Surgery for breast cancer

This is the most common treatment used for women with breast cancer. There are several different types of surgery.

When the cancer is relatively small, under three centimetres in size, it is usually possible for the surgeon to remove the lump along with a small amount of surrounding normal breast tissue; this is called breast-conserving surgery. This is usually combined with removal of some or all the lymph nodes under the arm. If the cancer is larger, or affects more than one area of the breast, or if the woman prefers, the whole breast is removed, this operation being known as mastectomy.

Other options for larger cancers are the use of drugs to shrink the cancer or more complex surgery, usually involving a plastic or oncoplastic surgeon to remove the cancer but leave the breast shape intact.

Breast-conserving surgery

This is also known as wide local excision (or lumpectomy). The aim of breast-conserving surgery is to remove the tumour with a clear rim of normal tissue around it. If all the cancer is not removed, there is a high chance that the cancer will re-grow. Radiotherapy is almost always given to the breast after breast-conserving surgery.

Margins

Margins, also known as ‘margins of resection’, refer to the distance between a tumour and the edge of the surrounding tissue that is removed along with it.

When a tumour is removed, some tissue surrounding it is also removed by a lumpectomy. The tumour with surrounding tissue is rolled in a special ink so that the outer edges, or margins, are clearly visible under a microscope. A pathologist checks the tissue under a microscope to see if the margins are free of cancer cells.

Depending upon what the pathologist sees, the margins of a tumour are described as follows:

• Positive margins: cancer cells extend out to the edge or are very close to the edge of the tissue removed by the surgeon

• Negative margins: no cancer cells are found at the inked margin and there is a thin rim of normal tissue, indicating that the cancer has been completely removed.

Knowing how close cancer cells are to the edge of the removed tissue helps in making the right treatment decisions. This is especially important in deciding whether additional surgery is needed.

Breast conserving surgery

Patients who are suitable for breast-conserving surgery are patients who have:

• a single cancer in the breast that measures three centimetres or less

• no evidence of spread beyond the lymph glands under the arm

• a breast size sufficient to produce a good cosmetic result after removal of the cancer.

Patients who are not usually considered for breast-conserving surgery are:

• those in whom cancer is locally advanced or the lymph nodes are stuck to each other

• those in whom cancer has spread beyond the breast and lymph glands

• women who prefer a mastectomy

• where removal of the cancer will leave a distorted breast.

There are some other reasons why a patient is sometimes not considered for breast-conserving surgery:

• If the tumour is in the central part of the breast, although it is usually possible to remove the nipple and still leave a reasonable result, results from this type of surgery do not always produce a satisfactory result so mastectomy is sometimes advised.

• Patients with specific diseases such as certain collagen vascular diseases, including systemic lupus erythematosus and polyarteritis nodosa, may not be suitable for radiotherapy which is usually given after breast-conserving surgery so mastectomy is usually advised for such patients.

• Where there is more than one tumour in the breast: until recently most women with more than one cancer in the breast were treated by mastectomy but there is good evidence that, provided that both cancers can be removed to clear margins, breast-conserving surgery is possible.

• Women with a strong family history of breast cancer or women who are carrying BRCA-1 or BRCA-2 mutations should have a thorough discussion of the pros and cons of lumpectomy as they have a higher risk of the cancer returning than women who do not carry an abnormal gene.

The balance between tumour size (assessed by imaging such as ultrasound) and the volume of the woman’s breast is the main factor that determines whether a patient is suitable for a lumpectomy. If a patient has a large breast, it may be possible to remove a cancer of larger than three centimetres by breast-conserving surgery. In contrast, in a patient with small breasts removing a two-centimetre cancer may produce an unsatisfactory breast shape after surgery. Tumour size does not relate to the chances of the cancer returning in the breast.

Although most surgeons perform lumpectomies or wide excisions, some surgeons remove larger portions of tissue and do an operation called a quadrantectomy.

It is possible to remove about ten per cent of the breast volume without leaving a deformed breast. If you are having breast-conserving surgery, ask your surgeon what operation will be performed and how your breast is likely to look after surgery.

