Surgery for breast cancer can be divided into three parts:

1. Operations to remove part or all of the affected breast.

The portion of the operation performed on the breast is designed to treat the cancer.

2. Operations to remove a sampling of the lymph nodes or the sentinel lymph node under the arm.

The portion of the operation performed on the lymph glands in the armpit (axilla) is designed to evaluate whether or not the cancer has spread as well as to remove the nodes into which the cancer has spread. This information is needed for further treatment decisions. This procedure is used as a means of diagnosis rather than a means of treatment.

3. Reconstruction to restore the form of the breast.

Lumpectomy/Partial Mastectomy/Segmental Mastectomy (Breast-Preserving Surgery)

Recent scientific studies involving thousands of early-stage breast cancer patients in the United States and in Europe demonstrate that breast-preserving treatment is as effective as either modified radical mastectomy or radical mastectomy for tumor control and survival.

Breast-preserving treatment involves both surgery (segmental mastectomy, partial mastectomy or lumpectomy) and radiation therapy to achieve the best possible results. These operations are designed to remove the breast cancer and preserve the breast shape. Initially, surgery is performed to remove the tumor in the breast and usually a sampling of the lymph nodes in the armpit.

After the patient has healed from surgery, external radiation therapy is used to treat the breast and the chest wall. In some patients, the lymph nodes behind the collarbone and the breastbone may also require treatment. To be effective in controlling cancer in the breast, radiation therapy (RT) lasting five to six weeks is usually given after any of these breast-preserving operations but particularly after a lumpectomy, which alone, without radiation therapy, is not adequate in most cases (the local recurrence rate is 20% without RT). 

Modified Radical Mastectomy

The term 'mastectomy' includes many different types of operations. With a modified radical mastectomy, the majority of breast tissue and skin over the breast, including the nipple/areola and a sampling of lymph nodes from the armpit, are removed. Sometimes the smaller muscle of the chest wall (pectoralis minor) is removed or the lining of this muscle removed but the larger muscle (pectoralis major) is left in place.

Total Mastectomy/Simple Mastectomy

This procedure involves only the removal of the breast; the lymph nodes are left intact. This surgery is referred to as a total or simple mastectomy and may be an option for patients diagnosed with carcinoma in situ that has not infiltrated the breast tissue.

Skin-sparing Mastectomy

This fairly new procedure is a variation on a total mastectomy in which the surgeon removes the breast tissue, nipple/areola and lymph nodes located near the breast tissue from a circular incision (approximately 4-1/2 centimeters in diameter) around the areola. An experienced surgeon is able to perform this procedure using a fiber optic retractor that allows the removal of the breast tissue through a small incision. Many women with early stage breast cancer are considered good candidates for a skin-sparing mastectomy. Skin-sparing mastectomies are often performed in conjunction with breast reconstruction. Preserving the skin results in women maintaining sensation in their reconstructed breast (but not in the rebuilt nipple and areola).

Radical (Halsted) Mastectomy

This operation is rarely performed today and is reserved for patients with extensive cancers of the breast that invade the underlying large muscle of the chest (pectoralis major). In addition to the entire breast, the lymph nodes in the armpit, the muscle of the chest wall and large amounts of skin are also removed. 

Prophylactic Mastectomy

A prophylactic mastectomy is the surgical removal of one or both breasts for the purpose of reducing the risk of breast cancer. Today, a typical prophylactic mastectomy involves the surgical removal of the entire breast and nipple (total mastectomy). Previously, surgeons may have performed a subcutaneous mastectomy; removing the breast tissue but sparing the nipple (this procedure is no longer recommended). Women may consider undergoing a prophylactic mastectomy (ies) for a variety of reasons:

• Having already undergone a mastectomy due to breast cancer, a patient might consider a prophylactic mastectomy to reduce the risk of developing cancer in her remaining breast.

