Professor Zoe Winters PhD (Oxon), FRCS (Edin), FCS (SA) SFHEA
There are two types of surgery for breast cancer. These are surgery to remove just the cancerous lump (tumour), known as breast-conserving surgery, and surgery to remove the whole breast, which is called a mastectomy. In many cases, a mastectomy can be followed by reconstructive breast surgery to recreate the breast that was removed.
Studies have shown that breast-conserving surgery followed by radiotherapy is as successful as total mastectomy in treating early-stage breast cancers.
Breast-conserving surgery ranges from a lumpectomy or wide local excision (WLE), in which just the tumour and a little surrounding breast tissue is removed, to a partial mastectomy or quadrantectomy, in which up to a quarter of the breast is removed.
If you have breast-conserving surgery, the amount of breast tissue you have removed will depend on:
Your surgeon will always remove an area of healthy breast tissue around the cancer, which will be tested for traces of cancer. If there is no cancer present in the healthy tissue, there is less chance that the cancer will recur. If cancer cells are found in the surrounding tissue, you may need to have more tissue removed from your breast.
After breast-conserving surgery, you will usually be offered radiotherapy to destroy any remaining cancer cells.
Simple Mastectomy, Preventive or Partial
A simple mastectomy is the removal of all the breast tissue, including the nipple in most cases. If there are no obvious signs that the cancer has spread to your lymph nodes, you may have a mastectomy, in which your breast is removed, along with a sentinel lymph node biopsy (SLNB).
What is preventive mastectomy?
Women who have a high genetic or familial risk of breast cancer may choose to have preventive mastectomy surgery. Preventive mastectomy is also called prophylactic mastectomy. It may be a total mastectomy with the removal of the entire breast and nipple. Or it may be a subcutaneous mastectomy, where the breast is removed but the nipple is preserved.
Studies show that the occurrence of breast cancer may be reduced by 90% or more after preventive mastectomy in women with a high risk of this disease. Sometimes, women who have had breast cancer in one breast will decide to have a preventive mastectomy to remove the other breast. This can reduce the chance of other breast cancers recurring. In some cases both breasts are removed. This is called a double mastectomy.
Breast reconstruction can be done at the time of the preventive mastectomy. When this happens it is called an immediate reconstruction. Breast reconstruction can also be scheduled for a later time as a delayed procedure. During breast reconstruction the surgeon may use synthetic implants or tissue flaps from another part of your body.
What is a partial mastectomy?
Doctors may perform a partial mastectomy on women with stage I or stage II breast cancer. The partial mastectomy is breast-conserving therapy where the part of the breast containing the tumour is removed. This procedure is then followed by radiotherapy of the remaining breast tissue. With radiotherapy, powerful X-rays target some of the breast tissue. The radiotherapy kills cancer cells and prevents them spreading.
A lumpectomy removes just the tumour and a small cancer-free area of tissue surrounding the tumour. This is also called a wide local excision. If cancer cells are found later, the surgeon may remove more of the tissue. This procedure is called re-excision.
Another type of partial mastectomy is called a quadrantectomy. For this procedure, the surgeon removes the tumour and more of the breast tissue than is removed with a lumpectomy.
In some cases, more surgery is required after a partial mastectomy. Sometimes, if cancer cells are still in breast tissue, it may be necessary to remove the entire breast.
If the cancer has spread to your lymph nodes, you will probably need more extensive removal (clearance) of lymph nodes from the axilla (under your arm).
What is a simple mastectomy?
This is the complete removal of the breast tissue including the nipple. The surgeon may also remove most of the overlying skin or may preserve nearly all of the skin envelope. The procedure may be followed with an immediate breast reconstruction, which is performed by a breast cancer Consultant surgeon and /or a Consultant Palstic surgeon.
Along with the mastectomy to remove the tumour, the surgeon will determine if the breast cancer has spread. This is called staging. After the cancer has been staged using CT imaging of the chest and abdomen, the surgeon will prescribe appropriate follow-up treatment, which can include radiotherapy, chemotherapy and/or medicines.
Some women choose to begin breast reconstruction surgery immediately following the mastectomy. However there are risks to be considered. You should discuss these risks with your breast cancer Consultant.
Breast reconstruction is surgery to make a new breast shape that looks as much as possible like your other breast. Reconstruction can be carried out at the same time as a mastectomy (immediate reconstruction), or it can be carried out later (delayed reconstruction). It can be done either by inserting a breast implant or by using tissue from another part of your body to create a new breast. The goal of reconstruction is to restore symmetry between the two breasts by replacing skin, breast tissue and the appearance of the nipple and areola.
The surgeon may recommend a breast implant as part of the procedure.
Lymph node surgery
To find out if the cancer has spread, a procedure called a sentinel lymph node biopsy (SLNB) may be carried out. The sentinel lymph nodes are the first lymph nodes that the cancer cells reach if they spread. They are part of the lymph nodes under the arm (axillary lymph nodes). The position of the sentinel lymph nodes varies, so they are identified using a combination of a radioisotope and a blue dye.
The sentinel lymph nodes are examined in the laboratory to see if there are any cancer cells present. This provides a good indicator of whether the cancer has spread.
If there are cancer cells in the sentinel nodes, you may need further surgery to remove more lymph nodes from under the arm.