Anatomy and Physiology?

The breast is composed of a system of lobes and ducts. There are 15 to 20 lobes; each of which empty into a single milk duct. The milk ducts end in a depression at the tip of the nipple. Lymph channels within the breast start at the nipple and travel along the major ducts into beds of lymph nodes contained under the pectoralis muscles and the axilla. Connective tissue, called stroma, hold the lobes and ducts together.

Who is at risk?

Breast cancer accounts for approximately 30 percent of all cancer diagnosed and approximately 16 percent of all cancer deaths in American women. A woman's lifetime risk of developing breast cancer is estimated at 1 in 8.

How is it diagnosed?

Most breast abnormalities are discovered through breast self-examination. If you find a lump in your breast, your physician will generally do one of two things. An ultrasound can be performed to determine if the lump is solid or filled with fluid (cyst). Cysts are common in women in their 30's and are generally benign. If the lump is solid, a needle biopsy will be performed. This involves inserting a needle and syringe into the lump to extract some cells for further analysis. Biopsy results can come back benign, malignant or indeterminate. In the case of an indeterminate lesion, your surgeon may have you repeat the biopsy or have surgery to completely remove the lump. Women over the age of 40 are advised to have a baseline routine mammogram formed. Mammogram results are generally given as such: category 0: which is a mammogram that needs to be re-done due to poor technical quality, category 1 - which is a completely negative mammogram, category 2  - the identification of a clearly benign abnormality, category 3- the identification of an abnormality that is probably benign, category 4: the identification of an abnormality suspicious for cancer, and finally category 4: the identification of a abnormality that is very likely cancer. Findings on a mammogram that need surgical biopsy include category 4 and 5. A category 3 result mandates a repeat mammogram within 3 to 6 months, while with category 4-6, the next mammogram can be performed at the regular time interval dictated by your risk category.

How do I prepare for surgery?

The night before surgery, you will be instructed to not eat or drink after midnight. If you were taking an aspirin or blood thinner, you will generally be asked to stop taking it five days before surgery. If you are over the age of 50, you may need an EKG and chest xray before surgery. If the tumor is palpable (able to felt on physical examination) then generally no further testing is needed. If the tumor is not palpable (not able to be felt under the skin) which is often the case with suspicious findings found on a routine mammogram, then a procedure to identify the area of concern for the surgeon is needed. This generally involves the placement of a very thin needle through the skin into the area of concern. The needle is generally placed under ultrasound or mammographic guidance. This is done in the radiology suite the same day of surgery. From the radiology suite, you will then go to the pre-operative area to await surgery.

How is the surgery performed?

Breast surgery changed radically in the 1970's. Previously, women with breast cancer were only offered one option and that is that of a radical mastectomy which involved removal of the entire breast, underlying chest muscle and lymph nodes in the axilla. It was found that the same results could be obtained without the disfiguring removal of the chest wall musculature. In the 1980's, it was further discovered that breast conservation surgery - removal of a small portion of the breast, also known as a lumpectomy and axillary node dissection (removal of most of the lymph nodes in the axilla) combined with radiation yielded equivalent results as a mastectomy. Finally in the 1990's, axillary dissection has become increasingly replaced with sentinel lymph node dissection (removal of 1-3 lymph nodes)

Lumpectomy:

The type of incision your surgeon will make will depend on a number of factors including where the area of concern is, the size of your breast, etc. Most incisions made are curved like a smile or a frown. Ask you surgeon ahead of time what kind of scar you will have. Lumpectomies are generally performed under local anesthesia. Your surgeon will instill some numbing medication under the skin. You may feel the prick of the needle and then some slight burning as the anesthetic is absorbed by your body. To remove the tumor or abnormal tissue, you surgeon will use an electric scalpel that uses heat to minimize bleeding. Your surgeon will remove the tumor as well as a rim of healthy tissue around it to ensure that the entire tumor is removed. If the tumor is not palpable, the removed tissue will be sent to the radiology suite to confirm that the entire suspicious area was removed. Once confirmation has been received from radiology, your surgeon will close the incision and a dressing will be placed.

Mastectomy

The incision used for a mastectomy is generally in the shape of an oval around the nipple. The incision spans the width of the breast. The entire breast tissue is removed from your skin down to your chest wall muscles, the pectoralis. Breast tissue spans from your clavicle, (collarbone), down to the crease the bottom of your breast makes with the skin. From side to side, breast tissue spans you're your sternum (breastbone in the center) to where your arm meets your body when standing upright with your arms at your side.  Once the breast tissue is entirely removed, drains are left in place to collect fluid that your body tends to accumulate to fill the empty space. The wound is closed with stitches and dressed with gauze and tape.