A wide local excision involves making an incision (cut) in the skin over the breast cancer and removing the cancer with a rim of surrounding breast tissue. After removal of the cancer, any bleeding is stopped and the skin is closed with an invisible stitch, which does not need to be removed.

If the cancer cannot be felt by the surgeon, it will be marked for the surgeon by a radiologist or radiographer in the X-ray department so that it can be removed. Methods available for marking cancers are described in the section on needle localisation biopsy (page 56).

While you are unconscious the surgeon will usually take an X-ray of the area removed to make sure that all the abnormality seen on the original mammogram has been removed. If the X-ray shows that the area of abnormality is close to one of the edges, the surgeon will remove more tissue from this area before stitching the wound.

Problems that can happen after wide local excision

The most common complications immediately after operation are bleeding and feeling unwell after a general anaesthetic (see below).

As a result of removal of the cancer with some surrounding tissue, the treated breast may be smaller than the normal breast after surgery. Depending on the position of the tumour, the treated breast may also change in shape.

About one in ten women gets an unsatisfactory cosmetic result after wide excision and radiotherapy. In these women, it is often possible to reshape the breast at a later date.

Breast-conserving surgery is successful at removal of the cancer and all the surrounding abnormal area in between 80 and 85 women out of 100. In between 15 and 20, when the cancer is looked at under the microscope, the pathologist reports that there is either invasive cancer or more often ductal carcinoma in situ (DCIS) at or close to one edge of the tissue removed, that is the margins are positive or involved.

The problem is that the surgeon cannot feel the DCIS when he or she is operating. Just because the surgeon has not removed all the cancer or DCIS does not mean that he or she is a bad surgeon; it is just that this type of disease cannot be felt by the surgeon.

If you are in that 15 to 20 per cent whose cancer has not been removed at one operation you will need a second operation to remove any remaining invasive cancer or DCIS in your breast. This usually means further removal of breast tissue known as a re-excision, although sometimes the pathologist reports that the cancer extends to many of the edges or margins of the tissue removed and a mastectomy may be required to clear all the disease.

Even if the pathologist reports that all the cancer cells have been removed, breast-conserving surgery is almost always followed by radiotherapy. The radiotherapy treats the remaining breast tissue and makes sure that any abnormal cells that could have been left behind elsewhere in the breast are destroyed by it.

The chances of survival are exactly the same whether a woman is treated by breast-conserving surgery (lumpectomy) and radiotherapy or mastectomy. Many women think that mastectomy is safer, but it is not necessarily.

The advantages of having a lumpectomy include that you still have your breast, which makes it easier when you wear clothes. It may also mean that you may feel more confident and women tend to report fewer sexual problems after lumpectomy than after mastectomy.

Many women are given the choice by the surgeon whether to have a lumpectomy and radiotherapy or mastectomy. It is important that you discuss this issue with your partner, surgeon and breast care nurse and, if you feel it appropriate, your GP.

If your surgeon gives you this option, it means that he or she is very confident that breast-conserving surgery will be successful in your case. In this situation, talking to somebody who has had the different operations can be helpful. Take your time before deciding and if you cannot decide tell your doctor.

Mastectomy

Between one in three and one in four women who have surgery for breast cancer cannot have breast-conserving surgery. Some women prefer mastectomy either because it may avoid radiotherapy or because they feel more secure with mastectomy than breast-conserving surgery.

There is no advantage to having your breast removed if it does not need to be removed. If your initial instinct is that you wish to choose a mastectomy, think about it carefully. When some women realise that mastectomy is not going to improve their outcome, women who otherwise would have chosen mastectomy change their mind and decide to keep the breast.

There are situations where a woman with a lump smaller than three centimetres may be advised to have a mastectomy. The following are the main ones:

• If there is more than one lump in the breast. Early research suggested that, if all the individual lumps were removed, there was a slightly greater chance that cancerous lumps were quite likely to develop later in other parts of the same breast. More recent work has suggested that it is safe to do two lumpectomies, provided that clear margins are obtained round both cancers. It depends on where the lumps are in the breast; if the two cancers are close to each other it may be easy to remove them and give radiotherapy and save the breast. If the two lumps are widely separated, it depends on whether the lumps can be removed and leave enough breast tissue to leave the breast shape intact.

