- 32 year old female diagnosed with triple negative breast cancer and admitted for MRM surgery. - She previously underwent lumpectomy which showed invasive ductal carcinoma. - She received 4 cycles of neoadjuvant chemotherapy and was scheduled for MRM. - Physical exam and tests showed no signs of metastasis. - She underwent MRM surgery which included removal of breast tissue and axillary lymph nodes.

1. CASE PRESENTATION
• MRM

2. PATIENT PARTICULARS
• NAME : Swapnali Sakat
• AGE : 32 yrs
• HUSBAND'S NAME : mohit
• ADDRESS : F-12 ESIS Flat, Anudh,Pune
• DATE OF ADMISSION :14/05/2023
• RELIGION :Hindu
• OCCUPATION :Housewife
• Marital status: Married
• DIAGNOSIS : CA BREAST ( RT)

3. PRESENTING COMPLAINTS
• 33 yr old female with no known co
morbidities, a case of Triple
negative breast cancer got
admitted at Command Hospital
(SC) Pune on 14-5-23 for
MRM.Patient had H/O lump RT
Breast 10 months back
,underwent lumpectomy.
• Post lumpectomy HPE report(
Invasive ductal carcinoma)

4. PRESENT HISTORY OF ILLNESS
Patient apparently well 10 months back when developed lump in
RT Breast ( insidious onset, gradually progressive initially 2x2
cm
Underwent lumpectomy in civil in oct 2022 based on FNAC
Report( Fibroadenoma with fibrocystic changes)
post lumpectomy HPE report shows Neoplastic ductal
epithelial cells ,Invasive Ductal Carcinoma ( RB Score-
2+3+2=7) Grade II
Reported to this hospital for further management

5. Contd…
• CECT ( C+ A+P) – NO evidence of metastatis
• 4 cycles of NACT done
Last dose of NACT on 7-3-23
Planned for MRM on 16-5-23

6. PAST MEDICAL/SURGICAL HISTORY
OF ILLNESS
• No significant medical history
• Patent had Classical LSCS 17 Yrs back and
lumpectomy in oct 2022.
FAMILY HISTORY OF ILLNESS
• No significant medical or surgical history of illness

7. PERSONAL HISTORY
• NUTRITION
 Dietary Habits : Non Vegetarian
 Meal Pattern : 3 meal pattern
 Smoking : Non Smoker
 Alcohol : Non Alcoholic
• HYGIENE
Patient performs all activities of daily living
herself and was well groomed

8. PHYSICAL EXAMINATION
 VITAL SIGNS:
 Temp : 98.4F
 Pulse : 90/min
 Respiration : 22/min
 BP : 110/70
 Nutritional status : Good
 Build : Average
 Height : 167cms
 Weight : 66 kg
 BMI :

9. CONTINUED
 Pallor : Not present
 Icterus : Not present
 Thyroid : normal
 Pedal oedema : not present
 Varicose vein : Not present
 Heart, liver & spleen : NAD
 Lungs : No signs of breathlessness, normal
lung sounds

10. Breast Examination ( RT)
 INSPECTION
• No visible lump or swelling
• Scar of previous surgery ( 6cm) in upper
quadrant
• RT NAC higher than left
• No discoloration /
crackles/ulceration/peau d orange/
dimpling/puckering of skin

11. CONTINUED
 PALPATION
• No local rise of temp
• Non tender
• Lump not palpable
 AXILLA
NO palpable lymph nodes

12. DIAGNOSTIC EVALUATION
• Blood investigations- WNL
• Chest x ray- NAD
• ECG- Normal
• FNAC Report post lumpectomy- Invasive
ductal carcinoma Grade II
• CECT ( Abdomen+ chest+pelvis)- No sighns of
metastais

13. BREAST ANATOMY

14. .
• Latin word Breast = Mammary gland.
• Modified sweat gland.
• Accessory organ of female reproduction
system

15. Situation and
extend
• Lies in superficial fascia
of pectoral region.
• Extended
Vertically - from 2nd to
6th ribs.
2nd
RIB
6th
RIB
Pectoral
fascia
Pectoralis
minor
Pectoralis
Major
Retro
mammary
space

16. Situation and
extend
• Lymphatics are
present in retro
mammary space.
• That is why in MRM we
dissect the
breast tissue with
pectoral fascia.

17. CONTD….
• Upper lateral quadrant
has lateral extension –
known as axillary tail of
Spence.
• It piers deep pectoral
fascia – known as foramen
of langer.
• It has direct
communication with
anterior group of
axillary lymph nodes.
• That is why we need to
remove axillary LN with
breast tissue with

18. Structure of breast
• It can be divided in 3 components
1. Skin with nipple areola
2. Parenchyma
3. Stroma

19. Structure of breast
• Nipple
- A conical projection
- Present just below the centre
of the breast at the level of
the fourth intercostal space
10 cm from the midline.
- pierced by 15 to 20
lactiferous ducts.
- It has a few modified
sweat and
sebaceous glands.

20. Structure of breast
• Areola
- Pigmented skin
surrounding Nipple.
- Rich in modified sebaceous
glands
- Oily secretions of these
glands lubricate the
nipple and areola, and
prevent them from
cracking during lactation.

