Mastectomy

Goals/Objectives

Choice of local therapy
Types of mastectomy
Lymph node dissection
Sentinel node and mastectomy

Breast Cancer: Surgical Therapy

Theodore N. Tsangaris

From Cameron JL, Cameron AM: Current Surgical Therapy, 10th edition (Mosby 2011)

Overview

As breast cancer care moves into the second decade of the twenty-first century, much has changed regarding diagnosis, staging, and treatment. However, in the multidisciplinary approach to breast cancer care, the surgeon remains the pivotal individual in orchestrating and delivering care to the patient.

Preoperative Evaluation

The surgeon may or may not be the first person to see the woman with a breast problem, so it is imperative that the surgeon be able to come to an evaluation of the problem quickly and accurately. The basic workup for any problem includes a good history, clinical exam, and a diagnostic bilateral mammogram. Digital mammography provides many advantages over traditional film-screen images, and ultrasound and magnetic resonance imaging (MRI) continue to be important supplemental studies, particularly for the difficult breast. Nipple aspiration, duct lavage, and ductoscopy continue to be promising research tools.

Breast biopsy should be preformed by core or fine needle aspiration (FNA). Both can be performed in the office or clinic, however, FNA requires an experienced cytologist. Preoperative FNA of suspicious lymph nodes in the ipsilateral axilla seen on ultrasound is becoming more widespread. Core biopsy is the diagnostic procedure of choice for clinical or mammographically detected masses or mammographic calcifications because of the histologic information it provides, and because the specimen is suitable for prognostic assays. Because core biopsy and FNA preserve breast integrity, they are preferred over excisional biopsy and should be considered the standard of care for tissue diagnosis. Excisional biopsy should be considered only in situations in which core biopsy is unsuccessful in obtaining sufficient tissue, or if there is discordance between the clinical or mammographic findings from core biopsy. In fact, incisional biopsy should almost never be performed.

Workup

The extensive metastatic workup for the newly diagnosed breast cancer patient should be avoided, and it is not appropriate for most early stage breast cancer patients. A good oral history, physical exam, and appropriate age-related preoperative studies should suffice for most of these individuals. Clinical evidence of locally advanced or systemic disease or pathologic confirmation of positive lymph nodes should initiate appropriate testing.

Invasive Breast Cancer

The surgical treatment of invasive breast cancer is much less controversial than the treatment of noninvasive disease. This is not to imply that defining an appropriate surgical treatment is not emotionally and intellectually challenging. Most early-stage breast cancers should be treated with breast conservation, lumpectomy, and radiation therapy. Because of local recurrence concerns, rare is the individual with invasive breast cancer who is appropriately treated with lumpectomy alone. Exceptions would include individuals over the age of 70 years with estrogen-receptor–positive breast cancers. Relative contraindications to breast conservation include 1) large breast cancer relative to a small breast size, 2) inability to undergo radiation therapy, and 3) multicentric disease. The validity of breast conservation for the treatment of invasive breast cancer is well documented in the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-06 and the many other similar and subsequent trials with extensive follow-up ( Figure 48-1-1 ).

F igure 48-1-1, Algorithm for treatment of invasive breast disease.

Surgical Technique

Lumpectomy

For those patients who meet the criteria for breast conservation, the basic principles of lumpectomy are well defined. First, the incision should be placed directly over the site of the tumor and in most situations should be curvilinear in nature to reflect the skin tension lines of the breast. Radial scars may be used for tumors located in the medial or infra-areolar aspects of the breast. Tunneling to the tumor should be discouraged. Accurate placement of the incision facilitates radiation therapy and short- and long-term follow-up, and it ultimately provides the best cosmetic result.

