We must always ask critical questions to improve on our existing knowledge. It is through criticizing ourselves that we go forward to improve the lives of our patients. In asking the right questions, we could arrive at better answers and outcomes. It does not imply that certain doctors in person are attacked, but by questioning our results and portraying it visually, must lead to better decision making.

Many case studies are presented here for all of us to learn from. The women concerned, gave us full consent to publish their photos on this site and their identities will be kept secret to protect their privacy. We thank them for their generous gesture.

The cases we selected focus mainly on what should be avoided, and what can be done to save the breast and still reach an acceptable cosmetic result. Our focus here is not on breast reconstruction, but to make use of the available natural breast tissue. In some cases, the help of our plastic surgical colleagues were obtained to make one breast smaller or the other bigger for better symmetry.

case study 1
32 yrs at diagnoses in 2004.Mastectomy for a 4cm tumor. The cancer recurred in the skin in 2005. Then had radical removal of pectoralis muscle down to the ribs and radical removal of axilliary glands plus radiation. She now faces the mutilation of her body and severe swelling of the arm and pain.17067/07

Today we should rather consider to treat pre-operatively, to shrink the tumor and to downstage surgery to lumpectomy. Often the positive glands can also become negative on PST. In this case one has large breast volume, and even a large 4cm tumor can be removed and still have enough breast to save.

She had a L breast reduction, but it did nothing to soften the mutilation.


case study 2

She has a strong family history of breast cancer in her mother at age 50 and her mother’s sister and her maternal grandmother. She developed DCIS (precancerous condition) in R breast at age 34.She decided to have both breasts amputated because of her family history and had immediate reconstruction with LATS tissue flaps. At operation a small focus of DCIS of 6×7 mm was found and a micro focus of Infiltration (IDC grade 11) She uses Kessar as the tumor was estrogen +.4194/2004. Now 36 in 2007.

She now experience severe marital problems and find it difficult to cope. She stopped working due to stress. The scars from the tissue flaps over her back cause stiffness and pain.

The serious question here is: Was intervention of such magnitude necessary for a small 7mm DCIS. Reconstruction is not without complication and could never replace your own breast. The psychological impact on her marriage and her self image often is underscored by surgeons and patients alike.

The cosmetic result is very good in this case but cannot make good the psychological damage done.


case study 3

D.O.B 3-7-62   she presented in Oct 1996(34yrs) with a massive tumor in L upper breast at least 6x7cm large. Incision biopsy confirms a Gr 11 infiltrative ductal carcinoma which was Er+ and PgR+.Deb 2317 Mrs.E.J.G

It was decided that she is inoperable and needs chemotherapy as only treatment. The tumor shrunk away on the treatment and could not be seen on a mammogram and sonar done on 16-4-97.

The site where the tumor was initially seen was excised anyway as well as 6 axilliary lymph nodes. No tumor was found remaining and the nodes were also negative. A small area of DCIS was found. She was further treated with an anti-estrogen (TAMOXIFEN) and later with FEMARA She is well and the above photo was taken 5-2007.Still asymptomatic and have little complains about the Femara. Very thankful and proud to have both her breasts.

COMMENT:  Lucky for her, she was found to be inoperable, otherwise she would have had a mastectomy.Unknowingly, and she received the treatment we would have given her today, 10yrs later

She would also have received Radiation of her full L breast today and was spared the side effects of this. The concept of Primary Systemic Treatment is today gaining ground as a method to reduce tumor size and save a larger volume of the conserved breast. We have managed close to 200 women this way in our Centre. We are grateful that she was one of many other women with similar outcomes to strengthen our efforts to save more breasts. \


case study 4-2

She was 39 yrs old when she developed Gr 111 cancer in L upper breast June 2005.She was already put on HRT since 1999 when she was 33yrs.The tumor was aggressive, poorly differentiated with lympho-vascular infiltration. The SLN was neg. She had a lumpectomy + SLN mapping and then received Chemotherapy and Radiotherapy.Deb 10922/2005 DOB 1-7-1965

She is fine today and the photo was taken in May 2007.We follow her closely for any signs of tumor activity. She is grateful that she could be saved from mastectomy for which she was booked.

Comment: We know today that it is not the amount of breast tissue removed that dictate the life expectancy, but the biology (Type) of the cancer. Treatment should be tailored to every cancer type and the surgery done to the breast should be the minimum necessary to remove all cancer cells.


case study 5

She was 54 when she felt a lump in the L medial breast. She was taking HRT for 4 yrs and her maternal grand mother had BR.CA.On mammography a tumor (2.5×2.6 cm) was seen in the L medial breast but a second tumor in the R lat breast also present (2×1 cm). Both tumors were Gr.111 on needle biopsy and the L axilliary glands were pos. on FNA cytology.13973/2006 DOB 24-7-52

Our team of breast specialist decided to treat her first before surgery. She was given chemo as PST.

The picture on the L shows the initial size of the R breast tumor and the R picture shows how the tumor size shrunk after 2 mths on treatment. Lumpectomy in Oct.2006 revealed no viable tumor cells in the position of the tumor (The tumor was marked with carbon tattoo before the surgery) and the SLN was negative.

Strangely, the tumor in the L breast did not respond favorably on the PST but the L axilliary glands were down staged to negative with SLN.


