Radical Mastectomy.	Modified Radical Mastectomy.
Simple (total) Mastectomy.	Partial Mastectomy
Images courtesy of the NIH/NCI.

Axillary Node Dissection

Axillary node dissection, the surgical removal of the axillary (armpit) lymph nodes, is usually performed on patients with invasive cancers. A radical mastectomy, modified radical mastectomy, or lumpectomy operation often includes axillary node dissection (this involves a separate incision for lumpectomy patients). After surgery, the axillary lymph nodes are examined under a microscope to determine whether the cancer has spread past the breast and to evaluate treatment options.

The most common side effect of axillary node dissection is lymphedema: chronic swelling of the arm. Approximately 10% to 20% of patients typically experience lymphedema when axillary node dissection is combined with radiation therapy. Patients are encouraged to report any tightness or swelling of the arm to their physicians as soon as symptoms occur to prevent possible long-term suffering. Other side effects of axillary node dissection include temporary to permanent limitations of arm and shoulder movement and numbness in the upper-arm skin.

Side effects of axillary node dissection:

• lymphedema (swelling of the arm)
• limitations of arm/shoulder movement
• numbness of upper-arm skin

Sentinel Lymph Node Biopsy

Sentinel lymph node biopsy is a procedure that involves removing only one to three sentinel lymph nodes (the first nodes in the lymphatic chain). To perform sentinel node biopsy, a radioactive tracer and/or blue dye is injected into a region of a tumor. The dye is then carried to the sentinel node (the lymph node most likely to be cancerous if the disease has spread from its original origin). If the surgeon determines that the sentinel node contains cancer, more lymph nodes are removed and examined. Surgeons detect the sentinel lymph node by either spotting the blue dye or by measuring a node’s radioactivity with a Geiger counter. If the removed sentinel node is cancer-free, additional lymph node surgery may be avoided. Research has shown that sentinel lymph node biopsy may safely eliminate the need to remove many lymph nodes and reduce the chances of lymphedema (chronic arm swelling). However, the procedure may not be appropriate for all patients. Click here to learn more about sentinel node biopsy.

Choosing Mastectomy as Breast Cancer Treatment

Breast cancer is often first detected by an abnormality on a mammogram (an x-ray examination of soft breast tissues used to identify lumps, cysts, tumors, and other abnormalities). Patients are urged to receive a mammogram if they notice any suspicious lumps during breast self-examination (BSE). If an abnormality is seen on the mammogram then additional breast imaging is usually ordered. Breast cancer is confirmed by biopsy.

After biopsy, several factors are evaluated when determining how to treat breast cancer including:

• tumor size
• tumor type
• cancer stage
• histologic grade
• lymph node status
• estrogen and progesterone receptors
• her-2-neu receptors

Click here for more information on staging breast cancer.

While some patients will be clear candidates for mastectomy, other women are faced with the choice between mastectomy or breast conserving therapy (lumpectomy, usually followed by radiation therapy). Though both mastectomy and lumpectomy have equal survival rates, there are advantages and disadvantages to both procedures. Lumpectomy may preserve the physical appearance of the breast but usually requires six to seven weeks of radiation therapy. Mastectomy may reduce local recurrence of breast cancer, but additional decisions about breast reconstruction are introduced. Patients are encouraged to educate themselves on all possible options and to thoroughly discuss treatment and reconstruction with their physicians before deciding on a course of treatment.

Mastectomy and Breast Reconstruction

It is important for women to realize that breast reconstruction is possible for the majority of breast cancer patients after mastectomy. Often modified radical mastectomy patients may undergo breast reconstructive surgery during the same operation to remove the breast.

Advantages to immediate breast reconstruction:

• Patients do not wake up to the "shock" of losing a breast.
• Patients may avoid additional reconstructive surgery.

Disadvantages to immediate breast reconstruction:

• Patients may find it emotionally difficult to weigh all of their reconstructive options while also dealing with their recent breast cancer diagnosis and treatment alternatives.
• Occasionally there may be complications with reconstructive healing that interfere with chemotherapy or radiation treatment, if needed.

Reconstructive surgery usually involves insertion of breast implant or a muscle flap. Click here to learn more about breast reconstruction.

