Lumpectomy and mastectomy – Procedures

What the Anesthesiologist Should Know before the Operative Procedure

Breast cancer is the second leading cause of cancer death in women, and In the United States, over a lifetime, 1 in 8 women will be diagnosed with breast cancer and 1 in 35 will die from the disease. In contrast, male breast cancer is rare, accounting for approximately 1% of male cancers. Mastectomy, the removal of one or both breasts, is the local treatment for breast cancer and may be combined with adjuvant treatments including radiation, chemotherapy, or hormone therapy. Mastectomy may be subdivided into:

Nipple sparing: removal of breast tissue with preservation of the nipple-areola complex

Skin sparing: removal of breast tissue, the nipple-areola complex, and scars from prior biopsy

Simple: removal of breast tissue, the nipple-areola complex, and skin

Modified radical: a simple mastectomy and removal of level I and II axillary lymph nodes

Radical mastectomy: removal of the entire breast, axillary lymph nodes, and both pectoralis major and minor muscles

The type of mastectomy performed depends on several factors, including size of the tumor, number of lesions, tumor type, and invasiveness (skin, axilla, underlying muscle) as well as patient preference. For patients with mutations of the BRCA genes, who have a greatly increased risk of developing breast cancer, mastectomy may be performed prophylactically. Reconstruction of the breast may immediately follow mastectomy or may be planned as a delayed procedure.

Breast cancer incidence increases with age, with most women presenting in their 6th and 7th decades, and therefore, significant comorbidities may be present that may require optimization prior to surgery. Typically, patients are admitted to the hospital postoperatively for 1 to 2 days’ observation, although simple mastectomy may be performed on an ambulatory basis provided that pain and nausea (the most common postoperative complications) are managed adequately.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Mastectomy is rarely an emergent or urgent procedure, although delay of the procedure much beyond the period of diagnosis theoretically increases the risk of metastases and spread of disease. Mastectomy is only truly elective if it is performed as a prophylactic procedure.

Emergent: if the cancer has developed into a fungating wound with concomitant sepsis or risk for significant bleeding or sepsis

Urgent: if there is increased risk for growth and spread of the disease (i.e., pregnancy with hormonal stimulation)

Elective: for breast cancer prophylaxis

2. Preoperative evaluation

Assessment of the patient should include a careful review of the medical history, including comorbid conditions, medications, and drug allergies in order to allow for perioperative and postoperative risk stratification. Evaluation for metastatic disease should be carried out to determine effects on organ systems, particularly spinal cord, lung, and brain. Review of previous chemotherapy treatments is important to identify any residual toxicities including anemia and doxorubicin cardiotoxicity. As mastectomy is rarely an emergent or truly urgent procedure, any uncontrolled medical condition or new pathology should be appropriately evaluated and treated prior to surgery.

Medically unstable conditions warranting further evaluation include myocardial infarction, active ischemia, unstable arrhythmias, decompensated heart failure, uncontrolled hypertension, COPD exacerbation, renal failure, acute hepatitis, TIA/stroke, uncontrolled endocrinologic disorders (thyrotoxicosis, pheochromocytoma, DKA), bleeding/clotting diathesis, acute fracture, uncontrolled psychiatric condition, and acute intoxication (drug and alcohol).

Delaying surgery may be indicated if: further medical optimization would reduce perioperative risk.

3. What are the implications of co-existing disease on perioperative care?

N/A

b. Cardiovascular system

Perioperative evaluation

Acute/unstable conditions: The 2007 ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery recommend preoperative evaluation and treatment prior to noncardiac surgery of the following conditions: unstable or severe angina, recent MI, decompensated heart failure, significant arrhythmias, and severe valvular disease. If these conditions are present or suspected, workup may include 12-lead ECG, Holter monitoring, cardiac markers, resting echocardiogram or cardiac consultation.

Baseline coronary artery disease or cardiac dysfunction Goals of management: Mastectomy is considered a low-risk procedure, and therefore, assessment of a patient’s functional status and severity of disease is necessary in order to properly risk stratify. Careful questioning to ascertain any changes in symptoms (chest pain, dyspnea, decreased exercise tolerance), medication changes, recent interventions or hospitalizations should be performed, and prior ECG, cardiac testing (noninvasive stress testing, catheterizations, echo) and laboratory data should be reviewed. Unless unstable or active cardiac conditions are present, further workup or intervention has not been shown to alter outcome.

Perioperative Risk Reduction Strategies

Monitoring- the need for invasive monitoring (arterial line, CVP, PA catheter, TEE) must be balanced against disease severity and risks of line placement. Given the low risk nature of mastectomy, the lack of significant blood loss or hemodynamic instability, the need for invasive monitoring is rare.

