This chapter explores the surgical management of both malignant and non-malignant breast conditions. In addition to the surgical approach for breast care patients, potential complications and nursing care essentials are discussed. A basic glossary of definitions related to breast conditions and surgery is also provided.
Breast surgery; breast cancer; breast reconstruction; mammaplasty; breast augmentation
Breast cancer is the second most common cancer among women in America; skin cancers are number one.1 All women are at risk for breast cancer. As of January 1, 2019, there are more than 3.8 million women living with breast cancer.2 The most significant risk factors are female gender, ethnicity, and advancing age.2 The median age for a breast cancer diagnosis is 62.2 The risk of breast cancer also increases if a woman has two or more first-degree relatives who were diagnosed with breast cancer at an early age.2 The chances of a woman having breast cancer are one in eight, or 13%.2 Although breast cancer rates between the ages of 60 and 84 are higher in white women, Non-hispanic Black women have a higher incidence before the age of 45 and are more likely to die of it at any age due to health care disparities.2 Although breast cancer in men is rare (nearly 100 times less common than in women), it does occur in less than 1% of all breast cancers.3 Approximately 1 in 833 men are expected to develop breast cancer during their lifetime.3
As an advocate for patients, the perianesthesia nurse must be supportive, caring, and reassuring to the patient having breast surgery. Positive support is the start of the patient’s rehabilitation process. Early detection, self-examination, mammography, and an increased public awareness are all important factors in decreasing annual breast cancer mortality. Breast cancer treatment today involves a combination of therapies including surgical excision of the tumor, radiation therapy alone, or a combination of surgery, radiation, and chemotherapy. New studies and treatment protocols are continuously being developed and subjected to trials, but early detection remains the best hope for cure.
Breast surgery is most commonly performed on women; however, procedures are occasionally performed on men and children. In addition to surgery for cancerous conditions of the breast, there are a number of procedures performed for benign conditions (cysts or fibroadenomas), cosmetic (macromastia, macromastia, asymmetry, gynecomastia) or diagnostic purposes.
AdenocarcinomaA general type of cancer that starts in glandular tissues anywhere in the body. Almost all breast cancers start in glandular tissue of the breast and therefore are adenocarcinomas. The two main types of breast adenocarcinomas are ductal carcinomas and lobular carcinomas. Benign breast lesions are the most commonly excised lesions (fibrocystic changes and fibroadenomas).
Augmentation MammaplastySurgery to enlarge or augment the size of the female breast with a breast implant; the most popular cosmetic procedure.
Breast BiopsyExcision of breast tissue for diagnostic purposes. Can be done as core biopsy with a needle, fine needle aspiration, or by an open surgical procedure. A needle localization can be performed when a suspected lesion is identified with mammogram results, which involves placing a thin needle or guide into the breast with mammographic visualization. The lesion is then excised and taken to the pathology laboratory to determine a diagnosis.
Breast ReconstructionReconstruction of the breast after mastectomy using autologous tissue or artificial implants.
Ductal Carcinoma In Situ (DCIS)Ductal carcinoma in situ (also known as intraductal carcinoma) is the most common type of noninvasive breast cancer. Cancer cells are inside the ducts but have not spread through the walls of the ducts into the fatty tissue of the breast. Nearly all women diagnosed at this early stage of breast cancer can be cured. The best way to find DCIS is with a mammogram. With more women getting mammograms each year, diagnosis of DCIS is becoming more common. DCIS is sometimes subclassified based on its grade and type to help predict the risk of return of cancer after treatment and to help select the most appropriate treatment. Grade refers to how aggressive cancer cells appear with a microscope. Several types of DCIS exist, but the most important distinction among them is whether tumor cell necrosis (areas of dead or degenerating cancer cells) is present. The term comedocarcinoma is often used to describe a type of DCIS with necrosis.
FibroadenomaA solid, round, rubbery lump that moves under the skin when touched. A benign lesion common in young women.
Infiltrating (or Invasive) Ductal Carcinoma (IDC)With a start in a milk passage or duct of the breast, this cancer has broken through the wall of the duct and invaded the fatty tissue of the breast. At this point, it has the potential to metastasize or spread to other parts of the body through the lymphatic system and bloodstream. Infiltrating ductal carcinoma accounts for approximately 80% of invasive breast cancers.
