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Preventing Recurrence is the Whole Point
Breast-Conserving Surgery
Minimally invasive lumpectomy
Surgical lumpectomy
Mastectomy
The mastectomy procedure
Recovery after mastectomy
Which Breast Cancer Surgery is Right for You?
Lymph Node Examination
Axillary lymph node dissection
Sentinel lymph node biopsy
Lymphedema

To give you the best chance for successful breast cancer recovery, all the cancer tissue must be removed through some type of surgery. Knowing the facts about surgical options puts you in position to choose the right procedure for you.

In the event you're diagnosed with breast cancer, some type of surgery probably will be required. Still, it's no time to panic. The whole aim is to remove the cancer in such a way as to prevent its recurrence, that is, to make sure it doesn't return.

Basically, there are two options in breast cancer surgery today. One is to remove just the tumor along with a safety margin of healthy breast tissue around it, leaving most of the breast. This is called breast-conserving surgery. It's usually followed by radiation therapy, where high-energy x-rays are used to destroy any cancer cells left behind. When preserving the breast isn't possible or is too risky, the only option is to remove the whole breast through a procedure called a mastectomy.

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If the tumor is small and located in one place in your breast, the best option might be breast-conserving surgery. The goal is to remove the whole tumor while saving as much of your breast as possible so it will still have a nice appearance. A margin of normal breast tissue around the tumor also is removed to make sure no cancer cells remain.

The technical name for this kind of surgery is partial mastectomy, but most people just call it lumpectomy. Sometimes large tumors are treated first with chemotherapy to shrink them before a lumpectomy is performed. Depending on how much tissue is removed, the procedure also might be called:

• Wide local excision—just the area around the lump is removed.
• Segmental mastectomy—a narrow segment of the breast is removed.
• Quadrantectomy—a one-quarter section of the breast is removed.

Breast-conserving surgery almost always requires additional treatment of the area with radiation therapy to kill any cancer cells that might have been left behind.

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If the tumor is very small, it's possible to take it out without surgery. For instance, using a core needle or vacuum-assisted biopsy system, small lesions can be removed along with a clear margin of healthy breast tissue. Essentially, the biopsy procedure becomes a lumpectomy.

New techniques also are being tested and used that allow doctors to "zap" small tumors. One method uses a laser beam to disintegrate (ablate) the cancer cells. Another relies on needles that are heated or frozen to extreme temperatures and then placed directly into the tumor to destroy the cancer cells.

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A surgical lumpectomy is similar to an excisional surgical biopsy. The surgery may be performed in a hospital operating room or outpatient surgery center and takes about an hour. It's done under local anesthesia, sometimes with sedation and you'll probably be able to go home the same day.

The surgeon will make a skin incision over the tumor area and remove the tumor with a small amount of surrounding healthy breast tissue. The tissue is sent to a pathologist who examines it under a microscope to make sure the margins are clear of tumor cells. If tumor cells are found along the edges, another lumpectomy will be done.

After the lumpectomy, you'll be taken to the recovery room for a short while and then discharged to go home. Unless you had an axillary lymph node dissection at the same time, you'll be able to resume regular activities soon. Normal side effects could include temporary pain, swelling and tenderness.

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Mastectomy is the surgical removal of the breast. The radical mastectomy was the mainstay of breast cancer treatment for centuries and involved removing the entire breast, the lymph nodes in the armpit and major muscles of the chest wall. But research in the 1980s proved there was no advantage in removing the chest muscles. For this reason, mastectomies done today involve the removal of breast tissue, but not muscles. The current trend is to save as much of the breast as possible through skin-sparing mastectomy. In this procedure the incision includes only the nipple, a narrow margin of skin around it and the skin right over the cancer. This leaves most of the breast skin intact so it can be used for a more natural-looking reconstruction.

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A mastectomy usually is done in a hospital under general anesthesia and takes a few hours. The surgeon will remove breast tissue extending from the collarbone to the edge of the ribs, and from the breastbone to the armpit. This tissue will be sent to the pathologist, who looks for signs of cancer beyond the breast. You probably will also have an axillary lymph node dissection-removal of lymph nodes from your armpit. Knowing whether or not there are cancer cells in these lymph nodes helps determine your future treatments.

If you've decided to have immediate reconstruction of your breast, the cosmetic surgeon will take over while you're asleep. The reconstruction can take anywhere from an hour to eight hours, depending on the reconstruction option chosen. Most women stay in the hospital for one night after a mastectomy and go home the next day. You might stay longer if you have a mastectomy and reconstruction at the same time.

