Surgery
Nearly all women with breast cancer will have some type of surgery to remove all the cancer in the breast. Features of the cancer may determine which options are possible. Main options include:
- Lumpectomy, in which only the cancer and a margin of unaffected surrounding tissue is removed.
- Mastectomy, in which the entire breast is removed.
- Lymph node removal to check whether the cancer has spread, which may be performed with either a lumpectomy or mastectomy.
- Sentinel node biopsy, in which the sentinel node, which is the first lymph node to which a breast tumor is likely to spread, is located and removed.
The goal of a lumpectomy is to remove the cancer without leaving residual cancer cells in the breast. It is usually followed by radiation to destroy any remaining cancer cells in the breast. A lumpectomy performed without subsequent radiation is not recommended because of a very high rate of cancer recurrence in the affected breast. Breast surgery for SCCA patients is performed at University of Washington Medical Center.
Women who are diagnosed with DCIS (ductal carcinoma in situ) often can have a lumpectomy, depending on the size of the cancer and also whether the surgeon can get good negative margins. (The margins are important in ensuring that no cancer tissue is left behind.) In some instances, however, mastectomy may still be required for DCIS.
Women who have invasive breast cancer (a tumor) may also be able to have a lumpectomy. The decision depends in part on the size of the tumor relative to the size of the woman’s breast, as well as if the cancer involves more than one segment of the breast.
Mastectomy
For women for whom lumpectomy is not an option or for those who desire to have no breast tissue at risk for recurrence, a mastectomy is the surgery of choice.
For some women, mastectomy is their only choice. These include women with certain types of breast cancer, including inflammatory breast cancer, as well as cancers that have advanced and are quite large by the time of diagnosis, and cancers that have spread to more than one-quarter of the breast.
Some women who could have a lumpectomy opt for a mastectomy instead for peace of mind. However, even if a woman’s only option is a mastectomy, she still has a number of choices about how the surgery can be done, and these newer procedures are much less disfiguring than the mastectomies of 30 years ago.
Until the 1970s, the most common surgery for breast cancer was the radical mastectomy, which was very disfiguring in that it removed the breast, lymph nodes, skin, and pectoralis muscle.
Then surgery advanced to the modified radical mastectomy, which leaves the muscle and takes only the breast tissue, an ellipse of skin, and the lymph nodes. This procedure is still done for inflammatory breast cancer, as well as for large, locally advanced tumors with known axillary lymph node involvement.
The most common procedure done today is called a total mastectomy, in which all the breast tissue is removed. At the same time, a sentinel lymph node biopsy is performed to see if the cancer has metastasized to the axillary nodes. One or two sentinel lymph nodes are removed during the mastectomy and checked immediately for evidence of spread. If these nodes are positive, then the surgeon will go ahead and remove most of the lymph nodes under the arm as part of an axillary dissection. With this surgery, the woman is left with a scar across the width of the breast, and the nipple is removed.
There are alternatives to a total mastectomy, however, including the skin-sparing mastectomy, nipple-sparing mastectomy, and the donut mastoplexy, which leave the patient with smaller scars.
A woman with a small cancer who plans to have immediate breast reconstruction may want to discuss whether she is a candidate for the skin-sparing procedure with both her oncologic and plastic surgeons. In this surgery, an incision is made around the nipple and areola, often with a small cut toward the side. The breast tissue is all removed through this small incision.
The nipple-sparing surgery also uses a small incision, one that leaves the nipple intact. This surgery is typically done for women who are having a prophylactic mastectomy because they are at high risk for breast cancer because of a family history, and generally not for woman with known cancers.
The donut mastopexy is not often performed for breast cancer in the United States, but is offered by SCCA surgeons under the direction of Dr. Benjamin Anderson.
Lymph Node Removal
If your breast cancer requires surgery—either a mastectomy or a lumpectomy—your surgeon will also want to remove some of the lymph nodes under your arm to see if the cancer has spread to these glands. Cancer in the lymph nodes increases the likelihood that cancer cells have spread to other parts of your body.
Until recently, surgeons would remove most of the lymph nodes in the armpit, usually between 10 and 20, in a procedure called an axillary lymph node dissection. However, the long-term side effects of removing these lymph nodes—including lymphedema (swelling of the arm), nerve injury, and reduced range of motion in the arm—can be uncomfortable and even debilitating.
Sentinel Node Biopsy
To avoid the problems associated with removing lymph nodes, SCCA offers a simpler procedure called sentinel lymph node mapping, or sentinel node biopsy, in which as few as one to three lymph nodes are removed.
In this procedure, the surgeon locates and removes the sentinel node, which is the first lymph node to which a breast tumor is likely to spread, if your cancer has spread beyond the breast. If the biopsy results are negative, no more surgery is necessary. If the results are positive, your surgeon will perform a complete axillary lymph node dissection and remove most of the remaining lymph nodes.
Sentinel node biopsy has few serious side effects, but it is not appropriate for all women. If this procedure is right for you, SCCA has a team of experienced surgeons led by Dr. David Byrd, who pioneered sentinel node biopsy in the Pacific Northwest.