Lumpectomy

A lumpectomy is one type of surgery for breast cancer. The malignant tumor and a surrounding margin of normal breast tissue are removed. Lymph nodes in the armpit (axilla) may also be removed.

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 variable. The patient's psychological outlook, as well as her lifestyle choices, should also be taken into account when treatment decisions aremade.

The severity of a cancer is evaluated or "staged" according to a fairly complex system. This considers the size of the tumor and whether the cancer has spread directly 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 areusually 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.

Many studies have compared the survival rates of women who have had removal of a breast (mastectomy) with those who have undergone lumpectomy and radiation therapy. The data is clear that for women with comparable stages of breastcancer, survival rates are equal between the two groups.

In some circumstances, a woman with later stage breast cancer may be able tohave a lumpectomy. Chemotherapy can be administered before surgery to decrease tumor size and the chance of spread in selected cases.

There are a number of factors that may prohibit a breast cancer patient fromhaving a lumpectomy. The tumor itself may be too large or located in an area,such as near the nipple, where it would be difficult to remove with good cosmetic results. Sometimes several areas of cancer are found in one breast, sothe tumor cannot be removed in a single mass of tissue. Tumors known to growvery rapidly would most likely not be treated with lumpectomy. A cancer whichhas 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 atreatment option. Sometimes lumpectomy may be attempted, but the surgeon is unable to remove the tumor with a sufficient amount of normal tissue surrounding it. This may be termed "persistently positive margins," or "lack of clearmargins," referring to the margin of unaffected tissue around the tumor. Lumpectomy is not used for women who have had a previous lumpectomy and have a recurrence of the breast cancer.

Because of the need for radiation therapy after lumpectomy, this surgery maybe medically unacceptable. A breast cancer discovered during pregnancy is notamenable to lumpectomy, due to the need for radiation therapy as part of thetreatment. Radiation therapy cannot be administered to pregnant women, for fear of injuring the fetus. Women with collagen vascular disease, such as lupus erythematosus, or scleroderma, would experience scarring and damage to their connective tissue if exposed to radiation treatments. A woman who has already had therapeutic radiation to the chest area for other reasons cannot haveadditional exposure for breast cancer therapy.

Some women may choose not to have a lumpectomy for other reasons. They may strongly fear a recurrence of breast cancer, and may consider a lumpectomy toorisky. Other women feel uncomfortable with a breast that has had a cancer, and they experience more peace of mind with the entire breast removed.

The need for radiation therapy may also be a barrier due to non-medical concerns. Some women simply fear this type of treatment and chose more extensive surgery so 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 the family and other responsibilities.

Lumpectomy is an imprecise term. Any amount of tissue, from 1-50% of the breast, may be removed and called a lumpectomy. Other names are no more definitein their meaning, although some idea of the scope of tissue removal may be implied. Breast conservation surgery is a frequently used synonym for lumpectomy. Partial mastectomy, quadrantectomy, segmental excision, wide excision, andtylectomy are other names for this procedure.

A lumpectomy is typically done in a hospital setting, but specialized outpatient facilities are sometimes preferred. The surgery is usually done while thepatient is under general anesthetic. Local anesthetic with additional sedation may be used for some patients. The tumor and surrounding margin of tissueis removed and sent to the pathologist. The surgical site is closed. If axillary lymph nodes were not removed before, a second incision is made in the armpit. The fat pad which contains lymph nodes is removed from this area and isalso sent to the pathologist for analysis. This portion of the procedure is called an axillary node dissection; it is critical for determining the stage of the cancer. Typically, 10-15 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.

The patient may stay in the hospital one or two days, or return home the sameday. 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 hasdissolvable stitches. The skin may be sutured or stitched; or the skin edgesmay be held together with steristrips, which are special thin, clear piecesof tape.

Routine preoperative preparations, such as taking nothing to eat or drink thenight before surgery, are typically ordered for a lumpectomy. Information regarding expected outcomes and potential complications should also be part ofpreparation for lumpectomy, as for any surgical procedure. It is especially important that women know about sensations they might experience after the operation, so the sensations 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 tumorsite, 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.

After a lumpectomy, patients are usually cautioned against lifting anything which weighs over five pounds for several days. Other activities may be restricted, 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, thepatient 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 feasible after lumpectomy. Other additional treatments, such as chemotherapy or hormone therapy, may alsobe prescribed. The timing of these is specific to each individual patient.

The risks are those which are common to any surgical procedure, including bleeding, infection, 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 areawhere 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; or 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.

Approximately 2-10% of patients develop lymphedema after axillary lymph nodedissection. This swelling of the arm can range from mild to very severe. It can be treated with elastic bandages and specialized physical therapy, but itis a chronic condition, requiring continuing care. Lymphedema can arise at any time, even years after surgery.

A new technique that may eliminate the need for removing many axillary lymphnodes is being tested. The term "sentinel node biopsy" is most frequently used to refer to this method. It is based on the idea that the condition of thefirst lymph node in the network, which drains the affected area, can predictwhether the cancer may have spread to the rest of the nodes. If this first, or sentinel, node is cancer-free, it is thought there is no need to look further. Many patients with early-stage breast cancers may be spared the risks andcomplications of axillary node dissection as the use of this approach continues to increase.

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.

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