Surgery for Breast Cancer
Nearly all women with breast cancer will undergo some kind of surgery as part of their treatment and/or diagnosis. The extent of surgery for breast cancer may range from removal of only a small piece of breast tissue to removing one or both breasts, including underarm (axillary) lymph nodes. The purpose of surgery in the management of breast cancer is to:
- Obtain a tissue sample for determining an accurate diagnosis.
- Determine the stage of the cancer and whether additional treatment is necessary.
- Treat the cancer locally.
Surgery is local therapy that can remove cancer cells in or near the breast but cannot treat breast cancer cells that have spread to other locations in the body. Cancer cells that have spread are called micrometastases and additional systemic treatment using chemotherapy and/or hormonal therapy is required to treat these areas of cancer. The information obtained during surgery and from other tests determines the likelihood that the cancer has spread and whether additional systemic treatment is necessary.
The surgical procedures utilized in the management of breast cancer include:
The following is a general overview of the role of surgery in the management of breast cancer. Surgery may be the primary treatment for some breast cancers, but for many women, multi-modality treatment, which utilizes two or more treatment techniques, is increasingly recognized as the best approach for improving a patient’s chance of cure or prolonging survival. In some cases, participation in a clinical trial utilizing new, innovative therapies may provide the most promising treatment. Circumstances unique to each patient’s situation may influence how these general treatment principles are applied. The potential benefits of multi-modality care, participation in a clinical trial, or standard treatment must be carefully balanced with the potential risks. The information on this website is intended to help educate patients about their treatment options and to facilitate a mutual or shared decision-making process with their treating cancer physician.
Surgical Procedures Used in the Management of Breast Cancer
The type of surgery that a patient with breast cancer undergoes depends largely on the size and location of the cancer, the breast size, feasibility of breast reconstruction, and how important breast preservation is to the patient.
A typical biopsy involves the surgical removal of a mass or “lump” of abnormal cells that can be evaluated under a microscope in order to provide an accurate diagnosis.
A simple (total) mastectomy involves the removal of the entire breast, but not the axillary (underarm) lymph nodes.
There are also different degrees of mastectomy, including the following:
- Partial (segmental) mastectomy is the removal of one-quarter or more of the breast and the lining over the chest wall. This may include removal of axillary lymph nodes. Reconstruction may be difficult after a partial mastectomy because of the drastic change to the contour and size of the breast after the procedure.
- Radical mastectomy is an aggressive therapy that consists of extensive removal of the entire breast, the lymph nodes under the arm in the axilla and the chest wall muscles under the breast.
- Modified radical mastectomy involves the removal of the entire breast and the lymph nodes in the axilla under the arm.
Removal of the cancer and a portion of surrounding tissue is called a lumpectomy. Because a lumpectomy alone is associated with a higher rate of cancer recurrence than mastectomy, patients who elect to have a lumpectomy are also treated with radiation therapy. This combination of lumpectomy and radiation therapy is called breast-conserving therapy.
A clinical trial has shown that breast conserving therapy is associated with a lower risk of local cancer recurrence compared to lumpectomy alone.
This trial involved 1851 women with breast cancer who underwent either total mastectomy (removal of the entire breast), lumpectomy alone, or lumpectomy and breast irradiation showed that the patients who underwent lumpectomy alone experienced significantly more breast cancer recurrences (39%) than those who also received radiation therapy (14%).
However, no significant differences were observed among the three groups of women with respect to disease-free survival, distant-disease–free survival, or overall survival.1
Two other clinical trials have also shown that breast conserving therapy and mastectomy produce identical long-term survival.
A clinical trial conducted by the National Cancer Institute evaluated mastectomy versus breast conserving therapy (lumpectomy, axillary lymph node dissection and radiation therapy) in 237 women with stage I or II breast cancer. Approximately 18 years after treatment, there was no detectable difference in overall survival, disease-free survival, or incidence of cancer in the contralateral (opposite) breast between patients treated with mastectomy and those treated with breast conserving therapy.2
Researchers evaluated the outcomes of 701 women 20 years after they underwent either mastectomy or breast conserving therapy. The women in this study had breast cancer that was 2 cm or less in size. While the women who underwent breast-conserving therapy experienced significantly more cancer recurrences (8.8% vs 2.3% for patients who underwent mastectomy), there was no difference between the two groups in long-term survival, spread of cancer, second cancers, or a cancer in the opposite breast.3
Evaluation of early stage breast cancer typically includes a biopsy and removal of axillary (under arm) lymph nodes in order to determine the stage of the cancer and whether the cancer has spread outside the breast. This is important because when axillary lymph nodes have cancer, more aggressive treatment is required in order to achieve the best chance for cure.
Axillary lymph node dissection: For over 30 years, the standard of practice for evaluating lymph nodes has been a surgical procedure called an axillary lymph node dissection. This procedure involves the removal of approximately 10-25 axillary lymph nodes and may be performed during the initial surgery or as a separate procedure.
