Cancer Institute A national cancer institute
designated cancer center

Breast Cancer Surgery

At the Stanford Cancer Center, we always try to address breast cancer patients' concerns about their appearance without compromising the effectiveness of treatment. A number of new technologies are today making it possible for more patients to receive aggressive treatment while sparing more of their breast tissue.

Although these treatments are not appropriate for all patients, your physician will help you understand the advantages and disadvantages and determine which options may be right for you.

Mastectomy and Lumpectomy

Women today have a choice when facing surgery for breast cancer. The choice is between lumpectomy (breast conservation) or a mastectomy (breast removal). Moreover, immediate reconstructive (plastic) surgery is possible in nearly all patients. The most important point however, is choice. Our breast surgeons strive to help a woman understand the disease and make the best-educated choice with her. 

Many factors come into consideration when choosing an operation, including family history and a patient's emotions. While mastectomy has been the cornerstone of breast cancer treatment for over a century, the results and long term follow-up of large national and international clinical trials have firmly established that breast conserving surgery is equivalent to mastectomy for women whose tumors are 5cm or less and localized to the breast ( Fisher et al NEJM 2002, Veronesi 2002).

Frequently, women believe that if mastectomy is chosen, further systemic treatments will be unnecessary. In fact, the systemic treatments are the same and the extent of surgery in the lymph node areas is also the same whether a lumpectomy or a mastectomy is performed.

Once a woman knows she has breast cancer, her best chance of survival is to eliminate any tumor in her breast, to keep the non-tumorous portion of her breast from making a new breast cancer  and to be treated with systemic chemotherapy as needed to eliminate any tumor cells that may have escaped from her breast cancer and spread to other parts of her body.

Breast cancer treatment uses surgery and/or radiation therapy to establish “local control” by freeing the breast from breast cancer, and “systemic treatment” which is achieved by using chemotherapy (as needed) to treat any cancer cells that have escaped to other parts of the body.

Neoadjuvant Chemotherapy

Many women today have the option of starting with the systemic treatment first before surgery is performed. This is called neoadjuvant therapy.

Sometimes this approach is selected because it provides information about how effective the treatment may or may not be for that tumor or for a given person.

A secondary reason for neoadjuvant therapy may be that tumor shrinkage can be achieved in over 80 percent of patients, making breast-preserving surgery more likely. Our surgeons have been participated in the national studies that have made these options possible today. 

In some instances, medical oncologists can treat tumors with chemotherapy before surgery in order to shrink them enough to allow a lumpectomy instead of a mastectomy. In these cases, surgery is almost always followed by additional radiation and/or chemotherapy.

Breast Conserving Surgery

A long time ago, mastectomy or removal of the entire breast, was always used to establish local control. But now, in many cases, women can keep their breasts by careful surgery to remove all signs of breast cancer followed by radiotherapy, called “breast conserving surgery” or “lumpectomy”.

Both mastectomy and breast conserving surgery have equal local control and identical survival for women with tumors 5 cm (2 inches) or less in diameter with positive or negative axillary lymph nodes, as shown by Protocol B-06 conducted by the National Surgical Adjuvant Breast and Bowel Project (NSABP).

Stanford surgeons have access to all the best and most advanced methods of diagnosing and analyzing breast cancer, and using careful surgical techniques can use lumpectomy in a large number of women, thus saving their breast.

Each woman is evaluated carefully by breast cancer surgeons to identify any and all suspicious areas in their breast so that surgery can be specially tailored to their body and treatment needs.

In some cases, women with small cancers will be given the option to participate in a (phase 2)  trial only offered at Stanford. After removal of the cancer, intraoperative radiation therapy, or IORT, can be given in a specially designed operating room at Stanford Hospital & Clinics.

Sentinel Lymph Node Biopsy and Axillary Node Dissection (Nodal Staging)

Part of the evaluation of patients with invasive breast cancer is the testing of lymph nodes in the areas surrounding the breast to see if cancer have spread there.  Knowing whether tumor cells have lodged in lymph nodes helps to determine the need for systemic treatments (hormonal or chemotherapy) and most importantly, it guides the selection of the  treatments as well as the need for regional radiation.

The armpit is known as the axilla in medical terms, and when the surgeon takes out lymph nodes in the armpit, it is known as an axillary lymph node dissection.  Recent studies have demonstrated that in women who do not have tumor cells in lymph nodes can limit the removal to just a few nodes.

