Types of breast cancer surgery

Discovering that you need breast cancer surgery can be overwhelming to say the least. Here we help you understand your surgical options, the procedures behind the names, and what this will mean for your body in the long term.

Breast conserving surgery

Lumpectomy (wide local excision)

A lumpectomy is a type of surgery that aims to maintain a normal breast appearance. The surgeon will remove the cancerous area and the margin (the border of normal breast tissue surrounding the tumour).

In some cases, a second incision may be needed to remove the lymph nodes. After the lumpectomy, you will require radiotherapy to treat the remaining breast tissue – this will reduce the risk of the cancer returning.

Women who are eligible for this treatment include those with:

Early-stage breast cancer
A small tumour

Your surgeon may advise against a lumpectomy if:

You have previously undergone radiation therapy to the same breast
The tumour is too large
You have at least two cancer areas in the same breast and these are too far apart to be surgically removed with a single incision

Positive or negative margins – what do these mean?

Following a lumpectomy, the excised breast tissue is analysed by a pathologist who will look for the presence of any cancerous cells in the healthy border around the tumour.

Negative or clear margins means the border is free from cancer cells.

Adequate margins: a margin is considered adequate if the tumour is far enough from the margin – although it should be noted that surgeons don’t always agree on what constitutes an adequate margin.

Clear but close margins: this means the border is cancer-free but the distance between it and the edge of the tumour is very small and may require another excision.

Positive margins: this means that the border still contains cancer cells, implying that not all cancer cells have been successfully removed during the surgery. In this case, a re-excision may be necessary, so the surgeon will remove more of the breast tissue until a clear surgical margin is obtained. If this is not possible, a mastectomy may need to be considered.

Quadrantectomy (segmental excision)

Compared to a lumpectomy, a quadrantectomy involves the removal of a larger area of breast tissue – around a quarter of the breast. This is then followed by radiation therapy. If you are concerned that your breasts may look very different after the procedure, you may decide to opt for breast reconstruction surgery, providing the timing is right for you.

Mastectomy

Your breast surgeon will try to conserve your breast in terms of tissue loss and appearance as much as possible. However, you may be advised to opt for a mastectomy if:

The tumour is large in comparison to the size of your breast
Different areas of cancer have been identified in different parts of the breast
A lump has been found in the centre of your breast
Cancer cells have grown extensively in your breast ducts
You have had chest radiotherapy in the past
You have inflammatory breast cancer
You suffer from connective tissue disease such as scleroderma or lupus – these conditions may render you more sensitive to the side effects of radiation therapy

A mastectomy involves the removal of the entire breast where the cancer is found. Sometimes, the nearby tissues are also removed. The following briefly describes the different types of mastectomy:

Total mastectomy

In this procedure (also known as a simple mastectomy), the surgeon will remove the whole breast including the nipple, but not the lymph nodes under your arm or the tissue found just below the breast. This is the most common type of mastectomy used to treat in-situ, microinvasive, or stage 1A breast cancers.

If you have a very high genetic risk of breast cancer, a double mastectomy (in which both breasts are removed) may be performed as a preventive measure.

You will not be eligible for a total mastectomy if the cancer has grown into the lymph nodes.

Skin-sparing mastectomy

Women planning for breast reconstruction surgery immediately following a mastectomy often opt for a skin-sparing mastectomy. During this procedure, most of the skin over the breast is left intact, but the nipple and areola are removed. Many women prefer this type of mastectomy because there is less resulting scar tissue and the reconstructed breast looks more natural.

However you will not be eligible for a skin-sparing mastectomy if:

The cancer is too big
The tumour has developed too close to the surface of the skin

Nipple-sparing mastectomy

This is a variation of the skin-sparing mastectomy in which the breast tissue is removed but the skin and nipple are retained. As a cautionary measure, your surgeon may recommend a dose of radiation to the nipple tissue during or after the surgery even if no cancerous cells were found below the nipple.

This type of mastectomy is an option for women with:

Small early breast cancer that is near the breast’s outer area
No traces of cancer in the skin or nipple
Small to medium sized breasts

Specific drawbacks of this surgery include:

There may be very little feeling left in the nipple as the nerves are cut during surgery
The nipple may shrivel or change dramatically in appearance following the procedure, as it no longer has a proper blood supply
The nipple may not sit in the correct position following breast reconstruction in women with larger breasts

It is worth noting that opinion is divided about nipple-sparing procedures, as many surgeons consider it not effective enough to be used as a standard treatment for breast cancer.

Modified radical mastectomy

This surgery is similar to a simple mastectomy except that the axillary (underarm) lymph nodes are also removed.

Radical mastectomy

The radical mastectomy involves the removal of the entire breast, the axillary lymph nodes and the chest wall (pectoral) muscles beneath the breast. This procedure is less common since the advent of the less extensive modified radical mastectomy, which is less invasive in terms of disfigurement and results in fewer side effects, and has been found to be as effective as the radical mastectomy. However, your surgeon may still prefer the radical mastectomy if cancerous cells have been discovered in your pectoral muscles.

Before starting treatment, you may find it helpful to talk to one or two breast cancer surgeons, and other women who have undergone breast cancer surgery. Websites such as Cancer Research UK and Breast Cancer Care also provide a wealth of information.