Radical mastectomy

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Portait of William Halsted

Radical mastectomy is a milestone surgical procedure pioneered by William Stewart Halsted involving the removal of breast, underlying chest muscle (including pectoralis major and pectoralis minor), and lymph nodes of the axilla as a treatment for breast cancer. Breast cancer is the most common cancer among women today, and is primarily treated by surgery, particularly during the early twentieth century when the mastectomy was developed with success.[1] However, with the advancement of technology and surgical skills, the extent of mastectomies has been reduced. Less invasive mastectomies are employed today in comparison to those in the past. Nowadays, a combination of radiotherapy and breast conserving mastectomy are employed to optimize treatment.

Pre Halstead treatments

In 460 BC, Hippocrates described breast cancer as a humoral disease.[2] This humoral theory of oncogenesis was accepted by the influential Roman physician Galen and remained the standard in the Middle Ages for over 1,300 years.[3] In 1957, Henri François Le Dran published a paper in which he reasoned that the disease spread through the lymphatic system and then into general circulation, effectively rejecting the humoral theory of cancer. Le Dran came to this conclusion after noting that axillary nodal involvement in a patient with breast cancer was indicative of a worse prognosis. His findings were significance because he recognized that cancer at its earliest phase of development is a local disease that could be surgically removed.

Portrait of Jean-Louis Petit, french surgeon

Jean Louis Petit was a large proponent of Le Dran's notion of breast cancer. A contemporary of Le Dran's, Petit described an ablative surgery that involved excising the breast, axillary lymph nodes, the underlying pectoral fascia, and possibly the pectoralis major. Wary of leaving potentially affected tissue, Petit was more inclined toward an extensive resection. These descriptions were published 24 years after his death in Petit's book Traits des Maladie Chirurgicals et des Operations. He noted that the operation may be considered the first radical mastectomy based on his extensive research. Unlike the more traditional mastectomy which followed Petit's operation, he did not remove large portions of the skin unless it was directly affected, suturing the skin shut instead to prevent hemorrhage.[4]

Despite Petit's publication, many surgeons were reluctant to perform a radical surgery even towards the end of the 19th century. There was still confusion regarding the mechanism of cancer spread. Furthermore, the risks were high without anaesthesia in many hospitals, blood transfusions, and complications due to infection. A number of doctors were unconvinced of the value posed by a radical surgery. It was in these conservative times that William Halsted published a paper on the radical mastectomy as it is known today.[5]

Radical Mastectomy

Halsted and Meyer were the first to achieve successful results with the radical mastectomy, thus ushering in the modern era of surgical treatment for breast cancer. In 1894, William Halsted published his work with radical mastectomy from the 50 cases operated at Johns Hopkins between 1889 and 1894.[6] Willy Meyer also published research on radical mastectomy from his interactions with New York patients in December 1894.[7] The en bloc removal of the breast tissue became known as the Halsted mastectomy before adopting the title "the complete operation" and eventually, "the radical mastectomy" as it is known today.[8]

The Halsted-Meyer Theory

Radical Mastectomy

Radical mastectomy was based on the scientific belief at the time that breast cancer spread locally at first, invading nearby tissue and then spreading to surrounding lymph ducts where the cells were "trapped". It was thought that hematic spread of tumor cells occurred at a much later stage.[1]

Features of Radical Mastectomy

Radical mastectomy involves removing all the breast tissue, overlying skin, the pectoralis muscles, and all the axillary lymph nodes. Skin was removed because the disease involved the skin, which was often ulcerated.[6][9] The pectoralis muscles were removed not only because the chest wall was involved, but also because it was thought that removal of the transpectoral lymphatic pathways were necessary. It was also thought, at that time, that it was anatomically impossible to do a complete axillary dissection without removing the pectoralis muscle.[6][7]

William Halsted accomplished a three-year recurrence rate of 3% and a locoregional recurrence rate of 20% with no perioperative mortality. The five-year survival rate was 40%, which was twice that of untreated patients.[6] However, post-operation morbidity rates were high as the large wounds were left to heal by granulation, lymphedema was  ubiquitous, and arm movement was highly restricted. Thus, chronic pain became a prevalent sequela. Because surgeons were faced with such large breast cancers that seemed to need drastic treatment methods, the quality of patient life was not taken into consideration.[9][10][11][12][13][14][15]

Nonetheless, due to Halsted and Meyer's work, it was possible to cure some cases of breast cancer and knowledge of the disease began to increase. Standardized treatments were created, and controlled long-term studies were conducted. Soon, it became apparent that some women with advanced stages of the disease did not benefit from surgery. In 1943, Haagensen and Stout reviewed over 500 patients who had radical mastectomy for breast cancer and identified a group of patients who could not be cured by radical mastectomy thus developing the concepts of operability and inoperability.[16] The signs of inoperability included ulceration of the skin, fixation to the chest wall, satellite nodules, edema of the s kin (peau d'orange), supraclavicular lymph node enlargement, axillary lymph nodes greater than 2.5 cm, or matted, fixed lymph nodes.[16] This contribution of Haagensen and his colleagues would eventually lead to the development of a clinical staging system for breast cancer, the Columbia Clinical Classification, which is a landmark in the study of biology and treatment of breast cancer.

