Depending on the stage, the location, and the type of tumor, you may be a candidate for various forms of surgery. In the early stages of breast cancer, breast-conserving surgeries (surgeries that remove only a portion of the breast) may be used. For early or later stages of breast cancer, or as a preventive measure, mastectomy (removal of the breast) may be performed instead.
Breast Conserving Surgeries
Lumpectomy, wide excision, segmentectomy, and partial mastectomy are known as breast-conserving surgeries. Only the malignant area and a small portion of the surrounding healthy tissue are removed. Sometimes, lymph nodes under the arm are also removed (axillary dissection). This procedure is almost always followed by a course of radiation therapy.
Today, breast-conserving surgeries are the preferred type of surgery for eligible women in the early stages of cancer. Studies have shown that breast-conserving surgeries combined with radiation therapy are just as effective as mastectomy in the early stages of breast cancer. However, not all women with stage I or II breast cancer are eligible for this type of surgery. Conditions that might make you ineligible for this procedure include:
- Multiple tumors in different areas of the breast (multicentric tumors)
- One tumor spread throughout the breast (diffuse tumor)
- Tumor located directly beneath the nipple
- A tumor that is large in relation to breast size
- History of scleroderma, systemic lupus, or dermatopolymyositis
- Current pregnancy in the first or second trimester (The radiation used with breast-conserving surgery can injure a fetus.)
- Previous high-dose radiation therapy to the affected breast
A total mastectomy involves the removal of the entire breast. Some lymph nodes from under the arm are also removed. Radiation therapy may or may not be required after a total mastectomy, depending on the size of the tumor and whether any cancer was found in the lymph nodes. This type of surgery may be used in some early stages of breast cancer, as well as some later stages.
This procedure does not include an axillary lymph node dissection and may be offered when patients are interested in a prophylactic procedure to reduce the chances of developing breast cancer. Because all of the breast tissue cannot be removed at the time of a mastectomy, your risk of developing breast cancer (even after surgery) is never 0% because there is always residual breast tissue left behind. In addition, a simple mastectomy is often performed in women who:
- Have ductal carcinoma in situ (DCIS)
- Have no risk of lymph node spread
- Are not good candidates for breast conserving surgery
Women have the option of having breast reconstruction done either at the time of the mastectomy, or some time after the operation. Some women may choose not to have breast reconstruction at all. It will be your decision to determine what you feel most comfortable with.
If you are considering reconstruction, it is best to discuss this option with a plastic surgeon prior to your mastectomy. If you will need radiation therapy because of the size of the tumor or the presence of any disease in the lymph nodes, make sure your plastic surgeon is aware. Sometimes, they prefer to wait for a period of time after the radiation therapy before they perform the reconstruction. Remember, reconstruction is cosmetic, while radiation therapy is part of the curative treatment for your breast cancer.
Women who have lymph nodes removed as part of breast cancer surgery may be at an increased risk for developing lymphedema, a condition caused by blockages of the lymph vessels. Lymph vessels run throughout the body carrying fluid, cells, and other material, but may become blocked when lymph nodes are removed. This will result in swelling of the arm.
To reduce the risk of developing lymphedema, the following precautions are recommended:
- Treat infections of the affected arm and hand immediately.
- Maintain a healthy weight. The greatest risk factor for the development of lymphedema is obesity.
- Wear gloves when doing house or garden work.
- Keep the affected hand well moisturized.
- Use the unaffected arm when having blood drawn or getting injections.
- For 4-6 weeks after surgery, use the unaffected arm when lifting heavy objects.
- Protect the arm from sunburn.
- Do not cut cuticles.
- Use insect repellant when outdoors.
- Keep skin clean.
Sentinel Lymph Node Procedures
This procedure is the standard of care in the US. Because of the possible side effects from a standard axillary lymph node dissection, patients may qualify to have a special procedure performed that may not require that many lymph nodes be removed; this has been shown to reduce the chances of swelling, pain, and lymphedema.
In brief, a radioactive tracer and blue dye is injected around the tumor in the breast, and the tracer is followed into the armpit. The lymph nodes that pick up the tracer are called the sentinel lymph nodes. The lymph nodes are removed and evaluated.
If there is no cancer, then there is a 95% chance that none of the other axillary lymph nodes have cancer and no further surgery to the armpit is required. If the lymph node has cancer, then a complete axillary dissection is performed.
There is some debate about whether a complete axillary dissection must be performed after a sentinel node procedure has shown rare cancer cells in the armpit. Several scientific groups are evaluating this very question, and you may be a candidate to enroll in a study. Ask your surgeon for more information. If your surgeon does not perform the sentinel lymph node procedure, you can talk with another doctor who has experience with this type of surgery.
- Reviewer: Michael Woods, MD
- Review Date: 12/2013 -