How is breast cancer treated with surgery?
Surgery is the mainstay of therapy for breast cancer. The choice as to which type of surgery is based on a number of factors, including the size and location of the tumor, the type of tumor, and the person's overall health and personal wishes. Breast-sparing surgery is often possible.
Lumpectomy involves removal of the cancerous tissue and a surrounding area of normal tissue. Generally the lymph nodes in the armpit are sampled at the same time. This is not considered curative and should almost always be done in association with other therapy such as radiation therapy with or without chemotherapy or hormonal therapy.
Simple mastectomy removes the entire breast but no other structures. If the cancer is invasive, this surgery alone will not cure it. It is a common treatment for DCIS, a noninvasive type of breast cancer. Modified radical mastectomy removes the breast and the axillary (underarm) lymph nodes but does not remove the underlying muscle of the chest wall. Although additional chemotherapy or hormonal therapy is almost always offered, surgery alone is considered adequate to control the disease if it has not metastasized. Radical mastectomy involves removal of the breast and the underlying chest wall muscles, as well as the underarm contents. This surgery is no longer done because current therapies are less disfiguring and have fewer complications.
General anesthesia, which renders the patient unconscious, is administered for all types of mastectomy. The surgeon makes a curved cut, called an elliptical incision, into the skin. The incision includes the nipple, areola, and the biopsy scar. The tumor and all of the breast tissue, including the nipple and areola, are removed. The initial incision may extend to the armpit to allow for removal of the lymph nodes. If a radical mastectomy is being performed, the surgeon also removes the muscles beneath the breast. At the end of the operation, one or two drains are inserted to drain excess fluid that may collect under the skin. Every effort is made to leave as much healthy skin intact as possible, but sometimes a substantial amount of skin is removed, resulting in a large, possibly disfiguring scar, and making breast reconstruction difficult. A mastectomy usually takes 2 to 3 hours. A radical mastectomy may take longer because the surgery is more complex.
Breast biopsy - A breast biopsy is the removal of breast tissue for examination by a pathologist. This can be accomplished surgically, or by withdrawing tissue through a needle. A needle biopsy removes part of the suspicious area for examination. There are two types, aspiration biopsy (using a fine needle), and large core needle biopsy. Either of these may be called a percutaneous (procedure done through the skin) needle biopsy.
The fine needle biopsy uses a very thin needle to withdraw fluid and cells that can be studied. This can be done in your physician’s office. No specialized equipment is needed. However, the use of an ultrasound helps to insure the guidance of the needle and that the specimen is taken from the right place. A large core needle biopsy uses a larger diameter needle to remove small pieces of tissue, about the size of a grain of rice. It can be done in a clinic or hospital. Ultrasound or x-ray is used for guidance of a large core needle biopsy.
A biopsy is recommended when a significant abnormality is found, either on physical examination and/or by an imaging test. Examples of abnormality can include a breast lump felt during physical examination and/or by an imaging test. It may also include a breast lump felt during a physical self-examination or tissue changes noticed from a mammogram test. Before a biopsy is performed, it is important to make sure that the threat of cancer cannot be disproved or ruled-out by a simpler, less invasive examination. It may be obvious that a lump is harmless when examined by an ultrasound.
Mastectomy - The surgical removal of the breast for the treatment or prevention of breast cancer. There are four types of mastectomies: partial mastectomy, or lumpectomy, in which the tumor and surrounding tissue is removed; simple mastectomy, where the entire breast and some axillary lymph nodes are removed; modified radical mastectomy, in which the entire breast and all axillary lymph nodes are removed; and the radical mastectomy, where the entire breast, axillary lymph nodes, and chest muscles are removed. The size, location, and type of tumor are very important when choosing the best surgery to treat a woman's breast cancer. The size of the breast is also an important factor. A woman's psychological concerns, and her lifestyle choices should also be considered when decisions are made.
The severity of a cancer is evaluated according to a complex system called Staging. This takes into account the size of the tumor, and whether it has spread to the lymph nodes, adjacent tissues and/or distant parts of the body. A mastectomy is usually the recommended surgery for more advanced breast cancers. Women with earlier stage breast cancers, who could have breast-conserving surgery (lumpectomy), may decide to have a mastectomy.
There are many factors that make a mastectomy the treatment of choice for a patient. A large tumor is often an indication of a later stage of breast cancer, when the removal of the entire breast is recommended. In addition, large tumors are difficult to remove with good cosmetic results. This is especially true if the woman has small breasts. Very rapidly growing breast cancers are usually treated with a mastectomy. Sometimes multiple areas of cancer are found in one breast, making removal of the whole breast necessary. A cancer that has already attached itself to nearby tissues, such as the skin or chest wall, is most likely to be removed with a mastectomy. Breast conserving surgery may be attempted, but may be unsuccessful. The surgeon is sometimes unable to remove the tumor with a sufficient amount or margin of normal tissue surrounding it. The entire breast needs to be removed in this situation. Recurrence of breast cancer after a lumpectomy is another indication for mastectomy.
Radiation therapy is almost always recommended following a lumpectomy. If a woman is unable to have radiation, a mastectomy is the treatment of choice. Pregnant women cannot have radiation therapy, for fear of harming the fetus. A woman with certain collagen vascular diseases, such as systemic lupus erythematosus or scleroderma, would experience unacceptable scarring and damage to her connective tissue from radiation exposure. Any woman who has had therapeutic radiation to the chest area for other reasons cannot tolerate additional exposure for breast cancer therapy. Diminished lung capacity due to other diseases also makes a woman a poor candidate for radiation therapy.
Prophylactic mastectomy, or removal of the breast to prevent future breast cancer, is controversial. Women with a strong family history of breast cancer and/or who test positive for a known cancer-causing gene may choose this option. Patients who have had certain types of breast cancers that are more likely to recur may elect to have the unaffected breast removed. Although there is some evidence that this procedure can decrease the chances of developing breast cancer, it is not a guarantee. It is not possible to be certain that all breast tissue has been removed. There have been cases where breast cancers have occurred after both breasts have been removed.
The decision to have mastectomy or lumpectomy should be carefully considered.
It is important that the woman be fully informed of all the potential risks and benefits of different surgical treatments before making a choice.