When a suspicious area is found on a mammogram or ultrasound but cannot be felt and requires further evaluation by a surgeon, needle localization may be recommended. The procedure is performed with aid of mammography or ultrasound by a radiologist prior to a scheduled surgical biopsy. The radiologist marks the area to be biopsied by the surgeon with a needle and wire. The wire is used later to guide the surgeon to the abnormal marked area for removal.
Since you must be alert, sedation is usually not recommended. First, the technologist will take a mammogram x-ray of your breast as usual. Then she will leave the room to develop the film. Your breast will remain compressed, and you will be asked to remain very still so that the position of the breast does not move between the compression paddles. After returning to the room, the technologist will cleanse the area for the needle with alcohol. She does this through small holes in the paddles. When the radiologist enters, he will place a needle into the breast. Numbing medication may or may not be used because the compression of the breast decreases the sensation of the needle. The procedure is mildly uncomfortable.
Second, pictures will confirm if the needle is located in the suspicious area. If the tip of the needle is not accurately placed, it will be repositioned and another picture taken. When the film confirms correct placement, the pressure paddles will be released and another picture at a different angle will be taken. This picture confirms the depth of the needle and its accurate placement and may also determine if an adjustment in placement of the needle is needed.
Mammography localization differs from ultrasound placement in that compression of the breast is not needed with ultrasound. Needle placement uses the same method.
When it is confirmed that the needle is positioned in the correct area, the radiologist will slide the wire out of the tip of the needle into your breast and then remove the needle, leaving the wire in place. The wire has a hooked tip that holds it in the area. Two final pictures are made to confirm the accuracy of the wire placement. The wire is taped to the outside of your breast. You will be able to feel the wire being inserted, but after the placement it is not painful. Copies of your films will be sent with you to surgery to enable the surgeon to locate the tip of the wire during the surgery.
In the surgery room, you will be given anesthesia. The surgeon will make an incision into the breast to remove the area marked by the tip of the wire. When the tissue is removed, it is sent back to the radiology department to be x-rayed so that the surgeon is assured it is the suspicious area that was seen on the mammogram. The pathology lab then analyzes the biopsy specimen to determine what types of cells are present. Pathology reports are sent to your physician when the results are complete.
The localization procedure may take 30 minutes or longer. The surgery will take from 30 minutes to one hour. You will be allowed to leave the outpatient surgery recovery area when your vital signs are normal. This is usually several hours, depending on the type of anesthesia you receive. You will be given instructions on how to care for the wound before you are discharged. Your doctor will have you return to the office to remove the stitches.
If a surgeon can feel a suspicious lump, an incisional biopsy may be performed using a surgical knife in an operating room to remove a portion of the suspicious lump, rather than the entire lump. An incisional biopsy is usually performed when the lump is large and a preliminary diagnosis is needed. This is routinely performed in the hospital on an outpatient basis.
Several days prior to the biopsy, you will be required to have lab work performed according to your doctor's orders. An assessment and medical history will be taken to determine any conditions, such as allergies and previous surgeries. Remember to write down the names of any medications or herbal medications that you take on a regular basis to report during your assessment.
On the day of the surgery you will report to the surgical unit. Local anesthetic in the breast only or general anesthetic, putting you to sleep, will be administered. The breast will be cleansed with an antiseptic to destroy bacteria on the skin. The surgeon will cut through the skin to the area of the lump and remove a small portion of the lump. Several stitches will close the area. You will be taken to an outpatient recovery room where you will be monitored until your vital signs are normal. You will be discharged if you are not experiencing vomiting, bleeding or excessive pain. A small bandage will cover the incision and you will be given discharge instructions on how to care for the wound.
Ask your doctor when you may get the area wet and when you may return to your normal activities. A return appointment with your physician will be made to have the stitches removed and to see how the wound is healing.
The biopsy tissue will be sent to the pathology lab and the results, stating whether the tissue is benign (not cancer) or malignant (cancerous), will be made available to your physician. Ask your physician when and how you will be informed of the results of the biopsy report.
There is potential for infection after an incisional biopsy because of the cut through the skin. Follow the instructions provided by your physician on how to care for the wound. Be sure to keep the bandage dry. Check the area for signs of increasing redness or a drainage that has a dark yellow-greenish tint or has a foul-smelling odor. Report any new, red bleeding if it should occur, or the formation of a hematoma, which will appear as a dark-red, firm area under the skin. Your physician will need to record the hematoma information on your medical chart because this can appear as a change on a future mammogram.
If a physician can feel a suspicious lump, it may be surgically removed from the body with an excisional biopsy. The procedure is performed in an operating room on an outpatient basis.
Several days prior to the biopsy, you will be required to have lab work performed according to your doctor's orders. An assessment and medical history will be taken to determine any conditions such as allergies or previous surgeries. Remember to write down the names of any prescription medications or herbal medications that you take on a regular basis for this assessment interview.
