comscoreLumpectomy

Lumpectomy

Lumpectomy, also called breast-conserving surgery, is a procedure that removes the breast cancer along with a small amount of the healthy tissue surrounding it.

Lumpectomy, also called breast-conserving surgery, is a procedure that removes the breast cancer along with a small amount of the healthy tissue surrounding it.

Unlike mastectomy, which removes all of the breast tissue, lumpectomy aims to preserve as much of your breast as possible.

 

What is lumpectomy?

Lumpectomy is surgery to remove the breast cancer tumor (the lump) and a rim of healthy tissue surrounding it (called the margin).

Removing the margin of healthy tissue helps ensure that all of the cancer has been taken out. Some surgeons also use a technique called cavity shave margins, in which they shave a thin layer of tissue from the area where the tumor was removed to make sure all of the cancer has been taken out.

Usually, the surgeon will also remove the first one to three underarm lymph nodes during the lumpectomy procedure (called a sentinel lymph node biopsy). A doctor called a pathologist will examine these lymph nodes to check for any signs that the cancer has spread.

Radiation therapy is usually recommended after lumpectomy to help reduce the risk of the cancer coming back (called recurrence).

Lumpectomy is sometimes referred to as an excisional biopsy (done to excise, or take out, a suspicious lump) or a partial mastectomy, since part of the breast is being removed. However, the amount of tissue removed can vary greatly. In a wedge resection, a larger wedge of tissue is removed. In a quadrantectomy, roughly a quarter of the breast is removed. Still, these are all considered forms of lumpectomy.

If you're considering lumpectomy, be sure to ask your surgeon how much tissue needs to be removed and how it might affect your breast’s appearance. In some cases, plastic surgery techniques can be used at the time of lumpectomy to get a better cosmetic result. This approach is called oncoplastic lumpectomy.

 

Lumpectomy plus radiation therapy

Radiation therapy is usually recommended after lumpectomy. The goal of radiation therapy is to destroy any cancer cells that may remain in the breast after the tumor is removed. This reduces the risk of the cancer coming back (recurrence).

Lumpectomy plus radiation therapy is sometimes referred to as breast-conserving therapy.

Your doctors will work with you to choose the type of radiation therapy you should receive, depending on your individual situation, age, and the features of your cancer. Examples include:

  • External whole-breast beam radiation. Traditionally, this form of radiation is given five days a week for five to seven weeks. A newer option is to have the same dose of radiation over three to five weeks, which is called an accelerated or hypofractionated radiation schedule.

  • Accelerated partial-breast radiation. This gives a larger dose of radiation over a shorter period of time just to the part of the breast where the cancer was, not the entire breast. It takes about one to two weeks. Certain women with early-stage breast cancer may be candidates.

With these types of radiation therapy, your doctor also may recommend a radiation boost toward the end of treatment. This is an extra dose of radiation targeted directly at the area where the cancer was removed. Depending on your diagnosis, your doctor also may recommend radiation that targets the nearby lymph nodes.

  • Brachytherapy or internal radiation: Brachytherapy methods place small pieces of radioactive material, called seeds, in the area where the cancer was. The seeds emit radiation into the surrounding tissue. The treatment is usually given over five days, with two treatments each day.

For certain groups of people, such as those with ductal carcinoma in situ (DCIS) that has low-risk features, and women older than 70 with early-stage, estrogen receptor-positive breast cancer, radiation therapy may not be recommended.

Learn more about Radiation Therapy.

Research shows that for most women with early-stage breast cancer, lumpectomy plus radiation is just as effective as mastectomy. Early-stage breast cancer is cancer that hasn’t spread beyond the breast or underarm lymph nodes.

Back in 2002, the influential NSABP-06 trial found that after 20 years of follow-up, total mastectomy did not offer an advantage over lumpectomy in terms of how long women lived (overall survival), how long they remained free of recurrence (disease-free survival), and whether they developed metastatic disease (cancer spreading beyond the breast). 1

Other studies have confirmed those results. For example:

  • A 2013 study of more than 112,000 women with stage I or stage II breast cancer found that overall survival and disease-free survival were higher for women who had lumpectomy surgery plus radiation than for those who had mastectomy. 2

  • A 2014 analysis of over 132,000 patients found that five- and 10-year breast-cancer specific survival rates were higher for women with early-stage cancer who had lumpectomy plus radiation vs. those who had mastectomy. 3

  • A 2021 study of nearly 49,000 women with early-stage breast cancer in Sweden found that overall survival and breast cancer-specific survival were higher for those who had lumpectomy and radiation vs. those who had mastectomy with or without radiation. 4

People often think that removing more breast tissue (mastectomy) is always a safer option with better outcomes. But research has not shown that to be the case.

