Mastectomy is a surgical procedure to remove the breast gland. A mastectomy is usually performed for breast cancer, the most common of which is breast cancer. Mastectomy can also be part of cancer prevention - we are talking about preventive mastectomy. Check what are the indications for a mastectomy, how does a mastectomy work, what are the types of mastectomy and what are the possible complications after a mastectomy.

Mastectomyis a group of various surgical procedures. There are many subtypes of mastectomy, differing mainly in the extent of the operation. Among them, you can distinguish, among others simple breast amputation, modified mastectomy and radical mastectomy. Thus, a mastectomy can be perceived as a group of surgical procedures with a different course and indications.

Mastectomy - what is it?

Surgical treatment is one of the basic and most important methods of breast cancer therapy. Surgical procedures in breast cancer are commonly used in the vast majority of cases of the disease. Surgical treatment is a standard part of the treatment of stage I to III breast cancer. Only stage IV disseminated breast cancer is not routinely treated with surgery.

There are two main pathways in breast cancer surgery - mastectomy, i.e. surgical removal of the breast, and the so-called breast conserving treatment. The aim of conserving treatment is to avoid amputation of the entire breast - during the procedure only neoplastic tissues are removed.

Conservation treatment plays a huge role in modern breast cancer surgery - this method is widely used, surgical techniques are constantly developed, and the effects of treatment are comparable to more extensive and crippling operations.

It cannot be said, however, that conserving procedures displaced mastectomy from the standards of surgical treatment of breast cancer. There are clinical situations in which it is impossible to save the breast - then a mastectomy is necessary to get rid of the cancer.

Mastectomy - types

Mastectomies is a group of various surgical procedures. We can divide them according to the indications for the operation and its scope:

Therapeutic and preventive mastectomy

The first criterion is relatively simple - we distinguish between therapeutic and prophylactic mastectomy. We perform therapeutic mastectomy in order to cure the disease (most often breast cancer).

Prophylactic mastectomy is indicated in some patients with a very high risk of developing breast cancer - then the breast is removed to prevent the development of the disease. Prophylactic mastectomy usually affects both breasts. Therapeutic mastectomy is usually unilateral, except in the rare cases of bilateral breast cancer.

Simple, radical and modified mastectomy

The scope of the surgery is the basis for distinguishing mastectomy subtypes:

  • straight,
  • radical
  • and the modified one.

The basis of a mastectomy is the removal of the breast gland. In some cases, it may also be necessary to excise other surrounding tissues - lymph nodes, fascia and pectoral muscles.

Historically, the most performed procedure for breast cancer was radical Halsted mastectomy. This is the most crippling variant of mastectomy - apart from the breast gland, the underlying pectoral muscles (smaller and larger) and the axillary lymph nodes on the side of the amputated breast were removed.

With the development of surgery, efforts were made to minimize the invasiveness of procedures, which is why nowadays radical Halsted mastectomy is performed extremely rarely. The first step in reducing the extent of the procedure was to develop a modified mastectomy technique that allowed the sparing of the pectoral muscles. This modification allows, among others to maintain better efficiency of the upper limb after the procedure.

Currently, radical modified mastectomy is performed in patients with breast cancer when the axillary lymph nodes are affected by a tumor. If, on the other hand, we are dealing with less advanced breast cancer, it is possible to perform the most sparing type of mastectomy - simple mastectomy.

This variant consists in removing only the breast gland with the underlying fascia of the pectoral muscle. To check if the neoplastic process has spread to the lymph nodes, simple mastectomy is often combined with the so-called sentinel node biopsy. Only when lymph node involvement is confirmed, the scope of the mastectomy can be widened.

Subcutaneous mastectomy

Modern surgical techniques in breast surgery make it possible to take care of the cosmetic aspect of the procedure. Traditional simple mastectomy removes all breast tissue,along with the overlying skin and nipple.

Currently, various types of so-called subcutaneous mastectomy, i.e. mastectomy sparing the skin and / or nipple. The preservation of the external "cover" of the breast gland in combination with the reconstruction of the shape of the breast (most often by implanting an implant) allows you to achieve favorable cosmetic effects of the procedure.

Palliative mastectomy

Breast cancer in the highest stage - stage IV is not routinely treated with surgery. However, there are clinical situations where surgery can also be used in advanced breast cancer. In this case, mastectomy is palliative - it does not increase the chances of curing the disease, but it can significantly improve the patient's quality of life.

An example of an indication for this type of mastectomy is a large tumor accompanied by ulceration, bleeding, oozing from the wound and other local complications.

Mastectomy - indications

Contemporary breast cancer surgery aims at a compromise between the smallest possible extent of the procedure and the greatest treatment effectiveness. Whenever a breast conserving treatment is available, it is considered first. However, there are clinical situations in which mastectomy has a clear advantage over sparing treatment.

Medical indications for mastectomy are primarily cases in which the removal of the neoplastic tumor itself is significantly difficult or impossible. This is the case for large tumors, tumors that are difficult to reach for the operator, and multifocal tumors.

Mastectomy is also performed in the event of failure of conserving treatment, that is, when the previous conserving surgery failed to remove the entire tumor or the disease recurred.

A separate group of indications for mastectomy are cases where there are contraindications to sparing treatment. It is worth knowing that breast-conserving treatment requires adjuvant treatment - most often radiotherapy. Only such a combination allows you to achieve efficiency comparable to more radical operations.

