OR WRITE-UP Pts. Profile: Mr.

Romulo Aban Corpus ,male, age 63, from 216 new site bakakeng , baguio city, came in for surgery. The procedure to be performed is mastectomy. His surgeon is Dr. Pablo Candelario ; anesthesiologist is Dr. Noel Delizo. His operation started at 7:55am and ended at around 9:00am , it went well without any complications and not causing any distress for the patient.

Pathophysiology
BREAST CANCER

Etiology/ Cause cancer is a general name given to a large group of dieases characterized by: a)uncontrolled growth and spread of abnormal cells b) proliferation (rapid reproduction by cell division) c) metastasis (spread or transfer of cancer cells from one organ or part to another) -cause is unkown: predisposing factors include family history, high fat diet, -low level ionizing radiation (more common in women than in men)

clinical manifestations -a non tender lump, usually in an upper outer quadrant -axillary lymph adenopathy (late) -fixed nodular breast mass (late) -discharge -edema of the arm

Diagnosis: -mammography -needle biopsy -surgical biopsy

Treatment : -mastectomy - lumpectomy -radiation therapy -chemotherapy including cyclophosphamide

Anatomy of the organ involved

Reconstructive surgery
After having a mastectomy (or some breast-conserving surgeries), a woman may want to consider having the breast mound rebuilt; this is called breast reconstruction. These procedures are not done to treat cancer but to restore the breast's appearance after surgery. If you are going to have breast surgery and are thinking about having reconstruction, it is important to consult with a plastic surgeon who is an expert in breast reconstruction before your surgery.

Decisions about the type of reconstruction and when it will be done depend on each woman's medical situation and personal preferences. You may have a choice between having your breast reconstructed at the same time as the mastectomy (immediate reconstruction) or at a later time (delayed reconstruction). There are several types of reconstructive surgery. Some use saline (salt water) or silicone implants, while others use tissues from other parts of your body (autologous tissue reconstruction). For a discussion of the different reconstruction options, see our document, Breast Reconstruction After Mastectomy. You may also find it helpful to talk with a woman who has had the type of reconstruction you might be considering. Our Reach to Recovery volunteers can help you with this.

Discussion of the procedure

For many, the thought of surgery can be frightening. But with a better understanding of what to expect before, during, and after the operation, many fears can be relieved. Before surgery: The common biopsy procedures let you find out if you have breast cancer within a few days of your biopsy, but the extent of the breast cancer will not be known until after imaging tests and the surgery for local treatment are done. Usually, you meet with your surgeon a few days before the operation to discuss the procedure. This is a good time to ask specific questions about the surgery and review potential risks. Be sure you understand what the extent of the surgery is likely to be and what you should expect afterward. If you are thinking about breast reconstruction, ask about this as well. You will be asked to sign a consent form, giving the doctor permission to perform the surgery. Take your time and review the form carefully to be certain that you understand what you are signing. Sometimes, doctors send material for you to review in advance of your appointment, so you will have plenty of time to read it and won't feel rushed. You may also be asked to give consent for researchers to use any tissue or blood that is not needed for diagnostic purposes. Although this may not be of direct use to you, it may be very helpful to women in the future. You may be asked to donate blood before some operations, such as a mastectomy combined with natural tissue reconstruction, if the doctors think a transfusion might be needed. You might feel more secure knowing that if a transfusion is needed, you will receive your own blood. If you do not receive your own blood, it is important to know that in the United States, blood transfusion from another person is nearly as safe as receiving your own blood. Ask your doctor about your possible need for a blood transfusion. Your doctor will review your medical records and ask you about any medicines you are taking. This is to be sure that you are not taking anything that might interfere with the surgery. For example, if you are taking aspirin, arthritis medicine, or a blood-thinning drug (like coumadin), you may be asked to stop taking the drug about a week or 2 before the surgery. Be sure you tell your doctor about everything you take, including vitamins and herbal supplements. Usually, you will be told not to eat or drink anything for 8 to 12 hours before the surgery, especially if you are going to have general anesthesia (will be asleep during surgery). You will also meet with the anesthesiologist or nurse anesthetist, the health professional who will be giving you the anesthesia during your surgery. The type of anesthesia used depends largely on the kind of surgery being done and your medical history. Surgery: Depending on the likely extent of your surgery, you may be offered the choice of an outpatient procedure (where you go home the same day) or you may be admitted to the hospital. General anesthesia is usually given whenever the surgery involves a mastectomy or an axillary node dissection, and is most often used during breast-conserving surgery as well. You will have

