Surgery for breast cancer

If you need surgery for breast cancer, the surgeons will do their best to conserve as much of your breast as possible.

However, this is only an option if:

it is medically responsible
the tumor is small enough
the tumor has shrunk after chemotherapy

Once the tumor has been removed, we will deliver radiotherapy to the entire breast (radiotherapy for breast cancer). Some women will need an additional dose delivered to the area where the tumor used to be.

Breast-conserving surgery is not always an option. Your practicing physician will discuss your options with you.

Breast-conserving surgery

Breast-conserving surgery, also known as a lumpectomy, means that your surgeon will remove the tumor while leaving as much of the healthy breast tissue as possible. After surgery, we will deliver radiation therapy to the entire breast, unless you are participating in a trial researching the possibilities of limited radiation treatment.

Breast-conserving surgery is not always an option. Your tumor needs to be relatively small, compared to the breast, for the best cosmetic results.

If the tumor is relatively large, breast-conserving surgery may still be an option if paired with plastic surgery. A section of the breast tissue will be replaced with fatty tissue from the surrounding areas. Another option is to pair the lumpectomy with a breast reduction surgery. Larger tumors can be safely removed with good results, although this surgery is only an option if the breasts are large enough. After either type of surgery, we will deliver radiation therapy as a follow-up treatment. If you received chemotherapy before your surgery, your surgeon will assess whether breast-conserving surgery is an option for you after your chemotherapy.

Breast amputation followed by reconstructive surgery (if desired)

If breast-conserving surgery is not an option, your surgeon will talk to you about the removal of the entire mammary gland. In over 80% of the cases, the breast skin and nipple can be conserved, allowing your surgeon to replace the removed tissue using a prosthesis or tissue expander. This will only require one surgery with a breast surgeon and plastic surgeon. Your surgeon can tell you whether this reconstructive surgery is an option for you. Your plastic surgeon will then discuss your reconstructive options with you.

Diagnostic tests

There are two types of diagnostic tests available that can detect whether your cancer spread to the lymph nodes: the sentinel node procedure and the MARI procedure.

Sentinel node biopsy

At the Netherlands Cancer Institute, we usually perform a sentinel node biopsy during surgery to find out whether the cancer has spread. The sentinel node is the first lymph node in the armpits that is connected to the tumor. This lymph node will be removed during surgery. The sentinel node will be analyzed by a pathologist anatomist to see if there are tumor cells in the lymph nodes.

Your surgeon will discuss the results of the sentinel node analysis with you. These results are expected to come in after approximately 8 work days, together with the results of the breast tissue margin analysis. If there were tumor cells found in the sentinel lymph node, there is reason to believe that the remaining axillary lymph nodes (lymph nodes found in the armpits) will require further treatment, such as radiation therapy. Some people will need a complete removal of all axillary lymph nodes (10 to 25), although this is very rare.

MARI procedure

If the diagnostic tests before your surgery show that there are metastases present in the lymph node(s), there is no need to perform a sentinel node biopsy during surgery. The Netherlands Cancer Institute will instead use the MARI procedure.

This means that the lymph node in which tumor cells were detected will be marked using an iodine seed, a metal marker the size of a chocolate sprinkle with a little bit of radioactive iodine inside. If more than one lymph node were affected, we will only mark the largest one. This lymph node is called the MARI node.

Because chemotherapy or hormone therapy often shrinks the tumors in the breast and lymph nodes, it can be hard to detect the tumor cells on an ultrasound after treatment. This is why the iodine seed marker is placed before the start of your treatment. The seed can retain its radioactivity for months, making the affected lymph node easy to detect at the end of your chemotherapy or hormone therapy.

During surgery, your surgeon will remove the marked lymph node (the MARI node) to send in for pathological analysis. You will receive the results of the test after about 8 work days, together with the tissue and breast tumor test results. If we detect tumor cells in the tissue, we will deliver radiation therapy to your axillary lymph nodes.

Depending on the stage of your illness before the start of your treatment, your MARI lymph node may need to be tested during surgery by means of a frozen section analysis. This will allow us to detect tumor cells in the lymph node within 30 minutes. If necessary, your surgeon can immediately remove the other lymph nodes as well (axillary clearance).

Preoperative screening

Before your surgery, you will be invited to meet with your anesthesiologist at the outpatient clinic for a consultation and a brief examination to assess your overall shape and any potential particularities we will need to keep in mind. The consultation assistant will measure your heart rate and blood pressure and will inquire about your height and weight. If needed, we can take those measurements during the appointment.

This preoperative screening will take approximately 20 minutes and will form the base of your anesthesia. Your anesthesiologist will listen to your lungs and heart and inspect your mouth and throat in preparation of the breathing tube that will be placed during surgery. Your anesthesiologist will also ask you:

whether you have been under anesthesia before
whether you have any other conditions
whether you have taken cancer medicine before
whether you have had radiation treatment before
whether you have any allergies
whether you smoke
whether you drink alcohol
what kind of medication you take

Please inform your anesthesiologist of the type of medication and dose you take, and how often you take it. Your physician may want to run more tests before your surgery, such as: electrocardiogram (ECG), lung x-rays, a lung function test, or a blood test.

General and local anesthesia

Before your surgery, you will be given general anesthesia, local anesthesia, or a combination of the two. General anesthesia means that you will be completely unconscious during surgery, whereas local anesthesia means that a part of your body will be numb and motionless.

General anesthesia

General anesthesia completely sedates your body. You will be given a cocktail of sleeping medicine, pain killers, and sometimes a muscle relaxant through IV. You will be unconscious within 30 seconds. You will be ventilated during the entire process.

If you are having major surgery, we will place a respiration tube in your throat. For smaller surgeries, a small cap in the back of the throat will suffice. We will closely monitor your heart rate, blood pressure, breathing, and temperature through our monitoring devices.

Local anesthesia

If you are given local anesthesia, you will be conscious during your surgery. Local anesthetics are usually administered through an epidural in the spine, and will temporarily numb all body parts underneath. We may place a tube to give you IV pain medication during and after surgery.

Your anesthesiologist will keep a close eye on your blood pressure, heart rate, breathing, and temperature in order to adapt the anesthesia if needed.

Most people undergoing major surgery will be given a mixture of general and local anesthetics.

Fertility preservation

Treatment for breast cancer may negatively affect your fertility levels, which is why the Netherlands Cancer Institute offers fertility preservation.