Mastectomy

mastectomy

Definition

Simple mastectomy is the surgical removal of one or both breasts. The adjacent lymph nodes and chest muscles are left intact. If a few lymph nodes are removed, the procedure is called an extended simple mastectomy. Breast-sparing techniques may be used to preserve the patient's breast skin and nipple, which is helpful in cosmetic breast reconstruction.


Purpose

Removal of a patient's breast is usually recommended when cancer is present in the breast or as a prophylactic when the patient has severe fibrocystic disease and a family history of breast cancer. The choice of a simple mastectomy may be determined by evaluating the size of the breast, the size of the cancerous mass, where the cancer is located, and whether any cancer cells have spread to adjacent lymph nodes or other parts of the body. If the cancer has not been contained within the breast, it calls for a modified radical mastectomy , which removes the entire breast and all of the adjacent lymph nodes. Only in extreme circumstances is a radical mastectomy, which also removes part of the chest wall, indicated.

A larger tumor usually is an indication of more advanced disease and will require more extensive surgery such as a simple mastectomy. In addition, if a woman has small breasts, the tumor may occupy more area within the contours of the breast, necessitating a simple mastectomy in order to remove all of the cancer.

Very rapidly growing tumors usually require the removal of all breast tissue. Cancers that have spread to such adjacent tissues as the chest wall or skin make simple mastectomy a good choice. Similarly, multiple sites of cancer within a breast require that the entire breast be removed. In addition, simple mastectomy is also recommended when cancer recurs in a breast that has already undergone a lumpectomy , which is a less invasive procedure that just removes the tumor and some surrounding tissue without removing the entire breast.

Sometimes, surgeons recommend simple mastectomy for women who are unable to undergo the adjuvant radiation therapy required after a lumpectomy. Radiation treatment is not indicated for pregnant women, those who have had previous therapeutic radiation in the chest area, and patients with collagen vascular diseases such as scleroderma or lupus. In these cases, simple mastectomy is the treatment of choice.

Finally, some women, with family histories of breast cancer and who test positive for a cancer-causing gene, choose to have one or both of their breasts removed as a preventative for future breast cancer. This procedure is highly controversial. Though prophylactic mastectomy reduces the occurrence of breast cancer by 90% in high-risk patients, it is not a foolproof method. There has been some incidence of cancer occurring after both breasts were removed.

Indications

Despite the increased ability to offer breast-conservation techniques to patients with breast cancer, there exist certain groups who may be better served by traditional mastectomy procedures including:

  • Women who have already had radiation therapy to the affected breast.
  • Women with 2 or more areas of cancer in the same breast that are too far apart to be removed through 1 surgical incision, while keeping the appearance of the breast satisfactory.
  • Women whose initial lumpectomy along with (one or more) re-excisions has not completely removed the cancer.
  • Women with certain serious connective tissue diseases such as scleroderma, which make them especially sensitive to the side effects of radiation therapy.
  • Pregnant women who would require radiation while still pregnant (risking harm to the fetus).
  • Women with a tumor larger than 5 cm (2 inches) that doesn't shrink very much with neoadjuvant chemotherapy.
  • Women with a cancer that is large relative to her breast size.
  • Women who have tested positive for a deleterious mutation on the BRCA1 or BRCA2 gene and opt for prophylactic removal of the breasts
  • Male breast cancer patients.

Description

Simple mastectomy is one of several types of surgical treatments for breast cancer. Some techniques are rarely used; others are quite common. These common surgical procedures include:

  • Radical mastectomy is rarely used, and then only in cases where cancer cells have invaded the chest wall and the tumor is very large. The breast, muscles under the breast, and all of the lymph nodes are removed. This produces a large scar and severe disability to the arm nearest the removed breast.
  • Modified radical mastectomy was the most common form of mastectomy until the 1980s. The breast is removed along with the lining over the chest muscle and all of the lymph nodes.
  • Simple, sometimes called total, mastectomy has been the treatment of choice in the late 1980s and 1990s. Generally, only the breast is removed; though, sometimes, one or two lymph nodes may be removed as well.
  • Partial mastectomy is used to remove the tumor, the lining over the chest muscle underneath the tumor, and a good portion of breast tissue, but not the entire breast. This is a good treatment choice for early stage cancers.
  • Lumpectomy just removes the tumor and a small amount of tissue surrounding it. Some lymph nodes may be removed as well. This procedure is gaining acceptance among surgeons and patients alike.

