Lumpectomy

Definition

Lumpectomy is a type of surgery for breast cancer. It is considered "breast-conserving" surgery because only the malignant tumor and a surrounding margin of normal breast tissue are removed. Lymph nodes in the armpit (axilla) may also be removed. This procedure is also called lymph node dissection.

Purpose

Lumpectomy is a surgical treatment for newly diagnosed breast cancer. It is estimated that at least 50% of women with breast cancer are good candidates for this procedure. The location, size, and type of tumor are of primary importance when considering breast cancer surgery options. The size of the breast is another factor the surgeon considers when recommending surgery. The patient's psychological outlook, as well as her lifestyle and preferences, should also be taken into account when treatment decisions are being made.

The extent and severity of a cancer is evaluated, or "staged," according to a fairly complex system. Staging considers the size of the tumor and whether the cancer has spread (metastasized) to adjacent tissues, such as the chest wall, the lymph nodes, and/or to distant parts of the body. Women with early stage breast cancers are usually better candidates for lumpectomy. In most cases, a course of radiation therapy after surgery is part of the treatment. Chemotherapy or hormone treatment may also be prescribed.

In some instances, women with later stage breast cancer may be able to have lumpectomies. Chemotherapy may be administered before surgery to decrease tumor size and the chance of metastasis in selected cases.

Contraindications to lumpectomy

There are a number of factors that may prevent or prohibit a breast cancer patient from having a lumpectomy. The tumor itself may be too large or located in an area where it would be difficult to remove with good cosmetic results. Sometimes several areas of cancer are found in one breast, so the tumor cannot be removed as a single lump. A cancer that has already attached itself to nearby structures, such as the skin or the chest wall, needs more extensive surgery.

Certain medical or physical circumstances may also eliminate lumpectomy as a treatment option. Sometimes lumpectomy may be attempted, but the surgeon is unable to remove the tumor with a sufficient amount of surrounding normal tissue. This may be termed "persistently positive margins," or "lack of clear margins." Lumpectomy is suitable for women who have had previous lumpectomies and have a recurrence of breast cancer.

Because of the need for radiation therapy after lumpectomy, this surgery may be medically unacceptable. A breast cancer discovered during pregnancy is not amenable to lumpectomy because radiation therapy is part of the treatment. Radiation therapy cannot be administered to pregnant women because it may injure the fetus. If, however, delivery would be completed prior to the need for radiation, pregnant women may

During a lumpectomy, a small incision is made around the area of the lump (A). The skin is pulled back, and the tumor removed (B). The incision is closed (C). (

Illustration by GGS Inc.

)

The need for radiation therapy may also be a barrier due to nonmedical concerns. Some women simply fear this type of treatment and choose more extensive surgery so that radiation will not be required. The commitment of time, usually five days a week for six weeks, may not be acceptable for others. This may be due to financial, personal, or job-related constraints. Finally, in geographically isolated areas, a course of radiation therapy may require lengthy travel and perhaps unacceptable amounts of time away from family and other responsibilities.

Demographics

The American Cancer Society estimated that in 2003, 211,300 new cases of breast cancer would be diagnosed in the United States and 39,800 women would die as a result of the disease. Approximately one in eight women will develop breast cancer at some point in her life. The risk of developing breast cancer increases with age: women aged 30 to 40 have a one in 252 chance of developing breast cancer; women aged 40 to 50 have a one in 68 chance; women aged 50 to 60 have a one in 35 chance; and women aged 60 to 70 have a one in 27 chance—and these statistics do not even account for genetic and environmental factors.

In the 1990s, the incidence of breast cancer was higher among white women (113.1 cases per 100,000 women) than African-American women (100.3 per 100,000). The death rate associated with breast cancer, however, was higher among African American women (29.6 per 100,000) than white women (22.2 per 100,000). Rates were lower among Hispanic women (14.2 per 100,000), American Indian women (12.0), and Asian women (11.2 per 100,000).

Description

Any amount of tissue, from 1–50% of the breast, may be removed and called a lumpectomy. Breast conservation surgery is a frequently used synonym for lumpectomy. Partial mastectomy, quadrantectomy , segmental excision, wide excision, and tylectomy are other, less commonly used names for this procedure.

The surgery is usually done while the patient is under general anesthetic. Local anesthetic with additional sedation may be used for some patients. The tumor and surrounding margin of tissue is removed and sent to a pathologist for examination. The surgical site is then closed.

If axillary lymph nodes were not removed before, a second incision is made in the armpit. The fat pad that contains lymph nodes is removed from this area and is also sent to the pathologist for analysis. This portion of the procedure is called an axillary lymph node dissection; it is critical for determining the stage of the cancer. Typically, 10 to 15 nodes are removed, but the number may vary. Surgical drains may be left in place in either location to prevent fluid accumulation. The surgery may last from one to three hours.

Diagnosis/Preparation

Routine preoperative preparations, such as having nothing to eat or drink the night before surgery, are typically ordered for a lumpectomy. Information about expected outcomes and potential complications is also part of preparation for lumpectomy, as it is for any surgical procedure. It is especially important that women know about sensations they might experience after the operation, so the they are not misinterpreted as signs of further cancer or poor healing.