 

Is lumpectomy plus radiation right for you?

Your doctor can help you choose the best surgery for your situation. Lumpectomy plus radiation therapy may be right for you if:

  • you've been diagnosed with early-stage breast cancer (cancer that has not spread beyond the breast or underarm lymph nodes)

  • you have one tumor that is relatively small compared to the size of your breast

  • you prefer to keep as much of your natural breast tissue as possible

  • you want to avoid mastectomy and reconstruction, which is a more involved process

  • you’re able to commit to daily radiation treatments over a period of weeks

You may not be a good candidate for lumpectomy plus radiation if:

  • you’ve already had radiation to the same breast for an earlier breast cancer

  • you have extensive cancer in the breast, multiple areas of cancer in the same breast, or inflammatory breast cancer, which usually require mastectomy

  • you have a small breast and a large tumor and removing the tumor would be extremely disfiguring

  • you have a connective tissue disease, such as scleroderma or Sjogren syndrome, which makes your skin more sensitive to the side effects of radiation

  • you have lupus or rheumatoid arthritis, in which case your doctor may recommend you avoid radiation therapy

  • you’re pregnant, which makes radiation therapy unsafe

  • you can’t commit to the daily schedule of radiation therapy, or distance from the nearest treatment center makes it impossible for you

  • there are factors that put you at higher-than-average risk for a future breast cancer, such as a strong family history or a confirmed genetic mutation associated with breast cancer risk

  • your surgeon has already made multiple attempts to remove the breast cancer with lumpectomy, but has not been able to completely remove the cancer and obtain clear margins

  • you believe you would have greater peace of mind with a mastectomy; even though research shows that lumpectomy plus radiation is just as effective as mastectomy for most women, some decide that they would feel better having the entire breast removed to avoid the anxiety of future breast cancer screenings

Keep in mind, if you have a larger tumor or multiple tumors in the same breast, you may be a candidate for oncoplastic lumpectomy, which uses plastic surgery techniques at the time of lumpectomy. It’s also possible that chemotherapy or hormonal therapy may be given first to shrink the size of a large tumor before it is removed.

About half of women in the United States who are eligible for lumpectomy have mastectomy instead, according to The National Center for Health Research (NCHR). 5 Mastectomy is a valid choice if it’s right for you, but it's important to make an informed decision. NCHR reported that women are more likely to have a mastectomy if they have an older surgeon, are treated at a community hospital vs. an academic medical center, and don’t have a private health insurance plan. So make sure the decision to have a mastectomy is your choice, and that you have explored all of your options to make the decision that is best for you.

 

Lumpectomy: What to expect

If you’re having or considering lumpectomy to remove the breast cancer, it can be helpful to know what to expect before, during, and after the surgery. Learn more.

 

Getting your pathology results after lumpectomy

In the days after the lumpectomy surgery, you’ll receive a pathology report. This report will explain the characteristics of the breast cancer, such as:

  • the size of the tumor

  • cell grade: how closely the cancer cells resemble normal, healthy cells

  • hormone receptor status: whether or not the breast cancer cells have receptors for the hormones estrogen and progesterone, which means these hormones are signaling the cancer to grow

  • HER2 status: whether the cells have too many copies of the HER2 gene, which can promote cancer cell growth

  • margins: negative margins mean that the pathologist finds no cancer cells at the edges of the removed tissue; positive margins mean that cancer cells were found at the edges of the tissue and additional surgery may be needed

These and other characteristics of the breast cancer will help you and your doctor decide on the best treatment plan for you.

Learn more at Understanding Your Pathology Report.

 

Re-excision lumpectomy

About 20% of people who have lumpectomy will require a second surgery — called re-excision lumpectomy — due to positive margins. 6

After lumpectomy, all of the tissue removed from the breast is examined carefully to see if cancer cells are present in the margins — the rim of normal, healthy tissue removed along with the cancer tumor. The tumor and surrounding tissue is rolled in a special ink so that margins will be clearly visible when thin slices of the sample are examined under a microscope.

