Surgery

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Why You Need Surgery •  Lumpectomy • Mastectomy
Lymph Node Examination

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Why You Need Surgery
To ensure the best chance for successful treatment of breast cancer, it is important to remove all the cancerous tissue, using the most direct approach possible. This means some type of surgery. Other treatments, such as radiation therapy, chemotherapy, or hormonal therapy cannot replace surgery, but do play a very important role later in the treatment process.

There are two surgical options: One is to remove just the tumor, with a safety margin of healthy breast tissue around it, conserving most of the breast. This is called wide local excision, partial mastectomy, or lumpectomy. The other option is to remove the entire breast in a procedure that is called a mastectomy.

We will review the pros and cons of each procedure. Then, in consultation with your healthcare team, and armed with an open mind, you can pick the procedure that is best for you.

 

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Lumpectomy

What is a Lumpectomy?
If the tumor is small and confined to a single location in the breast, you may have the option of having breast-conserving surgery. The goal of this relatively simple procedure is to remove the whole tumor, while conserving as much breast tissue as possible. A margin of normal breast tissue is also removed to make sure no malignant cells are left behind.

The technical term for this type of surgery is partial mastectomy. Most people commonly refer to it as a lumpectomy—a "lump-removal", so to speak. Depending on how much breast tissue is removed, the procedure may also be called wide excision, segmental mastectomy, or quadrantectomy. The specific technique used may vary from surgeon to surgeon and from case to case.

The cosmetic result of breast conserving surgery will vary with the location and size of the tumor, and the size of the breast. Removing a large tumor from a large breast may result in a normal-looking breast, but removing even a small tumor from a small breast may lead to noticeable change in breast size and shape that may be cosmetically significant.

Very large tumors may be treated first with chemotherapy (this is called neoadjuvant chemotherapy), in order to shrink them before removing them surgically. Currently there are new techniques that are being tested that would allow the physician to destroy a small tumor without surgery. These so-called ablation techniques rely on laser beams, or heated or cooled needles placed directly into the tumor to destroy the cells.

Breast conserving surgery almost always requires additional treatment of the breast area with high energy X-rays (radiation therapy) to kill any surviving cancer cells that might be left behind.

Before Surgery
A lumpectomy may be done in a hospital operating room, or in an outpatient surgery center. You may be able to go home the same day. You will want to have a friend or relative accompany you to the hospital, to provide moral support, to meet you after surgery, and to drive you home.

You'll probably be instructed not to eat or drink after midnight on the night before surgery.

If your tumor was found on a mammogram, but is difficult or impossible to feel by touch, your surgeon may request that a needle localization procedure be done before you go to surgery. For this procedure, a radiologist will use a special mammography unit to pinpoint the location of the tumor, then mark it by inserting a thin wire into the breast. The surgeon will follow this wire to find the tumor more easily during surgery.

Before the surgery you'll meet with the anesthesiologist to decide whether you'll have general or local anesthesia. The choice depends on your health and on your personal preferences.

You'll also be asked to sign an informed consent form as an indication that you understand the procedure and the possible complications, such as infection and bleeding. Make sure to read the form carefully and ask for explanations of any parts that you are not comfortable with.

The Surgical Procedure
A lumpectomy takes about an hour. The surgeon will make a skin incision over the tumor area and remove the tumor with a small amount of surrounding healthy breast tissue. This margin, about one-half to three-quarters of an inch in thickness, helps decrease the chance that any tumor cells are left behind.

The surgical specimen will be sent to a pathologist who will examine it under a microscope and determine whether the margins were clear of tumor cells. If tumor cells are found along the edges, it means that some cancerous cells may have been left behind. Another lumpectomy may be done to get clear margins. In some cases, a mastectomy may be required.

 

Recovery after Lumpectomy

After the lumpectomy, you'll be taken to the recovery room for a short while, and then discharged to go home. If you didn't have an axillary lymph node dissection at the same time as the lumpectomy, you'll be able to resume normal activities almost immediately. Follow the aftercare instructions you receive regarding how long to keep the incision dry, when to return for a follow-up visit to your surgeon, and when to have the sutures removed.

