Specialized Treatment

Lumpectomy, also known as breast conserving surgery, partial mastectomy or wide excision, involves remove the cancerous area of the breast with a border or margin of normal breast tissue surrounding the cancer.

A breast needle localization may be done before a lumpectomy or partial mastectomy.

A sentinel lymph node biopsy or an axillary lymph node dissection may be performed at the time of the lumpectomy.

In most patients, the lumpectomy or partial mastectomy is followed by radiation therapy to the affected breast. There are several types of radiation after breast-conserving surgery, and your surgeon and radiation oncologist will discuss these types with you. Most women receive whole-breast radiation therapy after surgery.

Lumpectomy/partial mastectomy with radiation is a treatment that provides the same survival benefit as a mastectomy.

A partial mastectomy or lumpectomy may not be a good choice for a woman who:

• Is pregnant and therefore should not expose the unborn child to the effects of radiation
• Has two or more areas of cancer that are not close together in the same breast
• Has a pacemaker or defibrillator on the same side of her chest
• Has already had whole-breast radiation therapy to the same breast
• Has a tumor that is located near the nipple or chest wall
• Is unable or unwilling to have radiation therapy
• Has a large tumor in a relatively small breast

However a patient with a large tumor may receive chemotherapy before surgery (called neoadjuvant therapy) in an attempt to shrink the cancer down, which can make her a better candidate for a lumpectomy. If this is an option for you, your surgeon and medical oncologist will discuss this with you.

Mastectomy is the surgical removal of the entire breast. There are different types of mastectomies. The type of surgery recommended will consider your overall health, age and breast cancer type. The types of mastectomies are:

• Simple (also known as a Skin-Sparing Mastectomy) – During a simple skin-sparing mastectomy, all of the breast tissue and nipple-areola complex are removed. This surgery is typically performed with a sentinel lymph node biopsy or an axillary lymph node dissection. Mastectomies may also be performed prophylactically (removal or a normal breast to decrease risk) in patients with a strong personal or family history of breast cancer. A skin-sparing mastectomy leaves much of the breast skin, which allows the reconstructed breast to look more natural.
• Total Mastectomy – During a total mastectomy, the surgeon removes the entire breast. No muscle is removed.
• Modified Radical Mastectomy – During a modified radical mastectomy, the surgeon removes the entire breast and axillary lymph nodes are removed. No muscle is removed.
• Radical Mastectomy - During a radical mastectomy, the surgeon removes the entire breast, nipple-areola complex and axillary lymph nodes. This procedure was commonly done in the past. However, in many cases, modified radical mastectomy has proven to be just as effective.
• Subcutaneous ("Nipple Sparing") Mastectomy – During a subcutaneous mastectomy, the surgeon will remove all breast tissue but save the nipple and areola. This is not possible in all breast cancers. The size and location of the cancer may eliminate this as an option.

The mastectomy incision leaves a horizontal, slightly curved line across the side of the chest where the breast was removed. Women may choose to have breast reconstruction as part of their surgery, or use a breast prosthesis afterward. Options for breast reconstruction include implants (may be performed in two stages, with the first stage often performed by the plastic surgeons at the time of mastectomy) or tissue (flap) reconstruction. After the removal of the breast, with or without reconstruction, one or more drains are placed in the surgical area, and a woman will stay overnight in the hospital. Breast reconstruction is often an option immediately following a mastectomy. You are encouraged to meet with a plastic surgeon specializing in breast reconstruction before your mastectomy to see what your reconstruction options are.

Breast needle localization may be used to locate and mark the area of breast tissue to be biopsied or to be removed in a lumpectomy/partial mastectomy.

During the procedure, you may be seated or lying on your back. A mammogram and/or ultrasound will be taken of your breast. If mammogram is used, your breast many need to remain in compression for a short time. The least amount of pressure needed will be used. You will be asked to remain very still so the position of the breast does not change. If the area of concern is not seen on the mammogram, your breast will be repositioned and another X-ray will be taken.

A small area of your breast will be cleaned with antiseptic. The doctor may inject medicine to numb the area. The doctor will place a needle or wire into your breast. X-rays will be taken to check the needle-wire placement. The needle may need to be repositioned by the doctor to mark the exact tissue to be removed. The final images will be reviewed by your surgeon. The needle/wire will be taped to your breast to hold it in position until your surgery time. Once the needle localization is finished, you will be taken to the pre-op holding area of the hospital where you will await your surgery.

For most women with early-stage breast cancer, the cancer has not moved from the breast, For stage 0 cancer (DCIS –ductal carcinoma in situ), the cancer has been caught early enough that, by definition, it will not be seen in the lymph nodes. For stage 1 and above breast cancers, your surgeon needs to make sure there is not microscopic spread of cancer to the lymph nodes, and this is done with a sentinel lymph node biopsy.

The sentinel nodes are the first lymph nodes in the chain of nodes draining the breast. If the breast cancer has moved from the breast to the axilla (underarm area), it will be seen in the sentinel lymph nodes. A patient has anywhere from 1 to 4 sentinel lymph nodes, and for each patient, it is a different number. During surgery, these nodes are identified and removed and are inspected by a pathologist to see if they contain cancer cells.

In order for the surgeon to locate the sentinel nodes, a radioactive substance is injected into the breast, near the nipple, before surgery. This may cause stinging, which will ease. Many doctors also inject a blue dye into the breast during the surgery, which also aids in detecting the nodes. During the surgery, the surgeon finds the sentinel nodes using an instrument that is like a Geiger counter, and also looks for blue discoloration of the nodes.