21. Structure of breast
• Parenchyma
- It is a compound tubulo-
alveolar gland
- 15 to 20 lobes.
- Each lobe is drained by a
lactiferous duct.
- The lactiferous ducts
converge towards the
nipple and open on it.
- Near its termination each
duct has a dilatation
called a lactiferous sinus

22. Structure of breast
• Stroma
- supporting
framework
- There are fibrous bands
that provide structural
support and insert
perpendicularly into the
dermis, termed the
suspensory ligaments of
Cooper.
That is why if involvement
of cooper’s ligament  skin
retraction

23. Blood
supply
1. Internal thoracic
artery, a branch of
the subclavian
artery, through its
perforating
branches.
2. The lateral thoracic,
superior thoracic
and acromiothoracic
branches of the
axillary artery.
3. Lateral branches of
the
posterior intercostal
arteries.

24. Lymphatic
drainage
• Specialized lymphatic
channels collect under
the nipple and areola and
form Sappey’s plexus.
75
%
axillary nodes
20
%
internal mammary
nodes
5% posterior intercostal
nodes

25. CONTD….
1. Level I nodes are
located lateral to the
lateral border of the
pectoralis minor
muscle.
2. Level II nodes are located
posterior
to the pectoralis minor
muscle.
3. Level III nodes
include the sub
clavicular nodes
medial to the
pectoralis minor

26. CONTD…
• The anterior (pectoral)
group lie along the lateral
thoracic vessels.
• The posterior
(scapular) group lie
along the subscapular
vessels.
• The lateral group lie along
the upper part of the
numerus, medial to the
axillary vein.
• .

27. CONTD….
• The central group lie in the fat of the upper
axilla.
• The apical (infraclaaicular) group lie deep to
the clavipectoral fascia, along the axillary
vessels

28. BREAST CANCER
• It is a disease in which cells of breast grow out
of control.

29. CLASSIFICATION

32. Imaging tests
▣ Breast exam
▣ Mammograms
▣ Breast ultrasound
▣ Breast MRI scan
▣ Biopsy

37. ▣ Surgery
▣ Radiation therapy
▣ Biological therapy (targeted drug therapy)
▣ Hormone therapy
▣ Chemotherapy
MANAGEMENT

40. MANAGEMENT IN MY PATIENT
• Preoperative investigations – WNL
• PAC fit
• Pre op instructions carried out as advised

41. trolley
Special instruments include
Skin hooks
Morris retractor
Liga clip applicator- 100,200,300

42. STEPS OF SURGERY
• 1. Anaesthesia
• 2.Position
-Supine position with arm abducted < 90 degree
-sandbag or bolster placed under thorax and
shoulder of affected side

43. • 3. Incision
• - oblique elliptical incision angled towards
axilla
• - includes entire areolar complex and previous
scar if any
• - 1-2 cm away from tumor margin

45. • 4. Extent of dissection
• - Superiorly till clavicle
• -laterally till anterior margin of latissimus dorsi
• -Medially to sternal border
• -Inferiorly till costal margin

47. • 5. Specimen retracted upwards and laterally to expose
P.minor
• 6.Dissection carried out till axillary node clearance.
• 7. Axillary investing fascia incised to expose axillary
group of lymph nodes
• 8. The interpectoral ( Rotter) group of lymph nodes
removed.
• 9. Dissection done from medial to lateral side or vice-
versa.

48. • 11. Investing layer of axillary vessels cut,
tributaries transfixed and cut
• 12.lateral group ( level 1) lymph nodes
removed
• 13. Thoracodorsal neurovascular bundle lies
over lat.dorsi with nerve more laterally,
subscapular (level 1) removed

49. • 14. level II Lymph nodes removed.
• 15. Central group of lymph nodes removed
carefully seprating from axillary vein.
• 16. Dissection carried out anterior and medial
to long thoracic nerve and specimen delivered

51. Care to be taken to preserve……
• Medial and long pectoral nerve
• Long thoracic nerve
• Nerve to latissimus dorsi
• Axillary vein
17. wound irrigated with saline
• 18 .2 drains 1 below and other above p.major
• 19. skin closed with stapler

53. IMMEDIATE POST OPERATIVE INSTRUCTIONS
• NPO till 1700 hrs
• Nourished on IV Fluids NS/RL/DNS @ 110ml/ hr
• Treatment
 Inj omnatax 1 gm TDS
 Inj PCM 1 gm TDS
 INJ Voveran75 mg TDS
• Watch for soakage
• Vitals monitoring

54. NURSING DIAGNOSIS
1. Acute pain related to skin incision and surgical
intervention
2. Risk for fluid volume deficit related to fluid and blood loss
during surgery
3. Risk for infection related to inadequate primary defence
secondary to surgical incision
4. Knowledge deficit related to postoperative care
5. Impaired self deficit related to surgical intervention

55. HEALTH EDUCATION
• Maintaining respiratory function
• Achieving rest and comfort
• Drug compliance
• Dietary changes: High protein diet
• Do and don’ts after surgery
• Care of wound and drain
• Staple removal at 14 days
• Family support
• Post mastectomy exercises