Breast Surgery

Breast cancer treatment:

Breast cancer treatment is divided into local and systemic treatments:

Local treatments: surgery and radiation are considered local treatments

Systemic treatment: Chemotherapy, Hormone therapy, Targeted therapy and Immunotherapy are considered systemic therapies for breast cancer.

Local breast cancer treatments:

Surgery:

Factors evaluated when determining surgical options:

  • Tumor type- diagnosed after biopsy
  • Tumor size-size may determine if lumpectomy is an option
  • Lymph nodes-possible involvement of cancer in the lymph nodes may determine surgical options.
  • Breast size- breast size compared to the tumor size may determine if lumpectomy surgery will be cosmetically acceptable.
  • Tumor location- tumor located under the nipple or two tumors in the same breast may not be cosmetically acceptable.
  • Mammogram- mammography films show whether cancer is multifocal (multiple cancers in one quadrant) or multicentric (multiple cancers in more than one quadrant).
  • Personal desire-patient’s desire for the type of surgery is considered.
  • Breast-conserving surgery: also called lumpectomy or partial mastectomy
    • Surgery to remove the cancer and rim of normal tissue around it.
    • How much breast tissue is removed depends on where and how big the tumor is, as well as other factors.
    • Advantages of breast conserving surgery:
      • Saves large portion of the breast, usually including the nipple and areola
      • Preserves body image
      • Allows you to wear your regular bras
      • Avoids the need for a prosthesis
      • Decreases surgical recovery time, usually several weeks shorter than mastectomy
      • Increases psychological acceptance unless monitoring remaining breast tissue for recurrence creates high level of anxiety
    • Disadvantages of lumpectomy:
      • Increases potential for additional surgery if positive tumor margins are noted after initial surgery
      • Requires time for radiation therapy to the remaining breast tissue (5 days a week, up to 6 weeks)
      • Changes in texture (lumpiness) or color (sun tanned appearance), along with decreased sensations (feeling) occur in the breast after radiation therapy.
      • May decrease the size of the breast
      • Increase risk of swelling in the breast or arm, especially if radiation is given.
      • Radiation may limit surgical option in the future
  • Mastectomy: is a surgery in which entire breast is removed.
    • Advantages of mastectomy:
      • Removes approximately 95% of the breast gland, reducing local recurrence to the lowest degree possible.
      • Allows breast reconstruction using your own body tissue or a synthetic implant
    • Disadvantages of mastectomy:
      • Changes in body image due to breast removal
      • Requires a breast prosthesis or reconstructive surgery to restore body image
      • Increases surgical recovery time; usually several weeks longer than lumpectomy

Some women might worry that having a less extensive surgery might rise their risk of the cancer coming back. But studies following thousands of women for more than 20 years show that when breast conservation surgery is done with radiation, survival is the same as having a mastectomy in people who are candidates for both types of surgery.

  • Lymph nodal evaluation:
    • Most patients with invasive tumor will require evaluation of their lymph nodes to see if cancer has spread outside of the breast.
    • Evaluation of the axillary lymph nodes are performed before surgery with an ultrasound biopsy to guide the surgeon in planning the method of node evaluation during surgery (axillary lymph node biopsy or axillary lymph node dissection.
    • Lymph node evaluation may not be required for older women or for women whose node status would not impact treatment decisions or extend their survival.
    • Sentinel lymph node biopsy (SLNB): Sentinel lymph node biopsy removes the first (sentinel) node that drains the tumor for an initial evaluation to see if it is positive for cancer. Tumors were may have one or more sentinel nodes. The sentinel nodes are the gate keepers to the rest of the lymphatic nodes. Sentinel lymph node biopsy removes the node most likely to indicate if cancer has spread from the breast. During the mastectomy, sentinel lymph node biopsy can be performed through the same surgical incision. During lumpectomy it requires a second incision.
      • Risks of SLNB- bleeding, infection, numbness inside of the arm, up to 10% risk of lymphedema.
    • Axillary lymph node dissection (ALND): Axillary lymph node dissection is a procedure in which the nodes under the arm are surgically removed, usually from levels one and two. The lymph nodes under the arm are divided into three levels. The number of lymph nodes in each level varies from person to person. Axillary lymph node dissection removes from 10-40 nodes. During mastectomy, axillary lymph node dissection can sometimes be performed through the same surgical incision. During a lumpectomy it requires a second incision.
      • Risks of ALND- bleeding, infection, numbness inside of the arm, up to 30% risk of lymphedema.