LUMPECTOMY / PARTIAL MASTECTOMY
Lumpectomy Houston – Partial Mastectomy
Lumpectomy is also known as a partial mastectomy and refers to the surgical removal of a breast tumor or lesion along with a rim or cuff of normal surrounding breast tissue (margin). Get the best partial mastectomy, or lumpectomy Houston has to offer with Dr. Miltenburg and the team at Breast Health Institute of Houston.
A lumpectomy is also known as a partial mastectomy. It refers to the surgical removal of a breast lesion along with a rim or cuff of normal surrounding breast tissue (margin). A lesion is any abnormal change in the breast tissue. A lesion can be benign, possibly malignant, malignant or unknown.
The indications for lumpectomy / partial mastectomy include removal of breast lesions where:
- The pathology of the lesion is unknown
- The lesion is benign
- The lesion is possibly malignant
- The lesion is malignant
In my practice I usually reserve the term partial mastectomy for malignant lesions. For all other cases, I use the term lumpectomy. Partial mastectomy and lumpectomy are the same operation but the terminology changes depending on the indication for surgery (malignant or unknown/benign/possibly malignant).
LUMPECTOMY WITH LOCALIZATION
If the breast lesion is not easy to feel (palpable), such as one detected on a mammogram, a guide-wire or marker needs to be placed prior to surgery to guide the surgeon. This is known as lumpectomy / partial mastectomy with localization. Using ultrasound, mammogram or in some cases MRI guidance, a thin, flexible guide-wire or an infrared marker is placed into the lesion on the day of surgery or days prior to surgery. This marker is different than the clip placed at the time of biopsy. The clip placed at the time of biopsy is Titanium and designed to be seen on a mammogram but it’s much too tiny to be seen in the operating room.
The patient is awake for the localization but local anesthetic can be used. Localization is less uncomfortable than biopsy because, since tissue is not being removed, there is no cutting involved. The guide-wire is very thin and has a hook on the end, which keeps it anchored in the breast. The other end comes out of the skin and is taped down. After the guide-wire is inserted the patient is taken to the operating room. Alternatively, an infrared marker can be placed into the lesion several days before surgery. The choice of localization technique depends on the facility and the circumstances. Both techniques are equally good and in each case the guide-wire or the infrared marker and the clip placed at the time of biopsy are removed along with the breast lesion so at the end of the surgery there is no foreign material in the patient’s body. See Special Topics – Techniques for Localizing Breast Lesions.
What to expect
The operation is usually done under general anesthesia. It takes 1 to 2 hours. A one to two-inch incision is made and with guidance the surgeon dissects through the breast tissue to the lesion. The goal of surgery is to remove the lesion along with a margin of normal breast tissue. This may seem straightforward but it’s not as easy as it sounds. In most cases the surgeon cannot feel or see the lesion. She or he uses the mammogram as a map and the wire or infrared marker as a compass. Based on the mammogram, ultrasound and MRI the surgeon estimates where the lesion starts and stops and therefore how much tissue to remove. There is a real art to it.
Once the lumpectomy tissue is removed the surgeon orients the specimen. There are 6 sidesormargins:
- Anterior (front)
- Posterior (back)
- Superior or cranial (top)
- Inferior or caudal (bottom)
- Medial (toward the center of the body)
- Lateral (toward the outside of the body)
The lumpectomy specimen may undergo mammogram or X-ray to help verify that the targeted area was removed (See Excisional Biopsy)
The last part of surgery
Once the tissue has been sent to the pathologist, the surgical cavity is irrigated and all the bleeding vessels are cauterized. If the patient has cancer and radiation is planned, the surgeon may place clips or a fiducial in the surgical cavity. This is done to let the radiation oncologist know precisely where the cancer was.
The incision is sewed closed with 2 rows of dissolving suturesplaced under the skin. A layer of “glue” is applied to the surface of the skin and then the incision is covered with a sterile bandage. The patient is either wrapped with an ACE bandage or placed in a surgical bra.
- Keep the dressing on and keep it dry for 3 days.
- On post-operative day 4 the dressing can be removed and the incision can get wet. However, don’t let the incision get too wet and don’t wash the incision or apply any antibiotic ointment, cream, etc. because it will cause the glue to lift off and the incision will open. By the 4th day after surgery the incision doesn’t have to be coveredany more but if you want to just use a bandage or gauze.
- Wear a bra all day and night for 3 days. After that, starting on post-op day 4,just wear a bra during the day. After 3 days you don’t have to wear a bra at night anymore but you can (some women find it more comfortable).
- Recovery time is about 1 week.