Excision of the tumor with adequate margins and preservation of cosmetic integrity are the primary goals of the surgeon performing lumpectomy. Johns Hopkins defines minimally adequate margins as 2 to 3 mm of microscopically free tissue. Specimens should be handled carefully in the operating room so that the integrity and orientation of the specimen are maintained, and it is unacceptable practice to omit orientation of an excised specimen. I use a 2-point orientation system with suture; the pathologist is then able to use colored ink to designate the margins. I empirically take additional tissue from the tumor cavity, incorporating all margins that are submitted separately to the pathologist. This practice provides the pathologist with margin tissue that is not subject to crush artifact or dye irregularities. I have therefore been able to reduce re-excision rates significantly.

Before closure of the wound, microclips are placed to delineate the tumor cavity. This facilitates identification of the tumor bed radiographically for the radiation oncologist and the mammographer. Reapproximating breast tissue or the placement of drains to close dead space is usually undesirable. The closure I use consists of a two-layer skin closure, and the breast tissue is allowed to reapproximate naturally.

The mastectomy is making a comeback of sorts. With the increased use of genetic testing and magnetic resonance imaging (MRI), more women are personally questioning breast conservation as an acceptable option. With the increased utilization of skin-sparing and nipple-sparing mastectomy, coupled with numerous reconstructive options, more women than ever are choosing ipsilateral and bilateral mastectomy.

When performing a mastectomy, oncologic and cosmetic principles should be considered simultaneously. It should be stressed again that the practice of core biopsy for diagnosis facilitates a superior cosmetic outcome in all mastectomies. Care should be taken to preserve the viability of the skin flaps, and the thickness of the flaps should be carefully considered. Remembering that skin, subcutaneous tissue, and fascia exist superficial to the glandular tissue, the flap thickness should reflect the breast size, body habitus, and weight of the patient. We dissect superficial to the fascial layer anteriorly and include the pectoralis fascia posteriorly with our dissection. It is important to respect the anatomic boundaries of the breast and in particular to not try to violate the inframammary fold, which adds little to the cancer operation but compromises the cosmetic outcome.

Nipple-Sparing Mastectomy

The evolution of the mastectomy procedure has brought us to the threshold of using another form of cosmetic enhancement, the nipple-sparing mastectomy (NSM). It should be noted that the nipple-sparing mastectomy is essentially the same operation as the subcutaneous mastectomy. A nipple-sparing mastectomy with reconstruction may alter the perceived loss to the patient while still providing an oncologically safe mastectomy that achieves a good cosmetic result.

The nipple-sparing mastectomy is essentially a skin-sparing mastectomy (SSM) with retention of the nipple areolar complex (NAC). The literature concerning the safety of SSM shows that the incidence of local recurrence is similar to conventional mastectomy, and after SSM it is most likely a manifestation of the tumor biology rather than preservation of the skin. Furthermore, local recurrence of breast cancer after SSM is not associated with systemic relapse. Similarly, NSM appears to be safe in selected patients in our series at Johns Hopkins. Our data also suggest that local and systemic recurrence after NSM are also secondary to tumor biology rather than preservation of the NAC.

Our current surgical technique for NSM is to remove the breast tissue through a lateral radial incision measuring 4 to 6 cm in length that is at least 2 cm from the edge of the areola. This incision may be extended medially above or below the NAC to access the internal mammary vessels for autologous free-flap anastomosis. A lateral inframammary fold incision may also be employed for the small- to medium-sized breast. Standard anatomic mastectomy borders are utilized. To assess the NAC base for tumor on permanent histologic evaluation, the NAC is inverted through the incision, and a thin slice of tissue is removed from the base to establish a true margin. This ensures viability of the NAC while obtaining an adequate tissue sample.

We do not advocate coring out the nipple duct bundle. Evidence suggests that breast cancer originates in the terminal duct lobular unit (TDLU), and only 9% of nipples contain TDLU. Additionally, coring out the nipple duct could disrupt the vasculature, increasing nipple necrosis and diminishing cosmetic results. The sentinel node is obtained through a separate axillary incision in the usual standard fashion and is routinely done prior to the mastectomy. Immediate reconstruction ensues, either with an autologous free flap, tissue expander, or implant.

