Understanding Breast Cancer Surgery: A Complete Patient Guide to Treatment Options

Table of Contents

• Practice Essentials: Core Principles of Breast Cancer Surgery
• Lumpectomy: Breast-Conserving Surgery
• Mastectomy: Complete Breast Removal
• Lymph Node Procedures: Sentinel Node Biopsy and Dissection
• Preoperative Preparation: Getting Ready for Surgery
• Surgical Techniques: What Happens During the Procedure
• Breast Reconstruction: Restoring Your Appearance
• Managing the Opposite Breast: Reducing Future Risk
• Postoperative Care: Recovery and Follow-up
• Potential Complications: Understanding the Risks
• Clinical Guidelines: Evidence-Based Recommendations
• Source Information

Practice Essentials: Core Principles of Breast Cancer Surgery

Surgery is considered the primary treatment for breast cancer, with many early-stage patients being cured with surgery alone. The main goals of breast cancer surgery include complete removal of the primary tumor with negative margins (cancer-free edges around the removed tissue) to reduce the risk of local recurrence, and pathological staging of both the tumor and axillary (armpit) lymph nodes to provide necessary prognostic information.

Several different surgical approaches are available, and the choice depends on multiple factors including tumor size, location, cancer type, and patient preferences. The two main categories are breast-conserving surgery (lumpectomy) and mastectomy (complete breast removal). Research has shown that for appropriate candidates, both approaches can provide equivalent survival outcomes when combined with appropriate additional treatments.

Lumpectomy: Breast-Conserving Surgery

Lumpectomy, also called partial mastectomy or segmental mastectomy, involves complete surgical removal of the primary tumor with the goal of achieving widely negative margins. Surgeons ideally aim for a 1-centimeter margin of healthy tissue around the cancer. This approach is applicable for most patients with stage I and stage II invasive breast cancers.

The landmark National Surgical Adjuvant Breast and Bowel Project's B-06 (NSABP-B06) study established that breast-conserving surgery with radiation therapy provides equivalent outcomes to modified radical mastectomy. This prospective trial followed 2,163 breast cancer patients randomized to three groups: modified radical mastectomy, lumpectomy with whole-breast radiation, or lumpectomy without radiation. At 20-year follow-up, researchers found no significant difference in overall survival, disease-free survival, or distant disease-free survival among the three treatment groups.

However, the study did reveal important differences in local recurrence rates. Patients who received lumpectomy alone without radiation had a significantly higher local recurrence rate of 39.2% compared to 14.3% for those receiving lumpectomy plus radiation therapy. Patients undergoing modified radical mastectomy had a 10.2% risk of chest wall recurrence.

Contraindications for Lumpectomy

Not all patients are candidates for lumpectomy. Relative contraindications include:

• Small breast size relative to tumor size
• Large tumor size (greater than 5 centimeters)
• Collagen vascular disease

Absolute contraindications include:

• Multifocal disease (cancer in multiple areas of the breast)
• History of previous radiation therapy to the treatment area
• Inability to undergo radiation therapy for invasive disease
• First or second trimester of pregnancy
• Persistent positive margins after attempts at conservation

Important factors that should NOT deter lumpectomy consideration include axillary node involvement and tumor location. Cosmetic considerations, while important, should never outweigh the clinical priority of obtaining negative surgical margins.

Surgical Techniques and Reexcision Rates

Lumpectomies may be performed with palpation guidance or with various image guidance techniques including wire localization, hematoma ultrasonographic guidance, or radioactive seed localization. The reexcision rate after lumpectomy ranges from 20-60% in published literature, meaning many patients require additional surgery to achieve clear margins.

According to 2018 guidelines from the American Society of Breast Surgeons, several strategies can help reduce reoperation rates:

• Complete preoperative imaging with appropriate modality selection
• Minimally invasive breast biopsy for cancer diagnosis
• Multidisciplinary planning before breast-conserving procedures
• Using cavity shaves for margins (reduces reexcision rate by 50%)
• Intraoperative margin evaluation techniques
• Compliance with Society of Surgical Oncology–American Society for Radiation Oncology margin guidelines

Mastectomy: Complete Breast Removal

A total mastectomy involves complete removal of all breast tissue extending to the clavicle (collarbone) superiorly, the sternum (breastbone) medially, the inframammary crease inferiorly, and the anterior axillary line laterally, with en bloc resection of the pectoralis major fascia. The nipple-areolar complex is removed along with a skin paddle to achieve a flat chest wall closure.

