According to medical terminology, Ablatio mammae (Latin : Ablatio = surgical ablation (synonym: ablation), mamma = mammary gland) and mastectomy (Greek : mastectomy = cutting out the breast) are synonyms. They refer to the surgical removal of the mammary gland and adjacent tissues also called mastectomy. There are, according to the necessary extension of the operation, different forms of Ablatio mammae / mastectomy:
- Total removal
- Partial (partial), breast-conserving removal.
General
Diagnosis and treatment of breast cancer (mammary carcinoma) have been refined over many years, so that with improvements in prognosis and quality of life, it is increasingly possible to avoid radicality in the area of the mamma (female breast), but also in the axillary (“affecting the axilla (armpit)”) lymphadenectomy (lymph node removal). Breast-conserving therapy (BET) is the goal. The current procedure consists of:
- Preoperative diagnosis of tumor biology by punch or vacuum biopsy (tissue sample).
- Interdisciplinary treatment planning (gynecologist, internal oncologist, radiation oncologist, pathologist) in the context of a tumor conference.
- Sentinel biopsy*
- Surgery
- Breast-conserving if possible
- Axillary lymph node diagnostics with possible waiver of axillary revision.
* Sentinel lymph node biopsy (sentinel lymph node) has been standard since 2004/2005. This is the first lymph node in the lymphatic drainage of a breast carcinoma, which is marked and removed using radionucleotides and / or dyes. If this is not affected by tumor cells, it can be assumed that the lymph nodes downstream of this lymph node are also not affected, so they do not need to be removed. There may also be several sentinel lymph nodes, which are then all removed. The method can be used for small tumors up to two centimeters in size.
Indications (areas of application) for total surgery
- Large tumors
- Invasive breast carcinoma – when tumor-to-breast size ratio is unfavorable.
- Multicentric carcinoma
- Failure to achieve resection (removal) in sano (“in healthy”) at postresection
- Multicentric DCIS (ductal carcinoma in situ) – pathological benign cell proliferation of the epithelium of the mammary gland ducts.
- Skin involvement (breakthrough of the tumor through the skin) and invasion of the surrounding musculature.
- Intramammary recurrence after breast-conserving therapy (BET) – recurrence of tumor within the breast at:
- DCIS
- Invasive carcinoma (if organ-preserving surgery is performed again, there is an increased risk of recurrence at 30% after 5 years).
- Contraindication (contraindication) for radiotherapy (radiotherapy) (part of breast-conserving therapy, BET) – e.g. pregnancy.
- Rejection of the Radiatio (radiotherapy) by the patient.
- Desire of the patient
- Inflammatory (“inflammatory”) breast carcinoma
- Prophylactic indication – due to genetic disposition.
- Very rare indications:
- Severe mastopathies – non-tumor, hormone-dependent proliferative (growing) or degenerative change in breast tissue that may result in nodular induration, edema (water retention), and pain
- Monitorability of the breast by imaging (eg, sonography/ultrasound, mammography) not possible.
- Desire of the patient – e.g. in gender identity disorders (transsexuality) to complete a male appearance.
Before the operation
Before surgery, a detailed medical history interview and a thorough physical examination should be performed, as well as preparation and examination by an anesthesiologist (anesthetist). Since this is an invasive procedure, the patient must be informed about risks and complications and her consent must be obtained in writing. Immediately preoperatively, the patient receives antibiotic prophylaxis.
Surgical procedures
Total ablatio mammae / mastectomy.
- Subcutaneous mastectomy
- Simple mastectomy (amputatio mammae simplex, ablatio simplex, mammary amputation).
- Modified radical mastectomy according to Payer (Ablatio mammae with axillary revision).
- Radical mastectomy (Rotter-Halsted mastectomy).