 

Radiation Therapy after Lumpectomy
An important part of breast conserving treatment is radiation therapy. Radiation therapy uses high energy X-rays applied to the breast area to kill any possible remaining cancer cells.

This can be done either with a special machine, which involves treatments five days a week for five to eight weeks at a special facility, or with special radioactive seeds, which only takes one to three days, and irradiates only part of the breast, or with various other techniques of accelerated partial breast radiation.

Is Lumpectomy Right for Me?
What is better, mastectomy or lumpectomy? Numerous research studies, involving thousands of women and many years of follow-up, show that there is no difference in survival between the two procedures. Despite these very conclusive studies, some physicians may still recommend a mastectomy, due to personal bias. If your doctor does not offer you a lumpectomy as an option, make sure you understand why.

Besides being equally effective, breast conserving surgery offers several advantages over a mastectomy. You keep your breast, (although you may notice a change in shape), and you avoid the emotional trauma of losing the breast. A good cosmetic result can be expected, and sensation in the nipple and skin area can usually be preserved.

However, not all women can have breast conserving surgery. If the tumor is large, or the breast is small, the cosmetic results may not be acceptable after the tumor is removed. Some women are unable or unwilling to undergo the course of radiation therapy required after a lumpectomy. And a few prefer the peace of mind they expect after a mastectomy.

To ensure that you are receiving the best treatment possible for your particular case, you must meet certain criteria that will make you a good candidate for breast conserving surgery.

A lumpectomy would not be recommended in the following situations:

• There is more than one tumor in the breast.

• The tumor is so big or the breast so small that the cosmetic result would not be satisfactory after removal of the tumor.

• The tumor was found to extend beyond the margins of the tissue removed during initial surgery.

• You are not willing to have radiation therapy, or there is no convenient radiation therapy facility near you.

• You prefer to have a mastectomy.

It is important to remember that no decision needs to be made overnight. You can take up to several weeks to gather information. You do not need to make the decision alone. Consult your healthcare professionals, consider getting a second opinion, and talk things over with your loved ones.

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Mastectomy

What is a Mastectomy?
Mastectomy, or surgical removal of the breast, has been used to treat breast cancer for several centuries.

The radical mastectomy, which removed the entire breast, the lymph nodes in the armpit, and one of the major muscles of the chest wall, was based on the mistaken belief that the more tissue removed, the better the chances of curing the cancer. This procedure caused so much deformity, that women feared it as much as the cancer itself.

In the 1970s and 1980s, research proved that there was no advantage in removing the chest muscles, and the modified radical mastectomy, which spares these muscles yielding a more cosmetically acceptable result, was introduced. Now the radical mastectomy is almost never used.

The modified radical mastectomy performed today removes as much of the breast tissue as possible, including the nipple and the areola, and a number of axillary lymph nodes, but not the muscles. Patients can choose from a variety of reconstruction techniques that offer pleasing cosmetic results.

The current trend that strives to preserve as much of the breast as possible has lead to the development of the so-called skin-sparing mastectomy. In this procedure the incision includes only the nipple, a narrow margin of skin around it, and the skin directly over the cancer, leaving most of the breast skin intact. This type of mastectomy makes it easier to have a single-stage reconstruction.

Before Surgery
A mastectomy is generally done in a hospital, under general anesthesia. After a date is set, someone on your surgeon's staff will review with you the admission process for the particular hospital where the operation will take place.

Ask someone in the surgeon's or hospital's business office whether your insurance covers surgical fees, hospital room, anesthesiologist's fees, and other charges. Make a list of all the medications you are taking, both prescription and over-the-counter, since some of them may have adverse effects during anesthesia or surgery. (For example, aspirin-containing preparations can increase bleeding.) Some medications may need to be discontinued weeks before surgery.

