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.
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
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
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.
You'll probably be instructed not to eat or drink after midnight
on the night 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
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
Breast needle localization X-ray
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
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
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
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
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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
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.
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
• 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
• 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,
• 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.
In a skin-sparing mastectomy only the nipple and areola are removed
Drains collect fluid from the surgical site
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.
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
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
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
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.
After the surgery, a drain may be placed into the armpit to help remove
blood and fluid that seeps out from the operated area.
Area of numbness after axillary dissection
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
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.
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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