Mastectomy - An Overview

Introduction:

Mastectomy is a surgical procedure done to remove the tissues of the breast. It is done in the treatment of breast cancer. The word mastectomy derives from the Greek word mastos, representing the female breast, and the Latin phrase ectomia, meaning removal or excision off.

The mastectomy procedure is divided into partial, simple, radical, and radically modified. Varieties of mastectomy deduct a portion of the tissue of the breast, and few procedures in mastectomy are more expensive. The surgeon decides the variety of this procedure based on the cause of the process. Different interpretations of the procedure involve skin-sparing and nipple-areola-sparing procedures. They are the procedures that are usually done after breast reconstruction.

What Are the Anatomical and Physiological Considerations in Mastectomy?

• The location of the breast is on the front wall of the thorax and overlays the major pectoralis muscle. The adult female breast's upper boundary approaches the second or third level of the rib and then expands lower to the crease. The sternal boundary is the median border, and the breast advances to the mid-axillary line laterally. About the breast, two-thirds overlap the major pectoralis muscle, and the remaining portion overlaps the serratus anterior and top area of the oblique abdominal muscles. The top area of the breast expands towards the top and laterally, that is, to the axilla, and it is referred to as the axillary tail of Spence. The breast splits into four types of quadrants. This helps in the examination and documentation of findings on breast imaging too. The four segments are upper internal, upper outermost, lower internal, and lower outward. Most of the tissues of the breast are present in the top outer quadrant, which involves the axillary tail of the Spence. Thus, it is a common site for breast cancer.

• The components of the breast include tissues of the mammary gland, which is wrapped by subcutaneous fat and skin and has external and deep fascial layers. The layers present superficially to the fascia are deep to the dermis, wrap the breast in the front region, and then advance towards the breast medially and laterally. The layer deep into the superficial fascia wraps the surface posteriorly to the breast and is situated to the pectoralis major fascia anteriorly. Suspensory ligaments of Cooper are bands of connective tissue that advance from the in-depth layer of superficial fascia, extend through the parenchyma of the breast, and enter perpendicularly into the dermis. Here in this area, the ligaments are weak, which is responsible for the ptosis of the breast. The tissue of the breast comprises epithelial parenchyma and tissues of the stroma. The epithelium component includes about ten to fifteen percent of the total volume of the breast, and the rest comprises the elements of the stroma. This stroma is created from around fifteen to twenty lobes, which are again split into lobules in twenty to forty numbers. Lobules are composed of diverged tubuloalveolar glands. The area between these lobes comprises adipose tissue. This lobe secretes into a main lactiferous vent that expands to the nipple.

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• Blood Supply to the Breast- The median part of the breast is supplied by the internal mammary artery providing diverse perforating units. The lateral part of the breast is supplied by the posterior intercostal vessels, lateral branches, and units of the axillary artery, which also involves the sidewards thoracic artery and pectoral units of the thoracoacromial artery. The arteries and veins cover the superior and lateral barrier of the muscle pectoralis to reach the breast.

• Venous Supply- It follows the arterial supply and is towards the axilla. The main venous supply is the perforating units of the internal thoracic vein, branches of the axillary vein, and posteriorly perforating units of the intercostal veins. Understanding the venous supply is important, as the lymphatic supply also follows the blood vessel for its supply. This lymphatic supply is very crucial as metastasis of cancer occurs through the lymph and veins network.

• Lymphatic Drainage- It is through the axilla in most cases. Lymph nodes found in the pectoralis minor laterally or downside are called Level I, which contains the outer mammary, a vein of the axilla, and scapular lymph node classes. Level II lymph nodes are situated in the pectoralis minor muscle deeply and have the central lymph node group and maybe a part of the subclavicular nodes.

Level III nodes are located in the upper border of the pectoralis minor muscle medially and superiorly and have the subclavicular lymph nodes. The Rotter's nodes supply into the central or subclavicular node groups describing a skip pathway for the cells to metastasize to these lymph nodes. Additional lymphatic drainage areas include the internal mammary chain, the intramammary regions laterally and medially, the interpectoral area, and the subclavicular lymph node.

What Are the Indications of Mastectomy?

• Malignancy of the breast, the central management of breast cancer, can be combined with neoadjuvant or adjuvant treatment involving radiation therapy, chemotherapy or hormone antagonist drugs, or a mixture of these. Characteristics of the tumor, including size and location, are important in deciding the treatment procedure. The survival rate is comparable in patients with mastectomy or lumpectomy and radiation therapy.

• Paget's breast disease is not a common presentation of breast cancer; in this, neoplastic cells are in the epidermis of the nipple-areolar complex. The disorder may stay on this site. Complete mastectomy with biopsy in the axillary sentinel nodes was the classic method for the treatment of Paget's disease. Major lumpectomy with a total reduction of the nipple-areolar complex is better for controlling this condition in patients without cancer in the other locations of the breast if done with radiation therapy.

• Patients who have done surgeries like lumpectomy or partial mastectomy and tumor cell involvement may be viewed for a mastectomy.

• In certain cases, mastectomy is done as a prophylaxis measure for patients with no malignancy.

What Are the Contraindications of Mastectomy?

Mostly this procedure is done safely and effectively. The factors that cause contraindications of mastectomy include systemic and locoregional factors.

• It is not indicated in patients with distant metastasis.

• This procedure is contraindicated in older patients with consequential medical co-morbidities and disorders in the organ.

• Patients with an expected elevated chance of mortality with surgery and anesthesia.

• In patients with progressive locoregional disease, In these cases, neoadjuvant therapy with chemotherapy, radiation therapy, or endocrine therapy is done to decrease the measurement of disorder and prefer surgery.

Conclusion:

Numerous important advancements have been made in treating breast cancer since Halsted first defined radical surgery in the late 1800s. More measures are identified for breast preservation, and multiple studies are going on to check the effectiveness of preserving surgery approximated with classic mastectomy procedures. Along with supportive measures like radiation and systemic therapy with chemotherapy and endocrine treatment, the pace of mastectomy has reduced.