Mastectomy

Breast cancer is the second most common malignancy in women in the

United States, only second in recent years to lung cancer. About 20% of
breast masses that are palpated (felt) end up being malignant in origin..

Anatomy

Figure 1 -
Anatomy of the
breast in a cross-
section through
the nipple.
 The breast is composed of a tissue made up of many glands
extending from the clavicle (collarbone), to the axilla (armpit), to
the fascia of the pectoralis muscle, and toward the arch or the
ribs. Lactiferous (milk) ducts of the breast form buds that become
15 to 20 lobules of glandular tissue. The function of the ducts is
to secrete milk, which travels to the nipple in a radial fashion
 The blood supply to the breast is from branches of the axillary
and internal thoracic (mammary) arteries. These vessels enter
the breast in a radial pattern
 Blood drains from the breast from branches of the axillary,
internal thoracic, lateral thoracic, and the posterior intercostal
veins
 Lymph is a tissue fluid similar in composition to dilute plasma.
Drainage of lymph from the breast is illustrated in figure 2.

 Figure 2 - Lymph
drainage from
the right breast.
 About 75% of the lymphatic drainage are to the axillary nodes.
Cancer cells tend to move along the lymphatic drainage and be
trapped in the lymph nodes. Lymph eventually drains into the
veins

Pathology

Most breast masses in women are benign. These include cysts,

fibroadenomas, abscesses, and papillomas

 Breast cysts are relatively common, especially in women

between the ages of 25 and 50, but are rare in post-menopausal
women. The cysts are fluid filled cavities that are hormone
dependent. Many women find that the cysts are influenced by
their menstrual cycle
 Fibroadenomas are the most common benign breast tumors in
women. They occur in premenopausal women, and are
composed of a solid mass of fibrous tissue
 Breast abscesses are infected pockets of pus that usually occur
around the nipple and areola. They are treated with antibiotics
and incision and drainge if necessary
 A papilloma is a benign polyp in a breast duct. It is usually
located underneath the nipple, and causes a bloody nipple
discharge

Breast cancers are described as either being in-situ (remaining in place)

or invasive, and as being ductal (from the duct tissue) or lobular (from the
lobules)

 Ductal carcinoma in situ arises in the epithelial (surface cell)

lining of the ducts of the breast. It does not invade into the
surrounding tissue. There are various classifications of these
 tumors including cribiform, papillary, and comedo, depending on
the histologic description. These tumors frequently present as
microcalcifications (small flecks of calcium) on a mammogram,
but can also be palpated as a mass. Treatment options include a
lumpectomy with or without radiation treatment, or a mastectomy
 Lobular carcinoma in situ (LCIS)is usually found incidentally on a
biopsy, as it does not produce a mass that can be palpated or
cause an abnormality on a mammogram. It is usually multicentric
(originates in several places) and in both breasts. Women with
LCIS have a high risk of developing invasive carcinoma in the
future. The only surgical option for LCIS is bilateral
mastectomies, However, all patients with LCIS do not progress
to invasive cancer, therefore most women choose to have
repeated screening and observation
 Infiltrating ductal carcinoma is the most frequent malignant
breast cancer. It originates in the ductal epithelium. It can
present as a palpable mass, skin dimpling, nipple retraction, and
often has mammographic abnormalities. Treatment options
include lumpectomy with radiation treatment or mastectomy.
Inflammatory breast carcinoma is an aggressive form of
infiltrating ductal carcinoma. It produces a painful, red breast with
a palpable mass and swelling making the skin look like an
orange peel (peau d'orange skin). This may clinically appear like
mastitis, an infection of the breast. The diagnosis is made by
biopsy. This cancer has usually already metastasized at the time
of diagnosis, and requires aggressive surgical and
chemotherapeutic treatment. Despite aggressive treatment, the
long term prognosis is still poor
 Invasive lobular carcinoma originates in the epithelium of the
lobules. It behaves similarly to invasive ductal carcinoma

Diagnosis

 Women between the ages of 35-50 should obtain a baseline

mammogram. Women over the age of 50 are advised to have
yearly mammograms. All women over the age of 18 are
instructed to do monthly self-breast exams (Figure 4) with a
yearly clinical exam by a physician. Any abnormalities on a
breast exam or mammogram need to be discussed with a
physician

Breast Self Exam

(from American
Cancer Society)
http://www.cance
r.org
1. Put a pillow under
your right shoulder
and place your right
arm behind your head.

2. Using the top third

of your three left
middle fingers, press
firmly to feel for lumps
in your right breast.

3. Move your fingers

around the breast in
either the Circle (a),
the Up and Down Line
(b), or the Wedge (c)
method. Make sure
you cover the entire
breast area.
 4. Place the pillow
under your left
shoulder. Now
examine your left
breast using the same
method with your
three right middle
fingers.