If no cancer cells are found in the margins, these are considered to be negative, or no ink on tumor. Positive margins mean that the cancer extends to the very edge of the removed tissue, raising concerns that some cancer might have been left behind. In that case, your surgeon will perform a re-excision lumpectomy to remove another margin of tissue that is cancer-free. You may hear your surgeon refer to re-excision as clearing the margins. If there are still positive margins after re-excision, your surgeon may need to try again or perform a mastectomy.

How large do lumpectomy margins need to be?

Over the years, surgeons have debated how large margins should be to ensure there are no cancer cells left behind after lumpectomy. Some believe the margin should be 2 mm or larger, and others feel that 1 mm or less is enough.

In February 2014, the American Society for Radiation Oncology (ASTRO) and the Society of Surgical Oncology (SSO) issued guidelines saying that margins should be considered clear, no matter how thin they are, using the no ink on tumor guideline. The guidelines also state that wider margins don’t lower the risk of the cancer coming back (recurrence) any more than narrower margins.

No ink on tumor remains the accepted standard for negative margins after lumpectomy for invasive breast cancer and, as a result, re-excisions to achieve wider margins have become less common. However, in 2016, SSO and ASTRO, along with the American Society of Clinical Oncology (ASCO), issued another guideline recommending that at least a 2-mm negative margin is best for reducing the risk of local recurrence in ductal carcinoma in situ (DCIS).

To reduce your chances of needing a re-excision, you can ask your surgeon:

  • how often they perform lumpectomy, and what their rate of re-excision is

  • whether they use the shave margins technique, which means shaving another thin layer of tissue from the area around where the tumor was removed

  • if they use any technology during the surgery to help ensure clean margins, such as 3D tomography, which can be used to take images of the tissue after it is removed, or MarginProbe, which uses electromagnetic waves to identify possibly cancerous tissue

 

Lumpectomy risks

Like all surgeries, lumpectomy carries certain risks, such as:

  • Seroma: A seroma is a buildup of fluid in the space left behind after surgery. It’s a normal occurrence after surgery, but in some cases, there can be a large buildup of fluid that has to be drained.

  • Infection: There is some risk of infection at the incision site. An infection of the breast skin, known as cellulitis, can develop in some people.

  • Loss of sensation: There is usually some numbness and loss of sensation in part of the breast after lumpectomy, depending on the size of the lump removed. Some or most of the feeling may return over time.

  • Scars, indentation, dimpling, and other cosmetic changes: Lumpectomy can lead to cosmetic changes that become visible over time as the skin heals. Oncoplastic lumpectomy techniques can help reduce this risk.

  • Breasts that don’t match exactly: Your breasts may not match precisely in size and shape after surgery. Removing breast tissue during lumpectomy usually makes the affected breast appear smaller. You may not know this right away, because swelling in response to surgery might make your breast appear temporarily larger. Also, radiation therapy can affect the size of the treated breast. Oncoplastic lumpectomy can help reduce this risk, especially if a large amount of tissue needs to be removed. Surgeons also can operate on the opposite breast to help restore symmetry.

  • Nerve pain: Some people experience burning or shooting pain in the arm, armpit, or chest wall that persists over time. It's referred to as post-mastectomy pain syndrome, but it can happen after lumpectomy as well.

  • Lymphedema: If underarm lymph nodes were removed, lymphedema can sometimes happen. It causes swelling of the arm, hand, and/or upper body.

 

Questions to ask your surgeon about lumpectomy

Here are some questions to ask your surgeon as you plan for lumpectomy surgery:

  • How many times do you perform lumpectomy in an average month? What percentage of your patients require re-excision?

  • What are the risks of lumpectomy?

  • How should I prepare for surgery?

  • How long will surgery take?

  • What is the size of the tumor relative to my breast size? How much tissue will be removed?

  • How will you know whether you have achieved clean margins? Do you use any techniques in the operating room that can assist you?

  • Will you remove any underarm lymph nodes (sentinel or axillary node dissection) along with the lump?

  • Are you able to hide the scar and rearrange the tissue to minimize any dents or other cosmetic issues (oncoplastic lumpectomy) after surgery? If not, can a plastic surgeon be called in?

  • If I need to have a larger portion of breast tissue removed (20% or more), do you have the training/experience to perform an oncoplastic lumpectomy to reduce and/or lift the breast and bring the opposite breast into balance? If not, can you team up with a plastic surgeon?

  • Will I have anesthesia? If so, what kind?

  • Will I need blood transfusions? Should I donate my own blood before surgery?

