43 Care of the breast surgical patient
Adenocarcinoma: A 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).
Breast Biopsy: Excision of breast tissue. The specimen is sent to the pathology laboratory for frozen sectioning. In addition, a needle localization can be performed when a suspected lesion is identified with mammogram results. The procedure involves placing a thin needle or guide into the breast with mammographic visualization. The lesion is then excised and taken to the pathology laboratory for frozen sectioning to determine a diagnosis.
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.
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: This rare type of invasive breast cancer accounts for approximately 1% of all breast cancers. In inflammatory breast cancer, 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 still persists. Cancer cells that block lymph vessels or channels in the skin over the breast cause these symptoms.
In Situ: This 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 (ductal carcinoma in situ) or lobules (lobular carcinoma in situ). It has not invaded surrounding fatty tissues in the breast nor 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.
Lumpectomy: Only 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.
Medullary Carcinoma: This 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 cancer.
Mucinous Carcinoma: This 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 cancer. Colloid carcinoma is another name for this type of breast cancer.
Paget Disease of the Nipple: This 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 Tumor: This 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 (or hylloides) tumors are usually benign but rarely 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 so likely to respond to chemotherapy or radiation therapy. In the past, both benign and malignant phyllodes tumors were called cystosarcoma phyllodes.
Tubular Carcinoma: Tubular carcinomas are a special type of infiltrating breast carcinoma and account for approximately 2% of all breast cancers. They have a better prognosis than usual infiltrating ductal or lobular carcinomas.
Breast cancer, the most common cancer in women,1 is a malignant tumor that develops from cells of the breast. Although breast cancer in men is rare, it does occur. With the newer forms of treatment of cancer of the breast, including improved forms of diagnosis, surgical procedures on the breast have increased. However, with earlier breast cancer diagnosis and with the advent of enhanced radiation and chemotherapy protocols, surgical procedures performed on the breast might not be as extensive as in years past. All women are at risk for breast cancer. The two most significant risk factors are female gender and older age.2 Ninety-five percent of new cases and 97% of breast cancer deaths occurred in women older than 40 years.2 Risk of breast cancer also increases if the woman’s mother, sister, or daughter has had the disease. Breast surgery is most commonly performed on women; however, procedures are occasionally performed on men and children. In addition, nondisease breast procedures may be performed for cosmetic purposes. Breast cancer is the second leading cause of death for women after lung cancer.1 The chances of a woman having breast cancer are one in eight. Chances of dying from breast cancer are approximately 1 in 33. Breast cancer is the most common cause of cancer in African American women and the second leading cause of death in African American women, exceeded only by lung cancer. Approximately 1 in 100 men is expected to develop breast cancer in a lifetime. As the patient’s advocate, 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 detections, self examination, mammography, and an increased public awareness are all important factors in decreasing annual breast cancer mortality.2 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 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 or with routine mammograms, breast ultrasound scans, or magnetic resonance imaging. A biopsy is done when the results of these other tests suggest breast cancer. The biopsy is the only way to know for certain. 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. 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 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 patient is usually admitted as a same-day surgery patient. 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. 43-1).
FIG. 43-1 A, In stereotactic procedures, patients lie facedown on a special table. The woman’s breast protrudes through a hole in the table’s surface, where it is lightly compressed and immobilized while a computer produces detailed images of the abnormality. B, When the biopsy area has been located and mapped, the Mammotome probe is inserted through a ¼-inch incision in the breast, where it gently vacuums, cuts, and removes breast tissue samples. C, The incision is then closed with a small adhesive bandage.
(From Rothrock J: Alexander’s care of the patient in surgery, ed 14, St. Louis, 2011, Mosby.)
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 dressing is usually a 4 × 4 sponge held in place with the patient’s bra. It 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. Pain should be minimal, if any, and easily controlled with minor analgesics.
If midazolam has been administered, the patient may repeatedly ask the same questions. The perianesthesia nurse must patiently repeat the answers and also ensure that the person who accompanies the patient at discharge understands the home care instructions.
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 number of surgical choices in the treatment of breast cancer (Fig. 43-2). Surgical treatment may range from breast-conserving techniques (lumpectomy) to modified radical mastectomy that involves the breast and the axillary nodes.
(Redrawn from Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care, ed 6, Philadelphia, 2010, Saunders.)