Breast Surgery and Oncology Department

Breast Cancer Surgery

Most women with breast cancer have some type of surgery as part of their treatment. There are different types of breast surgery, and it may be done for different reasons, depending on the situation and patients’ choice.

• The goal of surgery in breast cancer is to remove radically cancer and find out whether the cancer has spread to the lymph nodes under the arm (sentinel lymph node biopsy or axillary lymph node dissection) in early breast cancer patients or after neoadjuvant chemotherapy. 
• What type of surgery will be proposed to the patient, depend on cancer features, extent of disease, patient medical history, expected cosmetic result. In all cases, all options are discussed with patient before surgery.

 There are two main types of surgery to remove breast cancer:

• Breast-conserving surgery (also called a lumpectomy, quadrantectomy) – in this case only affected part of the breast is removed. The goal is to remove the cancer with some “normal” breast tissue – to have “free margins”. How much of the breast must be removed depends on the size, type, and location of the tumor and other factors.
• Mastectomy – a surgery in which the entire breast is removed, including all of the breast tissue and sometimes other nearby tissues. There are several different types of mastectomies: simple mastectomy, subcutaneous and skin-sparing mastectomy, and modified mastectomy. Some women may need a double mastectomy, in which both breasts are removed, - when breast cancer in both breasts is diagnosed, or in case of proven BRCA or other breast cancer high risk related gene mutations.

Choosing between breast-conserving surgery and mastectomy

Many women with early-stage cancers can choose between breast-conserving surgery (BCS) and mastectomy. The main advantage of BCS is that a woman keeps most of her breast, and in most cases esthetical result is good with all psychological consequences. But in most cases she will also need radiation. Women who have mastectomy for early stage cancers are less likely to need radiation. Also, if we know that radiotherapy cannot be performed (f.e. patient was treated with radiotherapy because of Hodgkin lymphoma, or previous breast cancer), possibility of mastectomy must be discussed.

BCS is advised when we expect to remove cancer and have acceptable cosmetic result. It depends on tumor and breast size ratio.

Mastectomy is proposed in case of presence of breast cancer high risk related gene mutation (f.e. BRCA mutations).

In all cases when mastectomy is chosen like method of surgery, reconstruction options should be discussed with the patient.

Some women might be worried that having a less extensive surgery might raise their risk of the cancer coming back. But the fact is, mastectomy does not give any better chance of long-term survival or a better outcome from treatment. This was proven by studies following thousands of women for more than 20 years: BCS with radiation and mastectomy are equal in survival rates.

Extent of surgery (BCS versus mastectomy) does not change need of chemotherapy. Need of chemotherapy is based on tumor type and extent of disease.

Breast-conserving Surgery (Lumpectomy)

Breast-conserving surgery (BCS) is an operation to remove the cancer with some surrounding healthy tissue and some axillaries lymph nodes, and preserve as much normal breast as possible. How much of the breast should be removed depends on the tumor size, type and location, and also from other factors. Breast-conserving surgery is sometimes called lumpectomy, quadrantectomy, or partial mastectomy.

Not all women with breast cancer are candidates for BCS. Sometimes, even in Stage I patients, we observe malignant calcification in whole breast, or there can be multifocal breast cancer, when foci of cancer are located in different parts of breast,- in this case even in Stage I patients mastectomy may be a choice.

Studies show that choosing BCS (plus radiation) over mastectomy does not affect a woman’s chances of long-term survival.

Breast-conserving surgery (BCS) is a good option for many women with early-stage cancers. The main advantage is that a woman keeps most of her breast. However, she will in most cases also need radiation therapy.

If patient is pregnant, depending on pregnancy stage, mastectomy is proposed, because radiation therapy cannot be started immediately (to avoid risking harm to the fetus).

In case of presence of breast cancer high risk related mutations, mastectomy will be advised.

Patient with serious connective tissue diseases such as scleroderma or lupus are advised to have mastectomy because especial sensitivity to the radiation therapy.

Inflammatory breast cancer is indication for mastectomy after neoadjuvant chemotherapy because of high risk of local relapse.