Although the performance of an axillary lymph node dissection has helped doctors and patients determine optimal treatment, removal of the axillary lymph nodes is commonly associated with chronic side effects. In addition to the risk of infection and other local complications of surgery, an axillary lymph node dissection can result in lymphedema, which is a buildup of lymph fluid in the tissues just under the skin. As blood circulates through the body and travels into smaller and smaller vessels, excess fluid, protein and other substances are pushed out into the surrounding tissue. This substance is called lymph fluid. Under normal circumstances, lymph fluid is removed from the tissues by the lymph system, which is a series of vessels and organs that moves the fluid back toward the heart and filters it through lymph nodes. Lymph nodes are specialized structures that are composed of white blood cells and serve to “clean” the lymph fluid of bacteria or other contaminants. When lymph nodes are removed, the lymph fluid builds up in the tissues. This build up of fluid may result in chronic swelling, numbness, limited shoulder motion, and pain to the arm on the side of the body that the surgery was performed.
For more information on managing lymphedema, go to Managing Side Effects of Treatment and Prevention.
Doctors have long desired a way to evaluate axillary lymph nodes that would result in less discomfort for patients. A sentinel lymph node biopsy is one way to accurately evaluate axillary lymph nodes and is associated with fewer side effects than axillary lymph node dissection.
Sentinel lymph node biopsy: A new approach to evaluating axillary lymph nodes for spread of cancer is called a sentinel lymph node biopsy. This procedure involves removing a single lymph node, called the sentinel node, which is the first lymph node to collect excess fluid surrounding the cancer. Prior to surgery, blue dye is injected near the cancer. The dye drains from the area containing the cancer into the nearby lymph nodes, through the sentinel node. The node containing the dye is removed during surgery and evaluated under a microscope to determine whether cancer has spread. Sentinel lymph node biopsy is becoming the standard approach for determining whether cancer has spread to the axillary lymph nodes.4
Researcher now indicates that sentinel node biopsy appears to be just as effective in determining cancer spread to axillary lymph nodes as an axillary lymph node dissection, and results in fewer side effects in patients with early stage breast cancer.5 A clinical trial compared the outcomes of patients treated with sentinel lymph node biopsy compared to axillary node dissection. This trial involved 516 patients with breast cancer that was no greater than 2 centimeters in diameter. Results showed that sentinel lymph node biopsy was accurate approximately 97% of the time. Nearly 4 years following therapy, cancer recurrences, spread of cancer, or a possible second breast cancer occurred in 10 patients in the sentinel node group, compared with 15 patients who underwent axillary lymph node dissection. Physical examination showed that no patients who were treated with sentinel node biopsy have developed cancer spread to the axillary lymph nodes. Patients treated with sentinel node biopsy only suffered from less pain, numbness, arm swelling and had greater arm movement than those who underwent axillary node dissection.
Breast reconstruction surgery has become increasingly refined and can be successfully accomplished in almost all women treated with mastectomy. The goal of breast reconstruction surgery is to create a breast that matches the opposite breast. This can be accomplished by using a breast implant alone, by actually reconstructing the breast with the patient’s own tissue, or by utilizing a combination of these two techniques. Breast reconstructive surgery can be performed immediately after mastectomy or it can be delayed for some time. If chemotherapy treatment or if radiation is to be given to the chest wall, many doctors prefer delayed reconstruction so that the healing of the reconstructed breast is not impaired.
The two techniques commonly used in breast reconstruction are:
- Synthetic breast implants
- Autologous reconstruction, which utilizes the patient’s own tissue
It is recommended that patient include a plastic surgeon in their team of physicians as early in their treatment as possible so that their chosen method of breast reconstruction can be incorporated into the overall treatment plan.
Breast implants: The simplest method of reconstructing the breast is with the use of synthetic implants. During this procedure, an implant that closely approximates the size and shape of the other breast is inserted through the mastectomy incision, under the pectoralis major (chest muscle). Implant surgery is relatively simple and can be performed at the time of initial surgery or delayed until after all treatment is completed. If performed at the time of mastectomy, implant surgery adds an additional 30 minutes or approximately 1½ hours is required if it is delayed and performed as a separate surgical procedure. Recovery from implant surgery is typically quicker after immediate reconstruction than after delayed reconstruction.
The procedure of implant surgery usually requires the surgeon to insert a temporary tissue expander under the pectoralis muscle in order to stretch the muscle and the skin over the chest wall. The tissue expander contains a valve-like opening or port through which small amounts of saline (salt water) can be injected. Every week or two, saline is injected into the expander until it is inflated to a size slightly larger than the implant. Because the expansion occurs gradually, there is minimal pain or discomfort associated with the procedure. When the tissue has been expanded to the point where it can accommodate the breast implant, the expander is replaced with the permanent implant.