Several mastectomy variations exist:

• Modified radical mastectomy: Total mastectomy with axillary lymph node dissection
• Radical mastectomy: Total mastectomy plus removal of pectoralis major and axillary lymph node dissection
• Extended radical mastectomy: Radical mastectomy with resection of internal mammary lymph nodes
• Skin-sparing total mastectomy (SSM): Preserves natural skin envelope
• Nipple-sparing total mastectomy (NSM): Preserves nipple-areolar complex

SSM and NSM are technically more challenging operations designed for patients choosing immediate reconstruction. These approaches preserve the patient's skin envelope and maintain the inframammary fold position while attempting complete tumor removal equivalent to traditional mastectomy.

Lymph Node Procedures: Sentinel Node Biopsy and Dissection

The American Society of Clinical Oncology (ASCO) has established updated guidelines for lymph node procedures in early-stage breast cancer:

• Women without sentinel lymph node (SLN) metastases should not undergo axillary lymph node dissection (ALND)
• In most cases, ALND should not be performed on women with 1-2 metastatic SLNs planning breast-conserving surgery with whole-breast radiotherapy
• ALND should be offered to women with SLN metastases who will undergo mastectomy
• SLN biopsy may be offered to women with operable breast cancer and multicentric tumors, DCIS patients undergoing mastectomy, previous breast/axillary surgery patients, and those treated with preoperative systemic therapy
• SLN biopsy should not be performed on women with large (T3/T4) or locally advanced invasive breast cancer, inflammatory breast cancer, DCIS (when breast-conserving surgery planned), or pregnant patients

Sentinel lymph node biopsy is currently preferred for axillary staging because it offers accuracy equivalent to ALND with less morbidity. The American College of Breast Surgeons states that SLN biopsy is suitable for virtually all patients with clinically node-negative T1-2 invasive breast cancers.

Axillary lymph node dissection (ALND) involves complete removal of level I and II lymph nodes, with level III nodes removed only if suspicious. This procedure carries significant surgical morbidity including:

• Lymphedema (~25% of patients)
• Shoulder dysfunction
• Wound infection
• Seroma (fluid collection)
• Nerve damage
• Numbness
• Chronic pain
• Rare brachial plexus injury

Preoperative Preparation: Getting Ready for Surgery

Preoperative preparation should address both psychosocial and surgical considerations. Patients often have unexpressed concerns about recurrence risk, need for additional treatments, surveillance requirements, rehabilitation length, and cosmetic outcomes. Discussion should include options for immediate versus delayed reconstruction.

From a surgical perspective, routine preoperative testing should be based on the patient's age, symptoms, and comorbid conditions. Preoperative administration of a first-generation cephalosporin antibiotic is common practice, though evidence of benefit is limited.

Surgical Techniques: What Happens During the Procedure

Successful breast surgery requires thorough anatomical knowledge, accurate disease assessment, and consideration of potential future operations. Incision placement is crucial—biopsy incisions should be planned with potential future mastectomy in mind. However, adequate surgical margins should never be compromised for cosmetic reasons.

For axillary procedures, dissection begins with incision of the clavipectoral fascia and identification of key structures. Level I and II lymphatic tissue is removed using a combination of techniques, with careful attention to preserving nerves when possible. Electrocautery is typically avoided during deep dissection to reduce complication risks.

For mastectomy, the standard elliptical incision includes the nipple-areolar complex and extends appropriately. Flap thickness should be approximately 1.0 cm, created in a relatively avascular plane. The breast tissue is removed along with the pectoral fascia, with careful attention to blood vessel management.

A 2018 randomized controlled study of 66 women found that multilevel, ultrasound-guided paravertebral blocks with total intravenous anesthesia improved recovery quality, postoperative pain control, and expedited discharge compared to traditional inhalational gas- and opioid-based general anesthesia.