• The cancer is directly under the nipple, so that the nipple would have to be removed at the same time. Rather than leave the breast without a nipple, it is sometimes, although not in most women, better to remove the breast altogether and consider a breast reconstruction (see page 177).

• Sometimes an operation to remove the lump is not successful, because the cancer or the DCIS is more extensive than was evident on X-rays. A second operation to remove more tissue can solve the problem, but if there is widespread change it is usual to remove the whole breast to ensure that no disease is left behind.

• Tissue surrounding an invasive cancer is affected by a large area of DCIS (this is usually visible on the mammogram). If all the disease cannot be removed by lumpectomy, a mastectomy may be the safest option.

• Where removal of the lump would result in a grossly misshapen breast, for instance in a woman with a lump between two and three centimetres in a smaller breast.

Mastectomy is an operation that removes the breast tissue. There are different types of mastectomy. Women who have mastectomy can also choose either to have or not to have a breast reconstruction. This is considered later, on page 177.

Different types of mastectomy

Simple mastectomy

A simple mastectomy removes the breast tissue but does not remove all the lymph glands or the chest wall muscles. If you have larger breasts then it may be better to remove the breast through the type of cut used for breast reduction which gives an upside-down T scar.

When performing a mastectomy a cut is made above and below the nipple and all the breast tissue down to the chest wall muscle is removed. Sufficient skin is removed so that at the end of the operation there will be no loose skin and a flat straight scar is left on the chest wall. The exact direction of the wound scar depends on where the tumour is situated but most mastectomy scars are horizontal or diagonal.

Modified radical mastectomy

This is performed through the same incision as a simple mastectomy. It involves removal of the breast and all the lymph nodes that drain the breast in the axilla. It is usually possible to do this without causing any damage to the chest wall muscles.

Radical mastectomy

This operation is hardly ever performed any more and involves removal of the breast, the axillary nodes and the underlying chest wall muscles.

Subcutaneous mastectomy

This is an operation that is performed in women with smaller cancers or DCIS, or who are at high risk of breast cancer. It removes all the breast tissue, but keeps as much skin as possible so that, when the breast is reconstructed, it looks as similar to the original breast shape as possible with very few visible scars. This operation is performed through an incision either under the nipple or at the edge of the breast. The nipple and the areola are left intact and no skin is removed.

Skin-sparing mastectomy

It is also possible to remove the breast through an incision that removes only a small amount of skin either over the cancer or around the nipple area. The advantage of a skin-sparing mastectomy is that the scars are kept to a minimum while at the same time all the breast tissue and skin over the tumour or the nipple are removed.

Removal of lymph glands during mastectomy

If all the lymph glands are being removed (axillary node clearance) or some of the axillary lymph glands are being removed (sentinel node biopsy or axillary node sample), this is usually performed through the same cut (incision) used to remove the breast.

What can you expect after the operation?

At the end of the operation, one or two drains are placed and these come out below the wound. Drains are plastic tubes that drain fluid which the body produces into the space under the skin. These drains are left in place for between three and five days. They are removed when the amount of fluid coming out of the drain reduces.

After mastectomy you may be in hospital between one and seven days depending on the extent of the surgery, whether you had a reconstruction at the same time and the policy of the hospital at which you are treated.

Problems that can occur after mastectomy

The most common complications immediately after operation are bleeding and feeling unwell after a general anaesthetic.

The edges of the mastectomy wound may not heal because of problems with the blood supply. If this happens the edges may become inflamed and can scab. This usually settles without any specific treatment. It is more likely when more skin is kept as in a subcutaneous (or skin-sparing) mastectomy and is also more common in women with diabetes or who smoke.

There can be extra tissue or lumpiness at the outer edge of the scar under the armpit. This lumpiness and swelling can settle over a period of time. Occasionally this extra tissue (the common name for this is a ‘dog ear’) needs to be trimmed at a later date.

Fluid can build up after the drains are removed which causes a swelling under the wound, called a seroma. If this is uncomfortable then a needle can be used to drain it.