This is accomplished through a procedure known as Sentinel Lymph Node Biopsy. Our surgeons have participated in large national clinical studies that are demonstrating the efficacy and long-term outcomes of this approach.  

Sentinel Lymph Node Biopsy can be done in two ways. Some surgeons use one method and others both. One approach is to inject a trace amount of a radioactive agent or radioisotope in the breast and/or a blue dye. In both instances, the agents are absorbed by the breast lymphatics and carried to one or more lymph nodes, the sentinel nodes. 

In the operating room, the surgeon uses a special Geiger counter that looks like a pencil to find the radioactive lymph nodes, called a gamma probe, which points out the most important lymph nodes that need removal. The surgeon also injects a little blue dye into the breast that is also carried up to the lymph nodes, and takes out any blue lymph nodes that are also important.

By using the special Sentinel Lymph Node Biopsy technique, the surgeon removes the most important nodes and leaves other lymph nodes alone safely, decreasing the possibility of a lifetime of a painful swollen arm for the woman.

Breast Brachytherapy

Lumpectomy leaves more of the breast intact than a mastectomy, however precisely because it spares breast tissue there is more concern that the cancer will recur. To reduce this risk, lumpectomy is usually followed by radiation treatment which is designed to kill any cancer cells that may remain in the breast undetected after surgery.

However, one reason that some women choose to have a mastectomy rather than a lumpectomy is the large time-commitment needed to complete the required radiation treatment that usually follows a lumpectomy.

The Stanford Cancer Center now offers more convenient forms of radiation therapy that may make it possible for some women to choose lumpectomy who had not been able to before.

Breast Cancer Recurrence: Local and Regional

Breast cancer can recur within the breast or in the skin or chest wall muscles after mastectomy. Additionally, breast cancer can reappear in lymph nodes either in the armpit area or in the upper chest.

Patients who experience these events need additional treatment and require the expertise of breast surgeons, medical oncologists and radiation therapists because both local and possibly changes or new systemic treatments will be recommended.

At the Jill and John Freidenrich Breast Center, patients have the option to form part of a study to help find new and better ways to treat this type of recurrences. 

Advanced-Stage Treatment

Some women have such extensive breast cancer or such abnormal findings that they cannot be safely treated by lumpectomy or breast-sparing surgery without threatening their possibility for life survival. These women are offered mastectomy or removal of all of the breast tissue to ensure that they have the best chance to live.

Other women have very advanced, large breast tumors that have caused reddened skin, skin sores or tumors that are stuck to the skin or the ribs. Most of these women have chemotherapy before any surgery to shrink the tumor, and this kind of chemotherapy is called neoadjuvant chemotherapy.

Surgery after the tumor has shrunk is guided by how the tumor feels to the physician, and results from imaging tests to make sure that any residual cancer is completely removed from the breast.

Plastic and Reconstructive Surgery

Many women desire breast reconstruction after a mastectomy, and some do not want reconstruction at all. For women who desire reconstruction, the plastic and reconstructive surgeon works with the woman's goals, medical history, body habitus, physical examination and potential need for adjuvant therapy to decide on the best type of reconstruction that can be designed for her needs.

At Stanford, breast reconstruction can be done using a water filled tissue expander placed in the site of the removed breast at the time of the mastectomy, subsequent expansion of the skin to replace the skin removed with the mastectomy followed by placing a permanent breast implant in the cavity created by the expander.

Another method of reconstruction available at Stanford is transferring tissue from the abdomen or back to fill the defect. Our breast and plastic surgeons have expertise and performing skin-sparing mastectomies where the entire breast skin surface and even in well-selected cases, part of the nipple-areolar complex can be saved too. 

The Transverse Rectus Abdominis Myocutaneous (TRAM) flap in which fat and muscle are transferred from the lower abdomen to the mastectomy site, and shaped to form a breast. Skin is used to reconstruct a nipple, which is subsequently tattooed the same color as the contralateral nipple. If more skin is needed to close the mastectomy site, a muscle from the back called the latissimus dorsi myocutaneous flap with an implant may be used.

In some cases, the surgeon has the option take the breast tissue and can leave with a small shell of tissue left under the skin with most of the skin intact. This is called a subcutaneous mastectomy, and the plastic and reconstructive surgeons will place  an implant in the cavity left by the empty space. The nipple may or may not be resected. Due to high rates of recurrences this operation is not routinely performed for cancer treatment or prophylactic prevention of cancer in high risk patients. 

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