The state of the body after surgery for breast cancer. Early and long-term consequences

It promotes the formation of rough scars on the tissue, and the peculiarity is that over time, scar changes only increase.

The need for the maximum possible restoration of body functions, improving the quality of life after breast removal - these are the tasks that rehabilitation is designed to solve. By definition, rehabilitation is a system of medical and psychological measures aimed at the effective and early return of the patient to society, to life and useful work, or to create medical conditions for a comfortable existence with the disease.

Mastectomy and other breast surgeries

Dear women!

Cancer is a very dangerous and insidious disease. After any surgical antitumor treatment, cancer cells and micrometastases always remain, which cannot be detected. And breast cancer is capable of producing so-called “dormant” metastases, which can become active even many years after an apparent recovery.
The generally accepted methods of conservative antitumor treatment - radiation, chemotherapy - are in many cases powerless against them, and often themselves contribute to cancer aggression.
According to medical statistics, even before the start of primary treatment, about 60% of breast cancer patients have either diagnosable or preclinical (non-diagnostic, “dormant”) micrometastases. Subsequently, cancer relapses affect up to 85% of patients, most of whom suffer from metastasis to the skeletal bones.
Recurrence of breast cancer- this is the resumption of the tumor process in a period of 6 months or more after antitumor treatment. In most cases, it occurs 3-5 years after completion of treatment, but in many the disease recurs within 1 year.
Young women under 35 years of age are most susceptible to relapse of the disease.
The mortality rate for recurrent breast cancer over 5 years ranges from 50 to 100%, many patients die within 1 year.
In modern oncology, a woman who has lived 5 years without recurrence of cancer is considered to have passed the milestone of five years of relapse-free survival (RFS) and is in remission.
The degree of cure of the disease is determined only after 10 years without relapse of cancer after antitumor treatment. But even this period for breast cancer is not an objective indicator - there are known cases of resumption of the cancer process 20 and even 25 years after supposedly successful treatment.
Do not rely only on passive medical observation and postoperative rehabilitation, and especially on immunity, the use of supposedly anti-cancer dietary supplements, herbal infusions and various “miracle” remedies. This attitude towards illness deadly!
The majority of women diagnosed with stage 4 breast or pelvic cancer who seek help through the ONCONET System are patients who have previously undergone radical surgery (the tumor and metastases were completely removed), most of whom carefully followed all postoperative recommendations. Many of them led a healthy lifestyle, taking “anti-tumor” supplements, herbs and the like.
Cancer can be cured well, but provided that it is done ON TIME and CORRECTLY!
For a certain period of time after a successful operation, you not only need to be observed by an oncologist and undergo rehabilitation, but also MUST undergo special supportive antitumor treatment.
Only this approach will give you the maximum chance of a full recovery!
Then - courses of active cancer prevention 1-2 times a year.
Remember that the greatest treasure in cancer is TIME, and its loss is irreparable.

Take care of yourself and your loved ones!
Save your life and health!

Development postmastectomy complications depends on the tactics of radical treatment. Each effect not only relieves the tumor, but also carries certain burdens and consequences for the patient. This is the peculiarity of oncology: by freeing one from the disease and prolonging life, it gives a significant change in the quality of this life.

Consequences of the operation:

● postmastectomy defect (removed mammary gland);

● cicatricial changes in the axillary area, leading to contracture (stiffness) of the shoulder and brachioplexitis (inflammation of the brachial plexus);

● curvature of the spine due to decreased load after removal of the mammary gland;

● stenosis (narrowing) or occlusion (closure) of the axillary and/or subclavian veins.

● fibrosis of the skin and soft tissues, disrupting the normal outflow of blood and lymph and leading to compression of nerve endings - brachioplexitis;

● pneumofibrosis, which causes impaired lymphatic drainage.

● phlebitis and phlebothrombosis;

● immune disorders.

It is more correct to talk about "combination treatment syndrome for breast cancer", the components of which are a combination of postmastectomy syndrome and chemoradiation complications syndrome. It is often difficult to separate these syndromes, because surgery itself is impossible without a scar, radiation therapy also causes tissue scarring, and some chemotherapy drugs increase radiation damage to tissues - radiosensitization.

Postmastectomy defect and scar changes in the axillary region that occur immediately after removal of the breast and regional lymph nodes subsequently lead to the development of contractures, secondary lymphedema and erysipelas. The swelling of the arm is partly caused by the removal of lymph nodes, partly by compression of the venous and lymphatic vessels by developing post-radiation fibrosis, and partly by post-chemotherapy phlebitis.

Complaints of patients with postmastectomy syndrome can be divided into three groups: stiffness of the shoulder joint, swelling of the arm on the side of the operation and pain syndrome - pain on the back of the arm and in the axillary region.

These processes, as a rule, occur for a fairly long time after removal of the mammary gland - from several months to 2-3 years. Therefore, the first 2-3 years are a favorable time for carrying out rehabilitation measures.

removal of the mammary gland is a very common complication and, to one degree or another, after radical treatment of breast cancer occurs in almost all women. Breast-conserving surgeries, such as radical resection followed by radiation therapy, also lead to lymphedema, but usually less severe. Taking antiestrogens (tamoxifen) can be complicated by thrombosis and, as a result, worsening postoperative edema. Damage to the veins of the arm (on the operated side) during chemotherapy is also unfavorable. In most cases, it is lymphedema that subsequently becomes the main reason for determining the disability group.

