Breast Surgery

What is cancer?

The body is made up of hundreds of millions of living cells. Normal body cells grow, divide, and die in an orderly fashion. During the early years of a person’s life, normal cells divide faster to allow the person to grow. After the person becomes an adult, most cells divide only to replace worn-out or dying cells or to repair injuries.

Cancer begins when cells in a part of the body start to grow out of control. There are many kinds of cancer, but they all start because of out-of-control growth of abnormal cells.

Cancer cell growth is different from normal cell growth. Instead of dying, cancer cells continue to grow and form new, abnormal cells. Cancer cells can also invade (grow into) other tissues, something that normal cells cannot do. Growing out of control and invading other tissues are what makes a cell a cancer cell.

Cells become cancer cells because of damage to DNA. DNA is in every cell and directs all its actions. In a normal cell, when DNA gets damaged the cell either repairs the damage or the cell dies. In cancer cells, the damaged DNA is not repaired, but the cell doesn’t die like it should. Instead, this cell goes on making new cells that the body does not need. These new cells will all have the same damaged DNA as the first cell does.

People can inherit damaged DNA, but most DNA damage is caused by mistakes that happen while the normal cell is reproducing or by something in our environment. Sometimes the cause of the DNA damage is something obvious, like cigarette smoking. But often no clear cause is found.

In most cases the cancer cells form a tumor. Some cancers, like leukemia, rarely form tumors. Instead, these cancer cells involve the blood and blood-forming organs and circulate through other tissues where they grow.

Cancer cells often travel to other parts of the body, where they begin to grow and form new tumors that replace normal tissue. This process is called metastasis. It happens when the cancer cells get into the bloodstream or lymph vessels of our body.

No matter where a cancer may spread, it is always named for the place where it started. For example, breast cancer that has spread to the liver is still called breast cancer, not liver cancer. Likewise, prostate cancer that has spread to the bone is metastatic prostate cancer, not bone cancer.

Different types of cancer can behave very differently. For example, lung cancer and breast cancer are very different diseases. They grow at different rates and respond to different treatments. That is why people with cancer need treatment that is aimed at their particular kind of cancer.

Not all tumors are cancerous. Tumors that aren’t cancer are called benign. Benign tumors can cause problems – they can grow very large and press on healthy organs and tissues. But they cannot grow into (invade) other tissues. Because they can’t invade, they also can’t spread to other parts of the body (metastasize). These tumors are almost never life threatening.

General types of treatment

Breast cancer treatments can be classified into broad groups, based on how they work and when they are used.

Local versus systemic therapy

Local therapy is intended to treat a tumor at the site without affecting the rest of the body. Surgery and radiation therapy are examples of local therapies.
Systemic therapy refers to drugs which can be given by mouth or directly into the bloodstream to reach cancer cells anywhere in the body. Chemotherapy, hormone therapy, and targeted therapy are systemic therapies.

Adjuvant and neoadjuvant therapy

Patients who have no detectable cancer after surgery are often given adjuvant (additional) systemic therapy. Doctors believe that in some cases cancer cells may break away from the primary breast tumor and begin to spread through the body by way of the bloodstream even in the early stages of the disease. These cells can’t be felt on a physical exam or seen on x-rays or other imaging tests, and they cause no symptoms. But they can go on to become new tumors in other organs or in bones. The goal of adjuvant therapy is to kill these hidden cells.

Not every patient needs adjuvant therapy. Generally speaking, if the tumor is larger or the cancer has spread to lymph nodes, it is more likely to have spread through the bloodstream. But there are other features, some of which have been previously discussed, that may determine if a patient should get adjuvant therapy.

Some patients are given treatment, such as chemotherapy or hormone therapy, before surgery. The goal of this treatment is to shrink the tumor in the hope it will allow a less extensive operation to be done. This is called neoadjuvant therapy.

Surgical Diagnosis of Breast Cancer

A breast biopsy is the removal of breast tissue to examine it for signs of breast cancer or other disorders. A breast biopsy removes a sample of breast tissue that is looked at under a microscope to check for breast cancer. A breast biopsy is usually done to check a lump found during a breast examination or a suspicious area found on a mammogram, ultrasound, or magnetic resonance imaging (MRI).

There are several ways to do a breast biopsy.