If the tumor is not able to be felt (not palpable), a pre-operative localization procedure is needed. A fine wire, or other device, is placed at the tumor site, using x ray or ultrasound for guidance. This is usually done in the radiology department of a hospital. The woman is most often sitting up and awake, although some sedation may be administered.

Aftercare

The patient may stay in the hospital one or two days, or return home the same day. This generally depends on the extent of the surgery, the medical condition of the patient, and physician and patient preferences. A woman usually goes home with a small bandage. The inner part of the surgical site usually has dissolvable stitches. The skin may be sutured or stitched; or the skin edges may be held together with steristrips, which are special thin, clear pieces of tape.

After a lumpectomy, patients are usually cautioned against lifting anything which weighs over five pounds for several days. Other activities may be restricted (especially if the axillary lymph nodes were removed) according to individual needs. Pain is often enough to limit inappropriate motion. Women are often instructed to wear a well-fitting support bra both day and night for approximately one week after surgery.

Pain is usually well controlled with prescribed medication. If it is not, the patient should contact the surgeon, as severe pain may be a sign of a complication, which needs medical attention. A return visit to the surgeon is normally scheduled approximately ten days to two weeks after the operation.

Radiation therapy is usually started as soon as possible after lumpectomy. Other additional treatments, such as chemotherapy or hormone therapy, may also be prescribed. The timing of these is specific to each individual patient.

Risks

The risks are similar to those associated with any surgical procedure. Risks include bleeding, infection, breast asymmetry, anesthesia reaction, or unexpected scarring. A lumpectomy may also cause loss of sensation in the breast. The size and shape of the breast will be affected by the operation. Fluid can accumulate in the area where tissue was removed, requiring drainage.

If lymph node dissection is performed, there are several potential complications. A woman may experience decreased feeling in the back of her armpit. She may also experience other sensations, including numbness, tingling, or increased skin sensitivity. An inflammation of the arm vein, called phlebitis, can occur. There may be injury to the nerves controlling arm motion.

There is a risk of developing lymphedema (swelling of the arm) after axillary lymph node dissection. This swelling can range from mild to very severe. It can be treated with elastic bandages and specialized physical therapy, but it is a chronic condition, requiring continuing care. Lymphedema can arise at any time, even years after surgery.

Normal results

When lumpectomy is performed, it is anticipated that it will be the definitive surgical treatment for breast cancer. Other forms of therapy, especially radiation, are often prescribed as part of the total treatment plan. The expected outcome is no recurrence of the breast cancer.

Morbidity and mortality rates

Approximately 2–10% of patients develop lymphedema after axillary lymph node dissection. Five percent of women are unhappy with the cosmetic effects of the surgery. The rate of cancer recurrence after five years is about 5–10%, and 10–15% after 10 years.

Alternatives

A procedure in which the entire affected breast is removed, called a mastectomy, has been shown to be equally effective in treating breast cancer as lumpectomy, in terms of rates of recurrence and survival. Some women may choose to have a mastectomy because they strongly fear a recurrence of breast cancer, and may consider a lumpectomy too risky. Others may feel uncomfortable with a breast that has had a cancer, and would experience more peace of mind with the entire breast removed.

A new technique that may eliminate the need for removing many axillary lymph nodes is being tested. Sentinel lymph node mapping and biopsy is based on the idea that the condition of the first lymph node in the network, which drains the affected area, can predict whether the cancer may have spread to the rest of the nodes. It is thought that if this first, or sentinel, node is cancer-free, then there is no need to look further. Many patients with early-stage breast cancers may be spared the risks and complications of axillary lymph node dissection as the use of this approach continues to increase.

Resources

books

Love, Susan M., with Karen Lindsey. Dr. Susan Love's Breast Book, 3rd ed. Cambridge: Perseus Publishing, 2000.

Robinson, Rebecca Y. and Jeanne A. Petrek. A Step-by-Step Guide to Dealing With Your Breast Cancer. New York: Carol Publishing Group, 1999.

periodicals

Apantaku, Leila. "Breast-Conserving Surgery for Breast Cancer." American Family Physician 66, no. 12 (December 15, 2002): 2271–8.

Dershaw, D. David. "Breast imaging and the conservative treatment of breast cancer." Radiologic Clinics of North America 40, no. 3 (May 2002): 501–16.

organization

American Cancer Society. 1599 Clifton Rd. NE, Atlanta, GA 30329-4251. (800) 227-2345. http://www.cancer.org .

National Cancer Institute (NCI) http://cancertrials.nci.nih.gov/types/breast/treatment/sentnode .

National Lymphedema Network. 2211 Post St., Suite 404, San Francisco, CA 94115-3427. (800) 541-3259 or (415) 921-1306. http://www.wenet.net/~lymphnet .

Ellen S. Weber, MSN
Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Lumpectomy is usually performed by a general surgeon or surgical oncologist. Radiation therapy is administered by a radiation oncologist, and chemotherapy by a medical oncologist. The procedure is frequently done in a hospital setting (especially if lymph nodes are to be removed at the same time), but specialized out-patient facilities are sometimes preferred.

QUESTIONS TO ASK THE DOCTOR

• Why is a lumpectomy recommended?
• What method of anesthesia/pain relief will be used?
• Will radiation or chemotherapy be administered?
• Will a lymph node dissection be performed?
• Am I a candidate for sentinel node biopsy?