There are four degrees of progression of lymphedema:

I degree - swelling of the hand;

II degree - swelling of the forearm;

III degree - swelling of the shoulder;

IV degree - trophic disorders.

Lymphedema is not so much a cosmetic defect as it is a neurovascular and functional disorder. This is clinically manifested by a change and distortion of sensitivity, a constant feeling of heaviness and limitation of movements in the joint, a decrease in muscle tone and strength. The frequent addition of an infection - erysipelas - creates a vicious circle: lymphedema promotes the development of infection, and the infection stimulates even greater stagnation.

No precise diagnostic measures are required to identify edema; an examination is sufficient for the doctor. Only in selected cases (clinical trials) are lymphoscintigraphy and magnetic resonance imaging (MRI) used to assess the stages of lymphedema development. With lymphoscintigraphy, a radioactive drug is injected intravenously, accumulating in the area of blockage of the lymphatic vessel. MRI is a very accurate layer-by-layer x-ray.

Unfortunately, treatment of lymphedema is ineffective, so the role of prevention is great.

A contraindication to treatment is the metastatic stage of the disease. Patients with a history of deep vein thrombosis should undergo special examination. For acute erysipelas, only LED therapy is allowed.

The first year after breast removal for radical treatment of breast cancer is crucial for medical rehabilitation. It is very important to use this period as wisely as possible to restore lost functions. But it is even more important not to contribute to the development of adverse events.

One of the most unpleasant complications of breast removal is lymphatic swelling of the arm on the side of the operation -. It can appear either 1-2 weeks after surgery or after several months or years.

After breast removal, to prevent swelling and treat it, it is recommended to wear compression-elastic bandages, hydrokinesitherapy in a swimming pool and therapeutic exercises, use of a pneumatic massager and hardware LED therapy.

Compression therapy

The creation of external pressure prevents fluid from leaving the vessels into the intercellular space. Elastic bandages have long been used for this purpose. But their effectiveness is low: the pressure on the tissue is initially low and decreases over time, its distribution is uneven. Currently, special contour products are being manufactured (gloves, sleeves, T-shirts) that allow creating the necessary pressure gradient with a maximum at the bottom and a minimum at the top.

The products are made from natural or artificial rubber, withstand repeated stretching, maintain optimal heat and water exchange, and are hypoallergenic. Natural rubber is more physiological and durable (10 months of wear versus 6 months for products made from artificial thread), but the sleeve requires special fixing belts. All products - gloves, sleeves or T-shirts - are selected individually, and it is better to do this with a specialist. A vest is required immediately after surgery to stop lymphorrhea and quickly fix the skin flap to the chest wall. If the swelling spreads to the chest wall in the long term, the need for a T-shirt may also arise. The jersey should only be selected by a specialist.

They have been especially successful in the manufacture of compression products in Germany and Switzerland, where quality control is extremely strict.

Pneumatic compression (pneumomassage)

This method of combating edema is considered the most effective and physiological. It helps to enhance venous and lymphatic outflow. There are two techniques: wave-like compression and compression of the entire limb at the same time. The procedure is carried out in a medical institution using special devices.

An alternative may be manual lymphatic drainage performed by a massage therapist, but this is quite expensive.

LED therapy

Intended for the prevention and treatment of erysipelas and is carried out with a special device. According to its biological characteristics, the emission of monochromatic light is close to a red helium-neon laser; it also stimulates local immunity, improves the rheological properties of blood and venous outflow. Treatment begins at the first signs of inflammation.

Preventive phototherapy is advisable in the first year after surgery every 3 months, in the second year - once every six months, then once a year.

Physiotherapy

Exercises after breast removal are necessary to restore normal arm function, so exercises begin in the hospital. signed by a physical therapy specialist.

Hydrokinesitherapy

It is carried out in a swimming pool and combines kinesiotherapy with aquamassage, relaxation and the positive psycho-emotional impact of group communication.

The best effect for lymphedema is achieved with the integrated use of all treatment methods against the background of antiplatelet therapy (taking drugs that prevent pathological blood clotting). But, unfortunately, the effect is very unstable, and after a short period of time the original swelling of the tissue returns.

Introduction

Anatomy of the breast.

The mammary gland is located on the anterior surface of the chest from the 3rd to the 7th ribs. This is a complex tubular-alveolar gland (derived from the epidermis, it is classified as a gland of the skin). The development of the gland and its functional activity depend on reproductive hormones. During puberty, excretory ducts are formed, and secretory sections - during pregnancy. The parenchyma of the gland consists of 15-20 individual complex tubulo-alveolar glands (lobes, or segments), opening by the excretory duct at the apex of the nipple. The lobes (segments) are represented by 20-40 lobules, consisting of 10-100 alveoli each.

Blood supply.

Arterial blood enters the mammary gland from the internal mammary artery (60%), external mammary artery (30%) and branches of the intercostal arteries (10%).

Venous drainage occurs through the intercostal and internal mammary veins.

