Standard therapy includes surgery to remove the cancer in the breast. Depending of the size and extent of tumor some patients may receive chemotherapy before surgery, although this is not common. Information about the spread of tumor cells to lymph nodes under the arm is often helpful in determining the need for chemotherapy or the best type of chemotherapy to be given. The presence of tumor cells in the lymph nodes under the arm suggests a greater likelihood that cancer cells may have spread to other areas in the body. The size of the breast tumor combined with the status of the lymph nodes under the arm determines the prognosis for a patient more accurately than any of the other characteristics described above.

Surgery Procedures

Removal of the cancerous breast tissue is performed by a breast surgeon in the operating room. It is important that all of the cancer be removed, and occasionally a second operation is required if the margins are involved with cancer cells when examined under the microscope. For all the surgeries that we provide information about in this section, the patient is given local anesthesia with sedation, which puts them to sleep for the entire operation. Many of the surgeries are considered to be outpatient surgeries, which means the patient has the surgery and leaves the hospital in the same day. Although some patients will have to stay one to three days, this is mainly for people who have a mastectomy.

Lumpectomy, Segmentectomy, Partial Masectomy

Lumpectomy, segmentectomy and partial mastectomy are all procedures that involved removing a certain amount of breast tissue, but not the entire breast.

Most patients have a lumpectomy (removal of the tumor only, also called breast conservation therapy) followed by radiation treatments over a course of 5 or 6 weeks. If a lumpectomy alone is performed, the rate of recurrence can be as high as 20-25%. For those who have radiation treatment after a lumpectomy, the recurrence rate is less than 10%. A segmentectomy involves removing a more extensive area of breast tissue. A partial mastectomy removes close to one quarter of the breast tissue. The amount of tissue removed will be determined by the size of the palpable mass (mass that can be felt) or the size of the abnormality present on imaging to include mammogram, ultrasound or MRI. Prior to your surgery, you and your surgeon should discuss how much breast tissue she/he expects to remove at the time of the surgical procedure.

On occasion lumpectomy, segmentectomy or partial mastectomy are done using needle localization for guidance. This technique is necessary only when the abnormality is seen by MRI , ultrasound or mammography and is not able to be felt. In this situation mammogram, ultrasound or MRI is used to identify exactly where the abnormality exists and a very fine wire is placed on that area to guide the surgeon. If an abnormality is palpable (able to be felt) then there is no need for needle localization to be performed prior to surgery.

Simple Mastectomy, Modified Radical Masectomy

Simple mastectomy involves removal of all breast tissue. This does not include removal of the underlying pectorals muscles and it does not include removal of the lymph node tissue underneath the arm. Prior to a simple mastectomy your surgeon may refer you to a plastic surgeon to discuss options available for reconstruction. Many women consider immediate or delayed reconstruction. For those considering immediate reconstruction, the plastic surgeons can perform some sort of reconstruction procedure in conjunction with the breast surgeon who is performing the simple mastectomy. This can be done during the same surgery.

Modified radical mastectomy involves removal of all the breast tissue as well as removal of the lymph nodes beneath the arm of the affected breast. This particular procedure may involve hospitalization from 24 to 48 hours.

Sentinel Lymph Node Biopsy

Lymph nodes under the arm can alert doctors as to whether cancer has spread from the breast into other parts of the body. The presence or absence of cancer in the lymph nodes will help in making the decision as to whether or not a patient needs chemotherapy following surgery for breast cancer. Sentinel lymph node biopsy is performed at the same time as a lumpectomy, segmentectomy, or partial/simple/modified radical mastectomy.

The lymph nodes are small, bean-shaped nodules that act like filters for the body’s immune system. Fluid travels through the body using the lymphatic system to pick up waste from cells and then filters this fluid though the lymph nodes to clean it and send it back into the bloodstream. The first place that breast lymphatics drain into is the lymph nodes under the arm, where there are as many as 20 or more lymph nodes.

The sentinel node is the first lymph node to contain cells if cancer has begun to spread, or metastasize, moving next to other nearby nodes. If the sentinel node is cancer-free, other lymph nodes will be cancer-free and do not need to be removed. If the cancer has spread to the sentinel lymph node, this procedure allows surgeons to clearly see the lymphatic pathway so cancerous nodes can be removed more accurately during surgery.

This procedure involves injecting blue dye and a mildly radioactive tracing element into the breast prior to the surgery. A local anesthetic is used so the procedure is painless. The “maps” produced by the dye and radioactive tracer can be detected within 20 minutes. The blue dye is absorbed in the sentinel node and can be seen by the surgeon during surgery. To detect the radioactive tracer concentrated in the sentinel lymph node a probe is used during surgery. This accurately pinpoints the sentinel node and distinguishes it from other surrounding lymph nodes.

Axillary Lymph Node Biopsy

Axillary Lymph node dissection involves removing all the lymph nodes under the arm on the side where breast cancer is found. This may be recommended if a sentinel lymph node is found to contain tumor cells at the time of a sentinel lymph node biopsy (see above) or if the patient has lymph nodes that can be felt during an exam and are considered to be suspicious for containing cancer cells. Most often, this operation requires general anesthesia, although occasionally local anesthesia with sedation is used. Complete removal of the lymph nodes involves removing a packet of fatty tissue beneath the arm pit which contains the lymph nodes. Typically the lymph nodes can not be seen with the naked eye and the surgeon and patient do not know the results of the lymph node tissue removal until it is analyzed in the laboratory. The pathologist will report the number of lymph nodes that have been removed and how many, if any, contain cancer cells. The number of lymph nodes under the arm varies from person to person. It could be as few as ten and as many as fifty. At the time of lymph node dissection, the surgeon may need to place a drain in the incision to collect excess fluid. This draining usually stops within several days. On occasion a drain is not used and this depends on the preference of the surgeon.

There is a nerve that runs through the lymph node area under each arm that provides sensation to the inner portion of the upper arm. Occasionally when the lymph nodes are removed, that nerve is cut and may result in temporary or even permanent numbness on the inside of the upper arm. Most often the nerve is left intact at the time of lymph node removal.

There are several potential complications from complete removal of the lymph nodes. The most common is lymphedema, which refers to swelling of the arm, hand or wrist. This can happen at any time, even years after an axillary lymph node dissection and may require physical therapy or one of several techniques for drainage of the lymphatic fluid that is causing the swelling in the arm. For those who undergo complete axillary lymph node dissection, it is advised to obtain educational materials and possibly a physical therapy consultation to be aware of symptoms for early treatment and possible ways to avoid lymphedema all together. A full lymph node dissection should not result in permanent weakness of the arm. Lymph node dissection may make the patient more susceptible to infection in that arm, so typically, IV blood draws and blood pressures in that arm are avoided if a full lymph node dissection has been performed. Such precautions are not necessary with a sentinel lymph node biopsy alone.