|Surgery for Inflammatory Breast Cancer Patients:
Most chemotherapy drugs that IBC patients initially receive are administered intravenously (injected into the vein). Many physicians recommend that IBC patients receive an implanted medical port or an external tubing system called a central venous catheter (CVC) that can be surgically implanted in the IBC patient's chest or arm (though it is usually implanted in the chest opposite to the affected breast and below the collarbone).
The CVC is an external tube which is tunneled under the skin to reach a major vein, but part of the tube of this system remains outside the skin, which can cause concern because there is a greater risk for infection and accidental dislodgement. Another advantage of the port over the CVC is that the port is more discreet.
Patients with severe medical conditions like cancer have often endured repeated needle sticks as medical professionals accessed their veins to administer therapies and draw blood samples during the course of treatment.
Continual needle pokes can devastate a patient's veins. In addition, the chemicals used to fight diseases like IBC can be very irritating if they come into contact with skin or surrounding tissues, and require patients to reschedule treatments to allow the affected tissues time to heal.
A medical port (such as an 'Infusaport') is a device about the size of a quarter, which is connected to the patient's veins. The top part of the device has a rubber membrane through which a needle can be inserted for the purpose of taking blood samples or giving chemotherapy drugs.
A central venous catheter (such as a 'Broviac') is a long pliable tube which works in a similar manner to a medical port. These devices will avoid the necessity of having needles inserted into the patient's hands, wrists, or elsewhere, and will greatly facilitate the patient's treatment. The doctors and nurses will be able to answer any questions a patient may have about these medical devices.
The ports are usually inserted and removed by a surgeon in an operating room via outpatient surgery. From the outside of a patient, a port appears as a small bump on the patient's skin. Inside the body, a flexible tube or catheter reaches from the port into one of the patient's larger blood vessels - giving the medication a route to the bloodstream.
Ports are made of biocompatible material such as titanium, which does not cause the body to react. The hard case has a self-sealing opening, or septum-about the size and feel of a pencil eraser-on the side that faces the skin, through which a needle can be inserted. That opening gives easy access to the system that delivers medication to the veins.
Before each treatment, a patient can have a numbing lotion rubbed on the skin above the port, which minimizes the pain felt when the needle is inserted into the self-sealing opening although most patients do not require the numbing lotion.
Because IBC usually affects the entire breast and is present in the dermal lymphatics, breast conservation surgery known as a lumpectomy or partial mastectomy (where only the tumor and a rim of surrounding tissue is removed), are usually not indicated.
Most IBC patients will receive a Modified Radical Mastectomy (MRM) after they receive their adjuvant (before surgery) chemotherapy. Some IBC patients will opt for a Prophylactic (preventative) Mastectomy for their unaffected breast, and that will usually be a Total (or Simple) Mastectomy. IBC patients are rarely given a Radical Mastectomy.
There are four general types of mastectomy:
1. A Subcutaneous Mastectomy removes the entire breast, but leaves the nipple and areola (the pigmented circle around the nipple) in place.
2. A Total (or Simple) Mastectomy is the removal of the whole breast, but not the lymph nodes under the arm (axillary nodes). This is often done as a Prophylactic Mastectomy for the non-affected breast of the IBC patient. A prophylactic mastectomy greatly reduces, but does not eliminate the risk of breast cancer.
3. A Modified Radical Mastectomy (MRM) is the removel of the whole breast and most of the lymph nodes under the arm (axillary nodes). Removal of these lymph nodes is called an axillary dissection. This is the standard surgery for the IBC breast.
4. A Radical Mastectomy involves removal of the chest wall muscles (pectorals) in addition to the breast and axillary lymph nodes, but it is rarely used today.
While the patient is anesthetized (unconscious and pain-free), an incision is made into the breast. The breast tissue is removed from the overlying skin and the underlying muscle. When an axillary dissection is done, it is typically via the same incision.
One or two small plastic surgical drains are usually left in place to prevent fluid from collecting in the space where the breast tissue used to be. Your surgeon will decide when these drains are removed, typically when the amount of fluid draining decreases to an acceptable volume. This ranges anywhere from a few days to a week or more. Many IBC patients go home with their drains and have them removed during an office visit.