Lymphatic system. Lymph from the outer quadrants of the mammary gland flows to a group of axillary lymph nodes. The axillary lymph nodes are divided into nodes of 3 levels (depending on their relationship with the pectoralis minor muscle). Lymphatic drainage occurs from the inner quadrants of the mammary gland to the parasternal lymph nodes.

Innervation: phrenic, intercostal, vagus and sympathetic nerves.

Types of breast surgery

Surgical interventions on the mammary gland can be divided into three groups:

Operations for inflammatory diseases (acute and chronic mastitis). These include, first of all, opening and draining the abscess. It is extremely rare for mastitis to remove the mammary gland (for gangrene of the mammary gland).

Surgeries for benign and malignant neoplasms (fibroadenoma, breast cancer, fibroadenomatosis). These include - enucleation of a breast tumor - sectoral resection of the mammary gland - radical resection of the mammary gland - mastectomy (removal of the mammary gland) - axillary lymphadenectomy - biopsy of axillary lymph nodes

Plastic surgeries include: - endoprosthetics (breast augmentation with a silicone prosthesis) - reduction mammoplasty (breast reduction) - mastopexy (breast lift) - breast reconstruction

Sectoral breast resection

The essence of the operation is the removal of a section of breast tissue suspected of cancer or a benign breast tumor.

Indications

Suspicion of breast cancer. For the purpose of establishing a diagnosis.

For benign diseases for therapeutic purposes (fibroadenomas, lipomas, granulomas, chronic mastitis, etc.).

Breast cancer (when sectoral resection is part of breast-conserving surgery).

Anesthesia

Local anesthesia with a solution of novocaine or, if the latter is intolerant, with another anesthetic (for example, lidocaine). General anesthesia is used for non-palpable formations, when the tumor is determined only by mammography and ultrasound, but cannot be detected during examination. Also, general anesthesia can be used for polyvalent allergies (intolerance to all drugs for local anesthesia). General anesthesia is also performed if sectoral resection is part of an organ-sparing operation.

Surgery

The surgeon marks the incision lines for sectoral resection and radical mastectomy using a stick with cotton wool and brilliant green. Using two semi-oval incisions running in a radial direction relative to the nipple, the gland tissue is dissected with an arcuate incision. Stepping 3 cm from the edge of the tumor through the entire thickness of the gland to the fascia of the pectoralis major muscle under the control of the hand fixing the tumor node, the surgeon makes an incision on the other side. The sector (area) with the tumor is removed. Stop the bleeding. Then the wound is sutured with separate sutures, capturing the bottom so that cavities do not form. If necessary, sutures are placed on the subcutaneous tissue. Separate interrupted sutures or a cosmetic suture are applied to the skin. The removed sector of the mammary gland is sent for urgent histological examination (lasts 20-30 minutes). If cancer is detected, it is necessary to expand the scope of the operation, which depends on specific conditions (tumor size, mammography and palpation data before surgery).

The scope of sectoral resection may be reduced if it is known that the tumor is benign.

Complications

Wound suppuration due to infection during or after surgery.

Accumulation of blood (hematoma) as a result of careless control of bleeding or any violations of the blood coagulation system.

results

The sutures are removed within 7-10 days. The cosmetic defect depends on the individual characteristics of the body and the execution of a simple or cosmetic suture. With the latter, the results are usually better.

Any operation is stressful for the patient, so sedatives are usually prescribed the day before. During surgery, do not worry, listen to your doctor. If you feel pain, it is best to say: “It hurts.” The doctor will definitely administer an additional painkiller.

After surgery, the dressings should be changed by a nurse or doctor. If early discharge from hospital or outpatient surgery is necessary. It is necessary to carry out dressings correctly yourself:

Wash your hands thoroughly with soap and water

Treat them with a swab dipped in a solution of alcohol or vodka

Carefully remove the bandage

Gently wipe the surface of the wound with a swab soaked in a solution of alcohol or vodka. Place a bandage folded 2-3 times on the wound and secure it with a plaster.

If you have the slightest doubt, you should consult a doctor. You should also consult a doctor if:

Temperature above 39 degrees two days after surgery

Severe pain in the area of surgery

During bandaging, pus discharge was discovered

You are reading an article from 1997. The Republican Research Institute of Oncology and Medical Radiology now has the name “ Republican Scientific and Practical Center of Oncology and Medical Radiology named after N. N. Alexandrov».

Exactly mammary cancer occupies a sad first place in female oncology, but regular self-monitoring, preventive visits to the clinic and timely detection of a malignant tumor allow oncologists to successfully cope with the disaster, preserving the woman’s life and health, but also her appearance and body beauty. Republican Research Institute of Oncology and Medical Radiology in recent years has been successfully developing a rehabilitation service, in which the main place is occupied by reconstructive and plastic surgery. We asked the scientific director of the department of general oncology and plastic surgery, Doctor of Medical Sciences, to tell us what exactly she does and how she helps people return to a full, high-quality life after severe suffering caused by the disease. Joseph Viktorovich ZALUTSKY.

- Recently, information flashed in the press about the First International Congress on Reconstructive and Plastic Surgery, where it was said that in the next decade it will be thoroughly introduced into oncology, thereby leaving the era of mutilating, organ-removing, and disabling operations in the past. Very strongly and encouragingly said. Do you think this forecast is realistic?

