Surgery is usually the first line of treatment for breast cancer unless the tumor is very large or has spread to other parts of the body. The surgical options for breast cancer include lumpectomy and mastectomy. Which surgical option is best depends on tumor size, breast size, and personal preference, as well as other aspects of the medical history. With either surgery, if the tumor is invasive (meaning it has grown beyond the breast duct where it began), removal of some of the lymph nodes under the arm will help determine whether or not the cancer has spread.
Lumpectomy (also referred to as breast-conserving surgery, quadrantectomy or partial mastectomy) removes the tumor and a rim of surrounding normal breast tissue. Lumpectomy may be done with or without preoperative imaging localization. If the tumor is not palpable, i.e. is only seen on breast imaging (mammogram, ultrasound or MRI) then under imaging guidance a small wire is placed into the abnormal tissue to indicate the tissue that should be removed. The removed specimen is then imaged to confirm that it contains the abnormal area.
Mastectomy removes the whole breast and usually some portion of the breast skin. In most cases the nipple-areolar complex is removed with the breast. Mastectomy is indicated if the involved area is too extensive for lumpectomy. Breast reconstruction can sometimes be done during the same surgery (immediate reconstruction) and sometimes at a later time (delayed reconstruction).
During the lumpectomy or mastectomy, removal of some of the lymph nodes in the armpit will determine if the cancer has spread (lymph nodes in the underarm are the first place breast cancer spreads). For early breast cancers, sentinel lymph node biopsy is a technique in which the lymph nodes that first drain the breast are identified and removed. This is usually about 2 lymph nodes, but can be just 1 or sometimes 3 or more. A special blue dye and/or a radioactive tracer is injected into the breast, travels to the lymph nodes, and allows identification the sentinel node(s). If there is minimal or no cancer in the sentinel nodes, then no additional lymph nodes need to be removed. This has the advantage of faster recovery and less risk of lymphedema (swelling of the arm) or nerve injury. If additional nodes need to be removed, this is called axillary node dissection. Axillary node dissection removes the lymph nodes within defined anatomic boundaries in the underarm. The exact number of lymph nodes removed depends on the patient, but is usually 10 or more.
After surgery, any tissue removed is sent for processing and analysis by a pathologist. Pathology results often take 4 to 5 working days to come back. Sometimes the pathology will indicate that further surgery is needed. Usually this is because the tumor larger or is more extensive than the breast imaging indicated.
Recovery time depends on the type and extent of surgery. For lumpectomy and lumpectomy with sentinel node biopsy, the surgery is usually performed as an outpatient procedure (the patient can go home after recovery and does not need to spend the night in the hospital). Patients are usually able to resume full activities within 1-2 weeks. After mastectomy the patient will stay in the hospital for 1 or 2 nights. The hospital stay may be more after certain types of immediate reconstruction. Mastectomy also requires the placement of surgical drains (plastic tubes which drain fluid from the surgical area) which the patient will go home with. They are taken out in the clinic once the output has decreased sufficiently and they are no longer needed.
Specific surgical recommendations will vary, depending on each patient's individual circumstances. When patients have questions about their treatment plan, they should ask their surgeon to explain the options and the reasons for a specific recommendation more thoroughly. It is always appropriate to seek a second surgical opinion, especially if the reason for a surgical recommendation is not clear.
