Most women who have been diagnosed with breast cancer are candidates for a breast preserving procedure. Breast cancer surgery procedures include: lumpectomy, mastectomy, lymph node biopsy, mastectomy and breast reconstruction.
A tumor removal (lumpectomy) can be performed through a small incision, hidden in areas such as around the areola, axilla and inframammary fold (under the breast).
To avoid leaving a divot after the tumor is removed, breast tissue can be relocated to even out the contour of the breast shape. If the tumor is large or the breast small, attempts are made to minimize unevenness. If additional aesthetic improvement is desired plastic surgery reconstruction can be considered once your pathology is clear and radiation (if recommended as part of your treatment plan) has been completed. Radiation treatment can change the appearance of the breast and any reconstruction must wait until the area has healed. There are many reconstructive options such as, fat injections, surgical flap rearrangement and breast implants to restore the breast to acceptable size and shape. Many patients who have a lumpectomy do not require any plastic surgical intervention, but it is an option if desired.
The history of breast cancer surgery is one of slowly evolving forward to the “less is more” philosophy. The first cures in breast cancer after centuries of failed medical intervention occurred in the late 19th century when Dr. Halstead removed the entire breast, chest muscles, and axillary lymph nodes in women presenting with huge, neglected tumors. His philosophy that the more radical surgery the better the cure proved erroneous but in a time without the options of radiation or chemo, it definitely was a step forward in the treatment of this generally fatal disease. Unfortunately his insistence that this was the only way stifled surgical advancement until the mid-20th century when intrepid surgeons began treating women with smaller tumors with slightly less mutilating surgery: the breast, skin, nipple and lymph nodes were removed but the chest muscles were left intact thereby minimizing cosmetic deformity and retaining better arm function. In the late 1960’s and 1970’s, rebel surgeons began removing the tumor without removing the entire breast in selected women with small tumors. There was higher recurrence noted until they began adding radiation to lumpectomy. A landmark study by Fischer et al confirmed that lumpectomy, axillary dissection (removal of all axillary lymph nodes) and radiation was equivalent to mastectomy. The recurrence was slightly higher but there was no difference in mortality. Subsequent studies have confirmed this data and reinforced that the recurrence is prohibitive (30 to 60 % depending on the study) with lumpectomy without radiation. Most patients that present with breast cancer are candidates for breast preserving procedures!
Mastectomy is still indicated in many patients, however, and with the advent of improved surgical and reconstruction techniques, the number of mastectomies now performed is actually increasing. The absolute indications for complete removal of the breast include multifocal cancer (multiple tumors in the same breast), extensive cancer in the breast (including noninvasive) precluding lumpectomy with clear margins, refusal or inability (perhaps because of prior treatment) to take radiation, recurrent breast cancer after prior radiation, inflammatory breast cancer and BRCA gene mutation. Removal of the affected breast is generally all that is required in patients who fit the criteria for mastectomy with breast cancer. However once a patient has breast cancer in one breast, she has a lifetime risk of getting breast cancer in the opposite breast. Generally this risk increases with age and does not warrant prophylactic contralateral breast removal in most patients.
In women with multiple other risk factors and or difficult to examine breasts and /or extreme fear of a second cancer, consideration of bilateral mastectomy is indicated.
In those patients with the BRCA gene mutation, their extremely high risk of developing breast cancer in either/both breasts (from 57 to 86% in multiple studies), warrants removal of both breasts before they get cancer. Until we master genetic engineering, removal of the target organs at risk for cancer is the safest preventative treatment we currently have available. Antihormone treatment with tamoxifen or aromasin also decreases the risk of developing breast cancer in high risk patients, but not as effectively as actually removing the breasts (50 to 70 percent with medication versus 95 percent with surgery.) Remember, as drastic as removing “normal” breasts may sound, the procedure dramatically minimizes the risk of developing breast cancer in the high risk patient; close surveillance with exams and imaging studies strives to catch a cancer early once it presents. Clearly a less aggressive/successful strategy. Women at high risk should consult with a breast specialist so that she understands the options and can choose the right approach for her. Gene positive patients are at risk for the frequently lethal ovarian cancer as well, and removal of their ovaries is also recommended, as soon as they have completed childbearing.
Those women with invasive lobular cancer have a higher risk of developing a new primary in the opposite breast than those with invasive ductal cancer. This fact coupled with the increased difficulty in demonstrating lobular cancers on imaging studies may lead a woman to consider bilateral mastectomies. Relative (rather than absolute) indications for mastectomy in breast cancer include dense, lumpy breasts with difficult to interpret imaging studies making post op surveillance difficult, cancer found at surgery which was missed or underestimated by imaging studies, again, making surveillance difficult and dangerous, large tumors in small breasts, making lumpectomy less cosmetically acceptable than mastectomy and reconstruction and implants. Radiation always affects breast implants in a cosmetically negative way. The degree of deformity including capsular contracture, asymmetry, hardness, and pain varies. Many patients accept the consequences, others require reconstructive surgery which may be minor or major including removal of the implant completely with flap construction. Studies using limited radiation may cause less deformity with comparable recurrence rates but data is incomplete but not yet the standard of care. Mastectomy generally precludes radiation and may avoid all these cosmetic issues. However, they create their own issues. Consultation with breast specialists in mastectomy and reconstruction is recommended so you can explore all of your options and make the right surgical decisions for you.
Prophylactic mastectomy may be indicated in patients without the known BRCA gene but with a strong family history of breast cancer and other risk factors including atypical ductal or lobular hyperplasia, lobular carcinoma in situ and dense breasts.