1. A fine-needle aspiration biopsy puts a thin needle through the skin, into the lump, and removes cells to look at. Needle aspiration may be done to see if the lump is solid or fluid-filled (cyst). If the lump is a cyst, it will go away after the fluid is removed. If there is no fluid, another type of biopsy will be done.
2. A core needle biopsy uses a large needle fitted with a special tip. The needle goes through the skin to the lump or area to take out a sample of tissue about the size of a pencil lead.
3. An open biopsy makes a cut in the skin and removes a sample of the lump or the entire lump. If the lump cannot be felt, a small wire can be put in the suspicious area during a mammogram or MRI done just before surgery. The wire then guides the surgeon to the suspicious area to take a biopsy sample.

Surgical Treatment for Breast Cancer

Most women with breast cancer have some type of surgery. Surgery is often needed to remove a breast tumor. Options for this include breast-conserving surgery and mastectomy. Breast reconstruction can be done at the same time as the mastectomy or done later on. Surgery is also used to check the lymph nodes under the arm for cancer spread. Options for this include a sentinel lymph node biopsy and an axillary (armpit) lymph node dissection.

Breast-conserving surgery

This type of surgery is sometimes called lumpectomy or partial mastectomy. It only removes a part of the affected breast, but how much is removed depends on the size and location of the tumor and other factors. If radiation therapy is to be given after surgery, small metallic clips (which will show up on x-rays) may be placed inside the breast during surgery to mark the area for the radiation treatments.

Lumpectomy removes only the breast lump and a surrounding margin of normal tissue. Radiation therapy is usually given after a lumpectomy. If adjuvant chemotherapy is to be given as well, radiation is usually delayed until the chemotherapy is completed.

If cancer cells are found at any of the edges of the piece of tissue removed, it is said to have positive margins. When no cancer cells are found at the edges of the tissue, it is said to have negative or clear margins. The presence of positive margins means that that some cancer cells may have been left behind after surgery. If the pathologist finds positive margins in the tissue removed with surgery, more tissue may need to be removed surgically. This operation is called a re-excision. If enough breast tissue can’t be removed to get clear surgical margins, a mastectomy may be needed.

The larger the portion of breast removed, the more likely it is that there will be a noticeable change in the shape of the breast afterward. If the breasts look very different after surgery, it may be possible to have some type of reconstructive or to have the unaffected breast reduced in size to make the breasts more symmetrical. It may even be possible to have this done during the initial surgery.

Possible side effects: Side effects of these operations can include pain, temporary swelling, tenderness, and hard scar tissue that forms in the surgical site. As with all operations, bleeding and infection at the surgery site are also possible.

Mastectomy

Mastectomy is surgery to remove the entire breast. All of the breast tissue is removed, sometimes along with other nearby tissues.

Simple mastectomy: In this procedure, also called total mastectomy, the entire breast, including the nipple is removed, excluding the underarm lymph nodes and muscle tissue from beneath the breast. Sometimes this is done for both breasts (a double mastectomy), especially when it is done as preventive surgery in women at very high risk for breast cancer. Most women, if they are hospitalized, can go home the next day.

Skin-sparing mastectomy: For some women considering immediate reconstruction, a skin-sparing mastectomy can be done. In this procedure, most of the skin over the breast (other than the nipple and areola) is left intact. This can work as well as a simple mastectomy. The amount of breast tissue removed is the same as with a simple mastectomy.

This approach is only used when immediate breast reconstruction is planned. It may not be suitable for larger tumors or those that are close to the skin. Implants or tissue from other parts of the body are used to reconstruct the breast. This approach has not been used for as long as the more standard type of mastectomy, but many women prefer it because it offers the advantage of less scar tissue and a reconstructed breast that seems more natural.

Modified radical mastectomy: This procedure is a simple mastectomy plus removal of axillary (underarm) lymph nodes.

Possible side effects: Aside from post-surgical pain and the obvious change in the shape of the breast(s), possible side effects of mastectomy include wound infection, hematoma (buildup of blood in the wound), and seroma (buildup of clear fluid in the wound). If axillary lymph nodes are also removed, other side effects may occur.

Choosing between lumpectomy and mastectomy

Many women with early-stage cancers can choose between breast-conserving surgery and mastectomy.

The main advantage of a lumpectomy is that it allows a woman to keep most of her breast. A disadvantage is the usual need for radiation therapy — most often for 5 to 6 weeks — after surgery. A small number of women having breast-conserving surgery may not need radiation while a small percentage of women who have a mastectomy will still need radiation therapy to the breast area.

