- Breast cancer treatment: full mastectomy and breast sectoral resection
- Radical mastectomy (full breast removal)
- Simultaneous mastectomy
- Mastectomy with endoprosthetics
- Subcutaneous mastectomy
- Radical resection of the mammary gland
Breast cancer treatment: full mastectomy and breast sectoral resection
Surgical removal of breast cancer, depending on the prevalence of the lesion may be organ-preserving (sectoral resection, quadrantectomy, radical resection), radical (mastectomy) or palliative (symptomatic). The cosmetic defect after radical mastectomy is eliminated by reconstructive and plastic surgeries (by its own tissues or by endoprosthetics) simultaneously or in a delayed period.
Surgical removal of tumors in the breast are usually supplemented with radiation therapy, chemotherapy or hormone therapy.
Radical mastectomy (full breast removal)
Radical mastectomy consists in the removal of the breast, together with the pectoral muscles (large and small), subclavian, axillary and subscapular tissue and lymph nodes (traditional mastectomy according to Halstead). There are modifications of radical mastectomy, characterized by a smaller volume: according to Patty (with the preservation of the large pectoral muscle), Maden (with the preservation of large and small pectoral muscles and axillary lymph nodes of the third level), etc.
Traditional radical mastectomy is indicated in the widespread tumor process. Modified procedures of radical mastectomy with preservation of pectoral muscles are more favorable for restoring the function of the arm on the side of the operation.
In the process of radical mastectomy, the mammary gland with surrounding fat, muscle tissue and lymph nodes, where the tumor cells can potentially be contained, must be removed. When choosing the method of radical mastectomy proceed from the reasons for the complete removal of the affected tissue, as well as the least traumatization and disability of the patient.
Given the prevalence and neglect of the oncological process, various variants of radical mastectomy are used: traditional (according to Halstead) or modified (according to Peyti or Maden). In continuation of radical mastectomy, reconstruction of the mammary gland (endoprosthetics, restoration using own tissues – LDM flap with the widest back muscle or TRAM flap with rectus abdominis muscles) can be performed. In some cases, before radial mastectomy, to achieve the state of operability and after the operation, radiation therapy, chemo-hormonotherapy or chemotherapy is performed.
A test that a mammologist prescribes before a radical mastectomy may include sonography, mammography, doktografiya (with discharge from the nipple), CT or MRI of the mammary glands, a biopsy of the tumor with a morphological verification of the diagnosis.
Indications and contraindications to mastectomy
Conducting radical mastectomy is absolutely indicated in sarcoma or breast cancer. The variant and volume of radical mastectomy is determined taking into account the germination of the tumor into the pectoral muscles and lesions of the lymph nodes.
Rarely, radical mastectomy is performed about a massive purulent process or gangrene of the breast.
Contraindications to radical mastectomy mammology considers the situation caused by the prevalence of the tumor process: the germination of the chest wall, swelling of the breast or upper limb, multiple metastasis to the lymph nodes, extensive ulceration of the skin, etc.
Common somatic contra-indications of radical mastectomy include conditions associated with severe cardiovascular insufficiency, decompensated metabolic disorders (diabetes mellitus, hepatic or renal insufficiency), cerebral circulation impairment, deep senile age.
Technique of surgery according to Halstead
When performing a radical mastectomy according to Halstead, along with the affected mammary gland, the pectoral muscles (small and large), their fascia, as well as the fat tissue of the axillary, subclavian and subscapular area with the lymph nodes located in it are removed.
For radical mastectomy, the patient is placed on the operating table on her back with a hand on the side of the operation that is 90 ° apart. The method of cutting the skin is selected based on the size and location of the tumor, as well as the option of closing the wound defect.
The standard incision in radical mastectomy is performed by the type of two half-ovals, fringing the gland, at a distance of 6-8 cm from the tumor. After the cut, the skin and subcutaneous tissue are successively cut off from the underlying tissues: top to the clavicle edge of the large pectoral muscle; in the medial direction – to the place of attachment of the fibers of the large pectoral muscle to the sternum; below – to the border of the upper 1/3 of the rectus abdominal muscle; in the lateral direction – to the latissimus muscle of the back.
After opening the fascia crosses the large and small pectoral muscles, widely allocate fiber with lymph nodes. Then the mammary gland is removed by a single block including large and small pectoral muscles, fascia, fiber of the axillary, subscapular and subclavian areas.