Original mastectomies involved huge incisions with removal of the nipple areolar complex and most of the chest wall skin. Even with reconstruction, the scars remain. As women presented with smaller and smaller tumors through early detection as a consequence of education, self-exam and better imaging techniques, surgeons took less and less skin with better cosmetic results and no cancer compromise. Experience with prophylactic mastectomies taught us to preserve the skin envelope then the nipple itself without losing flaps to ischemia (lack of blood supply). Studies are ongoing but results to date suggest that skin sparing, nipple preserving total mastectomies are safe and oncologically sound in the majority of patients both with and without cancer as long as effort is made to remove all the breast tissue (1-3% remaining is acceptable as it is impossible to remove every bit of breast tissue). Margins must be clear, particularly under the nipple, or reoperation is required. Occasionally the nipple must be removed if it is involved with cancer. In this situation, a new one may be reconstructed by plastic surgery if desired. Surgeons use different incisions to remove the breast tissue. The most cosmetically favorable incisions are circumareolar (around the nipple) and inframammary (under the breast) since these are the least visible. Some surgeons will extend the areolar incision laterally toward the axilla but these are obviously less cosmetically pleasing. Potential complications of mastectomy include bleeding, infection, and chest skin death (flap ischemia/necrosis). Serious complications are rare in capable hands, however. Mastectomy and reconstruction can also cause decreased sensation and numbness in the skin flaps and nipples. This improves with time but doesn’t always normalize. These results are variable in every patient but must be anticipated. The most concerning complication of mastectomy is luckily very rare but devastating. Even after mastectomy, breast cancer may recur. It may develop in retained breast tissue (that is why a breast specialist must remove as much breast as possible), or in the skin itself. This is a very unusual occurrence, and presents generally in patients with extensive and aggressive tumors. The goal of the oncologic surgeon is to remove the risk of cancer in the most cosmetically favorable manner. No compromise is acceptable when treating breast cancer for cure, but patients should not have to sacrifice their self-esteem and indeed their quality of life as a consequence. We expect patients to have a long life after breast cancer surgery and they must feel good about themselves.
Axillary lymph node biopsy
The axillary lymph nodes (found in the armpit) are always checked for tumors regardless of which breast surgery a patient undergoes. This is done to determine whether the cancer has spread outside the breast. The axillary lymph nodes are generally the first place where breast cancer spreads and although cancer confined only within the breast is more favorable than that involving the lymph nodes, axillary lymph node involvement is totally curable. Instead of removing all the axillary lymph nodes as was done in the past, we now minimize the surgery by checking the first draining lymph node of the cancer or “sentinel” lymph node. A blue dye given by the surgeon at the start of surgery and/or a radioactive solution injected by a radiologist prior to surgery is taken up by the lymphatics and delivered to a single or a few axillary lymph nodes. At the time of surgery, a small incision is made in the armpit (in a cosmetically favorable place, using a natural crease), and gentle dissection used to identify the sentinel lymph node (by its dyed-blue color or by radiation detection). The node is sent to pathology as a “frozen section” if the patient is undergoing a mastectomy since a positive sentinel lymph node mandates removal of a few more nodes to quantify how many nodes are involved and to render the patient cancer free. If the sentinel lymph node is negative for tumor, no further nodes are removed. If a mastectomy patient has more than three positive lymph nodes, radiation is generally recommended in addition to chemotherapy, so exact nodal involvement with tumor is critical to treatment decisions. In a lumpectomy patient who will receive radiation as recommended in all breast preservation patients, and chemo if the sentinel lymph node is positive, a recent scientific study (the “Z11” study) demonstrated that no benefit was derived from the removal of any additional lymph nodes, regardless of the status of the sentinel lymph node.
In addition to cosmetic removal of the breast, reconstruction is critical to the process of healing. Many women are comfortable with mastectomy and forgo reconstruction at the time of mastectomy. They have the option at any time to proceed with breast reconstruction in the future, but the nipple cannot be saved and the excess skin is removed at the time of surgery so the scar is larger and permanent. I endeavor to make the scar as thin, low on the chest and small as possible so it cannot be seen in v necked clothes, but it is clearly visible when a woman is nude. Many women use special mastectomy bras and silicone prostheses they can put into their own bras to look natural in clothes.
Every woman should consider reconstruction after mastectomy. Consultation with a plastic surgeon specializing in breast reconstruction prior to mastectomy is mandatory so a team can be chosen and an exact reconstructive technique agreed upon. Reconstruction at the same time as mastectomy is the standard of care except in rare circumstances such as some cases of inflammatory breast cancer, and uncertainty regarding reconstruction. Breast reconstruction after breast cancer is covered by your insurance company.
Implants are the most common type of reconstruction because they look great and are the easiest surgery from which to recuperate. Most patients are candidates for “one stage” reconstruction in which immediate implants are placed at the time of mastectomy. They are placed under the pectoralis muscle and supported by an internal bra made from a dermal matrix material. Lisa Cassileth, m.d. pioneered this technique as an alternative to the more commonly used “2 stage” technique in which deflatable implants or expanders or spacers are placed under the pectoralis muscle, pumped up over the next several weeks or months to stretch the sub muscular pocket and then swapped out for permanent implants at a later date. Patients with extremely large or droopy breasts needing a lift as well as those who have had radiation, may not be candidates for the one stage procedure.
Radiation injury can lead to scarring and loss of elasticity of the breast skin which may prohibit implant insertion in some patients. Using the patient’s own tissue from the abdomen (tram flap) or back (latissimus flap) may provide the best reconstruction option in these cases. Recurrent infection with implant insertion may lead to implant removal and either tissue flap reconstruction or extensive fat injections which can restore the normal breast contour in deformed breasts or indeed in absent breasts, may be indicated.
Every woman has the right to reconstruction after mastectomy if she desires it. Plastic surgical consultation should be undertaken before any woman decides she does not want it so she is certain she understands all of her options before proceeding with mastectomy