Pack all the personal belongings you may need: a nightgown, slippers, toiletries, books or an iPod, perhaps a favorite pillow, and a change of loose clothing to wear when you go home.

Most people undergoing surgery enjoy having a friend or relative accompany them to the hospital and meet them after the procedure. If you are going to be sent home the same day, you will definitely need someone to drive you.

You'll be instructed not to eat or drink anything after midnight on the night before the surgery.

On the day of the surgery, you'll first go through an admission process at the hospital. Your surgeon already will have reviewed with you all aspects of the procedure, and the possible risks and complications. On the day of admission, the hospital staff will ask you to sign an informed consent form listing your doctor's name and the name of the surgical procedure you are having. The form requires that you verify the following:

• That the risks of the surgery and the anesthetic have been explained to you.

• That intravenous medication, including drugs, anesthesia, and blood transfusions, may be administered.

• That any tissue removed during the surgery may be examined and disposed.

• That you understand all of the foregoing and that you consent to the surgery.

Make sure you feel comfortable with what you are signing. Cross out and initial anything you don't agree to. If there is anything on the form that worries you, ask to see your doctor.

Blood transfusions are rarely needed during lumpectomies or mastectomies, but may be required for certain types of breast reconstruction. Many people are concerned about contamination of banked blood with HIV, the virus that causes AIDS.

You may wish to discuss with your physician the possibility of donating and storing your own blood before your surgery so that it can be used, should you need it. You will need to donate the blood at least one week before surgery.

An anesthesiologist or a nurse anesthetist will meet with you and select a general anesthetic that is best suited to your medical condition.

They need to know about:

• Your medical history and any problems with your heart, lungs, circulation.

• Any current conditions such as skin infections, colds, or tooth decay.

• Any allergies.

• Any prescriptions, over-the-counter medications, or drugs that you may be taking

• Your smoking and drinking patterns.

The Surgical Procedure
The anesthesiologist will meet you in the staging area, start an intravenous line (an 3IV2) in one of your arms using a small needle, and perhaps give you something to help you relax.

When the surgical team is ready, you will be taken to the operating room. Several devices will be attached to you, such as an automatic blood pressure cuff, a heart monitor, and a blood oxygen monitor. The anesthesiologist will inject a drug into your vein through the tubing, and you will fall asleep almost immediately. A tube may be placed through your mouth to maintain a way for you to breathe during the surgery. Your blood pressure, pulse, and breathing will be closely monitored during the entire procedure.

The total mastectomy takes two to three hours. Breast tissue extends from the collar bone to the edge of the ribs, and from the breast bone to the muscles in the back of the armpit. The surgeon will make an incision, then remove as much of the breast tissue as possible.

The tissue will be sent to the pathologist, who will examine it for any evidence of cancer spread beyond the breast.

You may also undergo a procedure called an axillary lymph node dissection—removal of a number of lymph nodes, or a few sample nodes from your armpit for examination by the pathologist.

Presence or absence of cancer cells in these lymph nodes will help determine your future treatments. If your tumor was very small, or if the pathologist's report said that it was non-invasive (DCIS), then you may not have an axillary lymph node dissection.

You will find more information about this procedure in the section on axillary lymph node dissection later in this chapter.

When the procedure (mastectomy or node dissection) is completed, one or two tubes called drains will be placed under the skin to help remove the fluid that accumulates at the site of surgery. If you go home with the drains, you'll receive instructions on how to care for them. You'll be shown how to empty the suction bulbs attached to the drains and keep a record of the volume and color of the fluid removed. The drains will be removed at a follow-up visit to your surgeon, or as soon as the drainage decreases.

Immediate Reconstruction
If you've decided to have immediate reconstruction of the breast, the plastic surgeon will take over while you are still asleep. Reconstruction can be done using your own tissues—from the abdomen, back, or buttocks—or using a synthetic implant. The procedure may take anywhere from an hour to six or eight hours, depending on the method used.

Recovery after Mastectomy
After surgery, you'll be taken to the recovery room. As you wake up from the anesthetic, you may feel cold, and your throat may be sore from the tube used for anesthesia. You may fade between waking and sleeping for several hours.

