Surgery

Lumpectomy and mastectomy: the two operations

Lumpectomy

A lumpectomy removes the tumor and a small amount of normal tissue around it. Most of the breast skin and tissue stay in place. How the breast looks afterward depends on how much was taken out and where it was. It is also called breast-conserving surgery.

Radiation to the breast is usually given after a lumpectomy, to deal with any cells that might remain.

Mastectomy

A mastectomy removes the whole breast. Radiation is often not needed afterward, though in some situations it is still given.

Choosing between lumpectomy and mastectomy

Not everyone has a choice. Cancer in more than one part of the breast, a tumor that is large relative to the breast, certain gene changes, or previous radiation to the chest can make one option the only sensible one. Your surgeon should tell you plainly which situation you are in.

Where there is a choice, these are the things that actually tip it:

• Distance. Radiation after a lumpectomy means daily trips on weekdays for weeks. If you live a long way from a radiation center, that is a real consideration, not a trivial one.
• Keeping your breast. For many people this matters a great deal, and it is a legitimate reason to choose a lumpectomy.
• Peace of mind. For others, a mastectomy feels like the option they can live with, even knowing survival is the same. That is also legitimate.
• Follow-up. Keeping the breast means continuing mammograms on that side.
• Reconstruction. If you are considering it, it can change the timing and the type of mastectomy. See reconstruction.

Ask your surgeon which she would recommend for you and, more usefully, why. Then ask what she would say if you chose the other one. A second opinion at this point is normal and delays nothing important.

Kinds of mastectomy

Lymph node surgery: sentinel biopsy and dissection

The lymph nodes in the armpit are the first place breast cancer would go if it traveled. Checking them is how the team learns whether it has, and that answer shapes everything afterward. It is not done for treatment, it is done for information.

Sentinel lymph node biopsy

A sentinel lymph node biopsy is the usual approach now. A small amount of radioactive tracer is injected, and sometimes a blue dye as well, and it flows to whichever node the breast drains to first. That one, and sometimes a second, is removed and examined. If those nodes are clear, the rest are very likely clear too, and there is no reason to take them.

This replaced the old practice of removing all the armpit nodes as a matter of course, and it matters because taking fewer nodes carries a much lower risk of lymphedema.

Axillary dissection

If several nodes are known to contain cancer, a larger group is removed. This is a bigger operation on the armpit, with more numbness and a higher lymphedema risk, and it is not done unless there is a reason.

Margins, and when a second operation is needed

After a lumpectomy the pathologist checks the margin, meaning the rim of normal tissue at the cut edge. A clear margin means no cancer cells were sitting at that edge.

Sometimes the margin is not clear, and a second, smaller operation is needed to take a little more. This is disappointing and it is not a sign that anything went wrong. It is a known possibility of the operation, it is common enough that surgeons mention it beforehand, and it does not change your outlook.

The first days after breast surgery

Most breast surgery is done under general anesthetic. Many lumpectomies are same-day. A mastectomy may mean an overnight stay, and a mastectomy with reconstruction usually means longer.

• After a lumpectomy, expect numbness along the scar and soreness in the chest, armpit, and shoulder.
• After a mastectomy, expect numbness across the chest, and be prepared for the fact that it may not fully go away. Soreness in the chest, armpits, and shoulders is normal.
• If lymph nodes were removed, some numbness in the upper inner arm is common.
• A surgical drain may be left in after a mastectomy to carry off fluid. It empties into a small bulb you look after at home. Dr. Perkins leaves a drain in for at least 7 days, and it comes out once its output has been less than 30 mL in 24 hours for two days in a row. Someone will teach you how to manage it before you leave, and the drain log app keeps your record.
• A seroma, a pocket of clear fluid under the skin, is common. It is not an infection and it can be drained in the office if it becomes uncomfortable.

The After surgery page turns this into a day-by-day plan for your operation, with a daily check-in and links to the shoulder exercises and the drain log app.

Ask when you can drive, lift, return to work, and start shoulder exercises. Getting the shoulder moving again on the schedule your team gives you matters more than most people expect.

Lymphedema after node surgery

Lymphedema is swelling in the arm, hand, chest, or back caused by lymph fluid no longer draining freely. It can happen after lymph nodes are removed or treated with radiation. When it appears, it most often does so within about three years of surgery, though it can turn up later.

Two things are worth knowing. The risk is far lower after a sentinel node biopsy than after a full node dissection. And catching it early makes a large difference to how manageable it is, so report new swelling, heaviness, or tightness rather than waiting to see whether it settles.

Where this comes from

The warning-sign list above is general. Your surgeon’s own discharge instructions take priority over it.