A lumpectomy, also known as breast-conserving surgery, is a breast cancer procedure that involves the removal of a tumor, as well as a normal margin of healthy breast tissue around it. Compared to a mastectomy, which involves removing the entire breast, health care experts consider a lumpectomy to be a breast-conserving procedure. This is because it leaves the natural breast intact.
A lumpectomy is a surgical option to address early-stage breast cancer. It can also be done to rule out a certain cancer diagnosis. When a lumpectomy is used to remove cancer, radiation therapy to the breast is often followed to reduce the chance that the disease will recur.
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Anatomy and Physiology
The breast is made up of skin, subcutaneous tissue, and breast tissue and is located on the anterior thoracic wall. The pectoralis major muscle supports approximately two-thirds of the breast tissue, with the remaining one-third supported by the serratus anterior muscle and the upper section of the oblique.
The superficial fascia, which lies deep to the dermis, and the deep fascia, which is immediately anterior to the pectoralis major muscle fascia, are the two layers of fascia. These fascias are the landmarks of an oncological mastectomy, because the removal of the breast tissue must be done with the pectoral fascia for a complete resection and which remains a key element of this procedure.
The breast's anatomic borders are the second rib superiorly and the sixth rib inferiorly. The medial boundary is the sternum's lateral border, while the lateral boundary is the midaxillary line. The axillary tail of Spence refers to the extension of breast tissue into the axilla.
The blood flow to the breast is supplied by three main arteries. The first arterial pathway supplies roughly 60% of the blood flow to the breast. It is formed by the anterior perforating intercostal arteries, which branch out from the internal thoracic artery or the internal mammary artery. These vessels are in charge of supplying the breast's medial and central regions.
Another more than 30% of the blood supply to the breast is provided by branches of the lateral thoracic artery, which is an extension of the axillary artery, as well as pectoral branches of the thoracoacromial artery, which serves the upper outer quadrant. Finally, the remainder of the breast is supplied with blood via branches of the posterior intercostal arteries. The breast skin is supplied by the subdermal plexus.
Because of its perforating branches and anterior intercostal branches, the internal thoracic artery is critical for the nipple-areolar complex. The venous drainage of the breast follows the artery supply. Three major veins drain towards the axilla. These comprise the perforating branches of the internal thoracic vein, the perforating branches of the posterior intercostal veins, and the axillary vein tributaries.
The lateral and anterior cutaneous branches of the second through sixth intercostal nerves give the majority of the sensory innervation to the breast. The intercostobrachial nerve, which begins as a lateral cutaneous branch of the second intercostal nerve, is also worth noting.
This nerve provides sensory innervation to the medial portion of the upper arm and is commonly encountered by surgeons during axillary dissection. The thoracodorsal nerve, which supplies the latissimus dorsi and can result in "winged scapula" if unintentionally transected during surgery, is another nerve.
The axilla is the primary site of lymphatic drainage in the breast. The rest of the breast (i.e., the medial aspect) is drained by lymphatics that pass through the perforating branches of the internal mammary artery. In breast surgery, three layers of lymph nodes are identified and classified based on their proximity to the pectoralis minor.
The lymph nodes at a level I are positioned lateral to the pectoralis minor. Level II lymph nodes are superficial to the pectoralis minor and deep to the pectoralis major. Interpectoral lymph nodes, also known as Rotter's nodes, are classified as level II lymph nodes. There are level III lymph nodes medial to the pectoralis minor.
Who is a candidate for a lumpectomy?
Lumpectomy is typically recommended for women with newly diagnosed, early-stage breast cancers such as:
- stage I breast cancer
- stage II breast cancer
- DCIS (ductal carcinoma in situ)
There are a few other factors that determine whether you are a good candidate:
- your tumor is small relative to your breast size
- your tumor is in one area of your breast
- you’re able to receive radiation treatments after lumpectomy
Why is lumpectomy performed?