This is not a forecast, this is the reality of today. Our department has existed at the institute for seven years, during which time hundreds of patients have returned to life not as disabled people, not cripples, but practically healthy, productive members of society. They do not experience physical and mental suffering due to the consequences of extensive surgical operations, which until recently were considered the only possible ones in the fight against a deadly disease. All over the world, plastic and reconstructive surgery has been used in oncology, perhaps since the time when the doctor, figuratively speaking, swung a scalpel at an insidious tumor. This was especially relevant for the treatment of patients with tumors of the skin, soft tissues, and bones. And in our institute, from the first years of its existence, some recovery operations. To date, we have accumulated extensive scientific and practical experience; the department has the material and technical potential of the highest world level, and this allows us to carry out operations of any complexity, sometimes unique. I am convinced that now oncology simply cannot, has no right to do without a service like ours - after all, cancer, sad as it is to admit, is rapidly getting younger, and for many of our patients the loss of fullness, wealth, quality of life can devalue its value salvation. Is this why a young woman is afraid to go to the doctor, having discovered some strange lump in her chest, is tormented by fears and suspicions, making a fatal and completely stupid decision? come what may"... The mammary gland is a symbol of femininity. For many, the prospect of losing it is no less serious a trauma than the cancer itself. Unfortunately, our population is still very poorly informed about the possibilities of modern oncology.

- So let's inform! And let's start with women, who are often driven into a dead end by fear.

A significant amount of our department's work is related to treatment of breast cancer. Treatment is complex, including radiation and chemotherapy, but the main component is surgery. Recently, approaches to the scope of surgical intervention have changed significantly in global oncology. Previously, it was believed that the more tissue removed, the more reliable the result - extensive mutilating operations were performed, when the block of tissue removed included the mammary gland, pectoral muscles, areas of costal cartilage with adjacent peri-thoracic tissue, axillary and supraclavicular tissue. Further study of the features of breast cancer development and analysis of treatment results showed that the volume of the operation does not affect the reliability of the result. Therefore, they began to use the so-called organ preservation operations.

But here I would like to make a reservation: such an operation is impossible if a woman arrives for treatment late, when the tumor has reached a large size, then it is not possible to save the mammary gland.

During organ preservation operations a section of breast tissue with axillary tissue is removed. However, no matter what size the tissue sector is excised, deformation of the gland occurs and a certain physical defect remains. And here plastic surgery comes to the aid of oncologists.

Mammoplasty It has been used in our country since the 70s. In the course of its development, two directions emerged:

use as a plastic material tissue from the patient herself,
usage synthetic materials, so-called endoprostheses.

Breast reconstruction May be primary when it is performed simultaneously with tumor removal, and delayed, or secondary.

- That is, a woman who underwent extensive radical surgery several years ago or now, but in another city where there are no such opportunities as in Minsk, can come to your department and receive the desired help?

Certainly! Mammoplasty restores the shape of the operated gland, which not only eliminates the physical defect, but also has a huge positive psychological effect, freeing the woman from the inferiority complex and defectiveness, returning her to normal life.

Mammoplasty does not worsen the prognosis of the underlying disease and does not interfere with additional treatment, if necessary (both radiation and chemotherapy).

- Joseph Viktorovich, some women operated on with the old method are “given away” and made to suffer not so much by the removed mammary gland, but by something completely different - a deformed, swollen arm, which sometimes cannot be hidden by any fluffy clothing. Why does this happen? And is it possible to help here?

This kind of disaster happens not only after breast removal. Successful cures for many tumor diseases, unfortunately, often fail swelling of the arm or leg on the side where the operation was performed.

It's connected with removal of lymph nodes and vessels, the intersection of numerous small nerves, as well as the action radiation therapy.

Lymphedema, and subsequently its extreme degree - elephantiasis, or enlargement of the limbs, resembling the shape and size of an elephant’s leg, has been known as a disease since ancient times, it was described around 2500 BC. e. Hindu Drankvantar. Lymphedema of the extremities is a very serious disease that brings physical and mental suffering to the patient. But a poor prognosis and limited treatment options hampered medical interest in this problem, and patients had no choice but to go from one doctor to another and watch in horror the growing swelling of the extremities...

There are different flow options diseases:

stable when clinical signs of lymphedema, manifested in one or another segment of the limb, do not spread or increase over a long period of time;
slowly progressive- that is, with a gradual, sluggish increase in pathological manifestations;
rapidly progressing, in which the period of development of the disease from initial manifestations (I degree) to the pronounced clinical picture of the disease (III-IV degrees) is very short - up to a year, with a tendency to further progression.

By degrees of expression Lymphedema is distributed as follows:

in grade I, the swelling is insignificant, localized mainly on the hand or foot;
in degree II, the swelling already spreads to the forearm, persists constantly, the skin is difficult to fold (“soft swelling”);
grade III is characterized by dense, painless swelling of the entire upper or lower limb;
deforming edema (IV degree) disfigures the limb due to excessive growth of soft tissues and limits movement in the joints.

Just 5 years ago in our republic, such patients did not receive the necessary help, since the practical healthcare system did not have a specialized service for their rehabilitation.

