Surgery for Breast Cancer in Men

Most men with breast cancer have some type of surgery as part of their treatment. There are different types of breast surgery, and it may be done for different reasons, depending on the situation. For example, surgery may be done to:

• Remove as much of the cancer as possible (breast-conserving surgery or mastectomy)
• Find out whether the cancer has spread to the lymph nodes under the arm (sentinel lymph node biopsy or axillary lymph node dissection)
• Relieve symptoms of advanced cancer

Your doctor may recommend a certain operation based on your breast cancer features and your medical history, or you may have a choice about which type to have. It’s important to know your options so you can talk about them with your doctor and make the choice that is right for you.

Surgery to remove breast cancer

There are two main types of surgery to remove breast cancer:

Mastectomy

In this surgery, the entire breast is removed, including all of the breast tissue and sometimes other nearby tissues. Most men with breast cancer will undergo a mastectomy since men have a small amount of breast tissue. There are several types of mastectomies:

• 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. This is only needed if the cancer has grown into the pectoral muscles under the breast.

Breast-conserving surgery (BCS)

This surgery might also be called a lumpectomy, quadrantectomy, partial mastectomy, or segmental mastectomy. For this surgery, only the part of the breast containing the cancer is removed. The goal is to remove the cancer as well as some surrounding normal tissue. How much of the breast is removed depends on the size and location of the tumor and other factors.

BCS is commonly used to treat women with breast cancer. It is used much less often in men because most male breast cancers are located behind the nipple and many times have grown into the nipple, so they require more extensive surgery such as a mastectomy. If BCS is done, it is typically followed by radiation therapy.

Possible side effects of breast 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).

Surgery to remove nearby lymph nodes

To find out if the breast cancer has spread to axillary (underarm) lymph nodes, one or more of these lymph nodes may be removed and looked at in the lab. This is an important part of figuring out the stage (extent) of the cancer.

Lymph nodes may be removed either as part of the surgery to remove the breast cancer or as a separate operation.

Two types of surgery can be used to remove the lymph nodes:

• Sentinel lymph node biopsy (SLNB): A procedure in which the surgeon removes only the lymph node(s) under the arm to which the cancer would likely spread first. Removing only one or a few lymph nodes lowers the risk of side effects from the surgery.
• Axillary lymph node dissection (ALND): A procedure in which the surgeon removes many lymph nodes from under the arm. ALND is not done as often as it was in the past, but it might still be the best way to look at the lymph nodes in some situations.

Either of these procedures can usually be done at the same time as mastectomy or lumpectomy, but they might also be done in a second operation.

For a sentinel lymph node biopsy, 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 substance 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). This can be done with either:

• A radioactive substance and/or a blue dye, OR
• A liquid containing iron oxide particles

Lymph vessels will carry these substances into the sentinel node(s) over the next few hours. The sentinel nodes can then be found by:

• Using a special machine to detect either radioactivity or iron oxide particles
• Looking for nodes that have turned blue (or brown, if iron oxide particles were injected)

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 in the lab.

The lymph nodes can sometimes be checked for cancer during surgery. If cancer is found in the sentinel lymph node, the surgeon may go on to do a full ALND. If no cancer cells are seen in the lymph node at the time of the surgery, or if the sentinel node is not checked during surgery, the lymph node(s) will be examined more closely over the next several days. If cancer is found in the lymph node, the surgeon may recommend a full ALND at a later time.

If there are no cancer cells 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. This lets you avoid some of the potential side effects of a full ALND.

A SLNB might not always be the best option for checking the lymph nodes. If an underarm lymph node looks or feels large or abnormal by touch or by a test like ultrasound, it may be checked by fine needle aspiration (FNA). If cancer is found, a full ALND is typically recommended, so a SLNB is not needed.

SLNB is a complex technique that requires a great deal of skill. It should only be done by a surgical team experienced 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.

Possible side effects of lymph node surgery

As with other operations, pain, swelling, bleeding, and infection are possible.

Lymphedema: A 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 blocks the drainage from the arm, causing this fluid to build up.

This side effect has not been well studied in men. In women the risk of lymphedema is thought to be in the range of 20-30% after an ALND, and it is less common after a SLNB.   Lymphedema seems to be more common if radiation is given after surgery. Sometimes this starts soon after surgery, but it can take a long time to develop. For some people, the swelling lasts for only a few weeks and then goes away. Other times, the swelling lasts a long time. If your arm is swollen, tight, or painful after lymph node surgery, be sure to tell someone on your cancer care team right away. For more information about ways to prevent or manage lymphedema after breast surgery, see Lymphedema.

Limited arm and shoulder movement: You may also have limited movement in your arm and shoulder after surgery. This is more common after an ALND than a SLNB. Your doctor may give you exercises to ensure that you do not have permanent problems with movement (a frozen shoulder).

Some patients notice a rope-like structure that begins under the arm and can extend down toward the elbow. This, sometimes called axillary web syndrome or lymphatic cording. It is more common after an ALND than SLNB. Symptoms might not appear for weeks or even months after surgery. It can cause pain and limit movement of the arm and shoulder. This often goes away without treatment, although some people seem to find physical therapy helpful.

Numbness: Numbness of the skin of the upper, inner arm is another common side effect because the nerve that controls sensation here travels through the lymph node area.

Chronic pain after breast surgery

Some patients have problems with nerve (neuropathic) pain in the chest wall, armpit, and/or arm after surgery that doesn’t go away over time. This is called post-mastectomy pain syndrome (PMPS) because it was first described in women who had mastectomies, but it occurs after breast-conserving therapy, as well.

PMPS is thought to be linked to damage done to the nerves in the armpit and chest during surgery. But the causes are not known. Between 20% and 30% of women develop symptoms of PMPS after surgery. It isn’t clear how common this is in men after breast cancer surgery. It seems to be more common in younger patients, those who had a full ALND (not just a SLNB), and those who were treated with radiation after surgery. Because ALNDs are done less often now, PMPS is less common than it once was.

Symptoms of PMPS include:

• Pain and tingling in the chest wall, armpit, and/or arm
• Pain in the shoulder or surgical scar
• Numbness
• Burning or shooting pain
• A "pins and needles" sensation
• Severe itching

Most patients with PMPS say that their symptoms are not severe, but PMPS can cause you to not use your arm the way you should, and over time you could lose the ability to use it normally. Tell your doctor if you are having pain or other symptoms of PMPS. Nerve pain requires different treatment from other types of pain. See Cancer Pain for more information.