Mastectomy

Mastectomy

Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operation as a preventive measure. Alternatively, some women can choose to have a wide local excision, also known as a lumpectomy, an operation in which a small volume of breast tissue containing the tumor and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as "local therapies" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as chemotherapy, hormonal therapy, or immunotherapy.

The decision to perform a mastectomy is based on various factors, including breast size, the number of lesions, biologic aggressiveness of a breast cancer, the availability of adjuvant radiation, and the willingness of the patient to accept higher rates of tumor recurrences after lumpectomy and/or radiation. Outcome studies comparing mastectomy to lumpectomy with radiation have suggested that routine radical mastectomy surgeries will not always prevent later distant secondary tumors arising from micro-metastases prior to discovery, diagnosis, and operation. In most circumstances, there is no difference in both overall survival and breast cancer recurrence rate. While there are both medical and non-medical indications for mastectomy, the clinical guidelines and patient expectations for before and after surgery remain the same.

Mastectomy indications

Breast cancer

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

• women who have already undergone 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
• 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 child)
• women with a tumor larger than 5 cm (2 inches) that doesn't shrink very much with neoadjuvant chemotherapy
• women with cancer that is large relative to their breast size
• women who have tested positive for a deleterious mutation on the BRCA1 or BRCA2 gene and opt for a preventive mastectomy since they are at high risk for the development of breast cancer.

Other uses

Mastectomy has non-cancer medical uses as well, including cosmetic or reconstructive surgery. Men with gynecomastia may be eligible for mastectomy, but minimally invasive surgical techniques also exist. Transgender men may undergo a mastectomy as a gender-affirming surgery.

Side effects

Aside from the post-surgical pain and the obvious change in the shape of the chest and/or breast(s), possible side effects of a mastectomy include soreness, scar tissue as the site of the incision, short-term swelling, phantom breast pain (pain in the breast or tissue that has been removed), wound infection or bleeding, hematoma (buildup of blood in the wound), and seroma (buildup of clear fluid in the wound). If the lymph nodes are also removed, additional side effects such as lymphedema (swelling of the lymph nodes) may occur.

Upper limb problems such as shoulder and arm pain, weakness and restricted movement are a common side effect after breast cancer surgery. According to research in the UK, an exercise programme started 7–10 days after surgery can reduce upper limb problems.

Types

Currently, there are several surgical approaches to mastectomy, and the type that a person decides to undergo (or whether they will decide instead to have a lumpectomy) depends on factors such as the size, location, and behavior of the tumor (if one is present), whether or not the surgery is prophylactic, and whether the person intends to undergo reconstructive surgery.

• Simple mastectomy (or "total mastectomy"): In this procedure, the entire breast tissue is removed, but axillary contents are undisturbed. Sometimes the "sentinel lymph node"—that is, the first axillary lymph node that the metastasizing cancer cells would be expected to drain into—is removed. People who undergo a simple mastectomy can usually leave the hospital after a brief stay. Frequently, a drainage tube is inserted during surgery in their chest and attached to a small suction device to remove subcutaneous fluid. These are usually removed several days after surgery as drainage decrease to less than 20-30 ml per day. People that are more likely to have the procedure of a simple or total mastectomy are those that have large areas of ductal carcinoma in situ or even those persons that are removing the breast because of the possibility of breast cancer occurring in the future (prophylactic mastectomies). When this procedure is done on a cancerous breast, it is sometimes also done on the healthy breast to forestall the appearance of cancer there. The choice of this "contralateral prophylactic" option has become more typical in recent years in California, most notable in people younger than 40, climbing from just 4 percent to 33 percent from 1998 to 2011. However, the possible benefits appear to be marginal at best in the absence of genetic indicators, according to a large-scale study published in 2014. For healthy people known to be at high risk for breast cancer, this surgery is sometimes done bilaterally (on both breasts) as a cancer-preventive measure.
• Modified radical mastectomy: The entire breast tissue is removed along with the axillary contents (fatty tissue and lymph nodes). In contrast to a radical mastectomy, the pectoral muscles are spared. This type of mastectomy is used to examine the lymph nodes because this helps to identify whether the cancer cells have spread beyond the breasts.
• Radical mastectomy (or "Halsted mastectomy"): First performed in 1882, this procedure involves removing the entire breast, the axillary lymph nodes, and the pectoralis major and minor muscles behind the breast. This procedure is more disfiguring than a modified radical mastectomy and provides no survival benefit for most tumors. This operation is now reserved for tumors involving the pectoralis major muscle or recurrent breast cancer involving the chest wall. It is only recommended for breast cancer that has spread to the chest muscles. Radical mastectomies have been reserved for only those cases because they can be disfiguring and modified radical mastectomies have been proven to be just as effective.
• Skin-sparing mastectomy: In this surgery, the breast tissue is removed through a conservative incision made around the areola (the dark part surrounding the nipple). The increased amount of skin preserved as compared to traditional mastectomy resections serves to facilitate breast reconstruction procedures. People with cancers that involve the skin, such as inflammatory cancer, are not candidates for skin-sparing mastectomy.
• Nipple-sparing/subcutaneous mastectomy: Breast tissue is removed, but the nipple-areola complex is preserved. This procedure was historically done only prophylactically or with mastectomy for the benign disease over the fear of increased cancer development in retained areolar ductal tissue. Recent series suggest that it may be an oncologically sound procedure for tumors not in the subareolar position.
• Extended Radical Mastectomy: Radical mastectomy with intrapleural en bloc resection of internal mammary lymph node by sternal splitting.[2]
• Prophylactic mastectomy: This procedure is used as a preventive measure against breast cancer. The surgery is aimed to remove all breast tissue that could potentially develop into breast cancer. The surgery is generally considered when a woman has BRCA1 or BRCA2 genetic mutations. The tissue from just beneath the skin to the chest wall and around the borders of the breast needs to be removed from both breasts during this procedure. Because breast cancer develops in the glandular tissue, the milk ducts and milk lobules must be removed also. Because the region is so large-ranging, from the collarbone to the lower rib margin and from the middle of the chest around the side and under the arm, it is very difficult to remove all of the tissue. This genetic mutation is a high-risk factor for the development of breast cancer, family history, or atypical lobular hyperplasia (when irregular cells line the milk lobes.) This type of procedure is said to reduce the risk of breast cancer by 100%. However, other circumstances may affect the outcome. Studies have shown that pre-menopausal women have had a higher survival rate after this procedure had been done.

Wikipedia article: Mastectomy

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