Goals

• Balance oxygen supply and demand

• Increase supply

• Increase the fraction of inspired oxygen concentration (FiO2)

• Increase oxygen-carrying capacity (hemoglobin)

• Avoid tachycardia, which reduces the time spent in diastole and LV perfusion

• Increase coronary perfusion by increasing diastolic pressure and reducing LV end diastolic pressure (CPP = DAP – LVEDP)

• Avoid hypercarbia and acidosis, which reduce coronary blood flow

Reduce demand

• Reduce heart rate and oxygen consumption

• Decrease contractility

• Optimize afterload: avoid increases in myocardial wall tension and oxygen consumption without jeopardizing perfusion pressure

• Optimize Preload: maintain adequate stroke volume without increasing ventricular wall tension.

c. Pulmonary

Patients with pulmonary disease are at increased risk of postoperative pneumonia and dysfunction after general anesthesia. Metastases to the lung may result in pleural effusions and parenchymal invasion which may compromise pulmonary function.

COPD

Preoperative evaluation

A careful clinical history should be obtained, which includes smoking history, symptoms (dyspnea, exercise tolerance), frequency of exacerbations, oxygen requirements, prior hospitalizations or intubations, steroid use, current medication regimen, and any available pulmonary studies. Although PFTs are a useful measure of severity of disease and response to bronchodilators, they have not been shown to alter outcome for low-risk procedures.

Perioperative risk reduction strategies

• Continue current pulmonary medications perioperatively.

• Treat any underlying respiratory infections or exacerbations.

• Counsel patient to cease smoking to reduce airway irritability, if able to discontinue 6-8 weeks prior to surgery.

• A regional anesthetic (thoracic epidural or paravertebral block) may allow for improved analgesia and reduction of postoperative atelectasis (decreased splinting and more effective cough). Since a high thoracic level (T2-6) is required, the technique may not be best suited for pulmonary cripples who depend on accessory muscles to breathe.

• If a general anesthetic is used, mechanical ventilation should be optimized by adjusting the I:E ratio to allow for adequate expiratory time, reducing the respiratory rate, increasing FiO2, adding PEEP, using bronchodilators and humidifying gases. Deep extubation should be considered if appropriate to avoid triggering bronchospasm.

Reactive airway disease (asthma)

Preoperative Evaluation

Review of the clinical history to assess severity of disease, frequency of exacerbations, triggers, current medical regimen, use of steroids, and any hospitalizations and intubations.

Perioperative risk reduction strategies

• Continue medical regimen.

• Consider preoperative nebulized or aerosolized beta-2 agonist administration.

• Consider regional technique to avoid airway manipulation.

• If general anesthesia is utilized, consider using volatile agents that are bronchodilators.

• Avoid histamine-releasing medications such as morphine or atracurium.

• If appropriate, LMA may help to minimize airway reactivity.

• Mechanical ventilation should be optimized as in COPD.

d. Renal-GI:

Renal

Patients may be dehydrated from a prolonged NPO period.

Preoperative evaluation

• Dehydration: Patients volume status should be assessed by reviewing oral intake, vital signs, skin turgor, lab values. Appropriate rehydration should occur prior to anesthetic induction or regional technique.

• Laboratory data: baseline creatinine, BUN, sodium, potassium, and hemoglobin should be obtained.

• Chronic Renal insufficiency may result in metabolic disturbances including hyperkalemia, hypocalcemia, hyperphosphatemia, metabolic acidosis, fluid overload and pulmonary edema, and anemia. Medications and dialysis history should be reviewed, and baseline laboratory data obtained.

Perioperative risk reduction strategies

• Avoid nephrotoxins, drugs such as aminoglycosides and NSAIDs.

• Avoid drugs that depend on renal excretion for elimination.

• Avoid hypotension, hypoxia, and dehydration, which may decrease renal perfusion.

• Consider administration of blood products to treat anemia and ddAVP for decreased platelet function.

Gastrointestinal

Assess history of gastroesophageal reflux disease and need for a rapid sequence induction.

Perioperative risk reduction strategies

• Measures to reduce risk of pulmonary aspiration.

• Consider administration of a nonparticulate antacid, promotility agent (Reglan), H2 blocker, or proton pump inhibiter prior to induction of anesthetic.

e. Neurologic:

Preoperative evaluation

A careful history to evaluate for cerebrovascular disease (CVA, stroke), spine pathology, intracranial mass (metastatic disease), seizures and neuromuscular disorders should be taken.