an IV (intravenous) line put in (usually in a vein in your arm), which the medical team will use to give medicines that may be needed during the surgery. Usually you will be hooked up to an electrocardiogram (EKG) machine and have a blood pressure cuff on your arm, so your heart rhythm and blood pressure can be checked during the surgery. The length of the operation depends on the type of surgery being done. For example, a mastectomy with axillary lymph node dissection will usually take from 2 to 3 hours. After your surgery, you will be taken to the recovery room, where you will stay until you are awake and your condition

After surgery: How long you stay in the hospital depends on the type of surgery being done, your overall state of health and whether you have any other medical problems, how well you do during the surgery, and how you feel after the surgery. Decisions about the length of your stay should be made by you and your doctor and not dictated by what your insurance will pay, but it is important to check your insurance coverage before surgery.

An incision in the shape of an ellipse. OVERVIEW OF MRM PROCEDURE: 1.) An incision in the shape of an ellipse is made. (Incisions are made to avoid visibility in a low neckline dress or bathing suit.) 2.) The surgeon removes the minimum amount of skin and tissue so that remaining healthy tissue can be used for possible reconstruction. 3.) Skin flaps are made carefully and as thinly as possible to maximize removal of diseased breast tissues. 4.) The skin over a neighboring muscle (pectoralis major fascia) is removed, after which the surgeon focuses in the armpit (axilla, axillary) region. 5.) In this region, the surgeon carefully identifies vital anatomical structures such as blood vessels (veins, arteries) and nerves.

(Accidental injury to specific nerves like the medial pectoral neurovascular bundle will result in destruction of the muscles that this surgery attempts to preserve, such as the pectoralis major muscle.) 6.) In the armpit region, the surgeon carefully protects the vital structures while removing cancerous tissues. 7.) After the surgeon completes the mastectomy, two plastic tubes each about the width of a pen are gently sewn into place to draw off fluids. The ends of these drains are attached to a pocket-sized suction device. Nursing responsibility: Monitoring of the drains and drainage until the drains are removed 8.) After axillary surgery, breast reconstruction can be performed, if desired by the patient. Normal results If no complications develop, the surgical area should completely heal within three to four weeks. In general, women having a mastectomy and/or axillary lymph node dissection stay in the hospital for 1 or 2 nights and then go home. However, some women may be placed in a 23hour, short-stay observation unit before going home. Less involved operations such as lumpectomy and sentinel lymph node biopsy are usually done in an outpatient surgery center, and an overnight stay in the hospital is usually not needed. You may have a dressing (bandage) over the surgery site that may wrap snugly around your chest. You may have one or more drains (plastic or rubber tubes) coming out from the breast or underarm area to remove blood and lymph fluid that collects during the healing process. Your health care team will teach you how to care for the drains, which may include emptying and measuring the fluid and identifying problems the doctor or nurse needs to know about. Most drains stay in place for 1 or 2 weeks. When drainage has decreased to about 30 cc (1 fluid ounce) each day, the drain will usually be removed. Most doctors will want you to start moving your arm soon after surgery so that it won't get stiff.

