Surgery for Breast Cancer

Overview

Nearly all women with breast cancer will undergo some kind of surgery as part of their diagnosis and/or treatment. The extent of surgery for breast cancer may range from removal of only a small piece of breast tissue to removing one or both breasts, including underarm (axillary) lymph nodes. The purpose of surgery in the management of breast cancer is to:

  • Obtain a tissue sample for determining an accurate diagnosis.
  • Determine the stage of the cancer and whether additional treatment is necessary.
  • Treat the cancer locally.

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The surgical procedures utilized in the management of breast cancer include:

The following is a general overview of the role of surgery in the management of breast cancer. Surgery may be the primary treatment for some breast cancers, but for many women, multi-modality treatment, which utilizes two or more treatment techniques, is increasingly recognized as the best approach for improving a patient’s chance of cure or prolonging survival. In some cases, participation in a clinical trial utilizing new, innovative therapies may provide the most promising treatment. Circumstances unique to each patient’s situation may influence how these general treatment principles are applied. The potential benefits of multi-modality care, participation in a clinical trial, or standard treatment must be carefully balanced with the potential risks. The information on this website is intended to help educate patients about their treatment options and to facilitate a mutual or shared decision-making process with their treating cancer physician.

The type of surgery that a patient with breast cancer undergoes depends largely on the size and location of the cancer, the breast size, feasibility of breast reconstruction, and how important breast preservation is to the patient.

Biopsy

A biopsy is the removal of cells or tissue for further evaluation; it is often performed to determine whether cancer is present. A biopsy may involve surgical removal of all or a part of a breast lump, or use of a needle to remove tissue or fluid.

Mastectomy

A simple (total) mastectomy involves the removal of the entire breast, but not the axillary (underarm) lymph nodes.

There are also different degrees of mastectomy, including the following:

  • Partial (segmental) mastectomy is the removal of one-quarter or more of the breast and the lining over the chest wall. This may include removal of axillary lymph nodes. Reconstruction may be difficult after a partial mastectomy because of the drastic change to the contour and size of the breast after the procedure.
  • Radical mastectomy is an aggressive therapy that consists of extensive removal of the entire breast, the lymph nodes under the arm in the axilla and the chest wall muscles under the breast.
  • Modified radical mastectomy involves the removal of the entire breast and the lymph nodes in the axilla under the arm.

Lumpectomy

Removal of the cancer and a portion of surrounding tissue is called a lumpectomy. Because a lumpectomy alone is associated with a higher rate of cancer recurrence than mastectomy, patients who elect to have a lumpectomy are also treated with radiation therapy. This combination of lumpectomy and radiation therapy is called breast-conserving therapy. Among women with early-stage breast cancer, breast-conserving therapy and mastectomy produce similar rates of long-term survival.[1]

Axillary Lymph Node Evaluation

Evaluation of early stage breast cancer typically includes a biopsy and removal of axillary (under arm) lymph nodes in order to determine the stage of the cancer and whether the cancer has spread outside the breast. This is important because when axillary lymph nodes have cancer, more aggressive treatment is required in order to achieve the best chance for cure.

Axillary lymph node dissection: For over 30 years, the standard of practice for evaluating lymph nodes has been a surgical procedure called an axillary lymph node dissection. This procedure involves the removal of approximately 10-25 axillary lymph nodes and may be performed during the initial surgery or as a separate procedure.

Although the performance of an axillary lymph node dissection has helped doctors and patients determine optimal treatment, removal of the axillary lymph nodes is commonly associated with chronic side effects. In addition to the risk of infection and other local complications of surgery, an axillary lymph node dissection can result in lymphedema, which is a buildup of lymph fluid in the tissues just under the skin. As blood circulates through the body and travels into smaller and smaller vessels, excess fluid, protein and other substances are pushed out into the surrounding tissue. This substance is called lymph fluid. Under normal circumstances, lymph fluid is removed from the tissues by the lymph system, which is a series of vessels and organs that moves the fluid back toward the heart and filters it through lymph nodes. Lymph nodes are specialized structures that are composed of white blood cells and serve to “clean” the lymph fluid of bacteria or other contaminants. When lymph nodes are removed, the lymph fluid builds up in the tissues. This build up of fluid may result in chronic swelling, numbness, limited shoulder motion, and pain to the arm on the side of the body that the surgery was performed.

For more information on managing lymphedema, go to Managing Side Effects.

Doctors have long desired a way to evaluate axillary lymph nodes that would result in less discomfort for patients. A sentinel lymph node biopsy is one way to accurately evaluate axillary lymph nodes and is associated with fewer side effects than axillary lymph node dissection.

Sentinel lymph node biopsy: A newer approach to evaluating axillary lymph nodes for spread of cancer is called a sentinel lymph node biopsy. This procedure involves removing a single lymph node (or a small number of nodes), called the sentinel node, which is the first lymph node to collect excess fluid surrounding the cancer. Prior to surgery, blue dye is injected near the cancer. The dye drains from the area containing the cancer into the nearby lymph nodes, through the sentinel node. The node containing the dye is removed during surgery and evaluated under a microscope to determine whether cancer has spread. If the sentinel node is free of cancer, more extensive lymph node surgery is usually not required.

Sentinel lymph node biopsy is becoming the standard approach for determining whether cancer has spread to the axillary lymph nodes.[2] The procedure appears to be just as effective in determining cancer spread to axillary lymph nodes as an axillary lymph node dissection, and results in fewer side effects.[3] 

Breast Reconstruction

References


[1] Poggi MM, Danforth DN, Sciuto LC, et al. Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer Institute Randomized Trial. Cancer 2003;98(4): 697-702.

[2] Edge SB, Niland JC, Bookman MA, et al. Emergence of sentinel node biopsy in breast cancer as standard-of care in academic comprehensive cancer centers. Journal of the National Cancer Institute 2003;95:1514-1521.

[3] Veronesi U, Paganelli G, Viale G, et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. The New England Journal of Medicine 2003;349:546-553.

 

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