Looking at yourself either from above or in the mirror after surgery can be difficult, traumatic and very emotional. Some women are surprised at how neat the scar is, but most find it upsetting when they see it for the first time. There is no right time to look. Some women prefer to wait; others want to look immediately. You might want to do this when you have someone with you such as a breast care nurse.

Options for women with large tumours

If your surgeon tells you that your tumour is not suitable for breast-conserving surgery, there may be other options for you, which might include one of the following.

Primary systemic therapy

This involves having drug therapy as the first treatment so-called primary systemic therapy.

The aim of this treatment is to shrink the cancer down to a size where it can be removed by a lumpectomy. The drug treatment is most commonly chemotherapy, but increasingly hormone therapy is being used to shrink cancers in older women.

Very wide excision with reconstruction

Removal of a large part of the breast and replacement with tissue from elsewhere in the body (usually the back) is an option for some women. This is called partial breast reconstruction.

Mammoplasty

If removal of the cancer would make the breast smaller, it is possible at the same time to make the other breast smaller to match. This type of surgery is known as reduction mammoplasty. It is performed in only a few units, and is suitable for women with large tumours in reasonable sized breasts. If you have larger breasts and have always wanted them to be made smaller this may be an option for you.

Axillary surgical treatment for breast cancer

One of the first places that breast cancer spreads to is the lymph glands under the arm. There are a number of different axillary lymph node operations that are performed and the choice of surgery depends on the chances that the lymph nodes are likely to be affected.

Sometimes it is possible to see abnormal lymph nodes before operation using ultrasound and to biopsy them. In most instances, however, it is necessary for the surgeon to remove some or all of the lymph glands to have them tested.

When you have either breast-conserving surgery or mastectomy the surgeon will usually check whether your lymph glands are involved by removing a sample of them or all the lymph glands under your arm if they have been tested and shown to be affected.

Lymph node biopsy

A lymph node biopsy removes lymph node tissue with a needle to be looked at under a microscope for signs of infection or a disease, such as cancer. The needle can be a fine needle or a core needle (see page 53).

There are around 20 lymph glands under your arm and these are the most common place to which breast cancer may spread. Knowing whether this has happened and how many lymph glands are affected is important in both assessing the stage of the cancer and deciding the best type of treatment.

If all the surgeon wants to do is to test the lymph glands, removing the few lymph glands that drain the cancer is sufficient. If the lymph glands are known to be affected, removing them is effective treatment at controlling any disease in these lymph glands. To know exactly how many lymph glands are involved it is necessary to remove all of them. You do not need the lymph glands under your arm and your body can manage to function perfectly normally without these. Removing all the glands does, however, increase the rate of postoperative complications and increases the long-term chances of you getting swelling of your arm – lymphoedema.

Sampling the glands to test them

There are now a variety of methods available to check whether breast cancer has spread into the lymph glands.

Sentinel node biopsy

The first lymph node(s) draining a cancer is known as the sentinel node(s). In sentinel node biopsy a specially trained surgeon removes only these sentinel nodes to see if the cancer has reached them.

The sentinel nodes are identified by injecting blue dye plus a radioactive tracer material into the breast. This passes up to the lymph glands, and the surgeon then finds the draining or sentinel lymph glands because they are either stained blue or radioactive.

The radioactivity is detected with a small hand-held probe, which makes a loud noise when a lot of radioactivity is present in a particular lymph node. On average, a surgeon will find three sentinel nodes per patient.

Usually the radioactive injection is given two to three hours before surgery. The blue dye is injected at the time of surgery after you are unconscious. It has recently been shown that injecting both the radiotracer and blue dye together just before operation when you are under anaesthetic produces satisfactory results and saves the patient from having an injection when they are awake.

The most common places for injecting the blue dye and the radioactivity are around the cancer, into the skin over the cancer and underneath the nipple. Wherever the breast is injected, drainage is to the same few lymph nodes under the arm.

Sentinel node biopsy is successful at finding nodes in 98 of every 100 women. If the surgeon is planning a sentinel node biopsy but no sentinel nodes are found he or she will perform an axillary sample or remove sufficient nodes to check whether the cancer has reached them.

If a sentinel node biopsy shows that your lymph glands are affected by cancer your doctor may recommend that you have either a second operation to remove all the remaining lymph glands or radiotherapy to the remaining glands.

