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  1. 1. MASTECTOMYPresenter:Dr Janardhan TPost GraduateModerator:Dr Prakash MConsultant surgeon
  2. 2. Introduction• Definition: surgical removal of breast tissue partially or completely.• In a study conducted in 2004, – Highest mastectomies were done in Europe 60-70%. – USA- 56%. – Australia and New Zealand: 34%.
  3. 3. Introduction• Most common carcinoma in women. – 1.3 million women/ yr are diagnosed to have carcinoma breast. – 77% of incidence seen in women > 50yrs.• 2nd most common cause of death due to carcinoma. – 555,000/yr deaths due to carcinoma breast.
  4. 4. History• 549 A.D: court physician Aetius of Amida proposed to Theodora.• 1882: William Halsted- Radical mastectomy.• 1943: Patey and Dyson- Modified radical mastectomy.• 1981: Breast conservation surgery.
  5. 5. When is mastectomy indicated ?• Women with carcinoma breast.• Men with carcinoma breast.• Extensive benign disease of breast.• Prophylactic.• No/ minimal response to systemic therapy to CA breast.
  6. 6. Types of mastectomy1. Total or simple mastectomy: – Removal of the entire breast tissue, – No dissection of lymph nodes or removal of muscle. – Sometimes adjacent lymph nodes are removed along with the breast tissue.
  7. 7. Types of mastectomy2. Modified Radical Mastectomy (MRM): – Removal of breast tissue and axillary lymph nodes. – No removal of pectoral muscle. – 3 modifications: a. Patey’s b. Scanlon’s. c. Auchincloss.
  8. 8. Types of mastectomy3. Halsted’s Radical Mastectomy: – Most extensive type. – Breast tissue, axillary lymph nodes and pectoral muscles are removed. – Disadvantages: • Bad scars and unacceptable deformity. • Reduced range of mobility of shoulder
  9. 9. Types of mastectomy4. Subcutaneous mastectomy: 5. Skin sparing mastectomy: – Simple mastectomy – Total/simple mastectomy or modified radical mastectomy sparing nipple. with preservation of as much – Rarely done, as a large as breast skin as possible amount of breast tissue is needed for breast left in situ. reconstruction. – Local recurrence is acceptable, 0-3%.
  10. 10. Types of mastectomy6. Breast conserving surgery: – Wide local excision/Lumpectomy – Quadrantectomy.
  11. 11. Types of mastectomy7. Extended radical 8. Toilet mastectomy: mastectomy: – Done in fungating or– Radical mastectomy + ulcerative growths. enbloc resection of internal mammary lymph nodes + – Palliative simple supraclavicular lymph mastectomy. nodes.– Obsolete.
  12. 12. Which procedure is suitable for the given patient ?• Age • Menstrual status.• Size of the tumor • Size of the breast• Axillary lymph node status. • Availability of• Stage of the malignancy radiotherapy.• Biologic aggressiveness of the tumor • Patients choice.• Receptor status of the tumor. • Prophylactic/therapeutic/• Multicentricity or multifocality palliative.
  13. 13. Which procedure is best ?• When the tumor size is ≥ 1cm, becomes systemic.• No single method is considered better in terms of disease free survival or mortality.• Suitable local therapy + systemic therapy is the most appropriate approach.
  14. 14. Which procedure is best ?• Loco-Regional therapy include: a. Surgery b. Radiotherapy• Systemic therapy: a. Chemotherapy b. Hormonal therapy c. Monoclonal antibodies. However surgery is important to get rid of gross cancer
  15. 15. Pre-operative management• Triple assessment.• Metastatic workup.• Routine blood investigations.• Pre-anesthetic evaluation.• Control of medical conditions like diabetes and hypertension.• Counseling and written informed consent.• Parts preparation- neck to mid thigh including pelvic region, axilla and arm.
  16. 16. Anatomy of breast
  17. 17. Anatomy of axilla
  18. 18. TNM stagingStage Tumor Node MetastasisStage 0 Tis N0 M0Stage I T1 N0 M0Stage IIA T0 N1 M0 T1 N1 M0 T2 N0 M0Stage IIB T2 N1 M0 T3 N0 M0Stage IIIA T0 N2 M0 T1 N2 M0 T2 N2 M0 T3 N1 M0 T3 N2 M0Stage IIIB T4 N0 M0 T4 N1 M0 T4 N2 M0Stage IIIC Any T N3 M0Stage IV Any T Any N M1
  19. 19. Operative procedures-Mastectomy1. Simple mastectomy.2. Modified radical mastectomy.3. Breast conserving surgery.
  20. 20. Operative procedure• Anesthesia – General anesthesia.• Position – The patient is placed in supine position with the arm abducted < 90 degree. – Sandbag or folded sheet is placed under the thorax and shoulder of affected side.