Perioperative risk reduction strategies

• Avoid hypotension and hypocarbia, which may reduce cerebral perfusion

• Avoid seizure-triggering agents

• Avoid muscle relaxants in patients with severe neuromuscular disorders

Acute issues: Any new symptoms such as syncope, TIA’s, uncontrolled seizures, new onset headache, nausea, visual disturbances, muscle weakness or other focal neurological signs require further evaluation and treatment prior to surgery.

Chronic disease: A history of cerebrovascular disease may require higher blood pressures to maintain adequate cerebral perfusion, and invasive arterial blood pressure monitoring should be considered. Vasoconstrictor (phenylephrine) infusion may be necessary intraoperatively

Perioperative risk reduction strategies

• Avoid hypotension and hypocarbia, which reduce cerebral perfusion

• Avoid seizure triggering agents, maintain antiseizure drugs in the perioperative period

• Avoid muscle relaxants in patients with severe neuromuscular disorders

f. Endocrine:

Preoperative evaluation

A careful history should be obtained to evaluate for any preexisting endocrine disease such as diabetes, thyroid disease, or pituitary axis disorders. Laboratory date should be reviewed including electrolytes, serum glucose, HbA1c, thyroid studies.

Perioperative risk reduction strategies

Normoglycemia should be maintained in the perioperative period, and may reduce perioperative infection rate, and improve healing. Hormone replacement or suppressant medications should be continued in the perioperative period.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

N/A

4. What are the patient's medications and how should they be managed in the perioperative period?

N/A

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

This may include medications specific to diseases associated with surgery. Chemotherapuetic agents: Doxorubicin (Adriamycin) is frequently administered to breast cancer patients, and may result in cardiomyopathy. Patients are evaluated prior to treatment with either MUGA scan or echo to assess for preexisting abnormalities. These studies should be reviewed, and if clinical history is suspicious for Adriamycin-induced cardiac dysfunction (dyspnea, cough, decreased exercise tolerance, arrhythmias), further evaluation should occur prior to surgery.

i. What should be recommended with regard to continuation of medications taken chronically?

Cardiac:

Beta-blockers and antihypertensive drugs should be continued in the perioperative period. Consider holding diuretics, ACE inhibitors and ARBs on the day of surgery to avoid intraoperative hypotension. Anticoagulants and aspirin are typically held 5-7 days prior to surgery. For patients with cardiac stents, the optimal management of antiplatelet drugs should be discussed with the cardiologist and surgeon in order to balance the risk of thrombosis against increased surgical bleeding.

Pulmonary:

Continue perioperative medications such as inhaled beta-agonists, anticholinergics, leukotriene inhibitors, inhaled or oral steroids.

Renal:

Hold diuretics to avoid exacerbations of dehydration.

Neurologic:

Antiseizure and Parkinson’s medications should be continued perioperatively.

Antiplatelet:

See above.

Psychiatric:

Continue antidepressants and anxiolytics perioperatively.

j. How To modify care for patients with known allergies –

Review patient’s sensitivities to drugs, food products, adhesives, and surgical preparation solutions, including symptoms (adverse reaction vs. anaphylaxis) Avoid known or suspected allergens.

k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

If the patient has a known allergy to latex, prepare the operating room with latex free products and avoid puncturing latex stoppers when drawing up medications.

l. Does the patient have any antibiotic allergies- – Common antibiotic allergies and alternative antibiotics]

N/A

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia (MH)

Documented: Avoid all trigger agents such as succinylcholine and inhalational agents:

• Proposed general anesthetic plan: May include a TIVA technique.

• Ensure MH cart available: Dantrolene must be readily available [MH protocol].

• A clean anesthesia machine must be used. If an MH-specific machine is not available, then the machine should be flushed with high oxygen flow rates for at least 20 minutes, and all tubing and the CO2 absorbent should be replaced.

• Family history or risk factors for MH: The above precautions should be taken with patients who have a positive family history, history of central core disease, myopathy, or Duchenne’s muscular dystrophy.

Local anesthetics/ muscle relaxants

Allergic reactions to local anesthetics are rare, and typically to the ester local anesthetics. Avoidance of these agents and substitution with an amide local anesthetic is appropriate.

5. What laboratory tests should be obtained and has everything been reviewed?

Simple mastectomy is a low-risk procedure and is generally performed in relatively healthy women. Therefore, no preoperative laboratory testing is necessary, and it should be dictated on the basis of consideration of preexisting medical conditions. A radical mastectomy has the potential for significant blood loss, and obtaining a preoperative hemoglobin and blood bank sample would be prudent.

Additional testing may be necessary depending on the patient’s coexisting medical conditions.

