.

DEFINITION • MASTECTOMY - is surgery to remove all breast tissue from a breast as a way to treat or
prevent breast cancer. • Mastectomy is used to remove all breast tissue for breast cancer or patients with
very high risk of developing it. • Mastectomy to remove one breast (unilateral mastectomy) • both breasts
(bilateral mastectomy).
. 3. Types of breast surgery includes: • Total (simple) mastectomy – removal of breast tissue and nipple •
Modified radical mastectomy – removal of the breast, most of the lymph nodes under the arm, and often the
lining over the chest muscles • Lumpectomy – surgery to remove the tumor and a small amount of normal
tissue around it
. 4. Risk of Mastectomy • Bleeding • Infection • Pain • Swelling (lymphedema) • Formation of hard scar tissue
at the surgical site • Shoulder pain and stiffness • Numbness, particularly under your arm, from lymph node
removal • Buildup of blood in the surgical site (hematoma)
. 5. Providing preoperative nursing care for patients who are to undergo Mastectomy is an integral part of the
therapeutic regimen. The nursing goal is to provide support, alleviating anxiety, managing pain, and
providing information.
. 6. Nursing Interventions Rationale Check out and explore what information patient has about diagnosis,
expected surgical intervention, and future therapies. Note presence of denial or extreme anxiety. Provides
knowledge base for the nurse to enable reinforcement of needed information, and helps identify patient with
high anxiety, low capacity for information processing, and need for special attention. Note: Denial may be
useful as a coping method for a time, but extreme anxiety needs to be dealt with immediately. Ascertain
purpose and preparation for diagnostic tests. More understanding of procedures and what is happening
increases feelings of control and lessens anxiety. Implement an ambiance of concern, openness, and
availability, as well as privacy for patient and SO. Suggest that SO be present as much as possible. Time and
privacy are needed to provide support, discuss feelings of anticipated loss and other concerns. Therapeutic
communication skills, open questions, listening, and so forth facilitate this process. Encourage questions and
provide time for expression of fears. Tell patient that stress related to breast cancer can persist for many
months and to seek help and support. Provides opportunity to identify and clarify misconceptions and offer
emotional support. Consider role of rehabilitation after surgery. Rehabilitation is an essential component of
therapy intended to meet physical, social, emotional, and vocational needs so that patient can achieve the
best possible level of physical and emotional functioning.
. 7. Nursing Interventions Rationale Consider reports of pain and stiffness, noting location, duration, and
intensity (0–10 scale). Note reports of numbness and swelling. Be aware of verbal and nonverbal cues. Aids
in identifying degree of discomfort and effectiveness of analgesia. The amount of tissue, muscle, and
lymphatic system removed can affect the amount of pain experienced. Destruction of nerves in axillary region
causes numbness in upper arm and scapular region, which may be more intolerable than surgical pain. Note:
Pain in chest wall can occur from muscle tension, be affected by extremes in heat and cold, and continue for
several months. Discuss normality of phantom breast sensations. Provides reassurance that sensations are
not imaginary and that relief can be obtained. Facilitate patient to find position of comfort. Elevation of arm,
size of dressings, and presence of drains affect patient’s ability to relax, rest and sleep effectively. Provide
basic comfort measures (reposition on back or unaffected side, back rub) and diversional activities.
Encourage early ambulation and use of relaxation techniques, guided imagery, Therapeutic Touch.
Promotes relaxation, helps refocus attention, and may enhance coping abilities. Splint or support chest
during coughing and deep-breathing exercises. Facilitates participation in activity without undue discomfort.
Carry out appropriate pain medication on a regular schedule before pain is severe and before activities are
scheduled. Maintains comfort level and permits patient to exercise arm and to ambulate without pain
hindering efforts. Administer narcotics or analgesics as indicated. Provides relief of discomfort and pain and
facilitates rest, participation in postoperative therapy.
. 8. Mastectomy Complications Most patients recover from mastectomy without any problems, but
complications such as infection, lymphedema, and seroma can occur. •Infection usually manifests as
redness and swelling of the incision with pus or foul-smelling drainage. Fever may also indicate infection.
•Lymphedema may occur when the lymph nodes are removed. The arm on the affected side sometimes
becomes swollen when the lymph system is damaged by lymph node removal or radiation. Sometimes it
resolves on its own, but the condition can become chronic. •Seroma occurs when blood or fluid accumulates
in an area of the body that has just undergone surgery. Sometimes the body absorbs it, but if it becomes
painful or infected, it must be removed.
. 9. Nursing Interventions Rationale Stress proper hand washing technique Handwashing is the single most
effective way to prevent infection Provide regular catheter care To reduce risk of infection Instruct on proper
wound care For first line defense against nosocomial infections or cross contamination Encourage to eat
vitamin C rich foods To promote wound healing Emphasized necessity of taking antibiotics as directed To
boost the immune system Closely observe and instruct to report signs and symptoms of infection such as
fever, sore throat, swelling, pain and drainage To prevent and detect as early as possible the presence of any
progressing infection Inspect the wound for swelling, unusual drainage, odor redness, or separation of the
suture lines Wound infection are accompanied by signs of inflammation and a delay in healing Empty and
re-establish negative pressure in close wound drains at least once per shift Negative pressure pulls fluid from
the incisional area, which facilitates healing Post-operative Care
. 10. Nursing Interventions Rationale Elevate affected arm as indicated. Promotes venous return, lessening
possibility of lymphedema. Facilitate passive ROM (flexion and extension of elbow, pronation and supination
of wrist, clenching and extending fingers) as soon as possible. Early postoperative exercises are usually
started in the first 24 hr to prevent joint stiffness that can further limit movement and mobility. Have patient
move fingers, noting sensations and color of hand on affected side. Lack of movement may reflect problems
with the intercostal brachial nerve, and discoloration can indicate impaired circulation. Encourage patient to
use affected arm for personal hygiene (feeding, combing hair, washing face). Increases circulation, helps
minimize edema, and maintains strength and function of the arm and hand. These activities use the arm
 without abduction, which can stress the suture line in the early postoperative period. Help with self-care
activities as necessary. Conserves patient’s energy, prevents undue fatigue. Assist with ambulation and
encourage correct posture. Patient will feel unbalanced and may need assistance until accustomed to
change. Keeping back straight prevents shoulder from moving forward, avoiding permanent limitation in
movement and posture.
. 11. Recommendations: •Proper assessment should be done before and after operation to prevent post-op
complications such as bleeding. •Practice aseptic technique all the time - to prevent infection. •Inform treating
physician for any untoward complication noted – early detection can lessen the extent of damage that might
happened to the patient.

ctively participate in decision-making process related to treatment optionsFully comply with therapeutic planManage
side effects of therapyBe satisfied with support provided by significant others and health care providers

45 Nursing Intervention Complications; Heaviness Pain

Impaired motor function in armNumbnessParesthesia of the fingersCellulitis and progressive fibrosis can result

46 Measures to decrease Lymphedema

PositioningPlace in a semi-Fowler’s position with arm on affected side elevated on a pillow, never
dependentExerciseFlexing and extending fingers should begin in recovery room and progressive increase in
activityExercises are designed to prevent contractures and muscle shortening, maintain muscle tone, and improve
lymph and blood circulationPostoperative arm and shoulder exercises are instituted gradually at surgeon’s direction

47 Measure to decrease Lymphedema

Avoid constrictionDo not take Blood pressure readings on that armAvoid constrictive clothingCompressionWrap arm
with bandages going from distal to proximalUse intermittent pneumatic compression sleeve or a fitted elastic pressure
gradient sleeveMassage Therapy

48 Protection of the Arm with Lymphedema

Venipunctures, and injections should not be done on affected armApply insect repellantWear gloves when
gardeningUse cooking mittUse electric razor for shaving axillaAvoid cutting cuticles – push back cuticleNo heavy
liftingKeep clean and dry

49 Postoperative Exercises

50 Nursing Interventions
Relieve postmastectomy pain syndrome:Chest and upper arm pain, tingling down armNumbness, shooting or prickling
painUnbearable itching persisting beyond 3-month healing timeTreatment includesNonsteroidal antiinflammatory
drugsAntidepressantsTopical lidocaine patches or EMLA

51 Nursing Implementation
Postoperative discomfort can be minimized by administering analgesics ~30 minutes prior to exercisesWhen
showering is appropriate, warm water has a soothing effect and decreases joint stiffness

52 Nursing Implementation
Psychologic careAll aspects of care must include sensitivity to woman’s effort to copeNurse can help by:Assisting her to
develop a positive but realistic attitudeHelping her identify sources of support and strength to her

53 Follow up Care Must be follow-up for rest of life at regular intervals

Professional examinations every 6 months for 2 years, then annuallyPractice monthly breast self examinations (BSE)
on both breasts or remaining breast

Limited cell divisionUndergo apoptosisControlled growthWell differentiatedAdhere tightly togetherContact

inhibitedEuploidMALIGNANTRapidly dividing/multiplyingDo not undergo apoptosisUncontrolled growthAnaplastic
morphologyAdhere loosely togetherAble to move / metastasizeAneuploid

reast Cancer IDC Infiltrating (Invasive) Ductal Carcinoma

Most arise from the ducts80% of all breast cancers are IDCTumor is in ducts and/or lobules and fatty tissueIrregular
tumor borderDCIS -Ductal Carcinoma In Situ-NoninvasiveHas not spread to fatty tissueAbout 20% of all breast cancers

43 Clinical Manifestations Breast Cancer

Detected as lump or mammographic abnormality in breastMost often in upper, outer quadrant of breastNipple
discharge/Nipple retraction43 43

44 Clinical Manifestations Breast Cancer

Peau d’orange (orange peel) skin from plugging of dermal lymphaticsInfiltration, induration, dimpling of overlying skin in
large cancers
46 Collaborative CarePrognostic factors considered when treatment decisions are madeStaging of breast cancerTNM
systemTumor size (T)Nodal involvement (N)Presence of metastasis (M)46 46

47 Management of Breast Cancer: Surgery

Breast conserving surgeryLumpectomySentinel Lymph Node DissectionRadiation used with lumpectomy for stage I/II
cancersModified radical mastectomy with axillary node dissectionRemove breast and axillary lymph nodesModified
radical mastectomy-the most common surgical procedure.Lumpectomy and radiation is an alternative for stage I& II
disease.

48 Mastectomy

49 Nursing Care: Mastectomy

Relieving Pain and DiscomfortMaintaining Skin Integrity and Infection PreventionPromoting Positive Body
ImagePromoting Positive Adjustment and CopingPromoting Participation in Care – Post- mastectomy
exercisesManaging Post-op SensationsImproving Sexual Function

50 Nursing Care: Mastectomy

AssessmentV/SPainNeurovascular of affected armIncisions/DrainsPsychological state

51 Complications post operative

LymphedemaHematoma

52 Prevent LymphedemaNo B/P, injections, or venipunctures in affected armEarly movement of fingers post-
opElevation of arm above heartNo elastic bandages early post- op

53 Surgical Therapy: Follow-up Care

Follow-up must occur at regular intervalsProfessional examSelf breast examMammographyMost common site of
recurrence is at surgical site.53

54 Adjuvant Therapy Radiation therapy after breast conservation surgery

Systemic therapiesChemotherapyHormonal therapyBiologic therapyMost common side effects involveGastrointestinal
tractBone marrowHair follicles54

55 Nursing DiagnosesVaries, related to care of a patient diagnosed with breast cancerFollowing diagnoses, before
selection of treatment planDecisional conflictFearDisturbed body image55 55

56 Planning Overall goals

Actively participate in decision-making process related to treatment options.Fully comply with therapeutic plan.Manage
side effects of adjuvant therapy.Be satisfied with support provided by significant others and health care
providers.56 56

57 Nursing Implementation General Interventions

Education and psychosocial supportPost-op carePost-op exercises: Restoring arm functionPrevent
LymphedemaPrevent trauma, isometric exercisesDecongestive therapy, arm elevation, compression TXDiuretics57

58 Nursing Implementation Ambulatory and Home Care

Reporting of S/SX of complications and reoccurrenceImportance of annual mammography and BSEMental health
referralSpecific instructions about appointment times and treatment locations, if adjuvant therapy is usedFollow-up
related to reconstructive surgery58

59 Evaluation Expected outcomes Pain control Coping Body image

Knowledge about treatment procedure and diseaseCoordinated movement59

60 Prevention Follow guidelines for screening

Discuss hormone replacement therapy with MDExercise 30 minutes dailyDiet rich in fruits, vegetables, & whole grain.
Limit

ISK FACTORS*Being female- Women account for 99% of breast cancer cases.*Age 50 or older- Majority of cases
found in women who are postmenopausal. Incidencecontinues to increase after age 60.*Family history- Breast cancer
in a first-degree relative increases the risk. BRCA-1 or BRCA-2gene mutations result in 5%-10% of breast cancer
cases.*Personal health history of breast, colon, endometrial or ovarian cancers- Increases the risk,increases risk in
other breast and increases recurrence rates.*Early menarche (before age 12); late menopause (after age 55)- Long
menstrual history mayincrease risk of breast cancer.*Weight gain and obesity after menopause- Fat cells store
estrogen.*Exposure to ionizing radiation- Radiation is damaging to DNA.>> Lewis, et al. (2007). P

4 TYPES OF BREAST CANCER SURGERY

*Modified Radical*Radical*Axillary Node Dissection*Breast Conservation Surgery

5 MODIFIED RADICAL WHAT IS IT?

*Removal of the breast and axillary lymph nodes*Preservation of pectoralis muscle*Most commonly used with large
sized tumors*Breast reconstructive surgery is an option.POTENTIAL COMPLICATIONS*Short-term: Skin flap,
necrosis, seroma,hematoma, infection*Long-term: Sensory loss, muscleweakness, lymphedemaSIDE
EFFECTS*Chest wall tightness*Phantom breast sensations*Arm swelling*Sensory changesPATIENT ISSUES*Loss of
breast*Incision*Body image*Impaired arm mobility>> Lewis, et. al. (2007). P. 1353

6 BREAST CONSERVATION SURGERY W/ RADIATION THERAPY

WHAT IS IT?*Wide excision of tumor, sentinal lymph nodedissection and/or anterior lymph node dissection,radiation
therapy.PATIENT ISSUES*Prolonged treatment*Impaired arm mobility*Change in texture and sensitivity to
breastSIDE EFFECTS*Breast soreness*Breast edema*Skin reactions*Arm swelling*Sensory changes (breast and
arm)*Fatigue*Discomfort*Chest wall tightnessPOTENTIAL COMPLICATIONS: Short-term: Moist
desquamation,hematoma, seroma, infectionLong-term: Fibrosis, lymphedema, pneumonitis, rib fractures>> Lewis, et.
al. (2007). P. 1353

7 TISSUE EXPANSION & BREAST IMPLANTS

WHAT IS IT?*Expander used to slowly stretch tissue;Saline gradually injected into reservoir overweeks to
months.*Insertion of implant under muculofascial layerSIDE EFFECTS*Discomfort*Chest wall tightnessPOTENTIAL
COMPLICATIONS*Short-term: Skin flap, necrosis, wound separation,seroma, hematoma, infection*Long-term:
Capsular contractions,displacement of implantPATIENT ISSUES*Body image*Prolonged physician visits to expand
implants*Additional surgeries for nipple construction*Symmetry>> Lewis, et. al. (2007). P. 1353

8 MUSCULOCUTANEOUS FLAP PROCEDURES

WHAT IS IT?*Contains muscle, skin, blood supply.*Is transposed from latissimus dorsi to transverserectus abdominis
to chest wallSIDE EFFECTS*Pain related to two surgical sitesand extensive surgeryPATIENT ISSUES*Prolonged
postoperative recoveryPOTENTIAL COMPLICATIONS*Short-term: Delayed wound healing,Infection, skin flap
necrosis, abdominal hernia, hematoma.>> Lewis, et. al. (2007). P. 1353

9 PREOPERATIVE TEACHING
*Prior to preoperative teaching: Nurse should assess patient’s learning needs,realize that every patient is different, be
ready for any type of questions.*Inform patient that after her mastectomy she will be staying in the hospital for one
night.*If reconstruction occurs during surgery, stay could be 2-4 nights.*Evaluation by healthcare provider will be
done.*Blood tests, urinalysis, and ECG will be done before surgery.*Make healthcare provider aware of medications
which are currentlybeing taken, drug allergies, or any other allergies.*NPO after midnight.*Shower with antibacterial
soap the night before.*Inform patient that surgery lasts 1 to 2 hours, depending on type of mastectomy.*Inform patient
of postoperative care both in the hospital and at home.*Possibly show photographs of women who have had
mastectomy (if patient feels comfortable).>> Weaver. (2009). P. 44