On the day of the surgery, you will report to the surgical unit. Local anesthetic in the breast only or general anesthetic, put to sleep, will be administered. The breast will be cleansed with an antiseptic cleanser to destroy bacteria on the skin. The surgeon will cut through the skin to the lump and remove the entire lump and sometimes an area of tissue around the lump referred to as the margins. Several stitches will close the incision area. You will be taken to the recovery area where you will be monitored until your vital signs are normal, you are awake and are experiencing no vomiting, bleeding or excessive pain. You will then be discharged.
A small bandage will cover the incision. You will be given discharge instructions on how to care for the wound. Ask your healthcare provider when you may get the incision area wet and when you can return to normal activities. A return appointment will be made with your physician to have your stitches removed and to see how the wound is healing. The biopsy tissue will be sent to the pathology lab and the results, stating whether the tissue was benign (not cancerous) or malignant (cancerous) will be made available to your physician. Ask when and how you will be informed of the results of the biopsy report.
There is potential for infection after an excisional biopsy because of the cut through the skin. Follow the instructions provided by your physician on how to care for the wound and how to change the bandage. Be sure to keep the bandage dry. Check the area for signs of increasing redness, or a drainage that has a dark yellow-greenish tint or a foul-smelling odor. Report either new, red bleeding if it should occur, or the formation of a hematoma which appears as a dark, reddened, firm area under the skin. Your physician will need to record the hematoma formation on your medical chart because this can appear as a change.
Lumpectomy is a commonly used term to describe the removal of a tumor with varying amounts of surrounding tissues from the breast, leaving the remainder of the breast intact. Your physician will evaluate your candidacy for breast-conserving surgery (lumpectomy) by assessing:
• Size of your tumor compared to the size of your breast; a large tumor in a small breast will not produce good cosmetic results;
• Pregnancy (pregnancy disqualifies if there is a need for immediate radiation therapy);
• More than one tumor in your breast;
• Mammogram showing scattered micro-calcifications (may indicate high risk for recurrence);
• Location of tumor in breast (tumors under the nipple produce poor cosmetic results);
• Evidence of involvement of skin, muscle or chest wall from an invasive tumor;
• Large pendulous breast (may be difficult to adequately radiate the remaining tissues);
• Collagen vascular disease or lung disease;
• Restrictions on travel or transportation to clinic for daily radiation for five to six weeks;
• Your priorities regarding surgery.
Breast conserving surgery has advantages and disadvantages to consider. It is important that you understand these and discuss your feelings with your physician if you are a candidate for breast conserving surgery.
• Conserves a major portion of the breast, usually the nipple and areola;
• Hospitalization is shorter and surgery may even be done on an outpatient basis;
• Recovery time from surgery is shorter;
• Body image remains intact;
• Rarely requires reconstruction;
• You can wear your own bras and do not need a prosthesis;
• For most women, emotionally, it is not as difficult to accept as mastectomy.
• Recurrence of cancer in remaining breast tissue is a risk;
• Five to seven weeks of radiation therapy is usually required;
• Changes resulting from radiation to breast are in texture, color and sensation of feeling;
• Decrease in size of the remaining breast tissue after radiation therapy;
• Need to perform breast self-exam on breast after radiation, which causes increased lumpiness (psychologically difficult for some women);
• Possibility of second lumpectomy or mastectomy if cancer recurs in breast.
It is important to understand that even with local recurrence, the overall survival rate in patients is not less successful when compared to mastectomies.
This breast-conserving surgery is further defined according to the amount of breast tissue that is removed. Ask your physician which of the following surgeries you will need.
• Partial or Segmental Mastectomy
The tumor, over-lying skin and an area of tissue around the tumor are removed with this surgery. A portion of the lining of the chest muscle under the tumor and some of the skin may also be removed. Lymph nodes may or may not be removed through a separate incision under the arm.
The tumor and a wide area of tissue around the tumor are removed during surgery. Lymph nodes may or may not be removed through a second incision under the arm.
Lumpectomy removes the tumor and a small wedge of surrounding tissue. Lymph nodes may or may not be removed by a separate incision under the arm.
Incisions for the breast-conserving procedures described above look very similar, with the cosmetic appearance of the breast differing according to the size of the tumor and the amount of tissue removed.
Prior to hospitalization, you will be required to have a pre-admission work-up including blood work, electrocardiogram, and any other diagnostic tests your physician may feel necessary. Surgery is usually performed in a hospital with admission early the same day.
General anesthesia is usually given. The tumor with surrounding tissue is removed and lymph nodes under your arm may be removed in a separate incision to evaluate if the tumor has spread from your breast. The surgery time is around one hour, followed by several hours spent in the recovery room. Hospital stays are only one night, and some surgeries are now being performed on an outpatient basis. Pain is moderate and is controlled with oral pain medication after you are able to eat and drink. Some lumpectomy patients have a drain to remove fluid accumulation from the site. Instructions will be given by the nurse on how to empty the drain(s) and record the drainage until the surgeon removes the drains in several days. Recovery time at home is around one to two weeks.
