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Surgery

Surgery has a long history as the first line of treatment of breast cancer. With innovations in recent decades, surgery has become more targeted, with an aim to preserve as much healthy breast tissue as possible. Even mastectomy (breast removal) has become more refined and a less drastic option then decades ago.

Today, surgery to remove as much of the cancer as possible remains the primary treatment for breast cancer. The type of surgery performed depends upon:

• the size and location of the breast lump or tumor;
• the type and stage of the breast cancer;
• the size of the breast;
• and the woman's preference.

Surgery is sometimes performed primarily to diagnosis the breast abnormality. These procedures are called biopsies and their purpose is to obtain tissue samples that are sent to the pathologist for analysis. Several types of biopsy are available, and your surgeon will discuss with you the best procedure for you. The options include:

• Fine needle biopsy is done by using a very thin needle connected to a syringe. The needle moves in and out several times to obtain the samples.
  
  
• Core biopsy can be done using a larger needle to either remove a sample or the entire lump. Core biopsies sometimes benefit from visual guidance from mammogram, ultrasound, and MRI imaging. This type of guidance is used in stereotactic core biopsy.
  
  
• Open excisional biopsy (removing the entire lump or tumor) can be preformed with or without the assistance of mammography or ultrasound localization. Sometimes when the surgeon removes the entire lump at biopsy, this procedure becomes the treatment as well.

Likewise, your Jefferson breast surgeon can explain the comparative benefits and risks of each of the types of surgical options described below that are meant primarily as treatment operations (curative excisions). Your Jefferson surgeon is available to answering any questions or concerns you may have prior to surgery.

Types of breast cancer surgery

To ensure the best chance for successful treatment of breast cancer, it is important to remove all the cancerous tissue, using the most direct approach possible. This means some type of surgery. Other treatments, such as radiation therapy, chemotherapy, or hormonal therapy play a very important role later in the treatment process.

You may hear many different terms used to describe the kinds of surgery that can be done, but there are really two main options: breast-conserving surgery (partial mastectomy or lumpectomy) or mastectomy.

• In a lumpectomy, the surgeon removes the breast cancer lump and a portion of normal tissue around it. The surgeon may also remove some of the lymph nodes under the arm to determine if the cancer has spread.
  
  
• A partial (segmental) mastectomy involves removing the breast cancer and a portion of the normal breast tissue around the breast cancer. The surgeon removes the area (margin) of normal tissue surrounding the tumor for greater assurance of having removed all of the cancerous tissue. The operation is sometimes called a wide local excision. The surgeon may also remove the lining over the chest muscles below the tumor and some of the lymph nodes under the arm.

After these breast-conserving surgeries, the radiation oncologist may administer radiation therapy (high-energy x-rays), to destroy cancer cells that have not been removed during the lumpectomy procedure. Also, your breast care team may discuss with you the use of chemotherapy or hormonal therapies as additional preventive measures.

Other women may undergo nonbreast-conserving surgery called mastectomy (removal of the breast). Among circumstances in which your physician may recommend a mastectomy are these:

• if the cancer has spread to other parts of the breast tissue or has spread to the lymph nodes under the arm;
  
  
• or if the breast is very small and a lumpectomy would require removing additional breast tissue, resulting in a deformed breast.

There are three types of mastectomy. Your healthcare provider can explain the benefits and risks of each type:

• During a total (or simple) mastectomy, the surgeon removes the entire breast (including the nipple, the areola, and most of the overlying skin) and may also remove some of the lymph nodes under the arm (axillary lymph glands).
  
  
• During a modified radical mastectomy, the surgeon removes the entire breast (including the nipple, the areola, and the overlying skin), some of the lymph nodes under the arm (axillary lymph glands), and the lining over the chest muscles. In some cases, part of the chest wall muscle is also removed.
  
  
• During a radical mastectomy, the surgeon removes the entire breast

(including the nipple, the areola, and the overlying skin), the lymph nodes under the arm (axillary lymph glands), and the chest muscles. For many years, this was the standard operation. However, today, a radical mastectomy is rarely performed and is generally only recommended when the breast cancer has spread to the chest muscles.

Illustrations

Chemotherapy and sometimes radiation therapy is recommended after mastectomy surgery.

Whether you have a breast-conserving surgery or mastectomy, you may also have a procedure to remove some of the lymph nodes from under your armpit to examine if the cancer has spread. Lymph nodes are tiny bean-shaped organs into which various types of materials (bacteria, cancer cells) drain.

• An important development in the staging of breast cancer is the increased use of the procedure called sentinel lymph node biopsy, as an alternative to full, axillary-node dissection. The principle is simple. As lymphatic fluid drains away from the breast, it first passes through certain lymph nodes located in key parts of the drainage system. These are called sentinel lymph nodes, because they seem to act as the gatekeepers. If the sentinel node is free of cancer, the odds are that there will be no cancer in the other nodes located downstream.
  
  
• An axillary lymph node dissection can be done through a small incision in the armpit at the time of a lumpectomy or mastectomy. This procedure removes the lymph nodes to examine if the cancer has spread.

Finally, another type of surgery is meant to improve the cosmetic results of surgical breast treatments. Many women opt for these reconstructive procedures.

Complications

Any type of surgery carries some risk. Patients differ in their anatomy and their ability to heal. Complications from breast surgery are uncommon but can include:

• bleeding;
• fluid collection;
• infection;
• excessive scar tissue;
• and anesthesia problems.

Your Jefferson breast surgeon and breast specialists, including the radiation oncologists and medical oncologists, can explain the comparative benefits and risks of the treatments described above, in addition to answering any questions or concerns you may have prior to your undergoing a surgery and or other treatment that you have elected.