Surgery

The goal of breast surgery is to remove your tumor and evaluate or remove lymph nodes as necessary.

Lumpectomy (segmental mastectomy, partial mastectomy, wide excision)

This procedure is the removal of your breast tumor along with a small margin of healthy tissue surrounding the tumor. About 80 – 90 percent of the time, clear margins are achieved the first time. You may need a second surgery if the margin is not clear enough. This procedure is usually done in an outpatient setting and does not require staying in the hospital.

Often, your surgeon will leave small surgical metallic clips in your breast after a lumpectomy to mark where the tumor was. This helps your radiation oncologist target the correct area for treatment. These clips are also helpful in follow-up, since the location of the original tumor can be easily identified on a mammogram by the clips.

Studies have shown that overall survival rates in patients undergoing lumpectomy are equivalent to those who undergo a mastectomy. To determine if a lumpectomy is an option for you, your doctor considers several factors, which include:

1. Whether the tumor can be removed with clear margins
2. Whether the remaining breast tissue can be preserved with a natural shape
3. Whether radiation therapy can be performed
4. Whether the remaining breast tissue can be followed reliably in the future for recurrence
5. Your personal preference

Neoadjuvant (pre-operative) therapy and lumpectomy

Sometimes, if the tumor is too big to complete a lumpectomy, but you want to keep your breast, the team may consider giving you chemotherapy or hormone-blocking pills before surgery to reduce the size of the tumor. This will be discussed with you by the surgeon and medical oncologist.

Simple mastectomy

This is when your breast tissue is removed but your nerves and muscles are left intact. The option of immediate breast reconstruction will also be discussed with you.

Radical mastectomy

This is the removal of your entire breast, along with your underlying chest wall muscle and the surrounding lymph nodes in the armpit. This is rarely done today.

Modified radical mastectomy

This is the removal of your breast and the lymph nodes in your armpit. However, the muscle and nerves on your chest wall are left intact.

Nipple sparing mastectomy

This is when your breast and nipple/areola are removed while keeping as much of your skin as possible. This helps to keep the contour of your breast. Studies have demonstrated that this is a safe approach, and does not increase your risk of cancer recurrence. This technique is typically used when you’re planning immediate breast reconstruction.

Skin sparing total (simple) mastectomy and preservation of the nipple areolar complex

This is removal of your breast, while keeping the nipple/areolar and overlying skin. Some breast tissue is left behind the nipple, but your nipple sensitivity is not preserved.

Sometimes, the nipple does not heal well after surgery. Studies have shown that while this procedure is a safe approach in carefully selected patients, some patients are not candidates for this type of surgery. Your plastic surgeon and surgeon will help decide if this is an appropriate procedure for you.

Immediate breast reconstruction

You can have reconstructive surgery performed at the same time as your mastectomy. The surgery is coordinated between your surgeon and your plastic surgeon. Studies have shown that this is a safe approach and may result in a better cosmetic result.

Delayed breast reconstruction

You can also have reconstructive surgery after your mastectomy has healed and you’ve completed any additional cancer treatment. This may be the best option if you need radiation therapy, chemotherapy or other systemic treatment.

Axillary Surgery

Sentinel lymph node biopsy

Staging the axilla is important to determine if you need additional surgery, systemic treatment, or radiation. The goal of sentinel lymph node biopsy is to reduce your risk of lymphedema (but does not completely eliminate it) while providing accurate clinical information for the members of your oncology team. The sentinel lymph node procedure can be completed at the same time as a lumpectomy or mastectomy. Your breast is preoperatively injected with either a blue or radioactive dye. This allows the surgeon to correctly identify the lymph node or nodes which should be tested for metastases. The lymph node is evaluated by the pathologist after surgery, using two specialized stains to look for cancer cells.

Axillary node dissection

In an axillary dissection, the lymph nodes under your arm are removed. If your lymph nodes are positive prior to treatment (either by imaging, palpation, or biopsy), the surgeon may need to remove all your lymph nodes. If a sentinel lymph node biopsy is positive, you may need to return to surgery for completion dissection. Depending upon the number of lymph nodes involved, you may need radiation after surgery.

Axillary node dissection carries an increased risk of lymphedema when compared to sentinel lymph node biopsy. There are several studies which demonstrate that patients with minimal disease in the lymph nodes may not need an axillary dissection, but should have radiation. The doctors on your team will help you decide whether surgery or radiation is the best option for you.