  21. 21. Operative procedures- Simple Mastectomy• Indications: – Stage I and stage IIa carcinoma – Large cancers that persist after adjuvant therapy – Multifocal or multicentric CIS.• Incision: – Horizontal elliptical incision is marked so as to include the entire areolar complex. – Should be 1-2cm away from the tumor margins. – Skin sparing incision- if breast reconstruction is planned – Two skin edges should be of equivalent length
  22. 22. Simple Mastectomy-procedure• Skin incision is deepened with electro-cautery.• A plane between breast fat and the subcutaneous fat, seen as white fibrous plane.• Dissection is carried in this plane and flaps are raised inferiorly and superiorly.• Ideally thickness of the flap should be 7-10mm.
  23. 23. Simple Mastectomy-procedure• Extent of dissection: – Superiorly till clavicle, – Laterally till P.major lateral border – Medially to the sternal border, and – Inferiorly till infra-mammary fold• Breast tissue along with the pectoral fascia (controversial) is dissected from the P.major.
  24. 24. Simple Mastectomy-procedure• Usually started superiorly and the proceeded clock-wise ending in the axillary region.• Care must be taken to ligate perforating branches of lateral thoracic and anterior intercostal vessels.• Lateral branches of the medial pectoral neurovascular bundle is carefully dissected while removing axillary tail.• Wound irrigated with sterile water to crenate (shrivel or shrink) cancerous cells.• Subcutaneous tissue is closed using 00 absorbable interrupted sutures.• Skin closed using 00 non-absorbable mattress sutures or using staples.
  25. 25. Operative procedures- Modified radical Mastectomy• Indications: – LABC – Residual large cancers that persist after adjuvant therapy – Multifocal or multicentric disease.• Incision: – Oblique elliptical incision angled towards axilla. – Should include the entire areolar complex and previous scars, if present. – Should be 1-2cm away from the tumor margins. – Two skin edges should be of equivalent length
  26. 26. Modified radical Mastectomy-procedure• Procedure till approaching axilla is same as simple mastectomy.• Extent of dissection: – Superiorly till clavicle, – Laterally till anterior margin of latissimus dorsi. – Medially to the sternal border, and – Inferiorly till the costal margin near the insertion of the rectus sheath.
  27. 27. Modified radical Mastectomy-procedure• The specimen is retracted upwards and laterally to expose P.minor.• The dissection is continued to axillary lymph node clearance.• Care must be taken not to injure medial pectoral nerve and vessels.• The axillary investing fascia is incised to expose the axillary group of lymph nodes.
  28. 28. Modified radical Mastectomy-procedure1. Patey’s procedure: – The P.minor is removed for better visualization and easy dissection of level III lymph nodes.2. Scanlon’s procedure: – P.minor is retracted to expose level III nodes and dissected out.3. Auchincloss procedure: – Level I and II lymph nodes are cleared, level III nodes are left behind.
  29. 29. Modified radical Mastectomy-procedure• The inter-pectoral (Rotter) group of lymph nodes are removed.• Then dissection can be done either from medial to lateral or vise- versa.• The loose lateral areolar tissue in axillary space is dissected to expose the axillary vein.• The investing layer of axillary vessels is cut, the tributaries are transfixed and cut.• Dissection is carried out laterally including lateral grp (level I) of lymph nodes.
  30. 30. Modified radical Mastectomy-procedure• Thoracodorsal neurovascular bundle lies over the lat.dorsi, with nerve more laterally placed, subscapular (level I) nodes are removed.• The level II lymph nodes between superior trunk of intercostobranchial bundle and axillary vein are removed.• The central grp of lymph nodes are removed carefully separating from axillary vein and its tributaries.• While dissecting medially, long thoracic nerve is encountered, which lies anterior to the subscapular muscle. The dissection carried out anterior and medial to long thoracic nerve and the specimen delivered.
  31. 31. Modified radical Mastectomy-procedure• Care must be taken while dissecting in axillary area to preserve, – Medial and lateral pectoral nerve. – Long thoracic vessels and nerve – Nerve to latissimus dorsi. – Axillary vein.• Wound irrigated with sterile water to shrink/crenate cancerous cells.• 2 drains, 1 below and other above P.major are secured.• Subcutaneous tissue is closed using 00 absorbable interrupted sutures.• Skin closed using 00 non-absorbable mattress sutures or using staples.
