Mastectomy

The Slide contains the operative procedure and technique for breast removal.

1. MASTECTOMY

2. Anatomy of breast

3. Anatomy of axilla

4. 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%.

5. Introduction Most common carcinoma in women. 1.3 million women/ yr are diagnosed to have carcinoma breast. 77% of incidence seen in women > 50yrs. 2 nd most common cause of death due to carcinoma. 555,000/yr deaths due to carcinoma breast.

6. 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.

7. 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.

8. Types of mastectomy 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.

9. Types of mastectomy Modified Radical Mastectomy (MRM): Removal of breast tissue and axillary lymph nodes. No removal of pectoral muscle. 3 modifications: Patey’s Scanlon’s. Auchincloss.

10. Types of mastectomy 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

11. Types of mastectomy Subcutaneous mastectomy: Simple mastectomy sparing nipple. Rarely done, as a large amount of breast tissue is left in situ. Skin sparing mastectomy: Total/simple mastectomy or modified radical mastectomy with preservation of as much as breast skin as possible needed for breast reconstruction. Local recurrence is acceptable, 0-3%.

12. Types of mastectomy Breast conserving surgery: Wide local excision/Lumpectomy Quadrantectomy.

13. Types of mastectomy Extended radical mastectomy: Radical mastectomy + enbloc resection of internal mammary lymph nodes + supraclavicular lymph nodes. Obsolete. Toilet mastectomy: Done in fungating or ulcerative growths. Palliative simple mastectomy.

14. Which procedure is suitable for the given patient ? Age Size of the tumor Axillary lymph node status. Stage of the malignancy Biologic aggressiveness of the tumor Receptor status of the tumor. Multicentricity or multifocality Menstrual status. Size of the breast Availability of radiotherapy. Patients choice. Prophylactic/therapeutic/ palliative.

15. 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.

16. Which procedure is best ? Loco-Regional therapy include: Surgery Radiotherapy Systemic therapy: Chemotherapy Hormonal therapy Monoclonal antibodies. However surgery is important to get rid of gross cancer

17. Pre-operative management 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.

18. Operative procedures-Mastectomy Simple mastectomy. Modified radical mastectomy. Breast conserving surgery.

19. 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.

20. 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

21. 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.

22. 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.

23. 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.

24. 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

25. 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.

26. 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.

27. Modified radical Mastectomy-procedure Patey’s procedure: The P.minor is removed for better visualization and easy dissection of level III lymph nodes. Scanlon’s procedure: P.minor is retracted to expose level III nodes and dissected out. Auchincloss procedure: Level I and II lymph nodes are cleared, level III nodes are left behind.

28. 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.

29. 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.

30. 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.

31. Procedures: Mastectomy

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 1 st week.. Active shoulder and upper limb exercises are started from 2 weeks

33. C7physio.in Thanks……

34. Screening

35. MammoGram