MASTECTOMY SURGICAL REMOVAL OF BREASTS

Simple mastectomy is the surgical removal of one or both breasts. The adjacent lymph nodes and chest muscles are left intact. If a few lymph nodes are removed, the procedure is called an extended simple mastectomy. Breast-sparing techniques may be used to preserve the patient’s breast skin and nipple, which is helpful in cosmetic breast reconstruction.

Removal of a patient’s breast is usually recommended when cancer is present in the breast or as a prophylactic when the patient has severe fibrocystic disease and a family history of breast cancer. The choice of a simple mastectomy may be determined by evaluating the size of the breast, the size of the cancerous mass, where the cancer is located, and whether any cancer cells have spread to adjacent lymph nodes or other parts of the body. If the cancer has not been contained within the breast, it calls for a modified radical mastectomy, which removes the entire breast and all of the adjacent lymph nodes. Only in extreme circumstances is a radical mastectomy, which also removes part of the chest wall, indicated.

A larger tumor usually is an indication of more advanced disease and will require more extensive surgery such as a simple mastectomy. In addition, if a woman has small breasts, the tumor may occupy more area within the contours of the breast, necessitating a simple mastectomy in order to remove all of the cancer.

Very rapidlygrowing tumors usually require the removal of all breast tissue. Cancers that have spread to such adjacent tissues as the chest wall or skin make simple mastectomy a good choice. Similarly, multiple sites of cancer within a breast require that the entire breast be removed. In addition, simple mastectomy is also recommended when cancer recurs in a breast that has already undergone a lumpectomy, which is a less invasive procedure that just removes the tumor and some surrounding tissue without removing the entire breast.

Sometimes, surgeons recommend simple mastectomy for women who are unable to undergo the adjuvant radiation therapy required after a lumpectomy. Radiation treatment is not indicated for pregnant women, those who have had previous therapeutic radiation in the chest area, and patients with collagen vascular diseases such as scleroderma or lupus. In these cases, simple mastectomy is the treatment of choice.

Finally, some women, with family histories of breast cancer and who test positive for a cancer-causing gene, choose to have one or both of their breasts removed as a preventative for future breast cancer. This procedure is highly controversial. Though prophylactic mastectomy reduces the occurrence of breast cancer by 90% in highrisk patients, it is not a foolproof method. There has been some incidence of cancer occurring after both breasts were removed.

Demographics
According to the American Cancer Society in 2003, it was estimated that more than 260,000 new cases of breast cancer in women would occur that year. New cases of breast cancer in men were expected to reach 1,300. Rates of incidence have increased since 1980, due in part to the aging of the population. During the 1990s, breast cancer incidence increased only in women age 50 and over.

For approximately 80% of women, the first indication of cancer is the discovery of a lump in the breast, found either by themselves in a monthly self-exam or by a partner or by a mammogram, a special x ray of the breast that looks for anomalies in the breast. Early detection of breast cancer means that smaller tumors are found that require lessintensive surgery and better treatment outcomes. Simple mastectomy has been the standard treatment of choice for breast cancer for the past 60 years. Newer breast-conserving surgery techniques have been gaining in acceptance since the mid-1980s. For larger hospitals, facilities in urban areas, and health care institutions with a cancer center or high cancer patient volume, these newer techniques are being utilized at a more rapid rate, especially on the East Coast.

Interestingly, though, the National Cancer Institute found in 2003 that American women were 21% more likely to have a mastectomy than their counterparts in the United Kingdom. Though breast-conserving procedures are available and have proven to be viable options, some physicians and women still think breast removal will also remove all of their risk of cancer recurrence. It is clear that treatment options for cancer are highly individual and often emotionally charged.

Description
Simple mastectomy is one of several types of surgical treatments for breast cancer. Some techniques are rarely used; others are quite common.
These common surgical procedures include:
• Radical mastectomy is rarely used, and then only in cases where cancer cells have invaded the chest wall and the tumor is very large. The breast, muscles under the breast, and all of the lymph nodes are removed. This produces a large scar and severe disability to the arm nearest the removed breast.
• Modified radical mastectomy was the most common form of mastectomy until the 1980s. The breast is removed along with the lining over the chest muscle and all of the lymph nodes.
• Simple, sometimes called total, mastectomy has been the treatment of choice in the late 1980s and 1990s. Generally, only the breast is removed; though, sometimes, one or two lymph nodes may be removed as well.
• Partial mastectomy is used to remove the tumor, the lining over the chest muscle underneath the tumor, and a good portion of breast tissue, but not the entire breast. This is a good treatment choice for early stage cancers.
• Lumpectomy just removes the tumor and a small amount of tissue surrounding it. Some lymph nodes may be removed as well. This procedure is gaining acceptance among surgeons and patients alike.

Two other surgical procedures are variations on the simple mastectomy. The skin-sparing mastectomy is a new surgical procedure in which the surgeon makes an incision, sometimes called a keyhole incision, around the areola. The tumor and all breast tissue are removed, but the incision is smaller and scarring is minimal. About 90% of the skin is preserved and allows a cosmetic surgeon to perform breast reconstruction at the same time as the mastectomy. The subcutaneous mastectomy, or nipple- sparing mastectomy, preserves the skin and the nipple over the breast.

During a simple mastectomy, the surgeon makes a curved incision along one side of the breast and removes the tumor and all of the breast tissue. A few lymph nodes may be removed. The tumor, breast tissue, and any lymph nodes will be sent to the pathology lab for analysis. If the skin is cancer-free, it is sutured in place or used immediately for breast reconstruction. One or two drains will be put in place to remove fluid from the surgical area. Surgery takes from two to five hours; it is longer with breast reconstruction.