Mastectomy

Encyclopedia of Medicine by Ellen S. Weber

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Definition

Mastectomy is the surgical removal of the breast for the treatment or prevention of breast cancer.

Purpose

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.

Precautions

The decision to have mastectomy or lumpectomy should be carefully considered. It is important that the woman be fully informed of all the potential risks and benefits of different surgical treatments before making a choice.

Description

There are several types of mastectomies. The radical mastectomy, also called the Halsted mastectomy, is very rarely performed today. It was developed in the late 1800s, when it was thought that more extensive surgery was most likely to cure cancer. A radical mastectomy involves removal of the breast, all surrounding lymph nodes up to the collarbone, and the underlying chest muscle. Women were often left disfigured and disabled, with a large defect in the chest wall and significantly decreased arm sensation and motion. Unfortunately, and inaccurately, it is still the operation many women picture, when the word mastectomy is mentioned.

Surgery that removes breast tissue and some axillary or underarm lymph nodes and leaves the chest muscle intact is usually called a modified radical mastectomy. This is the most common type of mastectomy performed in the 1990s. The surgery leaves a woman with a more normal chest shape than the older radical mastectomy procedure, and a scar which is not visible in most clothing. It also allows for immediate or delayed breast reconstruction.

In a simple mastectomy, only the breast itself is removed. If a few of the axillary lymph nodes closest to the breast are also taken out, the surgery may be called an extended simple mastectomy.

There are other variations on the term mastectomy. A skin-sparing mastectomy uses special techniques that preserve the patient's breast skin for use in reconstruction. Total mastectomy is a confusing expression, as it may be used to refer to a modified radical mastectomy or a simple mastectomy.

A mastectomy is typically performed in a hospital setting, but specialized outpatient facilities are sometimes used. The surgery is done under general anesthesia. The type and location of the incision may vary according to plans for reconstruction or other factors, such as old scars. As much breast tissue as possible is removed. Axillary lymph nodes are taken out if they were not removed with biopsy. Approximately 10-15 nodes are usually removed. All tissue is sent to the pathology laboratory for analysis. If no immediate reconstruction is planned, surgical drains are left in place to prevent fluid accumulation. The skin is sutured, and bandages are applied.