Surgery

Types of surgery

Surgery aims to remove the cancer with a margin (border) of normal tissue to reduce the risk of the cancer coming back in the breast (known as local recurrence) and to try to stop any spread.

It is usually the first treatment for breast cancer, although sometimes chemotherapy or hormone therapy is offered first. This is to begin treating the whole body or to shrink the cancer so that surgery may be less extensive.

One of the first decisions you may have to make is which type of operation you'll have. You may be offered a choice of breast-conserving surgery or a total mastectomy.

Breast-conserving surgery

Breast-conserving surgery, usually called wide local excision or lumpectomy, is the removal of the cancer with a margin (border) of normal breast tissue around it.

A far  less common operation is a quadrantectomy, where around a quarter of the breast is removed (sometimes called a segmental excision). After a quadrantectomy the breast will usually be smaller and there may also be an indentation because of the amount of tissue removed.

There is  increasing use of oncoplastic surgical techniques, which means combining breast cancer surgery with plastic surgery to try to provide the best cosmetic outcome as well as the best cancer treatment. These techniques mean that there is less likely to be an obvious indentation, and that the shape and symmetry of the breasts are maintained.

Mastectomy

Mastectomy means removal of all the breast tissue including the nipple area. A simple mastectomy means that the entire breast is removed but the lymph nodes and muscles underneath the breast are not affected. However, some lymph nodes may be removed with the breast tissue taken during surgery. A simple mastectomy is often a suitable treatment for widespread DCIS (ductal carcinoma in situ).

A modified radical mastectomy removes the entire breast and some of the lymph nodes under the arm. Sometimes one of the small muscles on the chest wall is also removed.

If you are going to have a mastectomy, you will usually be able to have breast reconstruction. This can be done at the same time as your mastectomy (immediate reconstruction) or months or years later (delayed reconstruction). You may be offered a delayed reconstruction if there are medical reasons why an immediate one isn’t possible. If you would like more information, view our pages on breast reconstruction.

The right surgery for you

More than half of early stage breast cancers can be treated with breast-conserving surgery followed by radiotherapy.

Studies have shown that long-term survival is the same whether you have breast conserving surgery and radiotherapy or a mastectomy.

The type of surgery you have will be based on the type of cancer, the size, where it is in your breast and how much surrounding tissue needs to be removed. It will also depend on how large your breasts are.

The surgeon will want to give you the best cosmetic result possible as well as the most effective surgery. That means keeping as much as possible of your breast without increasing the risk of the cancer coming back.

Your surgeon may recommend the removal of the whole breast. Total mastectomy can be the better option when:

• your breast is small so the remaining tissue would look misshapen after breast-conserving surgery
• the cancer takes up a large area of the breast
• there is more than one area of cancer in the breast
• the cancer is in the centre of your breast or directly behind the nipple.

If your surgeon recommends a mastectomy they should explain why this is necessary. It may also be your preference to have a mastectomy.

For more information on the different surgical options see our booklets Treating breast cancer and Breast reconstruction.

Lymph node removal

For invasive breast cancer, it's recommended that some or all of the lymph nodes under the arm (the axilla) are removed to see whether or not they contain any cancer cells. Knowing whether lymph nodes are affected is important in helping your specialist team decide on any additional treatments to surgery.

People have different numbers of lymph nodes but on average there are around 20 lymph nodes under the arm. These are arranged in three levels (1, 2 and 3) and the number of nodes in each level will vary. Level 1 is closest to the breast and contains the largest number of lymph nodes.

Axillary sampling removes the lymph nodes closest to the breast from level 1, while axillary clearance removes the nodes up to level 3.

Sentinel node biopsy

Another way to find out if the breast cancer has spread to the lymph nodes under the arm is a sentinel node biopsy. This can either be carried out at the same time as the main breast surgery or in some cases beforehand. A sentinel node biopsy involves injecting a small amount of radioactive material and a dye into the body to identify the first, or sentinel, node(s) to receive lymph fluid from the cancer. This node is then removed and examined. If the sentinel node is clear of cancer cells it usually means that the other nodes are clear too so no more will need to be removed.

The result of the sentinel node biopsy will normally be available one or two weeks after your surgery.

Sentinel node biopsy is becoming standard practice for patients with cancers where there is no evidence of lymph nodes being affected from tests before your operation and when the surgeon cannot feel any enlarged lymph nodes under the arm. It is not a suitable procedure if tests before your operation show your lymph nodes are affected.

If the results of the sentinel node biopsy show that the node(s) removed is affected by cancer it may be recommended that you have a second operation to remove the remaining nodes. About 20–25% of women who have sentinel node biopsy go on to have further surgery to try to ensure all the affected lymph nodes have been removed.

Assessment of the sentinel lymph node during surgery

In some hospitals it may be possible to check the sentinel node(s) at the time of surgery. This means the surgeon can find out during your operation if the lymph node contains cancer cells and, under the same anaesthetic, do an axillary clearance if the lymph nodes are affected.

An example of this is a diagnostic test called OSNA (one step nucleic acid amplification). A substance (marker) is produced in breast cancer cells that is not found in a healthy lymph node. OSNA can detect small quantities of this substance.

Another type of biopsy known as a ‘frozen section’ can also be carried out during the operation. This involves freezing tissue that has been removed to prepare it for examination under a microscope. Samples can then be studied within a few minutes so the results can be passed to the surgeon.

These tests may avoid the need for a second operation if the cancer is found to have spread to the lymph nodes. However, some surgeons prefer to wait for the more detailed laboratory examination to be certain that no cancer is present in the sentinel lymph node.

Sentinel node biopsy is not appropriate for everyone and your surgeon will discuss whether or not this procedure is an option for you. If your surgeon says that you don’t need to have any lymph nodes removed during your surgery, they should explain why.

 

Last reviewed March 2012; next planned review 2013.