We do not know why the same type of tumor does not respond the same on PST, as in this case illustrated. This case brings out the value of PST as a method to measure response on our chemotherapeutic regime while the tumor is still in the breast. If we have first removed the tumor, we would never have known that the L breast tumor is unresponsive to our treatment and thus also the tumor seeds elsewhere in her body. It urged us to change the treatment protocol.


case study 6

This lady was 44yrs old when diagnosed with Ductal carcinoma Gr 11 strongly + for estrogen and progesterone receptors. She had a lumpectomy on the R breast which is hardly visible. The glands were positive and she had chemo, RT and ovarian ablation with Zoladex and still receives an estrogen receptor blocker and is fine. She is very happy that she could be saved a mastectomy without compromising her life expectancy. Another breast preserved6050/2003 DOB 15-05-59 diagn date: 07-2003


case study 7

She was treated with an aromatase inhibitor for 8 mths  before any surgery and the picture on the L shows how good the tumor size shrunk to half the original size (1.2 cm)This is a example of a 56 yr woman whom was diagnosed with Gr 111 ductal carcinoma in the L breast which was too large to remove and still preserve a good cosmetic breast volume. The tumor was 2.5 cm in diameter and was strongly estrogen receptor pos.Picture on the R

She was then operated(lumpectomy) and had a good cosmetic result and volume .Another  breast preserved.

14473/2006  DOB.17-07-1950


Case 8

This is a young girl of 20 yrs with asymmetrical breast development. It is of little clinical interest, but the psychological impact is huge. The R breast can be reduced to match the size of the L and her body image can easily be restored. This is a common presentation in our Breast Care Centre and an easy problem to solve with the help of our plastic surgical colleagues.


case 9

case 9 1

These women presented with a cancer behind the R nipple. The nipple-areola complex was removed in 2004.She still has her breast, although smaller. In her brazier, one would not know about her mishap. She is extremely happy to still have her breast and the appearance can be further improved with nipple reconstruction and areolar tattoo, but she is satisfied as it is.

COMMENT: The dogma that the breast must be removed when the nipple is involved, is now proven to be unnecessary’ as long as the tumor is removed with clear margins.


case 10

7092    DOB 1960

This woman had a R lumpectomy in Aug 2003.Grade 3 IDC. SLN was neg and she had CT and RT. Very good cosmetic result in a relative small breast. No cosmetic surgery was needed. She receives Kessar for 5 yrs.


case 11

2793 DOB 1966

This woman was 36 and an international swimmer when she got breast cancer in the R inf. breast in 2002. She had a lumpectomy + CT. + hormonal manipulation with ovarian obliteration with Zoladex and Tamoxifen She continued her swimming career and broke a few international records in the senior class. This picture was taken in Aug 2007.Who said that a breast cannot be saved if the volume is small? It is possible if there is a dedicated surgeon involved with experience and cosmetic skills. She is now 41 and continues to take part on international level and still break records. The future of women with breast cancer is dictated by her spirit and attitude.


case 12


She developed Br.Ca behind the nipple in 2001.The nipple-areola complex was removed and she received RT. Losing a nipple is far better than losing a breast. She is very happy and does not bother to reconstruct her nipple.


case 13


She had Primary Systemic treatment in 2004 before the tumor in the R lateral breast was removed with lumpectomy. She received RT and then hormonal manipulation for 5 yrs. The PST enabled us to shrink the tumor and to only remove a small portion of the r lateral breast with good cosmetic result. No reconstruction was needed.


case 14


case 14 1

10082 DOB 3/1971

She was 34 when she had a L mastectomy with a TRAM reconstruction in 2005.Nodes positive. The mastectomy did not prevent a local recurrence in 1/2007. This was excised. She still has a good result. She knows very well that it is the aggressiveness of a breast cancer that will cause recurrence and even mastectomy is no guarantee.


case 15

13053 DOB 1973

She had a large (3cm) tumor L upper breast. The tumor was first treated with PST and it shrunk to 6mm, and was then removed. The nipple can be moved more centrally later on and she will still have a good result with her own breast intact.


case 16


She was 50yr when she had a lumpectomy R inf. breast in 2005.She had RT and is on 5 yrs Kessar. Good result with little volume loss and minimal radiation damage.


case 17


She had PST for an 18x12mm tumor L breast which shrunk to a size of 12x8mm.Then had lumpectomy and RT. Good preserved volume due to smaller volume removed as result of PST.


case 18


She was 29 and unmarried in 2002 when she found a lump in the R lat breast. Incision biopsy was done but the tumor was incised and incompletely removed .Mastectomy was advised. She found more opinions and hope. The tumor bed was re-excised and she received RT and CT. The tumor was an aggressive Gr3 and so- called triple negative. She got married and this picture was taken in Sep 2007, 3 mths after her baby daughter was born. This was a victory over breast cancer for her and her family which would probably not be possible without her breast


case 19

4644 DOB 1946

Left lumpectomy in 1994. Ct and RT. /

She had a second breast cancer in the R breast in 3/2007 for which she also had a R inf. lumpectomy after PST. Also received RT to the R breast.

She is a very positive woman with much humor about her 2 episodes of cancer. She is very happy to have both breasts.


Breast 1

DeB; 2781 Mrs.E.S DOB: 26-02-1969

She was 33 yrs when she had a L Mastectomy in 2002 for DCIS with micro infiltration. Prostheses reconstruction. It was ER neg. and Oncogene pos. She had CT Local recurrence Feb 2004 and then received Herceptin.

Again local recurrence Oct 2005 and then received RT. This is a picture in May 2008.Still has a good cosmetic result


Mastectomy does not mean that no local recurrences could appear. The aggressiveness of the tumor, dictates whether local recurrence will appear.

The End