If, after sparing treatment, it is not possible to apply adjuvant treatment, it is advisable to perform a mastectomy. Such a situation may apply, for example, to pregnant patients for whom the use of radiotherapy is absolutely contraindicated (ionizing radiation may cause significant damage to the fetus).

Mastectomy is also recommended for patients at high risk of relapse after conserving treatment. The cause of such circumstances may be genetic burden - if the patient is a carrier of the BRCA1 or BRCA2 mutation, then she is at increased risk of developing further foci of breast cancer. In such a situation, mastectomy minimizes the risk of relapse.

Mastectomy - contraindications

To think about the successful treatment of breast cancer, surgery is in most cases essential. As long as there are indications for a mastectomy, preparing the patient for the procedure becomes one of the priorities of the treatment. The basis for qualifying for surgery is the stage of the tumor.

Surgery is not the preferred treatment pathway only in the most advanced, i.e. disseminated, breast cancer. In this case, the patient benefits more from the so-called systemic treatment, most often hormone or chemotherapy.

Contraindications to mastectomy may also apply to the general he alth of the patient. In the case of serious comorbidities, surgery may carry a significant risk of he alth deterioration. A patient may not be eligible for surgery if the potential risks exceed the benefits of surgery.

Mastectomy - course

The first stage of the mastectomy procedure is the anesthesia of the patient, performed by the anaesthesiologist. A mastectomy is usually performed under general anesthesia, i.e. full anesthesia. After obtaining anesthesia, the surgeon proceeds to remove the mammary gland. Depending on the planned scope of the procedure, it may sometimes be necessary to remove other surrounding tissues.

Important information that determines the course of mastectomy is the condition of the axillary lymph nodes on the side of the amputated breast. If the nodes are malignant, they should be removed during mastectomy (we are talking about a modified radical mastectomy). If the lymph nodes are not affected by the cancer, they should not be removed.

In practice, the decision to keep or remove lymph nodes is made on the basis of the so-called sentinel node biopsy. This examination consists in checking the condition of the lymph node, which is the first point of lymph outflow from the mammary gland. This knot is called the sentinel node - the entire volume of the lymph from the mammary gland, flowing down towards the armpit, must first flow through it.

So if we do not find cancer cells in the sentinel node, we can with a large oneother axillary lymph nodes are likely to be he althy as well. In such a situation, the surgeon is satisfied with a simple mastectomy, i.e. removal of the breast gland itself. In a situation where the sentinel node turns out to be occupied by cancer, other lymph node stations are also likely to be occupied. For this reason, all lymph nodes in the armpit are removed prophylactically.

After the mastectomy is completed, it is possible to reconstruct the removed breast. The decision to carry out it depends on the patient's preferences, as well as medical considerations. In many cases, reconstruction is performed simultaneously with a mastectomy.

However, if the mastectomy is not the last step in the local treatment of breast cancer - for example, radiotherapy is still planned after surgery, the reconstruction is usually postponed until the treatment is fully completed. Breast gland reconstruction can be made with silicone prostheses (implants), as well as with the use of the patient's own tissues. In the case of using implants, the external breast shell is reconstructed with the use of a dermal and muscular flap, usually taken from the area of ​​the latissimus dorsi muscle.

Reconstruction with the use of the patient's own tissues does not require the insertion of artificial materials in the breast, which allows for a more natural consistency and appearance of the breast gland. The source of tissues for such reconstruction is in most cases the abdomen, from which a fragment of the skin, subcutaneous tissue, and sometimes also the rectus abdominis muscle are taken.

The entire mastectomy procedure usually takes 1-3 hours, depending on the extent of the operation. If a simultaneous breast reconstruction is performed, the procedure may take an additional few hours. After the operation is completed, the patient remains in the recovery room where vital signs are monitored.

In the following days of hospitalization, regular inspections of the postoperative wound are performed and analgesic treatment is carried out. In the absence of significant complications, the patient may soon be released home.

Mastectomy - complications

Mastectomy, like other surgical procedures, is associated with the risk of complications. Early complications of mastectomy include pain, bleeding, and infection of the surgical wound. Prevention of these complications begins in the operating theater. At the end of the procedure, the anaesthesiologist introduces analgesic treatment, and the surgeon stops any bleeding and ensures that the rules of antisepsis are followed during the operation.

In the area of ​​the surgical woundusually 1-2 drains are also placed to control the discharge from the operated site. In the case of the presence of purulent or bloody content, it is necessary to re-dress the wound surgically.

The long-term complications of mastectomy include stiffness and tingling in the shoulder area associated with perioperative damage to nerve endings. The risk of chronic complications of mastectomy increases when lymph nodes are removed during the procedure.

Removing part of the lymphatic system significantly impedes the circulation and outflow of the lymph. When axillary lymph nodes are removed, the lymphatic circulation is disturbed mainly in the upper limb. A frequent complication of distant mastectomy is the so-called lymphoedema, or lymphoedema of the upper limb.

Lymphoedema can appear up to two years after a mastectomy. In the prevention and treatment of lymphoedema, various massage techniques are used, gymnastic exercises to improve lymph outflow, bandaging and frequent lifting of the upper limb.

  • Mastectomy in the treatment of breast cancer. How does breast amputation work?
  • Breast biopsy, i.e. precise diagnosis of breast changes
  • Types of breast cancer. Treatment depends on the type of breast cancer
  • Cancer blood test detects BRCA mutations

Category:

Oncology