Your surgeon will surgically remove a sample of the lump or the suspicious area, for evaluation by a pathologist. This biopsy may be aided by a pre-operative needle localization procedure, where your surgeon and radiologist inject markers guided by imaging into the breast to pinpoint the suspicious area to be examined. The needle localization is done while your breast is compressed in mammogram paddles. A picture of the breast is taken to find the area to be localized. The skin over the site is cleansed with Betadine and numbed, and then a needle containing a wire is inserted into the breast.
Two images of breast are taken. If necessary, the needle position will be adjusted and additional films are taken to confirm it is at the correct site. When the needle is in the correct place, it will be removed and a fine wire will remain in place to guide the surgeon during biopsy or lumpectomy. Another mammogram will be taken to map the relationship of the wire’s position to the lesion undergoing biopsy; the surgeon will use this map to guide the surgery.
Lumpectomy and mastectomy
Women today have a choice when facing surgery for breast cancer. The choice is between lumpectomy (breast conservation) or a mastectomy (breast removal). A number of new technologies make it possible for more patients to receive aggressive treatment while sparing more of their breast tissue. Although these treatments are not appropriate for all patients, your physician will help you understand the advantages and disadvantages and determine which options may be right for you. The results and long term follow-up of large national and international clinical trials have proven that breast conserving surgery is equivalent to mastectomy for women whose tumors are 5cm or less and localized to the breast.
Our surgeons work collaboratively with medical and radiation oncologists of the Mass General/North Shore Cancer Center to plan out the best course of treatment for each patient. Many women today have the option of starting with the systemic chemotherapy treatment (neoadjuvant therapy) first before surgery is performed. This approach may be necessary to show how effective the treatment may or may not be for that tumor or for a given person or it may be used to shrink the tumor to make breast-preserving surgery more likely. In many cases, chemotherapy and/or radiation therapy may be required after surgery to kill any remaining cancer cells.
Sentinel lymph node biopsy
Our Breast Health Center surgeons have access to the best and most advanced methods of diagnosing and analyzing breast cancer. Part of the evaluation of patients with invasive breast cancer is the testing of lymph nodes in the areas surrounding the breast to see if cancer has spread there. Knowing whether tumor cells have lodged in lymph nodes helps determine the need for systemic treatments (hormonal or chemotherapy) and most importantly, it guides the selection of the treatments as well as the need for radiation therapy. Lymphatic mapping with sentinel-node biopsy is used to determine if cancer cells have spread to the nodes without doing full lymph node dissection. By performing a sentinel lymph node biopsy, the surgeon removes the most important nodes and leaves other lymph nodes alone safely, decreasing the possibility of a lifetime of a painful swollen arm for the woman.
First, you will be given an injection of a radioactive liquid will be injected into one or more areas near the site of the cancer. The radioactive liquid will flow toward the sentinel nodes so they can be seen on the pictures that will be taken during the scanning and localized during the surgery. The injection will cause a brief stinging or burning sensation. To map the nodes of a breast tumor, you will lie on your back with your elbows out to the side and your hands behind or just over your head. The pictures will show the flow and area of increased absorption of the radioactive liquid in your lymph nodes. Your surgeon will use this as a guide (or map) to determine the location of the lymph nodes that drain the cancer.
After you are asleep in the operating room, your surgeon injects a small amount of a blue dye just under the nipple of the affected breast. This dye will travel toward the sentinel nodes. Your surgeon will then use a hand-held device to locate and measure the radioactivity of the liquid that was injected at the time of the mapping procedure. Once the surgeon finds the sentinel nodes with the device, he or she will make a small incision. The surgeon will see the nodes because they will be blue from the dye injected. The nodes will be removed and sent to the Pathology Department for examination under a microscope. This may be done during your operation, as a frozen section or after the operation, as a permanent section, depending on which your doctor believes is most appropriate.
If the pathology examination reveals there are cancer cells in the sentinel node, a full lymph node dissection will be done immediately or at a later date, as determined by your doctor. If an excision (surgical removal) or re-excision of the original tumor site is required, the surgeon will do this as well. If you had a frozen section and the results indicate that the sentinel node is free of cancer cells, the small incision will be closed and your breast operation will be completed. Additional studies will be done on the sentinel nodes. Further lymph node removal may be necessary, depending on the findings of these studies.
Breast reconstruction surgery
For women who desire reconstruction, our breast cancer surgeons work closely with plastic and reconstructive surgeons to evaluate the woman's goals, medical history, physical examination and potential need for additional cancer treatment to decide on the best type of reconstruction that can be designed for her needs.
Our breast reconstructive surgeons can offer women a number of reconstructive options, some of which can be done at the time of the mastectomy or lumpectomy. Our breast surgeons have expertise in performing skin-sparing mastectomies where the entire breast skin surface and even, part of the nipple-areola complex can be saved, too.
Breast reconstruction can be done using a water-filled tissue expander placed in the site of the removed breast at the time of the mastectomy, subsequent expansion of the skin to replace the skin removed with the mastectomy is followed by placing a permanent breast implant in the cavity created by the expander. Another method of reconstruction involves transferring tissue from the abdomen or back to fill the space left by the lumpectomy.
The Transverse Rectus Abdominis Myocutaneous (TRAM) flap in which fat and muscle are transferred from the lower abdomen to the mastectomy site, and shaped to form a breast. Skin is used to reconstruct a nipple, which is subsequently tattooed the same color as the other nipple. If more skin is needed to close the mastectomy site, a muscle from the back called the latissimus dorsi myocutaneous flap with an implant may be used.
Our breast surgeons work closely with our medical oncologists to assess and manage the treatment of high risk patients. These patients may be advised to have earlier, more frequent and advanced diagnostic testing, participate in genetic testing and counseling, be prescribed breast cancer prevention medications, or counseled to change lifestyle factors.