Surgical Options for Breast Cancer

The Breast Center Smilow Cancer Hospital 20 York Street, North Pavilion New Haven, CT 06510 Phone: (203) 200-2328 Fax: (203) 200-2075

SURGICAL OPTIONS

There are a number of surgical procedures available today for the treatment of breast cancer. You will likely have a choice and will need to make your own decision, in consultation with your specific surgeon, about the best option for you. We offer you a choice because the research on the treatment of breast cancer has clearly shown that the cure and survival rates are the same regardless of what you choose. The choices can be divided into breast conserving options (i.e. lumpectomy or partial mastectomy) or breast removing options (mastectomy). A procedure to evaluate your armpit (axillary) lymph nodes will likely occur at the same time as your breast surgery. This is done to help determine the likelihood that cells from your breast cancer have left the breast and spread (metastasized) to another more dangerous location. This information will be used to help decide about your need for chemotherapy or hormone blocking drugs after surgery.

PARTIAL MASTECTOMY (LUMPECTOMY) A partial mastectomy involves removing the cancer from your breast with a rim, or margin, of normal breast tissue. This allows the healthy noncancerous part of your breast to be preserved, and usually will not alter the sensation of the nipple. The benefit of this surgical choice is that it often preserves the cosmetics of the breast. Your surgeon will make a decision about the volume of tissue that needs removal in order to maximize the chance of clear margins as confirmed by our pathologist. Clear margins are required or additional surgery may be needed. If the cancer cannot be felt, a needle (or wire) localization with numbing medication will be done by one of our radiologists just prior to your operation to help guide the surgeon directly to your cancer.

Revised December 2017

Occasionally several wires may need to be placed in your breast to “bracket” an entire area of concern for excision (removal).

It is important to discuss with your surgeon the location of the scar and the likely cosmetic result or predicted breast deformity that may result from this procedure. Patients who choose this option will also require postoperative radiation therapy. If radiation therapy is not a good option for you, then the choice of a partial mastectomy may also not be a good one.

A partial mastectomy is usually done as an outpatient procedure, and can be done either under sedation or a general anesthesia. It is often done with a sentinel lymph node biopsy (see page 3 of this section).

MASTECTOMY A mastectomy is any procedure which involves removing the entire breast, usually including the nipple and the areola. There are a variety of ways that a mastectomy can be done depending upon the location and size of your cancer and whether you have decided to also have a reconstructive procedure. Choosing a reconstructive procedure does not affect your cancer treatment or survival rate. No muscle is removed and there should be no permanent disability from any of these procedures. The decision to have the mastectomy usually means that radiation treatments will not be needed. Your surgeon will help guide you through these decisions. The types of mastectomy include:

CONVENTIONAL MASTECTOMY: This procedure is usually done when there is no planned reconstruction. More skin is taken along with the breast tissue and nipple so that the skin will heal flat to the chest wall. After this, you may opt to either wear a prosthesis or have reconstruction some time in the future.

MODIFIED RADICAL MASTECTOMY: The entire breast and many of the lymph nodes under the armpit are removed. This is most commonly done when there is proof of cancer spread to these lymph nodes. Many different skin incisions can be used to accomplish this operation.

SKIN SPARING MASTECTOMY: This type of mastectomy leaves all of the breast skin, but removes the entire nipple and areola. Through a small central incision, all of the breast tissue is removed, and the breast is reconstructed at the same time.

Revised December 2017 NIPPLE SPARING OR AREOLAR SPARING MASTECTOMY: This type of mastectomy is a variation of a skin-sparing one that leaves the nipple and/or areola. This procedure is only appropriate in highly selected patients: either in a preventative (prophylactic) setting or when the cancer is very small and well away from the nipple.

All mastectomies are performed under general anesthesia and patients are admitted to the hospital. The type of reconstruction will determine the length of hospitalization. All patients having a mastectomy of any type will wake up with a small plastic drain coming out through their skin. This may be called a Jackson Pratt (JP) drain. There may even be several drains placed. These collect the fluid and blood that your body leaks into the area where the breast has been removed to help your wounds heal well. The drains are usually in place one to two weeks and will be removed in the office once they are draining less than 30 cc (1 oz) per day for two days in a row, and/or no more than three weeks from surgery. You will be taught how to empty and measure the drainage when you're in the hospital. A visiting nurse can also be arranged to help you with your drains.

LYMPH NODE SURGERY The most common place for breast cancer to spread to is to the lymph nodes under the arm. Removal of lymph nodes from under the arm is done to determine if the cancer has spread and to help stage the cancer. This is important in planning further treatments. The surgeon removes the nodes so that the pathologist can examine them under the microscope using special tests. Lymph node surgery is done either by removing a sentinel lymph node or nodes and/or by doing an axillary lymph node dissection.

SENTINEL LYMPH NODE BIOPSY A sentinel lymph node biopsy is a procedure which allows your surgeon to determine which lymph node or lymph nodes in your armpit are most at risk for having trapped a breast cancer cell. This procedure can be done at the same time as any of the breast cancer operations mentioned above, and is nearly always done if the cancer is invasive. In order to determine which lymph node(s) is draining your breast, your surgeon will inject one or two dyes into the skin of your breast after you are asleep. These dyes will be picked up by the lymph channels and will travel to the lymph nodes mapping the drainage of your individual breast. One dye is called technetium, which is radioactive. A handheld gamma probe (like a Geiger counter) will be used in the operating room to locate the correct lymph node. The other dye is deep blue in color, and can be seen trapped in a lymph node. Sometimes the lymph nodes will be sent directly to pathology while you're still asleep for a frozen section or rapid screening. This information may be used by your surgeon to determine whether additional nodes need to be removed. It is important to understand your surgeon's plan prior to your operation.

Revised December 2017 AXILLARY LYMPH NODE DISSECTION An axillary lymph node dissection is done when there are lymph nodes which can be easily felt in your axilla (armpit) or if you have a biopsy-proven positive lymph node pre-operatively. It may also be necessary if your sentinel lymph nodes show signs of cancer spread. A more extensive removal of lymph nodes will be done (usually between 10 and 20 nodes) and a drain will be placed through your skin. Most patients will stay overnight after this procedure.

All lymph node procedures carry some risk of arm swelling called lymphedema. For patients undergoing sentinel lymph node biopsy, the risk is much lower than for women needing axillary lymph node dissection. Although there is no way to absolutely prevent lymphedema, certain factors are known to increase its risk. These include obesity, postoperative infections, and radiation after lymph node removal. There are some techniques to minimize the risk of lymphedema including exercise and weight lifting.

Revised December 2017