VIDEO: Breast Cancer Surgeries – Lumpectomy, Mastectomy, and Lymph Node Removal * 2023
VIDEO: Breast Cancer Surgeries – Lumpectomy, Mastectomy, and Lymph Node Removal * 2023

Mastectomy or breast removal

Deciding between a mastectomy and lumpectomy can be difficult. Both procedures are equally effective for preventing a recurrence of breast cancer. But a lumpectomy isn’t an option for everyone with breast cancer, and others prefer to undergo a mastectomy.

Newer mastectomy techniques can preserve breast skin and allow for a more natural breast appearance following the procedure. This is also known as skin-sparing mastectomy.

Surgery to restore shape to your breast — called breast reconstruction — may be done at the same time as your mastectomy or during a second operation at a later date.


Stage of breast cancer requires a mastectomy

When the tumor is small enough to be completely eliminated by removing only a third or less of your breast tissue, your healthcare provider may recommend a partial mastectomy (lumpectomy). Large tumors often require a complete mastectomy (removal of your entire breast). So, while you may only need to have part of your breast removed in earlier stages, it all depends on your breast size and the size of the tumor.

You may be at higher risk of developing a second cancer if you’re genetically predisposed or if you’ve had breast cancer before. So, under those circumstances, a complete mastectomy can help treat your current cancer and prevent a second cancer in the future. Stage IV (metastatic breast cancer) is too far advanced for effective treatment with surgery.

Before surgery

Prior to undergoing the mastectomy, it is important to meet with the surgeon to discuss the relevant risks and benefits of receiving the surgery. Depending on the indication for mastectomy, there may be other options to address the clinical condition. One important consideration to discuss with the surgeon is whether breast reconstruction will occur and when this procedure will take place. One option is to have the reconstruction immediately after the mastectomy in the same surgery, whereas other patients opt for a subsequent surgery for reconstruction. This breast reconstruction surgery will be conducted by a plastic surgeon. In addition to the surgeon, a meeting with an anesthesiologist is pertinent in order to review the patient’s medical history and determine the plan of anesthesia.

Leading up to the day of the surgery, there are various considerations that patients can be cognizant of to facilitate their recovery following surgery. As with other surgeries that may lead to appreciable blood loss, it is advised not to take aspirin or aspirin-containing products for 10 days before the surgery. The reason for this is to prevent the anti-coagulative function of aspirin and other blood thinners that would make it difficult to achieve coagulation during the surgery. In addition, it is important for patients to tell the doctor about any medications, vitamins, or supplements that they are taking because some substances could interfere with the surgery. It is also pertinent for patients to not eat or drink 8 to 12 hours before surgery, however, there may be specific pre-operative instructions given by each patient’s care team.

Maintaining fitness and proper nutrition is also an important measure to consider prior to receiving a surgery because it has been shown that postoperative outcomes are improved in patients that exercise and maintain a healthy diet prior to surgery. In addition to nutrition and exercise, it is advised to reduce alcohol consumption and smoking. This concept of pre-rehabilitation is beneficial in mitigating post-operative complications and decreasing length of stay in the hospital. The rationale is that increasing a patient’s functional status prior to surgery will allow for a smoother and faster recovery in the postoperative setting.

Recent research has indicated that mammograms should not be done with any increased frequency than the normal procedure in women undergoing breast surgery, including breast augmentation, mastopexy, and breast reduction.

After surgery

Prior to leaving the hospital, people who have had a mastectomy will typically be given a prescription for pain medication to ameliorate any pain or discomfort at the surgery site. Recognizing signs of a surgical site infection including fever, redness, swelling, or pus is important. Any signs of infection should be reported to and assessed by a medical professional. In addition, signs of lymphedema due if lymph node removal is performed during mastectomy may be detected by the presence of heaviness, tightness, or fullness in the hand, arm, or axillary area region.

Regarding return to activity, it is advised not to engage in strenuous activity or lift objects above 5 pounds for up to six weeks after a mastectomy at the discretion of the physician. However, it is common for a member of the medical team to provide home exercises designed to maintain arm and shoulder movement and flexibility. Walking is also highly encouraged and allowed immediately after surgery. Most people who undergo a mastectomy can return to work and other regular physical activities in approximately 4 weeks after surgery.

People who have had a mastectomy will usually have a post-operative follow-up visit with their provider 1–2 weeks after surgery. The time at which a person can start to wear a bra or reconstructive breast varies and is often at the discretion of the physician.

Some people with breast cancer may require additional radiotherapy after their mastectomy procedure, with the goal of reducing the risk of the cancer returning to the lymph nodes and the tissue remaining in the wall of the person’s chest. The decision by the medical team for suggesting radiotherapy may differ between individual professionals. Most teams recommend radiotherapy after a masectomy for people who are at a higher risk of cancer recurrence, including those with large breast tumours (5 cm and larger) and people with cancer that has spread to multiple axillary lymph nodes (4 or more). The necessity and usefulness of radiotherapy on people at slightly lower risk, for example, the cancer has spread to 1-3 axillary lymph nodes, is not as clear.

Types of mastectomy

There are several surgical approaches to mastectomy, and the type that a person decides to undergo. Or whether they will decide instead to have a lumpectomy, depends on factors such as the size, location, and behavior of the tumor (if one is present). Whether or not the surgery is prophylactic, and whether the person intends to undergo reconstructive surgery.