It is possible to reconstruct the breast (with artificial implants or native tissue) at the same operation (immediate reconstruction) or at a later date, after other necessary treatments are given (delayed reconstruction). Most IBC patients are advised to wait at least one year after surgery before attempting reconstruction. Reconstruction adds to the complexity of the surgery.
The hospital stay varies from 1 to 3 days, depending on the type of surgery. Longer stays are common if breast reconstruction is included. As discussed earlier, surgical drains are commonly placed to remove any fluid that might collect.
Drains may be left in at the time of discharge from the hospital, and you will be instructed to measure the fluid that drains from them. Stitches are often placed under the skin and dissolve on their own. If non-dissolving stitches or clips are used, they are typically removed 7 to 10 days after surgery. Full recovery may take as long as 3-6 weeks.
It takes time for a woman to adjust to the loss of a breast. Talking to other women who have had mastectomies, to their partners, and family can help deal with these feelings. A health care provider can help locate support groups like the IBC E-mail List for the woman and her family. A mental health professional can help a woman and her family adjust.
Mastectomy is a very safe surgery, and most patients recover well with no complications; but as with any surgery, there are risks. The risks of any surgery are bleeding, infection, and injury to nearby tissues. Some post-operative pain and soreness is expected, but can usually be effectively treated with pain medication. There will also be a scar on the chest wall.
General anesthesia risks include potential breathing and heart problems, as well as possible reactions to medications. For a woman who is otherwise in good health, the risk of a serious complication due to general anesthesia is less than 1%.
The risks related specifically to the removal of the breast include a compromised blood supply to the skin of the chest wall, which may cause loss of some skin. In extreme circumstances, this complication may require a skin graft, but this is very rare. There is also a risk of bleeding into the space where the breast used to be. Sometimes a second operation is required to control bleeding, but this is also uncommon.
There are risks specifically related to removing the nearby lymph nodes (axillary dissection):
Many patients experience shoulder stiffness after removal of the lymph nodes in the armpit. This stiffness improves over time, especially with exercise and physical therapy.
A fluid collection, called a seroma, may collect in the armpit. This is relatively common and usually resolves on its own, but may require needle drainage.
Since the axillary (armpit) lymph nodes normally drain excess fluid from the arm, the removal of these can result in postoperative swelling of the arm on the same side as the breast which is removed. This swelling (called lymphedema) is uncommon, but when it occurs, it can be a persistent problem and carries an increased risk of infection.
There are some important nerves in the area of the axillary lymph nodes that are at risk during surgery. Many patients will have a numb patch on the inside of the arm after surgery. Nerves to muscles of the back and chest wall are also at risk, but your surgeon will make every effort to protect these nerves during surgery.
As cancers grow, they can shed cells that spread (or metastasize) to other parts of the body through the bloodstream and the lymph system. Since IBC occurs in the dermal lymphatic system, it is more easily metastasized to other parts of the body through the lymph system.
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After the cancer spreads, it can form new tumors in other parts of the body. These tumors are called metastases. They are most often found in the lymph nodes (glands) near the breast. If the cancer spreads through the blood, it most commonly travels to the bones of the pelvis, spine, legs, ribs, and skull. Metastases may also be found in the liver, lungs, and brain.
The treatments for metastatic breast cancer include radiation, chemotherapy, and hormone therapies. An IBC patient may have just one type of treatment or a combination of treatments. These treatments are not expected to cure metastatic cancer, but they do help to slow down growth of the tumor and decrease its size so that symptoms decrease.
Radiation is given to a specific part of the body, usually a bone, to kill the cells and shrink the tumors. This will decrease the pain. In cases where a tumor is in the bone, radiation therapy will decrease the risk of bone fracture.
During chemotherapy a combination of anticancer drugs are given through the veins to kill the cancer cells.
For hormone therapy, the IBC patient is given hormones in addition to or instead of other therapy. This treatment is often used for women who are older or who have additional medical problems. Tamoxifen may be used alone or in some cases in combination with chemotherapy.
A patient will probably take medicine to relieve pain. Even severe pain can be controlled by a combination of medicines that usually includes narcotics. People who are placed on narcotics to control pain do not become drug addicts. As radiation or chemotherapy treatment relieves the pain, the need for pain medication will gradually disappear.
How long an IBC patient will live after the discovery of metastatic breast cancer varies depending on how widespread the cancer is. Treatment of spread can sometimes give years of further control of the cancer.
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