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Types of breast cancer surgery

Before any operation your surgeon will talk to you about the most appropriate type of surgery in your case. Remember that they won't do any operation without your consent. The type of surgery you have depends on the size of the cancer in your breast, whether it has spread to any other part of your body, the size of your breasts, and your personal wishes. 

You may need to have the whole breast removed (mastectomy), only the lump removed (lumpectomy or wide local excision), or part of the breast removed (quadrantectomy). If you have the whole breast removed you can have a new breast shape made either during the initial operation or at a later date.

You may also need radiotherapy after the surgery, particularly with breast conserving surgery. Breast conserving surgery means taking away just the cancer, and leaving behind as much healthy breast tissue as possible. It includes lumpectomy and quadrantectomy.

Some women want to keep their breast at all costs. Other women want a mastectomy, because they want to feel the cancer has gone or they prefer not to have radiotherapy. Both treatment approaches work equally well for early breast cancer.

Checking the lymph nodes under the arm

Before the surgery you usually have an ultrasound scan of the lymph glands under the arm. If the lymph glands look abnormal your surgeon may take some cells or fluid to check for cancer cells. 

Your surgeon may check the lymph nodes during surgery using a sentinel node biopsy. They inject a small amount of radioactive fluid and a dye into the area of cancer to find the first node (or nodes) that lymph fluid goes to from the tumour. They remove the first nodes that take up the dye. If the lymph nodes contain cancer cells, your surgeon will remove all, or most, of the remaining nodes from under your arm.

 

CR PDF Icon You can view and print the quick guides for all the pages in the Treating breast cancer section.

 

 

Choosing the type of surgery

Before any operation your surgeon will talk to you about which type of surgery is most appropriate in your case. They won't do any operation or procedure without your consent.

The type of surgery you have will depend on

  • The size of the cancer in your breast
  • Whether it has spread to any other part of your body
  • The size of your breasts
  • Your personal wishes and feelings

In some situations you may be offered a choice of treatments. 

You may need to have

  • The whole breast removed (mastectomy)
  • Only the lump or area of cancer removed (called lumpectomy or wide local excision)
  • About a quarter of the breast tissue removed (quadrantectomy)

You may choose to have a new breast shape made (breast reconstruction) at the time of surgery or later. Having a reconstruction some time after the original surgery is called delayed reconstruction.

There are many types of breast surgery and you may hear other terms used. For example, breast conserving surgery includes lumpectomy (wide local excision) and quadrantectomy. 

If you have breast conserving surgery, you will need to have radiotherapy to the remaining breast tissue after your operation. The radiotherapy aims to treat any cancer cells that may still be in the breast tissue. You might also have radiotherapy to the lymph nodes above the collarbone after your surgery. You may also need radiotherapy after a mastectomy. This depends on how much risk there is of the cancer coming back in the chest muscle. 

Usually your surgeon will discuss your treatment with a radiotherapy doctor (clinical oncologist) after your operation, when all the breast tissue has been examined in the laboratory. The doctors can't plan your treatment until they have all the staging information. And this won't be available until after your operation.

Your surgeon will follow your wishes wherever possible when deciding which type of surgery they can offer. Some women want to keep their breast at all costs. Others want to have a mastectomy, because it makes them feel more sure that the cancer has gone. Or they want to avoid radiotherapy, if possible. 

A great deal of research has proved that breast conserving surgery with radiotherapy works as well as mastectomy at treating early breast cancer. So, some women with early stage breast cancer may be able to choose between a mastectomy or conservative surgery with radiotherapy. They may also have a choice about whether to have breast reconstruction at the same time or at a later date.

All breast surgery leaves a scar. Your surgeon will be able to tell you what to expect in your case and may be able to show you photos of what your breast is likely to look like after the surgery.

 

Surgery to remove just the area of cancer

Surgery to remove the area of cancer is called lumpectomy or wide local excision. The surgeon takes away just the cancer and a border of healthy tissue all around it. They leave behind as much healthy breast tissue as possible. They send the tissue that they remove to a pathologist for examination under a microscope. The pathologist checks for cancer cells in the border around the lump. If that border does not contain cancer cells, your report will say there is a healthy margin or clear margin. 

It is very important to have clear margins with any surgery to remove a cancer. It means that you can be reasonably sure that all the cancer cells have been taken away. So the risk of the cancer coming back in the future is lower.

You may need more surgery after a lumpectomy if there was no clear margin of tissue around the lump or area of cancer.

The scar on the breast after a wide local excision is usually quite small. If you have lymph nodes removed at the same time, the scar is under the armpit and so can't be seen from the front.

Diagram showing a lumpectomy scar

Another type of breast conserving operation is a quadrantectomy. This operation is not done very often now. It is like a wide local excision, but the surgeon takes away about a quarter of the breast tissue. The result is more noticeable than lumpectomy. So you may want to have breast reconstruction after conservative surgery to rebuild the area.