• A patient diagnosed with lobular carcinoma in situ (LCIS) might consider the procedure because patients with this type of breast cancer have an increased risk of developing cancer in the same and/or in their opposite breast.

• Women with a strong family history, particularly if two or more first degree relatives developed breast cancer prior to age 50, might consider a prophylactic mastectomy to reduce their risk.

• Women with a strong family history of breast cancer and who test positive for BRCA-1 or BRCA-2, which are known breast cancer susceptibility genes, might also consider a prophylactic mastectomy to reduce their risk.

It is important to note that there is little information available on the effectiveness of prophylactic mastectomies. Physicians and patients must work closely together to weigh the risks and benefits of this procedure. It is important to keep in mind that undergoing a prophylactic mastectomy does not guarantee that a patient will not develop breast cancer, because it is almost impossible to remove all of the breast tissue with any type of mastectomy. Breast cancer can still develop in the remaining tissue. It is important for patients to examine their mastectomy scars every month to check for signs of a recurrence. 

Subcutaneous Mastectomy

This operation is rarely performed today and is considered a poor option by most surgeons and oncologists. In this procedure, the breast skin and nipple/areola are left intact and the majority (but not all) of the breast tissue is removed through a small incision. Subcutaneous mastectomies have been associated with a high rate of recurrence, typically within the area of the nipple/areola.

Axillary Lymph Node Dissection

This surgical procedure removes some (lymph node sampling) or most (lymph node dissection) of the lymph nodes in the armpit (axilla) and behind the large muscles of the chest. With a mastectomy, this procedure is performed after the surgeon has removed the breast without the need for an additional incision. In the case of lumpectomy, unless the tumor is located in the upper, outer quadrant of the breast near the patientís underarm where the surgeon can reach the lymph nodes through the incision used to remove the tumor; a second incision will be necessary. There is no way for the surgeon to predetermine how many lymph nodes will be removed. An average number is between 10 and 15 nodes. Axillary lymph node dissections are performed to determine if the cancer has spread and whether further treatment to prevent spread (metastasis) or recurrence of cancer is necessary. This procedure is not a means of treatment. 

Newer Techniques

Lymphatic Mapping and Sentinel Node Biopsy

Due to the rise in the early detection of breast cancer, there have been an increasing number of dissections in which the axillary lymph nodes are free of disease. A new procedure is currently being used to determine if a single axillary lymph node called the sentinel node is the first to receive malignant cells from a breast carcinoma and whether or not a 'clean' sentinel node can accurately and reliably forecast the histological characteristics of the remaining axillary lymph nodes and a disease-free axilla.

If, in fact, a clear sentinel node proves over time to be a reliable means of predicting an axilla free of cancer, the need to perform a complete axillary lymph node dissection may be eliminated.

Sentinel Node Biopsy is a technique developed to help avoid removal of a large sampling of lymph nodes from the underarm (axilla) area that may lead to swelling (lymphedema) in the arm. At present, lymphatic mapping involves the use of a dye (isosulfan blue dye) injected subdermally (below the skin), close to the tumor site, either alone or in combination with a radioactive isotope tracer (filtered technetium-labeled sulfur colloid) to locate and identify the sentinel lymph node (SLN) in the axilla. The surgeon observes the dye as it travels along the lymph channel that connects the breast to the axillary lymph nodes. The first lymph node that turns blue - the "sentinel node" or "gatekeeper" -- is removed and examined for tumor cells by a pathologist. If no tumor cells are found, it can be safely assumed that no tumor cells have spread into other lymph nodes. (This procedure should only be performed by surgeons who are experienced with it.) These additional therapies are designed to control and kill cancer cells that could be in other parts of your body. The advantage: Finding out the stage of your cancer.† Note: It is important that the physician performing this procedure has proven experience with this newer technique. It is important to know how many times he or she has done a sentinel node biopsy and if it is the standard of care in the medical center. 

Back to Treatment Options

Last Updated: 06/01/2004

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