1Procedures Basic Format: Modified Radical Mastectomy with Axillary Node DissectionIntroduction: Breast Cancer is the unregulated growth of abnormal cells in breast tissue. It is the most commonly occurring cancer in women and the second leading cause of death in women in the US. The American Cancer Society estimates that more than 200,00 women will be diagnosed w/breast ca each year, and approx 40,000 women will die from it annually. There are racial differences in incidence and mortality of breast cancer: a. it is more prevalent in African American women up to age 40. B. Is more prevalent n Caucasian women over age 40 c. Asian, Hispanic, & American Indian women have a lowering incidence of developing breast cancer. African –A women are more likely to die from it because they are often diagnosed at an advanced stage. It can occur in the mammary gland of men. Until it can be prevented, early detection is the greatest hope for cure.B & K p. 637General surgery on the breast for males and females includes diagnostic procedures and those performed for known pathologic disease. Diagnostic techniques include mammaography, xeroradiography, ultrasonography, and thermography, as well as traditional tissue biopsy. The desired surgical procedure should be determined on an individual basis after careful diagnostic studies. Important things to consider (factors): size, location, type of diseased tissue, stage of malignancy.
2ObjectivesAssess the anatomy, physiology, and pathophysiology of the breastAnalyze the diagnostic and surgical interventions for a patient undergoing a Modified Radical Mastectomy w/Axillary Node DissectionPlan the intraoperative course for a patient undergoing Modified Radical Mastectomy w/Axillary Node DissectionAssemble supplies, equipment, and instrumentation needed for the procedure.
3Objectives Choose the appropriate patient position Identify the incision used for the procedureAnalyze the procedural steps for Modified Radical Mastectomy w/Axillary Node DissectionDescribe the care of the specimenDiscuss the postoperative considerations for a patient undergoing Modified Radical Mastectomy w/Axillary Node Dissection
4Terms and Definitions Benign vs Malignant Biopsy Frozen Section GynecomastiaIn situMammographyMammoplastyMastectomyXeroradiographyMAVCC p. 45 Specific Terms and DefinitionsXeroradiography: dx x-ray technique in which an image is produced electrically rather than chemically —this permits lower exposure times and radiation of lower energy than that of ordinary x-rays.
5Definition/Purpose of Procedure Ablative/Treatment: remove diseased tissueRemoval of the breast tissue and lymph nodes under the arm (axillary node dissection), leaving the chest wall muscles intactSTST: see p. 459 for general overview.B & K : usually performed for infiltrating ductal and localized small malignant lesions. There are various techniques involving the term “modified.” All include removal of the entire breast ( a total mastectomy). In addition, all axillary lymph nodes are resected. The underlying pectoralis major muscle is left in place, and the pectoralis minor muscle may or may not be removed. In patients with small lesions and no metastases, breast reconstruction may be performed immediately or a few days after the procedure.Alexander p. 652: Peformed after a tissue bx w/postive diagnosis of malignancy and involves removal of the involved breast and all axillary contents (all 3 levels of nodes –axillary, pectoral, and superior apical). The underlying pectoral muscles are not removed before or after removal of axillary nodes. It is performed to remove the involved area with the hope of decreasing the spread of malignancy.
6Modified Radical Mastectomy Picture on Rt from Lemone and Burke p : All breast tissue and the underarm lymph nodes are removed, but the underlying muscles remain.Alexanders p. 651 Axillary Node Dissection: Removal of the axillary nodes through an inciision in the axilla. An axillary dissection is usually done through an incision separate from that for other breast operations. The removal and examination of the axillary nodes allow for staging (Table 17-2 ) of the disease.Fig b
7Radical MastectomyB & K p. 640: performed to control the spread of malignant disease from large infiltrating cancers. After a positive finding on the issue biopsy, the entire involved breast is removed along with the axillary lymph nodes, the pectoral muscles, and all adjacent tissues. During the procedure, skin flaps and extensive exposed tissue are covered with moist packs for protection. The chest wall and axilla are irrigated before closure. L & B: p same
8Simple MastectomyFuller p. 321: removal of a breast to halt the spread of cancer. In recent years, there has been a trend away from radical treatment of breast cancer. The radical mastectomy, which in the past involved the removal of breast tissue, skin, muscle, fascia, and axillary lymph nodes, has been replaced by the simple mastectomy and the modified radical mastectomy.B & K p. 640 : May be performed for a malignancy that is confined to breast tissue wit negative nodes, as a palliative measure for an advanced ulcerated malignant tumor, or for the removal of extensive benign disease. It may be necessary to perform skin grafting if the primary closure of the skin flaps create an unacceptable tension. Skin flaps are loosely approximated, and grafts taken from the thigh are applied to the remaining defect. A latissimus dorsi or rectus abdominus myocutaneous flap may be peferred for reconstruction. A subcutaneous mastectomy may be performed for patients wit chronic cystic mastitis who have had multiple previous biopsies, for patients with multiple fibroadenomas or hyperplastic duct changes, and for patients with central tumors that are noninvasive in origin. All breast tissue is removed, but the overlying skin and nipple remain intact. A prosthesis may be inserted at the time of the surgical procedure, depending on the surgeon’s decision and patient’s wishes.L & B p. 1586: removal of the complete breast only (no lymph node dissection).Alexander p. 652: performed to remove extensive benign disease, if malignancy is believed to be confined only to the breast tissue, or as a palliative measure to removal an ulcerated advanced malignancy.
