Mastectomy
A mastectomy is the surgical removal of the entire breast,
usually to treat serious breast disease, such as breast cancer.
There are four general types of mastectomy:
- A SUBCUTANEOUS MASTECTOMY
removes the entire breast, but leaves the nipple and areola (the pigmented circle around
the nipple) in place.
- TOTAL MASTECTOMY (OR SIMPLE) is the removal of the
whole breast, but not the lymph nodes under the arm (axillary nodes).
- In a MODIFIED RADICAL
MASTECTOMY, the whole breast and most of the lymph nodes under the arm (axillary
nodes) are removed. Removal of these lymph nodes is called an axillary dissection.
- RADICAL MASTECTOMY involves
removal of the chest wall muscles (pectorals) in addition to the breast and axillary lymph
nodes. For many years, this operation was considered the standard for women with breast
cancer, but it is rarely used today. It is mostly of historical interest.
Why a Mastectomy is performed
The size, location, and type of tumor are very important when choosing the best surgery
to treat a woman's breast cancer. The size of the breast is also an important factor. A
woman's psychological concerns, and her lifestyle choices should also be considered when
decisions are made.
The severity of a cancer is evaluated according to a complex system called staging.
This takes into account the size of the tumor, and whether it has spread to the lymph
nodes, adjacent tissues, and/or distant parts of the body. A mastectomy is usually the
recommended surgery for more advanced breast cancers. Women with earlier stage breast
cancers, who could have breast conserving surgery (lumpectomy), may decide to have a
mastectomy.
There are many factors that make a mastectomy the treatment of choice for a patient. A
large tumor is often an indication of a later stage of breast cancer, when the removal of
the entire breast is recommended. In addition, large tumors are difficult to remove with
good cosmetic results. This is especially true if the woman has small breasts. Very
rapidly growing breast cancers are usually treated with a mastectomy. Sometimes multiple
areas of cancer are found in one breast, making removal of the whole breast necessary. A
cancer that has already attached itself to nearby tissues, such as the skin or chest wall,
is most likely to be removed with a mastectomy.
Breast conserving surgery may be attempted, but prove unsuccessful. The surgeon is
sometimes unable to remove the tumor with a sufficient amount, or margin, of normal tissue
surrounding it. The entire breast needs to be removed in this situation. Recurrence of
breast cancer after a lumpectomy is another indication for mastectomy.
Radiation therapy is almost always recommended following a lumpectomy. If a woman is
unable to have radiation, a mastectomy is the treatment of choice. Pregnant women cannot
have radiation therapy, for fear of harming the fetus. A woman with certain collagen
vascular diseases, such as systemic lupus erythematosus or scleroderma, would experience
unacceptable scarring and damage to her connective tissue from radiation exposure. Any
woman who has had therapeutic radiation to the chest area for other reasons cannot
tolerate additional exposure for breast cancer therapy. Diminished lung capacity due to
other disease also makes a woman a poor candidate for radiation therapy.
The need for radiation therapy after breast conserving surgery may make mastectomy more
appealing for nonmedical reasons. Some women fear radiation, and choose the more extensive
surgery, so radiation treatment will not be required. The commitment of time, usually five
days a week, for six weeks, may not be acceptable for other women. This may be due to
financial, personal, or job-related factors. In geographically isolated areas, a course of
radiation therapy may require lengthy travel, and perhaps unacceptable amounts of time
away from family or other responsibilities.
Some women choose mastectomy because they strongly fear recurrence of the breast
cancer, and lumpectomy seems too risky. Keeping a breast that has contained cancer may
feel uncomfortable for some patients. They prefer mastectomy, so the entire breast will be
removed.
The issue of prophylactic mastectomy, or removal of the breast to prevent future breast
cancer, is controversial. Women with a strong family history of breast cancer and/or who
test positive for a known cancer-causing gene may choose this option. Patients who have
had certain types of breast cancers that are more likely to recur may elect to have the
unaffected breast removed. Although there is some evidence that this procedure can
decrease the chances of developing breast cancer, it is not a guarantee. It is not
possible to be certain that all breast tissue has been removed. There have been cases
where breast cancers have occurred after both breasts have been removed.
Risks of Mastectomy
Mastectomy is very safe surgery, and most patients recover well
with no complications. As with any surgery, however, there are risks. Possible
complications are listed here, but keep in mind that unless stated otherwise, they usually
do not happen.
The risks of any surgery are bleeding, infection, and injury to nearby tissues. Some
post-operative pain and soreness is expected, but can be effectively treated with pain
medication. There will also be a scar on the chest wall. Scarring occurs with all surgery,
and is unavoidable.
General anesthesia risks include potential breathing and heart problems, as well
possible reactions to medications. For a woman who is otherwise in good health, the risk
of a serious complication due to general anesthesia is less than 1%.
The risks related specifically to the removal of the breast include a compromised blood
supply to the skin of the chest wall, which may cause loss of some skin. In extreme
circumstances, this complication may require a skin graft, but this is very rare. There is
also a risk of bleeding into the space where the breast used to be. Sometimes a second
operation is required to control bleeding, but this is also uncommon.
There are risks specifically related to removing the nearby lymph nodes (axillary
dissection):
- Many patients experience shoulder stiffness after removal of the lymph nodes in the
armpit. This stiffness improves over time, especially with exercise and physical therapy.
- A fluid collection, called a seroma, may collect in the armpit. This is relatively
common and usually resolves on its own, but may require needle drainage.
- Since the axillary (armpit) lymph nodes normally drain excess fluid from the arm, the
removal of these can result in postoperative swelling of the arm on the same side as the
breast which is removed. This swelling (called lymphedema) is uncommon, but when it
occurs, it can be a persistent problem and carries an increased risk of infection.
- There are some important nerves in the area of the axillary lymph nodes that are at risk
during surgery. Many patients will have a numb patch on the inside of the arm after
surgery. Nerves to muscles of the back and chest wall are also at risk, but your surgeon
will make every effort to protect these nerves during surgery.
There are also risks related to reconstructive surgery. If reconstructive surgery was
done using an implant, there is an increased risk of infection. There is also a risk that
the scar around the implant will contract.
This can make the breast feel hard, and can be treated by removing the scar tissue or
removing /replacing the implant. Each of these involves another surgery. Surgical scars
may fade with time, but they will never disappear entirely.
Reconstruction using native tissue from the abdomen, back, or buttocks carries a higher
risk of bleeding, and a small chance that the transferred tissue will lose its blood suppy
and have to be removed |