Surgery options
Surgery is one part of a treatment plan for early stage breast cancer. Surgery removes the disease in a local manner. Local treatment for breast cancer involves removing the cancer. That can be accomplished via lumpectomy or mastectomy. In general, radiation is given 4-6 weeks after a lumpectomy to reduce risk of recurrence. Not many people need radiation after a mastectomy unless the tumor is very large or if there are lymph nodes involved, skin involvement, or chest wall involvement. At the time of either lumpectomy or mastectomy, a sentinel node biopsy is performed for a diagnosis of invasive cancer to make sure the tumor has not spread to the lymph nodes. Sometimes an axillary dissection (complete removal of the lymph nodes) is performed if there is a lot of cancer in the lymph nodes.
LUMPECTOMY
Lumpectomy is breast conserving surgery. This involves taking only the cancer out and leaving the rest of the breast intact. Most breast cancers are diagnosed via mammogram and then via biopsy. At the time of biopsy, a small clip is left behind. This clip is so small and is not felt on clinical exam. Therefore before your surgery, a seed is placed where the clip was left behind to allow the surgeon to identify the area to be removed. Some institutions use wires and others radioactive seeds. My goal is to remove all of the cancer and leave you cancer-free. Therefore I take adequate margins around the tumor based on pre-operative mammogram and intra-operative x-ray evaluation of the specimen. If an appropriate candidate, you may have a plastic surgeon perform oncoplastic surgery or reduction mammoplasty on the other side for cosmesis and balance. It takes about 3-7 days for the final pathology to come back. If the margins are not adequate (positive margins), then a second surgery is needed to re-excise the margins. Risk of a positive margin is 12-20% nationally.
Who is a breast conservation candidate?
Small tumors
patients who are willing to get radiation
cancer is not in multiple areas of the breast (multicentric disease)
Mastectomy
Mastectomy is surgery that involves complete removal of the breast tissue. You may choose to have a mastectomy for personal reasons, genetic mutation (prophylactic surgery aka risk-reducing surgery), high-risk for breast cancer, large tumor, tumor involves the nipple, inflammatory breast cancer, wanting to avoid radiation, pregnancy, etc.
Nipple Sparing mastectomy
Involves saving the entire breast envelope including the skin and nipple-areolar complex for reconstructive purposes. Incisions are for illustrative purposes and may vary.
SKIN SPARING MASTECTOMY
Involves removal of the nipple- areolar complex but leaving behind some skin for reconstructive purposes. Incision is for illustrative purposes and may vary
SIMPLE MASTECTOMY
Involves removal of the entire nipple-areolar complex and breast tissue and electing to go flat.
lYMPH NODE SURGERY
If you have invasive cancer and lymph nodes do not appear to be involved on exam and/or on ultrasound, then a sentinel node biopsy may be performed at the time of surgery. Even though imaging may show no involvement of cancer in the lymph nodes, microscopic cells are not picked up on imaging. Therefore biopsy is performed to be assessed microscopically. The day of surgery you will have a dye or radioactive tracer injected at the tumor or around the nipple. This will travel through the lymphatic system and light up the sentinel nodes. The sentinel nodes are the first nodes to be affected IF cancer were to have traveled there.
If there appears to be a lot of cancer involved in the lymph nodes either on exam or on imaging or after a sentinel node biopsy, you may have to have an axillary dissection or complete removal of the lymph nodes under the arm.
Reconstruction
If you have either a lumpectomy or a mastectomy you may be candidate for reconstruction with a plastic surgeon.
For a lumpectomy, a plastic surgeon can perform a symmetry procedure on the other side via a reduction mammoplasty or tissue rearrangement.
For a mastectomy, a plastic surgeon can perform implant based reconstruction or autologous reconstruction. Implant-based reconstruction involves placing either an expander (balloon-like apparatus) or the implant right away. If an expander is placed, a second procedure will need to be formed a few months out to replace the balloon with an implant. Autologous reconstruction involves taking a patient's own tissue and recreating a breast. This surgery is more involved and the recovery time is longer than with implant-based reconstruction.