MASTECTOMY

Mastectomy
Mastectomy- surgical removal of one or both breast

partially or completely. - usually done to treat breast cancer. Lumpectomy- an operation in which a small volume of breast tissue containing the tumor and some surrounding healthy tissue is removed to conserve the breast

 Both mastectomy and lumpectomy are what are referred to as "local therapies" for breast cancer.

ANATOMY and PHYSIOLOGY of HUMAN BREAST

INDICATIONS
Women who have already had radiation therapy to the affected breast Women with 2 or more areas of cancer in the same breast Women whose initial lumpectomy along with (one or more) re-excisions has not completely removed the cancer Women with certain serious connective tissue diseases such as scleroderma, which make them especially sensitive to the side effects of radiation therapy

 Pregnant women who would require radiation while still pregnant (risking harm to the child) Women with a tumor larger than 5 cm (2 inches) that doesn't shrink very much with neo adjuvant chemotherapy Women with a cancer that is large relative to her breast size Women who have tested positive for a deleterious mutation on the BRCA1 or BRCA2 gene and opt for prophylactic removal of the breasts Male breast cancer patients

TYPES of MASTECTOMY

Simple mastectomy (or "total mastectomy")

In this procedure, the entire breast tissue is removed, but axillary contents are undisturbed. Sometimes the sentinel lymph node -that is, the first axillary lymph node that the metastasizing cancer cells would be expected to drain intois removed.

Modified Radical Mastectomy

The entire breast tissue is removed along with the axillary contents (fatty tissue and lymph nodes).

Radical mastectomy (or "Halsted mastectomy") this procedure involves removing the breast axillary lymph nodes pectoralis major and minor muscles behind the breast. This procedure is more disfiguring than a modified radical mastectomy Provides no survival benefit for most tumors.

Skin-sparing mastectomy
the breast tissue is removed through a conservative incision made around the areola (the dark part surrounding the nipple).

Nipple Sparing or Subcutaneous Mastectomy

Breast tissue is removed, but the nippleareola complex is preserved. This procedure was historically done only prophylactically or with mastectomy for benign disease over fear of increased cancer development in retained areolar ductal tissue.

Extended Radical Mastectomy

intrapleural en bloc resection of internal mammary lymph node by sternal splitting. Indicated when malignant disease is present in the medial quadrant or subareolar tissue because it tends to spread to the internal mammary lymph nodes.

COMPLICATIONS

LYMPHEDEMA
is caused by an abnormality of the lymphatic system leading to excessive build up of tissue fluid that forms lymph, known as interstitial fluid. Stagnant lymph fluid contains protein and cell debris that causes swelling of affected tissues. Lymph is responsible for transporting essential immune chemicals and cells

 is the accumulation of protein-rich fluid in soft tissues as a result of interruption of lymphatic flow. It occurs most frequently in the extremities, but it can also be found in the head, neck, abdomen, lungs, and genital regions. In post-mastectomy patients, chronic lymphedema has the potential to become a permanent, progressive condition.

 If it is allowed to progress, the condition can become extremely treatment resistant. Left untreated, lymphedema leads to chronic inflammation, infection and hardening of the skin that. Interstitial fluid can build up in any area of the body that has inadequate lymph drainage and cause lymphedema. condition that develops slowly and once present is usually progressive

 Divided in 2 Forms: PRIMARY LYMPHEDEMA - People can be born with abnormalities in the lymphatic system. - swelling can be present at birth or may develop later in life. - is associated with developmental abnormalities of the lymphatic system - may be manifested in neonates (congenital), adolescents (praecox), or patients older than 35 years (tarda).

 SECONDARY LYMPHEDEMA - is the most common form of lymphedema. - This usually occurs after oncologic surgery or radiation therapy. - occurs as a result of damage by : metastatic disease to the lymphatic system post-radiation changes to the underlying skin structures or surgical removal of one or more lymphatic nodal basins.

- occurs from damage to the lymphatic system, commonly from cancer and its treatment but also from trauma to the skin such as from burns or infections. - Lymphedema after breast cancer has been studied the most - but lymphedema can occur as a result of other cancers, including melanoma, gynecologic cancer, head and neck cancer or sarcoma.

PREVENTION
Make sure that all injections are given and blood tests are drawn in the unaffected arm. Avoid wearing nightgowns or clothing with elastic cuffs. Carry your handbag or heavy packages in the unaffected arm. Use an electric shaver when shaving underarms.

 Avoid sunburns and other burns to the affected arm. Make sure that all blood pressure tests are performed on the unaffected arm. Wear gloves when gardening and when using strong household detergents. Clean the skin of the affected arm daily and apply lotion. When drying the arm, be gentle, but thorough. Keep the arm elevated when possible.

 Keep the arm elevated when possible Do exercises regularly to improve drainage, but first consult with your physician or physical therapist. Eat a well-balanced, low-sodium diet. Avoid extreme hot or cold temperatures on the affected arm, such as heating pads or ice packs Take proper care of the fingernails and avoid cutting cuticles.

 Clean all cuts with soap and water, and then apply anti-bacterial ointment and a sterile dressing. Protect your fingers from needle pricks and sharp objects. Use a thimble when sewing. Avoid vigorous, repetitive movements against resistance (such as scrubbing, pulling, or pushing) with the affected arm. Notify your physician immediately of any signs of infection, such as redness, pain, heat, increased swelling, or fever.

NURSING CARE of SURGICAL CLIENTS

PREOPERATIVE CARE
Ensure that information is presented in an understandable format Support autonomous decision making while reducing the overwhelming nature of the experience. Make every effort to be present for the initial discussion between the physician and the client and the family

 clarify any misconceptions the client and family members may have. Ensure that the woman or family member signs informed consent form. Teach deep-breathing exercises a day before the surgery. Ensure that the woman or family member signs informed consent form. Teach deep-breathing exercises a day before the surgery.

INTRAOPERATIVE CARE
Ensure that suction apparatus will be placed in the wound to allow drainage of excess body fluids that accumulate when the lymph nodes are removed. An IV line may be in place for fluid replacement and antibiotics to reduce the risk of postoperative infection.

 Control pain by using the patient-controlled analgesia device or requesting analgesics before pain becomes severe.. Numbness or feelings of pins and needles in the axillary are common. Lying on ones back or on the side not operated on helps fluid drain from the site

POSTOPERATIVE CARE
Note any signs of bleeding on the dressing or on the bedding. Instruct to move the arm on the operated side to help regain mobility; specific exercises will be prescribed for increasing mobility after the incisions have healed Advise to avoid lifting heavy objects with the arm on the operated side.

 Instruct to be careful about injury and infection on the affected side. Request that caregiver should not perform blood pressures or venipunctures on the operative side to reduce the risk of injury and infection. Discuss potential sexual problems with ones partner, with a counselor, or with a breast cancer support group.