In case of BCS, surrounding tissue, resection “margins” are examined by a doctor, called a pathologist, with use a microscope. If the pathologist finds no cancer cells at any of the edges of the removed tissue, it is said to have negative or clear margins. Sometimes breast cancer cells spread past what the imaging studies are able to show.So if microscopic cancer cells are found at the edges of the tissue, it is said to have positive margins.

In case of “positive margins”, remains possibility that some cancer cells may still be in the breast after surgery, so the surgeon may need to go back and remove more breast tissue. This operation is called a re-excision. If cancer cells are still found at the edges of the removed tissue after the second surgery, a mastectomy may be needed.

It is very important discuses extent of surgery, possible cosmetic result and your expectation with your surgeon before surgery. Even after BCS, if breasts look very different after surgery, it may be possible to have some type of reconstructive surgery or to have an unaffected breast reduced to make the breasts more symmetrical (even). It may even be possible to have this done during the initial surgery.

Wire localization to guide surgery

Sometimes, if the cancer in your breast can’t be felt, is hard to find, and/or is difficult to get to, a mammogram or ultrasound may be used to place a wire in the cancerous area to guide the surgeon to the right spot. This is called wire localization. Usually, wire localization is performed under ultrasound guidance. If lesion can be not visualized by ultrasound, localization under x-ray guidance may be used. Rarely, a MRI might be used if the mammogram or ultrasound localization are not successful.  

After your breast is numbed, a mammogram or ultrasound is used to guide a thin hollow needle to the abnormal area. Once the tip of the needle is in the right spot, a thin wire is put in through the center of the needle. A small hook at the end of the wire keeps it in place. The needle is then taken out. The surgeon uses the wire as a guide to the part of the breast to be removed.

The surgery done as part of the wire localization may be enough to count as breast conserving surgery if the margins are negative. If cancer cells are found at the edge of the removed tissue (also called a positive margin), repetitive surgery may be required.  

It should be noted that a wire-localization procedure is sometimes used to perform a surgical biopsy of a suspicious area in the breast to determine if it is cancer or not, also in some cases of breast surgery for impalpable benign pathology. 

Mastectomy

Mastectomy is a way of treating breast cancer by removing the entire breast through surgery. It’s often done when a woman cannot or doesn’t want be treated with breast-conserving surgery (lumpectomy).

Types of mastectomies

There are several different types of mastectomies, based on how the surgery is done and how much tissue is removed.

Simple (or total) mastectomy.  In this procedure, the surgeon removes the entire breast, including the nipple, areola, and skin. Some underarm lymph nodes may or may not be removed depending on the situation. 

Skin-sparing mastectomy. In this procedure, most of the skin over the breast is left intact. Only the breast tissue, nipple and areola are removed. This type of mastectomy solves skin deficiency question in case of reconstruction.  Implants, expanders or tissue flaps from other parts of the body can be used for reconstruction, - patient can choose. Skin-sparing mastectomy is recommended in locally extend disease, in case when cancer is near to nipple-areola complex.  This type of surgery is not suitable for larger tumors or those that are close to the surface of the skin.

Nipple-sparing mastectomy. In this procedure, the breast tissue is removed, but the breast skin and nipple are left in place. This type of surgery is advised when cancer is locally extended, but distance between cancer and nipple-areola complex is safe, according to some authors, more than 2 cm radiologically. It is more often an option for women who have a small, early-stage cancer near the outer part of the breast, with no signs of cancer in the skin or near the nipple.

Retroareolar frozen section – investigation of tissue beneath nipple under microscope in operating theatre is recommended for such type of surgery. If tissue beneath nipple is not affected, nipple-areola complex can be left. Nipple sparing mastectomy can be followed by immediate or delayed breast reconstruction.

There are still some issues with nipple-sparing surgeries. Afterward, the nipple may not have a good blood supply, causing the tissue to shrink or become deformed. Because the nerves are also cut, there often may be little or no feeling left in the nipple. For women with larger breasts, the nipple may look out of place after the breast is reconstructed. This type of surgery is optimal in women with small to medium sized breasts. This procedure leaves less visible scars, but if it isn't done properly, it can leave behind more breast tissue than other forms of mastectomy.

Modified radical mastectomy. A modified radical mastectomy combines a simple mastectomy with the removal of the lymph nodes under the arm (called an axillary lymph node dissection).