5. If you find any

changes, see your
doctor right away.
Figure 4
 A suspicious area on mammography (Figure 3A) or abnormality
on breast examination may be investigated in several ways
 Figure 3a -
Mammogram
showing a tumor.
- C. Yutzy, M.D.
 An ultrasound of the breast can determine if the palpable mass is
cystic in nature. Most cystic breast masses are benign and can
be followed by a physician or aspirated to remove the fluid from
the cyst. Only about 1% of cystic masses is malignant
 A fine needle aspiration (FNA) can be carried out. This
procedure is done in the physician's office. The skin is
anesthetized with a local anesthetic, then several samples are
aspirated using a thin needle. A pathologist then examines the
samples. The accuracy of FNA is about 89-98%. The false
negative rate(i.e. not read as cancer when cancer was really
present) is 2-11%. The false positive rate (i.e. read as cancer
when it really was not there) is 1-3%
 Palpable breast masses or abnormalities on a mammogram can
be investigated using a stereotactic (computer localized) core
biopsy. This procedure is usually done in the radiology
department. The skin is anesthetized with local anesthesia. A
larger needle is used to obtain the specimen. The entire
procedure takes about one hour. A pathologist then examines
the specimen. This method has the advantage over FNA of using
a larger needle therefore obtaining a larger specimen. Also it can
be done for lesions that are not palpable and only seen on
mammography
 The most accurate method of investigating a breast lesion is by
excisional biopsy. This procedure must be done in the operating
room by a surgeon. It is useful for mammographic abnormalities
and also palpable lesions
 For non-palpable lesions detected by mammogram, a thin
needle is placed just prior to the operation (Figure 3B)
 Figure 3b -
Tumor localized
by insertion of a
fine needle. - C.
Yutzy, M.D.

 This needle is placed by a radiologist into or near the area to be

biopsied. The needle serves as a guide for the surgeon to the
location of the abnormal tissue seen on the mammogram. This
needle localization is not needed for palpable masse.
 In the operating room, most women receive sedation through an
intravenous needle and a local anesthetic injected into the
breast. The patient is awake, but does not feel the surgery.
Some women, however, prefer to be put to sleep with a general
anesthetic
 During the operation, the surgeon will make an incision near the
area of the breast abnormality. With needle localization, the
surgeon removes the breast tissue around the area of the
needle. The specimen will then be mammogrammed to be sure
the suspicious area has been removed (Figure 3C)
 Figure 3c -
Tumor
localization
confirmed by
mammograp
hy of the
specimen. -
C. Yutzy, M.D.

 If there is a palpable mass, the surgeon will remove this mass. A

pathologist then examines all specimens
 An excisional biopsy will leave a scar on the breast and can be
associated with complications such as infection and hematoma

Surgical Treatment

A patient with the diagnosis of breast cancer has several different

treatment options available.

 A lumpectomy (Figure 5) removes the area with the cancer

surrounded by a rim of normal tissue. It is technically similar to
an excisional biopsy. It is appropriate for early stage breast
cancer, and is usually combined with an axillary lymph node
removal on the same side as the cancer. The pathologist then
examines the lymph nodes for any spread of the cancer.
 Figure 5 -
Lumpecto
my
o Removing the lymph nodes is done to determine the
severity of the cancer and to help direct any further
treatment such as chemotherapy. Most women have a
general anesthetic for the procedure
o Following surgery most women have two incisions, one
for the axillary node dissection and one for the
lumpectomy. Also, most women will have a drain in the
axilla that is removed in the surgeon's office
o Complications of the axillary node dissection include
bleeding/hematoma, nerve damage, and chronic arm
swelling from lymphedema. Lumpectomy and axillary
node dissection usually requires radiation therapy after
the surgery.
o Studies have shown that this method of treatment for
early stage breast cancer has no survival difference, or
disease free survival difference from a more radical
mastectomy
 A modified radical mastectomy (Figure 6) removes the entire
breast with nipple and areola, overlying skin, and axillary lymph
nodes. It is used for early or late stage breast cancer. The lymph
nodes are removed to determine if the cancer has spread to the
nodes, and the need for additional treatment
 Figure 6 -
Modified
radical
mastectomy
o This procedure is done in the operating room, and
requires a general anesthetic. An elliptical incision is
made in the breast, extending about 5-7.5 cm beyond
the tumor. The incision extends into the axilla to allow
the axillary node dissection
o The breast tissue including the nipple and areola are
removed by dissecting the tissue off of the underlying
pectoralis major muscle.
o An axillary node dissection is then carried out removing
the nodes along the axillary vein down to the latissimus
dorsi muscle with care to preserve the long thoracic
nerve and thoracodorsal nerve
o Following removal, a pathologist examines the breast
and lymph nodes. Depending on the extent of the tumor,
radiation, and/or chemotherapy may be needed following
surgery. For very advanced cancers, chemotherapy
and/or radiation therapy may be advised before
undergoing surgery
o After the surgery patients need to be in the hospital for
1-2 days. Patients may also have 1-2 drains in place,
which the surgeon will remove in the office. These drains
are to prevent fluid collections underneath the skin,
which may become infected or lead to skin damage
 Some patients that have had a mastectomy elect to have breast
reconstruction. This procedure can be done at the time of the
mastectomy or later. The surgery is usually carried out by a
plastic surgeon. Reconstruction can be done by placing a breast
implant, or by reconstructing the breast using muscle from the
abdomen
 A recent alternative to axillary node dissection is sentinel lymph
node biopsy. This technique is based on the fact that the cancer
drains to one primary lymph node first, then spreading to further
lymph nodes. Therefore if the primary or sentinel lymph node is
negative for malignancy, then the cancer has not spread to the
axilla
o This is done in the operating room combined with a
lumpectomy. The tumor is injected either with dye and/or
 a radioactive material. The material then drains to the
lymph node. The first lymph node that receives the
material is the sentinel lymph node, which is then
removed
o A pathologist examines the lymph node. If the lymph
node is negative, no axillary lymph node dissection is
needed. If the sentinel lymph node is positive for cancer,
then an axillary lymph node dissection is done to
determine the extent of lymph node spread. This
technique is relatively new and may not be performed by
every surgeon

Complications

Possible complications of a mastectomy are

 bleeding/hematoma
 seroma/fluid collection
 nerve damage
 chronic arm swelling from lymphedema
 infection
 skin breakdown

After surgery

After surgery your surgeon may recommend that an oncologist, a

physician who is a cancer specialist, see you. The oncologist may
recommend a program of chemotherapy and radiation.

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