After any of these operations, you will need to have radiotherapy to kill off any breast cancer cells that may have been left behind in the rest of your breast tissue.

breast conserving surgery impact statement

 

Surgery to remove your whole breast

Some women need to have a mastectomy (removal of the whole breast). Mastectomy is the most suitable treatment if you have

  • A large lump, particularly in a small breast
  • A lump in the middle of your breast
  • More than one area of cancer in your breast
  • Areas of DCIS in the rest of the breast

There are different types of mastectomy

  • A mastectomy removes the breast tissue (including the skin and the nipple) and the tissues that cover the chest muscles
  • A radical mastectomy also removes the muscles of the chest wall (this operation is rarely done now)

The scar from a mastectomy extends across the skin of the chest and into the armpit.

Diagram showing a mastectomy scar

If you are having a mastectomy, your surgeon should discuss with you the options for breast reconstruction at the same time (immediate reconstruction). Breast reconstruction means that the surgeon creates a new breast shape for you. Breast reconstruction can also be done months or years after your original operation and is then called delayed reconstruction. You can talk it over with your doctor before your treatment and ask about the different methods of reconstruction. 

For detailed information, look at our breast reconstruction section which explains what reconstruction is and who it is for. It also discusses some common methods and possible problems.

If your doctors think there is a risk of the cancer coming back in the area of the scar, they may offer you radiotherapy after a mastectomy.

 

Checking the lymph nodes

If breast cancer spreads, it usually spreads first to the lymph nodes close to the breast. 

Diagram showing the network of lymph nodes in and around the breast

Checking the lymph nodes before surgery

If you have early breast cancer, you usually have an ultrasound scan under your arm (axilla) before surgery to see if the lymph nodes there look normal. If your doctor thinks some of the lymph glands look abnormal, they will take a biopsy, or a fine needle aspiration. The doctor uses the ultrasound scanner to guide a needle into the abnormal lymph nodes and take out some fluid or cells. They send the fluid or cells to the laboratory to check for cancer cells.

Checking during surgery (sentinel lymph node biopsy)

Sentinel lymph node biopsy is another way of finding out whether cancer cells have spread into any of the lymph nodes under the arm. Before your breast cancer surgery your doctor injects a small amount of mildly radioactive liquid into the breast, close to the tumour. The radioactive liquid is called a tracer. During the operation, your surgeon also injects a small amount of blue dye into the breast. The radioactive liquid and the dye drain away from the breast tissue into the lymph glands close to the area.

The surgeon can see when the dye reaches the first group of lymph nodes. And they use a small radioactive monitor to see when the tracer reaches the nodes. They call these the sentinel nodes. The surgeon removes about 1 to 3 of these nodes and sends them off to the lab to see if they contain cancer cells. If the surgeon thinks any of the sentinel nodes look as though they contain cancer cells, they remove the node and the nodes around it. Usually, the operation is then over, and you and your surgeon will get the results of tests on the sentinel node a week or so later.

If the lab finds that none of the lymph nodes contain cancer cells, you won't need to have any more nodes removed. 

If there are cancer cells in the sentinel nodes

If the laboratory finds cancer in the sentinel nodes, your surgeon will usually offer you a second operation to remove all, or most, of the nodes under the arm. They call this an axillary clearance. If it is not possible for you to have this operation for any reason, your doctor will offer radiotherapy to the armpit, to kill off any remaining cancer cells. They may also suggest radiotherapy to the lymph nodes above your collarbone, in an area called the supraclavicular fossa.

In some hospitals, your surgeon can get the laboratory to check the sentinel node while you are still under anaesthetic. This means the surgeon can find out if there is cancer in the sentinel nodes while you are still in the operating theatre. They can then continue to remove all the other nodes if necessary, so you avoid having a second operation.

The OSNA test

The National Institute for Health and Care Excellence (NICE) has recently approved a new sentinel lymph node test for surgeons to use during the operation. The test is called RD-100i OSNA. It works by picking up a protein (marker) called cytokeratin-19 (CK19), which is linked to breast cancer. This protein is not normally found in healthy lymph node tissue. The test gives results in about half an hour, so the surgeon can decide during the initial operation if they need to remove the other lymph nodes. This means that you avoid a second operation, and could mean that other treatments such as chemotherapy may start slightly sooner.

 

Removing all the lymph nodes from under the arm

Sometimes your surgeon may need to remove all or most of the lymph nodes from under your arm. This operation is called axillary lymph node dissection (ALND) or axillary clearance. Removing many of the lymph nodes in this area gives a risk of long term swelling of the arm called lymphoedema. 

There are ways of reducing the risk of lymphoedema and of managing it if it happens. You can read about this on our page about lymphoedema after breast cancer treatment.

 

More information about breast cancer surgery

If you have questions about breast cancer surgery you are welcome to phone the Cancer Research UK nurses on freephone 0808 800 4040. The lines are open from 9am to 5pm, Monday to Friday. They will be happy to answer any questions that you have.

You can also contact one of the breast cancer organisations or look at our breast cancer reading list.

You can find some helpful questions about surgery for breast cancer on the questions to ask your doctor page

The Bresdex Decision Aid website has information for  women who have been offered a choice between mastectomy or lump removal and radiotherapy

If you want to find people to share experiences with online, you could use Cancer Chat, our online forum. 

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Updated: 31 July 2014