Radical mastectomy. In this extensive operation, the surgeon removes the entire breast and axillary (underarm) lymph nodes (Madden mastectomy).

If cancer penetrates muscles beneath the breast, pectoral muscles can be removed (Halsted mastectomy).

Double mastectomy. If a mastectomy is done on both breasts, it is called a double (or bilateral) mastectomy. When this is done, it is often a risk-reducing surgery for women at very high risk for getting breast cancer, f.e. those with a BRCA gene mutation. Most of these mastectomies are simple mastectomies, but some may be nipple-sparing. Double mastectomy can be an option in case of bilateral breast cancer.

Who should get a mastectomy?

Many women with early-stage cancers can choose between breast-conserving surgery (BCS) and mastectomy. Mastectomy does not give any better chance of long-term survival or a better outcome from treatment comparing with BCS. Studies following thousands of women for more than 20 years show that when BCS can be done with radiation, doing a mastectomy instead does not provide any better chance of survival.

In some cases mastectomy is likely to be the best choice. For example, mastectomy might be recommended if the patient:

• Is  unable to have radiation therapy
• Would prefer a more extensive surgery instead of having radiation therapy
• Have had the breast radiation therapy in the past
• Have already had BCS along with re-excision(s) that did not completely remove the cancer
• Have two or more cancer-affected areas in the same breast that are not close enough to be removed together without changing the look of the breast too much
• Have a larger tumor (greater than 5 cm), or a tumor that is large relative to your breast size
• Is  pregnant and would need radiation therapy while still pregnant (risking harm to the fetus)
• Have a genetic factor such as a BRCA mutation, which might increase your chance of a second cancer
• Have a serious connective tissue disease such as scleroderma or lupus, which may make patient especially sensitive to the radiation therapy
• Have inflammatory breast cancer

For women who are worried about breast cancer recurrence, it is important to understand that having a mastectomy instead of breast-conserving surgery plus radiation only lowers your risk of developing a second breast cancer in the same breast. It does not lower the chance of the cancer coming back in other parts of the body.

After having a mastectomy a woman might want to consider having the breast mound rebuilt to restore the breast's appearance. This is called breast reconstruction. Although each case is different, most mastectomy patients can have reconstruction. Reconstruction can be done at the same time as the mastectomy (immediate reconstruction) or sometime later (delayed reconstruction).

If you are thinking about having reconstructive surgery, it’s a good idea to discuss it with your surgeon and a plastic surgeon before your mastectomy. This allows the surgical teams to plan the treatment that’s best, even if you wait and have the reconstructive surgery later. Some women choose not to have reconstructive surgery. Wearing breast prosthesis (breast form) is an option for women who want to have the contour of a breast under their clothes without having surgery. Some women are also comfortable with just ‘going flat,’ especially if both breasts were removed.

Surgery to remove axilla lymph nodes

If you have been diagnosed with breast cancer, it’s important to find out how far the cancer has spread. To help find out if the cancer has spread beyond the breast, one or more of the lymph nodes under the arm (axillary lymph nodes) are removed and checked under a microscope. This is an important part of staging. When the lymph nodes contain cancer cells, there is a higher chance that cancer cells have also spread to other parts of the body. Treatment decisions will often depend on whether cancer is found in the lymph nodes.

Lymph node removal can be done in different ways, depending on whether any lymph nodes are enlarged, how big the breast tumor is, and other factors.

Lymph nodes may be removed either as part of the surgery to remove the breast cancer or as a separate operation.

The two main types of surgery to remove lymph nodes are:

• Sentinel lymph node biopsy (SLNB) – a procedure in which the surgeon removes only the lymph node(s) under the arm to which the cancer would likely spread first. Removing only one or a few lymph nodes lowers the risk of side effects from the surgery. Sentinel nodes can be recognized using dye or radioactive agent injections, or both.
• Axillary lymph node dissection (ALND) – a procedure in which the surgeon removes many (usually 10-20) lymph nodes from under the arm. ALND is not done as often as it was in the past, but it might still be the best way to look at the lymph nodes in some situations.