Infiltrating (or Invasive) Lobular Carcinoma (ILC)ILC starts in the milk-producing glands. Similar to IDC, this cancer has the potential to spread (metastasize) elsewhere in the body. Approximately 10% to 15% of invasive breast cancers are invasive lobular carcinomas. ILC may be more difficult to detect with mammogram than IDC.
Inflammatory Breast Cancer (IBC)This rare type of invasive breast cancer accounts for approximately 1% of all breast cancers. In IBC, the skin of the breast appears red and feels warm as though it were infected and inflamed. The skin has a thick pitted appearance that doctors often describe as resembling an orange peel. Sometimes the skin develops ridges and small bumps that resemble hives. Doctors now know that these changes are not caused by inflammation or infection, but the name given long ago to this type of cancer persists. Cancer cells that block lymph vessels or channels in the skin over the breast cause these symptoms.
In SituThis term is used for an early stage of cancer in which it is confined to the immediate area at which it began. Specifically in breast cancer, in situ means that the cancer remains confined to ducts (DCIS) or lobules (lobular carcinoma in situ). It has not invaded surrounding fatty tissues in the breast or spread to other organs in the body.
Lobular Carcinoma In Situ (LCIS)Although not a true cancer, LCIS (also called lobular neoplasia) is sometimes classified as a type of noninvasive breast cancer. It begins in the milk-producing glands but does not penetrate through the wall of the lobules. Most breast cancer specialists think that LCIS itself does not become an invasive cancer but that women with this condition have a higher risk of developing an invasive breast cancer in the same or the opposite breast. For this reason, women with LCIS should have physical examinations two or three times per year and an annual mammogram.
LumpectomyOnly the tumor and surrounding tissue of a “breast lump” are excised. The rest of the breast remains intact. The procedure includes dissection of the axillary lymph nodes. The lump is generally smaller than 4 cm in diameter.
MammaplastySurgical procedures designed to reshape, resize, or reposition the breasts for cosmetic purposes; to correct breast pathology; or to reconstruct tissue following surgery.
MammoSiteThe MammoSite is a balloon catheter inserted following lumpectomy. The balloon catheter serves as a form of brachytherapy used to deliver radiation directly to the tumor site.
Mastopexy (Breast Lift)Reshaping (uplifting) the sagging breasts with surgical tightening of the skin.
Medullary CarcinomaThis special type of infiltrating breast cancer has a relatively well-defined distinct boundary between tumor tissue and normal tissue. It also has some other special features including the large size of the cancer cells and the presence of immune system cells at the edges of the tumor. Medullary carcinoma accounts for approximately 5% of breast cancers. The outlook or prognosis for this kind of breast cancer is better than for other types of invasive breast cancers.
Modified Radical MastectomyRemoval of the entire breast and axillary lymph nodes; the pectoralis major muscle is left intact. In some instances, the pectoralis minor muscle is excised.
Mucinous CarcinomaThis rare type of invasive breast cancer is formed by mucus-producing cancer cells. The prognosis for mucinous carcinoma is better than for the more common types of invasive breast cancers. Colloid carcinoma is another name for this type of breast cancer.
Paget Disease of the NippleThis type of breast cancer starts in the breast ducts and spreads to the skin of the nipple and then to the areola, the dark circle around the nipple. It is a rare type of breast cancer and occurs in only 1% of all cases. The skin of the nipple and areola often appears crusted, scaly, and red, with areas of bleeding or oozing. Women may notice burning or itching. Paget disease may be associated with in situ carcinoma or with infiltrating breast carcinoma. If no lump can be felt in the breast tissue and the biopsy shows DCIS but no invasive cancer, the prognosis is excellent.
Phyllodes TumorThis rare type of breast tumor forms from the stroma (connective tissue) of the breast, in contrast to carcinomas, which develop in the ducts or lobules. Phyllodes tumors are usually benign but on rare occasions they can be malignant with the potential to metastasize. Benign phyllodes tumors are successfully treated by removing the mass and a narrow margin of normal breast tissue. A malignant phyllodes tumor is treated with removal along with a wider margin of normal tissue or with mastectomy. These cancers do not respond to hormonal therapy and are not likely to respond to chemotherapy or radiation therapy.