10 POSTOPERATIVE TEACHING
*Monitor vital signs as ordered by physician*Monitor pain, bleeding, hematoma, seroma formation,and wound infection
(wound infections most likely to occur within first two weeks).*Follow dressing protocol (gauze and transparent
dressings most typical).*Encourage patient to look at incisions to see what is normal(benefits home care).*Expected to
have two surgical drains withmodified radical mastectomy.*Teach how to milk and strip clots throughdrainage tubing to
maintain patency.*Teach how to measure fluid from drainage device.*Monitor for phantom pain.*DO NOT use heating
pad. Altered sensation may result in burns.>> Weaver. (2009). P. 44

11 SENTINAL NODE BIOPSY WHAT IS IT?

*Mostly used for both palpable and non-palpable T1 and T2 tumors.*Helps surgeons and healthcare team determine
and identify the lymphnode(s) that drain first from the tumor site (sentinal node).IS THIS THE RIGHT CHOICE FOR
ME?*Sentinel lymph node biopsy should be offered as asuitable alternative to axillary dissection in a
womanwith:-Unifocal tumour of diameter less than orequal to 3 cm-Clinically negative axilla, including consideration
ofimaging finding.HOW IS IT DONE?*A radioisotope and/or blue dye is injected into the tumor site.*Where possible
lymphatic mapping with preoperativelymphoscintigraphy in combination with intraoperative use of thegamma probe
and blue dye should be used to locate the sentinel node.*It is then determined in which sentinal lymph nodes that
theradioisotope or blue dye appears.*The surgeon then makes a local incision in theaxilla and dissects the blue-stained
and/or radioactive lymph nodes.WHAT’S NEXT?*Generally one to four lymph nodes are removed.*Nodes are then
sent for a frozen section pathologic analysis.*If nodes are negative, no further removal is necessary.*If nodes are
positive, a complete axillary dissection is typically performed.*Sentinal node biopsy has been associated with lower
morbidity rates andgreater accuracy as with other performed methods.>> Lewis, et. al. (2007). P. 1351>> (2009) NZ
Guideline Group.>>Bonema, et. al. (2002). P

13 HOLISTIC HEALING TIME OF DIAGNOSIS

*Many women feel fear, shock, anger, anxiety, denial anddepression. They often wonder, “why me?”*As patient
questions regarding fears and concerns with cancer diagnosis.*Suggest women’s support groups*Assure the patient
that the healthcare team will be there for support.POST-MASTECTOMY*When evaluation patient after a mastectomy,
all areasof functioning should be taken into account: physical,cognitive, emotional and social.*Loss of feeling of
femininity, maternity and sexuality.*Family situation and marital status affect everyday functioning.NURSES ARE
HERE TO HELP*Patients need a professional and supportive attitude from health service employees.*Women who
receive better social support tend to recover more quickly, cope better, and have more selfrespect.*Extend support to
patients over an extended postoperative time.*The nursing staff should have an educational role towards women after
mastectomy and should be fully equipped toperform it.>> Skrzypulec, et. al. (2008). P. 613, 614, 617, 618.

14 WHAT ABOUT LYMPHEDEMA? WHAT IS IT?

*Occurs with the axillary lymph node dissection.*Includes swelling, tightness, heaviness, or pain in the hand, arm, or
chest on the sameside as surgery.*May occur a few months to up to 30 years after surgery.*The fewer the amount of
lymph nodes removed, the less chance of getting lymphedema.*About 30% of patients who undergo axillary lymph
node disection develop lymphedema.*About 7% of patients who have a sentinal node biopsy develop
lymphedema.RISK FACTORS*Increasing age*Obesity*Extensive axillary disease*Radiation therapy*Injury/infection of
the arm>> Weaver. (2009). PPATIENT PREVENTION*Inform healthcare provider to takeBP’s on unaffected
arm.*Avoid wearing tight clothing orjewelry on affected arm.*Use electric razor for shavingunderarms.*Wear sunscreen
with SPF of at leastSPF 15.*Wear rubber gloves when washingdishes to avoid harsh detergents.*Sleep on back or
non-surgical side.*Avoid heavy lifting for 4-6 weeks.

16 REVIEW QUESTIONS ANY FURTHER QUESTIONS?

*What percentage of women account for breast cancer cases?*Name two of the four types of major breast cancer
surgery.*What is one important precaution a patient should take to prevent lymphedemapost-mastectomy?ANY
FURTHER QUESTIONS?

17 WORKS CITEDLewis, Sharon L., Margaret M. Heitkemper, Shannon Ruff Disksen, Patricia Graber O’Brien, and
LindaBusher. Medical-Surgical Nursing (Single Volume) Assessment and Management of Clinical Problems.St. Louis:
Mosby, 2007.Skrzypulec, Violetta., Tobor, Ewa., Drosdzol, Agnieszka., Nowosielski, Kryzysztof.
“Biopsychosocialfunctioning of women after mastectomy.” Journal of Clinical Nursing (2008):Surgery for early invasive
breast cancer. In: New Zealand Guidelines Group. Management of earlybreast cancer. Wellington (NZ): New Zealand
Guidelines Group (NZGG); 2009:Weaver, Caroline. “Caring for a patient after mastectomy.” Nursing 2009 (2009):

SCREENING RECOMMENDATIONS

SCREENING MAMMOGRAM (Baseline) at age 40, and annually after age (Best 1 week after menstrual period)

BREAST SELF EXAM monthly, age 20

CLINICAL BREAST EXAM yearly after age 40

8 CLINICAL BREAST EXAM yearly after age 40

BARRIERS:

fear of pain, radiation, results

accessibility, cost

modesty

knowledge deficit

9 CANCER SCREENING: HIGH RISK

Screening:BSE monthly, age 20

CBE q6-12 mo., ages 25-35

Mammography annually, ages years of age

Options:

Decrease risk factors?

Prophylactic mastectomy

Chemoprevention

(Tamoxifen & other newer drugs)

10 BREAST SELF EXAM GOAL: Early detection IN PREPARATION FOR TEACHING:

Assess: knowledge base , motivation

fears and concerns

family history

risk factors

TEACHING: Use show and tell; use finger pads

EXAM: monthly, day 5-7 of menstrual cycle; after menopause same day each month

Use in conjunction with mammography & CBE

11 Breast Self Exam - Step 1

Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips.

Here's what you should look for:

Breasts that are their usual size, shape, and color.

Breasts that are evenly shaped without visible distortion or swelling.

If you see any of the following changes, bring them to your doctor's attention:

Dimpling, puckering, or bulging of the skin.

A nipple that has changed position or become inverted (pushed inward instead of sticking out).

Redness, soreness, rash, or swelling.

12 Breast Self Exam - Step 2 and 3

Raise your arms and look for the same changes.

While you're at the mirror, gently squeeze each nipple between your finger and thumb and check for nipple discharge
(this could be a milky or yellow fluid or blood).

13 Breast Self Exam - Step 4

Feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right
breast. Use a firm, smooth touch with the first few fingers of your hand, keeping the fingers flat and together.

Cover the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from
your armpit to your cleavage.

15 Breast Self Exam - Step 5

Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is
when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same
hand movements described in Step 4.

16 CLINICAL BREAST EXAM HISTORY: (Subjective data) Onset of problem?

What symptoms?

Pain associated with symptoms?

Self breast examination practices? Mammograms?

Reproductive history?
Tobacco & alcohol use?

Medical & surgical history?

Socio-economic information?

17 BREAST ASSESSMENT: INSPECTION & PALPATION

Symmetry

Size

Contour

Skin color, venous pattern, changes (edema or pitting)

Nipple changes

Lesions

Discharge- type, color

Mass

Axillary area

Area over clavicle

18 Equipment Needed

None

The patient must be properly gowned for this examination. All upper body clothing should be removed.

19 General Considerations

The patient must be properly gowned for this examination. All upper body clothing should be removed.

Breast tissue changes with age, pregnancy, and menstrual status.

The procedure described here can also be used for self-examination using a mirror for inspection.

20 Inspection Give a brief overview of examination to patient. [1]

Have the patient sit at end of exam table.

Ask the patient to remove gown to her waist, assist only if needed.

Have the patient relax arms to her side.

Examine visually for following:

Approximate symmetry

Dimpling or retraction of skin

Swelling or discoloration

Orange peel effect on skin

Position of nipple

Observe the movement of breast tissue during the following maneuvers:

Shrug shoulders with hands on hips

Slowly raise arms above head

Lean forward with hands on knees (large breasts only)

Have the patient replace the gown.

Reassure the patient, if the exam is normal so far, say so.

21 Palpation Have the patient lie supine on the exam table.

Ask the patient to remove the gown from one breast and place her hand behind her head on that side.

Begin to palpate at junction of clavicle and sternum using the pads of the index, middle, and ring fingers. If open sores
or discharge are visible, wear gloves.

Press breast tissue against the chest wall in small circular motions. Use very light pressure to assess superficial layer,
moderate pressure for middle layer and firm pressure for deep layers.

Palpate the breast in overlapping vertical strips. Continue until you have covered the entire breast including the axillary
"tail." [2]

Palpate around the areola and the depression under the nipple. Press the nipple gently between thumb and index finger
and make note of any discharge.

Lower the patient's arm and palpate for axillary lymph nodes.

Have the patient replace the gown and repeat on the other side.

Reassure the patient, discuss the results of the exam.

22 Fibroadenoma – benign, glandular and fibrous, small, rubbery, nontender

23 BENIGN BREAST DISORDERS FIBROADENOMA

Most common cause of breast masses, especially in teens & young women (to early 30’s)

Often upper, outer quadrant

Solid, slowly enlarging, benign mass, unattached to surrounding breast tissue

Usually round, firm, easily movable, nontender, clearly distinct from surrounding tissue

Enlarges slowly

24 FIBROCYSTIC BREAST DISEASE

Most common in adult women, ages 20-30

Ducts dilate & cysts form, more diffuse

May occur in stages:

Stage 1: premenstrual sx, bilateral, 20’s

Stage 2: sx +, bilateral, nodular, 30’s

Stage 3: cystic, smooth, painful or tender, 35-55

25 FIBROCYSTIC BREAST DISEASE

Treatment (usually symptomatic) may include:

Hormones (oral contraceptives, estrogen, progestin, Danazol)

Vitamins C, E, B complex
Diuretic agents

NaCl, avoid caffeine

Anti-inflammatory meds (Ibuprofen) as needed

Wear supportive bra

Heating pad, ice

26 DUCTAL ECTASIA Dilation & thickening of ducts in subareolar area

Occurs usually in women nearing menopause

Masses due to inflammatory response, may feel tender, hard, irregular (may be difficult to distinguish from malignancy)

Redness, edema over mass site

Greenish-brown nipple discharge

Enlarged axillary nodes

27 Ductal ecstasia – benign, inflamed and dilated, subareolar duct, nipple discharge green/black and sticky, can
become abscess

28 INTRADUCTAL PAPILLOMA

Occurs usually in women nearing menopause

Rarely palpable mass

Serosanguineous nipple discharge (usually microscopic exam of discharge)

Surgical excision if indicated

29 OTHER BENIGN BREAST DISORDERS Large breasts

Disproportionate to rest of body

Difficult, expensive to find clothes to fit

Can cause backaches

Can cause fungal infections under breasts

Can be treated by REDUCTION

MAMMOPLASTY

30 GYNECOMASTIA ( breast size in male)

Can be secondary to other diseases such as lung Ca

90% bilateral

May be due to:

Aging

Estrogen excess (malnutrition, liver disease, hyperthyroidism)

Androgen deficiency

Obesity
Drugs

Chronic renal failure

31 BREAST CANCER Most diagnosed invasive cancer in females

Second leading cause of breast masses & cancer deaths overall

80% diagnosed in women over age 50

Early detection & treatment key to survival

Localized with no regional spread: cure 75%-90%

5 and 10 year survival rates drop with axillary lymph node involvement

Incidence lower in African-American & Hispanic women, but death rates higher (highest death rate is Hawaiian)

32 BREAST CANCER: ETIOLOGY/ RISK FACTORS

70% women diagnosed with breast cancer have no identifiable risk factors other than age & gender

Age: > 45, as age , risk

History: client’s & family’s

3X in females with affected 1st degree relative (but 90% have no affected relatives)

in women with multiple affected 1st degree relatives, or if relative has Ca bilaterally or diagnosed at early age

33 Invasive Ca – ducts or lobules, irregular, poorly delineated

34 Non invasive Ca – ductal in situ or lobular in situ, abnormal mammogram

35 risk in early menarche (before 12) & late menopause

in nulliparity or 1st pregnancy after age 30

in exposure to ionizing radiation (esp. before age 20)

with hx of previous breast Ca, & risk for recurrence if diagnosed at earlier age or with hx of ovarian Ca

with age

36 QUESTIONABLE RISK FACTORS

Diet: high in animal fats, low in fiber

Obesity

Oral contraceptives

Alcohol/ Tobacco

Hormone replacement rx > 5 years

37 BREAST CANCER: PREVENTION IN HIGH RISK WOMEN

TAMOXIFEN: results of Breast Cancer Prevention Trial in women high risk for breast Ca-> those receiving had Ca by
45%

EVISTA: lower incidence of Breast Ca

ARIMIDEX: new Ca prevention drug being studied

PROPHYLACTIC MASTECTOMY:

often with immediate reconstruction

38 BREAST CANCER INFILTRATING DUCTAL CARCINOMA

Most common, 80% of all breast Ca’s

Hardness on palpation, may be 5-9 years before mass is palpable

May be NONINVASIVE (remain in duct) or INVASIVE (penetrate surrounding tissue causing irregular mass)

As grows, fibrosis develops, causes shortening of Cooper’s ligaments, causes skin dimpling (more advanced disease)

Often metastasizes to axillary nodes

39 COMPLICATIONS OF BREAST CANCER

Tumor invades lymphatic channels

Blocks skin drainage causing skin edema & “orange peel” appearance, may -> skin breakdown

Metastasis occurs from seeding of CA cells into blood and lymph systems

Most common metastatic sites are *bone, lungs, brain, and liver

40 BREAST CANCER IN MEN 1% of all cases of breast cancer

Average onset 60 years of age

Risk factors: hx of mumps orchitis, Klinefelter’s syndrome

Symptoms can include:

Hard, nonpainful, subareolar lesion

Nipple erosion, retraction, or discharge (75% have Ca)

Treatment: modified radical mastectomy with radiation

v 5 year survival rates are only 58% in Stage 1

41 ASSESSMENT: BREAST CANCER HISTORY:

Risk Factors

Mass

When & by whom discovered When sought care

Health maintenance practices:

BSE, Mammograms, Diet, Alcohol use,

Medications including hormone supplements

42 BREAST CANCER: PHYSICAL ASSESSMENT MASS

Location – usually upper, outer quadrant of breast

Size
Shape

Hard consistency, with irregular borders

Fixed, not movable

Nipple, Skin Changes (orange peel appearance, ulceration, shortening of Cooper’s ligaments with dimpling)

Lymph nodes

Usually nontender, painfree unless in later stages

43 PSYCHOSOCIAL ASSESSMENT

Fear of cancer & prognosis

Previous experiences with cancer

Knowledge, education level

Threats to body image

Threats to sexuality and intimate relationships

Support systems

Need for other resources or counseling

44 BREAST ASSESSMENT

SBE

CBE

Mammography, Galactography

Ultrasound

MRI

45 DIAGNOSTIC ASSESSMENT LABORATORY:

Pathology reports

Study of cancer markers

Liver enzymes

Serum calcium

Alkaline phosphatase

46 RADIOGRAPHIC Mammography Chest X ray Bone Scan Brain Scan Liver Scan

CT- Chest and abdomen

47 DIAGNOSTIC ASSESSMENT

Ultrasonography- differentiates fluid filled from solid masses

Breast biopsy with pathology report

Estrogen and progesterone receptors (women with ER + tumors have longer survival rate)
Tumor cell differentiation (women with well differentiated tumors have longer survival)

Pathology exam of lymph nodes

48 BREAST BIOPSY INDICATED: If needle aspirated fluid is bloody

No fluid is aspirated from lesion

Suspicious mammogram

Mass still present after aspiration

Cytological study shows malignant cells

49 BREAST BIOPSY:NURSING CARE

Assess anxiety & fear (80% are negative)

Education

Prior to biopsy, avoid agents interfering with blood clotting

NPO

Care of biopsy site

Avoid strenuous exercises for 1 week

Pain management

Supportive bra for 3-7 days

Post test: Monitor:

Effects of anesthesia

Toleration of fluids, food, ambulation

50 STAGE 3 (no metastasis evident)

BREAST CANCER STAGING

STAGE 1

Tumor smaller than 2cm & no lymph node involvement

STAGE 2

Tumor 2-5 cm with lymph nodes

STAGE 3 (no metastasis evident)

