Breast cancer surgery: lumpectomy, mastectomy and the lymph nodes

Most breast lumps are harmless, and tests at a breast clinic usually show a lump is not cancer (NHS). The assessment combines an examination, a scan, usually a mammogram or ultrasound, and a needle biopsy; biopsy results can take about a week.

When cancer is confirmed, its size, type and receptors guide the order of treatment. Chemotherapy is sometimes given before surgery to make the cancer smaller (NHS). The team meets, reviews the images and pathology together, and only then recommends the operation.

A lumpectomy, also called breast-conserving surgery or wide local excision, removes the cancer with a rim of healthy tissue and keeps as much of the breast as possible. It usually suits a single area of cancer smaller than 5 cm that is small relative to the breast, in a woman able to have radiotherapy afterwards (American Cancer Society).

The pathologist checks the edges, or margins. If cancer cells reach the edge, a second operation to remove more tissue is often needed (ACS). Most women then have radiotherapy to the breast, and it is usually a day-case operation with a return to regular activities within 2 weeks.

A mastectomy removes the whole breast. It may be advised when the cancer is large for the breast size, there are several areas of cancer, radiotherapy is not possible, cancer remains after repeat lumpectomy, or there is a gene change such as BRCA; some women also choose it (ACS). Skin-sparing and nipple-sparing types keep more of the breast's skin and suit some early cancers.

A single mastectomy usually takes about an hour and a half, and many women go home the same day or after 1 or 2 days (NHS). Breast reconstruction can sometimes be done at the same time or later, so it is worth discussing before surgery.

In a sentinel node biopsy, a tracer (a radioactive substance, blue dye or an iron-oxide liquid) is injected near the tumour or nipple, and the surgeon removes only the first few nodes it reaches (ACS). If they are clear, the other nodes can usually be left alone.

This matters because arm swelling (lymphoedema) is less likely. The American Cancer Society puts the risk at about 5% to 17% after sentinel node biopsy and about 20% to 30% after a full axillary dissection, which removes about 10 to 40 nodes, usually fewer than 20 (ACS).

Breast-conserving surgery may not be suitable for inflammatory breast cancer, during pregnancy if radiotherapy would be needed straight away, or with some connective tissue diseases that make radiotherapy unsafe (ACS). In those cases a mastectomy is usually discussed.

For early-stage cancers that suit both, the choice is often yours, made with the surgeon after the team meeting. Bring someone you trust to the consultation, and take time to ask every question.

Bring the actual mammogram, ultrasound and MRI images, not only the reports, with the biopsy report. If reconstruction is a possibility, discuss it with your breast surgeon and a plastic surgeon before the operation (ACS).

It helps to arrange some help at home for the first days and to learn the arm exercises you will be shown after surgery (ACS). Tell the team about every medicine you take, including blood thinners and supplements.

You may go home with a small drain, a tube that collects fluid from the wound; it is usually removed within a few days or weeks. Most usual activities return in about 3 weeks after mastectomy, the wounds take around 6 weeks to heal fully, and heavy lifting should wait 2 to 3 weeks (NHS).

Drive only once the wounds have healed and the seatbelt feels comfortable. Gentle arm exercises help the shoulder recover, and most women return to most daily activities within about 4 weeks, longer after reconstruction (ACS).

Possible problems include bleeding, infection, a collection of fluid (seroma) or blood (haematoma), painful scarring and blood clots (NHS). Numbness in the chest or upper arm, a stiff shoulder and lasting nerve pain can also happen (ACS).

After lumpectomy the breast can change shape or develop a dimple or firm scar (ACS). When lymph nodes are removed, lymphoedema is a long-term risk, as described above.

• Sudden pain or swelling in the breast or armpit
• Bleeding from a wound
• Sudden loss of feeling in the arm
• Redness, heat or discharge from the wound, or a fever

Severe difficulty breathing, chest or upper back pain or a very fast heartbeat can mean a clot in the lung: call an ambulance or go to an emergency department straight away (NHS).

For early-stage breast cancer, choosing breast-conserving surgery with radiotherapy does not affect the chances of long-term survival compared with mastectomy, based on studies of thousands of women followed for more than 20 years (ACS).

Your overall outlook depends on the stage and type of cancer, which the pathology report confirms after surgery. Radiotherapy, hormone therapy or chemotherapy may follow, and your oncologist will explain what applies to you.

A fibroadenoma is a common benign lump of glandular and connective tissue, most often found in women in their 20s and 30s. It usually feels firm or rubbery, like a marble, and a biopsy confirms the diagnosis (ACS).

Not every fibroadenoma needs removal. Surgery may be advised if it is large, growing, troublesome or unusual on imaging; otherwise it can be watched (ACS). Any new lump should still be checked (NHS). The same careful approach applies to neck lumps in thyroid surgery.

Sources: ACS, ACS, NHS. The right choice depends on the cancer, the breast and your preferences.

The cost depends on the hospital and room class, the type of operation (lumpectomy, mastectomy, with or without lymph node surgery or reconstruction), tracer materials for sentinel node biopsy, and the length of stay. Imaging, pathology and follow-up visits add to it; radiotherapy and chemotherapy are priced separately.

To go over your reports and ask for a current written quote, book a consultation with Dr. Yasser, and ask the clinic about payment options. Our page on colon cancer surgery shows the same team approach for bowel tumours.