Radical MastectomyRemoval of the entire breast, skin, nipple, areolar complex, and pectoralis major and minor muscles with axillary node dissection.
Reduction MammaplastyRemoval of excess breast fat, glandular tissue, and skin to resize and reshape large breasts.
Triple Negative Breast CancerThis type of breast cancer is diagnosed when the three common receptors for breast cancer are negative (estrogen, progesterone, HER-2/neu gene), which makes it resistant to traditional hormone therapies.
Tubular CarcinomaTubular carcinomas are a special type of infiltrating breast carcinoma that account for approximately 2% of all breast cancers. They have a better prognosis than usual infiltrating ductal or lobular carcinomas.
Breast cancer is often first suspected when a lump is felt or an abnormal area is found on mammogram results. Lumps in the breast often are discovered during monthly self-examination, by an intimate partner, routine mammograms, breast ultrasound scans, or magnetic resonance imaging. A biopsy is done when the history and exams suggest breast cancer. The biopsy is one definitive test for confirming breast cancer. The lumps or masses are aspirated or excised and sent for definitive diagnoses.
For many of the female patients who undergo a biopsy, the diagnosis is fibrocystic disease. Fibrocystic disease describes a variety of benign and localized tumors or swelling within the breast tissues including cysts, masses, and intraductal papillomas (Fig. 43.1). Other nonfibrocystic conditions also may cause breast lumps. Inflammatory conditions, such as breast abscesses, fat necrosis, and lipomas of the skin (e.g., sebaceous cysts), can cause breast lumps.
A breast biopsy can be a one-step (biopsy and mastectomy, if needed) or two-step procedure. Two-step procedures are the most common practice. The two-step procedure allows the patient to be educated about the choices and given the opportunity to make an informed decision regarding the type of surgery or course of treatment to be performed in the event of a positive biopsy finding. The short delay between the biopsy and further treatment has not been shown to affect survival rates. If more extensive surgery is planned in the event of a positive biopsy result, the patient must have given preoperative informed consent for the definitive surgical procedure.
The biopsy procedure can be done in diagnostic settings with local anesthesia or as an outpatient in a surgery setting. The patient may undergo needle biopsy, incisional biopsy, or excisional biopsy. A needle biopsy includes the introduction of a disposable cutting-type needle through the mass to entrap a core of tissue. The needle is withdrawn, and the specimen is sent to the pathology laboratory. In an incisional biopsy, a portion of the mass is surgically excised along a curved incision line. An excisional biopsy may be needed to remove the entire mass and some of the adjacent tissue around it for examination. A stereotactic procedure may be performed in which the patient lies face down on a special table. The breast protrudes through a hole in the table and is lightly compressed while the computer provides detailed diagnostic images. The biopsy area is located, and a probe is inserted to remove the tissue specimens (Fig. 43.2).
Because of the patient’s natural apprehension, the patient may receive intravenous moderate sedation along with local anesthesia. Monitored anesthesia care may also be indicated. If the patient meets Phase I discharge criteria while still in the operating suite, the patient may bypass the Phase I postanesthesia care unit (PACU). Otherwise, the patient is usually awake on arrival in the PACU but drowsy because of the sedation. Routine admission procedures are accomplished. The head of the bed may be elevated 45 degrees.
The surgical site should be inspected for excessive drainage, which occurs only rarely. The patient can resume fluid and food intake as soon as the cough and gag reflexes have fully returned and nausea has subsided. The perianesthesia nurse should also inspect the surgical area for early signs of a developing hematoma. Pain should be minimal, if any, and easily controlled with regional or local anesthesia, minor analgesics, compression dressings, and ice.
The goals for surgical interventions for breast cancer include diminished potential for local recurrence, reduction of therapeutic surgeries, and minimization of morbidity and mortality.4 Most women need some type of surgery to treat the breast tumor and remove as much of the cancer as possible. Surgical treatment choice depends on the stage of the disease, the size and site of the mass, and the patient’s individual choice. Advances in early diagnosis and modifications in surgical techniques have increased the numbers of surgical choices in the treatment of breast cancer (Fig. 43.3). Surgical treatment may range from breast-conserving techniques (lumpectomy) to modified radical mastectomy that involves the breast and the axillary nodes.