Tumor larger than 5cm, no + lymph nodes or

Smaller than 2 cm, with + lymph nodes, or

2-5 cm with + nodes

STAGE 4

Tumor of any size, + or – lymph nodes, with distant metastasis evident

52 POSSIBLE NURSING DIAGNOSES

Anxiety related to possible diagnosis of cancer

Grieving, Anticipatory, related to loss

Pain, Acute related to breast disease

Sleep Pattern, Disturbed related to pain and anxiety

Body Image, Disturbed related to possible loss of body part

Sexual dysfunction related to body image and/or self esteem

53 INTERVENTIONS ANXIETY: GOAL: EFFECTIVE COPING

Allow time for ventilation of feelings

Active listening

Promote client’s decision making abilities

Active participation in choice of treatment

Be flexible

Utilize outside resources

54 NONSURGICAL INTERVENTIONS

Indicated for clients with late-stage breast cancer

Indicated for clients who cannot withstand major surgical procedures

Based on client preferences, age, menopausal status, pathologic results, hormone receptor status

Interventions include chemotherapy, (ER+may have Tamoxifen) & radiation therapy

55 SURGICAL MANAGEMENT Breast Conserving (Stages 1 & 2) Lumpectomy

Lumpectomy with lymph node dissection

Simple Mastectomy-breast tissue & usually nipple removed, lymph nodes remain intact

Modified radical Mastectomy-Removal of entire breast tissue and axillary lymph nodes; pectoral muscles & nerves
remain intact

56 SURGICAL MANAGEMENT SENTINEL LYMPH NODE BIOPSY

Identifies clients with axillary involvement without palpable nodes

Dye indicates lymph node path, with first reactive nodes removed & examined

Absence of positive sentinel nodes prevents unnecessary radical dissections

57 POSSIBLE NURSING DIAGNOSES: MASTECTOMY

Pain related to tissue trauma from surgery

Skin integrity, Impaired due to surgical incision

Mobility, Impaired Physical related to pain & tissue trauma

Infection, Risk for related to disruption in skin integrity

Body Image, Disturbed related to loss of breast

Social interaction, Impaired related to changes in body image

Knowledge, Deficient related to exercises to regain arm mobility

58 MASTECTOMY:PREOPERATIVE CARE

Include significant other

Recognize & deal with anxiety, lack of knowledge, & body image issues

Review type of procedure & presence of drainage devices

Describe location of incision

Instruct in mobility restrictions

Implement basic pre & post op teaching

Provide written materials

59 MASTECTOMY: POSTOPERATIVE CARE

Anesthesia recovery

Pain management

Assess vital signs q30 min –q4hours

Assess dressing for bleeding

Wound care , observe incision for swelling , infection

Maintain skin integrity

Prevention of infection

Institute measures to promote respiratory function

Drainage tube care, usually JP’s with gentle suction

60 MASTECTOMY: SPECIFIC POSTOPERATIVE CARE

Semi-fowler’s position- HOB 30

Elevate affected arm, DO NOT USE FOR PROCEDURES- (No BP, labs, or injections) BE SURE TO PLACE A SIGN
OVER BED!

Early ambulation & assistance with prescribed exercises (flex, extend fingers, lower arm, & wrist) consult physician
before full arm exercises on the affected side

Teach drainage tube care

MASTECTOMY: SPECIFIC POSTOPERATIVE CARE

61 MASTECTOMY: POSSIBLE COMPLICATIONS

Hematoma at incision site

Infection

Seroma (accumulation of serosanguineous fluid after drain removed)

Nerve trauma

Impaired arm mobility

Lymphedema

Psychological effects

62 BREAST RECONSTRUCTION

May begin during the original operative procedure

Skin flap- (autogenous reconstruction)

Saline filled prosthesis

Progressive tissue expander

Nipple creation

If not done immediately, temporary or permanent prosthesis may be given

TRAM flap reconstruction often used

63 ADJUNCT THERAPY Decision based on Disease stage

Age & menopausal status

Client preferences

Pathologic examination

Hormone receptor status

Genetic predisposition

64 ADJUNCT THERAPY Radiation therapy

Kill Ca cells which might be remaining

External beam qd for 6-7 wks or partial breast brachytherapy with radioactive seeds bid for 5 days

Skin changes a major side effect

Mild soap, rubbing

No perfumed soaps/deodorants, nondrying soap if itching occurs

Hydrophilic lotions

No tight clothes, underwire bras, excessive temperatures, UV lights

65 Chemotherapy Often for remaining cells locally + distant sites Dangerous with many side effects: Meds to N& V
Prevention & dealing with infection from bone marrow depression Promote communication & deal with anxiety Deal
with side effects of taste changes, alopecia, mucositis, dermatitis, fatigue, weight gain or loss

66 Hormonal Therapy Estrogen receptor blocking agents (Tamoxifen, Evista)

Agents to inhibit estrogen synthesis (Lupron, Zoladex)

Aromatase blocking agents to block circulating estrogen

(arimidex, Femara)

67 Stem Cell transplantation

Autologous:
Bone marrow transplantation taken from client’s bone marrow

Peripheral blood stem cell transplantation taken from client’s circulating blood

Allogenic:

Bone marrow or peripheral blood taken from a health donor

Targeted Therapy

Herceptin if indicated

68 DISCHARGE TEACHING Usually does not require modifications in home

Incision, Drain care

Dressing, Wound care

Exercises to regain full range of motion

Prevention, Signs of infection and what to do

Protection of affected arm- LIFETIME

Measures to promote positive body image

Management of lymphedema if occurs

Reach for Recovery, ENCORE, or other community resources

69 DISCHARGE TEACHING: CARE OF INCISION

Light dressing, keep dry

No lotions, ointments, deodorants

Observe for continued redness, swelling, heat, tenderness after 1st few weeks

Loose fitting clothes

ROM exercises when sutures, drains removed

Shower after sutures, drains removed

70 EVALUATION Evaluate expected outcomes: Client will

Be free of infection

Demonstrate correct BSE

State positive feelings related to self image

Regain full ROM in affected arm

Be free of lymphedema

A mastectomy is surgery to remove all breast tissue from a breast as a way to treat or prevent breast cancer.

For those with early-stage breast cancer, a mastectomy may be one treatment option. Breast-conserving surgery
(lumpectomy), in which only the tumor is removed from the breast, may be another option.
Deciding between a mastectomy and lumpectomy can be difficult. Both procedures are equally effective for preventing
a recurrence of breast cancer. But a lumpectomy isn't an option for everyone with breast cancer, and others prefer to
undergo a mastectomy.

Newer mastectomy techniques can preserve breast skin and allow for a more natural breast appearance following the
procedure. This is also known as skin-sparing mastectomy.

Surgery to restore shape to your breast — called breast reconstruction — may be done at the same time as your
mastectomy or during a second operation at a later date.

Why it's done

A mastectomy is used to remove all breast tissue if you have breast cancer or are at very high risk of developing it. You
may have a mastectomy to remove one breast (unilateral mastectomy) or both breasts (bilateral mastectomy).

Mastectomy for breast cancer treatment

A mastectomy may be a treatment option for many types of breast cancer, including:

Ductal carcinoma in situ (DCIS), or noninvasive breast cancer

Stages I and II (early-stage) breast cancer

Stage III (locally advanced) breast cancer — after chemotherapy

Inflammatory breast cancer — after chemotherapy

Paget's disease of the breast

Locally recurrent breast cancer

Your doctor may recommend a mastectomy instead of a lumpectomy plus radiation if:

You have two or more tumors in separate areas of the breast.

You have widespread or malignant-appearing calcium deposits (microcalcifications) throughout the breast that have
been determined to be cancer after a breast biopsy.

You've previously had radiation treatment to the breast region and the breast cancer has recurred in the breast.

You're pregnant and radiation creates an unacceptable risk to your unborn child.

You've had a lumpectomy, but cancer is still present at the edges (margin) of the operated area and there is concern
about cancer extending to elsewhere in the breast.

You carry a gene mutation that gives you a high risk of developing a second cancer in your breast.

You have a large tumor relative to the overall size of your breast. You may not have enough healthy tissue left after a
lumpectomy to achieve an acceptable cosmetic result.

You have a connective tissue disease, such as scleroderma or lupus, and may not tolerate the side effects of radiation
to the skin.

Mastectomy to prevent breast cancer

You might also consider a mastectomy if you don't have breast cancer, but have a very high risk of developing the
disease.
A preventive (prophylactic) or risk-reducing mastectomy involves removing both of your breasts and significantly
reduces your risk of developing breast cancer in the future.

A prophylactic mastectomy is reserved for those with a very high risk of breast cancer, which is determined by a strong
family history of breast cancer or the presence of certain genetic mutations that increase the risk of breast cancer.

Request an Appointment at Mayo Clinic

Risks

Risks of a mastectomy include:

Bleeding

Infection

Pain

Swelling (lymphedema) in your arm if you have an axillary node dissection

Formation of hard scar tissue at the surgical site

Shoulder pain and stiffness

Numbness, particularly under your arm, from lymph node removal

Buildup of blood in the surgical site (hematoma)

How you prepare

Meet with your surgeon to discuss your options

Before your surgery, you'll meet with a surgeon and an anesthesiologist to discuss your operation, review your medical
history and determine the plan for your anesthesia.

This is a good time to ask questions and to make sure you understand the procedure, including the reasons for and
risks of the surgery.

One issue to discuss is whether you'll have breast reconstruction and when. One option may be to have the
reconstruction done immediately after your mastectomy, while you're still anesthetized.

Breast reconstruction may involve:

Using breast expanders with saline or silicone implants

Using your body's own tissue (autologous tissue reconstruction)

Using a combination of tissue reconstruction and implants

Breast reconstruction is a complex procedure performed by a plastic surgeon, also called a reconstructive surgeon. If
you're planning breast reconstruction at the same time as a mastectomy, you'll meet with the plastic surgeon before the
surgery.

Preparing for your surgery

You'll be given instructions about any restrictions before surgery and other things you need to know, including:
Tell your doctor about any medications, vitamins or supplements you're taking. Some substances could interfere with
the surgery.

Stop taking aspirin or other blood-thinning medication. A week or longer before your surgery, talk to your provider about
which medications to avoid because they can increase your risk of excessive bleeding. These include aspirin, ibuprofen
(Advil, Motrin IB, others) and other pain relievers, and blood-thinning medications (anticoagulants), such as warfarin
(Coumadin, Jantoven).

Don't eat or drink 8 to 12 hours before surgery. You'll receive specific instructions from your health care team.

Prepare for a hospital stay. Ask your doctor how long to expect to stay in the hospital. Bring a robe and slippers to help
make you more comfortable in the hospital. Pack a bag with your toothbrush and something to help you pass the time,
such as a book.

What you can expect

Sentinel node biopsy

Sentinel node biopsy

A mastectomy is an umbrella term used for several techniques to remove one or both breasts. In addition, the surgeon
may also remove nearby lymph nodes to determine whether the cancer has spread.

During an axillary node dissection, the surgeon removes a number of lymph nodes from your armpit on the side of the
tumor.

In a sentinel lymph node biopsy, your surgeon removes only the first few nodes into which a tumor drains (sentinel
nodes).

Lymph nodes removed during a mastectomy are then tested for cancer. If no cancer is present, no further lymph nodes
need be removed. If cancer is present, the surgeon will discuss options, such as radiation to your armpit. If this is what
you decide to do, no further lymph nodes will need to be removed.

Removing all of the breast tissue and most of the lymph nodes is called a modified radical mastectomy. Newer
mastectomy techniques remove less tissue and fewer lymph nodes.

Other types of mastectomy include:

Total mastectomy. A total mastectomy, also known as a simple mastectomy, involves removal of the entire breast,
including the breast tissue, areola and nipple. A sentinel lymph node biopsy may be done at the time of a total
mastectomy.

Skin-sparing mastectomy. A skin-sparing mastectomy involves removal of all the breast tissue, nipple and areola, but
not the breast skin. A sentinel lymph node biopsy also may be done. Breast reconstruction can be performed
immediately after the mastectomy.

A skin-sparing mastectomy may not be suitable for larger tumors.

Nipple-sparing mastectomy. A nipple- or areola-sparing mastectomy involves removal of only breast tissue, sparing the
skin, nipple and areola. A sentinel lymph node biopsy also may be done. Breast reconstruction is performed
immediately afterward.

Before the procedure

Your doctor or nurse will tell you when to arrive at the hospital. A mastectomy without reconstruction usually takes one
to three hours. The surgery is often done as an outpatient procedure, and most people go home on the same day of the
operation.

If you're having both breasts removed (a double mastectomy), expect to spend more time in surgery and possibly an
additional day in the hospital. If you're having breast reconstruction following a mastectomy, the procedure also takes
longer and you may stay in the hospital for a few additional days.

If you're having a sentinel node biopsy, before your surgery a radioactive tracer and a blue dye are injected into the
area around the tumor or the skin above the tumor. The tracer and the dye travel to the sentinel node or nodes, allowing
your doctor to see where they are and remove them during surgery.

During the procedure

A mastectomy is usually performed under general anesthesia, so you're not aware during the surgery. Your surgeon
starts by making an elliptical incision around your breast. The breast tissue is removed and, depending on your
procedure, other parts of the breast also may be removed.

Regardless of the type of mastectomy you have, the breast tissue and lymph nodes that are removed will be sent to a
laboratory for analysis.

If you're having breast reconstruction at the same time as a mastectomy, the plastic surgeon will coordinate with the
breast surgeon to be available at the time of surgery.

One option for breast reconstruction involves placing temporary tissue expanders in the chest. These temporary
expanders will form the new breast mound.

For women who will have radiation therapy after surgery, one option is to place temporary tissue expanders in the chest
to hold the breast skin in place. This allows you to delay final breast reconstruction until after radiation therapy.

If you're planning to have radiation therapy after surgery, meet with a radiation oncologist before surgery to discuss
benefits and risks, as well as how radiation will impact your breast reconstruction options.

As the surgery is completed, the incision is closed with stitches (sutures), which either dissolve or are removed later.
You might also have one or two small plastic tubes placed where your breast was removed. The tubes will drain any
fluids that accumulate after surgery. The tubes are sewn into place, and the ends are attached to a small drainage bag.

After the procedure

After your surgery, you can expect to:

Be taken to a recovery room where your blood pressure, pulse and breathing are monitored

Have a dressing (bandage) over the surgery site

Feel some pain, numbness and a pinching sensation in your underarm area

Receive instructions on how to care for yourself at home, including taking care of your incision and drains, recognizing
signs of infection, and understanding activity restrictions
Talk with your health care team about when to resume wearing a bra or wearing a breast prosthesis

Be given prescriptions for pain medication and possibly an antibiotic

Results

The results of your pathology report should be available within a week or two after your mastectomy. At your follow-up
visit, your doctor can explain the report.

If you need more treatment, your doctor may refer you to:

A radiation oncologist to discuss radiation treatments, which may be recommended if you had a large tumor, many
lymph nodes that tested positive for cancer, cancer that had spread into the skin or nipple, or cancer remaining after the
mastectomy

A medical oncologist to discuss other forms of treatment after the operation, such as hormone therapy if your cancer is
sensitive to hormones or chemotherapy or both

A plastic surgeon, if you're considering breast reconstruction

A counselor or support group to help you cope with having breast cancer

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or
manage this disease.
high fat foodsDecrease alcohol intakeBreast Cancer Screening

ain Management

People experience different types and amount of pain or discomfort after surgery. The goal of pain
management is to assess your own level of discomfort and to take medication as needed. You will
have better results controlling your pain if you take pain medication before your pain is severe.
You will be given a prescription for Vicodin for the management of moderate pain. It is
recommended to take medication for pain when pain is experienced on a regular schedule.
Ibuprofen (Advil or Motrin) or Tylenol can be added to or replace the Vicodin.

Everyone is different and if one plan to decrease your pain is not working, it will be changed.
Healing and recovery improve with good pain control.

Please notify us of any drug allergies, reactions or medical problems that would prevent you from
taking these drugs. Vicodin is a narcotic and should not be taken with alcoholic drinks. Do not use
narcotics while driving.

Narcotics also can cause or worsen constipation, so increase your fluid intake, eat high fiber foods
— such as prunes and bran — and make sure that you get up and out of bed to take small walks.

An icepack may be helpful to decrease discomfort and swelling, particularly to the armpit after a
lymph node dissection. A small pillow positioned in the armpit also may decrease discomfort.

Although you will not have felt it at the time, nor remember it afterwards, you will have had a tube
down your throat during the surgery. This can often cause a sore throat for a few days following
your surgery.

Incision and Dressing Care

Your incision, or scar, has both stitches and steri-strips, which are small white strips of tape, and is
covered by a gauze dressing and tape or a plastic dressing.

