Breast surgery

| April 12, 2007

In-Depth Report

Mastectomy
Surgeries that conserve the breast
After surgery
Complications and side effects of surgery

Breast surgery

Almost all women with breast cancer will have some kind of surgery to remove the cancer. There are a number of different options to discuss with your breast surgeon. They range from the now rarely performed radical mastectomy to the more common breast-conserving surgeries in which the surgeon removes only the cancer with a margin of normal, surrounding tissue. At the same time, when an invasive cancer exists, the surgeon also removes one or more of the axillary (underarm) lymph nodes to examine under the microscope for cancer cells. Women who have a mastectomy may decide to have breast reconstruction at the same time or at a later date.

Mastectomy

Mastectomy is a procedure that removes the entire breast. The operation has several variations in which different degrees of surrounding muscle and lymph nodes are taken out, too. All forms of mastectomy are performed under general anesthesia or with an epidural block plus intravenous sedation. In certain circumstances, a mastectomy is a better option than breast-conservation surgery, in which most of the breast is left intact.

Modified radical mastectomy. The most commonly performed procedure for patients with invasive breast cancer, modified radical mastectomy is the removal of the entire breast, including the nipple, areola, and axillary lymph nodes (see Figure 4) . This type of mastectomy has several variations in which nerves and chest wall muscles are also excised if cancer has invaded those areas. If an immediate breast reconstruction is desired, the nipple and areola are excised, but as much remaining skin as possible is preserved. The plastic surgeon joins the surgical team to perform the reconstructive part of the operation.

Many health care teams decide to defer the reconstruction portion of the treatment plan until the mastectomy has been completed and the entire analysis of the removed breast and breast cancer is fully examined. For example, it is important to know that the removed cancer does not include any cancer cells that are present at the so called surgical margin. This can be determined only after a detailed analysis is undertaken by a pathologist. A pathologist is a medical doctor that specializes in the analysis of specimens to help determine a diagnosis and prognosis. Further surgery may then be necessary prior to proceeding with the breast reconstruction.

Figure 4: Modified radical mastectomy

The breast is composed primarily of fat and breast tissues and also has nerves, arteries, veins, and lymphatic vessels that carry lymph fluid to the lymph nodes. The lobules are milk-producing glands and the ducts carry the milk from the lobules to the nipples during breast-feeding. Breast cancer usually starts inside the gland and in time it may break through the gland wall and spread to other parts of the body through the lymph channels or blood vessels. The pathologist can determine by looking at the removed breast cancer whether cells have invaded either the lymphatics or blood vessel channels (so called lymphovascular invasion).

Simple (total) mastectomy. In a simple mastectomy, the surgeon removes the entire breast, including the nipple and areola, but not the lymph nodes or muscles underneath.

Radical mastectomy. Rarely performed today, this extensive operation removes the entire breast, the pectoral muscles of the chest wall, and all the axillary lymph nodes up to the collarbone. A common side effect of this procedure is the painful swelling and tenderness of the arm known as lymphedema (see "Lymphedema") . This procedure is now seldom used because, overall, modified radical mastectomy has proved to be equally effective with fewer side effects.

Surgeries that conserve the breast

Some of the same factors that caused radical mastectomy to fall from favor also prompted the development of breast-conservation surgery. The realization that mastectomy did not cure all cancers, the use of mammography to identify smaller and smaller cancers, and the success of radiation therapy following surgery all suggested that it was not necessary to always remove the entire breast.

For most women, surgery that leaves most of the breast intact, followed by radiation therapy, is as effective as mastectomy for long-term survival. This is especially true if the cancer is occurring in only one portion of the breast. However, if the cancer is present in several areas of the breast (called multifocal breast cancer), lumpectomy and radiation may not be the best choice.

The terms "lumpectomy," "wide excision," and "partial mastectomy" are used interchangeably to describe surgeries in which only the cancer and a margin of surrounding cancer-free tissue is removed (see Figure 5) . If examination of the tissue that is removed shows that cancer is present at its margin, the surgeon can remove additional tissue in a procedure called a reexcision. Lumpectomy is nearly always followed by radiation therapy.

Very little, if any, skin is removed during breast-conservation surgery, and, if possible, the incision is located so it won't show when you're wearing a bathing suit or low-cut dress. Surgery for invasive cancers usually includes removal and analysis of the axillary lymph nodes to see if the cancer has spread to them. Surgery is usually performed with intravenous sedation with local anesthesia, a spinal block, or general anesthesia. In some situations, such as when the cancer is relatively large in relation to the breast, chemotherapy and or hormonal therapy can be used before surgery to shrink the tumor and allow for less tissue removal and breast distortion.

