through lymphatic channels, “Boneti said. “A simplistic way to think of it is as the piping of any hydraulic system. When you stage breast cancer, you need to remove the lymph nodes to find out how advanced the cancer is. Transacting part of this pipeline of multiple lymph nodes coming up from the arms can back up the system, so fluids build up. It can be mild, maybe just heaviness or discomfort, or make the arm swell to three times its normal size. Once it happens, it is irreversible. Women with lymphedema say it feels worse than the mastectomy. It is a big deal for that reason.”

In the 1980s, surgeons learned that by sampling lymph nodes under the arm for cancer, they could identify the lymph nodes that were cancerous instead of removing all the nodes. Doing that significantly decreased the amount of lymphedema. A trial with thousands of patients showed the rate of lymphedema with the ancillary node technique was 14 percent, and with the sentinel lymph node technique was only eight percent.

“Eight percent is still high,” Boneti said. “We wanted to make it lower than that.  Dr. Klimberg had a brilliant idea to sample the lymphatics from the breast instead of the arm. Clearly they run together. She wondered if we could take what we need and leave the rest. That is what we do. We sample lymph nodes and leave behind ones not involved. It has significantly reduced lymphedema to half of what everyone else does. Our lymphedema rate is only 3 percent.”

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