Types of surgery for breast cancer

The surgery you have depends on the stage of the breast cancer and what you decide is right for you.

Your surgeon usually tries to keep as much of the breast as possible (breast-conserving surgery, or lumpectomy), although you may need to have the whole breast removed (mastectomy). The chances of surviving early breast cancer are similar with breast-conserving surgery and radiotherapy, or a mastectomy.

During the operation, your surgeon may remove some or all of the lymph nodes in your armpit to check them for cancer cells. There are different types of lymph node surgery

If you are having a mastectomy, your surgeon will ask if you want a new breast shape to be made at the same time. This is called breast reconstruction.

You may be asked to decide which operation you have, in this situation you will be given time to talk it over carefully with your surgeon and breast care nurse. Make sure you have the information you need to make the right decision for you.

Surgery for breast cancer

Surgery is one of the main treatments for breast cancer. The operation you have depends on:

  • the size of the cancer
  • the position of the cancer
  • your own preference.

Your surgeon and breast care nurse will talk to you about your options. You may be asked to decide which operation you have.

Your surgeon will usually recommend breast-conserving surgery. This keeps as much of the breast tissue and the shape of the breast as possible. In some situations, they may recommend having the whole breast removed (mastectomy). Your surgery will usually include removing some or all of the lymph nodes in your armpit .

Some women have hormonal therapy or chemotherapy before their operation. The aim is to shrink the cancer to avoid a mastectomy.


Wide local excision (breast conserving surgery)

The surgeon removes the cancer and some normal looking tissue around it (the margin). This is called a wide local excision (WLE). It may also be referred to as a lumpectomy.

In early breast cancer, having a WLE followed by radiotherapy is as effective as a mastectomy. Having radiotherapy after a WLE reduces the risk of the cancer coming back in the breast.

If the cancer is very small, you may need a fine wire to mark the area so the surgeon can find it more easily. This is called wire localisation.

After a WLE, most women are pleased with the appearance of their breast.

Removing a larger area of breast tissue

Some women need to have a larger area of breast tissue removed. Surgeons can use different ways to help improve the appearance of your breast if you need a lot of tissue removed. They may reshape the breast by moving the breast tissue around and making it smaller. Sometimes, they take tissue from somewhere else in the body to help reshape the breast.

Or, they may suggest you have the other breast made smaller so both breasts are the same size. This can be done at the same time as surgery or at a later time.

You will still need radiotherapy as part of your treatment.

Clear margins

After breast-conserving surgery, the pathologist examines the tissue that has been removed. They check the area (margin) around the cancer. If there are cancer or pre-cancer cells (DCIS) at the edges, you will need another operation to remove more tissue. Making sure the margins are clear reduces the risk of the cancer coming back in the breast.

If your surgeon doesn’t think another breast-conserving operation is likely to be successful, they usually recommend a mastectomy.


Removing the breast (mastectomy)

Breast surgeons usually try to do an operation that means you can keep your breast (breast conserving surgery). But there are situations when they may recommend a mastectomy. This may be when:

  • the lump is large in proportion to the rest of your breast
  • there is cancer in different parts of the breast
  • there is widespread DCIS in the breast
  • you have had radiotherapy to the chest before to treat another cancer, such as Hodgkin lymphoma.

Breast reconstruction

If you are having a mastectomy, your surgeon will usually ask if you want a new breast shape made at the same time. This is called immediate breast reconstruction. You can choose to delay reconstruction until after you have completed radiotherapy or chemotherapy.

You may decide not to have immediate reconstruction. But if you want reconstruction in the future, it’s best to mention this before you have a mastectomy. You don’t have to make a definite decision at this stage, but it will help the surgeon to plan your initial surgery.

Breast reconstruction is specialised surgery carried out by a plastic surgeon or oncoplastic surgeon. There are different types of reconstruction. A new breast shape can be made using:

  • a silicone implant
  • tissue taken from another part of your body.

You may be able to talk to a plastic surgeon before surgery about your options for reconstruction.


