In medicine, mastectomy is the medical term for the surgical
removal of one or both breasts, partially or completely.
Mastectomy is usually done to treat breast cancer; in some cases,
women and some men believed to be at high risk of breast cancer
have the operation prophylactically, that is, to prevent cancer
rather than treat it. It is also the medical procedure carried out
to remove breast cancer tissue in males. Alternatively, certain
patients can choose to have a wide local excision, also known as a
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,
targeting the area of the tumor, as opposed to systemic therapies
such as chemotherapy, hormonal therapy, or immunotherapy.
Traditionally, in the case of breast cancer, the whole breast was
removed. Currently the decision to do the mastectomy is based on
various factors including breast size, number of lesions, biologic
aggressiveness of a breast cancer, the availability of adjuvant
radiation, and the willingness of the patient to accept higher
rates of tumor recurrences after lumpectomy and radiation. Outcome
studies comparing mastectomy to lumpectomy with radiation have
suggested that routine radical mastectomy surgeries will not
always prevent later distant secondary tumors arising from
micro-metastases prior to discovery, diagnosis, and operation
Mastectomy indications
Despite the increased ability to offer breast-conservation
techniques to patients with breast cancer, there exist certain
groups who may be better served by traditional mastectomy
procedures including:
women who have already had radiation therapy to the affected
breast
women with 2 or more areas of cancer in the same breast that are
too far apart to be removed through 1 surgical incision, while
keeping the appearance of the breast satisfactory
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 fetus)
women with a tumor larger than 5 cm (2 inches) that doesn't
shrink very much with neoadjuvant 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
There are a variety of types of mastectomy in use, and the type
that a patient decides to undergo (or whether he or she will
decide instead to have a lumpectomy) depends on factors such as
size, location, and behavior of the tumor (if there is one),
whether or not the surgery is prophylactic, and whether or not
the patient intends to undergo reconstructive surgery.
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 into—is
removed. This surgery is sometimes done bilaterally (on both
breasts) on patients who wish to undergo mastectomy as a
cancer-preventative measure. Patients who undergo simple
mastectomy can usually leave the hospital after a brief stay.
Frequently, a drainage tube is inserted during surgery in their
chest and attached to a small suction device to remove
subcutaneous fluid. These are usually removed several days after
surgery as drainage decrease to less than 20-30 ml per day.
Modified radical mastectomy: The entire breast tissue is
removed along with the axillary contents (fatty tissue and lymph
nodes). In contrast to a radical mastectomy, the pectoral
muscles are spared.
Radical mastectomy (or "Halsted mastectomy"): First
performed in 1882, this procedure involves removing the entire
breast, the axillary lymph nodes, and the pectoralis major and
minor muscles behind the breast. This procedure is more
disfiguring than a modified radical mastectomy and provides no
survival benefit for most tumors. This operation is now reserved
for tumors involving the pectoralis major muscle or recurrent
breast cancer involving the chest wall.
Skin-sparing mastectomy: In this surgery, the breast
tissue is removed through a conservative incision made around
the areola (the dark part surrounding the nipple). The increased
amount of skin preserved as compared to traditional mastecomy
resections serves to facilitate breast reconstruction
procedures. Patients with cancers that involve the skin, such as
inflammatory cancer, are not candidates for skin-sparing
mastectomy.
Nipple-sparing/subcutaneous mastectomy: Breast tissue is
removed, but the nipple-areola complex is preserved. This
procedure was historically done only prophylactically or with
mastecomy for benign disease over fear of increased cancer
development in retained areolar ductal tissue. Recent series
suggest that it may be an oncologically sound procedure for
tumors not in the subareolar position.
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