Breast Reconstruction: Restoring Your Appearance

Breast reconstruction after mastectomy may be performed immediately or delayed. Most patients undergoing mastectomy for prophylaxis or early-stage breast cancer are reconstruction candidates. Immediate reconstruction generally provides superior cosmetic results because skin-sparing or nipple-sparing techniques can preserve the natural breast skin envelope and inframammary crease.

Reconstruction options include:

• Implant-based methods: Tissue expanders followed by saline or silicone implants
• Autologous tissue-based methods (flaps):
  • TRAM (transverse rectus abdominis myocutaneous) flap
  • Latissimus dorsi flap
  • DIEP (deep inferior epigastric perforator) flap
• Combination approaches: Using both implants and autologous tissue

Despite federal laws requiring insurance coverage for reconstruction, most mastectomy patients do not undergo reconstruction due to provider biases, patient preferences, or lack of available specialty services. Patients should have realistic expectations—multiple operations are often needed for revisions, symmetry procedures, and nipple reconstruction.

Potential reconstruction complications include:

• Infected or ruptured prosthetic implant
• Capsular contracture (scar tissue forming around implant)
• Flap necrosis or loss
• Fat necrosis
• Asymmetry
• Scarring

A multivariate analysis study found that nipple-sparing mastectomy and weight of breast resection are significant risk factors for skin flap necrosis, while resection weight is associated with nipple-areolar complex necrosis.

Managing the Opposite Breast: Reducing Future Risk

Patients diagnosed with breast cancer who are not known carriers of a deleterious BRCA mutation have approximately a 0.7% annual risk of developing cancer in the opposite breast. Known BRCA mutation carriers face a much higher 3% annual risk of contralateral breast cancer.

The decision for contralateral prophylactic mastectomy (CPM) is personal and influenced by multiple factors including cancer stage, desire for symmetry, comorbidities, histologic risk factors, family history, surveillance difficulties, and degree of risk aversion. Patients with locally advanced breast cancers should particularly discuss these options with their care team.

Postoperative Care: Recovery and Follow-up

Immediate postoperative care involves monitoring wound healing, addressing complications like seroma, infection, bleeding, or nerve damage, following up on pathology results, and encouraging early mobility with range-of-motion exercises.

Long-term follow-up recommendations include:

• Baseline mammography of both breasts (or remaining breast) at 6 months postoperatively
• Clinical assessment every 4 months during the first 2 years
• Clinical assessment every 6 months through the fifth year
• Annual clinical assessments thereafter for life
• Annual mammography and chest radiography
• No additional testing unless symptoms develop (bone pain, headache, abnormal lab findings)

Potential Complications: Understanding the Risks

All surgical procedures carry potential risks. After total mastectomy, complications may include:

• Local recurrence risk (5-10%)
• Wound infection
• Seroma (fluid collection)
• Mastectomy skin flap necrosis
• Hematoma (blood collection)
• Chronic pain
• Incisional dog ears (skin excess at incision ends)
• Lymphedema (arm swelling)
• Fibrosis (tissue thickening)

Axillary lymph node dissection carries particularly significant risks including approximately 25% rate of lymphedema, shoulder dysfunction, nerve damage, and chronic pain.

Clinical Guidelines: Evidence-Based Recommendations

Current clinical guidelines emphasize personalized treatment approaches based on tumor characteristics, patient factors, and evolving evidence. Key principles include:

• Breast-conserving therapy with radiation is oncologically equivalent to mastectomy for appropriate candidates
• Sentinel lymph node biopsy has largely replaced routine axillary dissection for node-negative patients
• Margin status critically impacts local recurrence risk, with 2mm or greater generally considered clear
• Multidisciplinary care planning improves outcomes and reduces reoperation rates
• Reconstruction options should be discussed with all mastectomy patients
• Follow-up care should be lifelong with appropriate surveillance imaging

Source Information

Original Article Title: Surgical Treatment of Breast Cancer
Authors: Mary Jo Wright, MD; James Neal Long, MD, FACS
Publication Details: Updated April 10, 2020, Drugs & Diseases > Plastic Surgery section
Note: This patient-friendly article is based on peer-reviewed research and clinical guidelines from authoritative medical sources.