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. This is the most common surgery for men with breast cancer.

• 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 contains only a small amount of tissue located 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 it is used, it is typically followed by radiation therapy.

Possible side effects of 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: 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 due to damage of 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 in many cases 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 pigmented 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. It is most suitable for smaller tumors when the lymph nodes do not feel enlarged.

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 such a biopsy, ask your health care team if this is something they do regularly.

What to expect with surgery

For many, the thought of surgery can be frightening. But with a better understanding of what to expect before, during, and after the operation, many fears can be relieved.

Before surgery: You usually meet with your surgeon a few days before the operation to discuss the procedure. This is a good time to ask specific questions about the surgery and review potential risks. Be sure you understand what the extent of the surgery is likely to be and what you should expect afterwards.

You will be asked to sign a consent form, giving the doctor permission to perform the surgery. Take your time and review the form carefully to be certain that you understand what you are signing. Sometimes, doctors send material for you to review in advance of your appointment, so you will have plenty of time to read it and won't feel rushed.

You may be asked to donate blood before an operation such as a mastectomy, if the doctor thinks a transfusion might be needed during or after the operation. You might feel more secure knowing that if a transfusion is needed, you will receive your own blood back. If you do not receive your own blood, it is important to know that in the United States, blood transfusion from another person is nearly as safe as receiving your own blood. Ask your doctor about your possible need for a blood transfusion.

Your doctor will review your medical records and ask you about any medicines you are taking. This is to be sure that you are not taking anything that could interfere with the surgery. For example, if you are taking a blood-thinning medicine (even aspirin), you may be asked to stop taking it about a week or two before the surgery. Be sure you tell your doctor about everything you take, including vitamins and herbal supplements. Usually, you will be told not to eat or drink anything for 8 to 12 hours before the surgery, especially if you are going to have general anesthesia (will be "asleep" during surgery).

You will also meet with the anesthesiologist or nurse anesthetist, the health professional who will be giving you the anesthesia during your surgery. The type of anesthesia used depends largely on the kind of surgery being done and your medical history.

Surgery: Depending on the likely extent of your surgery, you may be offered the choice of an outpatient procedure (where you go home the same day) or you may be admitted to the hospital.

General anesthesia is usually given whenever the surgery involves a mastectomy or an axillary node dissection, and is most often used during breast-conserving surgeries as well. You will have an IV (intravenous) line put in (usually into a vein in your arm), which the medical team will use to give medicines that may be needed during the surgery. Usually you will be hooked up to an electrocardiogram (EKG) machine and have a blood pressure cuff on your arm, so your heart rhythm and blood pressure can be checked during the surgery.

The length of the operation depends on the type of surgery being done. A mastectomy with axillary lymph node dissection often takes from 2 to 3 hours.

After surgery: After your surgery, you will be taken to the recovery room, where you will stay until you are awake and your condition and vital signs (blood pressure, pulse, and breathing) are stable.

How long you stay in the hospital depends on the surgery being performed, your overall state of health and whether you have any other medical problems, how well you do during the surgery, and how you feel after the surgery. Decisions about the length of your stay should be made by you and your doctor and not dictated by what your insurance will pay, but it is important to check your insurance coverage before surgery.

As a general rule, men having a mastectomy and/or axillary lymph node dissection stay in the hospital for 1 or 2 nights and then go home. However, some men may be placed in a 23-hour, short-stay observation unit before going home. In this situation, a home care nurse will visit you to monitor and provide care.

You will have a dressing (bandage) over the surgery site that may snugly wrap around your chest. You may have one or more drains (plastic or rubber tubes) coming out from the breast or underarm area to remove blood and lymph fluid that collects during the healing process. Your health care team will teach you how to care for the drains, which may include emptying and measuring the fluid and identifying problems the doctor or nurse needs to know about. Most drains stay in place for 1 or 2 weeks. When drainage has decreased to about 30 cc (1 fluid ounce) each day, the drain will usually be removed.

Doctors rarely put the arm in a sling to hold it in place. Most doctors will want you to start moving the arm soon after surgery so that it won't get stiff.

Care of the surgery site and arm should be discussed with your health care team. Written instructions about care after surgery are usually given to you and your caregivers. These instructions should include:

• the care of the surgical wound and dressing
• how to monitor drainage and take care of the drains
• how to recognize signs of infection
• when to call the doctor or nurse
• when to begin using the arm and how to do arm exercises to prevent stiffness
• what to eat and not to eat
• use of medications, including pain medicines and possibly antibiotics
• any restrictions of activity
• what to expect regarding sensations or numbness in the breast and arm
• when to see your doctor for a follow-up appointment

Most patients see their doctor within 7 to 14 days following the surgery. Your doctor should explain the results of your pathology report at this visit and talk to you about the need for further treatment. If you will need more treatment, you may be referred to a radiation oncologist and/or a medical oncologist.

Last Medical Review: 09/24/2008
Last Revised: 05/13/2009