Breast Surgery ppt RPN Student Copy 2023.pdf

Breast Surgery S425: RPN PERIOPERATIVE PROGRAM Learning Objectives Describe the normal anatomy of the breast. Differentiate between benign and malignant breast lesions. Describe the risk factors associated with breast cancer. Describe the surgical procedures used to treat benign and maligna...

Breast Surgery S425: RPN PERIOPERATIVE PROGRAM Learning Objectives Describe the normal anatomy of the breast. Differentiate between benign and malignant breast lesions. Describe the risk factors associated with breast cancer. Describe the surgical procedures used to treat benign and malignant breast disease. Understand the importance of specimen handling in breast surgeries. Understand instrument isolation for cases with carcinoma. Compare and contrast a sentinel node biopsy and an axillary node biopsy as it relates to treatment of breast cancer. Introduction Breast surgery is to diagnose and treat breast disease Breast cancer is the most common cancer in women 1:8 women will develop breast cancer Early detection is a result of decreasing incidences Anatomy Bilateral mammary glands Extend from 2nd to 6th rib Lateral edge of sternum, anterior axillary line Fascial support from ___________________ Tail of Spence extends laterally to the axilla 12 to 20 glandular lobes; each has a single duct Ducts terminate on the nipple Pigmented areola surrounds the nipple Blood Supply Internal mammary artery Anterior aortic intercostal arteries Pectoral branch of the axillary arteries Lymphatics Follow the course of the blood vessels Axillary and internal thoracic nodes are the main area of drainage Nerve Supply Anterior lateral intercostal nerves Medial intercostal nerves Cervical plexus Benign Lesions Lesions Features Fibroadenoma Most common – solid mass Fibrocystic Tender, mobile, fluctuates in size Ductal ectasia Tissue inflammation and fibrosis, nipple discharge Intraductal papilloma Mass in duct, not palpable, nipple discharge Most Common Benign Lesions Fibroadeonoma and Fibrocystic Breast Disease – Affects primarily young women < 30yrs – Solid or mobile – Painless or tender – Grow very slowly – Usually discovered spontaneously Breast Cancer Most common diagnosis is infiltrating ductal carcinoma Survival is improved with early detection The larger the tumor = likely chance lymph nodes are involved 60 years Age Menstrual history Genetic factors Radiation exposure Oral contraceptives Family history Dense breasts Obesity Previous breast Hx of breast cancer cancer Screening Technologies Recommended for women ages 45 – 55 annual screening 55 + biennial screening High risk (with BRCA1) = 30 years + Mammography - Screening and Diagnostic Ultrasound Wire Localization MRI Mammography Film or digital based Detects abnormal densities, irregular margins, calcifications, microcalcifications, masses as small as 1 cm Ultrasonography Differentiates between solid and cystic lesions Sensitivity and specificity less definitive than mammography  Mammography A- Mass B- Clustered Microcalcifications Additional Screening Technologies MRI Useful for imaging dense tissue Improves tumor staging Molecular Breast Imaging (MBI) Inject radiotracer absorbed by breast tissue/tumor Used to detect cancer in dense breast tissue Palpable abnormality not found on mammogram Diagnostic Testing Fine-needle aspiration biopsy (FNAB) Ultrasound-guided fine-needle aspiration biopsy Core needle biopsy Ultrasound-guided Stereotactic MRI-guided Open Breast Biopsy Fine Needle Aspiration Biopsy Used for differentiation of solid and cystic masses New, dormant mass as well Aspirates (tissue and fluid) with small needle (22G) Sent to Cytology Ultrasound guided Core Needle Biopsy Preferred method – cost effective and minimally invasive Outpatient setting Used for palpable mass (lump) or suspicious area on mammogram (non- palpable) Large biopsy needle inserted in breast tissue sample Specimen sent to Pathology  Breast Biopsy with Wire Localization Wire placed into breast lump before surgery Used to localize nonpalpable (small) mammographic lesions Repeat mammogram, Localization, and biopsy