Local Treatments for ILC: Surgery and Radiation Therapy

Local treatments such as surgery and radiation therapy are given to treat the invasive lobular carcinoma (ILC) itself and any nearby areas that may be affected by cancer, such as the chest and lymph nodes.

Surgery

People with invasive lobular carcinoma need surgery not only to remove the cancer, but also to confirm whether or not cancer is in the lymph nodes. You will work with your doctor to determine what surgery is right for you, based on the stage and grade of the cancer and other factors specific to your situation.

In most cases, surgery is the first treatment for ILC. However, if the tumor is large or the cancer has spread to many lymph nodes or other parts of the body, treatments such as chemotherapy or hormonal therapy may be given first to shrink the cancer.

Possible surgical procedures include the following:

• Lumpectomy: The surgeon removes only the tumor (the “lump”) and some of the normal tissue that surrounds it. Sometimes, axillary (underarm) lymph nodes are removed for examination.
• Mastectomy:
  • Partial or segmental mastectomy (sometimes also called quadrantectomy): The surgeon removes the portion, or segment, of the breast that contains the tumor. In some cases, up to one-quarter of the breast needs to be removed. Depending on your situation, your doctor may want to also remove some lymph nodes.
  • Total or simple mastectomy: Removal of the breast tissue only, without removal of the axillary (underarm) lymph nodes or any muscle tissue beneath the breast.
  • Modified radical mastectomy: Surgery to remove the breast, the lining of the chest wall muscle, and some of the lymph nodes under the arm.

In another type of mastectomy called radical mastectomy, all of the muscle under the breast would also be removed. However, radical mastectomy is not often done today because the more limited forms of this surgery generally are just as effective.

If you are having a mastectomy, you may decide you want to have breast reconstruction as well. This is additional surgery to rebuild the breast. Breast reconstruction often can be done at the time of mastectomy, or it can be done at a later date. You can talk with your surgeon about what is best for your individual situation.

As you plan for surgery, your surgeon may also talk with you about removing one or several of your lymph nodes to find out if cancer has traveled there. If it has, there is a greater chance that the cancer could have traveled to other parts of the body. The lymph nodes are part of the body’s “filtration system,” removing bacteria and other foreign substances from the body. Breast cancer cells can make their way to the lymph nodes under the arm, which offer them a pathway to other parts of the body. Knowing whether or not the lymph nodes have any breast cancer cells in them is important in selecting the best treatment.

Unless the tumor is very small and has other features that convince your doctor that lymph node spread is highly unlikely, you will need to have one of the following procedures as part of your surgery:

• Sentinel lymph node biopsy: In this procedure, your surgeon looks for the very first lymph node — the “sentinel node” — that filters fluid draining away from the area of the breast that contains the cancer. If cancer cells are breaking away from the tumor and traveling away from your breast through the lymph system, the sentinel lymph node is more likely than other lymph nodes to contain cancer. The surgeon uses a special radioactive substance or dye to identify that first node and the couple of nodes where it drains. These nodes are then removed and sent for examination by a pathologist. If the lymph nodes are cancer-free, no further surgery is necessary. If cancer is found, then more lymph nodes in the armpit need to be removed, either now or at a later date.
  
  Sentinel lymph node biopsy is a relatively new approach, so it’s important to have it done by a surgical team experienced in this technique. It may be right for you if your surgeon has reason to believe that none or just a few of your lymph nodes are likely to be affected.
• Axillary lymph node dissection: The surgeon removes a group of lymph nodes from under the arm to examine them for any signs of cancer. After surgery, he or she will tell you whether any lymph nodes had cancer cells in them, and if so, how extensive the cancer was in each node. One risk with axillary node dissection is the development of arm lymphedema, or swelling caused by backup of lymph fluid in the arm. Sentinel node biopsy carries a lower risk of lymphedema. There are many ways to reduce the risk of lymphedema or manage it if it does develop.

Radiation therapy

Radiation therapy directs high-energy rays at the breast, chest area, under the arm, and/or the collarbone area to destroy any invasive lobular carcinoma cells that may be left behind. This treatment also reduces the risk of recurrence (the cancer coming back). Radiation therapy is most often recommended after surgeries that conserve healthy breast tissue, such as lumpectomy and partial mastectomy. Radiation therapy may be recommended after mastectomy as well, especially if the tumor was large (over 5 centimeters) and/or the lymph nodes were involved.

Possible ways of giving radiation therapy include the following:

• External beam radiation uses a machine called a linear accelerator to deliver the radiation therapy. The treatments are directed to the entire breast after lumpectomy, to the area of skin and muscle where mastectomy was done, and possibly to any areas where lymph nodes were involved. Treatment is given daily for about 5 to 7 weeks.
• Internal partial-breast irradiation, also called brachytherapy, is a form of treatment in which radioactive materials such as seeds or pellets are temporarily placed in or near where the tumor was removed.
• External partial-breast irradiation is a method of external beam therapy that zeroes in on the area around where the cancer was. This area is at highest risk of recurrence. Partial-breast radiation takes only 5 to 10 days for treatment, versus 5 to 7 weeks for whole breast radiation. Researchers are studying partial-breast radiation for use after lumpectomy to see how the benefits compare to the current standard of radiation to the whole breast. Because this technique is still under investigation, it is not yet widely available.

You and your doctor can work together to determine what form of radiation therapy is best for you.