Women who do not wish to have further surgery may be fitted with an external prosthesis (an artificial breast) after healing from mastectomy. Most prostheses are made to resemble the body’s own weight and touch. According to the American Cancer Society, it is essential for women to have their prostheses properly weighed to balance the body and anchor their bra. Women should take their time in determining which prosthesis is right for them as prices vary considerably. Several manufacturers also make special mastectomy bras that have breast pockets sewn into them. Click here to find resources for breast prosthesis and mastectomy bras.

Before Surgery

Most mastectomy patients will meet with their surgeon a few days prior to surgery to ask any questions they may have about the procedure and its risks. Patients must also sign a consent form which they should review carefully. It may also be necessary for patients to donate blood for a possible blood transfusion during surgery.

Patients are encouraged to discuss any medications they may be taking that could interfere with surgery. Patients will typically be instructed not to have any food or drink at least eight hours before surgery.

The Mastectomy Procedure

General anesthesia is administered during mastectomy, and an EKG monitor (electrocardiogram) is connected to the patient to monitor heart rates. Blood pressure and vital signs are also monitored throughout the surgery.

To perform a simple mastectomy, a surgeon makes an incision along the perimeter of the breast (closest to the tumor area), leaving most of the skin intact. Typically, the nipple is not removed during simple mastectomy, although milk ducts leading to the nipple are cut. The underlying tissue is gently cut free and removed. Often a plastic or rubber drainage tube is inserted in the affected area. The skin is carefully closed with stitches or clips, which are usually removed within a week, and a dressing (bandage) normally covers the site. Mastectomy with axillary (armpit) lymph node dissection usually lasts between 2-3 hours. Immediate breast reconstruction will increase the duration of surgery.

The drainage tube placed in the breast or under the arm removes blood and lymph node fluid accumulated during the healing process. Drainage tubes are usually removed within two weeks, when the drainage is reduced to less than 30 ccs (1 fluid oz) per day.

Possible effects of mastectomy include:

• wound infection
• hematoma (blood trapped in the wound)
• seroma (clear fluid trapped in the wound)
• lymphedema: temporary to permanent limitations of arm/shoulder movement (if lymph nodes are removed during the operation)
• numbness in the upper-arm skin
• phantom breast pain

After Surgery

After mastectomy, patients generally spend two to three days in the hospital, although some may stay up to eight days. Most modified radical mastectomy patients spend an average of three days at the hospital, and those who have breast reconstruction in addition to mastectomy may spend three to six days, depending on the body’s rate of healing.

Major soreness from mastectomy usually lasts two to three days, although many mastectomy patients do not experience soreness after surgery. A linear scar at the mastectomy site is probable. Many patients do experience a pulling sensation near or under their arm after mastectomy.

Patients should receive instructions before leaving the hospital concerning:

• care of the wound and dressing
• type of pain/sensations to expect
• use of pain medications
• how to monitor the drainage tube
• how to recognize signs of infection
• any restricted activities
• emotional feelings to expect
• proper diet
• when to begin arm exercises to reduce stiffness
• when to wear a bra
• when to begin wearing a prosthesis (if chosen)

Source: American Cancer Society Online: Surgery: What to Expect

Physicians will normally schedule follow up exams seven to 14 days after mastectomy. At the follow up exam, the results of the pathology report are usually shared with patients. Radiation treatment may or may not be necessary after mastectomy. Patients with problems or concerns after surgery should contact their surgeon right away.

Click here for information on exercising after mastectomy.

Phantom Breast Pain

Studies have shown that many women experience phantom breast sensations after mastectomy. In a recent study conducted at Johns Hopkins Hospital, more than one third of 279 mastectomy patients experienced phantom breast pain after mastectomy. The incidence of phantom breast pain was similar, regardless of whether or not the women had breast reconstruction after breast cancer surgery. Symptoms of phantom breast pain may include:

• Unpleasant itching
• Pins and needles
• Pressure
• Throbbing

Physicians believe that phantom breast pain occurs after mastectomy for the same reasons as phantom pains occur after limb amputations. According to Srinivasa Raja, MD of Johns Hopkins, during mastectomy, small nerves are cut between the breast tissue and skin area. This causes the neural connections in the brain to undergo neural plasticity (reorganization). This process, as well as the spontaneous firing of electrical signals from the ends of cut or injured nerves, causes phantom sensations, said Dr. Raja. Women who experience breast pain prior to mastectomy are most likely to have sensations of pain in the breast area after surgery.