Sometimes women who have had the blue dye injected into their breast find that their urine is bluish-green for a short time after surgery or that their skin may be somewhat blue.

For staging purposes of your breast cancer, it is critically important to see if there are cancer cells in the lymph nodes and, if so, how many lymph nodes are involved.

If the sentinel nodes do not contain cancer cells, the surgeon does not need to remove any more lymph nodes. If the sentinel nodes do contain cancer cells, the surgeon will often remove more axillary tissue with nodes. This is called a complete axillary lymph node dissection. You may need to have a drain placed in the axilla after a complete node dissection.

There may be numbness or tingling in the underarm or the upper back of the arm after lymph node removal. If this occurs after only sentinel nodes are removed, it will last only days or weeks. When this occurs after an axillary node dissection, it may be more noticeable and may last longer. Although the degree of numbness will decrease over time, some slight numbness may be permanent.

For some women, it is known before surgery that cancer is in the lymph nodes. In these cases, a sentinel node biopsy may not be needed. Instead, the patient may undergo an axillary node dissection.

For most women with early-stage breast cancer, the cancer has not moved from the breast, For stage 0 cancer (DCIS –ductal carcinoma in situ), the cancer has been caught early enough that, by definition, it will not be seen in the lymph nodes. For stage 1 and above breast cancers, your surgeon needs to make sure there is not microscopic spread of cancer to the lymph nodes, and this is done with a sentinel lymph node biopsy.

The sentinel nodes are the first lymph nodes in the chain of nodes draining the breast. If the breast cancer has moved from the breast to the axilla (underarm area), it will be seen in the sentinel lymph nodes. A patient has anywhere from 1 to 4 sentinel lymph nodes, and for each patient, it is a different number. During surgery, these nodes are identified and removed and are inspected by a pathologist to see if they contain cancer cells.

In order for the surgeon to locate the sentinel nodes, a radioactive substance is injected into the breast, near the nipple, before surgery. This may cause stinging, which will ease. Many doctors also inject a blue dye into the breast during the surgery, which also aids in detecting the nodes. During the surgery, the surgeon finds the sentinel nodes using an instrument that is like a Geiger counter, and also looks for blue discoloration of the nodes.

Sometimes women who have had the blue dye injected into their breast find that their urine is bluish-green for a short time after surgery or that their skin may be somewhat blue.

For staging purposes of your breast cancer, it is critically important to see if there are cancer cells in the lymph nodes and, if so, how many lymph nodes are involved.

If the sentinel nodes do not contain cancer cells, the surgeon does not need to remove any more lymph nodes. If the sentinel nodes do contain cancer cells, the surgeon will often remove more axillary tissue with nodes. This is called a complete axillary lymph node dissection. You may need to have a drain placed in the axilla after a complete node dissection.

There may be numbness or tingling in the underarm or the upper back of the arm after lymph node removal. If this occurs after only sentinel nodes are removed, it will last only days or weeks. When this occurs after an axillary node dissection, it may be more noticeable and may last longer. Although the degree of numbness will decrease over time, some slight numbness may be permanent.

For some women, it is known before surgery that cancer is in the lymph nodes. In these cases, a sentinel node biopsy may not be needed. Instead, the patient may undergo an axillary node dissection.

If you have a lumpectomy and a sentinel node biopsy, you will likely go home the day of your surgery. If you have a mastectomy and/or an axillary node dissection, you may spend the night in the hospital. Breast reconstruction surgery also requires at least an overnight hospital stay. If you have a drain in place after surgery, the nurses will instruct you and your family how to care for the drain before you go home. It is not difficult. Also, you will be asked to wear your surgical bra as much as possible after surgery, to decrease swelling at the breast and underarm sites. It is best to be fitted for your surgical bra in the days before your surgery so you know it will be comfortable. Some surgeons allow patients to shower with the drain in place and some do not. Be sure to ask your surgeon if you are allowed to do so.

Certain patients may qualify for a shortened course of radiation therapy. As with conventional radiation therapy, it is often called whole breast radiation therapy and usually starts several weeks after surgery so the area has some time to heal. Sometimes, a physician will recommend chemotherapy to be administered before radiation. Treatments are usually given daily over a three or four week period and may include a "boost" to the site of cancer.

Mount Carmel offers radiation therapy treatment in the prone position (face down) for some women with early stage breast cancer. This allows the patient to lie comfortably while the breast falls away from the body, helping to limit radiation exposure to the heart, lungs and skin.

Breath-hold gating treatment is a technique that accounts for movement of the treatment site as a result of the patient's breathing and respiratory cycle. It allows the heart and lungs to fall away from the chest wall where the radiation is directed, helping to minimize radiation exposure.

Chemotherapy given before surgery in patients with large tumors. This chemo may shrink the tumor enough that a lumpectomy becomes an option. In patients with locally advanced breast cancer, neoadjuvant chemotherapy may reduce the size of the tumor in the breast and/or lymph nodes and make it easier to surgically remove the cancer.

Chemotherapy used for early-stage invasive breast cancer to get rid of any cancer cells that may be left behind after surgery and to reduce the risk of the cancer coming back. This type of chemotherapy is done after surgery and before radiation (if radiation is recommended for you

Tamoxifen is the only anti-hormonal medication that is used in pre-menopausal women. The most common side effects are hot flashes, vaginal dryness and sometimes mood swings. Rare but more serious side effects include cancer of the lining of the uterus and blood clots. Most women tolerate this medication well.

These medications (Arimidex, Femara, Aromasin) are used in women who have gone through menopause and reduce the risk of breast cancer recurrence. Some of the more common side effects of these medications are joint discomfort and hot flashes.