Mastectomy

Mastectomy

A mastectomy is surgery to remove all breast tissue from a breast as a way to treat or prevent breast cancer.

For those with early / locally advanced stage breast cancer, a mastectomy may be one treatment option. Breast-conserving surgery (lumpectomy), in which only the tumour is removed from the breast, may be another option. Deciding between a mastectomy and lumpectomy can be difficult. Both procedures are equally effective for preventing a recurrence of breast cancer. But a lumpectomy isn’t an option for everyone with breast cancer, and others prefer to undergo a mastectomy.

Newer mastectomy techniques can preserve breast skin and allow for a more natural breast appearance following the procedure. This is also known as skin-sparing mastectomy. Surgery to restore shape to your breast — called breast reconstruction — may be done at the same time as your mastectomy or during a second operation at a later date.

You may have been recommend a mastectomy instead of a lumpectomy plus radiation if:

  • You have two or more tumours in separate distant areas of the same breast.
  • You have widespread or malignant-appearing calcium deposits (microcalcifications) throughout the breast that have been determined to be cancer after a breast biopsy.
  • You’ve previously had radiation treatment to the breast region and the breast cancer has recurred in the breast.
  • You’re pregnant and radiation creates an unacceptable risk to your unborn child.
  • You’ve had a lumpectomy, but cancer is still present at the edges (margin) of the operated area and there is concern about cancer extending to elsewhere in the breast.
  • You carry a gene mutation that gives you a high risk of developing a second cancer in your breast.( Hereditary Breast Cancer )
  • You have a large tumour relative to the overall size of your breast. You may not have enough healthy tissue left after a lumpectomy to achieve an acceptable cosmetic result.
  • You have a connective tissue disease, such as scleroderma or lupus, and may not tolerate the side effects of radiation to the skin.

Mastectomy to prevent breast cancer

You might also consider a mastectomy if you don’t have breast cancer, but have a very high risk of developing the disease.
A preventive (prophylactic) or risk-reducing mastectomy involves removing both of your breasts and significantly reduces your risk of developing breast cancer in the future.

A prophylactic mastectomy is reserved for those with a very high risk of breast cancer, which is determined by a strong family history of breast cancer or the presence of certain genetic mutations that increase the risk of breast cancer.

Types of mastectomy include:

  • Total mastectomy: A total mastectomy, also known as a simple mastectomy, involves removal of the entire breast, including the breast tissue, areola and nipple. Axillary staging /clearance ( Armpit dissection) may be done at the time of a total mastectomy.
  • Skin-sparing mastectomy: A skin-sparing mastectomy involves removal of all the breast tissue, nipple and areola, but not the breast skin. Axillary staging /clearance (Armpit dissection) may be done at the time of a total mastectomy. Breast reconstruction can be performed immediately after the mastectomy. A skin-sparing mastectomy may not be suitable for larger tumours.
  • Nipple-sparing mastectomy: A nipple- or areola-sparing mastectomy involves removal of only breast tissue, sparing the skin, nipple and areola. Axillary staging /clearance ( Armpit dissection) may be done at the time of a total mastectomy. Breast reconstruction is performed immediately afterward.
  • Modified radical mastectomy: It’s a total mastectomy with excision of nipple and areola with armpit clearance. But the chest wall muscles are spared.
  • Radical mastectomy: Its total mastectomy with armpit clearance with removal of other structures that are involved by tumour like chest wall muscles, underling ribs and sternal bone. The reconstruction by various flaps may be necessary for the closure of defect

After the procedure

After your surgery, you can expect to:

  • Be taken to a recovery room where your blood pressure, pulse and breathing are monitored
  • Have a dressing (bandage) over the surgery site
  • Feel some pain, numbness and a pinching sensation in your underarm area
  • Usually ICU is not needed unless you have a serious comorbidities like uncontrolled diabetes, heart disease, serious hypertension etc.
  • You will be infused Intravenous fluids for hydration for the day of surgery
  • You will be given antibiotics, pain killers, antacids either orally or through venous access
  • You will be kept fasting for 6 hrs after surgery and then allowed to eat completely
  • You will be mobilised out of bed next day of surgery
  • If you have undergone armpit surgery too, you will be instructed not to use your upper limb of operated site for ant injections and will instructed to protect it from any injuries and abrasions. You will be given a pressure garment to apply on that limb for initial few months of surgery
  • You will be taught and instructed few breathing exercises and exercises: massage techniques of the upper limb of operated side.
  • You will be having a tube inserted at your operated site to withdraw the collected fluids from operated site. It may stay with you beyond your discharge from hospital. Its usually removed once the daily output gets reduced to safe value. You will be instructed and taught how to take care of the drain tube.
  • Receive instructions on how to care for yourself at home, including taking care of your incision and drains, recognizing signs of infection, and understanding activity restrictions
  • Talk with your health care team about when to resume wearing a bra or wearing a breast prosthesis
  • Be given prescriptions for pain medication and possibly an antibiotic
  • Your excised tissue is sent to histopathology examination. The report gets ready in 4 to 10 days of time after your surgery. This report guides your doctor for further adjuvant therapies. So its mandatory to collect this report and visits your Surgeon during your follow ups
  • If the period is uneventful, you will be discharged from hospital after 3 to 5 days
  • You need to continue all your previous medications for your comorbidities by consulting your respective specialties for the changes in prescription.

Probable complications

There are chances of

  • Skin flap necrosis: Its due to poor blood supply to the skin conserved during surgery. Skin discolours from bluish to black. It needs re excision of that part of skin and resuturing. If the necrosis is extensive, it might require wider excision and flap reconstruction for closure.
  • Wound infection: Its common in diabetic patients. Its self-limiting with daily dressing and antibiotics. But if its uncontrollable it may need surgical debridement
  • Seroma: It’s a collection of body fluid ( lymph ) at operated site. Its major morbidity after axillary ( armpit ) surgery. Its extensive in overweight patients and in those where there is extensive nodal involvement requiring thorough Lymph node clearance.
  • Pyoma: The collected fluid ( seroma) can get infected and turn into pus. It needs to be drained and debrided. Its curable with antibiotic cover.
  • Haematoma: there are chances of bleeding at operated site and blood gets accumulated at site to present as haematoma. The presentation is usually with blood in the tube inserted at time of surgery, drop in blood pressure due to blood loss and drop in haemoglobin ( HB) percent. It needs reexplanation and finding out the bleeding points and taking care of it wither by ligating or coagulating . It usually occur in patients on anticoagulants ( blood thinners ) and uncontrolled hypertension.
  • Heaviness and numbness in armpit and inner upper arm: Its due t armpit dissection. The numbness and heaviness is due to sacrifice of cutaneous nerves of sensations. Its called hypoesthesia or anaesthesia . It can’t be recovered completely but can get reduced over a long time
  • Burning: Its due to handling of nerves of sensation during armpit dissection. It may get worse especially at night time or at rest. If its extreme , you need to consult your surgeon to modify pain killers and add neuromodulators.
  • Deep seated aching sensation in armpit: Its again due to handling of nerves during armpit dissection.
  • Swelling of upper limb of operated site: Its lymph oedema. It’s one of the common long term complication of axillary clearance ( armpit dissection ) The nodes are excised from armpit as a part of cancer clearance, there is tendency of accumulation of lymph in the soft tissue of upper limb of operated side. It can start and evident even after 2 years of your surgery. It’s called Lymphedema of upper limb. Though its not curable effectively, Its preventable. A vigorous upper limb exercises, lymph massage, physiotherapy and use pressure garments during initial postoperative phase prevents future Lymph oedema.

Next therapy

Once the drain tube & sutures are removed and wound is healed completely, You will be guided for your next adjuvant therapy. It’s usually decided in a tumour board consisting of all the subspecialties by discussing your final histopathology report of surgical specimen, your cancer stage, type of cancer, comorbidities and your general health status.

Treatments General Principle

The main pillars of your breast cancer therapy are Surgery , Chemotherapy , Hormonal Therapy and Radiation Therapy.

Breast Conservation Surgery

The initial surgical treatment of breast cancer was typically wide excision, but...