Mastectomy

CHAPTER 21 Mastectomy



Robert E. Roses, Brian J. Czerniecki




Case Study


A 52-year-old female presents to her physician’s office after palpating a firm mass in her right breast. She has no history of breast disease. She was 12 years of age at the time of menarche and is premenopausal. She has no children, nor has she ever been pregnant. Her last screening mammogram, 2 years earlier, was normal. An older sister was diagnosed with breast cancer at the age of 55 years and underwent a mastectomy.


On physical examination, a firm, irregular mass is noted just above the areola in the right breast. No overlying skin changes or axillary lymphadenopathy is appreciated.


A mammogram is obtained, which shows a stellate mass in the right breast (Fig. 21-1). A core needle biopsy is obtained and shows poorly differentiated invasive ductal carcinoma.


image

Figure 21-1 Mammogram. Craniocaudal view of the right breast shows a stellate mass.


(From Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 17th ed. Philadelphia, Saunders, 2004.)




BACKGROUND


Breast cancer is the most common malignancy in women, excluding cancers of the skin. Fortunately, the majority of breast cancers are diagnosed as early-stage lesions and are therefore amenable to surgical intervention with good anticipated outcomes (for current staging, see Box 21-1). The surgical management of breast cancer has undergone a dramatic transformation over the past several decades. Until the mid-1970s, radical mastectomy, a procedure that involved removal of breast tissue, the underlying pectoralis muscles, and regional axillary nodes, was the procedure of choice for the treatment of breast cancers. This operation was subsequently replaced by the modified radical mastectomy (which spares the pectoralis muscles) and the total or simple mastectomy (a pectoralis-sparing mastectomy without axillary lymphadenectomy). Over the past 2 decades, breast-conserving therapy, consisting of partial mastectomy (lumpectomy) and radiation therapy, has assumed a prominent role in the treatment paradigm for increasing numbers of breast cancers. More recently, sentinel lymph node biopsy has greatly reduced the number of axillary lymph node dissections performed on patients without clinically evident nodal metastases.



BOX 21-1


Joint Committee on Cancer Staging System for Breast Cancer



TNM Definitions



Primary Tumor (T)



• Tx: Primary tumor cannot be assessed

• T0: No evidence of primary tumor

• Tis: Ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), or Paget’s disease of the nipple with no tumor

• T1: Tumor not larger than 2 cm in greatest dimension

• T2: Tumor larger than 2 cm but not larger than 5 cm in greatest dimension

• T3: Tumor larger than 5 cm in greatest dimension

• T4: Tumor of any size with direct extension to chest wall or skin


Regional Lymph Nodes (N)



• Nx: Regional lymph nodes cannot be assessed

• N0: No regional lymph node metastasis

• N1: Metastasis to movable ipsilateral axillary lymph nodes

• N2: Metastasis to ipsilateral fixed or matted axillary lymph nodes or to ipsilateral internal mammary nodes in the absence of clinically evident axillary node metastasis

• N3: Metastasis in ipsilateral infraclavicular or supraclavicular lymph nodes or to ipsilateral internal mammary nodes in the presence of clinically evident axillary node metastasis


Distant Metastasis (M)



• Mx: Cannot be assessed

• M0: No distant metastasis

• M1: Distant metastasis


AJCC Stage Groupings



• 0: Tis, N0, M0

• 1: T1, N0, M0

• IIa: T0–T1, N1, M0; T2, N0, M0

• IIb: T2, N1, M0; T3, N0, M0

• IIIa: T0–T2, N2, M0; T3, N1–N2, M0

• IIIb: T4, N0–N2, M0

• IIIc: Any T, N3, M0

• IV: Any T, Any N, M1

From Singletary SE, Allred C, Ashley P, et al: Revision of the American Joint Committee on Cancer staging system for breast cancer. J Clin Oncol 20:3628–3636, 2002. Reprinted with permission from the American Society of Clinical Oncology.




Risk factors for breast cancer include age, history of breast cancer, atypical ductal hyperplasia, atypical lobular hyperplasia, LCIS, family history, BRCA1 or BRCA2 mutation, early menarche, late menopause, nulliparity, exogenous hormone usage, and thoracic radiation.


This chapter focuses on partial mastectomy and total mastectomy, which remain important components of the management of in situ and invasive breast cancers. Sentinel lymph node biopsy is addressed in detail in Chapter 23, as is axillary lymphadenectomy, which is sometimes performed in conjunction with total mastectomy.



INDICATIONS FOR MASTECTOMY



I. Invasive Breast Cancer: Most early breast cancers are treated with partial mastectomy and radiation (breast-conserving therapy) (Fig. 21-2). Contraindications to this approach include: large tumor burden relative to small breast size, previous radiation therapy or other contraindications to radiation therapy (e.g., pregnancy), and multicentric disease (cancer foci in multiple quadrants of the breast). Sentinel lymph node biopsy is performed in conjunction with partial or total mastectomy for most invasive and some in situ cancers. Axillary lymphadenectomy is indicated in patients with sentinel lymph nodes containing metastases or clinically positive axillary nodes.

II. Ductal Carcinoma in Situ (DCIS): DCIS is a premalignant lesion characterized by clustered malignant cells confined by a basement membrane. Most often, DCIS is diagnosed by screening mammography. Microcalcifications are the most common associated mammographic finding. DCIS is most often treated with breast-conserving therapy. In patients with extensive or diffuse disease, however, mastectomy is sometimes performed.

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May 26, 2018 | Posted by in GENERAL SURGERY | Comments Off on Mastectomy

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