Physicians recommend that patients who experience phantom sensations in the breast area after surgery report their symptoms to their physicians immediately so that the pain can be properly managed. In some cases, exercise or breast massage may help alleviate phantom breast pain, although patients should first discuss these options with their physicians. In more severe cases, medications may be prescribed to reduce phantom breast pain. Phantom breast pain does not indicate that cancer cells are still present in the breast area or that cancer may return.

Exercising After Mastectomy and Lymph Node Removal

It is important that a patient ask her physician when it is safe to begin exercising and using the surgery-side arm again after a mastectomy. While there are no contraindications to performing any number of exercises after full recovery from mastectomy, there are certain precautions that should be taken by any person who has undergone a mastectomy, especially those who have had accompanying lymph node dissection.

Any minor injury to the skin on the side of the mastectomy may become infected more easily than an injury on the other arm. This is because the lymphatics have been disrupted and lymph nodes have been removed, leaving the arm more vulnerable to invading organisms such as bacteria. The lymphatics normally serve to drain fluids from the limb and the lymph nodes act, in some sense, as a filter, removing harmful substances from the lymph fluid.

Up to 20% of women who have undergone mastectomy and axillary lymph node dissection experience some edema (swelling) in the arm and report a higher incidence of irritation to minor skin trauma for this reason. Click here for more information on lymph nodes and breast health.

In addition, there may be a higher chance of axillary vein thrombosis (a clot in the deep vein in the armpit) in women who have undergone surgery in that area; especially if a more complete axillary dissection with the removal of 30 or more lymph nodes is performed. This is because the lymph nodes are normally located near blood vessels, and (unavoidable) scarring at or near the axillary vein may result from surgery. This scarring may tether, kink, or narrow the blood vessel and make it more susceptible to further injury.

While an increased incidence of deep vein thrombosis has not been reported in the medical literature after axillary surgery, it has been, in rare cases, associated with strenuous upper body exercise, since overdeveloped musculature may affect nearby nerves, veins, and arteries (thoracic outlet syndrome). Therefore, many physicians recommend tempering upper extremity exercise after surgery with periods of rest and keeping the arm elevated above the level of the heart for a few hours, to avoid undue swelling. Mastectomy patients should be careful not to exercise too intensely in order to avoid preventable injury.

On a positive note, regular use of the muscles after mastectomy will keep joints limber, stretch and soften scar tissue, help recruit (open up) new lymphatics, and promote blood flow and actually help reduce clot formation. These benefits generally outweigh the risks of a careful exercise program after mastectomy.

Recurrence of Breast Cancer

Occasionally breast cancer can return (recur) after mastectomy or other treatment. There are three types of breast cancer recurrence: local, regional, and distant. With local recurrence, cancerous tumor cells remain in the original site, and over time, they grow back. A regional recurrence of breast cancer is more serious than local recurrence because it usually indicates that the cancer has spread past the breast and the axillary (underarm) lymph nodes. A distant breast cancer recurrence, also known as a metastasis (spread), is the most dangerous type of recurrence. With this type of recurrence, breast cancer spreads to distant regions of the body, such as the bone, lung, liver, or brain.

Treatment will depend on the type and severity of the breast cancer recurrence. Breast cancer recurrences may be treated with additional surgery, chemotherapy, radiation, or other drug therapies (such as tamoxifen).

Additional Resources and References

• The American Cancer Society provides information on mastectomy at http://www.cancer.org/
• To learn more about lumpectomy (breast-conserving therapy), please visit http://www.imaginis.com/breasthealth/lumpectomy.asp
• To learn more about axillary (underarm) lymph node removal, please visit http://www.imaginis.com/breasthealth/lymph_nodes.asp
• To learn more about sentinel node biopsy, please visit http://www.imaginis.com/breasthealth/sentinelnode.asp
• To learn more about breast cancer recurrence, please visit http://www.imaginis.com/breasthealth/bcrecurrence.asp