Do not remove the dressing, steri-strips or stitches. We will remove the dressing in seven to 10
days. We also will remove the sutures in one to two weeks unless they absorb on their own. If the
dressing or steri-strips fall off, do not attempt to replace them.

You may shower one day after the drain(s) is out and if you have a plastic dressing.

If you have gauze and paper tape, you may remove it two days after surgery and shower after that.
Use a towel to dry your incision thoroughly after showering. Be careful not to touch or remove the
steri-strips or sutures.

Bruising and some swelling are common in women after surgery.

A low-grade fever that is under 100 degrees Fahrenheit is normal the day after surgery.

You will have a Jackson-Pratt (JP) drain after your surgery. This drain is a plastic tube from under
the skin to outside your body with a bulb attached to it. Empty the drain two to three times per day
or when the bulb is full. Write down the amount drained on a sheet of paper. Your nurse will teach
you how to empty your drain. An information sheet on JP drains is included in your binder.

A home care nurse may be assigned to check your progress at home.

Activity

Avoid strenuous activity, heavy lifting and vigorous exercise until the stitches are removed. Tell your
caregiver what you do and he or she will help you make a personal plan for "what you can do when"
after surgery.

Walking is a normal activity that can be restarted right away.

You cannot do housework or driving until the drain is out. You may restart driving when you are no
longer on narcotics and you feel safe turning the wheel and stopping quickly.

Following a lymph node dissection, don't avoid using your arm, but don't exercise it until your first
post-operative visit.
You will be given exercises to regain movement and flexibility. You may be referred to physical
therapy for additional rehabilitation if it is needed.

Most people return to work within three to six weeks. Return to work varies with your type of work,
your overall health and personal preferences. Discuss returning to work with us.

Diet

You may resume your regular diet as soon as you can take fluids after recovering from anesthesia.

We encourage eight to 10 glasses of water and non-caffeinated beverages per day, plenty of fruits
and vegetables as well as lower fat foods. Talk with us about recommendations for healthy eating.

A nutritionist is available for consultation in the Breast Care Center. Call the front desk to schedule
an appointment.

Follow-Up Care

The pathology results from your surgery should be available within one week after your surgery.

We will contact you by telephone with the results or will inform you at your post-operative visit.
Please let us know the telephone number where you may be reached with the results.

Follow-up appointments are generally made before surgery with your physician and a nurse. Your
sutures will be removed in approximately 10 to 14 days. Call the Breast Care Center if you do not
have or remember your appointment.

Your dressing will be changed or removed at your post-operative visit.

When to Contact Us

Contact us for the following problems, any unanswered questions and emotional support needs.
Call (415) 353-7070 and ask to speak with a nurse during the day, or the answering service in the
evening to reach your doctor or the doctor on call.

Pain that is not relieved by medication

Fever more than 100 degrees Fahrenheit or chills

Excessive bleeding, such as a bloody dressing

Excessive swelling

Redness outside the dressing

Discharge or bad odor from the wound

Allergic or other reactions to medication(s)

Constipation

Anxiety, depression, trouble sleeping, need more support

COMPLICATIONS MASTECTOMY-SPECIFIC COMPLICATIONS INCISIONAL DOG EARS

LYMPHEDEMA NERVE DAMAGE GENERAL COMPLICATIONS BLOOD LOSS INFECTION
CARDIAC PROBLEMS ADVERSE DRUG REACTIONS GENERAL WOUND COMPLICATIONS
WOUND INFECTIONS HAEMATOMA SEROMA VENOUS THROMBOEMBOLISM CHRONIC
PAIN

8. PSYCHOLOGY CHANGES IN BODY IMAGE QUALITY OF LIFETHREAT OF PASSING AWAY

TOUGH TREATMENT PROCESS

9. SOCIETY PATIENT FAMILY AND FRIENDS SOCIETY

ASTECTOMY - is surgery to remove all breast tissue from a breast as a way to treat or prevent
breast cancer. • Mastectomy is used to remove all breast tissue for breast cancer or patients with
very high risk of developing it. • Mastectomy to remove one breast (unilateral mastectomy) • both
breasts (bilateral mastectomy).

Types of breast surgery includes: • Total (simple) mastectomy – removal of breast tissue and nipple
• Modified radical mastectomy – removal of the breast, most of the lymph nodes under the arm, and
often the lining over the chest muscles • Lumpectomy – surgery to remove the tumor and a small
amount of normal tissue around it

Risk of Mastectomy • Bleeding • Infection • Pain • Swelling (lymphedema) • Formation of hard scar
tissue at the surgical site • Shoulder pain and stiffness • Numbness, particularly under your arm,
from lymph node removal • Buildup of blood in the surgical site (hematoma)

Providing preoperative nursing care for patients who are to undergo Mastectomy is an integral part
of the therapeutic regimen. The nursing goal is to provide support, alleviating anxiety, managing
pain, and providing information.

Nursing Interventions Rationale Check out and explore what information patient has about
diagnosis, expected surgical intervention, and future therapies. Note presence of denial or extreme
anxiety. Provides knowledge base for the nurse to enable reinforcement of needed information, and
helps identify patient with high anxiety, low capacity for information processing, and need for
special attention. Note: Denial may be useful as a coping method for a time, but extreme anxiety
needs to be dealt with immediately. Ascertain purpose and preparation for diagnostic tests. More
understanding of procedures and what is happening increases feelings of control and lessens
anxiety. Implement an ambiance of concern, openness, and availability, as well as privacy for
patient and SO. Suggest that SO be present as much as possible. Time and privacy are needed to
provide support, discuss feelings of anticipated loss and other concerns. Therapeutic
communication skills, open questions, listening, and so forth facilitate this process. Encourage
questions and provide time for expression of fears. Tell patient that stress related to breast cancer
can persist for many months and to seek help and support. Provides opportunity to identify and
clarify misconceptions and offer emotional support. Consider role of rehabilitation after surgery.
Rehabilitation is an essential component of therapy intended to meet physical, social, emotional,
and vocational needs so that patient can achieve the best possible level of physical and emotional
functioning.

Nursing Interventions Rationale Consider reports of pain and stiffness, noting location, duration,
and intensity (0–10 scale). Note reports of numbness and swelling. Be aware of verbal and
nonverbal cues. Aids in identifying degree of discomfort and effectiveness of analgesia. The
amount of tissue, muscle, and lymphatic system removed can affect the amount of pain
experienced. Destruction of nerves in axillary region causes numbness in upper arm and scapular
region, which may be more intolerable than surgical pain. Note: Pain in chest wall can occur from
muscle tension, be affected by extremes in heat and cold, and continue for several months. Discuss
normality of phantom breast sensations. Provides reassurance that sensations are not imaginary
and that relief can be obtained. Facilitate patient to find position of comfort. Elevation of arm, size of
dressings, and presence of drains affect patient’s ability to relax, rest and sleep effectively. Provide
basic comfort measures (reposition on back or unaffected side, back rub) and diversional activities.
Encourage early ambulation and use of relaxation techniques, guided imagery, Therapeutic Touch.
Promotes relaxation, helps refocus attention, and may enhance coping abilities. Splint or support
chest during coughing and deep-breathing exercises. Facilitates participation in activity without
undue discomfort. Carry out appropriate pain medication on a regular schedule before pain is
severe and before activities are scheduled. Maintains comfort level and permits patient to exercise
arm and to ambulate without pain hindering efforts. Administer narcotics or analgesics as indicated.
Provides relief of discomfort and pain and facilitates rest, participation in postoperative therapy.

Mastectomy Complications Most patients recover from mastectomy without any problems, but
complications such as infection, lymphedema, and seroma can occur. •Infection usually manifests
as redness and swelling of the incision with pus or foul-smelling drainage. Fever may also indicate
infection. •Lymphedema may occur when the lymph nodes are removed. The arm on the affected
side sometimes becomes swollen when the lymph system is damaged by lymph node removal or
radiation. Sometimes it resolves on its own, but the condition can become chronic. •Seroma occurs
when blood or fluid accumulates in an area of the body that has just undergone surgery. Sometimes
the body absorbs it, but if it becomes painful or infected, it must be removed.
 Nursing Interventions Rationale Stress proper hand washing technique Handwashing is the single
most effective way to prevent infection Provide regular catheter care To reduce risk of infection
Instruct on proper wound care For first line defense against nosocomial infections or cross
contamination Encourage to eat vitamin C rich foods To promote wound healing Emphasized
necessity of taking antibiotics as directed To boost the immune system Closely observe and instruct
to report signs and symptoms of infection such as fever, sore throat, swelling, pain and drainage To
prevent and detect as early as possible the presence of any progressing infection Inspect the
wound for swelling, unusual drainage, odor redness, or separation of the suture lines Wound
infection are accompanied by signs of inflammation and a delay in healing Empty and re-establish
negative pressure in close wound drains at least once per shift Negative pressure pulls fluid from
the incisional area, which facilitates healing Post-operative Care

Nursing Interventions Rationale Elevate affected arm as indicated. Promotes venous return,
lessening possibility of lymphedema. Facilitate passive ROM (flexion and extension of elbow,
pronation and supination of wrist, clenching and extending fingers) as soon as possible. Early
postoperative exercises are usually started in the first 24 hr to prevent joint stiffness that can further
limit movement and mobility. Have patient move fingers, noting sensations and color of hand on
affected side. Lack of movement may reflect problems with the intercostal brachial nerve, and
discoloration can indicate impaired circulation. Encourage patient to use affected arm for personal
hygiene (feeding, combing hair, washing face). Increases circulation, helps minimize edema, and
maintains strength and function of the arm and hand. These activities use the arm without
abduction, which can stress the suture line in the early postoperative period. Help with self-care
activities as necessary. Conserves patient’s energy, prevents undue fatigue. Assist with ambulation
and encourage correct posture. Patient will feel unbalanced and may need assistance until
accustomed to change. Keeping back straight prevents shoulder from moving forward, avoiding
permanent limitation in movement and posture.

Recommendations: •Proper assessment should be done before and after operation to prevent
post-op complications such as bleeding. •Practice aseptic technique all the time - to prevent
infection. •Inform treating physician for any untoward complication noted – early detection can
lessen the extent of damage that might happened to the patient.

Other procedures Toilet Mastectomy In locally advanced tumour (LABC), tumour with breast
tissue removed – prevent fungation Post-chemotherapy Significance: (?) Extended Radical
Mastectomy Radical Mastectomy + Removal of Internal Mammary Nodes (ipsilateral +/-
contralateral) Not done at present SR_Ca_Breast_Rx 17

COMPLICATIONS of M.R.M/MASTECTOMY Injury/ Thrombosis of Axillary Vein Seroma Shoulder

Dysfunction Pain and Numbness Flap Necrosis and infection Lymphoedema and its problems
Axillary hyperaesthesia Winged Scapula SR_Ca_Breast_Rx 18

LYMPHANGIOSARCOMA (Stewart- Treve’s Syndrome) In ipsilateral upper limb Develops in

people with Lymphoedema after Mastectomy with Axillary clearance. 3-5 years after development
of Lymphoedema Presentation: Multiple subcutaneous nodules Requires Forequarter
Amputation Poor prognosis SR_Ca_Breast_Rx 19

II. RADIOTHERAPY Approach Indications; 1. Conservative Breast Surgery adjuvant [Breast] 2.

Total Mastectomy [Axilla] 3. High-risk of relapse patients 1) Invasive Carcinoma 2) Extensive in-situ
Carcinoma 3) Age < 35 years 4) Multifocal disease 4. Bone secondaries [Palliative] 5. Atrophic
Schirrous Carcinoma [Curative] 6. Pre-Operatively (reduce tumour size and downstage) 7. >4 +’ve
Axillary LN, Pectoral fascia involvement, positive surgical margins, Extra-nodal spread
SR_Ca_Breast_Rx 20

Chest Wall Axilla Post-BCS T3 tumour>5cm Residual disease LABC Positive margin/close
surgical margin <2cm Conservative surgery Inflammatory Carcinoma >4 nodes +’ve
Extra-nodal spread Axillary status unknown/ not assessed MANDATORY! Local + Axilla
Tangential fields: 50 Gy- 25 fractions-5 weeks Another 10 Gy to tumour bed Internal Mammary
and Supra-clavicular area may be included in the radiation field SR_Ca_Breast_Rx 21

External Radiotherapy Over Breast area, axilla, Internal mammary and Supra-clavicular area
Total dosage: 5000 cGy units 200-cGy units daily 5 days a week for 6 weeks Internal
Radiotherapy SR_Ca_Breast_Rx 23

25. III. HORMONE-THERAPY Approach Principles; Used in ER/PR +’ve patients only All age
groups included now Relatively safe Easy to administer Adequate prophylaxis against Ca of
opposite breast Useful in Metastatic Carcinoma Reduces recurrence – improves quality of life
and longevity SR_Ca_Breast_Rx 25

26. Includes; Medical i. Oestrogen Receptor Antagonists – Tamoxifen 20 mg ii. Progesterone

receptor Antagonist iii. Oral Aromatase Inhibitors – Letrozole 2.5 mg OD, Anastrozole, Exemestane;
Aminoglutethimide [Medical Adrenalectomy] iv. Androgens – inj.Testosterone propionate 100mg IM
three times a week, Fluoxymestrone 30 mg daily v. LHRH Agonists – Goserelin (Zoladex) [Medical
Oophorectomy] vi. Progestogens – Medroxypregesterone acetate 400 mg Surgical i. Ovarian
Ablation by a. Surgery (Bilateral Oophorectomy) b. Radiation ii. Adrenalectomy iii. Pituitary ablation
SR_Ca_Breast_Rx 26

27. Tamoxifen SERM (Selective Estrogen Receptor Modulator) Blocks cytosolic ER in breast
tissue Dose: 10 mg BD or 20 mg OD for 5 days T1/2: 7 days. Shows effects after 4 weeks
Cheap, easily available, effective Indications: Carcinoma Breast Fibroadenosis Male
infertility Desmoid tumours Side-effects: ‘Tamoxifen Flare’: Flushing, tachycardia, sweating,
pruritis vulva, vaginal atrophy and dryness (pre-menopausal), vaginal discharge (post-menopausal),
fluid retention, weight gain Agonistic action: Endometrium (Ca), Bone (Osteoporosis, pathological
#), Coagulation system (DVT, TIA, CVA, MI) SR_Ca_Breast_Rx 27

28. Letrozole Non-steroidal competitive inhibitor of Aromatase Reduces Oestrogen levels by 98%
More expensive, more effective, fewer side-effects Indications: 1. Adjuvant Endocrine therapy
in Post-menopausal women with hormone sensitive breast cancer 2. Metastatic disease 3.
Recurrent disease Dosage: 2.5 mg OD for 5 years or for 3 years after Tamoxifen Side-effects:
Vaginal atrophy, bleeding p.v, CVS problems and osteoporosis. SR_Ca_Breast_Rx 28

29. Novel drugs - Biologicals 1. TRANSTUZUMAB (Herceptin) Monoclonal Ab. Blocks Her-2/Neu
receptors (Tyrosine kinase receptor) Useful only in Her-2/Neu +’ve cases Metastatic d/s
Intravenous infusion 4mg/kg loading, 2mg/kg maintenance dose for 1 year 2. BEVACIZUMAB
Vascular Growth Factor receptor inhibitor 3. LAPITINAB Combined Growth Factor receptor inhibitor
SR_Ca_Breast_Rx 29

30. IV. CHEMOTHERAPY Approach Types; A. Adjuvant Chemotherapy Administration of

Cytotoxics after surgery Eliminate clinically undetectable distant spread B. Neoadjuvant
Chemotherapy Administration of Cytotoxics in large operable tumours before surgery Reduce
loco-regional tumour burden – downstage Amenable to surgical resection after 3 doses C.
Palliative Chemotherapy Advanced Ca Breast Metastatic Ca Breast SR_Ca_Breast_Rx 30

31. Indications; All node +’ve patients Primary tumour >1cm in size Poor prognostic factors
Advanced Ca Breast Inflammatory Ca Breast Metastatic Ca Breast Drugs; CMF Regime CAF
Regime MMM Regime Cyclophosphamide Cyclophosphamide Methotrexate Methotrexate
Adriamycin Mitomycin-C 5-Fluorouracil 5-Fluorouracil Mitozantrone SR_Ca_Breast_Rx 31

32. Chemotherapy Regimes CAF and CMF – commonly used, monthly/3 weeks cycles for 6
months Taxanes Eg: PACLITAXEL and DOCETAXEL G2/M phase arrestors Use:
Metastatic Ca Breast 1st line: CMF > CAF > MMM 2nd line: Taxanes 3rd line: Gemcitabine
SR_Ca_Breast_Rx 32