Hemoglobin levels:

May consider a preoperative hemoglobin level in patients with history of bleeding, recent chemotherapy or radiation therapy, anemia, and renal failure.

Electrolytes:

May consider obtaining preoperative values in patients on chronic diuretics and steroids, patients with a history of renal insufficiency and dialysis.

Coagulation panel:

Consider obtaining in patients with a history of bleeding abnormalities or liver disease and those taking anticoagulants.

Imaging:

Need for chest radiograph and ECG should be dictated by clinical history.

Other tests:

Additional testing should be dictated by clinical history (e.g., TSH in patients suspected for thyroid disease beta-HCG for patients who may be pregnant).

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Simple mastectomy may be performed under general or regional anesthesia, or combined technique.

Regional anesthesia

May be performed with sedation or combined with a general anesthetic to provide postoperative analgesia.

Neuraxial

The breast is innervated by the anterior cutaneous branches of Intercostal nerves 1-6 (T1-6) and the lateral cutaneous branches of intercostal nerves 2-7 (T2-7), therefore a high thoracic epidural may be utilized for the anesthetic or for postoperative analgesia. If axillary dissection is to be undertaken, additional blockade of the lower cervical roots may be required (superficial cervical plexus block).

Benefits

• Thoracic epidural for mastectomy is associated with reduced postoperative nausea and vomiting, improved analgesia, and possibly shorter hospital stay when compared to general anesthesia

• Avoidance of airway manipulation and triggering of bronchospasm in patients at significant risk

Drawbacks

• Contraindicated in patients on anticoagulants (ASRA guidelines should be followed)

• Sympathectomy may not be well tolerated in patients with CAD, valvular lesions and cerebrovascular disease

• Patients may not be able to tolerate the psychological distress of mastectomy under light sedation if used as the sole anesthetic.

• Local anesthetic supplementation may be necessary for inadequate dermatomal coverage, and axillary dissection

• May not be appropriate for patients with pulmonary compromise who require accessory muscle use

• Potential for urinary retention and lower extremity weakness

Issues

• Complications of neuraxial techniques include headache, infection, bleeding, epidural hematoma and nerve injury, paralysis, and local anesthetic toxicity.

Peripheral nerve block

The paravertebral block may be utilized as the sole anesthetic or combined with general anesthesia to provide perioperative analgesia, and may be performed unilaterally or bilaterally. The same considerations as for epidural apply.

Benefits

• Improved analgesia when compared to general anesthesia alone

• Reduced PONV when compared to general anesthesia alone

• Greater patient satisfaction when compared to general anesthesia alone

• Potential for earlier hospital discharge postoperatively

• Avoidance of general anesthesia

• Avoidance of epidural side effects: urinary retention, lower extremity weakness

• Suggestion of reduced recurrence of disease. Further studies are underway to determine the validity.

Drawbacks

• Anticoagulation is a relative contraindication.

• Sympathectomy may not be well tolerated.

• Patients may not be able to tolerate the psychological distress of mastectomy under light sedation if used as the sole anesthetic.

• Local anesthetic supplementation may be necessary.

• May not be appropriate technique for patients with COPD.

Issues

• Complications include high spinal, epidural block, headache, infection, bleeding, nerve injury, failure, local anesthetic toxicity and pneumothorax.

b. General Anesthesia

May be used as the sole anesthetic or combined with a regional technique.

Benefits

• Provides for a secure airway and management of pulmonary mechanics

• May be better tolerated psychologically

• Better tolerance for longer procedures

• Avoids risks of regional techniques

• An LMA can be utilized to reduce airway irritability if muscle relaxation is not required for immediate reconstruction procedures

Drawbacks

• Higher incidence of PONV compared to regional techniques

• Less patient satisfaction compared to regional techniques

• Hemodynamic swings

• Risk for pulmonary aspiration

• Risk for postoperative myalgias with use of depolarizing muscle relaxants

c. Monitored Anesthesia Care

Not adequate as the sole anesthetic technique for this procedure.

6. What is the author's preferred method of anesthesia technique and why?

Combined paravertebral block and general anesthetic is our preferred method of anesthesia for mastectomy as it results in excellent perioperative analgesia, a reduction in the incidence of PONV, greater patient satisfaction, and the potential for earlier hospital discharge. The paravertebral block is a safe and effective technique when performed by an experienced practitioner, and avoids the complications associated with a high thoracic epidural. Currently there is great interest in regional techniques for mastectomy as a result of literature that suggests a possible reduced recurrence rate of disease. Utilizing 0.5% bupivacaine in volumes of 15 to 40 mL, an average block duration of 16 hours can be obtained. Postoperatively patients are supplemented with parenteral narcotics as needed, and are usually transitioned to oral analgesics on postoperative day 1.