Treatment decisions

The chances of surviving early breast cancer are similar whether you have breast-conserving surgery and radiotherapy or a mastectomy. Your surgeon and specialist nurse may ask you to choose the treatment you feel suits you best.

Making treatment decisions can be difficult. It’s important to talk it over carefully with your surgeon and breast care nurse. Make sure you take your time and have the information you need to make the right decision for you. You may also want to talk it over with someone close to you, such as a partner, family or friends.

You can also get support by calling our cancer support specialists on 0808 808 00 00.

It’s helpful to think about the possible advantages and disadvantages before making a decision.

Breast-conserving surgery and radiotherapy

Advantages

  • it keeps the appearance and sensation of the breast
  • recovery is shorter and easier than with a mastectomy
  • it may be less likely to affect your sex life and relationships.

Disadvantages

  • you may need more than one operation to get clear margins
  • you need three or more weeks of radiotherapy after the surgery (some women will also need radiotherapy after a mastectomy)
  • radiotherapy has short-term side effects, and some women may have long-term side effects.

Mastectomy

Advantages

  • You may not need radiotherapy after a mastectomy. But some women will need it. Ask your cancer specialist about this.
  • You may feel less anxious.

Disadvantages

  • you lose your breast permanently
  • it takes longer to recover after having a mastectomy
  • it changes your appearance, which may affect your confidence, sex life and relationships
  • you will need a longer operation and possibly further surgery if you want breast reconstruction afterwards. However, reconstruction may help to reduce other disadvantages for some women.


Surgery to the lymph nodes

Your surgeon may remove some or all of the lymph nodes in your armpit to check them for cancer cells. This can:

  • get rid of any lymph nodes that contained cancer cells (you may need more treatment if only some nodes were removed)
  • give information about the stage of the cancer, which helps when making decisions about having other treatments.

There are different types of lymph node surgery.

Sentinel lymph node biopsy (SLNB)

A sentinel lymph node biopsy is a way of checking lymph nodes in the armpit. SLNB isn’t suitable for everyone. It may be done if:

  • you had a small cancer
  • the ultrasound of your armpit was normal.

Surgeons remove the smallest number of lymph nodes possible (usually one to three) to see if there are any cancer cells. Removing only a small number of lymph nodes reduces the risk of side effects that can occur after lymph node surgery. These include swelling of the arm known as lymphoedema and stiffness of the arm.

The lymph nodes that are the most likely to have cancer cells are called the sentinel lymph nodes. These are the first ones that lymph fluid drains to from the breast.

If there are no cancer cells in the sentinel nodes you won’t need surgery to remove more lymph nodes.

If any nodes from the SLNB contain cancer cells, your cancer specialist will talk to you about further treatment.

You may be offered another operation to remove the remaining lymph nodes. Some women have radiotherapy to the rest of the lymph nodes instead of more surgery.

Your surgeon will explain if SLNB is an option for you.

How an SLNB is done

Before the sentinel lymph nodes can be removed, the surgeon needs to check which nodes are the sentinel lymph nodes.

On the day of surgery, or sometimes the day before, the doctor injects a harmless amount of radioactive liquid into your breast. During the operation, the surgeon uses a handheld machine to find the lymph nodes that have picked up the radioactivity. The surgeon also injects a blue dye into your breast during the operation. This stains the lymph nodes blue. The lymph nodes that absorb the radioactivity or become blue first are the sentinel lymph nodes.

The surgeon can then remove blue or radioactive nodes (sentinel nodes). These are tested to see if there are any cancer cells.

Removing all the lymph nodes

In some cases, the surgeon will recommend removing all the lymph nodes in the armpit. This is called an axillary lymph node dissection (ALND). It aims to get rid of any nodes that contain cancer cells. An ALND is usually done when:

  • there are cancer cells in the fine needle aspiration (FNA) of the lymph nodes
  • the SLNB or sampling shows there are cancer cells in the nodes.

There is an increased risk of developing swelling of the arm called lymphoedema after having an ALND.

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