33. EARLY CARCINOMA BREAST [ECB] - Management Breast Conservation Surgery – Wide
Local Excision/ QUART/ SSM; RT locally Patey’s Operation [MRM] Tamoxifen 10mg BD
Sentinel Lymph Node Biopsy [SNLB] Regular follow-up with Radioisotope Bone scan CEA
tumour marker Indications for Total Mastectomy in EBC; Tumour size >5cm Multicentric
tumour High-grade (poorly-differentiated) tumour Tumour margin not clear after BCS
SR_Ca_Breast_Rx 33

34. ADVANCED CARCINOMA BREAST Refers to; Locally Advanced Carcinoma Breast [LACB]
Inflammatory Ca Breast Bilateral Ca Breast Metastatic Ca Breast Fixed
axillary/supra-clavicular LN SR_Ca_Breast_Rx 34

35. Management of ACB LACB Neoadjuvant Chemotherapy Response assessment

Non-responders: RT + Surgery Responders: Surgery (Toilet Mastectomy/MRM) Inflammatory Ca
Breast ‘Mastitis carcinomatosis’/ ‘Lactating Ca of Breast’ T4d LACB (Stage IIIB) Neoadjuvant
ChemoT and RT Surgery (if downstaged) + Axillary clearance SR_Ca_Breast_Rx 35

36. SR_Ca_Breast_Rx 36
37. Metastatic Ca Breast Hematogenous spread to; Bone: most common. Vertebra – Batson’s
(valveless) venous plexus and posterior intercostal veins, Ribs, Humerus, Femur Lungs –
‘Cannon-ball’ 20 in parenchyma, Pleural effusion, Chest wall 20 Liver Brain Treatment strategies;
Chemotherapy: CMF/CAF Radiotherapy Tamoxifen, Oophorectomy Transtuzumab, Bevacizumab
Hypercalcemia – Hydration, steroids, Palmidronate 90mg i.v once a month Internal fixation of
pathological # SR_Ca_Breast_Rx 37

40. CARCINOMA BREAST in PREGNANCY - Management 1st Trimester 2nd Trimester 3rd
Trimester MRM MRM MRM Axillary node +’ve: Termination of pregnancy + Chemotherapy
Chemotherapy carefully After delivery – Chemotherapy with suppression of lactation Note the
following; Hormone treatment contra-indicated: Teratogenic Radiotherapy: No role MRI is the
investigation of choice Can become pregnant 2 years after completion of therapy as recurrence
rates are highest in 2 years SR_Ca_Breast_Rx 40

41. Follow-up Clinical examination in detail @ regular intervals Yearly/2-yearly Mammography of

the treated and contralateral breast is a must Bone-scan, CT Chest/abdomen, tumour markers are
done only if there is clinical suspicion. Not a regular routine follow-up at present SR_Ca_Breast_Rx

42. BREAST RECONSTRUCTION Done in young patients with early stage of disease
Symmetry is the most important factor Factors deciding reconstruction; Amount of skin
retained – SSM best Stage of Carcinoma Earlier Radiotherapy Type of flap used Timing
Immediate Reconstruction: in Early stages with good response to neoadjuvants. CI in LABC
Delayed Reconstruction: 3-9 months after surgery. Done in LABC. Allows post-op RT without
prosthesis exposure, avoids fibrosis and fat necrosis where TRAM flap in used SR_Ca_Breast_Rx

43. Methods of Reconstruction 1. Breast Implants – Silicone gel 2. Expandable Saline prosthesis 3.
Flap with implant/expanders 4. External breast prosthesis 5. Flap reconstruction 1. Latissimus dorsi
(LD) flap 2. Contralateral Tranversus Abdominis (TRAM) flap 3. Superior Gluteal flap 4. Ruben’s
flap: soft tissue over Iliac crest SR_Ca_Breast_Rx 43

47. Complications of Implants; Pain, exposure of implant and rupture Displacement,

extrusion Infection Capsular contraction LD Flap TRAM flap Myocutaneous flap
Myocutaneous flap Subscapular artery Superior Epigastric artery Easy Ipsilateral or
contralateral flap Can be placed over prosthesis Gives bulk. No need of prosthesis Reliable,
well-vascularised Free TRAM flap into IMA Low complication rate Mesh placement in
abdomen required Unsightly donor area on back Donor site morbidity & fat necrosis
SR_Ca_Breast_Rx 47

OMPLICATIONS OF MASTECTOMYCOMPLICATIONS OF MASTECTOMY Seromas - the most

common Wound infections Hemorrhage Lymphedema - increased risk in: extensive ALND
the delivery of radiation therapy the presence of pathologic lymph nodes obesity Nerve
injury

Anxiety related to diagnosis of breast cancerCollaborative Problem: Potential for Metastasis

Anticipatory Grieving r/t loss and possible or impendingdeath

Acute Pain r/t tumour compression on nerve endings

Disturbed Sleep Pattern r/t pain and anxiety

Disturbed Body Image r/t loss of a body part

Sexual Dysfunction r/t body image or self-esteemdisturbance

he nurse provides:

Preoperative care

psychologic preparation,preoperative teaching; assess need for drainage tube,mobility restrictions,

length of hospital stay, possibilityof additional therapy; address body image issues

Postoperative careavoid using affected side for B/P,injections, blood draws; care of drainage tubes,
comfortmeasures, client teaching, ambulation, adls, exercise,
Halsted radical mastectomy

breast tissue, nipple,underlying muscles, lymph nodes (rarely performed)

Modified radical mastectomy

breast tissue, nipple,lymph nodes

Simple mastectomy

breast tissue, nipple (lymphnodes left intact)

Lumpectomy

only tumour , small amount of surrounding tissue removed

e nurse provides:

Preoperative care

psychologic preparation,preoperative teaching; assess need for drainage tube,mobility restrictions,

length of hospital stay, possibilityof additional therapy; address body image issues

Intra-operative care

circulator, scrub

Postoperative care

avoid using affected side for B/P,injections, blood draws; care of drainage tubes, comfortmeasures,
client teaching, ambulation, adls, exercise,

reast ReconstructionThe nurse:

Assesses incision, flap sites

Teaches client to avoid pressure flap, suture lines

Cares for drainage devices

Teaches client to avoid sleeping in prone position

Teaches client to avoid contact sports

Teaches client to minimize pressure to breast during sexual relations

Teaches client to refrain from driving

Reassures client that optimal appearance may not occur for 3-6 monthspost

surgery

Reviews BSE procedure

Reminds client that mammograms should be scheduled at least yearlyfor the rest of her life

Refers to ACS

Assesses the client’s attitude toward appearance restoration

Measures to optimize body image

Information to enhance interpersonal relationships

Exercises to regain full ROM

Measures to prevent infection of incisionHealth Care Resources:

The nurse makes referrals to community resources

Monitor for adverse effects of radiation therapy such asfatigue, sore throat, dry cough, nausea,
anorexia.
Monitor for adverse effects of chemotherapy; bonemarrow suppression, nausea and vomiting,
alopecia,weight gain or loss, fatigue, stomatitis, anxiety, anddepression.

Realize that a diagnosis of breast cancer is a devastatingemotional shock to the woman. Provide
psychologicalsupport to the patient throughout the diagnostic andtreatment process.

Involve the patient in planning and treatment.

Describe surgical procedures to alleviate fear.

Prepare the patient for the effects of chemotherapy, andplan ahead for alopecia, fatigue.

Administer antiemetics prophylactically, as directed, forpatients receiving chemotherapy.

Administer I.V. fluids and hyperalimentation asindicated.

Help patient identify and use support persons or familyor community.

Suggest to the patient the psychological interventionsmay be necessary for anxiety, depression, or
sexualproblems.

Teach the recommended cancer-screening procedures.

e commonly used chemotherapy drugs include:

cyclophosphamide

epirubicin

fluorouracil(5FU)

methotrexate

paclitaxel(Taxol)

doxorubicin( Ad riam yc in® )

docetaxel(Taxote re ®) .

Chemotherapy

Pathological connections between the esophagus and the trachea or major bronchi are termed
tracheoesophageal fistula (TEF) and bronchoesophageal fistula (BEF), respectively.

ETIOLOGIESMost TEFs in adults are acquired and due to esophageal or lung cancer.
Congenital TEFs are rare in adults.
 ●Acquired – Malignancy, typically esophageal or lung cancer, accounts for over 50 percent of
TEFs. However, TEFs are rare as a complication of malignancy; about 5 to 15 percent of
patients with esophageal malignancy and 1 percent of patients with bronchogenic carcinoma
develop TEF [1-4]. Less commonly, TEFs are due to benign conditions (eg, prolonged
endotracheal intubation, surgical or endoscopic interventions)
●Congenital – Most congenital TEFs present in childhood and are typically associated with
esophageal atresia. Rarely, a small congenital H-type TEF (communicates with a normal
esophagus) may present in adulthood.

CLINICAL FEATURESTEF should be suspected in patients with a known risk factor who
have one or more of the following:

●Frequent coughing following solid and liquid intake

●Recurrent purulent bronchitis or pneumonia
●Recurrent aspiration
●Unexplained malnutrition

Patients who are receiving mechanical ventilation can develop TEF from prolonged endotracheal
intubation may present with acute respiratory distress, worsening oxygenation, loss of tidal volume
during ventilation, and gastric distension.

In most patients, the symptoms develop over days to weeks (eg, those due to malignancy) while in
others the symptoms may be acute (over hours; eg, those due to intubation). The onset may also
depend upon the location and size of the fistula in that large proximal TEFs may present earlier
than smaller distal TEFs.

Symptoms of the underlying cause may also be present (eg, cough and hemoptysis from lung
cancer or dysphagia and weight loss from esophageal cancer).

Since the condition is uncommon and the symptoms are nonspecific, the diagnosis is often
delayed.

DIAGNOSTIC EVALUATIONAn esophagram and endoscopy should be performed in

patients with suspected TEF. There are no specific laboratory findings, although some patients with
lung infection may have a leukocytosis or elevated erythrocyte sedimentation rate. TEFs should be
identified and treated promptly since spontaneous closure is rare and if left untreated, patients
progress to respiratory failure and death. There are no guidelines on how best to evaluate and
diagnose TEFs. Our approach, outlined in this section, is based upon observational series and our
experience.

Imaging — The diagnosis of TEF is traditionally made with contrast-enhanced esophagography

that demonstrates displacement of the contrast into the lung; barium preparation is preferred over
Gastrografin because the latter is extremely hypertonic and can induce pulmonary edema,
pneumonia, or death, whereas aspiration of small amounts of barium seems to have little clinical
relevance [5]. In patients who cannot swallow (eg, mechanically ventilated patients), contrast
studies may not be feasible such that chest computed tomography (CT) is an alternative. Chest CT
scan with three-dimensional reconstruction and oral or intravenous contrast medium may localize
the fistula, identify details of the fistula etiology, and examine tracheal/esophageal anatomy, all of
which are important for evaluating potential therapies.

Endoscopy — In most cases, bronchoscopy and/or endoscopy should be performed to confirm

imaging findings and localize the fistula (picture 1 and picture 2). In cases where a malignant
etiology is suspected a biopsy should be performed to confirm the diagnosis. However, recognition
of smaller fistulas can be challenging especially if the mucosa is red and swollen. Orally
administered methylene blue before bronchoscopy with observation of bubbles leaking into the
airway has been described as helpful in identifying small fistulas [6].

DIAGNOSISThe diagnosis of TEF is usually based upon a combination of clinical, radiographic,

and endoscopic findings. While contrast imaging, computed tomography, and endoscopy are not
always necessary for the diagnosis, all three are typically done since they provide complimentary
diagnostic and therapeutic information.
MANAGEMENT AND OUTCOMESSpontaneous closure of TEF is rare. Without
treatment, the outcome is poor and can be measured in weeks. The management of TEF requires a
multidisciplinary approach involving thoracic surgery, oncology, gastroenterology, and
interventional pulmonary experts. Careful assessment of the etiology, size, anatomy (tracheal and
esophageal), burden of the underlying disease, and patient comorbidities as well as the risk-benefit
ratio of various repair options should be undertaken when deciding about the best treatment
approach. In general, surgery with a curative intent is usually performed for benign TEF, whereas
palliative management is reserved for malignant TEF (algorithm 1and algorithm 2) Since
malignancy is the more common etiology, palliative endoscopic/bronchoscopic treatments are more
frequently administered.

There is a paucity of data and no consensus or guidelines on how best to manage TEF. Significant
variation among clinicians exists but practice is evolving as expertise in interventional pulmonology
grows. The approach outlined here is influenced by our expertise in interventional pulmonology and
we recognize that this strategy may not always be universally applied, particularly when
interventional expertise is not available.

Initial management — Initial general measures that should be undertaken include eliminating
oral intake, keeping the head of the bed elevated at 45 degrees or greater, administering anti-reflux
therapy, frequent oral suctioning, treating pulmonary infection/aspiration pneumonia, and
oxygenation with supplemental oxygenation (if indicated). Nasogastric tubes should be removed, if
present. A gastrostomy tube is also sometimes placed to suction gastric contents which potentially
reduces further leak from gastroesophageal reflux (eg, mechanically ventilated patient or patient
with TEF in the lower one-third of the esophagus). In patients who are considered for endoscopic
stenting some experts recommend placing a gastrostomy or jejunostomy tube prophylactically for
enteral nutrition. If this is not feasible, total parenteral nutrition is appropriate

If patients are receiving mechanical ventilation, extubation is preferable but is not always feasible.
For those who cannot be extubated, bypassing the site of the TEF by advancing the endotracheal
tube (ETT) or placing an extra-long tracheostomy tube, should be performed ensuring that the
inflated cuff is below the fistula; ETTs or tracheostomy tubes with continuous subglottic aspiration (if
available) are preferable. Some experts also lower the tidal volume and positive end-expiratory
pressure in an attempt to minimize air leak through the fistula and avoid TEF enlargement, although
this maneuver is of unproven benefit. Many experts wait until patients are weaned off mechanical
ventilation before attempting surgical repair since it has been shown that positive pressure
ventilation is associated with an increased incidence of anastomotic dehiscence and restenosis
following surgery [1,7-11].

Treat underlying cause — While therapy is mostly aimed at treating the fistulous
communication, efforts targeted at treating the underlying cause should be simultaneously
undertaken This may involve treating any underlying disorder such as malignancy or infection, or
removing the patient from mechanical ventilation, if feasible.

Malignant lesions (palliative therapy) — Patients with malignant TEF are treated palliatively
(algorithm 1). While there are rare case reports of malignant TEF being treated surgically (eg,
surgically-fit patients with minimally invasive localized disease or surgery after oncologic therapy), it
is not generally recommended and frequently not feasible [12]. (See 'Patients or lesions suitable for
surgery' below.)

The treatment for most malignant TEFs, particularly those >5 mm involves stenting of the
esophagus, airway, or both. A smaller proportion of patients have small lesions (eg, ≤5 mm) which
are generally treated with local bronchoscopic therapies (eg, clipping or fibrin glue). The choice of
palliative intervention depends upon lesion size and location as well as level of expertise and
patient comorbidities. In most cases, a complete or partial response can be achieved to allow
patients to survive a few more weeks or months with an improved quality of life. The rationale for
this approach is based upon our experience and that of others [13].

Fistula in mid-proximal esophagus — The majority of TEFs are located in the middle one-third of
the esophagus (since most cancers are located within this region) and most of those are treated
with double stenting (ie, concomitant esophageal and tracheal stents).

First line: Double (combined) stenting — For patients with malignant TEF involving the mid to
proximal esophagus, airway (typically tracheal) stenting in addition to esophageal stenting should
be performed. While an airway stent is indicated in those with an associated stenotic airway lesion,
it is also appropriate in those without airway stenosis since, unlike distal esophageal stents, stents
placed in the mid to proximal portion of the esophagus can result in potential airway compromise
and worsening of TEF; thus, placement of a concomitant airway stent can prevent this
complication .

One retrospective study evaluated the clinical efficacy of airway stenting in 61 patients with TEF
[15]. Almost every patient who underwent double stenting had a complete response (defined as no
leakage of contrast medium after radiography and clinical symptom resolution without recurrence
for more than two weeks) compared with two-thirds of patients who had airway stenting alone. In
another retrospective study of 30 patients with large fistulas and airway stenosis, patients who
received a double stent had a greater mean survival than those who received an airway stent alone
(110 versus 24 days) [16]. In another study of 112 patients with TEF, double stenting was
associated with improved survival when compared with airway stenting alone (252 versus 219
days) .

Airway stent — The airway stent should be placed first followed by the esophageal stent,
preferably in one setting, although one procedure is not always feasible; this reduces the risk of
airway obstruction by the esophageal stent and decreases the risk of esophageal stent migration.

