Surgery

Mastectomy is the medical term for surgical removal of the breast. It refers to a number of different operations, ranging from those that remove the breast, chest muscles and underarm lymph nodes,to those that remove only the breast lump.

Based on the size and location of the lump, your doctor will recommend the type of surgery that offers you the best chance of successful treatment.

Most medical and surgical procedures carry some risk. The risks are categorized small or serious, frequent or rare. Because there is such a wide range of potential risks and benefits from various treatments for the different stages and kinds of breast cancer, you should discuss with your doctor the particular benefits and risks of treatment methods suitable for you.

Mastectomy

Radical Mastectomy
This type of surgery removes the breast, the chest muscles, all of the underarm lymph nodes, and some additional fat and skin. It is also called a "Halsted Mastectomy" (after the surgeon who developed the procedure). A radical mastectomy was the standard treatment for breast cancer for over 70 years and is, for all intents and purposes, never used for treatment.

Modified Radical Mastectomy or Total Mastectomy with Axillary Node Dissection 
This procedure removes the breast, the underarm lymph nodes, and the lining over the chest muscles. It is also called "total mastectomy with axillary (or underarm) dissection." Today, it is the most common treatment of early stage breast cancer where lymph node involvement has been proven.

ADVANTAGES:
• Keeps the chest wall muscles and the muscle strength of the arm.
• In most cases, radiation treatments are not necessary after surgery.
• Since all the breast tissue has been removed, there is no need for follow-up mammograms after surgery.

DISADVANTAGES:
• The breast is removed.
• In some cases, there may be swelling of the arm because of the removal of the lymph nodes.
• 8 to 10% risk of lymph edema.

Total or Simple Mastectomy
This type of surgery removes only the breast. Ideally a few of the underarm lymph nodes closest to the breast are removed to assure complete removal of the axillary tail of the breast. This is most often used to treat non-invasive breast cancers or in prophylactic mastectomies.

ADVANTAGES:
• Most or all of the underarm lymph nodes remain, so the risk of swelling of the arm is greatly reduced.
• Breast reconstruction is easier.

DISADVANTAGES:
• The breast is removed.
• If cancer has spread to the underarm lymph nodes, it may remain undiscovered.

Skin Sparing Mastectomy

The mastectomy is performed through a small keyhole using the nipple/areola complex as the only skin that is removed. The cosmetic result of the reconstruction with this operation is sometimes better than with standard mastectomies. This is a common procedure performed by experienced breast surgeons when used in combination with immediate reconstruction.

Lumpectomy

This procedure removes the tumor plus a surrounding rim of normal breast tissue. Occasionally the skin and the lining of the chest muscle below the tumor will need to be removed to obtain clear margins. A margin of normal tissue must be removed to insure the tumor has been completely removed. (A 5mm margin of normal tissue is optimal, but a 2mm margin is mandatory to decrease the risk of local recurrence after radiation therapy.) It is followed by approximately six weeks of radiation therapy.

ADVANTAGES: 
• Breast is not removed.
• There is no difference in cure rates or recurrence rates between lumpectomy and mastectomy. 
• The post-operative complication rates are a little lower with lumpectomy than with mastectomy and reconstruction.

DISADVANTAGES: 
• Since the majority of the breast tissue is left and the entire breast needs to be treated, radiation therapy is always needed after lumpectomy.
• Sometimes there is a positive or close margin after lumpectomy and a second operation may be needed to remove more breast tissue and obtain a clear margin.

Sentinel Lymph Node Biopsy

Axillary lymph node evaluation has been the standard of care in breast cancer treatment. This procedure involves the removal of two levels of lymph nodes from the axilla (armpit) to determine if the cancer has spread locally. This is considered part of the staging of the breast cancer and is routinely done at the time of the definitive breast cancer surgery.

For your convenience and information, we have included a list of Frequently Asked Questions specifically on sentinel lymph node biopsies.

One of the debilitating side effects of axillary dissection has been lymphedema (arm swelling). This occurs in approximately 8 to 10% of patients. The arm may also become numb above the elbow at the level of the triceps muscle. You must protect your arm from cuts and scrapes for the rest of your life to prevent lymphangitis (an infection in the lymphatics of the arm).

