Breast cancer surgery

Mastectomy: invasive ductul carcinoma. Source:https://en.wikipedia.org/wiki/Mastectomy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:  Soroush Seifirad, M.D.[2]

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## Overview

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Surgery is the mainstay of treatment for breast cancer.[1]

## Surgery

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* Surgery involves the physical removal of the tumor, typically along with some of the surrounding tissue and frequently sentinel lymph node biopsy.[2]

* Standard surgeries include:

* Mastectomy: Removal of the whole breast.
* Quadrantectomy: Removal of one-quarter of the breast.
* Lumpectomy: Removal of a small part of the breast.

* If the patient desires, then breast reconstruction surgery, a type of cosmetic surgery, may be performed to create an aesthetic appearance.

In other cases, women use breast prostheses to simulate a breast under clothing or choose a flat chest.

* Breast-conserving surgery, a less radical cancer surgery than mastectomy

## Mastectomy

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* Mastectomy (from Greek μαστός "breast" and ἐκτομή ektomia "cutting out") 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, people believed to be at high risk of breast cancer have the operation prophylactically, that is, as a preventive measure. It is also the medical procedure carried out to remove cancerous tissues.

* Alternatively, some patients can choose to have a wide local excision, also known as a lumpectomy (see below), 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.
* Traditionally, in the case of breast cancer, the whole breast was removed.

* Currently, the decision to do the mastectomy is based on various factors, including breast size, the number of lesions, biologic aggressiveness of breast cancer, the availability of adjuvant radiation, and the willingness of the patient to accept higher rates of tumor recurrences after lumpectomy and radiation.[1]

* 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.

* According to cancer.org, aside from the post-surgical pain and the obvious change in the shape of the breast(s), possible side effects of a mastectomy include wound infection, hematoma (buildup of blood in the wound), and the seroma (buildup of clear fluid in the wound). If the lymph nodes are also removed, additional side effects may occur

### Epidemiology

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* Mastectomy rates vary tremendously worldwide, as was documented by the 2004 'Intergroup Exemestane Study', an analysis of surgical techniques used in an international trial of adjuvant treatment among 4,700 females with early breast cancer in 37 countries. The mastectomy rate was highest in central and eastern Europe at 77%. The USA had the second highest rate of mastectomy with 56%, western and northern Europe averaged 46%, southern Europe 42% and Australia and New Zealand 34%.[3]

* Between 2005 and 2013, the overall rate of mastectomy increased 36 percent, from 66 to 90 per 100,000 adult women. The rate of hospital-based bilateral mastectomies (inpatient and outpatient combined) more than tripled, from 9.1 to 29.7 per 100,000 adult women, whereas the rate of unilateral mastectomies remained relatively stable at around 60 per 100,000 women.

* From 2005 to 2013, the rate of bilateral outpatient mastectomies increased more than five-fold and the inpatient rate nearly tripled. The rate of unilateral mastectomies nearly doubled in the outpatient setting but decreased 28 percent in the inpatient setting. By 2013, nearly half of all mastectomies were performed, outpatient.

### Mastectomy subtypes

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* Currently, there are several surgical approaches to mastectomy, and the type that a person decides to undergo (or whether she or he 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 axillarylymph 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 the 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.[4] 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.[5]
* 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.[6]
* 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.[7]
* Extended Radical Mastectomy: Radical mastectomy with intrapleural en bloc resection of internal mammary lymph node by sternal splitting.[6]
* Prophylactic mastectomy: This procedure is used as a preventative 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 the person has BRCA1 or BRCA2 mutations in their genes. 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 (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 peoples have had a higher survival rate after this procedure had been done.

A patient after mastectomy.Source:https://en.wikipedia.org/wiki/Mastectomy

## Lumpectomy

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* Lumpectomy (sometimes known as a tylectomy, partial mastectomy, breast segmental resection or breast wide local excision) is surgical removal of a discrete portion or "lump" of breast tissue, usually in the treatment of a malignant tumor or breast cancer.
* It is considered a viable breast conservation therapy, as the amount of tissue removed is limited compared to a full-breast mastectomy, and thus may have physical and emotional advantages over more disfiguring treatment. Sometimes a lumpectomy may be used to either confirm or rule out that cancer has actually been detected.
* A lumpectomy is usually recommended to patients whose cancer has been detected early and who do not have enlarged tumors.
* Although a lumpectomy is used to allow for most of the breast to remain intact, the procedure may result in adverse effects that can include sensitivity and result in scar tissue, pain, and possible disfiguration of the breast if the lump taken out is significant.
* According to National Comprehensive Cancer Network guidelines, lumpectomy may be performed for ductal carcinoma in situ (DCIS), invasive ductal carcinoma, or other conditions.[3]

* A lumpectomy is a surgery to remove a breast tumor along with a "margin" of normal breast tissue. The margin is the healthy, noncancerous tissue that is next to the tumor.
* A pathologist analyzes the margin excised by the lumpectomy to detect any possible cancer cells.
* A cancerous margin is "positive" while a healthy margin is "clean" or "negative".
* A re-excision lumpectomy is performed if the margin is detected to be positive or cancerous cells are very close to the margin.
* Sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) may be used to determine if cancer has progressed away from the breast and into other parts of the body.

