The Saul and Joyce Brandman Breast Center has the latest state-of-the-art technology and instrumentation, coupled with the expertise of surgeons and specialists dedicated to working together to give you the best possible care and outcome. Surgical treatment options for breast cancer include:
- Axillary Node Dissection
- Lumpectomy/Segmental Mastectomy
- Modified Radical Mastectomy
- Radical Mastectomy
- Skin-Sparing Mastectomy
- Sentinel (Blue) Node Biopsy
- Postsurgical Treatment
Axillary lymph node dissection helps determine the stage of the breast cancer, which in turn helps determine treatment choices. It is performed either after a lumpectomy or at the same time as a modified radical mastectomy. Some of the lymph nodes under the arm are removed and analyzed.
Lumpectomy and segmental mastectomy (also called a partial mastectomy) are types of breast sparing surgery. The surgeon removes the breast cancer and some normal tissue around it.
A small cut is made over the lump and it is removed in one piece. It is then sent immediately to the laboratory for examination. The skin is then stitched back together again. This is only possible if the lump is detected at an early stage, before the cancer has spread. Often some of the lymph nodes are removed.
In segmental mastectomy, a larger amount of the surrounding tissue is removed. Occasionally some of the lining over the chest muscles below the tumor is removed.
If it is benign, then there will be no additional treatment. If the lump is malignant, then treatment will depend on the size and spread of the tumor. Most women receive radiation therapy to destroy any cancer cells remaining in the area.
In modified radical mastectomy, the surgeon removes the whole breast, most of the lymph nodes under the arm and often the lining over the chest muscles. The smaller of the two chest muscles also may be taken out to help in removing the lymph nodes.
Breast reconstruction may be done at the same time as the mastectomy or at a later time. For women who do not wish to undergo reconstruction, breast prostheses or special bras can improve appearance and body image after a mastectomy.
In radical mastectomy (also called Halsted radical mastectomy), the surgeon removes the breast, both chest muscles, all the lymph nodes under the arm, and some additional fat and skin. For many years, this operation was considered standard for women with breast cancer, but it is almost never used today. In rare cases, radical mastectomy may be suggested if cancer has spread to the chest muscles.
Following surgery, there is a chance that the cancer can return or spread even years later. Factors known as prognostic indicators help physicians and patients estimate the risk of recurrence over time. These include whether the cancer has spread to the lymph nodes and the size of the tumor. In addition, the histological grade (how much the cancer resembles normal tissue) and the presence of hormone receptors are considered.
When chemotherapy or tamoxifen is used following surgery, this is called adjuvant therapy. The risk of distant recurrence can be lowered by chemotherapy or hormone therapy. Hormone therapy is indicated if either of the hormone receptors for estrogen or progesterone are present.
For patients who are already at a low risk for recurrence, adjuvant therapy, especially chemotherapy will not be warranted. The side effects outweigh the small reduction in risk achieved with therapy.
Cancer surgery involves the science and art of excising primary tumors and possible metastatic sites (possible areas where the cancer has spread). The most common metastatic sites are the regional lymph node regions. The axillae (arm pit) is a lymph node basin for breast cancer. The information gained from removing the lymph nodes aids in the staging the breast cancer and helps in the decision making for further treatment such as chemotherapy. In the past, patients diagnosed with breast cancer who were suspected of having cancer spread to the lymph nodes had a full dissection (complete removal of all the lymph nodes) of the suspected lymph node basin. This occasionally resulted in complications such as infection, wound breakdown, seromas (a fluid collection which can be uncomfortable) and infrequently, lymphedema (swelling of the arm).
Now there is a way to accurately diagnose the suspected lymph node to avoid the more invasive, full dissection procedure by having a physician perform a sentinel (blue) node biopsy. The first node in a basin is identified as the sentinel lymph node (SLN) and has been proven to be the area where the cancer first spreads. If there are no tumor cells seen in the SLN then there is only a very small risk that tumor cells have traveled to the other lymph nodes in the lymph node basin. This SLN can be located by injecting a special blue dye or a radioactive substance near the nipple, around the cancer or biopsy area. These substances have the right particle size so that they are taken up by the lymphatic system and will color the first node or the SLN. If cancer cells are breaking off the primary tumor they will travel to the same first node, carried by the lymphatic vessels (convey fluids from tissues into the bloodstream). If the cancer has metastasized or spread from the breast tumor, this is the lymph node most likely to contain a metastasis (or cancer). This allows us to remove only those lymph nodes or SLN(s) that are more likely to harbor cancer cells.
- If the sentinel node contains cancer, additional lymph nodes may have to be removed.
- If the sentinel node is free of cancer, additional lymph node surgery may be avoided.