Mastectomy

Mastectomy is surgery to remove the entire breast. All of the breast tissue is removed, sometimes along with other nearby tissues. Simple mastectomy: In this procedure, also called total mastectomy, the surgeon removes the entire breast, including the nipple, but does not remove underarm lymph nodes or muscle tissue from beneath the breast. Sometimes this is done for both breasts (a double mastectomy), especially when it is done as preventive surgery in women at very high risk for breast cancer. Most women, if they are hospitalized, can go home the next day. Skin-sparing mastectomy: For some women considering immediate reconstruction, a skinsparing mastectomy can be done. In this procedure, most of the skin over the breast (other than the nipple and areola) is left intact. This can work as well as a simple mastectomy. The amount of breast tissue removed is the same as with a simple mastectomy. This approach is only used when immediate breast reconstruction is planned. It may not be suitable for larger tumors or those that are close to the skin. Implants or tissue from other parts of the body are used to reconstruct the breast. This approach has not been used for as long as the more standard type of mastectomy, but many women prefer it because it offers the advantage of less scar tissue and a reconstructed breast that seems more natural. A variation of the skin-sparing mastectomy is the nipple-sparing mastectomy. This procedure is more often an option for women who have a small early stage cancer near the outer part of the breast, with no signs of cancer in the skin or near the nipple. In this procedure, the breast tissue is removed, but the breast skin and nipple are left in place. This is followed by breast reconstruction. The surgeon often removes the breast tissue beneath the nipple (and areola) during the procedure, to check for cancer cells. If cancer is found in this tissue, the nipple is involved with cancer and must be removed. Even when no cancer is found under the nipple, some doctors give the nipple tissue a dose of radiation during or after the surgery to try and reduce the risk of the cancer coming back. There are still some problems with nipple-sparing surgeries. Afterward, the nipple does not have a good blood supply, so sometimes it can wither away or become deformed. Because the nerves are also cut, there is little or no feeling left in the nipple. In women with larger breasts, the nipple may look out of place after the breast is reconstructed. As a result, many doctors feel that this surgery is best done in women with small to medium sized breasts. This procedure leaves less visible scars, but if it isn't done properly, it can leave behind more breast tissue than other forms of mastectomy. This could result in a higher risk of cancer developing in than for a skin-sparing or simple mastectomy. This was a problem in the past, but improvements in

technique have helped make this surgery safer. Still, many experts consider nipple-sparing procedures too risky to be a standard treatment of breast cancer. Modified radical mastectomy: This procedure is a simple mastectomy plus removal of axillary (underarm) lymph nodes. Surgery to remove these lymph nodes is discussed in further detail later in this section. Radical mastectomy: In this extensive operation, the surgeon removes the entire breast, axillary lymph nodes, and the pectoral (chest wall) muscles under the breast. This surgery was once very common, but it was found that a modified radical mastectomy was just as effective. This meant that the disfigurement and side effects of a radical mastectomy were not needed, so these surgeries are rarely done now. This operation may still be done for large tumors that are growing into the pectoral muscles under the breast. Possible side effects: Aside from post-surgical pain and the obvious change in the shape of the breast(s), possible side effects of mastectomy include wound infection, hematoma (buildup of blood in the wound), and seroma (buildup of clear fluid in the wound). If axillary lymph nodes are also removed, other side effects may occur (see the section, "Axillary lymph node dissection").

Instruments Used

A Deaver retractor (manual) is used to retract deep abdominal or chest incisions. Available in various widths.

A Richardson retractor (manual) is used to retract deep abdominal or chest incisions

Cutting and Dissecting Instruments

Are sharp and are used to cut body tissue or surgical supplies.

7 handle with 15 blade (deep knife) - Used to cut deep, delicate tissue. 3 handle with 10 blade (inside knife) Used to cut superficial tissue. 4 handle with 20 blade (skin knife) - Used to cut skin.

Straight Mayo scissors - Used to cut suture and supplies. Also known as: Suture scissors.

Curved Mayo scissors - Used to cut heavy tissue (fascia, muscle, uterus, and breast). Available in regular and long sizes.

Metzenbaum scissors (A) - Used to cut delicate tissue. Available in regular and long sizes.

Clamping and Occluding Instruments

Are used to compress blood vessels or hollow organs for hemostasis or to prevent spillage of contents. A hemostat is used to clamp blood vessels or tag sutures. Its jaws may be straight or curved. Other names: crile, snap or stat.