9Segmental ResectionB & K p. 640: a wedge or quadrant (quadrantectomy) of breast tissue is removed; this wedge includes the tumor mass and the lobe in which it is growing. Some surgeons explore the axilla and take a few lymph nodes for histologic studies.
10LumpectomyFrom Lemone and Burke p. 1586: Lumpectomy: only the tumor and a small margin of surrounding tissue are removed. May be same as segmental resection. May be performed with lymph node dissection (see Alexander’s p. 650).B & K p. 639: Also considered a partial mastectomy, consists of removal of entire tumor mass alongwith at least 1-2 cm of surrounding nondiseased tissue. This procedure is recommended for peripherally located tumors that measure less than 5 cm. Lumpectomy is contraindicated if breast size precludes postoperative radiation or if negative margins around the tumor cannot be obtained.Fig a
11Relevant A & PMammary glands are between the 3rd and 7th ribs at ant. Chest wallAreolaNippleCooper’s LigamentsTail of SpenceL & B p The mammary glands are located between the third and seventh ribs on the anterior chest wall. They are supported by the pectoral muscles—they lie on the pectoralis major-- and are richly supplied with nerves, blood, and lymph.The areola is the pigmented area slightly below the center of each breast and contains sebaceous glands and nipple. The nipple is usually protrusive and becomes erect in response to cold and stimulation. Primary purpose: supply nourishment for infant.The breasts are made of adipose tissue, fibrous connective tissue, and glandular tissue. Cooper’s ligaments support the breast and extend from the outer breast tissue to the nipple, dividing the breast into lobes. Each lobe is made of alveolar glands connected by ducts which open to the nipple. Lobes are separated by connective tissue and adipose tissue deposits. Each lobe is subdivided into lobules which contain secreting cells, alveoli, arranged in grape-like clusters. Each lobe is drained by a single lactiferous duct that opens on the nipple. The central and upper portions of the breast are mostly glandular.B & K: The mammary glands are bilateral organs lying in the superficial fascia of the pectoral area. They are attached to the underlying muscles by loose areolar tissue and suspended by Cooper ligaments. The breasts extend from the border of the sternum to the anterior axillary line (also called the Tail of Spence) and from approximately the first to the 7th rib. They are highly vascular. The blood supply is derived laterally from the thoracic branches of the axillary, intercostal, and internal mammary arteries. Venous drainage forms an anastomotic circle around the base of the nipple, with branches draining the circumference of the gland into the axillary and internal mammary veins. Lymphatic drainage follows the same path as the venous system and empties into the thoracoabdominal and lateral thoracic vessels. Innervation arises from the anterior and lateral cutaneous nerves of the thorax.
13Anatomy of BreastNote Tail of Spence and location of Pectoralis Major (from MAVCC Procedures Unit 3). The breast approximates a circular outline except at the upper, outer quadrant where the axillary Tail of Spence lies up into the axilla. There are 53 lymph nodes in the axillary area.
15Pathophysiology: Breast CA Begins as a single transformed cellIs hormone dependentClassified: non-invasive (in situ) vs invasiveCategories: CA of mammary ducts, ca of mammary lobules, or sarcoma of the breastMost: adenocarcinomas70% Infiltrating ductal carcinomaMetastasis to other sitesLemone and Burke p. 1582: Non invasive vs invasive depends on penetration of tumor into surrounding tissue. It may remain a noninvasive disease, or an invasive disease without metastasis, for long periods of time.Breast cancer may be categorized as carcinoma of the mammary ducts, carcinoma of mammary lobules, or sarcoma of the breast.Most are adenocarcinomas and seem to arise from the terminal section of the breast ductal tissue. There are many histologic types, but the most common is infiltrating ductal carcinoma—about 70% of cases are this. The MOST malignant form of breast cancer is Inflammatory carcinoma of the breast, which is a systemic disease (involves the whole body/blood stream). With the Inflammatory type, edema of the skin, called Peau d’orange, is usually present.Breast cancer can metastasize to other parts of the body. Common sites it goes to: bone, brain, lung, liver, skin, lymph nodes
16Breast Cancer Location by Quadrant B & KWhere are breast cancer lesions most likely to be found? Most Cancers are detected in the Upper outer quadrant of the breast.
