Most men with breast cancer have some type of surgery. This usually involves an operation called a mastectomy. Many cancers may also require axillary (armpit) lymph node sampling and removal.

Mastectomy

A mastectomy removes all of the breast tissue, sometimes along with other nearby tissues.

In a simple or total mastectomy, the surgeon removes the entire breast, including the nipple, but does not remove underarm lymph nodes or muscle tissue from beneath the breast.
In a modified radical mastectomy, the surgeon extends the incision to remove the entire breast and lymph nodes under the arm as well. .
If the tumor is large and growing into the chest muscles, the surgeon must do a radical mastectomy, a more extensive operation removing the entire breast, axillary lymph nodes, and the chest wall muscles under the breast.

Breast-conserving surgery

Breast-conserving surgery, such as a lumpectomy (removal of only the breast lump and a surrounding margin of normal tissue), is a treatment option for many women with breast cancer. It is not used as often in men, mainly because the male breast has only a small amount of tissue beneath the nipple. Removing most male breast cancers requires removing almost all of the breast tissue. And because men have less breast tissue, male breast cancers are more likely to have reached the nipple or skin over the breast or the chest wall at an early stage, which requires more extensive surgery. But breast-conserving surgery may be an option in some cases if the tumor is not thought to have reached the nipple. If this type of surgery is done, it is typically followed by radiation therapy.

Possible side effects of breast-conserving surgery: Aside from post-surgical pain, temporary swelling, and a change in the appearance of the breast, possible side effects of surgery include bleeding and infection at the surgical site, hematoma (buildup of blood in the wound), and seroma (buildup of clear fluid in the wound).

Axillary lymph node dissection (ALND)

To determine if the breast cancer has spread to axillary (underarm) lymph nodes, some of these lymph nodes may be removed and looked at under the microscope. This is an important part of staging and determining treatment and outcomes. When the lymph nodes are affected, there is an increased likelihood that cancer cells have spread through the bloodstream to other parts of the body.

As noted above, axillary lymph node dissection is part of a radical or modified radical mastectomy procedure. It may also be done along with a breast-conserving procedure, such as lumpectomy. Anywhere from about 10 to 40 lymph nodes are removed.

Whether or not cancer cells are present in the lymph nodes under the arm is an important factor in considering adjuvant therapy. Axillary dissection is used as a test to help guide other breast cancer treatment decisions.

Possible side effects of axillary node dissection: As with other operations, pain, swelling, bleeding, and infection are possible.

The main possible long-term effect of removing axillary lymph nodes is lymphedema (swelling of the arm). This occurs because any excess fluid in the arms normally travels back into the bloodstream through the lymphatic system. Removing the lymph nodes sometimes causes this fluid to remain and build up in the arm. Sometimes the swelling lasts for only a few weeks and then goes away. Other times, the swelling is long lasting.

Certain measures can help prevent or reduce the effects of lymphedema. You can learn about these in a booklet on lymphedema available from the American Cancer Society. If you develop swelling, tightness, or pain at any time in the arm, be sure to tell the nurse or doctor right away.

You may also have short- or long-term limitations in arm and shoulder movement after surgery. Numbness of the upper inner arm skin is another common side effect. This is because of damage to the nerves under the arm and is not related to lymphedema.

Sentinel lymph node biopsy (SLNB)

Lymph node dissection is a safe operation and has low rates of serious side effects, but often doctors may do a sentinel lymph node biopsy instead. This procedure tells the doctor if cancer has spread to lymph nodes without removing all of them first.

In this procedure the surgeon finds and removes the sentinel node (or nodes) -- the first lymph node(s) into which a tumor drains, and the one(s) most likely to contain cancer cells if they have started to spread. To do this, the surgeon injects a radioactive substance and/or a blue dye into the area around the tumor, into the skin over the tumor, or into the tissues just under the areola (the colored area around the nipple). Lymphatic vessels will carry these substances into the sentinel node(s) over the next few hours. The doctor can use a special device to detect the radioactivity in the nodes that the radioactive substance flows into or can look for lymph nodes that have turned blue. (These are separate ways to find the sentinel node, but are often done together as a double check.) The doctor then makes an incision (cut) in the skin over the area in the armpit and removes the nodes. These nodes (often 2 or 3) are then looked at by the pathologist.

If there is no cancer in the sentinel node(s), it's very unlikely that the cancer has spread to other lymph nodes, so no further lymph node surgery is needed. The patient can avoid some of the potential side effects of a full axillary lymph node dissection (see above), but there may still be a small risk of lymphedema.

If the sentinel node(s) contains cancer, the surgeon will usually do a full axillary lymph node dissection to see how many other lymph nodes are involved. This may be done at the same time or several days after the original sentinel node biopsy. The timing depends on how easily the cancer can be seen in the lymph node at the time of surgery. If it is obvious that the sentinel node contains cancer, the surgeon can proceed to the axillary dissection right away. But at other times it may only be found by thorough microscopic study by a pathologist after the SLNB is complete.

A sentinel lymph node biopsy is not always appropriate. If an underarm lymph node appears large or abnormal by touch or by ultrasound, it may be checked by fine needle aspiration. If cancer is found, a sentinel node biopsy is not needed.

Sentinel lymph node biopsy is a complex technique that requires a great deal of skill. It should be done only by a surgical team known to have experience with this technique. If you are thinking about having this type of biopsy, ask your health care team if this is something they do regularly.

Last Medical Review: 01/14/2010
Last Revised: 08/17/2010