Airway stents should cover at least 20 mm beyond the proximal and distal margin of the fistula . In
addition, the stent should be 10 to 20 percent larger than the internal airway diameter at the fistula
site. Straight stents are often used for proximal airway TEFs while L- or Y-shaped ones are used for
lower airway TEFs.

Factors that affect success include apposition between the stent and esophageal and/ortracheal
wall around the fistula, adequacy of stent covering of the fistula, and the degree of associated
esophageal or tracheal stenosis. A variety of airway stents are available for clinical application in
the tracheobronchial tree for treatment of TEF. Options include covered self-expanding metal stents
(ie, tubular mesh that is partially- or fully-covered), silicone stents, or hybrid stents. Although there
are no comparative studies available, we prefer to use covered self-expanding metal stents since
they have the following advantages over silicone stents:

●Preferable inner diameter to wall thickness ratio.

●Excellent expansion and adherence to the tracheal wall creating a good seal (silicone stents
do not self-expand so they do not conform to the tracheal wall as readily).
●Fewer episodes of stent migration (due to the above); although fully-covered metallic stents
may migrate more than partially covered, both migrate less than silicone stents.
●Less airway obstruction due to improved secretion clearance.
●Ease of insertion using a flexible bronchoscope (silicone stents require a rigid bronchoscope).
●Available sizes for larger airways (airway diameter >18 mm and ≤20 mm; silicone stents not
available for large airways)
●Ease of deployment, which decreases the risk of expanding the size of the TEF orifice at the
time of stent placement.

The disadvantages of using a metallic over a silicone stent are:

●Greater tumor in growth and esophageal spill (of food particles and liquid material) into the
trachea through partially covered metal stent interstices (at the proximal and distal end of the
stent, which is not covered)
●Difficulty removing (often due to tumor infiltration and excellent adherence properties).
●Less durability due to increased risk of stent fracture (500 to 1000 days).

Thus, a metallic stent may be preferred for patients with malignant fistulas, those in whom
short-term use is planned, for TEF associated with tortuous airways, those with an airway
diameter >18 and ≤20 mm, or TEF located in upper and mid airway (stents placed in the upper
airway have a greater chance of migrating than those in the lower airway). On the other hand, a
silicone stent may be preferred when long-term use is needed (eg, >500 days or when TEF is
associated with benign airway stenosis) since they last longer and are more durable than metallic
stents.

Esophageal stent — The upper margin of the esophageal stent should be slightly higher than the
upper margin of airway stent, which is thought to reduce the risk of esophageal stent migration
(picture 4). The stent length and diameter are chosen according to the location of the lesion, size of
the TEF and degree of esophageal stenosis. Stents must cover 2 cm beyond the proximal and
distal margins of the TEF, should be wide enough to press firmly against the esophageal wall, and
are usually placed under direct visualization through endoscopy or under fluoroscopy. Technical
details and efficacy of stenting for esophageal lesions are provided separately. Second line
options — Second line options include:

●Airway stent alone – Airway stenting alone (picture 3) (ie, without concomitant esophageal
stent) is indicated in rare circumstances when an esophageal stent is not feasible. Examples
include TEF located in the high proximal esophagus (where an esophageal stent is often not
feasible since patients do not tolerate them due to pain), TEF associated with a completely
occluded esophageal lumen that precludes the passage of an esophageal guide wire, and
severe esophageal stenosis that is at risk of rupture from esophageal stenting.
●Esophageal stent – If an esophageal stent is feasible but an airway stent is not, due to the
size of the airway (≥20 mm), then an esophageal stent may be placed, taking into
consideration that airway encroachment and worsening of fistula size are potential
complications. (See 'Esophageal stent' above.)

Distal esophagus fistulas — Distal esophageal fistulas are less common than mid or proximal
ones and are more likely to communicate with major bronchi than with the trachea (ie, BEF).
Management is dependent upon whether or not endobronchial stenosis is present.

No airway stenosis: Esophageal stent — For patients with large TEFs/BEFs in the distal
esophagus without concomitant airway stenosis, an esophageal stent (picture 4) alone is indicated.
An airway stent is not needed since esophageal stents in this location are not typically associated
with airway compromise or worsening TEF [14].

Few studies have selectively compared outcomes using individual stenting strategies. Nonetheless,
one prospective study reported survival rates of 263 days in those with esophageal stents
compared with 219 days for those who received an airway stent alone and 252 days for those who
received a combined airway-esophageal stent [17].

If an esophageal stent migrates (eg, because there is no esophageal stenosis), TEF is persistent or
worsened by the stent, or the airway is compromised by the stent, esophageal stent replacement
with a concomitant airway stent are options (ie, double stenting). .

Airway stenosis: Double stent — For patients with large TEFs in the distal esophagus with
concomitant airway stenosis (typically bronchial), double stenting is indicated. Bronchial stents are
not more difficult or less feasible to place than tracheal stents. Bronchial stents can be placed up to
distal left main stem bronchus and distal right bronchus intermedius. A frequent problem that is
encountered with right BEF when the communication is at the level of the right upper lobe (RUL)
bronchus is that in order to seal the defect, the RUL needs to be removed from ventilation (ie,
“jailed”) with a stent that is placed from the right main stem (RMS) bronchus and the bronchus
intermedius (BI). Another problem with right-sided BEF is that there can be a size mismatch
between the RMS and the BI so placing a stent of ideal size and fit can be an issue.

Benign lesions (potentially curative) — The intent of treating benign TEF is curative with
surgery. However, not all patients or lesions are suitable for surgical repair. Importantly, definitive
surgical repair cannot be performed unless the underlying disorder is curable and site of potential
anastomosis is disease-free (algorithm 2). Palliative procedures are frequently performed as a
bridge to surgery while the underlying disorder is being treated.

Patients or lesions suitable for surgery — Surgical repair is technically difficult surgery that uses
a cervicotomy, cervicosternotomy, or thoracotomy approach; thus, expertise in both esophageal
and tracheal surgery are critical for success. The surgical approach for TEF depends upon the size
of the fistula

●For small lesions, the fistula is divided and repaired using one or two layers of omental or
muscle flaps (between the esophagus and trachea) over a nasogastric tube.
●Large fistulas with tracheal injury may require major esophageal and/or tracheal surgery
including any combination of the following: esophageal diversion (esophagostomy) or
 resection, full thickness skin graft esophageal reconstruction, tracheal or laryngotracheal
resection and reconstruction, and muscle flap interposition.

Immediate extubation following surgery is the goal since it is thought that postoperative mechanical
ventilation may lead to wound dehiscence and fistula recurrence. (See 'Initial management' above.)

Successful fistula closure following surgical intervention for benign TEF has been reported in 75 to
94 percent of patients with median follow-up times between 23 months and 12.5 years [20-24]. The
majority are able to resume oral intake (>70 percent) and do not require prolonged mechanical
ventilation after surgery. One retrospective study reported that in patients with benign TEF,
reintervention was less likely in those who had surgery compared with patients who had
non-surgical interventions (eg, stenting) [12].

Surgery is frequently fraught with complications (up to 50 percent) [18-20,22,25]. Perioperative

mortality as high as 11 percent has been reported. Major complications include wound dehiscence,
recurrent TEF, pneumonia, vocal cord paralysis, and tracheal stenosis.

Patients or lesions NOT suitable for surgery — Patients with benign lesions who are not good
surgical candidates (eg, critically ill patients) or who have lesions not suitable for surgery (eg, large
fistulas that prohibit reconstruction or resection or fistulas that involve or are close to the major
vessels [eg, following esophagectomy]) should undergo palliation or local therapy depending on
size. Such interventions are also indicated in patients who need a bridge to surgery (eg, patients on
mechanical ventilation or receiving antibiotics for infection).

Fistulas >5 mm: Palliative interventions — Patients in this subgroup are treated with palliative
stenting similar to those with malignant TEF. However, most experts deploy only one stent, airway
or esophageal, rather than double stenting. The choice of stent depends upon which site can
achieve the best “fit” (ie, better sealing effect) and local expertise. When one stent does not seal the
defect then double stenting is appropriate. This approach is based upon the rationale that, unlike
malignant lesions, the ideal goal of stenting for benign lesions is to provide a bridge to curative
surgery; this strategy, maximizes the sealing effect with a single stent and minimizes the risk of
stent-related complications. For example, double stenting may interfere with the healing process
long term because of the constant friction between stent walls, and unlike malignant fistulas, benign
fistulas have less risk of airway obstruction after deployment of an esophageal stent in the mid to
proximal region, thereby decreasing the need for double stenting. The details of palliative
interventions are discussed above. (See 'Malignant lesions (palliative therapy)' above.).

Fistulas ≤5 mm: Local therapies — Local therapies are usually preferred in patients with small
benign lesions based upon the rationale that risks of stent insertion and their complications
outweigh the benefits; stenting is reserved for those who fail local therapies.

Endoscopic clip placement — Gastrointestinal over-the-scope-clipping (OTSC) is a new

generation technique that allows closure of gastrointestinal defects including fistulas. The OTSC
device is attached to an applicator integrated onto the tip of the endoscope. It requires soft and
expandable tissue in order to launch, and is therefore only applied to the gastrointestinal side of the
TEF. The major benefits of such devices are speed (procedural time is on average measured in
minutes), ease of deployment, and persistent sealing. Small case reports suggest adequate fistula
closure following OTSC in TEF [26-29] but further studies are needed to adequately assess
outcome in this population with this technique.

Occlusive therapies — Closure of small TEFs with local injection of tissue adhesive, fibrin glue,
vascular plugs, septal occluders, or silicon rings has been used in individual cases with variable
success [30-35]. However, such methods are uncommonly used owing to their temporary effect and
dissolution of occlusive material two weeks following injection leading to recanalization of the
fistula.

Investigational therapies — Laser and argon plasma coagulation thermal ablation have also been
used in children for refractory congenital TEF in an attempt to promote re-epithelialization [36,37].
However, success has not been reported in adults with non-congenital TEF.

FOLLOW-UPIn most circumstances patients should undergo a repeat contrast-enhanced

esophagram within 48 hours following therapy to make sure complete seal has been achieved and
to prevent further pulmonary soiling. In addition, patients should be monitored for symptom relief
and maintenance of the response. A complete response is one where no leak is identified and the
patient can resume eating and drinking for a minimum of two weeks. A partial response is one
where the leak is reduced and symptoms improve for the same time period; however, patients
cannot eat. In the latter, reintervention may be considered depending upon the original procedure;
this may involve stent replacement, placement of a concomitant airway stent (if not already in
place), and/or additional local therapies. There should be a low threshold to re-image and perform
endoscopy or bronchoscopy in those who develop new or progressive symptoms that suggest
fistula recurrence (up to 11 percent in benign acquired TEF) or a stent-related complication (like
obstruction), which is not unusual [20].

he approach to treatment of adult patients with tracheoesophageal fistulas depends on whether the
fistula is congenital or acquired in origin. Most adults have acquired tracheoesophageal fistulas, and
treatment depends on whether the fistula is a result of a benign process or a malignancy, with the
latter usually primary esophageal cancer. For patients with benign tracheoesophageal fistulas,
treatment is almost always initially supportive followed by definitive surgical correction. In general,
depending on the size and location of the tracheal aspect of the fistula, surgical therapy involves
primary repair of the fistula and, if necessary, resection and reconstruction of the trachea. For
patients with malignant tracheoesophageal fistulas, treatment depends on whether the patient is
resectable and/or medically fit for surgical therapy. However, most patients with malignant
trach-eoesophageal fistulas have advanced disease and can only be treated with palliative measures.
The current standard of palliative therapy for patients with malignant tracheoesophageal fistulas is
the endoscopic or radiologic placement of covered self-expanding metallic stents (SEMS), which allow
closure of the fistula. All three types of commercially available covered SEMS have been used in this
capacity with success. Other, less common treatment options for selected patients with malignant
tracheoesophageal fistulas include chemotherapy and radiation, surgical bypass, esophageal
exclusion, and fistula resection and repair.

. Risk Factors for gastric cancer Diet nitroso compounds low fruit/vegetable, high fried foods/processed
meat High salt intake Obesity Smoking (HR 2-3) ? Alcohol H. Pylori Low socioeconomic status
Hereditary diffuse gastric cancer 40-67% lifetime risk for men, 60-83% for women Immigrants from
endemic areas maintain native country risk, risk to offspring similar to new homeland
. 9. Precursors of Gastric Cancer Adenomatous polyps Chronic atrophic gastritis Pernicious gastritis
Menetries’s disease Previous gastric surgery for non- cancerous conditions
. 10. Symptoms at presentation
. 11. Symptoms (cont’d) Dysphagia: more common with proximal gastric tumors Occult GI bleeding very
common, overt bleeding <20%.
. 12. Signs Palpable abdominal mass: most common physical finding If cancer spreads via lymphatics…
Left supraclavicular node (Virchow’s) Periumbilical node (Sister Mary Joseph) Left axillary node (Irish)
Enlarged ovary (Krukenberg's tumor) Ascites
. 13. Investigations Routine blood examination low hemoglobin , high ESR stool examination for occult
blood gastric function test - will reveal gross hypo / achlorhydria Endoscopy – helpful in diagnosing early
cases and taking biopsy Ultrasonography - helps in assesing thickening of agstric wall, local invasion,
peritoneal involvement , ascitis CT scan - extent of the disease , lymph node involvement , liver metastasis
Barium studies Staging laproscopy
. 14. Diagnosis Endoscopy Gold standard Single biopsy from ulcer -> sensitivity ~ 70% Seven biopsies
from ulcer -> sensitivity >98% Brush cytology increases sensitivity of single biopsies, aid in multiple
biopsies unclear
. 15. Preoperative Staging Abdominal / pelvic CT scanning Endoscopic ultrasound (EUS) Depth of the
tumour Enlarged perigastric/coeliac lymph nodes
. 16. Endoscopic ultrasound A small, high frequency ultrasound transducer incorporated into the distal end of
the endoscope. Advantages: - superior resolution. - image not compromised by intervening gases. - lesion as
small as 2-3 mm in diameter can be imaged.
. 17. Barium studies False negative in as many as 50% of cases Sensitivity as low as 14% in early cases
May be superior to EGD for linitis plastica EGD may be normal while “leather-bottle” will be apparent on
radiograph
. 18. Staging Laparoscopy
. 19. Malignant Neoplasms of the Stomach Primary Adenocarcinoma (94%) Lymphoma (4%) Malignant GIST
(1%) Haematogenous spread Breast Malignant melanoma Direct invasion Pancreas; Liver; colon; ovary
. 20. Staging of Gastric Cancer Two systems: Japanese classification (more elaborate and anatomic
based) Western: developed by American Joint Committee on Cancer (AJCC) and International Union
Against Cancer (UICC) -- more widely used Tumors at GE junction of in cardia of stomach within 5cm of GE
junction Classified using esophageal staging
. 21. Gastric carcinoma CLASSIFICATION Depth of invasion EARLY GASTRIC CA - mucosa &
submucosa ADVANCED GASTRIC CA - into or through muscularis propria Macroscopic growth pattern –
Ming classification Expanding Infiltrative - "linitis plastica" Histologic subtype Intestinal Diffuse
(gastric); poorly differentiated; "signet ring" cells
. 22. Gastric carcinoma CLASSIFICATION WHO Classification: 1. Adenocarcinoma: a. Papillary
adenocarcinoma b. Tubular adenocarcinoma c. Mucinous adenocarcinoma d. Signet-ring cell carcinoma 2.
Adenosquamous carcinoma 3. Squamous cell CA 4. Small cell CA 5. Undifferentiated CA 6. Others Lauren
Classification: 1. Intestinal type (53%) 2. Diffuse type (33%) 3. Unclassified (14%) Ming Classification: 1.
Expanding type (67%) 2. Infiltrative type (33%)
. 23. Histologic type: 1. Papillary 2. Tubular 3. Mucinous 4. Signet ring Mode of spread: 1. Direct 2. Lymphatic
3. Hematologic 4. Transcoelomic route
. 24. Linitis Plastica Diffuse-type gastric cancer Tumor often infiltrates the submucosa and muscularis
propria Superficial biopsies may be falsely negative Combination of strip and bite biopsy needed if
suspicious for linitis plastica
. 25. Linitis Plastica, “leather bottle stomach”
. 26. Staging workup Biopsy Imaging CT: evaluates for metastases (M stage) 20-30% with negative
CT have intraperitoneal disease at laparatomy Accuracy of 50-70% for T stage Slightly worse accuracy
for N stage compared to EUS EUS: most reliable nonsurgical method to evaluate depth of invasion More
accurate than CT for T stage 65-90% accurate for N stage
. 27. Staging workup PET More sensitive than CT for detection of distant metastases. Also useful for
detecting LNs Negative PET not helpful- even large tumors can be falsely negative if metabolic activity low.
Most diffuse gastric cancers (signet ring) are not FDG avid
. 28. Staging workup Serologic markers CEA, CA-125, CA 19-9, CA 72-4 may be elevated but have low
sensitivity/specificity None are diagnostic Preoperative elevation in markers usually pretends high risk of
adverse outcome No serologic finding should exclude surgical consideration
. 29. AJCC Staging System
. 30. AJCC Staging System
. 31. Treatment Locoregional (stage I-III) disease Potentially curable multidisciplinary evaluation and
consideration of surgery Advanced (stage IV) disease Palliative therapy Studies indicate longer survival
and better quality of life with systemic treatment
. 32. Surgery The extent of gastric resection depends on: - tumor size - location - depth of invasion -
histological type
. 33. Treatment Complete surgical resection with removal of LNs (only chance of cure) Possible in < 1/3 of
cases Subtotal gastrectomy for distal carcinomas, total or near-total for proximal masses Reduction of
tumor bulk (palliative) Chemotherapy (cisplatin + 5-FU or irinotecan) Partial response in 30-50% of
patients Radiation (for pain control, no mortality benefit with XRT alone)
. 34. The Japanese Research Society for Gastric Cancer The 16 lymph node locations were classified into 4
concentric groups: N1, N2, N3, N4 Periepigastric Extraepigastric
. 35. What is the ideal extent of lymphadenectomy ? D0- removes less than all relevant N1 nodes D1-
removes N1 nodes only - Lt and Rt cardiac - Lt and Rt gastro-epiploic - Sub and Supra pyloric D2- removes
all N1 and N2 nodes - Lt gastric - Common hepatic - Celiac - Splenic hilum and along splenic artery D3-
removes all N2 and N3 nodes
. 36. The residual tumor (R) classification The absence or presence of demonstrable residual tumor after
conclusion of the treatment (UICC) R0 resection -no demonstrable residual tumor R1 resection-
microscopically demonstrable residual tumor (e.g. diseased residual margin) R2 resection – macroscopically
visible tumor Distinction between primary palliative intervention (R1&R2) vs. potentially curative ones (R0)
. 37. Prognosis Stage TNM Features % of Cases* % 5-year survival* 0 TisN0M0 Node negative; limited to
mucosa 1 90 IA T1N0M0 Node negative; invasion of lamina propria or submucosa 7 59 IB T2N0M0 Node
negative; invasion of muscularis propria 10 44 II T1N2M0 Node positive; invasion beyond mucosa but within
wall 17 29T2N1M0 T3N0M0 Node negative; extension through wall IIIA T2N2M0 Node positive; invasion of
muscularis propria or through wall 21 15 T3N1-2M0 IIIB T4N0-1M0 Node negative; adherence to
surrounding tissue 14 9 IV T4N2M0 Node negative; adherence to surrounding tissue 30 3 Any M1 Distant
Metastases ** Data from American Cancer Society
. 38. Pharmacologic Therapy Cisplatin + epirubicin & infusional 5-FU or + irinotecan Complete
remissions are uncommon. Partial responses in 30-50% of cases are transient. Overall influence on
survival has been unclear. Adjuvant chemotherapy alone following complete resection has only minimally
improved survival. Perioperative treatment and postoperative chemotherapy + radiation therapy reduce
the recurrence rate and prolongs survival.
. 39. Treatment: Supportive: Nutrition (jejunal enteral feedings or total parenteral nutrition), Correction of
metabolic abnormalities that arise from vomiting or diarrhea Treatment of infection from aspiration or
spontaneous bacterial peritonitis. To maintain lumen patency, endoscopic laser treatment or stenting for
palliation.
. 40. Screening Mostly barium studies, EGD is concerning findings Some use serum pepsinogen testing
for high risk with EGD confirmation H. pylori: sensitivity 88%, specificity 41% (Japan) 5-year survival
74-80 in screened group, 46-56% for non- screened group.
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7. INCIDENCE• Most (85%) cases of gastric cancer are adenocarcinomas that occur in the lining of the
stomach (mucosa). Approximately 40% of cases develop in the lower part of the stomach (pylorus);
40% develop in the middle part (body); and 15% develop in the upper part (cardia). In about 10% of
cases, cancer develops in more than one part of by: Katherine L. Laud, SN Created the organ.