If the lump is small and your breast is medium or large, the cosmetic change may not be noticeable. Removal of a large tumor from a small breast, however, can involve a substantial loss of breast tissue and may disfigure the breast. The breast that's been operated on may now be smaller than and a different shape from your other breast. Also the nipple area may be off-center or shaped differently.

Speak with your surgeon in advance about what changes to expect in the size and shape of your breast, the placement of the surgical scar, and its length. You might be able to minimize the cosmetic changes by having neoadjuvant chemotherapy to shrink the tumor before surgery. Neoadjuvant chemotherapy is becoming increasingly common, particularly for T2 and T3 breast cancers, as a means of optimizing appearance after lumpectomy. If a noticeable size discrepancy between your breasts seems likely, consider having a mastectomy and breast reconstruction, instead. Or, as another alternative, you can choose a reduction mammoplasty, a procedure in which the second breast is reduced in size.

Figure 5: Lumpectomy/partial mastectomy

In this breast-conserving procedure, the surgeon removes only the cancer and a margin of normal surrounding tissue. The nipple and the areola are left intact. For central cancers, the surgeon may place the incision on the border of the areola in order to obtain the best cosmetic effect and to allow the woman to wear a bathing suit or low-cut dress without a scar showing. If the tumor is invasive, lymph nodes under the arm may be removed for analysis.

After surgery

Recovery depends on the type of surgery. Following mastectomy, you are likely to go home the same day or the day after. You will probably have two or more soft plastic drainage tubes inserted beneath the skin flaps and in the underarm area to allow lymph fluid to drain and the incision to heal more easily. Surgery may be followed by chemotherapy, radiation, or both, depending on the cancer stage and other diagnostic factors.

Your clinician can remove your postoperative drains after one or two weeks, when daily fluid output is minimal. You will have learned before surgery how to care for the drains and the small containers (pinned to a shirt or looped through a belt) into which they empty. Most sutures (stitches) in breast surgery are hidden under the skin and dissolve over time; if external sutures have been used, however, they must be removed after the surgery.

If you have had breast-conservation surgery, you will probably return home the same day, depending on your overall health and recovery from anesthesia. You may experience some breast tenderness, bruising, and swelling, but not much pain. You will probably feel well enough to return to work after a few days of rest.

Whether you had a mastectomy or lumpectomy, if your lymph nodes were removed, your underarm area will be tender and sore for several weeks.

Complications and side effects of surgery

Breast surgeries can cause complications such as an infection at the site of the incision, a hematoma (an accumulation of blood in the wound that can be painful), or a seroma (an accumulation of clear lymphatic fluid under the incision). An infection should be treated immediately with antibiotics. A large hematoma requires follow-up surgery in which the surgeon takes out the hematoma and seals off the source of the bleeding. A seroma may cause discomfort. If the discomfort keeps you awake or prevents you from performing daily activities, tell your surgeon; the seroma can be drained through a needle in your surgeon's office.

Because the surgeon must cut some nerves on the chest wall during a mastectomy, the most common permanent side effect of this surgery is a loss of sensation on that side of the chest. You probably will retain some sensitivity around the edges, but the scar area almost always will be numb. In addition, if you are very large-breasted, the loss of one breast may cause an imbalance severe enough to pull your spine out of balance, causing back pain and discomfort. If you do not have breast reconstruction, you may decide to have the remaining breast reduced in size (reduction mammoplasty) to improve your balance.

Lumpectomy or mastectomy?

After learning that you have breast cancer, you will very quickly begin making decisions about your treatment. One of the first decisions is about surgery. Although your surgeon and other members of your health care team will guide you with information and advice, ultimately the decision will be yours. Particularly if you have early-stage breast cancer, you will have to choose between mastectomy and breast-conservation surgery.

In 1990, the National Institutes of Health recommended breast-conservation therapy (lumpectomy or partial mastectomy plus radiation therapy) instead of mastectomy as an effective local control for most women with Stage I or II breast cancer. Five years later, an analysis of all the randomized studies ever performed showed long-term survival rates to be equal for mastectomy and breast-conservation surgeries in early-stage cancers. In other words, both procedures offer the same chances for survival. Since these reports were published, the use of breast-conserving surgery has steadily increased.

There are some advantages and disadvantages to each type of surgery (see "Breast surgery") . It's worth taking a little time to gather information about your choice. Making a decision about surgery while you're still in a state of shock over your diagnosis is not necessary. In most cases, breast cancer surgery can be performed several weeks after the diagnosis, giving you the chance to learn more about cancer and cancer treatments. You also may want to seek a second opinion, preferably from a breast cancer specialist at another breast center, hospital, or medical school. The more informed you are about breast cancer, the more likely it is that you will find a treatment appropriate for your cancer and your needs.

Created by the Faculty of the Harvard Medical School

Review Date: 2007-04-12

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