For several decades, surgery has been the primary therapy for breast cancer. Several recent studies have been in favor of abandoning radical treatments in favor of conservative and less invasive surgeries of the breasts. Adjuvant or neoadjuvant therapy, such as hormone therapy, chemotherapy, and/or radiation therapy, is frequently used in conjunction with surgical treatment of breast cancer.
The purpose of a lumpectomy is to remove cancerous or abnormal tissue from the breast while maintaining its initial appearance. With early-stage breast cancer, studies show that lumpectomy, then radiation therapy, is as beneficial as removing the entire breast (mastectomy) in preventing recurrence.
If a biopsy reveals that you have cancer and it is thought to be small and early, your doctor may suggest a lumpectomy. The doctor can also address and remove some non-cancerous or precancerous breast irregularities through a lumpectomy.
On the other hand, the doctor may not advise on a lumpectomy for breast cancer if;
- You have a history of scleroderma, a group of disorders that harden the skin or other tissues, making it difficult to heal after a lumpectomy.
- You have had systemic lupus erythematosus, which is a chronic inflammatory disease that can get worse if you receive radiation treatments.
- You have two or more tumors in various quadrants of the breast that cannot be removed with a single surgery and are affecting the appearance of your breast.
- You have received prior radiation treatment to the breast area, which makes additional radiation treatments highly risky.
- If you have cancer that has metastasized to the entire breast and underlying skin, a lumpectomy is unlikely to completely eradicate the malignancy.
- You have a huge tumor and smaller breasts that could result in an asymmetrical appearance
- You do not have access to radiation therapy
Preparation for lumpectomy
A few days before you have a lumpectomy, we make an appointment with the surgeon. You have to list all the relevant questions of what you need to know, without forgetting the course of the procedure and the associated risks.
Your healthcare team will give you tips on how to prepare for your lumpectomy surgery and other important information. You can usually go home the same day because the surgery is done as an outpatient procedure.
Lastly, be sure to disclose any medications, vitamins, or supplements that you are currently taking to your doctor. This is because they can interfere with the procedure. In general, you should do the following to prepare for your lumpectomy:
- Stop using aspirin or any other blood-thinning medications to minimize bleeding risks
- Avoid eating or drinking anything for at least 8 to 12 hours before the procedure.
- Have someone drive you home after surgery
Surgical site identification
The first step when it comes to lumpectomy treatment is to locate the problem in the breast (localization procedure). A radiologist, who uses imaging techniques to identify and treat disorders, may use mammograms or ultrasounds to find the tumor. Then he will put a needle, a thin wire, or a small radioactive seed in it. This is helpful in guiding the surgeon to locate the exact area and this identification must be removed during the procedure.
For a breast lump or mass that can be felt on the skin, this localization technique may not be necessary. This is because the surgeon can easily palpate and locate the abnormal region to be removed.
How to Prepare for Lymph Node Removal?
The surgeon may sometimes recommend removal of the lymph nodes around the armpit. This is to check if cancer has moved further away from the breast. In most cases, doctors recommend the procedure (sentinel node biopsy) to remove some lymph nodes for early-stage breast cancer.
Sometimes the results can show that the cancer is present in the lymph node before the procedure, or there is a risk that it has spread even more. In such a case, the surgeon may suggest the removal of some lymph nodes around the armpit. This procedure is known as an axillary lymph node dissection.
Surgical procedures to remove lymph nodes include;
- Sentinel node biopsy
This procedure involves removing the first one or just two lymph nodes into which the tumor drains (sentinel nodes). The nodes are then checked for the presence of cancer. The procedure is usually recommended by the doctor when there are no other concerns regarding lymph node enlargement prior to surgery.
A radioactive agent, a blue dye, or sometimes both, is injected into the region around the tumor or into the skin over cancer before surgery. The surgeon will be able to detect and remove the sentinel node or nodes as the dye moves into them.
There is no need to remove more lymph nodes if there is no malignancy in them. If cancer is found, the surgeon will talk with you about available treatment options, including radiation to the armpit. There will be no need to remove more lymph nodes in the armpit if you choose this option.