9. MORTALITY• Stomach cancer is the second leading cause of cancer death worldwide (737, 000
deaths, 10% of the total). The highest mortality rates are in Eastern Asia and the lowest in Northern
America (World Cancer Research Fund International, 2008).• Deaths: 10,570 in United States (NCI,
2010)• Deaths: 1,484 in Philippines (DOH, 1998) Created by: Katherine L. Laud, SN

11. ETIOLOGY/RISK FACTORS• Family history of gastric cancer• Helicobacter pylori infection (a
common bacteria that can also cause stomach ulcers)• History of an adenomatous gastric polyp larger
than 2 centimeters• Common in men• Smoking

12. ETIOLOGY/RISK FACTORS• Risk increases after age 50• History of chronic atrophic gastritis•
Previous stomach injury• History of pernicious anemia• Evidence suggest that gastric cancer may be
linked to diet, such as salty food, smoked fish, preserved meats, and low in fresh fruits and
vegetables.

13. ETIOLOGY/RISK FACTORS• Some studies have found that a diet high in red meat is another
possible risk factor. Eating red meat an average of about twice a day seems to raise the risk of
stomach cancer. This risk is increased even more if the meat is barbecued and well done.• Workers in
the coal, metal, and rubber industries

15. PREVENTION, SCREENING, DETECTION• Changing lifestyle or eating habits (balanced diet)•
Avoiding things known to cause cancer• Taking medicines to treat a precancerous condition or to
keep cancer from starting

16. PREVENTION, SCREENING, DETECTION• There is no standard or routine screening test for stomach
cancer. However, upper endoscopy has been studied as a screening test to find stomach cancer at an
early stage.

17. PREVENTION, SCREENING, DETECTION• Scans - these may include ultrasound, MRI or CT scans•
Complete blood count (CBC) to check for anemia• Esophagogastroduodenoscopy (EGD) with biopsy•
Stool test to check for blood in the stools .

19. CLASSIFICATION• T Stage for Gastric Cancer - Tis (Carcinoma in situ), T1, T2, T3, T4• N Stage of
Gastric Cancer - N0, N1, N2, N3• M Stage for Gastric Cancer - M0, M1 .

21. CLINICAL FEATURES• Weight loss and persistent abdominal pain, Dysphagia• Feeling bloated after
eating only a small meal• Nausea and vomiting, Hematemesis• Melena .

23. DIAGNOSIS AND STAGING• Thorough history and physical examination• MRI, CT Scan, Upper
Endoscopy• Biopsies .24. DIAGNOSIS AND STAGING*STAGING• Stage 0: Tis, N0, M0• Stage IA: T1, N0,
M0• Stage IB: Any of the ff: T1,N1,M0; T2,N0,M0• Stage IIA: Any of the ff: T1,N2,M0; T2,N1,M0;
T3,N0,M0• Stage IIB: Any of the ff: T1,N3,M0; T2,N2,M0; T3,N1 SN T4a,N0,M0 ., M0;

25. DIAGNOSIS AND STAGING• Stage IIIA: Any of the ff: T2,N3,M0; T3,N2,M0; T4a,N1,M0• Stage IIIB:
Any of the ff: T3,N3,M0; T4a,N2,M0; T4b,N0 or N1,M0• Stage IIIC: Any of the ff: T4a,N3,M0; T4b,N2
or N3,M0• Stage IV: Any T,any N,M1 .
.27. METASTASIS• Stomach cancer usually begins in cells in the inner layer of the stomach. Over time,
the cancer may invade more deeply into the stomach wall. A stomach tumor can grow through the
stomachs outer layer into nearby organs, such as the liver, pancreas, esophagus, or intestine..28.
METASTASIS• Stomach cancer cells can spread by breaking away from the original tumor. They enter
blood vessels or lymph vessels, which branch into all the tissues of the body. The cancer cells may be
found in lymph nodes near the stomach. The cancer cells may attach to other tissues and grow to
form new tumors that may damage those tissues. by:.

30. SURVIVAL The overall 5-year relative survival rate ofStage IA 71% people with stomachStage IB
57% cancer in the United States is about 28%. OneStage IIA 45% reason for this is thatStage IIB 33%
most stomach cancersStage IIIA 20% are found at an advancedStage IIIB 14% stage. The outlook for
survival is better if theStage IIIC 9% cancer is in the lower partStage IV 4% of the stomach than if it
is*The survival rates above come from theNational Cancer Institutes SEER database. in the upper
partThey are based on people diagnosed with (American Cancerstomach cancer and treated with
surgery Created by: Katherine L. Laud, SNbetween 1991 and 2000 Society).

he StomachHollow organ in the upper abdomen, under the ribs </li></ul><ul><li>5 layers:
</li></ul><ul><ul><li>Inner layer – where most stomach cancer begins
</li></ul></ul><ul><ul><li>Submucosa – support tissue for the inner layer
</li></ul></ul><ul><ul><li>Muscle layer – create a rippling motion that mixes and mashes food
</li></ul></ul><ul><ul><li>Subserosa – support tissue for the outer layer
</li></ul></ul><ul><ul><li>Outer layer (serosa) – covers the stomach and hold it in place
</li></ul></ul>

3. Benign Tumors <ul><li>Are not cancer </li></ul><ul><li>Not life-threatening </li></ul><ul><li>Can

be removed and usually do not grow back </li></ul><ul><li>Cells do not invade the tissues around
them </li></ul><ul><li>Cells do not spread to other parts of the body </li></ul>

4. Malignant Tumors <ul><li>Are cancer </li></ul><ul><li>Generally more serious than benign tumors
</li></ul><ul><li>May be life-threatening </li></ul><ul><li>Often can be removed but sometimes
grow back </li></ul><ul><li>Cells can invade and damage nearby tissues and organs
</li></ul><ul><li>Can spread (metastasize) to other parts of the body </li></ul>

5. Stomach Cancer <ul><li>Can affect nearby organs and lymph nodes </li></ul><ul><li>Stomach
tumor can grow through stomach’s outer layer into nearby organs (such as the pancreas, esophagus
or intestine) </li></ul><ul><li>Can spread through the blood to the liver, lungs and other organs
</li></ul><ul><li>Can also spread through the lymphatic system to lymph nodes all over the body
</li></ul>

6. Stomach Cancer

7. Risk Factors <ul><li>Exact causes unknown </li></ul><ul><li>Age – most are age 72 or older
</li></ul><ul><li>Sex – men most likely than women </li></ul><ul><li>Race – more common in Asian,
Pacific Islander, Hispanic and African-Americans </li></ul><ul><li>Diet – diet high in foods that are
smoked, salted or pickled </li></ul><ul><li>Helicobacter pylori infection – raises risk of stomach
inflammation and stomach ulcers </li></ul><ul><li>Smoking – people who smoke more at risk
</li></ul><ul><li>Certain health problems: stomach surgery, chronic gastritis, pernicious anemia.
</li></ul><ul><li>Family history – rare type of stomach cancer runs in some families </li></ul>

8. Symptoms <ul><li>Early stomach cancer – no clear symptoms </li></ul><ul><li>Discomfort in the

stomach area </li></ul><ul><li>Feeling full or bloated after a small meal </li></ul><ul><li>Nausea and
vomiting </li></ul><ul><li>Weight loss </li></ul><ul><li>Other health problems, such as ulcer or
infection, can cause the same symptoms. </li></ul>

9. Diagnosis <ul><li>Personal and family health history </li></ul><ul><li>Physical exam – checks

abdomen for fluid, swelling or other changes </li></ul><ul><li>Upper GI series – x-rays of esophagus
and stomach </li></ul><ul><li>Endoscopy – use of a thin, lighted tube (endoscope) to look into the
stomach </li></ul><ul><li>Biopsy – checks tissue sample under a microscope for cancer cells
</li></ul>

10. Other Tests <ul><li>Blood tests – CBC to check for anemia and how the liver is working
</li></ul><ul><li>Chest x-ray – checks for tumors in the lungs </li></ul><ul><li>CT scan – detailed
pictures of the organs </li></ul><ul><li>Endoscopic ultrasound </li></ul><ul><li>Laparoscopy – small
incisions in the abdomen. The surgeon may remove lymph nodes or take tissue samples for biopsy.
</li></ul>

11. Stages of Stomach Cancer <ul><li>Stage 0 – cancer found only in the inner layer of the stomach
</li></ul><ul><li>Stage 1 </li></ul><ul><ul><li>Tumor invaded only the submucosa – cancer cells may
be found in up to 6 lymph nodes </li></ul></ul><ul><ul><li>Tumor invaded the muscle layer or the
subserosa </li></ul></ul><ul><ul><li>Cancer cells have not spread to lymph nodes or other organs
</li></ul></ul>

12. Stages of Stomach Cancer <ul><li>Stage II </li></ul><ul><ul><li>Tumor has invaded only the
submucosa – cancer cells have spread to 7-15 lymph nodes </li></ul></ul><ul><ul><li>Tumor has
invaded the muscle layer or subserosa – cancer cells have spread to 1-6 lymph nodes
</li></ul></ul><ul><ul><li>Tumor has penetrated outer layer of the stomach
</li></ul></ul><ul><ul><li>Cancer cells have not spread to lymph nodes or other organs
</li></ul></ul>

13. Stages of Stomach Cancer <ul><li>Stage III </li></ul><ul><ul><li>Tumor has invaded the muscle
layer or subserosa – 7-15 lymph nodes or </li></ul></ul><ul><ul><li>Tumor has penetrated the outer
layer – 1-15 lymph nodes </li></ul></ul><ul><ul><li>Tumor has invaded nearby organs, such as the
liver or spleen </li></ul></ul><ul><ul><li>Cancer cells have not spread to lymph nodes or distant
organs </li></ul></ul>

14. Stages of Stomach Cancer <ul><li>Stage IV </li></ul><ul><ul><li>Cancer cells have spread to more
than 15 lymph nodes or </li></ul></ul><ul><ul><li>Tumor has invaded nearby organs and at least 1
lymph node </li></ul></ul><ul><ul><li>Cancer cells have spread to distant organs
</li></ul></ul><ul><li>Recurrent cancer </li></ul><ul><ul><li>Has come back
</li></ul></ul><ul><ul><li>May recur in the stomach or in another part </li></ul></ul>

15. Treatment <ul><li>Local therapy - removes or destroys cancer in or near the stomach
</li></ul><ul><ul><li>Surgery – either partial or total gastrectomy
</li></ul></ul><ul><ul><li>Radiation – uses high energy rays to kill cancer cells
</li></ul></ul><ul><li>Systemic therapy – the drug enters the bloodstream and destroys or controls
cancer throughout the body </li></ul><ul><ul><li>Chemotherapy – uses anticancer drugs
</li></ul></ul>

16. Treatment <ul><li>Complementary and alternative medicine (CAM)

</li></ul><ul><ul><li>Acupuncture </li></ul></ul><ul><ul><li>Massage therapy
</li></ul></ul><ul><ul><li>Herbal products </li></ul></ul><ul><ul><li>Vitamins or special diets
</li></ul></ul><ul><ul><li>Visualization </li></ul></ul><ul><ul><li>Meditation
</li></ul></ul><ul><ul><li>Spiritual healing </li></ul></ul>

17. Nursing Management <ul><li>Discuss situation and provide information about all procedures and
treatment. </li></ul><ul><li>Help client talk about feelings or concerns about illness.
</li></ul><ul><li>Discuss current and planned treatment measures. </li></ul><ul><li>Stress the
importance of completing the prescribed treatments. </li></ul><ul><li>Discuss stress reduction
techniques and refer for stress reduction counseling or workshops as indicated.
</li></ul><ul><li>Help arrange meeting with social worker, counselor or member of the clergy if
needed. </li></ul>
Treatment EMR Surgical resection Adjuvant therapy Palliative therapy

39. TREATMENT OF LOCALIZED DISEASE STAGE I DISEASE(EARLY GASTRIC CANCER) TREATMENT

OPTIONS FOR PATIENTS WITH EGC INCLUDE • EMR • LIMITED SURGICAL RESECTION, •
GASTRECTOMY.