  • How can I expect my breast to look after lumpectomy? Will the appearance change over time?

  • What is the likely impact of radiation therapy on the breast after lumpectomy?

  • Will I need to stay overnight in the hospital after surgery?

  • How long will it take to recover?

  • Are there any precautions I should take as I recover? Will you give me written instructions to follow?

  • How should I care for the surgical site and dressings? Will I need a surgical drain (which collects fluid during healing), and if so, how should I care for it?

  • Are there exercises I need to do after surgery?

  • When can I return to my normal routine and activities?

  • Will I be at risk for lymphedema after surgery?

  • If I am not happy with the appearance of my breasts after a few months have passed, what options do I have?

 

Reconstruction options: Oncoplastic lumpectomy and reconstruction after lumpectomy

Lumpectomy can cause cosmetic changes to the breast, such as visible indentation, a tight scar, or distortions in the nipple’s appearance. Radiation therapy after lumpectomy can worsen the treated breast’s appearance, and it also can affect its size and shape, leading to an unbalanced appearance (asymmetry).

Before having lumpectomy, ask your surgeon to describe what changes you may experience in the breast’s appearance. This can depend on the size and location of the cancer, as well as the size of your breast relative to the cancer. Your reconstruction options include:

Oncoplastic lumpectomy: This approach uses plastic surgery techniques during lumpectomy surgery to give you a better cosmetic outcome after the cancer is removed. Your breast surgeon may be able to perform this if they have formal training and experience using oncoplastic techniques. If not, or if your case is complex, they can partner with a plastic surgeon.

Oncoplastic surgery techniques are generally used to either:

  • rearrange nearby breast tissue to fill in the space left behind after the cancer is removed to prevent “dents” and place the scar where it is less visible

  • remove the breast tissue containing the cancer and combine this procedure with a breast reduction, a breast lift, or both — and operate on the opposite breast to bring them into balance

Reconstruction after lumpectomy: If you have a traditional lumpectomy plus radiation and aren’t happy with your appearance after healing (six months to one year), you can have reconstruction with a plastic surgeon at that time. Options include fat grafting or tissue transfer to fill in dents or divots, or to remedy scarring or hardening. A tissue flap or implant can be used if the treated breast is distorted or shrunken. A plastic surgeon also can operate on the opposite breast to achieve better balance.

If you don’t want more surgery, another option is to use a breast prosthesis, or breast form, to achieve a more balanced appearance. There are partial breast prostheses that can be used to fill out a bra or bathing suit top. Your best bet is to work with a professional mastectomy fitter, who can help tailor a solution that works for you.

Learn more at Prosthetics: An Alternative to Reconstruction.

 
References
  1. Fisher B et al. 20 Year follow up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. NEJM 2002; 347 (16).

  2. Hwang, E.S., Lichtensztajn, D.Y., Gomez, S.L., Fowble, B. and Clarke, C.A. (2013), Survival after lumpectomy and mastectomy for early stage invasive breast cancer. Cancer, 119: 1402-1411. https://doi.org/10.1002/cncr.27795

  3. Agarwal S, Pappas L, Neumayer L, Kokeny K, Agarwal J. Effect of Breast Conservation Therapy vs Mastectomy on Disease-Specific Survival for Early-Stage Breast Cancer. JAMA Surg. 2014;149(3):267–274. doi:10.1001/jamasurg.2013.3049. https://jamanetwork.com/journals/jamasurgery/fullarticle/1813803

  4. de Boniface, J., et al. Survival After Breast Conservation vs Mastectomy Adjusted for Comorbidity and Socioeconomic Status: A Swedish National 6-Year Follow-up of 48 986 Women. JAMA Surg. 2021;156(7):628–637. doi:10.1001/jamasurg.2021.1438 https://jamanetwork.com/journals/jamasurgery/fullarticle/2779531

  5. Diana Zuckerman, PhD. Mastectomy v. Lumpectomy: Who Decides? National Center for Health Research. https://www.center4research.org/mastectomy-v-lumpectomy-who-decides/

  6. Sheldon Feldman, MD. FACS. 20% of Women Getting Lumpectomies Need a Second Surgery, but This Risk Can Be Lowered. Sharsheret.org, September 9, 2019. https://sharsheret.org/20-of-women-getting-lumpectomies-need-a-second-surgery-but-this-risk-can-be-lowered/

— Last updated on January 28, 2022, 8:57 PM