Review with your physician if these types of lymphatic mapping techniques are applicable for your case:
This technique involves obtaining a preoperative lymphoscintigram to image the basins at risk for metastatic disease and provide a roadmap for the surgeon. This study is performed under the direction of a radiologist specializing in nuclear medicine. The actual tumor or cancer site is injected with a special protein that is labeled with a minute amount of radioactivity. The radioactivity is small and is no more than what is produced by routine chest X-rays or mammograms. No adverse reactions have been reported to the injection of this radio-labeled colloid. The radioactive protein flows through the lymphatic channels toward the lymph node basins. This allows an X-ray image to be obtained of the basins into which tumor cells migrate. The surgeon can use a radiation detector during surgery to pin point the lymph node that has the highest radiation counts.
Patients are injected intraoperatively with a vital blue dye (lymphazurin blue). It is injected around the nipple or the primary breast cancer site. The dye is then absorbed by the lymphatics. After the injection, a small incision is made in the arm pit to search for the sentinel node. Blue-stained lymphatic channels are identified and followed to the sentinel node(s), which are stained blue. One to four SLN(s) are removed and submitted to pathology for evaluation. All blue staining nodes, or "hot" nodes (lymphoscintigraphy), are harvested and called sentinel nodes. Hot nodes are described as nodes with radiation counts three times the background count. If the background count continues to be high, additional nodes are located and removed until the activity in the basin returns to a normal background.
Not everyone is a candidate for sentinel (blue) node biopsy. Currently patients with newly diagnosed early stage invasive breast cancer are eligible for these lymphatic-mapping procedures. Early stage tumors measure 2 cm or less. These procedures are not recommended with patients with suspected or proven lymph node involvement or visible evidence of cancer in the blood stream or in the lymph nodes. It is preferable that excisional biopsies of breast masses be performed after the lymphatic mapping.
Lymph node biopsy surgery always produces some postoperative discomfort for about a week. Swelling or fluid builds up under the incision and can remain for several weeks. Infection is uncommon but can develop up to seven days later.
The most serious complication of any procedure involving the lymph nodes is lymphedema. The treatment of lymphedema is limited. Once lymphedema develops, the patient is at increased risk for developing infection in the involved arm. Patients that have lymphedema must be observant because lymphedema makes patients more prone to infection in the involved arm, and with each infection lymphatic channels may be injured making the lymphedema worse.
The best approaches to lymphedema are its prevention and active physical therapy treatment. Our dedicated team of physical therapists offer therapies, exercises, support garments and activities to treat and avoid lymphedema, as well as a list of activities to stay away from to avoid injury and improve healing.
SLN biopsy has the advantage of a low complication rate and combined with its accuracy in staging makes it the best option for patients with early breast cancer. If no tumor is found when the SLN is carefully examined by special stains, then there is no need to complete the dissection to remove more nodes. This significantly reduces the rate of lymphedema. Still, it is important to understand that this technique is new. Not all cancer specialists feel that this procedure adequately samples the lymph nodes. Additionally, there is always a chance that an involved lymph node will be left behind but this is also true with the conventional lymph node surgery.
Breast cancer treatment often involves surgical removal of the tumor and remaining breast tissue, resulting in an unsightly scar across the chest. Even the most expertly reconstructed breast leaves long scars that disfigure an otherwise excellent result.
With the advent of modern, minimally invasive surgical techniques, a long scar can be avoided. Using a procedure called a skin-sparing mastectomy, the breast tissue is surgically removed while leaving the skin intact. To thoroughly remove the breast tissue, the nipple also needs to be removed, but the areola (the pigmented skin around the nipple) may be saved in many cases.
A minimal incision is used for skin-sparing mastectomy. This incision is placed either around the areola or in a lollipop-like shape so that the resulting scar is completely below the level of the nipple. Complete removal of tumor and breast tissue can be made without the unnecessary removal of uninvolved, healthy breast skin. Whenever feasible, the incision around the areola can be made on the breast in a manner consistent with accepted practice in breast cosmetic surgery.
After a skin-sparing mastectomy, the empty skin envelope can be tailored to an optimal shape by the reconstructive plastic surgeon. This can also correct pre-existing problems like breast droopiness and poor shape. The skin envelope is filled with either the patient's own tissue, a prosthesis or a combination of both.
A TRAM (transverse rectus abdominis muscle) flap is a breast reconstruction technique using the patient's own excess abdominal fat tissue. The advantages of this operation are that it avoids the use of an implant and accomplishes a tummy tuck at the same time. The disadvantages are the long abdominal scar and that it requires a much longer recovery period. For a few patients, tissue can be transferred from the back muscles or even the buttocks.
Since these tissue operations may not be feasible for every woman, the skin envelope can also be filled with a modern prosthetic implant. The prosthesis is made of silicone and is filled with silicone gel, saline or a combination of both. Some implants are adjustable after surgery.