  32. 32. Post-operative care• Wound examined on post-op day 3.• Drain can be removed when it is < 30ml.• Any collection is to be aspirated under aseptic precautions.• Staples can be removed after 10days.• Arm movements started in the 1st week..• Active shoulder and upper limb exercises are started from 2 weeks
  33. 33. Breast conserving surgery• Method: • Indications: – Wide local – Stage 0 (CIS), Stage I, excision/Lumpectomy Stage IIa breast or Quadrantectomy + carcinoma. axillary lymph node – Single lesion. clearance + radiotherapy. – Clinically downstaged LABC (controversial)
  34. 34. Breast conserving surgery• Contraindications: • Advantages:– Multicentric tumor. – Maintenance of appearance– Positive margins after excision. and function of breast.– Size > 4cm (relative). – Disease free interval is same as– Advanced stages. MRM.– No assess to radiation/ poor patient compliance. – Better quality of life and– C/I for radiation: SLE/ Rheumatoid psychological advantage. arthritis/ Scleroderma/ pregnancy/ prior chest radiation.
  35. 35. Breast conserving surgery-Procedure• Incision-circular/ radial/ subareolar incision near to the tumor, about 3-4cm.• Excision of the carcinoma tissue with a margin of atlaeast 1cm of normal breast tissue to get a 2-mm cancer-free margin. – If tumor is situated superficially then excision of that part of skin. – If tumor is deep then tumor is excised till pectoralis major.• Depending on post-surgical defect – Primary closure or – Reshaping of breast tissue is done.
  36. 36. Breast conserving surgery- Lumpectomy• After skin incision, subcutaneous tissue is deepened using electric cautery.• While dissecting the breast tissue, better to use scalpel.• Care must be taken while dissecting to palpate the tumor, so that entire lesion is excised. Specimen radiography can be done to check for clear margins.• Hemoclips are applied along the margins of the cavity.• Wound closed in 2 layers: – Subcutaneous tissue with interrupted inverted 3-0 absorbable suture. – Skin with subcuticular 3-0 absorbable sutures.
  37. 37. Breast conserving surgery-ProcedureQuadrantectomy:• Usually done for lesion in the upper outer and inner lower quadrants.• Radial incision is taken.• Entire breast tissue in that quadrant is excised till pectoral fascia.• Wound closed in multiple layers: – Breast tissue with interrupted 3-0 absorbable suture. – Subcutaneous tissue with interrupted inverted 3-0 absorbable suture. – Skin with subcuticular 3-0 absorbable suture.
  38. 38. Breast conserving surgery• Quadrantectomy v/s Lumpectomy. – Lumpectomy has more local recurrence risk. – Lumpectomy has better cosmetic outcome.
  39. 39. Breast conserving surgery• After BCS, radiotherapy is essential, otherwise the local recurrence rate is unacceptably high• Without radiotherapy, the local recurrence can be as high as 40%
  40. 40. Survival after BCS and Mastectomy Trial Endpoint Overall Survival Disease-free Survival CS&RT Mastect CS&RT MastectNCI Milan 18 yrs 65% 65% N/AInstitut Gustav 73% 65% N/A 15 yrsRoussyNSABP B-06 12 yrs 63% 59% 50% 49%NCI USA 10 yrs 77% 75% 72% 69%EORTC 8 yrs 54% 61% N/ADanish Breast 79% 82% 70% 66% 6 yrsCancer Group
  41. 41. Follow-up after breast conservation surgery• Mammogram at 6 months after radiotherapy• Clinical evaluation and mammogram every yearly then after.• If local recurrence detected, mastectomy must be done.
  42. 42. Complications• Most Common, – Reduced ROM of the shoulder – Numbness – Lymphoedema – Pain
  43. 43. Complications• Less common, – Hematoma – Skin flap necrosis – Fibrosis – Winging of scapula – Postural changes – Psychological implications – Chronic/phantom pain
  44. 44. Breast reconstruction surgery• The most common reason of breast reconstruction surgery, is for psychological well being.• Reconstructive surgery post mastectomy can be either immediate or delayed. – Immediate • Skin sparing • Better outcomes – Delayed • When immediate reconstruction is contraindicated. • Other reconstructive options
  45. 45. Breast reconstruction surgery• Types: – Latissimus dorsi myocutaneous flap. – Transverse rectus abdominus myocutaneous (TRAM) flap.
  46. 46. References• F. Charles Brunicardi, editor. Schwartz’s Principles of surgery. 9th ed. McGraw Hill; 2010. chapter 17.• Fischer, Josef E, editors. Mastery of Surgery. 5th ed. Lippincott Williams & Wilkins; 2007. chapter 41-46A.• DeVita, Vincent T, editors. DeVita, Hellman & Rosenbergs Cancer: Principles & Practice of Oncology. 9th ed. Lippincott Williams & Wilkins; 2008. chapter 43• Zollingers atlas of surgical operations. 8th ed.