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Breast Conserving Surgery
Nearly all women with breast cancer will have some type of surgery. Lumpectomy removes the breast cancer and the surrounding area, or margin, of normal tissue. If cancer cells are present at the margin (the edge of the excisional biopsy or lumpectomy specimen), a re-excision can be done to remove the remaining cancer. In almost all cases, radiation therapy follows lumpectomy. Doctors call this combination (of lumpectomy and radiation) breast conserving therapy. It's an option for most, but not all women with breast cancer. Those who probably should not undergo lumpectomy or breast conserving therapy are:
In a simple (total) mastectomy procedure surgeons remove the entire breast but do not remove any lymph nodes from under the arm, or muscle tissue from beneath the breast. In a modified radical mastectomy, surgeons remove the entire breast and some axillary (underarm) lymph nodes. This is the most common surgery for women with breast cancer in whom doctors remove the whole breast.
Radical mastectomy removes not only the entire breast, but axillary lymph nodes, and the chest wall muscles under the breast as well. At one time this surgery was quite common. But it left women disfigured and caused side effects. The modified radical mastectomy has proved as effective as radical mastectomy, which doctors now rarely perform.
Some possible side effects of both mastectomy and lumpectomy include wound infection, hematoma (accumulation of blood in the wound), and seroma (accumulation of clear fluid in the wound).
Sentinel Node Biopsy
Whether a woman has had a radical or modified radical mastectomy or a lumpectomy, her physicians need to know whether the cancer has spread to the lymph nodes, a jumping-off point from which cancer cells can then spread throughout the body.
Surgeons once believed that removing as many lymph nodes as possible would reduce the risk of distant metastasis and improve the chances of a cure. We now know that systemic treatment offers the best prospect of wiping out cancer cells that have spread beyond the breast.
Removing the lymph nodes under the arm is in fact the most difficult part of the surgery a patient must deal with. A revolution in the surgical management of breast cancer patients is that we can now identify through a small biopsy those patients who actually need the lymph node dissection. Since 60 percent of our patients do not have spread to their lymph nodes, sparing them an axillary dissection — removal of more lymph nodes in the axilla (armpit) — is a major breakthrough.
How does this work? A blue dye is injected around the tumor and is absorbed by the lymphatic pipes that then travel to the lymph nodes. The first lymph node — the sentinel node — that drains the tumor, the one most likely to contain spread if there has been any, turns blue from the dye, allowing the surgeon to identify and remove it. In experienced hands, the sentinel node is accurate at predicting the presence of disease in the remaining nodes greater than 98 percent of the time.
Reconstructive Breast Surgery
These procedures won't treat cancer, but they restore the breast's appearance after mastectomy. Breast reconstruction can be done at the same time as mastectomy (immediate reconstruction) or at a later time (delayed reconstruction). Surgeons may use implants, or tissue from other parts of the body; they call the latter autologous tissue reconstruction. How do a woman and her doctor decide on the type of reconstruction and when to undergo the procedure? The answer to that depends on the woman's personal preferences and details of her medical situation, such as how much skin is removed and whether she needs chemotherapy.