Our retrospective results, and those reported elsewhere in the literature, suggest that NAC preservation may be oncologically safe in patients with defined clinical and pathologic criteria. We propose the following criteria for NSM: tumors 4.5 cm in size or smaller, tumors located 2.5 cm or more from the areolar edge or 4 cm or more from the nipple center, and no gross involvement of the NAC, including bloody nipple discharge or Paget's disease. The tumor-to-nipple or tumor-to-areolar distance is assessed clinically if possible and/or mammographically, with ultrasound, or with MRI to obtain precise distance. Tumors that are multicentric, mutifocal, or those that contain extensive ductal carcinoma in situ (DCIS) and otherwise meet the stated criteria can be included. Women who have undergone neoadjuvant therapy and subsequently meet the criteria for tumor size and location can also be considered, but inflammatory breast cancer is absolutely excluded.

Further studies at Johns Hopkins and other institutions are needed to further clarify the validity of our current criteria for NSM, long-term oncologic outcomes, and cosmetic and body image evaluation and satisfaction.

Reconstruction

At our institution, all patients who meet the requirements for mastectomy are considered for immediate reconstruction. Often this is just a temporizing tissue expander, but it starts the reconstructive process that all women deserve. Implants and autologous tissue transfers are the mainstay of breast reconstruction. Among autologous tissue transfers, utilization of the more technically demanding deep inferior epigastric perforator (DIEP) flap is preferred over its less sophisticated cousin, the transverse rectus abdominis muscle (TRAM) flap, as it provides superior cosmesis with limited abdominal wall morbidity. Ultimately the type of reconstruction should be based on the cosmetic and physiologic needs of the patient. Oncologic considerations should have little impact on the decision of the plastic surgeon except in those situations of locally advanced disease in which postmastectomy radiation will be used. Those with locally advanced disease should initially have a tissue expander placed until all treatments for the cancer have been completed.

Surgical Treatment of Breast Cancer

Kelly K. Hunt
Marjorie C. Green
Thomas A. Buchholz

From Townsend CM: Sabiston Textbook of Surgery, 19th edition (Saunders 2012)

Clinical Trials Comparing Breast-Conserving Therapy with Mastectomy

Six prospective clinical trials have randomized more than 4500 patients to mastectomy versus breast-conserving therapy ( Table 48-2-1 ). In all these trials, there was no survival advantage for the use of mastectomy over breast preservation. Ipsilateral breast recurrence rates were higher in patients undergoing breast-conserving surgery, but local recurrences could be salvaged by mastectomy at the time of recurrence, with no significant detriment in survival rates. Data from these trials have served to define predictors of local recurrence after lumpectomy and have led to modifications in surgical and radiation techniques to reduce local recurrence.

T able 48-2-1

Randomized Trials Comparing Breast Conservation vs Mastectomy

Trial	No. of Patients	Max Tumor Size (cm)	Systemic Therapy	Follow-Up (yr)	% Survival Lumpectomy + XRT	% Survival Mastectomy	Local Recurrence (BCT) (%)
NSABP B-06 ^a	1851	4	Yes	20	47	46	14 *
Milan Cancer Institute ^b	701	2	Yes	20	44	43	8.8 *
Institute Gustave-Roussy ^c	179	2	No		73	65	13
National Cancer Institute ^d	237	5	Yes	10	77	75	16
EORTC ^e	868	5	Yes	10	65	66	17.6
Danish Breast Cancer Group ^f	905	None	Yes	6	79	82	3

BCT, Breast-conserving therapy; EORTC, European Organization for Research and Treatment of Cancer; NSABP, National Surgical Adjuvant Breast and Bowel Project; XRT, radiation therapy.