Whatever surgery they are going to have, most women like to have a friend or relative meet them after the operation. You can ask your surgeon how long it will take before you will be brought to your room after surgery and to arrange with the hospital to allow that person to meet you there.

Most women will stay in the hospital for one or two nights after a mastectomy, and somewhat longer after a mastectomy with reconstruction.

Each woman reacts to surgery differently. Most can take a short walk in and out of their hospital room the day of surgery. The next day, most are able to eat a regular diet and get around.

Once you're home, you'll probably feel more tired than usual for a while. Don't be discouraged. You've just been through general anesthesia and major surgery, and fatigue is to be expected.

Take sponge baths for a few days after surgery until your incision starts to heal. Don't shower until your drains are removed, and the surgeon tells you that it is alright to get the incision wet. When you do shower, treat the skin gently and pat, rather than rub, the incision.

Immediately after surgery, you'll probably have trouble moving your arm due to muscle tightness and soreness around the shoulder. Use the arm as tolerated immediately after surgery, but avoid active stretching or pulling until the drains are removed and you get your doctor's approval. Don't be afraid to enlist the help of a friend or relative until your arm function returns.

Many women return to work as soon as they feel better, even while their chemotherapy and radiation treatments are continuing. If your job requires lifting or strenuous physical activity, you may need to change your activities until you have fully regained your strength.

Exercises After Mastectomy
The goal of exercising is to regain the full range of motion in your shoulder and arm as soon as possible. But don't attempt to begin exercising without specific instructions from your healthcare provider.

Exercises must be done in stages. After the drains are removed, your doctor or physical therapist may assign pendulum-like movements with your arm, to begin loosening any tightness in the shoulder area.

• Holding on to something for support (such as a chair or desk), lean forward at the waist and swing your arm in gradually enlarging circles. Make ten circles, rest, then repeat in the other direction.

After the sutures are removed, you may be told to begin stretching exercises to regain full motion in the shoulder.

• Walk your fingers up the wall, until you feel mild pain in the incision, and note how far you can reach each day.

• Throw a rope or an old tie over a door, and move your arms up and down in a see-saw motion.

• Walk your arm up your back as far as you can.

Many communities offer swimming, exercise, and dance classes specifically for breast cancer patients. The YWCA Encore program is one of them. Check the Resources section for other suggestions

Is Mastectomy Right for Me?
Numerous research studies, involving thousands of women and many years of follow-up, show that there is no difference in survival in patients treated with lumpectomy and radiation, or with mastectomy.

There is a slightly higher rate of local cancer recurrence (in the breast area itself) following lumpectomy: one out of a hundred women treated with lumpectomy will develop a local recurrence within a year. (In other words, there is a 1% per year recurrence rate. The chance of having a recurrence within ten years is 10%.) Local recurrences are not life threatening, and can be controlled by performing a mastectomy.

Since there is no difference in numbers of life-threatening distant metastases (cancer in other sites in the body) between lumpectomy and mastectomy, there is no difference in life expectancy between the two procedures.

So the choice is between running a slightly higher risk of a local recurrence following lumpectomy, or accepting a mastectomy.

The advantages of a mastectomy are that no radiation therapy is required, and there is a decreased risk of local recurrence. Some women prefer the procedure because of the peace of mind they expect after the removal of the breast.

The disadvantages include more extensive surgery, and the emotional impact of losing the entire breast, including the nipple.

Your choice will be dictated by various factors. Here are a few considerations that would favor mastectomy over lumpectomy:

• The tumor is so big or the breast is so small that the cosmetic result would not be satisfactory after tumor removal.

• There is more than one tumor location in the breast.

• You are unwilling or unable to undergo radiation treatment

• You prefer to have a mastectomy.

 

Remember that no decision needs to be made overnight. You can take up to several weeks to gather information. And you do not need to make the decision alone. Consult your healthcare professionals, consider getting a second opinion, and talk things over with your loved ones.