- Axillary lymph node dissection
This procedure involves removing some of the lymph nodes in the armpits. The surgeon usually suggests axillary lymph node dissection if the biopsy performed before the operation indicates signs of cancer.
Breast-conserving surgery is referred to by a variety of terminologies, such as quadrantectomy, lumpectomy, or partial mastectomy. These phrases may differ significantly in approach, but they all have the same purpose in mind: breast preservation. Non-palpable tumors necessitate the use of image-guided localization methods, as discussed in the equipment section above.
A lumpectomy of the breast is normally performed under general anesthesia, which puts you in a sleeping condition for the entire procedure.
The surgeon will begin by creating an incision above the tumor or the area where the wire or seed is located. They will then remove the tumor and some of the nearby tissue and take it to a lab for evaluation. If you are having a sentinel node biopsy, your doctor will perform the same procedure for your sentinel lymph node (s), or axillary lymph nodes, when you have an axillary lymph node dissection.
The incision for a lumpectomy is determined by a variety of factors. When physically or cosmetically doable, it may be positioned inside the Langer lines over the mass, or a radial incision, especially in the event of a big tumor. Regardless of where the incision is made, it is critical to keep the prospect of a future mastectomy in mind. Following the incision, subcutaneous flaps are produced around the tumor.
Once removed, it is critical to orient the specimen, especially if re-excision is required in the future. The existence of the biopsy clip and any preoperatively implanted markers is subsequently confirmed by intraoperative specimen imaging. Many surgeons will remove an extra 0.5 to 1.0 cm of tissue to accompany the specimen if a narrow margin is suspected or indicated. "Shave margins," or excising an extra 1 mm of tissue, have been demonstrated to potentially lower margin positive and re-excision rates.
It is also a routine procedure to insert radiopaque clips into the tumor cavity to guide future radiation therapy and imaging. The incision is subsequently closed in layers by the surgeon. On the skin, an absorbable suture is often employed.
A surgical drain is a tube of rubber that is introduced after surgery to collect excess fluid that collects in the region where the tumor was removed. The drain is attached to a suction-capable plastic bulb.
After the procedure is done, the surgeon will cover the incisions with stitches or sutures to preserve the shape of the breast. This will dissolve over time on its own or you may have your doctor remove them later. To keep the incision closed while it heals, the surgeon may apply thin adhesive strips or glue.
What to Expect After Your Lumpectomy Procedure?
You will be transferred to a recovery room after surgery. Here, the healthcare team will monitor your blood pressure, breathing, and pulse. Once you are in a stable condition after outpatient surgery (usually a lumpectomy and sentinel node biopsy), you will be released.
If you have axillary lymph node dissection and have discomfort or bleeding, you may need to stay in the hospital for a day or two. Also, you should expect the following;
- A dressing or bandage is applied to the surgical site.
- In the saddlebag area, you may experience numbness, pain, and a pinching sensation.
- Instructions on how to care for the wound and dressing after surgery, as well as how to identify signs of infection.
- Anti-inflammatory and potentially antibiotic prescriptions
- Some limitations of the activity
- A doctor's appointment, usually seven to fourteen days after surgery.
Lumpectomy recovery time
The time it takes to recover following surgery might range from a few days to a week. After a lumpectomy without a lymph node biopsy, you should be able to return to work in two or three days. After one week, you should be able to resume typical physical activity, such as going to the gym.
You should receive the results of your surgery after a week or a few days. Your doctor will review the results with you during your post-surgery follow-up appointment. If you need additional treatment, your doctor might suggest that you consult with:
- The surgeon to discuss the procedure further if the margins surrounding the cancer were not cancer-free
- A post-operative medical oncologist to discuss other treatment options, including hormone therapy if you have hormone-sensitive cancer, chemotherapy, or both.
- A radiation oncologist to talk with you about radiation treatments, which are generally recommended after a lumpectomy.
- A therapist or support group can help you cope with breast cancer.