 

 

 

Sentinel lymph node dissection/axillary dissection

Sampling of the lymph nodes is necessary to determine if there has been any spread of the cancer. If there is evidence of lymph node spread, your doctor will advise you regarding treatment options. There are two ways to determine lymph node spread: axillary dissection and sentinel lymph node sampling. As a first step, most surgeons will recommend sentinel lymph node sampling. If there are large nodes that can be felt under the skin or an imagining study revealed suspicious looking lymph nodes, then generally an axillary dissection will be recommended. Lymph node sampling is generally done at the same time as your breast surgery if it is known before hand that the tumor in the breast is cancer. The trend over the last decade or two has been towards sentinel lymph node sampling versus axillary dissection. Sentinel lymph node sampling is less morbid with fewer complications which will be touched on in the next section.

Axillary Dissection

A two-to-three-inch incision is made in the skin crease underneath your arm. General anesthesia will be used to remove the lower two of three levels of axillary nodes in the armpit. The removed nodes are sent to a pathologist who will examine them under a microscope looking for signs of cancer. Since multiple studies are done on the lymph nodes, a full pathology report is generally not available for several days, usually at the time of your first office visit. Sentinel lymph node sampling involves the removal of just 1-3 sentinel lymph nodes. The sentinel lymph nodes is the first or first few lymph nodes that will drain the tumor site thereby being the first site of spread. If these lymph nodes contain no cancerous cell, the likelihood of metastasis is very low. Sentinel lymph node sampling requires the use of a radioactive dye which limits its use in pregnant patients. First, a radioactive dye is injected intravenously. It travels to the first 1 -3 nodes. Then a blue dye is injected in the skin either underneath the nipple or in the skin overlying the tumor. Then an incision is made in the axilla. The sentinel lymph node(s) will be blue and "hot"(radioactive). The lymph nodes are removed and then sent to the pathologist to review.

Complications of surgery?

With both a lumpectomy and mastectomy, you may find that you have numbness and/or extra sensitivity of the skin along the incision site. This is due to nerves that were cut when the incision was made. This usually improves over time. Depending on how much breast tissue was removed during the lumpectomy, you may find that your breasts do not match in size and shape. There is also a risk of fluid collecting under the scar. If you had some bleeding underneath the skin after surgery, the breast may swell considerably and turn black and blue. Most of the time the bleeding is self-limited and stops on its own. Your body will break down the blood products and absorb it. This can take several weeks. If there has been a large amout of bleeding that it is causing tension on the skin, then a second operation may be required to evacuate the blood. Clear fluid can also build up underneath your incision. This is called a seroma. A seroma is a collection of fluid that builds up from disruption of lymphatic channels or from your body's attempt to seal a cavity. If a seroma does form, the fluid generally becomes absorbed over time. If it does not, then serial drainage of the seroma with a needle and syringe through the skin can often resolve it. There is a risk of infection with every incision made. This can generally be treated with antibiotics. 

Sentinel lymph node dissection/axillary dissection

The risks involved with a sentinel lymph node or axillary dissection are similar to the ones listed above with just a few differences. You may have some staining of your skin from the blue dye injected. This staining may persists for several weeks but it will go away. The most serious risk which is far much more common with axillary dissection than with sentinel lymph node dissection is lymphedema. Removal of the lymph nodes can cause delayed drainage of fluid from your arm resulting in a persistently swollen arm. Sometimes the lymphedema progresses to numbness and stiffness of the harm resulting in some disability, sometimes permanently. Physical therapy and massage can improve arm strength and mobility. Finally, a rare complication which is mentioned since it can cause some disability is a winged scapula. This results from damage to the long thoracic nerve which can be injured more commonly during an axillary dissection than with a sentinel lymph node dissection. Damage to this nerve results in a scapula that bows outward and occasionally shoulder pain and discomfort.

What to expect after surgery?

Lumpectomy

If you are having a lumpectomy only, you will generally go home the same day. You will spend some time in the recovery room after surgery and will be released once you are able to tolerate some liquids and crackers without any nauseau or vomiting.

Mastectomy/Axillary Dissection

If you are having a mastectomy, axillary dissection, or a lumpectomy with sentinel lymph node dissection, you will be admitted to the hospital overnight. Most often you will find that you have two drains coming out of your incision. This is to drain the fluid that accumulates in the space where your tumor was and prevent the formation of a seroma. You will typically go home with this drain. Your nurse will tell you how to care for it. You help your surgeon know when the drain is ready to be removed by emptying the drain once a day and recording the volume that is removed. It's important after surgery to get out of bed as early as possible, ideally the same day after surgery. Getting out of bed helps speed up recovery. You generally will be advised not to bathe after surgery, but you can shower.  In general, for the most part, surgeons use absorbable sutures (stitches). They do not need to be removed. The stitches will dissolve over time. If you have staples or stitches visible outside the skin, those will be removed in the doctor's office at your first follow-up visit.

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