Patient advocacy organizations in your area can put you in touch with other women who had the same type of surgery that you are considering, and who will be happy to discuss your choice with you. 

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Lymph Node Examination

Why Examine the Lymph Nodes
Arteries and veins carry blood to and from various parts of the body. Some fluid seeps out of these blood vessels, and is returned to the blood stream by a network of thin tubes called lymphatic ducts. This fluid, called lymph, helps the body wash away foreign particles or other debris that can collect in the spaces between cells.

Lymphatic ducts from both the breast and the arm come together in the axilla, or armpit. There, the lymph is filtered through tiny bean-shaped organs called lymph nodes. Foreign particles (such as bacteria from an infection in the finger, or break-away cancer cells from a tumor in the breast) are trapped in the lymph nodes before they can enter the general circulation.

Whether you've had a mastectomy or a lumpectomy you may also have a procedure to remove some of the lymph nodes from your armpit and have them examined for evidence of cancer spread. Removing the lymph nodes does not help eliminate the cancer from your body. But determining whether cancer cells have spread to these lymph nodes is important for deciding what additional therapy will be needed.

 

Axillary Lymph Node Dissection
An axillary lymph node dissection can be done through a separate small incision in the armpit at the time of a lumpectomy, or through the main surgical incision as part of a mastectomy. The surgeon will remove a portion of the fat pad within which ten to twenty lymph nodes are imbedded. The tissue removed will be sent to the pathologist. Each node will be sliced and examined under the microscope for presence of cancer cells. The pathology report, which your physician will receive three to ten days after surgery, will indicate how many nodes were positive (in other words, had cancer cells in them).

An axillary lymph node dissection takes about an hour. The surgeon will need to exercise particular care to avoid injuring one of several important nerves that pass through this area.

Sentinel Node Biopsy
An important development in the staging of breast cancer is the increased use of a procedure called sentinel lymph node biopsy as an alternative to a full axillary node dissection. The principle is simple. As lymphatic fluid drains away from the breast, it first passes through certain lymph nodes located in key parts of the drainage system. These are called sentinel nodes, because they seem to act as gatekeepers. If the sentinel node is free of cancer, the odds are that there will be no cancer in the other nodes located downstream.

The procedure begins with the injection of a blue dye and/or of a small amount of radioactive material into the area near the tumor. The lymphatic fluid carries the dye to the first node in its path—the sentinel node. During surgery, the node is identified, removed and examined. If no cancer cells are found, a full dissection can be avoided.

This procedure takes longer, and requires a surgeon who is experienced in sentinel node biopsy, but it does help avoid the potentially serious complications such as damage to nerves and lymph ducts that can occur with the standard procedure.

Side Effects
After the surgery, a drain may be placed into the armpit to help remove blood and fluid that seeps out from the operated area.

Care for the incision is the same as for the lumpectomy or mastectomy: keeping it dry until the incision begins to heal and the drains are removed.

Damage to one or more of the nerves that pass through the axilla, either accidentally or because the injury was unavoidable, may result in long term numbness in the armpit area, or weakness in some of the shoulder muscles. Often the numbness will improve over several years, but the sensitivity will never be normal. The weakness can generally be overcome with time.

Lymphedema
One of the more serious problems that may arise after an axillary lymph node dissection is a condition called lymphedema. It's caused by scarring of lymph vessels in the underarm area after removal of the lymph nodes and their connecting ducts. The circulation of lymph fluid is slowed, causing swelling of the arm, limiting its function, and making the arm more prone to infection.

As many as 10-20% of women undergoing axillary lymph node dissection will develop lymphedema of the arm. The condition may occur soon after surgery, or years later. While it is difficult to predict who will develop lymphedema, there are several precautions that you must take to help you avoid it. These include avoiding over-using the arm, and protecting it from skin infections and injuries.

For women who develop lymphedema, the treatment will focus on lymph-draining massage, special compression bandages, and special exercises, all under the supervision of a qualified therapist.

 

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