A mosquito is used to clamp small blood vessels. Its jaws may be straight or curved.

Grasping and Holding Instruments

Are used to hold tissue, drapes or sponges. An Allis is used to grasp tissue. Available in short and long sizes. A "Judd-Allis" holds intestinal tissue; a "heavy allis" holds breast tissue.

A Babcock is used to grasp delicate tissue (intestine, fallopian tube, ovary). Available in short and long sizes.

A Kocher is used to grasp heavy tissue. May also be used as a clamp. The jaws may be straight or curved. Other names: Ochsner.

DeBakey forceps are used to grasp delicate tissue, particularly in cardiovascular surgery

towel clips- for securing and holding towels in place.

Thumb forceps are used to grasp tough tissue (fascia, breast). Forceps may either have many teeth or a single tooth. Single tooth forceps are also called "rat tooth forceps."

Mayo-Hegar needle holders are used to hold needles when suturing. They may also be placed in the sewing category

Nipple-Sparing Mastectomy

Nipple-sparing mastectomy (NSM) has now entered the mainstream for both the treatment and prevention of breast cancer. It is not however, the standard of care for either. NSM in the past was known as subcutaneous mastectomy. In the 1970's, subcutaneous mastectomy was occasionally performed for fibrocystic disease, breast cancer prevention and less frequently for cancer. By the 1980's, reports of cancer occurring in the residual breast tissue led the procedure into disfavor. It was not until the last several years that this procedure was essentially reborn as nipple-sparing mastectomy. In examining the studies of subcutaneous mastectomy done in prior decades it was apparent that there were several problems that led to relatively poor results. Most importantly, most subcutaneous mastectomies of the 1970's were performed with a focus on cosmetics and less concern about removing a maximum amount of breast tissue. In many instances breast tissue was left behind intentionally to improve cosmetic results and to prevent necrosis (death) of the nipple. NSM is now usually performed by a surgical oncologist, breast surgeon or general surgeon with a focus on maximizing breast tissue removal, while still attempting to maximize the cosmetic outcome. The term "nipple-sparing mastectomy" now refers to a more radical removal of breast tissue than was carried out during the subcutaneous mastectomy era. There has never been a comparative study that compares nipple-sparing mastectomy with standard or standard skin-sparing mastectomy. A skin-sparing mastectomy preserves the breast skin but does not preserve the nipple. There are large series of skin-sparing mastectomies (SSM) that have been studied suggesting that results are likely similar to standard mastectomy techniques. However, as in NSM, no randomized comparative studies comparing SSM with standard mastectomy techniques have been carried out. At this time, there are no large studies of NSM followed for sufficient time to verify its ultimate safety. Because there are no studies to draw upon,

surrogate information must be used to make a judgment as to its appropriate use.