Axillary node sampling

Lymph node sampling aims to remove four lymph glands to check whether any of them is affected by cancer. Any cancer that spreads to the lymph glands under your arm affects the lowest lymph glands first, which is why sampling four of these low lymph glands checks, with a great degree of accuracy, whether any glands are affected.

Sampling is usually combined with injection of blue dye under the nipple to increase the certainty that the nodes removed are likely to induce the sentinel nodes draining the cancer.

Both sentinel node biopsy and axillary node sampling are performed through a small cut (incision) in your armpit just below where the hair grows. At the end of the operation the wound is closed with an invisible stitch that does not need to be removed.

If any of the sentinel nodes or sampled nodes contain cancer, the remaining lymph glands will need to be treated either by a second operation to remove the remaining nodes or by a course of radiotherapy.

Selection of different axillary treatments

Sentinel lymph node biopsy is a good option when there are no obvious lymph glands to feel and no abnormal lymph glands visible on ultrasound. It can be used before or after chemotherapy.

Most units have a policy on who is suitable for sentinel node biopsy. It is important to understand exactly which operation you are having and why the surgeon is recommencing that particular procedure for you. Not all breast units offer sentinel node biopsy. Ask because it may be possible to refer you to another hospital if that is the best option for you.

Axillary node clearance

Lymph node clearance aims to remove all the lymph glands. It checks exactly how many are involved. It removes all the nodes so that no affected nodes are left behind. It is performed only in patients whose lymph glands have been shown to be affected by scanning and biopsy of the nodes either with a needle or after surgery to remove the sentinel nodes.

The operation is performed through a slightly larger cut in your armpit than that used for sentinel node biopsy. At the end of the operation the wound is closed with an invisible stitch that does not need to be removed.

A drain is usually placed after axillary clearance to remove the fluid that the body produces in the days after the operation. The drain usually remains in place for between three and five days. It is possible for you to go home with your drain still in place. Please ask your surgeon if you would like further information about this.

Problems that can happen after axillary node surgery

The most common problem is pain, swelling and discomfort under the arm which lasts for a few weeks. Do not be afraid to take regular painkillers. Ensure that the arm keeps mobile by practising the exercises taught to you while in the ward.

The most common complications immediately after operation are bleeding and feeling unwell after a general anaesthetic.

Numbness

There are a number of nerves that pass through the armpit to the inner side of the arm. The nerves that supply feeling to the upper inner part of the arm are sometimes damaged during removal of all the lymph glands. Your surgeon will make every attempt not to damage these nerves. They are much less commonly damaged during sentinel lymph node biopsy.

Even if the nerves have not been cut they will be stretched and so this area may feel numb and it will take some time after surgery before normal feeling returns. You should therefore be prepared for some slight loss of feeling in the upper inner part of the arm on the side of the surgery. In about half of patients this recovers during the first few months after operation.

Shoulder stiffness

You will be taught a series of exercises after surgery by a physiotherapist. It is important that these are carried out. Shoulder stiffness and reduction in the movement of the shoulder are common problems in those who do not manage to do their shoulder exercises.

You may get some pain and discomfort after surgery and experience soreness when performing your exercises. Do not be afraid to take regular painkillers after surgery because this will make it less painful and allow you to do your exercises with less discomfort.

During this period of recovery, there may be some pain or discomfort down the inside of your upper arm, but this usually settles after a few weeks.

Lymphoedema

Lymphoedema or swelling of the arm (caused by collection of fluid in the tissues after removal of or damage to lymph nodes) can follow removal of all the axillary lymph nodes (axillary clearance) or may occur if, after a sentinel node biopsy or axillary node sampling, radiotherapy is given to the axilla.

About 6 in every 100 women develop significant arm swelling after axillary clearance. The severity of swelling and chances of getting swelling are much less after sentinel node biopsy and radiotherapy.

Arm swelling or lymphoedema can occur many years after an operation. Specialist assessment and treatment are required and may involve referral to a physiotherapist.

Treatment consists of skin care, regular massage, active exercise, and wearing a sleeve or other compression garment.

Physical management of lymphoedema

Lymphoedema is chronic swelling that is essentially incurable. Physical symptoms can be controlled with treatment.