In an attempt to better diagnose lymph node metastasis and decrease complications associated with axillary dissection, a method of lymph node mapping adopted from melanomatreatment has been used to identify the sentinel (the first line of defense) lymph node. This lymph node can be evaluated for microscopic metastasis through a procedure called cytokeratin staining. It generally takes 7 days to receive the results and is far more sensitive than the naked eye of the pathologist.

We know that women previously thought to be node negative; and therefore, have local disease, have died of distant metastasis. This may be related to our previous inability to find these microscopic metastatic deposits and treat them aggressively with chemotherapy.

The absolute answers to these questions still have not been completely resolved. Sentinel lymph node identificationis indicated in almost all breast cancer operations, and is appropriate in both lumpectomy and mastectomy patients. Parameters may vary from surgeon to surgeon and will be based upon your individual tumor characteristics. The procedure to identify the node starts with an injection of radioactive tracer called technetium sulphur colloid. It may be injected the day before surgery or the morning of surgery. It must remain in the breast for 3 to 4 hours before you are taken to the operating room.

At the time of surgery, after you are asleep, a vital blue dye may be injected behind the nipple. These two modalities allow us to identify the sentinel lymph node in greater than 90% of patients. When a sentinel lymph node is found at surgery, a frozen section (quick diagnoses) is performed. Once the sentinel node is identified, your surgeon will manually check your axilla for other nodes that may have tumor in them.

If the frozen section reveals spread of cancer cells to the lymph node, a level I and II axillary node dissection is performed. If the frozen section is negative for spread of the cancer, then no further lymph node surgery is performed at that time. At your postoperative visit, you will discuss your final pathology, which will include the results of your margins of tumor resection and the cytokeratin staining (high tech evaluation for spread) for microscopic metastasis.

If the cytokeratin stains are positive, you may need to go back to the operating room for the completion of level I and IIaxillary node dissection to complete your staging. The need for further surgery will be discussed with your surgeon and medical oncologist.

Breast Reconstruction

As you consider mastectomy as a treatment option, you should be aware of breast reconstruction, a way to recreate the breast's shape after a natural breast has been removed. This procedure is gaining in popularity, although many women are still unaware of it.

Today, almost any woman who has had a mastectomy can have her breast reconstructed. Successful reconstruction is no longer hampered by radiation-damaged, thin skin, tight skin, or the absence of chest wall muscles. The options for immediate reconstruction after mastectomy will be discussed with your surgeon and again when you consult with a plastic and reconstructive surgeon.

Reconstruction is not for everyone and may not be right for you. After mastectomy, many women prefer to wear artificial breast forms or prostheses inside their surgical bras. Both a general surgeon and a plastic surgeon may help you decide whether to have breast reconstruction. 

You should discuss breast reconstruction before your surgery because the position of the incision may affect the reconstruction procedure. A procedure called a skin-sparing mastectomy has been able to greatly enhance the final reconstruction results and should also be discussed with your surgeon prior to the operation.

Having breast reconstruction at the time of your cancer surgery can lead to better cosmetic results, decreased risks from additional anesthesia and added psychological benefits to you. All of these benefits can result from immediate reconstruction, without compromising the curative aspects of your cancer operation.

Axillary Node Dissection

Axillary node dissection refers to the staging procedure performed in conjunction with lumpectomy for breast conservation or mastectomy. The procedure involves an axillary incision below the hairline when performed with a lumpectomy and is performed through the mastectomy incision with removal of the breast.

Removal of level I and II lymph nodes includes the tissue between the axillary portion of the breast and the area above the axillary vein underlying the pectoral muscles. The axillary nodes (level III nodes) lying superior to the pectoral major muscle are preserved to decrease the incidence of armedema. It may also remove a small nerve in the process resulting in numbness to the posterior aspect of the arm. Determining whether the lymph nodes are involved with the tumor will stage the cancer to determine if chemotherapy will be needed.

Informed Consent

When surgery is recommended, most health care facilities require patients to sign a form stating their willingness to permit diagnosis and medical treatment. This certifies that you understand what procedures will be done and that you have consented to have them performed.

Before consenting to any course of treatment, ask your doctorfor information on:
• The recommended procedure 
• Its purpose 
• Risks and side effects 
• Likely consequences with and without treatment 
• Other available alternatives 
• Advantages and disadvantages of one treatment over anotherYou are likely to discover that your anxiety over treatment decreases as your understanding of breast cancer and its treatment increases.