Pre OP Nipple-sparing mastectomy for cancer

Post OP

Without comparative studies, investigators have focused on the risk of finding occult (not diagnosable by examination or imaging studies) cancer cells in the nipple in women undergoing mastectomy for cancer. There have in fact been at least 13 studies which have looked at the incidence of occult nipple involvement by carefully examining the nipple under the microscope after its removal for cancer. Each study has slightly different results but there is some general agreement as to what factors lead to an increase in risk of occult nipple involvement. 1. Proximity of the cancer to the nipple: The closer the cancer is to the nipple the more likely cancer cells will be found in the nipple. Most investigators agree that at least 2 cm (a bit less than an inch) should separate the cancer from the nipple. Some investigators think that a 4cm distance is safer and utilize this distance in their recommendations. 2. Tumor size: As tumors increase in size, whether invasive or non-invasive (DCIS), the incidence of occult nipple involvement increases. Investigators differ on whether 3 or 4 cm should be the cutoff. 3. Lymph node involvement: A definite risk factor but not as significant as (1) or (2). 4. Multicentricity (cancer in more than one breast quadrant): This factor was not examined by all studies but was significant in those where it was studied. Nipple-sparing mastectomy for risk-reduction (prophylactic) Women undergo risk-reduction mastectomy for a variety of reasons including: 1. Test positive for a mutation in the BRCA 1/2 genes. 2. Strong family history of breast cancer without a positive genetic test. 3. Women undergoing mastectomy for cancer and wish to reduce their risk in the opposite breast. The issue in performing NSM for risk reduction centers around the milk ducts which exist in the nipple and the understandable concern that these ducts might serve as a source of new breast cancers. There are little in the way of actual studies which can support or deny that cancers actually arise in the ducts of the nipple. However, if one looks in the scientific literature, it will be difficult to find any studies which deal specifically with the risk of forming cancers in the nipple. (We are not speaking here about Paget's disease, which is cancer that has spread to the nipple from an underlying site in the breast.) Because cancers originating in the nipple have not been reported in the cancer literature, it seems reasonable to conclude that cancer originating in the nipple is rare or at the least, unusual. The low risk of nipple cancers may be at least partially explained by examining the actual anatomic origin of breast cancer. From very scholarly studies carried out in the 1970's, it has been discovered that virtually all breast cancers begin not in the large milk ducts similar to the ones found in the nipple but in the small microscopic ducts and milk-producing areas of the breast (lobules). A study publish by our group in 2008 in the Annals of Surgical Oncology examined this very question. We studied the nipple anatomy in patients undergoing mastectomy in which the nipple was removed. Our

study found that the small ducts and lobules in which breast cancer arises were rare in the nipple. In the very few cases in which lobules were found, there were few in number and found only at the junction of the nipple with the underlying breast tissue and not near the tip of the nipple. From this study it seemed reasonable to conclude that because the anatomic structures needed to form a breast cancer were rare in the nipple, that cancer originating in the nipple should also be rare.

Technical Issues Surgical complications related to nipple-sparing surgery are not unusual. The ability to get oxygen to the remaining breast skin is related to blood supply. The blood supply to the nipple and areola is particularly tenuous following NSM. Necrosis (tissue death) of the nipple-areola has been noted in virtually all reported series. It appears to vary from a high near 20% to a low of 2-3%. Many factors likely account for the differences including experience of the surgical team, choice of incision, breast size (increase risk in larger breasts) and on how effectively breast tissue is removed from behind the nipple and areola. In some circumstances, necrosis can occur to only the most superficial layers of the skin and complete healing usually occurs within a few weeks. Some surgeons feel the need to intentionally retain breast tissue behind the nipple and areola while others feel that nothing short of an attempt to remove all visible breast tissue is appropriate. It should be noted however, that intentionally retaining breast tissue behind the nipple could be problematic particularly in patients carrying a BRCA 1/2 genetic mutation. Patients electing to undergo NSM should also note that in almost all instances, the nipple will have little to no sensation. It is not unusual for some patients note a return of sensation to the breast skin but few report a return of anything but the most minimal sensation in the nipple.

Conclusion Nipple-sparing mastectomy is currently being performed at high-volume breast centers throughout the country. It would be fair to say that it is still investigational. However, we do believe that it is a procedure that warrants serious consideration when mastectomy is needed to treat cancer or desired for risk reduction. In the cancer setting, strict selection criteria should be followed at all times (as outlined above) in order to minimize the risk of recurrent cancer in the nipple. Cancers greater than 2cm from the nipple, less than 4cm in size can be considered. Axillary node status and multicentricity should be considered on a case-by-case basis. In the risk reduction setting, it is our feeling that there is minimal risk to retaining the nipple as long as great care is taken to remove all visible breast tissue from beneath the nipple. Coring of the nipple (removing tissue from within the nipple itself) should be considered in appropriate cases.

PINES CITY COLLEGES MAGSAYSAY AVENUE, BAGUIO CITY

(BREAST CANCER) Or write-up

SUBMITTTED BY : CARINO, MARIA CHRISTINA SUBMITTTED TO: MARJORIE ILONEN 5/25/2011