Simple mastectomy (or “total mastectomy”):

In this procedure, the entire breast tissue is removed, but axillary contents are undisturbed. Sometimes the “sentinel lymph node”—that is, the first axillary lymph node that the metastasizing cancer cells would be expected to drain into—is removed. People who undergo a simple mastectomy can usually leave the hospital after a brief stay. Frequently, a drainage tube is inserted during surgery in their chest and attached to a small suction device to remove subcutaneous fluid. These are usually removed several days after surgery as drainage decrease to less than 20-30 ml per day.

People that are more likely to have the procedure of a simple or total mastectomy are those that have large areas of ductal carcinoma in situ or even those persons that are removing the breast because of the possibility of breast cancer occurring in the future (prophylactic mastectomies).

When this procedure is done on a cancerous breast, it is sometimes also done on the healthy breast to forestall the appearance of cancer there. The choice of this “contralateral prophylactic” option has become more typical in recent years in California, most notable in people younger than 40, climbing from just 4 percent to 33 percent from 1998 to 2011.

However, the possible benefits appear to be marginal at best in the absence of genetic indicators, according to a large-scale study published in 2014. For healthy people known to be at high risk for breast cancer, this surgery is sometimes done bilaterally (on both breasts) as a cancer-preventive measure.

Modified radical mastectomy:

The entire breast tissue is removed, along with the axillary contents (fatty tissue and lymph nodes). In contrast to a radical mastectomy, the pectoral muscles are spared. This type of mastectomy is used to examine the lymph nodes because this helps to identify whether the cancer cells have spread beyond the breasts.

Radical mastectomy (or “Halsted mastectomy”):

First performed in 1882, this procedure involves removing the entire breast, the axillary lymph nodes, and the pectoralis major and minor muscles behind the breast. This procedure is more disfiguring than a modified radical mastectomy and provides no survival benefit for most tumors. This operation is now reserved for tumors involving the pectoralis major muscle or recurrent breast cancer involving the chest wall. It is only recommended for breast cancer that has spread to the chest muscles. Radical mastectomies have been reserved for only those cases because they can be disfiguring, and modified radical mastectomies have been proven to be just as effective.

Skin-sparing mastectomy:

In this surgery, the breast tissue is removed through a conservative incision made around the areola (the dark part surrounding the nipple). The increased amount of skin preserved as compared to traditional mastectomy resections serves to facilitate breast reconstruction procedures. People with cancers that involve the skin, such as inflammatory cancer, are not candidates for skin-sparing mastectomy.

The effectiveness and safety profile of skin-sparing mastectomy procedures have also not been well studied. In a skin sparing masectomy, the skin flap may be perfused with fluids and indocyanine green angiography is sometimes suggested to help prevent the skin that has been saved from dying to improve reconstruction if their person wishes. There is no clear evidence on the effectiveness of this approach.

Nipple-sparing/subcutaneous mastectomy:

Breast tissue is removed, but the nipple-areola complex is preserved. This procedure was historically done only prophylactically or with mastectomy for the benign disease over the fear of increased cancer development in retained areolar ductal tissue. Recent series suggest that it may be an oncologically sound procedure for tumors not in the subareolar position.

Extended Radical Mastectomy:

Radical mastectomy with intrapleural en bloc resection of internal mammary lymph node by sternal splitting.

Prophylactic mastectomy:

This procedure is used as a preventive measure against breast cancer. The surgery is aimed to remove all breast tissue that could potentially develop into breast cancer. The surgery is generally considered when a woman has BRCA1 or BRCA2 genetic mutations. The tissue from just beneath the skin to the chest wall and around the borders of the breast needs to be removed from both breasts during this procedure. Because breast cancer develops in the glandular tissue, the milk ducts and milk lobules must be removed also.

Because the region is so large-ranging, from the collarbone to the lower rib margin and from the middle of the chest around the side and under the arm, it is very difficult to remove all the tissue. This genetic mutation is a high-risk factor for the development of breast cancer, family history, or atypical lobular hyperplasia (when irregular cells line the milk lobes.) This type of procedure is said to reduce the risk of breast cancer by 100%. However, other circumstances may affect the outcome. Studies have shown that pre-menopausal women have had a higher survival rate after this procedure had been done.

Who might get a mastectomy

Many women with early-stage cancers can choose between breast-conserving surgery (BCS) and mastectomy. You may prefer mastectomy as a way to “take out all the cancer as quickly as possible.” But the fact is that in most cases, mastectomy does not give you any better chance of long-term survival compared to BCS. Studies of thousands of women over more than 20 years show that when BCS is done along with radiation, the outcome is the same as having a mastectomy.

Mastectomy might be recommended if you:

  • Are unable to have radiation therapy
  • Would prefer more extensive surgery instead of having radiation therapy
  • Have had the breast treated with radiation therapy in the past
  • Have already had BCS with re-excision(s) that did not completely remove the cancer
  • Have two or more areas of cancer in different quadrants of the same breast (multicentric) that are not close enough to be removed together without changing the look of the breast too much
  • Have a tumor larger than 5 cm (2 inches) across, or a tumor that is large relative to your breast size
  • Are pregnant and would need radiation therapy while still pregnant (risking harm to the fetus)
  • Have a genetic factor such as a BRCA mutation, which might increase your chance of a second cancer
  • Have a serious connective tissue disease such as scleroderma or lupus, which may make you especially sensitive to the side effects of radiation therapy
  • Have inflammatory breast cancer
  • NYU Langone doctors may recommend the procedure for men who have extensive ductal carcinoma in situ and those who have a large invasive cancer or multiple tumors.

For women who are worried about breast cancer coming back, it is important to understand that having a mastectomy instead of breast-conserving surgery plus radiation only lowers your risk of developing a second breast cancer in the same breast. It does not lower the chance of the cancer coming back in other parts of the body, including the opposite breast.

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