A. Breast Conservation (generally referred to as a Lumpectomy or partial mastectomy):
In order to be a candidate for breast conservation the cancer needs to be localized to a small area of the breast so that we can encompass it with a lumpectomy. The components of Breast Conservation include:
(performed as an outpatient under twilight anesthesia)
- Lumpectomy: (with preoperative wire localization if not palpable). About 15% of the time the margins are found to be positive on final pathologic review and a second (30-45 min) procedure is necessary to remove more tissue and clear the margins. Pathology results are available 4-5 days after surgery.
- Sentinel lymph node biopsy: (using blue and radioactive dye). Sentinel node biopsy is not necessary for most noninvasive cancers (DCIS). Please note that the blue dye will cause the urine to be blue for approximately 24 hours after surgery. Generally, 1-3 sentinel nodes are removed. If the nodes do not contain cancer then no further surgery under the arm is necessary. If the nodes are positive for cancer cells then a follow-up axillary dissection may be necessary, however the trend is to do fewer axillary dissections especially since new evidence suggests that in some cases it is not necessary.
- Axillary Dissection: This is the removal of additional lymph nodes and may be required if your sentinel nodes contain cancer. If performed, a small drain will be placed under the arm and it will remain in place for 10-14 days. This procedure raises the risk of lymphedema (arm swelling) to approximately 15-20%, compared to sentinel node biopsy alone which has a 1-2% risk of lymphedema.
- Radiation Therapy: Lumpectomy patients generally require postoperative radiation therapy, which is given 5 days/week for 6-7 weeks. You may be a candidate for a newer technique called Partial Breast Irradiation (PBI). Patients with small, low-grade DCIS may not require radiation. You will consult with a Radiation Oncologist regarding post-operative radiation therapy and your options.
- Chemotherapy: Chemotherapy is a combination of drugs given intravenously to kill any cells that may have escaped to other parts of the body prior to surgery. The recommendation for chemotherapy is made by the Medical Oncologist and depends on a number of factors such as patient age, size of tumor, lymph node involvement, grade, estrogen receptor status, etc. Radiation therapy and chemotherapyhave different goals and are not mutually exclusive.
Patients who have very large cancers or cancer cells scattered over a large portion of the breast are not candidates for breast conservation and therefore require a mastectomy: Some patients may prefer a mastectomy even if they are candidates for breast conservation. Radiation is usually not necessary after a mastectomy. Mastectomy options include:
- Skin-sparing mastectomy with immediate reconstruction:
This procedure involves removal of all breast tissue that implies breast parenchyma nipple and areola. After the mastectomy and sentinel lymph node biopsy is completed (and follow-up axillary dissection if the sentinel lymph node contains cancer) the Plastic Surgery team comes into the operating room and performs the first phase of the immediate reconstruction. You will meet with the Plastic Surgeon prior to the day of surgery to decide the appropriate reconstruction technique (options include temporary expander followed by permanent implant, TRAM flap or Latissimus Dorsi flap).
- Traditional mastectomy without reconstruction:
This procedure involves removal of all breast tissue and overlying skin, nipple and areola.If a patient chooses this option she will have a flat chest on the side of the mastectomy and can wear a prosthesis that fits inside her bra. When a mastectomy is performed, postoperative radiation is generally not necessary unless the cancer is more than 5 cm. in diameter or there are positive lymph nodes. The recommendation for chemotherapy is the same whether the patient chooses breast conservation or a mastectomy. A mastectomy without reconstruction or with expander reconstruction generally requires an overnight stay in the hospital. When the reconstruction is performed with your own tissue (TRAM flap or Latissimus flap) the hospital stay is generally several days.
The overall survival is exactly the same whether breast conservation or a mastectomy is performed. The risk of the cancer returning within the affected breast or on the chest wall is approximately 5-6% for breast conservation and 2-3% for a mastectomy. If the cancer recurs in the breast after a lumpectomy a mastectomy is then generally required at the time of the recurrence.