If any of the lymph nodes under the arm or around the collar bone are swollen, they may be checked for cancer spread directly with a needle biopsy (either a fine needle aspiration or a core needle biopsy). If cancer is found in the lymph node, more nodes will need to be removed during an axillary lymph node dissection. Even if the nearby lymph nodes are not enlarged, they will still need to be checked for cancer.

Sentinel lymph node biopsy (SLNB)

In a sentinel lymph node biopsy (SLNB), the surgeon finds and removes the first lymph node(s) to which a tumor is likely to spread (called the sentinel nodes). To do this, the radioactive substance and/or a blue dye will be injected into the affected breast, at the area around cancer, or the area around the nipple. Lymphatic vessels will carry these substances along the same path that the cancer would likely take. The first lymph node(s) the dye or radioactive substance travels to will be the sentinel node(s).

After the substance has been injected, the sentinel node(s) can be found either by using a special device to detect radioactivity in the nodes, or by looking for nodes that have turned blue. To double check, both methods are often used. The surgeon cuts the skin over the area and removes the node(s) containing the dye or radioactivity.

The few removed lymph nodes are then checked closely for cancer cells by a doctor called a pathologist. This is sometimes done during the surgery. This way, if cancer is found in the sentinel lymph node(s), the surgeon may go ahead with a full axillary dissection (ALND) to remove more lymph nodes while you are still on the operating table. If no cancer cells are seen in the node(s) at the time of the surgery, or if the sentinel node(s) are not checked by a pathologist at the time of the surgery, they will be examined more closely over the next several days.

If cancer is found in the sentinel node(s) later, the surgeon may recommend a full ALND at a later time to check more nodes for cancer. Recently, however, studies have shown that in some cases it may be just as safe to leave the rest of the lymph nodes behind. This is based on certain factors, such as the size of the breast tumor, what type of surgery is used to remove the tumor, and what treatment is planned after surgery. Based on the studies that have looked at this, skipping the ALND may be an option for women with tumors 5 cm or smaller who are having breast-conserving surgery followed by radiation. For some women who have had mastectomy and will also have radiation, skipping the ALND might be an option.

If there is no cancer in the sentinel node(s), it's very unlikely that the cancer has spread to other lymph nodes, so no further lymph node surgery is needed.

Although SLNB has become a common procedure, it requires a great deal of skill.

Axillary lymph node dissection (ALND)

In this procedure, anywhere from about 10 to 40 (though usually less than 20) lymph nodes are removed from the area under the arm (axilla) and checked for cancer spread. ALND is usually done at the same time as a mastectomy or breast-conserving surgery (BCS), but it can be done in a second operation. This was once the most common way to check for breast cancer spread to nearby lymph nodes, and it is still sometimes needed. For example, an ALND may be done if a previous biopsy has shown one or more of the underarm lymph nodes have cancer cells. 

Breast reconstruction after surgery

Any women undergoing surgery for breast cancer may have the option of breast reconstruction. In the case of a mastectomy, a woman might want to consider having the breast mound rebuilt to restore the breast’s appearance after surgery. In some breast-conserving surgeries, a woman may consider having fat grafting in the affected breast to correct any dimples left from the surgery. The options will depend on each woman’s specific situation.

There are several types of reconstructive surgery, although options may depend on medical situation and personal preferences. Breast reconstruction can be done at the same time as the breast cancer surgery (immediate reconstruction) or at a later time (delayed reconstruction).

It is better to discuss esthetical moments and possibility of reconstruction with your breast surgeon and a plastic surgeon before your initial surgery. This gives the surgical team time to plan out the treatment options that might be best for you, even if you plan to have the reconstructive surgery later.

Surgery for advanced breast cancer

Although surgery alone is very unlikely to cure breast cancer that has spread to other parts of the body, it can still be helpful in some situations, either as a way to slow the spread of the cancer, or to help prevent or relieve symptoms from it. For example, surgery might be used:

• When the breast tumor is causing an open wound in the breast (or chest)
• To treat a small number of areas of cancer spread (metastases) in a certain part of the body, such as the brain
• When an area of cancer spread is pressing on the spinal cord
• To treat a blockage in the liver
• To provide relief of pain or other symptoms

If your doctor recommends surgery for advanced breast cancer, it’s important that you understand its goal—whether it’s to try to cure the cancer or to prevent or treat symptoms.