Research Institute of Oncology, having created rehabilitation unit, naturally, came face to face with this problem, since it arose among many former patients of the institute and regional oncology clinics. From all over the republic, people suffering from lymphedema come to our department, for whom, at their place of residence, it was offered as the only method of treatment... limb amputation. Unfortunately, even today there are surgeons who are ready to provide such a “disservice.”

In our department we have a choice of methods and sequence lymphedema treatment is carried out individually, taking into account the stage of edema, the structural features of the lymphatic and venous systems. Patients with degrees I-II of edema who did not have erysipelas can be successfully treated with conservative treatment using pneumomassage and medications, promoting the redistribution of edematous fluid. If the effect cannot be achieved or the patient has already developed grade III-IV edema, we offer surgical treatment to remove excess tissue swelling by liposuction, and also produce Greater omentum tissue grafting from the abdominal cavity to a swollen arm or leg. The omental graft in this case serves as a newly created lymphatic apparatus.

Good effect in complex conservative treatment of lymphedema
can be achieved using pneumomassage.

Over five years of work in this direction, our plastic surgeons have accumulated solid experience in the fight against a disease long considered incurable. In addition, we have developed recommendations for those suffering from lymphedema, so that by using them at home, patients can independently resist the increase in lymphedema.

- I believe our magazine can bring this valuable information to those who need it...

It will be great and won't take up much space. For lymphedema Patients must take the following measures and observe a number of precautions:

Limit loads on a sore limb, try not to carry a load weighing more than 3 kg with a swollen hand. It is unacceptable to stand on your feet for a long time if one of them is swollen, and you should not keep your swollen arm down for a long time.
It is useful to periodically apply to a sore arm or leg elevated position, to do this, you should comfortably lay it on a hard cushion or pillow for 15-20 minutes every 3-4 hours.
Gives a good effect massage the sore limb with a warm shower for 10-15 minutes after physical therapy exercises.
Can't be allowed damage and microtraumas, because due to the removal of lymphatic vessels and nodes, the limb on the side of the operation becomes less able to resist infection.
Should be avoided compression and bandaging the edematous limb, which can increase the symptoms of edema: shoes and sleeves of clothing should be loose.
If you suddenly accidentally injured your arm (leg) and suspected signs erysipelas (redness of the skin, an increase in its temperature and body temperature to high numbers, a feeling of fullness or burning in the affected limb), you should consult a doctor immediately.

If the measures listed above do not lead to a reduction in swelling resulting from surgery or radiation therapy, you need to contact the only one existing in the republic today specialized center for the treatment of lymphedema of the extremities, which is located at the Belarusian Research Institute of Medical MRI, in the department of general oncology and plastic surgery.

- Joseph Viktorovich, given your rich experience in plastic surgery, we can assume that not only cancer patients turn to you for help. Do you accept them? Or do you consider purely cosmetic purposes an unaffordable luxury when there are so many “your” patients...

No, I don't think so. Because the doctor cannot ignore the suffering of people due to serious defects in appearance. In addition, aesthetic surgery is an excellent opportunity for me and my colleagues to improve and develop rehabilitation care for cancer patients.

Patients often come to us with serious deformities and defects of the body which made them disabled.

In fact, all of them were denied help in other medical institutions. The poor development of aesthetic surgical services in the republic, coupled with the increasing need of the population for it, forced our employees four years ago to master and successfully use the techniques of this complex branch of plastic surgery.

Today at the department operations are performed:

to eliminate skin and soft tissue defects of almost any size, endoprosthetics of bones of the musculoskeletal system;
reconstruction of the mammary gland with its congenital amastia (underdevelopment), increase and decrease in the size of the mammary glands;
elimination of excess fatty tissue;
correction of any deformities of the eyelids, nose, lips, ears;
elimination of facial wrinkles.

Conducted the conversation Olga SVERKUNOVA.
Published in the magazine “Health and Success”, No. 6, 1997.

Removal of a tumor in the mammary gland

Tumor removal is usually performed for fibroadenoma. A skin incision is made either above the tumor itself, or along the edge of the areola (peripapillary circle), or along the inframammary fold (fold under the mammary gland). The last two options are more aesthetically pleasing. Usually, after a year, the scar from such an incision is quite difficult to find. The tumor itself is removed, without damaging the ducts of the mammary gland (and there are no problems for subsequent breastfeeding), there is no deformation of the gland, and there is no deficiency in the volume of the gland. The “hole” at the location of the tumor is sutured, and an intradermal suture is placed.

Should I avoid or try to delay surgery for breast cancer?

Surgical treatment of breast cancer is undoubtedly the main method of complex treatment. Its effectiveness increases significantly when combined with chemotherapy, hormonal therapy and radiation therapy.

One of the main principles of breast cancer treatment in the European clinic is to carry out mainly organ-preserving operations and operations for complete removal of the mammary gland (mastectomy), taking into account individual indications.

The essence of organ-conserving surgery for breast cancer is to remove only the focus of the breast tumor with a small amount of surrounding healthy tissue (lumpectomy and quadrantectomy). This operation is usually followed by a course of radiation therapy to the area of remaining breast tissue and regional areas.

It is important to know that for invasive cancer, both of these operations are combined with the mandatory removal of axillary lymph nodes - lymphadenectomy. For non-invasive forms of cancer, a complete three-level removal of lymph nodes is currently not performed, since this sharply worsens the quality of life of patients - swelling of the upper limb (lymphedema), impaired mobility in the shoulder joint, and chronic pain develop.