40. ENDOSCOPIC MUCOSAL RESECTION • A SUBSET OF PATIENTS WITH EGC CAN UNDERGO AN R0
RESECTION WITHOUT LYMPHADENECTOMY OR GASTRECTOMY. • THIS APPROACH INVOLVES THE SUB
MUCOSAL INJECTION OF FLUID TO ELEVATE THE LESION AND FACILITATE COMPLETE MUCOSAL
RESECTION UNDER ENDOSCOPIC GUIDANCE • EMERGING VARIATIONS OF EMR TECHNIQUES
INCLUDING THE CAP SUCTION AND CUT VERSES A LIGATING DEVICE. • EMR-RELATED COMPLICATION
RATES, INCLUDING BLEEDING AND PERFORATION • TUMOURS INVADING THE SUB MUCOSA ARE AT
INCREASED RISK FOR METASTASIZING TO LYMPH NODES AND ARE NOT USUALLY CONSIDERED
CANDIDATES FOR EMR • EMR IS EMERGING AS THE DEFINITIVE MANAGEMENT OF SELECTED EGCS

41. LIMITED SURGICAL RESECTION • PATIENTS WITH SMALL (LESS THAN 3 CM) INTRA MUCOSAL
TUMOURS AND THOSE WITH NON-ULCERATED INTRA MUCOSAL TUMOURS OF ANY SIZE MAY BE
CANDIDATES FOR LIMITED RESECTION. • SURGICAL OPTIONS FOR THESE PATIENTS MAY INCLUDE
GASTROTOMY WITH LOCAL EXCISION. • THIS PROCEDURE SHOULD BE PERFORMED WITH
FULLTHICKNESS MURAL EXCISION (TO ALLOW ACCURATE PATHOLOGIC ASSESSMENT OF T STATUS) •
AIDED BY INTRA OPERATIVE GASTROSCOPY FOR TUMOUR LOCALIZATION. • FORMAL LYMPH NODE
DISSECTION IS NOT REQUIRED IN THESE PATIENTS

42. GASTRECTOMY WITH LYMPH NODE DISSECTION THIS PROCEDURE SHOULD BE CONSIDERED FOR •
PATIENTS WITH EGC WHO CANNOT BE TREATED WITH EMR OR LIMITED SURGICAL RESECTION •
PATIENTS WHO HAVE INTRA MUCOSAL TUMOURS WITH POOR HISTOLOGICAL DIFFERENTIATION •
SIZE >3 CM • WHO HAVE TUMOUR PENETRATION INTO THE SUB MUCOSA OR BEYOND. THERE IS NO
CONSENSUS ON THE EXTENT OF LYMPHADENECTOMY THAT SHOULD BE PERFORMED AS PART OF
GASTRECTOMY FOR EGC. DISSECTION OF LEVEL I LYMPH NODES IS A REASONABLE MINIMUM
STANDARD AT THIS TIME.

43. STAGE II AND STAGE III DISEASE • SURGICAL RESECTION IS THE CORNERSTONE OF TREATMENT
FOR PATIENTS WITH LOCALIZED GASTRIC CANCER; INDEED, SURGICAL RESECTION CAN BE CURATIVE
IN MOST PATIENTS WITH EGC. • HOWEVER, FOR STAGES II AND III DISEASE, SURGERY IS NECESSARY
BUT OFTEN NOT SUFFICIENT FOR CURE. • THE GENERAL THERAPEUTIC GOAL IS TO ACHIEVE A MICRO-
AND MACROSCOPICALLY COMPLETE RESECTION (R0). • THE EXTENT OF GASTRIC RESECTION IS
DETERMINED BY THE NEED TO OBTAIN A RESECTION MARGIN FREE OF MICROSCOPIC DISEASE. • A
LINE OF RESECTION AT LEAST 6 CM FROM THE TUMOUR MASS IS NECESSARY TO ENSURE A LOW RATE
OF ANASTOMOTIC RECURRENCE. • THE APPROPRIATE SURGICAL PROCEDURE SHOULD BE
DETERMINED BY THE LOCATION OF THE TUMOUR AND THE KNOWN PATTERN OF SPREAD.

44. PROXIMAL TUMOURS OF THE STOMACH • PROXIMAL TUMOURS OF THE STOMACH COMPRISE UP
TO HALF OF ALL GASTRIC CANCERS • RESECTED BY TOTAL GASTRECTOMY OR PROXIMAL SUBTOTAL
GASTRECTOMY. • TUMOURS OF THE GE JUNCTION MAY REQUIRE ESOPHAGOGASTRECTOMY WITH
CERVICAL OR THORACIC ANASTOMOSIS • TOTAL GASTRECTOMY WITH ROUX-EN-Y
ESOPHAGOJEJUNOSTOMY IS GENERALLY THE PREFERRED OPTION • TO AVOID POSTOPERATIVE
MORBIDITY OF REFLUX ESOPHAGITIS AND IMPAIRED GASTRIC EMPTYING ASSOCIATED WITH
PROXIMAL SUBTOTAL GASTRECTOMY.

45. MID BODY TUMOURS • MIDBODY TUMOURS COMPRISE 15% TO 30% OF TUMOURS • GENERALLY
REQUIRE TOTAL GASTRECTOMY TO ACHIEVE ADEQUATE MARGINS.

46. DISTAL TUMOURS • DISTAL TUMOURS MAY BE RESECTED BY DISTAL SUBTOTAL GASTRECTOMY OR
TOTAL GASTRECTOMY WITH NO DIFFERENCE IN OVERALL SURVIVAL • RISKS OF SPECIFIC SEQUELAE
OF TOTAL GASTRECTOMY SUCH AS EARLY SATIETY, WEIGHT LOSS, AND THE NEED FOR VITAMIN B12
SUPPLEMENTATION • NUTRITIONAL STATUS AND QUALITY OF LIFE ARE SUPERIOR FOLLOWING
SUBTOTAL GASTRECTOMY • MAKING IT THE PREFERRED OPTION WHEN ADEQUATE MARGINS CAN BE
OBTAINED WHILE MAINTAINING AN ADEQUATE GASTRIC REMNANT

47. Residual Disease R Status • • • • • • Tumor status following resection. Assigned based on
pathology of margins. R0- no residual gross or microscopic disease. R1- microscopic disease only. R2-
gross residual disease. Long term survival only in R0 resection.

48. “D” Nomenclature Describes extent of resection and lymphadenectomy. • D1- removes all nodes
within 3cm of tumor. • D2- D1 plus hepatic, splenic, celiac, and left gastric nodes. • D3- D2 plus
omentectomy, splenectomy, distal pancreatectomy, clearance of porta hepatis nodes. • Current
standards include a D1 dissection only.

49. LAPAROSCOPIC GASTRIC RESECTIONS • LAPAROSCOPIC GASTRIC RESECTIONS HAVE BEEN

REPORTED FOR THE TREATMENT OF GASTRIC CANCER • ADVANTAGES OF REDUCED PAIN, SHORTER
HOSPITALIZATION, AND IMPROVED QUALITY OF LIFE. • LONG-TERM OUTCOME WITH RESPECT TO
CANCER RECURRENCE AWAITS

50. Lymph Node Dissection • AJCC: number rather than location of LN is prognostic. • Extent of
dissection controversial. • Nodal involvement indicates poor prognosis, and more aggressive
approaches to remove them are taking favor. • Ongoing trials regarding this in Europe. • Critics argue
that the apparent benefit associated with extended LND reflects stage migration (each LN is reviewed
more carefully).

51. EXTENDED LYMPHADENECTOMY • D1 RESECTION REFERS TO THE REMOVAL OF GROUP 1 LYMPH

NODES • D2 DISSECTION OF GROUP 1 AND 2, • D3 RESECTION TO A D2 RESECTION PLUS REMOVAL OF
PARA-AORTIC LYMPH NODES. • TO EFFECT COMPLETE REMOVAL OF STATION 10 (PARASPLENIC) AND
STATION 11 (PARAPANCREATIC)

52. ROLE OF SPLENECTOMY IN GASTRIC CANCER • THE PURPOSE OF SPLENECTOMY IN GASTRIC

CANCER, ASIDE FROM MANAGING DIRECT TUMOUR EXTENSION, IS FOR • REMOVAL OF LYMPH
NODES AT THE SPLENIC HILUS (STATION 10) AS A PART OF AN EXTENDED LYMPH NODE RESECTION
(D2) FOR PROXIMAL GASTRIC CANCER. • JAPANESE SURGEONS PERFORM SPLEENECTOMY AND
PARTIAL PANCREATECTOMY DURING D2 RESECTIONS FOR PRIMARIES WHOSE DRAINAGE INCLUDES
THESE ECHELONS • BECAUSE OF THE INCREASED MORBIDITY IN THE PATIENTS RECEIVING THESE
ADJUNCTIVE RESECTIONS, WESTERN SURGEONS DO NOT TYPICALLY RESECT THE SPLEEN OR
PANCREAS UNLESS INVOLVED BY DIRECT EXTENSION FROM A T4 TUMOUR.

53. R STATUS-CARCINOMA STOMACH • THE TERM R STATUS WAS FIRST DESCRIBED BY HERMANEK IN
1994, IS USED TO DESCRIBE THE TUMOR STATUS AFTER RESECTION. • R0 DESCRIBES A
MICROSCOPICALLY MARGIN-NEGATIVE RESECTION, IN WHICH NO GROSS OR MICROSCOPIC TUMOUR
REMAINS IN THE TUMOUR BED. • R1 INDICATES REMOVAL OF ALL MACROSCOPIC DISEASE, BUT
MICROSCOPIC MARGINS ARE POSITIVE FOR TUMOUR. • R2 INDICATES GROSS RESIDUAL DISEASE. •
BECAUSE THE EXTENT OF RESECTION CAN INFLUENCE SURVIVAL, THIS R DESIGNATION TO
COMPLEMENT THE TNM SYSTEM. • LONG-TERM SURVIVAL CAN BE EXPECTED ONLY AFTER AN R0
RESECTION; THEREFORE, A SIGNIFICANT EFFORT SHOULD BE MADE TO AVOID R1 OR R2 RESECTIONS

54. STAGE IV DISEASE • BECAUSE 20% TO 30% OF GASTRIC CANCER PATIENTS PRESENT WITH STAGE
IV DISEASE-PALLIATIVE TREATMENT. • SURGICAL PALLIATION OF ADVANCED GASTRIC CANCER MAY
INCLUDE RESECTION OR BYPASS ALONE OR IN CONJUNCTION WITH PERCUTANEOUS, ENDOSCOPIC,
OR RADIOTHERAPY TECHNIQUES. • NON OPERATIVE THERAPIES INCLUDE LASER RECANNULIZATION
AND ENDOSCOPIC DILATION WITH OR WITHOUT STENT PLACEMENT INCLUDES •
GASTROJEJUNOSTOMY • DEVINES EXCLUSION PROCEDURE • ENDOSCOPIC LASER SURGERY OR •
ENDO LUMINAL STENT PLACEMENT AS PALLIATIVE THERAPY TO RELIEVE SYMPTOMS AND IMPROVE
THE QUALITY OF LIFE

55. OPERATIVE PROCEDURE

56. PARTIAL GASTRECTOMY

57. SUB TOTAL GASTRECTOMY

58. TOTAL GASTRECTOMY

59. TOTAL GASTRECTOMY WITH SPLENECTOMY & DISTAL PANCREATECTOMY

60. TECHNIQUE OF OPERATION

61. TECHNIQUE OF OPERATION BEGINNING WITH LAPAROSCOPY ALLOWS FOR CAREFUL INTRA
OPERATIVE STAGING OF DISEASE. INSPECTION FOR • THE PRESENCE OF ASCITES • HEPATIC
METASTASES • PERITONEAL SEEDING • FIXATION TO UNDERLYING STRUCTURES DISEASE IN THE
PELVIS-“DROP” METASTASIS OVARIAN INVOLVEMENT ONCE DISTANT METASTASES HAVE BEEN
RULED OUT A MIDLINE ABDOMINAL INCISION CAN BE USED TO GAIN ADEQUATE EXPOSURE TO THE
UPPER ABDOMEN.

62. STRUCTURES REMOVED IN RADICAL GASTRECTOMY • • • • • ENTIRE GREATER AND LESSER

OMENTUM STOMACH ALONG WITH GROWTH {CLEARANCE OF 5-7cm } APPROPRIATE LYMPH NODE
DISSECTION{D1/D2/D3} DISTAL PANCREAS AND SPLEEN CONTINUITY MAINTAINED BY ROUX en Y
ESOPHAGOJEJUNOSTOMY

63. A MID LINE UPPER ABDOMINAL INCISION IS PREFERED

64. UPPER ABDOMEN EXPOSED

65. GREATER OMENTUM MOBILISED ALLOWING ELEVATION OF STOMACH,EXPOSURE OF LESSER SAC

66. LESSER CURVATURE IS MOBILISED BY INCISING GASTRO HEPATIC LIGAMENT,DIVISION OF RIGHT

GASTRODUODENAL ARTERY AND VEIN

67. DUODENUM IS DIVIDED DISTAL TO PYLORIC V.OF MAYO

68. FOR TOTAL GASTRECTOMY OESOPHAGEAL RESECTION LINE IS DEFINED

69. RESULTANT DEFECT AFTER TOTAL GASTRECTOMY WITH OUT SPLEENECTOMY

70. AN ESOPHAGOJEJUNOSTOMY FOLLOWING TOTAL GASTRECTOMY

71. EXTENDED LYMPHADENECTOMY

72. LYMPH NODE STATIONS

73. R1 RESECTION- DISTAL STOMACH

74. R2 RESECTION- DISTAL STOMACH

75. R1 RESECTION- MID STOMACH

76. R2 RESECTION- MID STOMACH

77. ADJUVENT CHEMO IMMUNO THERAPY The immune depression encourages the growth of tumor
cells in certain patients. Numerous immunomodulators have been found to enhance T-cell function
and stimulate natural killer cells. Immunotherapy alone has rarely been shown to be effective
against residual tumors. The advantages are greatest in patients with Stage III and IV disease or
patients who underwent R0 resection. Results are mixed

78. ADJUVENT THERAPY • Rationale is to provide additional loco-regional control. • Radiotherapy-

studies show improved survival, lower rates of local recurrence when compared to surgery alone. • In
unresectable patients, higher 4 year survival with mutimodal tx, in comparison to chemo alone.
79. CHEMOTHERAPY • Numerous randomized clinical trials comparing combination chemotherapy in
the adjuvant setting to surgery alone did not demonstrate a consistent survival benefit. • The most
widely used regimen is 5-FU, doxorubicin, and mitomycin-c. The addition of leukovorin did not
increase response rates.

80. ADVANCED UNRESECTABLE DISEASE • Surgery is for palliation, pain, allowing oral intake •
Radiation provides relief from bleeding, obstruction and pain in 50-75%. Median duration of palliation
is 4-18 months

81. MULTIMODAL THERAPY • Adjuvant chemotherapy – – – – Possible small advantage OR 0.84 (0.74
– 0.96) Western 0.96 Asian 0.58 • Janunger 2001 • Neo-adjuvant chemotherapy (ECF) – MAGIC trial •
Surgery +/- chemo – 503 patients – Higher curative resection rate • 79% vs 69% – Better survival at 2
years • 48% vs 40%

82. PALLIATIVE CHEMO THERAPY • Median survival benefit 3 – 6 months • Combination therapy
superior • 50% gain improvement in QOL

83. COMPLICATIONS OF GASTRECTOMY • • • • • • LEAKAGE FROM ESOPHAGO JEJUNOSTOMY

FISTULA FROM WOUND/DRAIN SITE LEAKAGE FROM DUODENAL STUMP PARA DUODENAL
COLLECTIONS BILIARY PERITONITIS CATASTROPHIC SECONDARY HAEMORHAGE

84. LONG TERM COMPLICATIONS • • • • • REDUCED CAPACITY DUMPING DIARRHOREA NUTRITIONAL

DEFICIENCIES VITAMIN B12 DEFICIENCY

85. PROGNOSIS AFTER SURGICAL TREATMENT • IN JAPAN 75% OF PATIENTS WHO UNDERWENT
CURATIVE RESECTION 5yr SURVIVAL RATE IS 50-70% • IN WEST 25-50% OF PATIENTS WHO
UNDERWENT CURATIVE RESECTION 5yr SURVIVAL RATE IS 20-30%

86. PROGNOSIS • The TNM classification/staging of gastric cancer is the best prognostic indicator •
The 5 years survival rate depends on the depth of gastric cancer invasion • Patients in whom tumors
are resectable for cure also have good prognosis

87. PREVENTION Eradication of H. Pylori infection in those high risk population • Chronic gastritis with
apparent abnormality (atrophy, IM) • Post early gastric cancer resection • Family history of gastric
cancer • Gastric ulcer Management of dietary risk factor • Intake adequate amount of fruits,
vegetables • Minimize their intake of salty/smoked foods Tightly follow up those with precancerous
condition Endoscopic or radiologic screening

88. DETECTION OF EARLY CANCER • Endocytoscopic screening (general population or high risk
persons) • Careful observation • Japan is the only country that had conducted large nationwide mass
population screening of asymptomatic individuals for gastric malignancy