Risks of lumpectomy
As with any other surgery, lumpectomy is also a surgical procedure that carries several risks of complications. These include;
- Surgical site infection
- Temporary swelling of the surgical area
- Hard scar tissue that forms in the surgical area
- Changes in the size, shape, and appearance of the breasts, especially when a large section is removed
What is a re-excision lumpectomy?
A re-excision lumpectomy is the second operation that some women have when their pathology findings show cancer cells in the margins, which is the healthy tissue that is removed during a lumpectomy.
Re-excision indicates that the surgeon reopens the surgical site to remove an extra margin of tissue with the objective of obtaining a cancer-free margin. This process is also referred to as "cleaning the edges."
Lumpectomy vs mastectomy
A lumpectomy, also known as breast-conserving surgery, is a surgical treatment that removes only the cancerous area of the breast and a margin of surrounding tissue. Mastectomy, on the other hand, is the surgical removal of all breast tissue. Mastectomy can be performed for a variety of reasons. These individuals have advanced disease, such as T2 (more than 5 cm) tumors, multicentric or multifocal disease, chest wall involvement, or inflammatory breast cancer, which is classified as T4.
Patients with Paget disease, which indicates tumor cells in the epidermis of the nipple-areolar complex, are another rationale for mastectomy. Up to 90% of people with Paget disease have cancer in another part of the unilateral breast. If followed by whole breast radiation therapy, central lumpectomy with sentinel lymph node biopsy is a potential choice in people who do not have further cancer elsewhere in the breast.
Mastectomy is also the recommended treatment option in patients who have initially undergone breast-conserving surgery and have persistently positive margins, as well as patients who have previously undergone breast-conserving surgery and radiation and develop a recurrence or new primary cancer in the unilateral breast. There are several types of mastectomies:
- Total (or Simple) Mastectomy: Involves removal of the breast tissue, nipple, areola and some skin. These can be either unilateral or bilateral (removal of both breasts).
- Skin-sparing Mastectomy: Surgical removal of the breast tissue, nipple and areola removing less skin to provide coverage for immediate breast reconstruction.
- Nipple-sparing Mastectomy: Surgical removal of breast tissue while preserving all skin, the nipple, and the areola; performed in combination with immediate breast reconstruction.
- Modified Radical Mastectomy: Surgical removal of the breast tissue, nipple, and areola coupled with axillary lymph node dissection, which removes the bulk of the lymph nodes in the underarm area.
Contraindications to lumpectomy
Prior radiation therapy, pregnancy, multicentric tumors (tumors in more than one quadrant of the breast), failure to acquire clean margins (large tumor or penetration into surrounding tissues), and physical incapacity to withstand radiation therapy are all absolute contraindications to lumpectomy.
Multifocal tumors, connective tissue pathology, and a significant tumor-to-breast size ratio are relative contraindications. Recurrences of breast cancer in a breast that has already been treated with radiation need a mastectomy.
In many situations, a lumpectomy results in minimal scarring or alterations to the breast. If the surgery is more extensive, there are numerous options to improve the look of the breast. Breast lift surgery, breast reduction surgery, tissue rearrangement, and, in certain situations, cosmetic plastic surgery on the opposite breast to make them seem the same are all options.
As part of the curative treatment for breast cancer, surgery is frequently required. The choice to continue with mastectomy or breast conservation surgery is dictated by both the patient and the illness. Some individuals, such as those with inflammatory breast cancer, require chemotherapy and/or radiation treatment to downstage their tumor or axillary nodes.
Surgery is usually the initial step in the treatment of early-stage breast cancer. Adjuvant radiation is indicated in virtually all patients undergoing breast-conserving treatment after surgery because recurrence chances are unacceptably high without it.
Lumpectomy is a surgical procedure that can remove breast cancer while preserving natural breast tissue. This could make you feel a lot like yourself after cancer therapy. If you want to preserve the shape and appearance of your breast, talk to your doctor about whether a lumpectomy is right for you.
Sometimes factors, such as a large tumor or the inability to receive radiation after lumpectomy surgery, can make the procedure not suitable for you. In such cases, your doctor may suggest a different treatment option. Also, breast cancer treatment must be tailored to your specific needs.