Therefore, in the European clinic, as part of the first comprehensive examination, it is mandatory to carry out. The essence of this technique is to determine whether the axillary lymph node is affected by cancer. This technique makes it possible to carry out organ-preserving treatment and preserve axillary lymph nodes if they are not affected by metastases. This certainly has a positive effect on the patient’s future quality of life. The presence of cancer cells in the sentinel lymph node indicates a high risk of detecting these cells in distant organs and tissues of the body, that is, the risk of developing metastases. In this case, MRI and scintigraphy are performed. We mandatory carry out histological and immunohistochemical studies of surgical material (removed breast tissue and lymph nodes).

Sectoral breast resection

This operation is performed for nodular mastopathy (a combined diagnosis that includes situations with a lump in the mammary gland of unknown origin). A skin incision is made either above the seal, or along the edge of the areola, or along the submammary fold. The seal is removed, the resulting defect in the gland tissue is sutured, and an intradermal suture is applied.

A special sectoral resection technique is used for intraductal papilloma (usually a small tumor located in the duct and manifested by discharge from the nipple). A dye is injected into the duct. A skin incision is made along the edge of the areola, a stained duct is found behind the nipple, it is crossed at this point, and isolated to the periphery of the nipple so that the papilloma is removed. The gland tissue and skin are sutured with an intradermal suture.

At the European Clinic, a well-known Russian mammologist surgeon, Doctor of Medical Sciences (author of more than 300 published works, board member of the Russian Society of Oncology and Mammology, author of three patents for inventions) conducts consultations and performs operations.
Sergei Mikhailovich performs the entire range of surgical interventions on the mammary gland, including organ-preserving and reconstructive plastic surgeries.

Central breast resection

It is used for intraductal papilloma, when it cannot be localized, for multiple intraductal papillomas located in the central sections of the ducts. The operation is acceptable in cases where breastfeeding is not expected. After a skin incision made along the edge of the areola, all ducts are crossed behind the nipple. The gland tissue with the central sections of the ducts is isolated to 2–3 cm and removed. The gland tissue defect is sutured and an intradermal suture is applied.

Nipple resection

Used for nipple adenoma, a rare benign tumor, or as a diagnostic step for the morphological diagnosis of Paget's cancer. The nipple is resected wedge-wise and interrupted sutures are applied with thin suture material. Some of the ducts intersect, which can complicate subsequent lactation.

Mastectomy - removal of the mammary gland (without lymph nodes). Performed for non-invasive forms of cancer (ductal carcinoma in situ, lobular carcinoma in situ), hereditary breast cancer syndrome, as a preventive operation. If simultaneous breast reconstruction is not planned, a thin linear scar remains on the breast. In cases where the operation is combined with simultaneous reconstruction of the mammary gland, mastectomy is performed using the technique of skin-sparing mastectomy (the nipple-areolar complex is removed, all other skin of the gland is preserved) or subcutaneous mastectomy (all skin of the gland is preserved). After such operations, a “skin bag” remains, which must be filled by a plastic surgeon. The aesthetic result of such operations is usually very good.

Radical mastectomies

Radical mastectomy according to Halsted

Radical mastectomy, that is, an operation that includes removal of the mammary gland with pectoral muscles and fatty tissue of levels 1–3, began to be performed by William Stewart Halsted since 1882 at the John Hopkins Hospital (John Hopkins Hospital, Baltimore, Maryland, USA). The first description of an operation performed on 13 patients dates back to 1891, this description was part of an article on wound healing (W. S. Halsted “The treatment of wounds with especial reference to the value of the blood clot in the management of dead spaces.” John Hopkins Hospital Rep., 1890–1891. 2:255.). The removal of fatty tissue is due to the presence of lymph nodes here, which were often affected by cancer metastases and consisted of multiple dense nodes of various sizes. The anatomical division of fiber is made relative to the pectoralis minor muscle: fiber outward from the pectoralis minor muscle is level 1 fiber, anterior and posterior from the pectoralis minor muscle - level 2, inward from the pectoralis minor muscle - level 3. The removal of muscles was explained by the fact that in advanced forms of the disease (which were the majority), the lymphatic vessels passing through the muscles and fascia covering the muscles were affected by the metastatic process.

The disadvantages of the operation include deformation of the chest wall. Currently, the indications for radical mastectomy according to W. S. Halsted are invasion of the pectoralis major muscle by the primary tumor and involvement of the Rotter lymph nodes, as well as palliative operations.

Patey & Dyson modified radical mastectomy

D. H. Patey and W. H. Dyson in 1948 proposed a modified method of radical mastectomy, which differs from W. S. Halsted's operation by preserving the pectoralis major muscle. The block of tissue removed includes the mammary gland, pectoralis minor muscle and lymph nodes of levels 1–3. In most cases, the operation is not inferior in effectiveness to the Halstead operation; its advantage is less trauma and less deformation of the chest wall. At the same time, not everything is simple with the remaining pectoralis major muscle. When removing the pectoralis minor muscle, 1–2 small nerve branches (lateral pectoral nerve and a branch of the medial pectoral nerve) innervating the outer part of the pectoralis major muscle are inevitably transected. Subsequently, of course, this leads to atrophy of the outer part of the pectoralis major muscle.