Two other surgical procedures are variations on the simple mastectomy. The skin-sparing mastectomy is a new surgical procedure in which the surgeon makes an incision, sometimes called a keyhole incision, around the areola. The tumor and all breast tissue are removed, but the incision is smaller and scarring is minimal. About 90% of the skin is preserved and allows a cosmetic surgeon to perform breast reconstruction at the same time as the mastectomy. The subcutaneous mastectomy, or nipple-sparing mastectomy, preserves the skin and the nipple over the breast.

During a simple mastectomy, the surgeon makes a curved incision along one side of the breast and removes the tumor and all of the breast tissue. A few lymph nodes may be removed. The tumor, breast tissue, and any lymph nodes will be sent to the pathology lab for analysis. If the skin is cancer-free, it is sutured in place or used immediately for breast reconstruction. One or two drains will be put in place to remove fluid from the surgical area. Surgery takes from two to five hours; it is longer with breast reconstruction.

Diagnosis/Preparation

If a mammogram has not been performed, it is usually ordered to verify the size of the lump the patient has reported. A biopsy of the suspicious lump and/or lymph nodes is usually ordered and sent to the pathology lab before surgery is discussed.

When a simple mastectomy has been determined, such preoperative tests as blood work, a chest x ray , and an electrocardiogram may be ordered. Blood-thinning medications such as aspirin should be stopped several days before the surgery date. The patient is also asked to refrain from eating or drinking the night before the operation.

At the hospital, the patient will sign a consent form, verifying that the surgeon has explained what the surgery is and what it is for. The patient will also meet with the anesthesiologist to discuss the patient's medical history and determine the choice of anesthesia.

Aftercare

If the procedure is performed as an outpatient surgery , the patient may go home the same day of the surgery. The length of the hospital stay for inpatient mastectomies ranges from one to two days. If breast reconstruction has taken place, the hospital stay may be longer.

The surgical drains will remain in place for five to seven days. Sponge baths will be necessary until the stitches are removed, usually in a week to 10 days. It is important to avoid overhead lifting, strenuous sports, and sexual intercourse for three to six weeks. After the surgical drains are removed, stretching exercises may be begun, though some physical therapists may start a patient on shoulder and arm mobility exercises while in the hospital.

The breast area will fully heal in three to four weeks. If the patient had breast reconstruction, it may take up to six weeks to recover fully. The patient should be able to participate in all of the activities she has engaged in before surgery. If breast reconstruction is done, the patient should realize that the new breast will not have the sensitivity of a normal breast. In addition, dealing with cancer emotionally may take time, especially if additional treatment is necessary.

Since breast removal is often emotionally traumatic for women, seeking out a support group is often helpful. Women in these groups offer practical advice about such matters as finding well-fitting bras and swimwear, and emotional support because they have been through the same experience.

Finally, for women who chose not to have breast reconstruction, it will be necessary to find the proper fitting breast prosthesis. Some are made of cloth, and others are made of silicone, which are created from a mold from the patient's other breast.

In some case, the patient may be required to undergo additional treatments such as radiation, chemotheraphy, or hormone therapy.

Breast Reconstruction

Breast reconstruction, especially if it is begun at the same time as the simple mastectomy, can minimize the sense of loss that women feel when having a breast removed. Although there may be other smaller surgeries later to complete the breast reconstruction, there will not be a second major operation nor an additional scar.

If there is not enough skin left after the mastectomy, a balloon-type expander is put in place. In subsequent weeks, the expander is filled with larger amounts of saline (salt water) solution. When it has reached the appropriate size, the expander is removed and a permanent breast implant is installed.

If there is enough skin, an implant is installed immediately. In other instances, skin, fat, and muscle are removed from the patient's back or abdomen and repositioned on the chest wall to form a breast.

None of these reconstructions have nipples at first. Later, nipples are reconstructed in a separate surgery. Finally, the areola is tattooed in to make the reconstructed breast look natural.

Breast reconstruction does not prevent a potential recurrence of breast cancer.

Risks

The risks involved with simple mastectomy are the same for any major surgery. There may, however, be a need for more extensive surgery once the surgeon examines the tumor, the tissues surrounding it, and the lymph nodes nearby. A biopsy of the lymph nodes is usually performed during surgery and a determination is made whether to remove them. Simple mastectomy usually has limited impact on range of motion of the arm nearest the breast that is removed, but physical therapy may still be necessary to restore complete movement.

There is also the risk of infection around the incision. When the lymph nodes are removed, lymphedema may also occur. This condition is a result of damage to the lymph system. The arm on the side nearest the affected breast may become swollen. It can either resolve itself or worsen.

As in any surgery, the risk of developing a blood clot after a mastectomy is a serious matter. All hospitals use a variety of techniques to prevent blood clots from forming. It is important for the patient to walk daily when at home.

Finally, there is the risk that not all cancer cells were removed. Further treatment may be necessary.