Several weeks after a lumpectomy, radiation therapy is usually given to the remaining breast tissue for five to seven weeks. Treatments usually are given Monday through Friday and require only 10 to 15 minutes. Radiation therapy is painless and you will not be radioactive. You can interact with your family as usual. However, changes that may occur are a slight sunburn effect to the breast area resulting in change of color and sensitivity to the breast, sore throat, dry cough and fatigue. Most women are able to continue their usual activities while they are receiving radiation therapy.
Lumpectomy is an alternative surgery to mastectomy for breast cancer. Survival rates are equal to mastectomy. If you would like to discuss your decision with a woman who had a lumpectomy, ask your healthcare provider for a name or call the local American Cancer Society for the name of a volunteer who has had a lumpectomy. The decision should be carefully considered and discussed with your physician.
Mastectomy is a general term used to describe the surgical procedure to remove the breast. There are several types of mastectomy surgeries:
Modified Radical Mastectomy
Removes the breast tissue, nipple, areola, underarm lymph nodes and the lining over the chest muscles. This surgery may also be referred to as a total, conservative or limited mastectomy, and is the most frequently performed type of mastectomy.
Full or Complete Radical Mastectomy
Removes the breast, nipple, areola, all three levels of lymph nodes, small chest muscle, the pectoralis minor, medial pectoral nerve and the lining over the chest wall muscle.
Simple or Prophylactic Mastectomy
Removes the breast tissue, nipple, areola and some of the incidental lymph nodes.
Ask your surgeon which of the mastectomy surgeries you will receive.
There are advantages and disadvantages to mastectomy.
• Mastectomy removes 95 percent of the breast gland and reduces local recurrence of cancer to the lowest possible rate.
• Reconstruction to restore your body image (breast) is available using implants or your own body tissues.
• Mastectomy changes body image because of the removal of the breast.
• Prosthesis or reconstruction is needed to restore body image (breast).
• Hospitalization and recovery time are slightly longer than lumpectomy.
If you would like to discuss mastectomy surgery with someone who has experienced it, ask your healthcare provider for the name of a breast cancer patient or call the American Cancer Society and ask to have a volunteer call you. It is very important that you understand the surgical procedure and have your questions answered.
Surgery for mastectomy is performed in a hospital. Prior to your surgery, you will have a pre-admission work-up, which will include a profile of your blood and body chemistry, urinalysis, chest x-ray, electrocardiogram and any other test your physician may feel is necessary. You will need to bring your insurance card or any special instructions to the hospital. Inform your nurse of any allergies you have and any medications you presently take, including non-prescription, herbal or vitamins. A list of any other physicians involved in your care, such as a heart specialist, needs to be provided. Your nurse will give you instructions concerning any special preparations before surgery.
Admission for surgery is early the same day. The length of surgery, without immediate reconstruction, is approximately one hour. Recovery time in a post-anesthesia room requires several hours. Immediate breast reconstruction will require a longer period of time. Mastectomy may be done as an outpatient and you are allowed to return home the same day. Hospitalization usually lasts from one to three days.
When you awake from surgery, you may have one or several drains coming from your incision area. Pain will be moderate and is often controlled with medication by mouth after you are able to eat and drink. Most women are surprised at the small amount of pain they experience. Your physician will have pain medications ordered for you. As soon as you are awake, you will be able to walk to the bathroom with assistance. It is important that you elevate your surgical arm on a pillow above the level of your heart to prevent swelling. Use your arm to wash your face, comb your hair and feed yourself. However, do not begin any exercises until your physician gives you permission. When your first dressing is changed, it is very important that you look at your incision to learn what is normal so you can later evaluate changes that occur. Your physician or nurse will provide instructions for dressing changes and care of your drains.
Drains need to be pinned to the clothing and emptied when they become heavy. Do not allow them to pull on your skin. It is very important to accurately record the amount of drainage emptied because physicians determine when to remove the drains based on the amount of drainage per day.
Recovery at home will require several weeks. It is important that you rest when needed. If you experience an increase in pain, run a fever or notice any signs of infection in your incision area, such as pus or increased swelling, notify your physician. Sutures or staples will be removed in approximately one week. Drains will be removed when the amount of drainage is below a certain level or at a designated time by your surgeon. This time may vary. It is not unusual for some women to have their drains for several weeks.
Reconstruction of the breast is an option some women wish to consider. Talk with your surgeon prior to your surgery. Some women may have immediate reconstruction while others have delayed reconstruction surgery. Ask for written information on reconstruction to better understand the options available for women who have a mastectomy.