If there is not enough skin to cover the implant, the muscle over the chest wall has been removed, or the skin has been damaged by radiation and cannot be stretched, the surgeon can remove a fan-shaped section of muscle and skin from the back that remains attached to a portion of skin or pedicle. The pedicle contains the blood supply for the flap and this procedure is referred to as the latissimus dorsi flap. The flap is tunneled under the skin and pulled out through an opening in the chest where it is sutured in place over the mastectomy site. The implant can then be placed under the muscle to complete the reconstruction. The latissimus dorsi flap procedure is more complicated than a simple implant insertion. It leaves a scar on the woman’s back and requires a longer recuperation. There is a potential for shoulder problems because a portion of the muscle required for shoulder motion has been removed. However, this procedure usually creates a better result than an implant, especially in women with large breasts or those who have received previous radiation treatment. The risks and benefits of the various implant procedures should be carefully discussed with your surgeon in order to achieve the best results.
There are currently two types of implants available in the United Statesfor breast reconstruction, silicone gel implants and saline-filled implants.
Silicone gel implants have generated a fair amount of controversy regarding their safety because of the question as to whether they can trigger certain connective tissue and autoimmune diseases. In 1992, the Food and Drug Administration restricted the use of silicone implants in order to evaluate whether they were indeed associated with autoimmune conditions. Patients who desired reconstructive surgery with silicone gel implants after mastectomy were given access to clinical trials. Studies completed thus far have failed to show an increased risk of autoimmune disease among women with silicone implants, although the follow-up is relatively short. It is interesting to note that other countries did not take silicone implants off the market.
Saline-filled implants have not been associated with any risks. If saline implants leak, the saline is absorbed into the body and is harmless. Many women prefer the silicone gel implants to the saline filled implants because the silicone feels more like breast tissue.
Autologous reconstruction of the breast: Autologous reconstruction of the breast utilizes the body’s own tissue to build a mound that feels and appears like a natural breast. Autologous breast reconstruction is major surgery compared to breast implants. It requires several hours in the operating room and is associated with the complications of any major surgery. Two major surgical techniques are currently used for autologous reconstruction of the breast. These are the TRAM flap (transverse rectus abdominis myocutaneous) and the free flap.
The TRAM flap procedure utilizes tissue taken from the woman’s abdomen. Tissue containing a section of the skin, the underlying fat, and a portion of the abdominal muscle is excised except for one or two pedicles of tissue, which remain attached to the abdomen. The remaining attached tissue serves as the blood supply for the flap that will be used to reconstruct the new breast. The flap is tunneled under the abdominal wall to the chest and then rotated to fit the mastectomy wound. The smooth edges are made by attaching the edges of the breast incision to the flap. The TRAM flap procedure thus creates a breast with a natural texture very similar to a normal breast. Side effects associated with the TRAM flap procedure may include abdominal weakness and an increased risk of developing an abdominal hernia, which is a bulging of the internal tissues through an area of weakness in the abdominal wall. Because of these potential problems, modifications of the TRAM flap technique have been developed. These newer techniques limit the amount of muscle which is removed with the flap.
A free flap , or a free TRAM, utilizes an island of fat and skin that is entirely removed from the abdomen. Since the fat and skin are completely excised from the abdomen, a new blood supply to the tissue must be provided. This requires a surgeon who specializes in microsurgery to attach the blood vessel supply in the flap to those in the chest wall. This procedure is technically more difficult to perform than the TRAM flap, but less muscle is removed. An even more complicated technique called a Deep Inferior Epigastric Perforator (DIEP) flap removes no muscle.
Reconstructive surgery utilizing breast implants, autologous reconstruction of the breast, and other new surgical techniques will continue to be developed and refined in order to produce the best breast reconstruction for women desiring this procedure. Each of the currently available techniques has advantages and disadvantages that will be unique to each patient’s circumstance. Individuals deciding to undergo breast reconstruction surgery should discuss these options with a qualified plastic surgeon in order to ensure the result they achieve is satisfactory.
Strategies to Improve Treatment
The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. Future progress in the surgical treatment of breast cancer will result from the continued evaluation of new treatments in clinical trials. Participation in a clinical trial may offer patients access to better treatments and advance the existing knowledge about treatment of this cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. Areas of active investigation aimed at improving the surgical treatment of breast cancer include the following:
Skin-sparing mastectomy:A new mastectomy procedure is being developed at several surgical oncology programs around the United States. A skin-sparing mastectomy removes the entire breast tissue, similar to a mastectomy, but leaves the skin covering the breast intact and capable of housing fat and muscle from other parts of the body. The procedure is more difficult than a traditional mastectomy in that the surgeon must make a small incision in the breast about the size of a half-dollar and then carefully remove all the breast tissue inside the breast. When done correctly, an empty envelope of skin exists that can than be filled with fat and muscle taken from the woman’s back or abdomen. Because the surgery uses fat from the woman’s own body, the newly constructed breast behaves just like the companion breast when weight is gained or lost.
3 Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. The New England Journal of Medicine 2002;347;1227-1232.
4 Edge SB, Niland JC, Bookman MA, et al. Emergence of sentinel node biopsy in breast cancer as standard-of care in academic comprehensive cancer centers. Journal of the National Cancer Institute 2003;95:1514-1521.
5 Veronesi U, Paganelli G, Viale G, et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. The New England Journal of Medicine 2003;349:546-553.
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