For most women with stage I or II breast cancer, breast-conservation therapy (lumpectomy/partial mastectomy plus radiation therapy) is as effective as mastectomy. Survival rates of women treated with these 2 approaches are the same. But breast-conservation therapy is not an option for all women with breast cancer.

When deciding between a lumpectomy and mastectomy, be sure to get all the facts. You may have an initial gut preference for mastectomy as a way to “take it all out as quickly as possible. This feeling can lead women tend to prefer mastectomy more often than their surgeons do. But the fact is that in most cases, mastectomy does not give you any better chance of long-term survival or a better outcome from treatment. Studies following thousands of women for more than 20 years show that when a lumpectomy can be done, doing mastectomy instead does not provide any better chance of survival.

Sentinel Lymph Node Biopsy and Axillary Lymph Node Dissection

Lymph nodes are small round organs that are part of the body’s lymphatic system. They are found widely throughout the body and are connected to one another by lymph vessels. Groups of lymph nodes are located in the neck, underarms, chest, abdomen, and groin. A clear fluid called lymph flows through lymph vessels and lymph nodes.

Lymph nodes are also important in helping to determine whether cancer cells have developed the ability to spread to other parts of the body. Many types of cancer spread through the lymphatic system, and one of the earliest sites of spread for these cancers is nearby lymph nodes.

The lymph vessels of the breast drain into the lymph nodes in your axilla (underneath your arm), in the high majority of cases, and sometimes into the lymph nodes along your sternum, (or breastbone), and above your clavicle (collarbone).

Sentinel lymph node biopsy

A sentinel lymph node is defined as the first lymph node to which cancer cells are most likely to spread from a primary tumor. Sometimes, there can be more than one sentinel lymph node.

A sentinel lymph node biopsy (SLNB) is a procedure in which the sentinel lymph node is identified, removed, and examined to determine whether cancer cells are present.

A negative SLNB result suggests that cancer has not developed the ability to spread to nearby lymph nodes or other organs. A positive SLNB result indicates that cancer is present in the sentinel lymph node and may be present in other nearby lymph nodes (called regional lymph nodes) and, possibly, other organs. This information can help determine the stage of the cancer (extent of the disease within the body) and develop an appropriate treatment plan.

In this procedure, the first lymph node(s) to which a tumor drains are found and removed. This lymph node, known as the sentinel node, is the one most likely to contain cancer cells if they have started to spread. To do this, a radioactive substance and/or a blue dye is injected into the tumor or the area around it. Lymphatic vessels will carry these substances into the sentinel node(s), usually located in the axilla (arm pit). An incision is then made in the skin over the area and removes the node(s) containing the dye (or radiation). These nodes (often 2 or 3) are then looked at closely by the pathologist.

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. The patient can avoid the potential side effects of a full axillary lymph node dissection (ALND).

SLNB is usually done at the same time the primary tumor is removed. However, the procedure can also be done either before or after removal of the tumor.

Axillary lymph node dissection

Although axillary lymph node dissection (ALND) is a safe operation and has low rates of most side effects, removing many lymph nodes increases the chance that the patient will have lymphedema after surgery. Anywhere from about 10 to 40 (though usually less than 20) lymph nodes are removed. To lower the risk of lymphedema, a sentinel lymph node biopsy (SLNB) may be performed to check the lymph nodes for cancer.

Up to 30% of women who have an axillary lymph node dissection develop lymphedema. It occurs in up to 3% of women who have a sentinel lymph node biopsy.

Reconstructive surgery

After having a mastectomy (or some breast-conserving surgeries), a woman may want to consider having the breast mound rebuilt; this is called breast reconstruction. These procedures are not done to treat cancer but to restore the breast’s appearance after surgery. If you are going to have breast surgery and are thinking about having reconstruction, it is important to consult with a plastic surgeon who is an expert in breast reconstruction before your surgery.

Decisions about the type of reconstruction and when it will be done depend on each woman’s medical situation and personal preferences. You may have a choice between having your breast reconstructed at the same time as the mastectomy (immediate reconstruction) or at a later time (delayed reconstruction). There are several types of reconstructive surgery. Some use saline (salt water) or silicone implants, while others use tissues from other parts of your body (autologous tissue reconstruction).