What prophylactic antibiotics should be administered?

A cephalosporin is typically administered within 30 minutes of the procedure. A suitable alternative is chosen if the patient has a history of penicillin or cephalosporin allergy.

What do I need to know about the surgical technique to optimize my anesthetic care?

Mastectomy ranges from simple to radical (as described above), and the more invasive procedures (axillary dissection and removal of chest muscle) may be associated with greater blood loss. However, the type of mastectomy should not impact the anesthetic management.

Mastectomy with immediate reconstruction: Placement of tissue expanders or implants under the pectoralis muscle often requires muscle relaxation by the plastic surgeon. During axillary dissection, however, the surgeon may want to avoid muscle relaxation in order to avoid injury to the brachial plexus. This should be considered when planning airway management and muscle relaxant use.

What can I do intraoperatively to assist the surgeon and optimize patient care?

Communicate with the surgeon to determine muscle relaxant needs.

What are the most common intraoperative complications and how can they be avoided/treated?

Hypotension due to sympathectomy and preoperative dehydration. Adequate fluid resuscitation and vasoconstrictor (ephedrine, phenylephrine) administration are usually sufficient to manage the issue.

a. Neurologic: *** Type Here.

N/A

b. If the patient is intubated, are there any special criteria for extubation?

The standard criteria for extubation should be followed.

c. Postoperative management

What analgesic modalities can I implement?

A multimodal approach utilizing intravenous and oral opioids, regional technique, and Tylenol or NSAIDs.

What level bed acuity is appropriate?

Bed acuity depends on patient’s perioperative condition, intraoperative course, and hospital resources. The patient is typically discharged from the PACU to a standard floor bed. Unilateral simple mastectomy may be performed on an ambulatory basis.

What are common postoperative complications, and ways to prevent and treat them?

• PONV: utilize a regional technique and minimize narcotic use

• Pain: utilize a multimodal approach

What's the Evidence?

“ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary”. JACC . vol. 50. 2007. pp. 1707-32. (Excellent review of perioperative cardiovascular risk assessment for patients undergoing noncardiac surgery, including grading of the level of evidence.)

Kitowski, NJ, Landercasper, J, Gundrum, JD. “Local and paravertebral block anesthesia for outpatient elective breast cancer surgery”. Arch Surg. vol. 145. 2010. pp. 592-94. (Retrospective review of a prospective database of 70 patients undergoing outpatient breast surgery supporting benefits of regional anesthesia.)

Thavaneswaran, P, Rudkin, GE, Cooter, RD. “Paravertebral block for anesthesia: a systematic review”. Anesth Analg. vol. 110. 2010. pp. 1740-4. (Systematic review of peer-reviewed literature assessing the safety and efficacy of paravertebral blocks for surgical anesthesia.)

Schnabel, A, Reichl, SU, Kranke, P, Pogatski-Zahn, EM, Zahn, PK. “Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized control trials”. Br J Anaesth. vol. 105. 2010. pp. 842-52. (Meta-analysis of 15 RCT’s providing evidence to support superiority of paravertebral block in addition to general anesthesia or alone in providing postoperative pain control with fewer adverse effects in breast surgery.)

Doss, NW, Ipe, J, Crimi, T. “Continuous thoracic epidural anesthesia with 0.2% ropivacaine versus general anesthesia for perioperative management of modified radical mastectomy”. Anesth Analg. vol. 92. 2001. pp. 1552-7. (Small prospective study supporting the superiority of thoracic epidural anesthesia over general anesthesia for perioperative management of patients undergoing modified radical mastectomy.)

Deegan, CA, Murray, D, Doran, P. “Anesthetic technique and the cytokine and matrix metalloproteinase response to primary breast cancer surgery”. Reg Anesth Pain Med. vol. 35. 2010. pp. 490-95. (Small RCT demonstrating reduced levels of protumorigenic cytokines in patients receiving regional anesthesia for primary breast cancer surgery.)

Exadaktylos, AK, Buggy, DJ, Moriarty, DC. “Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis”. Anesthesiology. vol. 4. 2006. pp. 660-4. (Provocative retrospective analysis of a small population of breast cancer patients suggesting that paravertebral anesthesia and analgesia reduces recurrence risk.)

Spear, SL, Carter, ME, Schwarz, K. “Prophylactic mastectomy: indications, options, and reconstructive alternatives”. Plast Reconstr Surg. vol. 115. 2005. pp. 891-909. (Excellent review of reconstructive plastic surgical procedures following mastectomy.)

(Excellent source of general breast cancer information and recent statistics.)

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