17Pathology: Breast CA Staging Stage 1Stage IIStage IIIStage IVSize< 1-2 cm2-5 cm> 5 cmLarge & fully integrate w/surrounding tissueLocationConfined to breastBreast mass w or w/o susp ALNodesBreast mass w palpable, fixed Ax &/or subclavicular L Nodes. No D MetastasisDistant MetastasisExtension to skinLympedemaSurgical OptionsSegmental; Breast Conservation Surg for Stages I & II Lumpectomy w/AND & Rad TxTotal MastectomyModified or Radical MastectomyRadical or Extended Rad MastLemone & Burke: p. 1582:Staging is a system of classifying cancer according to the size of the tumor, involvement of the lymph nodes, and metastasis to distant sites, and the presence /absence of distant metastasis (L & BTable 48-6; STST p. 458). Staging provides important information for making decisions about treatment options and is also used as a basis for prognosis.B & K p. 639What is breast conservation? Surgical Tx of choice for many women, includes lumpectomy to excise a primary tumor and axillary node dissection followed by radiation therapy. This approach maintains appearance and function of the breast. The surgeon may prefer to perform the lumpectomy first, then the axillary node dissection. The patient must be reprepped and redraped between procedures. A separate set of instruments is used for each procedure to avoid possible tumor cell implantation in the axilla.A transverse incision for axillary dissection, approx 1 cm below the axillary hairline, extends fro the pectoralis major muscle anteriorly to the latissimus dorsi muscle posteriorly. Lymphoareolar tissue between these muscles is removed—at least 1- lymph nodes.
19Manifestations of Breast Cancer Breast mass or thickeningUnusual lump in underarm or above collarbonePersistent rash near nipple areaFlaking or eruption near the nippleDimpling, pulling, or retraction in an area of the breastNipple dischargeChange in nipple positionBurning, stinging, or pricking sensationL & B p Do you know the Signs and Symptoms? This is uselful info for women naturally—but men can assist and advise their partners as well. Prevention and monthly Breast Self Exam (BSE) is KEY.
20Diagnostics Exams Preoperative Testing Initial breast exam or mammographyChest x-rayBone scanningPreoperative Testing
21Surgical Intervention: Special Considerations Patient/Family FactorsHigh Anxiety/Apprehension due to upcoming loss/disfigurement: alert to need for therpeutic communication & alleviation via medsRoom Set-up: StandardHave mammograms in the ORNotify pathology if Frozen sections will be required before case begins—ensure pathologist presentUniversal ProtocolMay use special techniques for CancerMay prefer to irrigate with sterile water to crenate (shrivel or shrink) cancerous cells.Special Techniques for Cancer MAVCC p. 70Another emotional consideration is worry about facing emotional responses from family members
22Surgical Intervention: Anesthesia Method: GeneralEquipment: Typical monitors and machines
23Surgical Intervention: Positioning Position during procedureSupine with operative side close to bed edgeArm on operative side is extended to < 90 degrees on a padded armboardSupplies and equipment: May place small sandbag or folded sheet under shoulder of affected side; may use special arm table or double itSpecial considerations: high risk areas
24Surgical Intervention: Skin Prep Method of hair removalAnatomic perimetersShoulder, upper arm extending down to the elbow (circumferentially), the axilla, & chest to table line and to the shoulder opposite from affected side—access to underarm for AND and possible extend to fingertips of operative sideArm on operative side should be draped free using stockinette & drapes that allow free movement of the arm to facilitate access to the axillaSolution optionsBetadine or HibiclensGoldman Pocket Guide P.57: Circulator use gentle circular motions (potential of dislodging tumor cells) at lesion extending up neckline and don to umbilicus with wide margin beyond the midline. Prepare around the shoulder, under the arm and down the table on the affected side.The circulator will hold out the prepped arm to receive the double or impervious stockinette (prob 6 inch), the arm is then held by scrubbed personnel.