* Includes only women whose excision margins were negative. Data from the following sources:

a Fisher B, Anderson S, Bryant J, et al: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347:1233, 2002.

b Veronesi U, Cascinelli N, Mariani L, et al: Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 347:1227, 2002.

c Arriagada R, Le M, Rochard F, et al: Conservative treatment versus mastectomy in early breast cancer: Patterns of failure with 15 years of follow-up data. J Clin Oncol 14:1558, 1996.

d Jacobson J, Danforth D, Cowan K, et al: Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer. N Engl J Med 332:907, 1995.

e van Dongen J, Voogd A, Fentiman I, et al: Long-term results of a randomized trial comparing breast-conserving therapy with mastectomy: European Organization for Research and Treatment of Cancer 10801 Trial. J Natl Cancer Inst 92:1143, 2000.

f Blichert-Toft M, Rose C, Andersen J, et al: Danish randomized trial comparing breast conservation therapy with mastectomy: Six years of life-table analysis. Danish Breast Cancer Cooperative Group. J Natl Cancer Inst Monogr 11:19, 1992.

NSABP B-06: Mastectomy Versus Lumpectomy with Irradiation Versus Lumpectomy Alone.

A total of 1851 patients with tumors up to 4 cm in diameter and clinically negative lymph nodes were randomized in B-06 to receive modified radical mastectomy, lumpectomy alone, or lumpectomy with postoperative irradiation of the breast without an extra boost to the lumpectomy site. ¹ All patients with histologically positive axillary nodes received chemotherapy. At 20 years of follow-up, overall survival and disease-free survival were the same in all three treatment arms ( Figure 48-2-1 ).

F igure 48-2-1, A, Disease-free survival, B, distant disease-free survival and C, overall survival after 20 years of follow-up in the NSABP protocol B-06. There were no significant differences in the three randomized arms of this trial.

NSABP B-06 provided valuable information about rates of ipsilateral breast cancer recurrence after lumpectomy, with or without breast irradiation. At 20 years of follow-up, local recurrence rates were 14.3% in women treated with lumpectomy and radiation therapy and 39.2% in women treated with lumpectomy alone ( P < .001; Figure 48-2-2 ). For patients with positive nodes who received chemotherapy, the local recurrence rate was 44.2% for lumpectomy alone as opposed to 8.8% for lumpectomy plus radiation therapy.

F igure 48-2-2, Cumulative incidence of a first recurrence of cancer in the treated conserved breast during 20 years of follow-up in the NSABP protocol B-06. The data presented here are for patients achieving a pathologically tumor-free margin after lumpectomy. There were 570 women treated by lumpectomy alone and 567 treated by lumpectomy and ipsilateral breast irradiation.

Reference

1. Fisher B, Anderson S, Bryant J, et. al.: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002; 347: pp. 1233-1241.

Simple Extended and Modified Radical Mastectomy

V. Suzanne Klimberg

From Klimberg, VS: Atlas of Breast Surgical Techniques: A Volume in the Surgical Techniques Atlas Series, 1st edition (Saunders 2009)

Step 1

Surgical Anatomy

Figure 48-3-1 demonstrates the extent of dissection of the chest wall. The dissection extends from the 1 ^st or 2 ^nd rib superiorly, to the rectus inferiorly, to the sternum medially, and to the latissimus laterally. The classic anatomy of the lymph nodes is demonstrated in Figure 48-3-2 .
Figure 48-3-3 shows the en bloc anatomy of the chest wall.
Figure 48-3-4 shows a transverse view of the anatomy and the positioning of nerves and vessels, demonstrating the positions of the thoracodorsal bundle and the long thoracic nerve relative to the axillary musculature.

Step 2

Preoperative Considerations

The primary indication for a simple extended mastectomy (SEM) is for a ductal carcinoma in situ larger than 4 cm (because of risk of recurrence and unidentified invasive cancer), when a sentinel lymph node (SLN) is not identified or SLN biopsy cannot be performed. The procedure is rarely performed today.
The indications for a modified radical mastectomy (MRM) include the following:
- Negative margins for the primary tumor cannot be achieved, and the SLN is positive.
- The tumor is larger than 5 cm.
- Nodes are clinically palpable.
- Inflammatory breast cancer is present.
- Multiple tumors are present (although recent data indicate that SLN biopsy is feasible in such patients).

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