The four cornerstones of treatment are:

1. Skin care to maintain good skin condition and reduce the risk of infection

2. Exercise to promote lymph flow and maintain good limb function

3. Manual lymphatic drainage – gentle skin massage encourages lymph flow and is carried out by a trained therapist

4. Support/compression – multilayer lymphoedema bandaging is applied to reduce the size and improve the condition of the limb to allow fitting of elastic compression garments, which, when fitted correctly, control swelling and encourage lymph flow

General complications after surgery for breast cancer

Bleeding

Even though all visible bleeding is stopped during the operation, bleeding from the cut edges of the breast tissue can occasionally start afterwards and cause blood to collect in the wound. This is uncommon, and happens in 1–2 of every 100 patients. It is more common after mastectomy than lumpectomy.

The normal time for this to develop is within the first few hours after the operation. This is the reason for checking the wound after surgery. If a large amount of blood collects (called a haematoma), this needs to be drained, usually by a second operation.

Seroma

The body produces its own natural healing fluid. Some people produce more than others and this can cause swelling at the site where the lump or the lymph glands have been removed. This is known as a seroma.

The fluid may require removal with a needle and syringe when you return to the clinic. As the area is often numb after surgery, this is usually a painless procedure.

Infection

Any operation wound can become infected. It is uncommon to get infection in breast wounds but approximately 1 in 10 women does get some infection after breast cancer surgery. If infection develops, it is often a week after surgery before any features show.

Signs of wound infection include the wound being red, swollen and very tender, and there may also be a discharge through the wound. Most infections settle with antibiotics.

Deep venous thrombosis

This is when clots form in the veins of the legs. These clots can move from the veins in the legs up to the lung (called a pulmonary embolus). This is uncommon because, when you are in hospital, the doctors and nurses take specific precautions to stop this happening.

These precautions involve wearing stockings to support the veins, having regular injections into your stomach of drugs that thin the blood to stop it clotting, and having special boots that you wear in the operating theatre which keep the blood in your legs flowing.

Pain after operation

Although the acute pain after surgery will settle within a few weeks of the operation, the area where you have had surgery can feel uncomfortable for months and years.

After breast surgery, some women develop chronic pain. This can be made worse if you suddenly increase activity such as going to the gym or gardening. Pain is rarely a symptom that the cancer is back and usually responds to medication and regular gentle exercise.

Frozen shoulder

This is not uncommon after an operation on the lymph glands under the arm. It is easier to stop this than treat it. Following the exercises recommended by your care team usually prevents this complication. If you find your shoulder becoming stiff and your shoulder movement is restricted report this to your doctor.

Fat necrosis

Any operation damages the surrounding tissue. This is sometimes a problem for the blood supply of the fat in the breast (or in tissue brought into the breast for a reconstruction). This can cause areas of fat to die (necrosis) which can form a worrying lump. Simple tests can quickly prove that such a lump is innocent.

Cording

After surgery on the breast or axilla, blood and lymphatic vessels in the area, including in the upper arm, get blocked or are no longer connected to a lymph node, so the vessel collapses and becomes fibrous. If the fibrous tissue tightens it produces tight bands across the armpit, below the breast and down the arm. This is colloquially called ‘cording’. It can be painful. Regular exercises stretch the cords and they usually settle with time. Rarely the cords need to be divided surgically.

KEY POINTS

• Surgery for breast cancer usually involves either an operation to remove the cancer lump (followed by radiotherapy – called breast-conserving surgery) or an operation to remove the whole breast (called mastectomy)

• The decision on the appropriate surgery depends on the site and the size of the cancer in the breast relative to the size of the breast

• If an invasive cancer is present the armpit lymph nodes will be checked to see if there is any sign of spread of the cancer

• This is best done by taking the first few lymph nodes that drain the cancer (sentinel node biopsy)

• Axillary node clearance is a bigger operation which removes all the nodes in the armpit if there are cancer cells in the lymph nodes

• If only a few lymph nodes have been taken and there are cancer cells in them, further treatment with either another operation to remove the rest of the lymph nodes or radiotherapy to the armpit will be needed

•