occur on same day Specimen sent to radiology with wire Staging of Breast Cancer TNM classification (Tumor, Node, Metastasis) Treatment is based on the stage of breast cancer Tumors are also evaluated for their estrogen- and progesterone- binding abilities This will influence the treatment plan Stage Description 0 1. Ductal carcinoma in situ (DCIS): Intraductal carcinoma; Abnormal cells in the lining of a duct 2. Lobular carcinoma in situ (LCIS): Abnormal cells in the lining of a lobule 1 Tumor < 2 cm with no axillary lymph node involvement and the cancer has not spread outside the breast 2 Tumor is 2 to 5 cm, with/without axillary lymph node involvement 3 Tumor is < or equal to 5cm with axillary lymph node, other lymph involvement, and surrounding breast tissue 4 Cancer has spread beyond lymph nodes and to other organs of the body (lungs, brain, liver, bone) Surgical Treatment Considerations Procedures are based on: Size and site of mass Cell characteristics Stage of disease Patient’s choice Perioperative Nursing Considerations Emotional impact of diagnosis on patient Anxiety level Supine position Arm on armboard for potential of axillary dissection Minor count Prep – dependent on procedure Instrument contamination SPECIMEN MANAGEMENT! Specimens Lahey Thyroid Forcep – instrument to retrieve breast biopsies Isolate contaminated instruments on sterile field Test: _________________ Dry sterile specimen container Sent to pathology immediately and wait for results with how to proceed Sequence of Specimen Communication 1. Surgeon to Scrub Nurse 2. Scrub Nurse to Surgeon 3. Scrub Nurse to Circulating Nurse 4. Circulating Nurse to Scrub Nurse 5. Circulating Nurse verifies completed specimen form and patient label to Scrub Nurse __________ sending to the lab Specimens numbered and marked with “Silk Marking Stitch” for tissue orientation Example: Specimen #1: Right breast sentinel lymph node, suture at apex, for ‘Quick-Section’ Surgical Interventions 1. Lumpectomy 2. Sentinel Lymph Node Biopsy 3. Axillary Lymph Node Dissection 4. Simple Mastectomy 5. Modified Radical Mastectomy Types of Breast Biopsies Incisional biopsy – Removes portion of the mass Excisional biopsy – Removes entire mass with small margin Wire localization – Performed by radiologist prior to surgery Lumpectomy Treatment of choice for small tumors Surgical procedure to remove: A suspected malignant tumor or lump A small margin of surrounding breast tissue Can be combined with a Sentinel Lymph Node Biopsy (SLNB) Tissue is sent to lab for ‘Quick Section’ Surgeon waits in OR for result – standby Results determine how to proceed Sentinel Lymph Node Biopsy Sentinel Lymph Node - the first node that fluid (lymphatic drainage from tumor) passes through SLN Biopsy Determines prognosis of the diagnosis Remove 1 – 5 SLN from underarm Node identified with injection of methylene blue or technetium-99 Sent for ‘Quick Section’ Surgeon waits for results to determine next steps SLNB Results Negative SLNB Indicate decreased likelihood of additional lymph node involvement Positive SLNB Malignant Requires axillary dissection and adjunctive therapy Sentinel Node Equipment Gamma-Tracer Probe Technetium-99 Imaging assists the surgeon in Methylene Blue Dye identifying where the SLN lies Axillary Lymph Node Dissection Removal of axillary nodes through an incision in the axillary area Allows for staging of disease Simple vs. Modified Mastectomy Simple ◦ Removal of the entire involved breast without lymph node dissection Modified Radical ◦ Removal of involved breast and all axillary contents Simple Mastectomy Done to remove: Excessive benign disease Malignancy is confined only to breast tissue Palliative measure to remove ulcerated advance malignancy Modified Radical Mastectomy Removal of the entire breast tissue and axillary lymph nodes Not the muscle under the breast Surgical Instruments 42 Lahey Thyroid Forcep Louer / Mixter / Right Angle References Rothwell, J. (2022). Alexander’s Care of the Patient in Surgery (17th ed.) Mosby Elsevier Tighe, S. (2015). Instrumentation for the Operating Room (9th ed.), Mosby. ORNAC Standards 2023