* Sentinel lymph node biopsy is the analysis of a few removed sentinel nodes for the presence of cancerous cells. A radioactive substance is used to dye the sentinel nodes for easy identification and removal.
* If cancer is detected in the sentinel node then further treatment is needed. [2]Axillary lymph node dissection involves the excision of lymph nodes connected to the tumor by the armpit (axilla). Radiation is usually used in conjunction with the lumpectomy to prevent future recurrence. The radiation treatment can last five to seven weeks following the lumpectomy. Although the lumpectomy with radiation helps to decrease the risk of the cancer returning, it is not a cure and cancer may still come back.[8][1]

## Complications

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* After surgical intervention to the breast, complications may arise related to wound healing. As in other types of surgery, hematoma (post-operative bleeding), seroma (fluid accumulation), or incision-site breakdown (wound infection) may occur.

* Breast hematoma due to an operation will normally resolve with time but should be followed up with more detailed evaluation if it does not. Breast abscess can occur as a post-surgical complication, for example after cancer treatment or reduction mammaplasty. Furthermore, if a breast has already undergone irradiation (as in radiation therapy for treating breast cancer), there is a heightened risk of complications (e.g. reactive inflammation, the occurrence of a chronic draining wound, etc.) for breast biopsies or other interventions to the breast, even those often considered "minor" surgeries. The combined effects of radiation and breast cancer surgery can in particular lead to complications such as breast fibrosis, secondary lymphedema (which may occur in the arm, the breast or the chest, in particular after axillary lymph node dissection), breast asymmetry, and chronic/recurrent breast cellulitis, each of these having long-term effects.

* Ultrasound can be used to distinguish between seroma, hematoma, and edema in the breast. Further possible complications are fat necrosis (premature cell death of fat cells) and scar retraction (shrinking of the area around the surgical scar). In rare cases after breast reconstruction or augmentation, late seroma may occur, defined as seroma occurring more than 12 months postoperatively.

* There is preliminary evidence suggesting that negative-pressure wound therapy may be useful in healing complicated breast wounds resulting from surgery.

* Postoperative pain is common following breast surgery. The incidence of poorly controlled acute postoperative pain following breast cancer surgery ranges between 14.0% to 54.1%. Regional anesthesia is superior compared to general anesthesia for the prevention of persistent postoperative pain three to 12 months after breast cancer surgery.

* In post-surgical medical imaging, many findings can easily be mistaken for cancer. In MRI, scars that occurred many years before are normally "silent".

## References

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1. ↑ 1.0 1.1 1.2 Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER et al. (2002) Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347 (16):1233-41. DOI:10.1056/NEJMoa022152 PMID: 12393820
2. ↑ 2.0 2.1 Zujewski J, Eng-Wong J (2005) Sentinel lymph node biopsy in the management of ductal carcinoma in situ. Clin Breast Cancer 6 (3):216-22. DOI:10.3816/CBC.2005.n.023 PMID: 16137431
3. ↑ 3.0 3.1 DeSantis C, Siegel R, Bandi P, Jemal A (2011) Breast cancer statistics, 2011. CA Cancer J Clin 61 (6):409-18. DOI:10.3322/caac.20134 PMID: 21969133
4. ↑ Newman LA (2014) Contralateral prophylactic mastectomy: is it a reasonable option? JAMA 312 (9):895-7. DOI:10.1001/jama.2014.11308 PMID: 25182096
5. ↑ Kurian AW, Lichtensztajn DY, Keegan TH, Nelson DO, Clarke CA, Gomez SL (2014) Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011. JAMA 312 (9):902-14. DOI:10.1001/jama.2014.10707 PMID: 25182099
6. ↑ 6.0 6.1 Noguchi M, Sakuma H, Matsuba A, Kinoshita H, Miwa K, Miyazaki I (1983) Radical mastectomy with intrapleural en bloc resection of internal mammary lymph node by sternal splitting. Jpn J Surg 13 (1):6-15. PMID: 6887660
7. ↑ Gerber B, Krause A, Reimer T, Müller H, Küchenmeister I, Makovitzky J et al. (2003) Skin-sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction is an oncologically safe procedure. Ann Surg 238 (1):120-7. DOI:10.1097/01.SLA.0000077922.38307.cd PMID: 12832974
8. ↑ Fisher B, Redmond C, Poisson R, Margolese R, Wolmark N, Wickerham L et al. (1989) Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 320 (13):822-8. DOI:10.1056/NEJM198903303201302 PMID: 2927449

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