The main decisions that need to be made regarding the surgical treatment of breast cancer are what type of surgery will be done on the breast and what type of surgery will be done on the lymph nodes. For most women with early breast cancer, there will be an option for mastectomy, or complete removal of the breast, versus lumpectomy, or breast-conserving surgery (also referred to as partial mastectomy). Whether a few or all of the lymph nodes will need to be removed is dependent on the type of breast cancer and how extensive it is when diagnosed.
Radical mastectomy. Radical mastectomy was introduced over a hundred years ago and was the first effective operation for local control of breast cancer at a time when breast tumors were usually discovered when they were large. Although this procedure effectively removed the breast cancer, it also left the woman with a large deformity after her breast, underlying chest wall muscles (pectoralis major and minor muscles), and axillary lymph nodes were all removed. The mutilating aspects of radical mastectomy and the early diagnosis of smaller breast cancers led to the development of the modified radical mastectomy, which preserves the pectoralis major muscle. Further, there is no evidence to suggest that removal of the chest wall muscles increases survival. If the breast cancer is involving the chest wall muscles, a small portion of the muscle can be removed (which will preserve function), or the breast can be removed from the muscle and the muscle can be radiated to help prevent local recurrence.
Modified radical mastectomy. Today, radical mastectomy is rarely performed. With the modified radical mastectomy, the surgeon removes the breast, nipple-areola and lymph nodes in the axilla. The largest chest wall muscle, the pectoralis major, remains intact. This muscle is located in the front of the chest and helps to support the breasts; preservation of this muscle greatly reduces the deformity resulting from the mastectomy.
Simple mastectomy. A total mastectomy or simple mastectomy may be done without removing all of the axillary lymph nodes. It is very much the same operation as the breast removal portion of the modified radical mastectomy. Depending on the extent of the tumor in the breast, and also depending on whether or not the patient is to have immediate breast reconstruction, variable amounts of skin are removed. Total or simple mastectomy is indicated in patients who require mastectomy to remove the breast cancer fully but who have no evidence of axillary lymph node involvement. However, for patients with invasive breast cancer, axillary staging is still required and this can be accomplished with a concurrent sentinel lymph node biopsy. For patients undergoing total or simple mastectomy for extensive DCIS (noninvasive breast cancer), most surgeons also recommend a sentinel lymph node biopsy concurrently in the event that any invasive malignancy is found on the final pathology.
Skin-sparing mastectomy. For patients who are to have mastectomy with immediate reconstruction, a skin-sparing and/or nipple-sparing mastectomy may be considered. This approach is only appropriate for those individuals who have no tumor involvement of the skin area to be saved. With this procedure, only minimal skin is removed and the breast is removed from underneath the skin. This allows the surgeon to preserve the natural breast skin envelope for reconstruction. Recently, nipple-sparing techniques that allow preservation of the nipple areolar complex have also been developed. Patients undergoing nipple-sparing procedures are selected carefully on an individual basis.
Lumpectomy. Breast-conserving surgery and irradiation is an option for primary treatment of breast cancer that has become widely accepted. As its name implies, the chief advantage of this treatment approach in comparison with mastectomy is that a woman’s natural breast is preserved. The surgeon removes only the cancerous lump along with a small margin of normal breast tissue. This procedure is referred to as a lumpectomy; it is also called partial mastectomy. Its safety has been proven beyond a doubt by the results of seven large randomized studies involving thousands of women. The local recurrence has been shown to be less than 5% at 5 years, and survival is no different between mastectomy and lumpectomy with radiation. Thus, breast-conserving surgery is an excellent option for most women with early-stage breast cancer.