25Surgical Intervention: Draping/Incision Types of drapes: Chest/Breast drape; stockinetteOrder of drapingAnticipated area is outlined with adhesive towels or cloth towels & clipsChest/Breast drapeDraping of arm includes placement of sheet on armboard and appl of stockinette over entire armSpecial considerations: may need 2 set-ups; use of Sterile water intraop irrigationState/Describe incision: usually elliptical for MRM—see slide
26Surgical Intervention: Supplies General: Prep set, basic pack, basin set, chest drapes, ESU pencil/holder, gloves, Blades # 10 x 3, drsg: 4 x 4’s & ABDsSpecificSuture: Silk, Dexon, Nylon for drainMedications on field (name & purpose)Catheters & Drains: Closed wound drainage system x 2 (Jackson Pratt vs Hemovac)
27Surgical Intervention: Instruments General: Major traySpecific: extra hemostats (Adair breast clamps/large towel clips or Criles )Rake retractorsIf skin graft anticipated: Brown dermatome w/mineral oil, tongue blades, etc.
28Surgical Intervention: Equipment General: Suction, ESU with Dispersive electrode—may need to simultaneouslySpecific: may need additional armboard or special armrest
29Surgical Intervention: Procedure Steps Overview Breast incised ellipticallyIncision deepened to encompass entire breastBreast removed en bloc w/ALNsAxillary lymph nodes are removedWound is closedFuller p
30Surgical Intervention: Procedure Steps Surgeon incises skin around the breast elliptically and deepens w/ESU pencil—lateral extension toward the axilla thru the subcutaneous tissue. Bleeding is controlled w/hemostats and ligatures or ESUSurgeon dissects the skin from the underlying tissue w/#10 blade on # 3 knife handle and or ESU pencilBlades dull easily and will need changing—notify Surgeon each timeCrv. Metzenbaum scissors are used to isolate large vessels from the breast tissue when the surgeon extends the incision into the axillaBeren’s retractors are used to elevate skin flaps. Allis or Kocher clamps are placed along breast tissue edges and retracted up by surgeon or assistantSee Alexander for full page of Procedural Steps p. 653, Fig
31Elliptical IncisionAlexander p. 644: This surgery’s elliptic incision with lateral extension toward the axilla gives good costmetic result for plastic surgery reconstruction and provides good arm movement because the pectoralis muscles are not removed , and usually does not require a skin graft.
32Surgical Intervention: Procedure Steps The margins of skin flaps are covered w/warm moist lap pads and held away w/retractors.The intercostal arteries and veins are clamped and ligated.The axillary flap is retracted for complete dissection of the axilla.Careful attention is directed to preventing injury to the axillary vein & medial and lateral nerves of the pectoralis major muscleThe fascia is dissected from the lateral edge of the pectoralis muscle. Ligation of vessels is performed in the axilla & adjacent to sternum. The fascia is then dissected to the serratus anterior muscle. The thoracic & thoracodorsal nerves are preserved
33Surgical Intervention: Procedure Steps Be sure to keep exposed tissue moist with lap packs for protectionSurgeon dissects the breast and axillary fascia away from the latissimus dorsi muscle and suspensory ligaments—from near the clavicle to midportion of the sternum. The pectoralis major muscle is left intact.The specimen is passed to STSRWound is inspected for bleeding sites, which are ligated & electrocoagulated, then irrigated (NS).
34Surgical Intervention: Procedure Steps Surgeon places closed-wound suction drainage tube(s) thru stab wounds and secured to skin w/nonabsorbable suture on a cutting needleA few absorbable suture may be used in the subcutaneous tissue to approximate the skin edges.Surgeon closes w/interrupted nonabsorbable sutures or staple, anchors drains, and connects to closed suction reservoir.The dressing may be one of several: simple gauze, bulky held in place w/Surgi-Bra, or gauze and elastic wrap.
35Counts Initial: Sponges, Sharps, Instruments, Small items First closingFinal closingSpongesSharpsInstrumentsSmall Items
36Dressing, Casting, Immobilizers, Etc. Types & sizes: 4 x 4’s & Abd padsMay need ACE wraps or Surgical BraType of tape or method of securing—Silk or Paper or Foam compression tape
37Specimen & CareIdentified as Breast and axillary lymph nodes, Left or RightHandled: Routine/large containerAsk : if estrogen or progesterone receptors studies are to be performed on a specimen, it is saved in Normal Saline or Dry
38Postoperative Care Destination PACUExpected prognosis (Good, Depends on Dx)Referral to Reach to Recovery rehabilitative Program and Physical Therapy possible
39Postoperative Care Potential complications Hemorrhage (vascular breast—watch)InfectionOther: Damage to….Surgical wound classificationClass I
40References Alexander: pp. 637-655 Berry & Kohn: pp. 637-641 Fuller: ppMAVCC Proc Unit 3 pSTST: ppLemone & Burke: pp