- Do lift, push or pull anything heavier than 10 pounds for at least 2 weeks.
- Avoid sports and activities that cause bouncing for at least 1 month.
- Do not submerge the incision in a bath tub, swimming pool, lake or sea water for 6 weeks.
what can you expect the breast to look like after lumpectomy?
The breast is quite forgiving. A skilled surgeon can remove quite a bit of tissue from the breast and once everything has healed the breast will not look smaller or dented or distorted. How can this be? When breast tissue is removed during lumpectomy a hole or space is left behind. Our bodies don’t like empty spaces so the body makes seroma fluid to fill the space. This is a normal physiological response. In other parts of the body, seromas can cause problems, but in the breast, a seroma is important to maintaining the shape, volume, and contour of the breast after a lumpectomy. Overtime (3-4 months) the body will absorb the seroma fluid and replace it with solid tissue. So, when the patient is naked and looks in the mirror, it looks like nothing happened. Sometimes you can feel an indentation or loss of volume in the area of a lumpectomy but you cannot see it. Of course, results vary but, in my experience, most patients have an excellent cosmetic outcome.
Keep in mind that these results refer to patients who have a lumpectomy only. If, however, lumpectomy is followed by radiation the breast may look normal initially but over time it frequently becomes smaller and distorted. For the most part this due to the radiation. Whereas surgery heals over time, radiation decays but never completely goes away.
LUMPECTOMY/PARTIAL MASTECTOMY for patients with cancer
If the lesion has already been biopsied and is known to be a non-invasive malignancy (ductal carcinoma in situ or DCIS), the margin should be 2 mm. If the lesion is known to be an invasive cancer (invasive ductal carcinoma or invasive lobular carcinoma) the margin does not have to be 2 mm. As long as there are no cancer cells comingto the edge of the lumpectomy specimen (no tumor on ink), the margin is considered negative (negative margin). The reason the margin in DCIS needs to be larger than with invasive cancer is because research shows that DCIS has more of a tendency to have additional cancer cells a little way apart from the main tumor (multifocal ormulticentric cancer).
Depending on the circumstances, the specimen is sent for permanent pathology or the pathologist does a preliminary evaluation of the specimen while the patient is under anesthesia. The latter is done to help obtain negative marginsand avoid a second surgery.It is important to keep in mind that intraoperative margin evaluation is technically difficult. In select cases a frozen section may be performed to evaluate a margin that looks close but again this is a preliminaryevaluation. Frozen section is not done on all the margins. The margin results may change once the entire area is processed and evaluated under the microscope.
Everyone is anxious to know that we “got it all” during surgery. The surgeon can give their opinion of whether he or she thinks they “got it all” but no one can be sure until the final pathology report is issued.According to the College of American Pathologists, tissue removed from the breastshould be placed in Formalin, a fixing solutionwithin one hour and must remain in Formalin for a minimum of 6 hours up to a maximum of 72 hours. This fixation time is crucial so that the tumor markers can be evaluated accurately. Once the tissue is fixed it is sliced then placed on glass slides and stained. In many cases 30 or 40 slides are made and the pathologist looks meticulously at each and every one. Often times, more than one pathologist reviews the slides. Here’s the deal: Evaluation of the tissue by the pathologist is critically important and treatment decisions are made based on the pathology report so do you don’t want to rush the process. Let the professionals take their time and do a good job.
Some surgeons, in an attempt to obtain negative margins in a single operation, remove additional tissue from all 6 or a select side of the cavity created in the breast during lumpectomy (shave margins). This will result in more tissue being removed and a larger cavity in the breast. This may or may not affect the cosmetic outcome.
There is a 10 to 40% chance that the final pathology report, which comes out about a week after surgery, will report a positive margin. This can happen even if the shave margin technique was used. If there is a positive margin and you need additional surgery it’s not the end of the world. A second operation to obtain negative margins is a pretty straight forward surgery. It’s a tiny blip in the overall situation. Having said that, half of the time no additional cancer is found. If there are several positive margins or if a second lumpectomy fails to obtain negative margins, mastectomy may have to be considered.
If negative margins are obtained and the patient completes radiation therapy, the chance of cancer re-occurring in the breast (local recurrence) is approximately 7%. If the patient has lumpectomy only and no radiation, the chance of cancer recurring in the breast is approximately 1 in 3 (33%). That is why lumpectomy and radiation always go together.
If there is a local recurrence, it’s not the end of the world. At that point the patient will need a mastectomy. However, the chance of dying from breast cancer (cancer mortality) is the same as if the patient had a mastectomy in the first place.