On occasion, when a tissue sample cannot be obtained with image guidance such as stereotactic biopsy or ultrasound guided core needle biopsy or even MRI guided biopsy an excisional biopsy is needed. This can be done in the operating room with anesthesia either with palpation guidance if the lesion is palpable or after needle localization of the lesion if it cannot be felt.
Lumpectomy/ Partial mastectomy
If there is a breast lump that is suspicious or it has been biopsied and proven to be malignant, the lump is removed surgically. The terms lumpectomy which means surgical removal of a lump or partial mastectomy which means surgical removal of a part of the breast are used interchangeably. There is no real difference between the two. Often we refer to lumpectomy when there is an actual lump in the breast. However, with modern technology and regular screening most breast cancers are found so early that a lump has not yet developed. In that case we prefer to say partial mastectomy.
Sentinel lymph node biopsy
When invasive breast cancer is found the possibility of the cancer to spread to the rest of the body is present. Invasive breast cancer has the potential to spread locally, through the blood stream and through the lymphatic system. We do not have a blood test to see if the cancer has spread but we can examine the lymph nodes in the arm pit which are the filters of the lymphatic system. This process requires the injection of dye into the breast and the tracing of this to the arm pit. This procedure is done in the operating room at the time of the cancer surgery.
Axillary lymph node dissection
In some instances a person can have several lymph nodes involved with cancer and then the nodes in the arm pit need to be removed. There are not a set number of lymph nodes that we look for but rather the lymph nodes that are in an anatomical area of the arm pit. Unfortunately this procedure is associated with a higher risk of lyphedema (swelling) in the arm on the side where the dissection was carried out. This procedure is done rarely now and the reasons for this can be discussed at the time of the consultation and discussion of surgery.
Simple mastectomy is the removal of the breast tissue in such a fashion that in the end there is a flat surface. This type of surgery is also done with great care that redundant tissue and skin is not left behind. After the surgery there is a drain left in place for several days. This drain is important to remove all excess fluid and this way the skin can heal down to the chest wall and prevent the potential infection of the otherwise accumulating fluid.
Skin sparing mastectomy
This procedure needs to be followed by immediate breast reconstruction. It is the removal of the breast tissue under the skin without taking most of the skin away and thus allowing the plastic surgeon to reconstruct the breast using the patents tissue that is in place. The reconstruction is cosmetically more pleasing with this procedure. It is also considered oncologicaly safe, meaning form the cancer treatment perspective.
Nipple sparing mastectomy
In this case immediate reconstruction is necessary at the time of surgery. the procedure is as it sounds taking away the breast tissue only and leaving the nipple and areola in place. It is a longer procedure that carries the risk of the nipple and areola not surviving the process. In order to ensure the best cosmetic outcome the characteristics of the patient have to be considered including the cancer size and its proximity to the skin or nipple therefore only a select few parents qualify for nipple sparing mastectomy. However, the specifics can be discussed at the time of consultation.
Partial breast radiation device placement (MammoSite)
At the time of surgery the cancer is removed from the breast and in the cavity a balloon catheter is placed. This is only a place holder for the final device. The final device is placed only after the final pathology is received and the margins of the excision are negative and the lymph nodes are negative. If the margins are positive are excision is necessary and the patient will need external beam radiation, the traditional way. The advantage of this device is that the radiation will last only 5 days instead of the 6 weeks. There are several criteria that give guidelines on who is eligible for this type of radiation but most of them agree that the tumor needs to be less than 3 cm, only in one place in the breast, the margins of excision to be negative for cancer and the sentinel node to be negative. You can see more detail on the page “patient criteria”. The description of the MammoSite placement and its use is available on the page named “MammoSite description.”
Oncoplastic Breast Surgery
I offer oncoplastic surgery, which provides women the opportunity to have cancerous tissue removed and their breast repaired cosmetically — all in one surgery.
In the past, women with breast cancer have had cancerous tissue removed by one surgeon — through a lumpectomy— and then would later undergo a separate procedure with a plastic surgeon for either repair or reconstruction.
I am a cancer surgeon trained in performing cosmetic techniques that better preserve the breast’s shape with fewer procedures and less trauma.
During this procedure, the breast tumor is removed with a rim of normal tissue to ensure complete resection of the cancer. After the cancer is removed the breast tissue is reshaped in such a way that there is no cavity left in the breast. This process is safe and it does not impact the cancer treatment however it has the distinct advantage of decreasing the risk of a deformed breast.
This technique can allow a woman with a larger tumor, who otherwise would need a mastectomy, to undergo a lumpectomy with preservation of the breast. Post-lumpectomy radiation would still be required as is standard for all breast conservation treatment.