Hemostasis of the wound surface is carried out, drainage for lymph drainage is established in the axillary zone. The cut on the front chest wall is sutured. The operation of radical mastectomy lasts 1.5-2 hours.
Radical mastectomy according to Halstead is now performed in the case of a tumor of large pectoral muscle.
With advanced radical mastectomy, the main technical steps correspond to Halstead’s operation, but the chest is additionally opened to remove parasternal lymph nodes.
Modified variants of radical mastectomy differ in a smaller volume: in the Peyti operation, the mammary gland is removed in a block with a small pectoral muscle and axillary tissue; with mastectomy according to Maden, pectoral muscles are retained, and iron and axillary tissue are removed. Mastectomy according to Maden retains its radicality, but it is more gentle due to the preservation of pectoral muscles and the function of the limb.
Complications after full mastectomy
Patients who underwent radical mastecutomy from 7-10 days are recommended to perform gymnastics and massage for the limb on the side of the operation in order to maximize the preservation of the volume of hand functions. If untimely initiation of restorative therapy, mobility in the shoulder joint may worsen.
After a radical mastectomy, the sensitivity of the skin of the breast may temporarily be affected by the type of numbness or hyperesthesia resulting from the intersection of nerve fibers. In the early postoperative period, it is possible to accumulate under the skin in the region of a blood wound or serous contents with the formation of a hematoma or seromy, as well as their suppuration.
Postoperative bleeding with radical mastectomy usually develops against a background of impaired hemostasis.
Removal of the lymphatic drainage pathways in radical mastectomy naturally leads to lymphorrhoea-the accumulation of lymph in the postoperative wound. The lymph drainage develops after the removal of drainage and is eliminated by puncture or by open method. Abundant lymphorrhea occurs in obese patients, in lean patients – less pronounced.
Removal of axillary lymph nodes during radical mastectomy can lead to the development of lymphedema – lymphatic edema of the extremity.
After a radical mastectomy, special antitumor therapy is prescribed to prevent recurrent breast cancer.
Simultaneous mastectomy and reconstruction with their own tissues combine radical removal of the breast, affected by a cancerous tumor, with a simultaneous reconstructive operation – the restoration of the breast with the help of autothyskens.
The main advantage of a one-stage mastectomy with reconstruction of one’s own tissues is the reconstruction of the physiological shape and size of the breast, the absence of a need for delayed reconstructive surgery, and the alleviation of psychological trauma. Reconstruction of the breast with its own tissues is more often performed using a skin-muscle flap (TRAM-flap), a skin-fascial flap (DIEP-flap), and other autothytes.
Mastectomy with endoprosthetics
Mastectomy with one-stage endoprosthetics of the breast is an operation of radical removal of the mammary gland with simultaneous reconstruction of the lost breast with the help of an endoprosthesis. Endoprosthetics of the mammary gland is possible only in the case of performing a mastectomy with the preservation of a large pectoral muscle.
Immediately after the mastectomy, an implant-expander is placed under the skin, to gradually stretch the tissues. In the future, the expander can fulfill the role of an endoprosthesis or be replaced by a permanent silicone implant. Mastectomy with one-stage endoprosthetics allows you to recreate the close to the natural volume and shape of the breast, accompanied by minimal trauma and rapid recovery.
Subcutaneous mastectomy consists in the complete removal of glandular and adipose tissue of the mammary gland with axillary, subclavian and subscapular lymph nodes, but the preservation of the skin of the breast along with the nipple-areolar complex. Conditions for performing subcutaneous matectomy is a tumor up to 2 cm in diameter, located 2 or more cm from the nipple in the depth of the breast.
Subcutaneous mastectomy allows you to restore the shape of the mammary gland with your own tissues or with the help of an implant by reconstructive-plastic surgery. After subcutaneous mastectomy, radiation or chemotherapy is indicated.
Radical resection of the mammary gland
Radical resection of the mammary gland is an expanded removal of the area of the breast tissue (up to 1 / 3-1 / 2 of its volume), including the fascia of the large pectoral muscle, small pectoral muscle, fatty tissue with subclavian, axillary and subscapular lymph nodes. Radical breast resection is indicated at an early stage of breast cancer, with a diameter of the tumor node up to 3 cm, its location in the upper-outer quadrant, a sufficient volume of the breast and the absence of metastases in the lymph nodes.
After radical resection, radiotherapy is mandatory. Postoperative period can be complicated by abundant lymphatic drainage, wound suppuration, impaired mobility of the shoulder joint.