mastectomy 1.pptx

Cancer

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 2 nd to 6 th ribs. 2 nd RIB 6 th 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 connecting axillary tail in continuity .

18. Structure of breast It can be divided in 3 components Skin with nipple areola Parenchyma 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 Internal thoracic artery, a branch of the subclavian artery, through its perforating branches. The lateral thoracic, superior thoracic and acromiothoracic branches of the axillary artery. 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…. Level I nodes are located lateral to the lateral border of the pectoralis minor muscle. Level II nodes are located posterior to the pectoralis minor muscle. Level III nodes include the sub clavicular nodes medial to the pectoralis minor muscle.

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

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

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

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

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

34. 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

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

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

37. 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.

38. 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

39. 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

40. 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

41. 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

42. NURSING DIAGNOSIS Acute pain related to skin incision and surgical intervention 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

43. 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