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 (breast conservation surgery), in which only the cancer and a margin of cancer-free surrounding tissue are removed
- Mastectomy, in which the entire breast is removed
- Lymph node removal, which may be performed with either a lumpectomy or mastectomy, to check whether the cancer has spread to lymph nodes in the area
- Sentinel node biopsy, in which the sentinel node (the first lymph node to which a breast tumor is likely to spread) is located and removed so it can be checked for cancer
Breast surgery for Seattle Cancer Care Alliance (SCCA) patients is performed by breast surgeons at University of Washington Medical Center (UWMC). If you need surgery for breast cancer and you are considering breast reconstruction, you may also want to read about reconstructive procedures performed for SCCA patients by plastic surgeons at UWMC.
The goal of a breast-conservation surgery is to remove the tumor without leaving cancer cells in the breast, but also without removing more breast tissue than necessary. Often this means a lumpectomy. If a larger segment of the breast tissue needs to be removed, the procedure might be called a quadrantectomy.
Often women who are diagnosed with ductal carcinoma in situ (DCIS) can have breast-conserving surgery, depending on the size of the cancer and whether the surgeon can get negative margins—a zone of cancer-free tissue all the way around the tumor. The margins are important in ensuring that no cancer tissue is left behind. Some women with DCIS need a mastectomy.
Wire Localization Procedure
If a cancer can’t be felt but is found with mammography or ultrasound, surgeons require guidance in finding the cancer to remove it. With a mammogram or ultrasound, a radiologist will numb the skin and introduce a guide wire to mark the cancer, similar to an unfurled paperclip, into the breast and tape it in place. The surgeon uses this wire, to locate the cancer within the breast and remove it with lumpectomy. This wire is placed on the morning of surgery at SCCA by the same breast radiologists who perform breast biopsies and is generally very well tolerated.
For Invasive Cancer
Women who have invasive breast cancer may also be able to have breast-conserving surgery, or they may need a mastectomy. The decision depends in part on the size of the tumor relative to the size of the woman’s breast and whether the cancer involves more than one segment of the breast.
Some breast-conserving surgical procedures are referred to as oncoplastic procedures. This means they are designed to remove the tumor with negative margins (the “onco” part) and to preserve the shape and appearance of the breast (the “plastic” part). One example is called donut mastopexy, which is offered by SCCA surgeons. Read more about this and other procedures in the section on breast reconstruction.
If lumpectomy is not an option or if a woman wants 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, such as inflammatory breast cancer; women with cancers that have advanced and are quite large by the time of diagnosis; and women with 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. Newer procedures are much less disfiguring than the mastectomies of 30 to 40 years ago. Back then the most common surgery for breast cancer was the radical mastectomy, in which the breast, lymph nodes, skin, and pectoralis muscle were removed; this is rarely done now.
Modified Radical Mastectomy
In the modified radical mastectomy, the surgeon removes only the breast tissue, an ellipse of skin, and the lymph nodes, and leaves the muscle. This procedure is done for inflammatory breast cancer, as well as for large, locally advanced tumors with known axillary (underarm) 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 (meaning cancer is present), then the surgeon removes most of the lymph nodes under the arm (axillary lymph node dissection). With this surgery, the woman has a scar across the width of her breast, and her nipple is removed. A total mastectomy is sometimes called a simple mastectomy.
Skin-Sparing Mastectomy and Nipple-Sparing Mastectomy
There are alternatives to a total mastectomy, including the skin-sparing mastectomy and the nipple-sparing mastectomy. Each of these leaves the patient with smaller scars.
A woman with cancer that does not involve the skin who would like to have immediate breast reconstruction may want to talk with her oncologic and plastic surgeons about whether she is a candidate for a skin-sparing mastectomy. In this surgery, an incision is made around the nipple and areola. All the breast tissue, including the nipple and areola, is removed through this small incision. Our plastic/reconstructive surgeons can then insert either a temporary expander (which is exchanged later for an implant) or a woman’s own abdominal tissue (“tummy tuck” or DIEP flap) to reconstruct the breast using that same incision.
The nipple-sparing mastectomy also uses a small incision, either underneath the fold of the breast or on the outer aspect of the breast, one that leaves the nipple intact. This surgery is typically done for women who are having a prophylactic mastectomy—meaning they do not have any known breast cancer but they are having their breast removed because they are at high risk for breast cancer due to family history. Nipple-sparing mastectomy may also be offered to select women with small, early stage cancers that are far away from the nipple.
If your breast cancer requires surgery, your surgeon may remove some of the lymph nodes under your arm on the same side to see if the cancer has spread there. Cancer in these lymph nodes increases the chance that cancer cells have spread to other parts of your body.
Until the mid 2000s, surgeons routinely removed most of the lymph nodes in the armpit, usually between 10 and 20, in a procedure called an axillary lymph node dissection. Although this operation still needs to be performed for many patients with cancerous lymph nodes, it is not typically done if there’s no evidence that cancer has spread to the lymph nodes. The long-term side effects of axillary lymph node dissection include lymphedema (swelling) of the arm, nerve injury, and reduced range of motion in the arm; these can be uncomfortable and even debilitating.
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 nodes—the first lymph nodes to which your breast cancer is likely to have spread. During surgery, these nodes can be checked for cancer. If the biopsy results are negative (cancer-free), no more surgery is necessary. If the results are positive, your surgeon may need to perform an axillary lymph node dissection, removing 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 R. Byrd, MD, who pioneered sentinel node biopsy in the Pacific Northwest.
Surgery for Lymphedema
Plastic surgeons at UWMC now offer surgery to treat lymphedema in the arm.