Partial (segmental) ablatio mammae / mastectomy = breast-conserving operation (BEO) (preferred surgical method). It is performed as:
- Excision
- Lumpectomy
- Quadrantectomy
- Ductectomy
In subcutaneous mastectomy, the mammary gland body is removed while the skin and mammilla-areola complex (nipple and areola) are preserved. A variant is the so-called skin-sparing mastectomy (SSM; skin-sparing breast removal). Here, the nipple is also removed and only the skin is left, so that immediate reconstruction of the breast is possible. Subcutaneous mastectomy is suitable for treating high-risk patients who have a genetic predisposition to breast cancer (= prophylactic mastectomy). The responsible genes are called BRCA1 and BRCA2. The lifetime risk of breast cancer in BRCA1/2 mutation carriers is on average 70%; affected women develop the disease about 20 years earlier. For contralateral breast carcinoma, the average risk is 40%. Simple mastectomy (amputatio mammae simplex, ablation simplex, mammary amputation) involves removal of the mammary gland, the mammilla-areola complex, the surrounding fatty tissue, the fascia of the pectoralis major muscle (connective tissue covering the large pectoral muscle), and the skin. After this operation, there is an oblique scar that runs toward the axilla (armpit). This operation is also suitable for preventive mastectomy. Another method is modified radical mastectomy, which is also called surgery according to Payer. Here, the mammary gland body including mammilla-areola complex and pectoralis fascia as well as axillary lymph nodes and axillary adipose tissue are removed. Depending on the location of the tumor, the surgical procedure also changes. An older type of surgery is radical mastectomy, also known as Rotter-Halsted surgery, which is no longer used today. In this method, the pectoralis major muscle (large chest muscle) and, if necessary, the pectoralis minor muscle (small chest muscle) are also removed. Since the absence of the female breast can be a heavy psychological burden for women, reconstruction of the breast with the patient’s own tissue or an implant is advisable. In breast-conserving surgery (BEO; synonym: breast-conserving therapy), the extent of surgery required and the procedure depends on the size of the abnormal finding or the finding to be clarified, the localization, the dignity (biological behavior of tumors; i.e., whether they are benign (benign) or malignant (malignant)), and whether it is:
- palpable (palpable) changes
- Delineable
- Not delimitable, diffuse
- non-palpable changes, presentable
- Mammographic or
- Magnetic resonance imaging (MRI)
Non-palpable (palpable) changes must be marked preoperatively (“before surgery”) by dye or by means of a fine wire. Excision is performed for palpable sharply demarcated benign findings without surrounding tissue (usually for benign/ benign findings e.g. fibroma/ connective tissue tumor). In lumpectomy (wide excision, thylectomy, or tylectomy (Greek tylos = “lump”, “nodule“), only the tumor, as well as the tissue adjacent to it, is removed. In quadrantectomy, an entire quadrant of the breast, with the overlying skin spindle, is removed. For ductctomy in the case of secretion of a milk duct, this is probed through the nipple with a blunt cannula and a dye is injected under slight pressure, which can then be surgically visualized and removed. Breast-conserving surgery (BEO) is always followed by radiotherapy (radiation therapy) of the breast. The surgery is performed under general anesthesia.
After surgery
After surgery, the patient must wear a compression bandage for 24 hours, and wound healing should be monitored regularly. Within the first two years after surgery, there is a quarterly follow-up, and later a semiannual follow-up. Part of this follow-up is a clinical examination as well as sonography (ultrasound) and mammography (X-ray examination of the breast) of the opposite side.
Possible complications
- Pain
- Wound healing disorders
- Inflammation due to infection
- Hemorrhage (bleeding)
- Hematoma formation (bruise)
- Nerve or vascular damage
- Paresthesias (sensory disturbances in the wound area) due to nerve damage.
- Pain
- Seroma formation (accumulation of wound secretions)
- Lymphedema (water accumulation due to disruption of lymphatic drainage).
- Tumor recurrence (recurrence of the tumor).
- Suture insufficiency (dissolution of the suture).
The above complications can occur with varying frequency in all forms of mastectomy. However, they are significantly less frequent in breast-conserving surgery (BEO). Further notes
- There is no rationale for mastectomy in early, primary stage T1-2, N0-1, M0 breast cancer (early breast cancer) that does not have a genetic cause. According to a population-based study from the Netherlands, after a median of 11.4 years, 77% of women who had breast-conserving surgery and radiation or 60% of women who had the affected breast removed had survived. After a median of 9.8 years, women with T1NO tumors and breast-conserving therapy had the benefit of a 26% reduced risk of metastasis (formation of daughter tumors).
- In the United States, young women with locally invasive cancer in one breast also have the contralateral (other) healthy breast removed prophylactically in one in three cases. This may be explained by the belief that the second-disease risk is similar in BRCA1/2-negative families and that the specific genetic defect just needs to be found (however, this assumption is incorrect).
- In a study of nearly 130,000 patients with stage T1-2, N0-1 as well as T1-2, N2 tumors conducted by the Erasmus Cancer Institute in Rotterdam, the first study period (1999-2005; n = 60. 381), the probability of cancer-specific survival was 28 percent higher with breast-conserving therapy compared with mastectomy (hazard ratio [HR]: 0.72; 95% confidence interval: 0.69-0.76; p < 0.0001), and overall survival was 26 percent higher (HR: 0.74; 95% confidence interval: 0.71-0.76; p < 0.0001). In the second study period (2006-2015; n = 69,311), breast-conserving therapy also fared better than mastectomy for both survival parameters in stage T1-2, N0-1 tumors (HR: 0.75; 95% confidence interval: 0.70-0.80; p < 0.0001 and HR: 0.67; 95% confidence interval: 0.64-0.71; p < 0.0001, respectively); but not in T1-2, N1 tumors.
- Mastectomy: Mastectomy does not exclude the possibility that tumor nests have already formed in the vicinity of the carcinoma, which later trigger recurrence. In a study with an average follow-up of 30 months, 19 of the 185 patients (10%) underwent mammary ultrasonography (breast ultrasound) after unilateral mastectomy because recurrence (recurrence of disease) was suspected. Eleven of these patients underwent biopsy (tissue sampling), which confirmed recurrence in a total of two patients (1%).