Madden modified radical mastectomy

Modification of radical mastectomy according to J.L. Madden involves preserving both pectoral muscles and removing fiber from levels I and II.

Radical mastectomy with pectoral muscle sparing

It is a variant of modified radical mastectomy, developed at the Federal State Budgetary Institution Russian Cancer Research Center named after. N. N. Blokhin RAMS. It involves removal of the mammary gland, removal of levels I–III fiber without removal of the pectoralis minor muscle, in contrast to the Patey & Dyson operation. The advantage of the operation is the complete removal of fiber and preservation of muscles and their innervation.

Palliative mastectomy

All previous operations performed for cancer were called “radical”. This meant that the disease was removed with the smallest “roots” and should not return; the operation was aimed at preventing the development of metastases. In other cases, when the tumor has already metastasized or when the local spread of the disease is so great that the development of metastases is most likely to follow after the operation, the operation cannot claim to be called radical. In such cases, it can be performed for palliative purposes, that is, in order to eliminate the immediate troubles associated with the presence of a tumor - tumor decay, bleeding; or in order to reduce the volume of tumor tissue and create conditions for more effective drug treatment.

Assessment of oncological risk of operations including primary reconstruction

Our clinic performs a wide range of oncological surgeries, including simultaneous breast reconstruction. The question arises: is it safe? Does additional surgery provoke the rapid development of metastases?

To answer these questions, we analyzed information about 503 patients with stage I-III breast cancer who received treatment at the Federal State Budgetary Institution Russian Cancer Research Center named after. N. N. Blokhin RAMS in 1992-2002. The main group included 124 patients, average age 41.5 years (24–67). Women were operated on with radical mastectomy with preservation of the pectoral muscles in combination with primary breast reconstruction: an expander (n=14) or a skin-fat flap on the latissimus dorsi muscle using an endoprosthesis (n=18), or a transverse rectoabdominal flap on a muscular pedicle (n=92). The control group consisted of 379 patients, mean age 40.1 years (26–79). 145 patients underwent organ-preserving surgery, 234 underwent radical mastectomy with preservation of the pectoral muscles. The groups were comparable in terms of the main factors influencing prognosis (stage, age, treatment). Drug and radiation treatment was carried out according to general principles. Median follow-up duration was 63.7 (20.4–140.5) months.

The local recurrence rate was:

in the mammary gland after organ-preserving operations - 4.1%;
after modified radical mastectomy - 1.7%;
after modified radical mastectomy with primary reconstruction - 1.6% (p>0.05).

Over the entire period of observation, relapse of the disease (that is, not only locally, but in any organs and tissues) was observed in 18.6±3.5% in the group with breast reconstruction (in 23 patients) and in 18.2±2.0 % in the control group (in 69 patients, p>0.05). The disease-free survival and overall survival curves in the compared groups were not statistically different.

According to multivariate analysis the fact of performing primary breast reconstruction does not affect the development of disease relapse. Analysis of factors influencing the relapse of the disease shows the predominant influence of such known factors as T, N criteria, age, and chemotherapy. The fact of primary reconstruction did not have a statistically significant effect on the process of tumor recurrence. Thus, Primary breast reconstruction can be safely performed in patients with breast cancer.

However, the greater the volume of operations, the more likely complications of their healing are, especially in patients with concomitant diabetes mellitus, obesity and long-term smoking. In them, prolonged wound healing may delay adjuvant radiation therapy and chemotherapy. Therefore, for patients with planned adjuvant chemotherapy or radiation therapy who have the listed factors that impair wound healing, it is preferable to refuse primary reconstruction.

Organ-conserving surgery for breast cancer

The history of the development of organ-sparing operations for breast cancer is relatively short. Such operations became possible due to a combination of three main factors: 1) earlier detection of the disease; 2) the realization that expanding the scope of surgery for early forms of cancer does not lead to improved survival of patients; 3) the use of radiation exposure to the preserved mammary gland as a powerful means of reducing the likelihood of local relapse.

G.Crile Jr. in 1975 presented 10-year results of a randomized trial comparing breast-conserving partial mastectomy with total mastectomy. In the comparison groups there were 42 patients with primary operable cancer. Cancer mortality rates over 10 years were 34% and 38%, respectively.

Lumpectomy

The minimal surgical intervention in terms of the volume of breast tissue removed - lumpectomy (lump - lump, piece, lump), was developed during the research of the National Breast and Bowel Surgery Supplementation Project (USA, NSABBP).

The study included patients with a tumor size of no more than 4 cm. Groups of patients with different types of treatment were compared: lumpectomy (group 1), lumpectomy with radiation therapy (group 2), modified radical mastectomy (group 3).

During a 12-year follow-up, local relapse in the mammary gland developed in patients of the 1st group in 35%, of the 2nd group - in 10%. There were no significant differences in overall survival and survival without distant metastases between the compared groups. The general conclusion about the equal effectiveness of breast-conserving treatment and radical mastectomy was also confirmed at 20-year follow-up. The rate of local recurrence after lumpectomy was 39.2%, after lumpectomy with irradiation - 14.3%.

