Breast Surgery

There are multiple surgical approaches that are used in the treatment of breast cancer. In the past radical mastectomy was the standard treatment for breast cancer. Currently radical mastectomy is rarely performed and is limited to locally advanced tumors that do not respond to chemotherapy. When a mastectomy is performed, we do either a simple mastectomy in which only the breast is removed or a modified mastectomy in which the breast and lymph nodes are removed. Also, rather that removing all the draining lymph nodes when it is required, we now start by removing the sentinel lymph node, and only remove other nodes if the sentinel node is positive. A new operation that is currently being performed is the nipple sparing mastectomy which can be used in selected cases.

Currently, the most common type of breast cancer surgery involves removal of the entire tumor plus a rim of normal tissue. If the tumor can be completely removed the breast can be saved. A course of radiation is done after surgery, but this approach provides survival rates that are just as good as with mastectomy. The removal of the tumor with a margin of normal surrounding tissue is called a lumpectomy. The term partial mastectomy is often used to as an alternative word to describe the removal of just the cancer and a rim of normal tissue. Thus, the term partial mastectomy as used by most surgeons is synonymous with lumpectomy, and does NOT imply a removal of the entire breast. In most cases the sentinel node will be removed at the time of the lumpectomy.

Lumpectomy/Partial Mastectomy

Studies from around the world have demonstrated that patients with breast cancer have the same survival, whether they are treated with a lumpectomy followed by radiation vs. mastectomy. Lumpectomy is especially appropriate and successful with small cancers. Thus, our primary objective in treating breast cancer patients is to save the breast whenever possible and prudent. Lumpectomy involves the removal of the tumor with a margin of normal tissue. To accomplish this in one operation, careful pre-treatment planning is essential, with careful review of the mammogram and the underlying pathology. The lumpectomy specimen must be meticulously removed and oriented by the surgeon. The surface must be carefully color coded with special dyes so the status of the margins (i.e., the distance between the tumor cells and the edge of the specimen) can be accurately established. If the margin can be adequately cleared, the breast can be saved. Most patients will then undergo a course of radiation therapy.

Sentinel Lymph Node Biopsy

Most patients with invasive cancer will be advised to undergo some form of lymph node removal surgery. The status of the regional lymph nodes (axillary nodes) is one of the most important determinants of prognosis, and thus is extremely important to the patient and the oncologist. Patients with tumor-free lymph nodes have a statistically improved prognosis, and patients with tumor in lymph nodes will typically benefit from more aggressive forms of treatment likely including chemotherapy. Thus, the regional lymph nodes become extremely important to us in treatment planning.

In the past it was routine to remove a large sample of lymph nodes from under the arm (called a lymph node dissection) in all patients with invasive cancer. This was often times associated with local numbness and burning (as well as restriction of shoulder motion), and in 10% of the cases, arm swelling (lymphedema) occurred as a later consequence of lymph node surgery. For more information on lymphedema, please refer to the corresponding link: Lymphedema.

A sentinel lymph node biopsy eliminates the need for lymph node dissection in most patients. It was originally thought that tumor cells entering the lymphatics would be distributed randomly in the regional lymph nodes, and thus it was felt that all nodes had to be removed to do adequate pathologic staging. More recently, it has been determined that the lymph nodes drain to 1 to 4 specific nodes first, and then go on to the other nodes. These initial draining nodes are called the sentinel lymph nodes, and studies have demonstrated that if the sentinel nodes are free of breast cancer cells, the overwhelming probability is that the remaining lymph nodes will also be negative. Thus, in those patients who have negative lymph nodes, further lymph node dissection can be safely avoided.

Recent data has shown that if a lumpectomy is performed with a sentinel lymph node biopsy, the removal of the remaining lymph nodes is not necessarily required even if they turn out to be positive. Please ask your doctor about this exciting new development as we continue to stay up to date with the latest advances in breast care. This particular advancement will decrease the need for completion axillary dissection and the increased risk of lymphedema in these women.

Radical Mastectomy

A radical mastectomy includes removal of the entire breast, plus the removal of the underlying chest wall muscles (pectoralis major, pectoralis minor), along with removal of the axillary lymph nodes. This was a standard treatment for breast cancer until approximately 30 years ago. It is rarely performed today.

Simple Mastectomy

Mastectomy involves removal of all breast tissue, usually including the nipple. Mastectomy can be followed by immediate reconstruction in one operation for properly selected patients. Most patients who are not candidates for immediate reconstruction are candidates for delayed reconstruction. A plastic surgeon performs the reconstruction. A simple mastectomy is removal of all of the breast glandular tissue. No lymph nodes are purposefully removed with a simple mastectomy , however some low lying lymph nodes are often discovered in the portion of breast tissue that extends to the underarm, this area is called the “Tail of Spence”. Some women have lymph nodes enmeshed with breast tissue and others do not. Simple mastectomy does NOT include removal of the underlying pectoralis muscles or the skin that covers the chest wall. Simple mastectomy without reconstruction results in a smooth, flat chest wall with a horizontal scar. A breast prosthesis may be worn in a bra to maximize symmetry in clothing.

Modified Radical Mastectomy

A modified radical mastectomy is similar to a simple mastectomy, but the lymph nodes under the arm are removed along with the breast specimen. This procedure is only necessary for patients who are found to have tumor in the lymph nodes under the arm. Our first step in determining whether or not there is tumor in the lymph nodes is physical examination, review of mammogram and ultrasound images. If any of these are suggestive of tumor in the lymph nodes a needle biopsy is performed to verify tumor cells. If all of these tests appear normal then a sentinel node biopsy is performed in the operating room. Sentinel node biopsy is a technique to identify the node or nodes most likely to have tumor cells. If these nodes are removed and examined by a pathologist and found to be tumor-free then the rest of the nodes are presumed to also be tumor-free. If the sentinel nodes show tumor cells, we remove the first two levels of three total levels of lymph nodes under the arm (this area can contain anywhere between 10 to 30+ lymph nodes, depending on an individual’s anatomy). A drain is typically placed into this area at the time of the operation to eliminate excess fluid build-up, and it is left there for one to two weeks.

Nipple Sparing Mastectomy

Nipple sparing mastectomy is a new technique for properly selected candidates. Nipple sparing mastectomy involves removal of all of the breast glandular tissue while leaving the surface of the breast intact. A careful intra-operative analysis of the tissue directly behind the nipple is performed to determine that the tissue is tumor-free. Immediate reconstruction is almost always performed by a plastic surgeon after removal of the breast tissue. Any type of reconstruction may be combined with nipple sparing mastectomy, but each individual must be evaluated to optimize the cosmetic outcome.

Since the nipple is the central cosmetic feature of the breast preserving it allows patients to have a less psychologically difficult recovery from mastectomy.