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Once you're home, you'll probably feel more tired than usual for a while. But don't worry-fatigue is normal after any surgery. You'll also probably have arm muscle tightness and shoulder soreness. Avoid stretching or pulling until the drains are removed and you get your doctor's approval. Now's the time to lean on your support team for help.

Your goal is to regain full motion in your shoulder and arm as soon as possible. But make sure to get precise exercise instructions from your treatment team. Many groups-such as the YWCA Encore program-offer swimming, exercise and dance classes just for breast cancer patients. See the Resources page for other options.

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It's only natural to ask which is better, mastectomy or lumpectomy? The fact is, many research studies involving thousands of women and decades of follow-up show there's no difference in survival between the two procedures. Despite this, some physicians still only recommend mastectomy due to personal bias. If your doctor does so, make sure you know the reasons why. It's your breast and you have a right to ask.

Besides being equally effective, breast-conserving surgery offers other advantages over a mastectomy. Number one, you avoid the emotional trauma of losing your breast. Two, a good physical appearance of your breast can be expected. And last but not least, sensation in your nipple and skin usually is preserved.

That said, not all women can have breast-conserving surgery. For example, it wouldn't be recommended if:

• You have multiple tumors that are far apart in your breast.
  
• You previously had radiation treatment in the affected breast.
  
• The tumor is so big or your breast so small in comparison that your breast's appearance wouldn't be very good after the tumor is removed.
  
• The tumor is found to extend beyond the margins of the tissue removed during surgery.
  
• You're not willing to have radiation therapy—or there's no convenient radiation therapy facility near you.
  
• You prefer a mastectomy for peace of mind, since it lowers your fear of recurrence.
  
• You had a previous lumpectomy and re-excision (second lumpectomy) in the same breast but these didn't remove all the cancer.

Remember, you don't have to decide overnight. Take your time and gather the facts. Plus, you don't need to decide alone. Talk things over with your treatment team. Discuss the choices with your support team. And don't be afraid to get a second opinion. You can also discuss your choices with the Susan G. Komen Foundation, the American Cancer Society's Reach to Recovery program, WIN-ABCs Breast Buddy program and the Y-Me Breast Cancer organization. These groups will be happy to put you in touch with other women who had breast cancer surgery. It can really help to talk things over with someone who's been there before. See the Resources page for contact info.

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Whether you have a mastectomy or a lumpectomy, you might have a procedure to remove lymph nodes from your armpit. Seeing if cancer cells have spread to the lymph nodes helps determine the likelihood that cancer cells have spread to other parts of the body. Knowing this helps your treatment team decide what additional therapy is needed.

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An axillary lymph node dissection can be performed through a small incision in your armpit during a lumpectomy or through the main surgical incision in a mastectomy. The surgeon will remove a small pad of fat that contains 10 to 40 lymph nodes. It will be sent to the pathologist who slices and examines each node under a microscope, searching for the cancer cells. The pathology report will show how many nodes were positive (have cancer cells in them).

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Doctors now can see if cancer has spread to the lymph nodes without removing so many of them. In this procedure, the surgeon removes the sentinel nodes-the first lymph nodes into which any tumor would have to drain. These nodes are the ones most likely to contain cancer cells if it has started to spread. The pathologist examines these nodes and, if they do in fact contain cancer, the surgeon then will do a full axillary lymph node dissection. If the sentinel nodes are cancer-free, it's not likely the cancer has spread to other lymph nodes. That way, you avoid the potential side effects of full lymph node dissection, such as lymphedema. If you're thinking about having a sentinel biopsy, ask your treatment team if this is something they do regularly. It takes lots of experience to do it correctly.

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Lymphedema is a possible side effect of axillary lymph node dissection. It's caused by scarring of lymph vessels in the underarm area after removal of lymph nodes. This scarring slows circulation of lymph fluid so the arm swells, limiting movement and increasing the risk of infection.

About 1 out of 5 women who have an axillary lymph node dissection develop lymphedema. It can occur soon after surgery or years later. It's hard to predict who will develop lymphedema, but there are several precautions you can take. Avoid overuse of the arm and protect it from skin infection or injury. If your arm feels painful, tight or swollen after surgery, tell your doctor right away. He or she will recommend treatment that focuses on therapeutic massage, special compression bandages and physical therapy.

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