From the point of view of surgical techniques, organ-sparing operations of the first stage (partial mastectomy, quadrantectomy, radical resection) in their original form (wide wedge-shaped resections without additional restoration of the shape of the gland) are a thing of the past. Modern organ-saving surgeries include lumpectomy and oncoplastic resection. A detailed analysis of world experience on the oncological risk of organ-conserving operations is presented below.

Having gained our own experience in performing lumpectomy, we came to the need to modify it. The modification concerns two points: the tumor must be removed with a supply of healthy tissue around it, and the gland tissue must be sutured. For small tumors (up to 1–2 cm), lumpectomy remains the best operation: non-traumatic and elegant.

If the tumor is large or centrally localized, in order to preserve the shape of the gland, there is a need for additional efforts to move tissue, and/or intervention on the contralateral gland to maintain symmetry, that is, the need to perform oncoplastic resections.

Oncoplastic resections

The term “oncoplastic resection” is generally accepted in the world literature and implies the performance of breast resection for cancer using plastic surgery methods to restore the shape of the gland, and it is also possible to combine it with simultaneous surgical intervention on the opposite gland to restore symmetry.

One of the first operations that can be classified as oncoplastic resection (the term “oncoplastic resection” was proposed later) was breast reconstruction according to A. Grisotti - the most successful method of restoring the shape of the gland after removal of its central part. After resection of the central part of the gland along with the nipple and areola, a skin incision is made vertically down from the medial edge of the resulting wound, which is then extended laterally along the inframammary fold. Below the wound defect, part of the skin is de-epidermised, leaving an island of skin corresponding in size to the areola. In the projection of the vertical part of the skin incision, the gland tissue is dissected throughout its entire thickness to the submammary space, and the entire lower-outer quadrant of the gland is mobilized. The mobilized gland tissue is rotated, its part located under the skin island is moved to the central section and sutured. Subsequently, tattooing of the newly created “areola” and nipple plastic surgery can be performed.

In Russia, the period of oncoplastic resections started in the early 90s, when an operation using the inverted “T” reduction plastic technique was proposed. The operation was performed for lower tumor localizations; reduction plastic surgery of the opposite gland was mandatory.

Currently, there are a lot of options for oncoplastic resections; we can say that there are as many of them as there are patients. The technique and course of the operation is dictated by the oncological situation, the shape of the mammary glands, the characteristics of the tissue condition, and the surgeon’s favorite techniques.

Organ-conserving operations are not automatically an adequate type of treatment. A thorough examination of patients who are planning such an operation is necessary. It is better to have a mastectomy than breast-conserving surgery that does not meet the oncological criteria.

The “cleanliness” of the resection margins is the main indicator of the adequacy of organ-saving surgery. Organ-conserving surgery is recognized as a radical option for local treatment only in combination with radiation therapy.

After breast cancer surgery: nutrition, prognosis, risk of recurrence

Surgery is the most radical method of treating cancer. But, even if the tumor is completely removed and the doctor has declared remission, there is still a risk of relapse in the future. Every woman who has successfully completed treatment should be under the supervision of a doctor.

You will have to visit a mammologist every few months. Over time, the doctor will invite you for examinations less and less often, after 5 years - approximately once a year (if no relapses have occurred during this time). Your doctor will order a mammogram 6–12 months after surgery, which will then need to be done annually. For certain indications, regular examinations by a gynecologist, determination of bone density and other studies are prescribed.

How long do you live after surgery for breast cancer?

The average life expectancy after breast cancer surgery is estimated by the five-year survival rate. It refers to the percentage of patients who remain alive five years after diagnosis. Five-year survival rate for breast cancer primarily depends on the stage at which treatment is started:

Stage I - almost 100%.
Stage II - 93%.
Stage III - 72%.
Stage IV - 22%.

In addition to the stage, factors such as age, the general health of the woman, the type of tumor, and lifestyle also play a role. There are no specific recommendations that would help to significantly improve the prognosis of survival after surgery for breast cancer. You need to lead a healthy lifestyle in general: eat right, maintain physical activity, monitor your body weight, avoid smoking and alcohol.

Proper nutrition after breast cancer surgery

After treatment, the body recovers, so it must receive enough protein. In the immediate postoperative period, you should not worry about excess calories, even if you are overweight. Now it's important to recover. You can lose weight later.

Some substances found in plant foods help improve health and reduce the risk of relapse:

Phytoestrogens, which are contained in soy, according to some studies, help reduce the risk of recurrence of estrogen-positive cancer. Other studies have not found this effect.
Antioxidants found in many fruits and vegetables, especially in broccoli, blueberries, carrots, and mangoes. They help protect cells from damage.
Lycopene- one of the antioxidants that gives red color to tomatoes and pink color to grapefruit.
Beta-carotene gives orange color to carrots and apricots. There is some evidence that it helps prevent cancer.

Should you take dietary supplements? Nutritionists believe that a diet rich in a variety of fresh foods is much better than dietary supplements.

Bibliography:

S. M. Portnoy, S. N. Blokhin, Kh. S. Arslanov, et al. Assessment of the oncological risk of simultaneous reconstructive operations for breast cancer. Questions of Oncology, 2008, No. 6, 720–723.