Extended Radical Mastectomies

According to the Halsted-Meyer theory, the major pathway for breast cancer dissemination was through the lymphatic ducts. Therefore, it was thought that performing wider and more mutilating surgeries that removed a greater number of lymph nodes would result in greater chances of cure.[17] From 1920 onwards, many surgeons performed surgeries more invasive than the original procedure by Halsted. Sampson Handley noted Halsted's observation of the existence of malignant metastasis to the chest wall and breast bone via the chain of internal mammary nodes under the sternum and employed an "extended" radical mastectomy that included the removal of the lymph nodes located there and the implantation of radium needles into the anterior intercostal spaces.[18] This line of study was extended by his son, Richard S. Handley, who studied internal mammary chain nodal involvement in breast cancer and demonstrated that 33% of 150 breast cancer patients had internal mammary chain involvement at the time of surgery.[19] The radical mastectomy was subsequently extended by a number of surgeons such as Sugarbaker and Urban to include removal of internal mammary lymph nodes.[20][21] Eventually, this "extended" radical mastectomy was extended even further to include removal of the supraclavicular lymph nodes at the time of mastectomy by Dahl-Iversen and Tobiassen.[22] Some surgeons like Prudente even went as far as amputating the upper arm en bloc with the mastectomy specimen in an attempt to cure relatively advanced local disease.[23] This increasingly radical progression culminated in the ‘super-radical’ mastectomy which consisted of complete excision of all breast tissue, axillary content, removal of the latissimus dorsi, pectoralis major and minor muscles and dissection of the internal mammary lymph nodes.[24] After retroscpective analysis, the extended radical mastectomies were abandoned as these massive and disabling operations proved to be not superior to those of the standard radical masectomies.

Reduced Mastectomies

Pectoralis Major
Pectoralis Minor

The Patey-Dyson Mastectomy

Breast Anatomy

Up until the first half of the 20th century, the idea that breast cancer spread centrifugally was accepted. When J.H. Gray published his study in 1940, he challenged the belief that extended radical mastectomies were necessary.[25] Gray's study showed that while the dermis was full of lymphatic vessels and a likely plane of cancer spread, the fascia, on the other hand, was devoid of lymphatic vessels and an unlikely plane of cancer spread. These findings spurred Patey and Dyson to experiment with a reduced mastectomy that preserved the pectoralis major.[26] After reviewing mastectomies performed between 1930 and 1943, they found no difference in survival or local recurrence rates between those who had underwent their operation, in which the pectoralis major was spared, and those who underwent the standard radical mastectomy. Therefore, they concluded, "A modified radical operation in which the pectoralis major is preserved shows results as good as those of the standard radical operation, and in addition has positive advantages".[26]

The Madden-Auchincloss Mastectomy

In 1972, John Madden and colleagues conducted their own "modified" radical mastectomy, in which both the pectoralis major and the pectoralis minor were preserved, on a series of patients. The results were similar to those using the standard radical mastectomy.

Yet Patey argued that complete axillary dissection was not possible if the pectoralis minor was preserved. Furthermore, he contested that the muscle would be rendered useless anyways because the pectoralis minor's nerve and blood supply would not be conserved.[26] However, Madden's lymphangiographic data proved otherwise. The research showed that it was possible to clear the axilla and preserve the neurovascular supply to the pectoralis minor muscle.[27] Another doctor, Hugh Auchincloss also presented data in favor of the modified radical mastectomy preserving the pectoralis minor.[28] He also questioned the need to perform complete axillary dissection, suggesting instead that the Berg level III axillary nodes should only be removed when evidently invaded, since metastases from breast carcinoma do not involve the axillary nodes as a unit but progress from level to level.[29] Crile went further and claimed that immediate axillary dissection should only be performed if the axilla was evidently involved and only subsequently performed if axillary involvement developed.[30] His findings showed that survival rates following delayed axillary dissection were on part with or even better than following preventative lymph node dissection.[30]

Another objection to preserving the pectoralis minor was that the interpectoral (Rotter) nodes were a potential site for disease recurrence. Nevertheless, recurrence at this site is rare, and even if it occurs, muscle invasion is unusual.

Simple Mastectomy

Simple Mastectomy

A simple mastectomy is an operation that involves the removal of the pectoral fascia and the breast, but neither of the pectoralis muscles nor the axillary lymph nodes. Kennedy and Miller first developed the simple mastectomy based on the belief that a radical mastectomy was not always necessary to treat women with breast cancer.[31] In 1965, Kaae and Johansen compared simple mastectomy and postoperative radiotherapy with extended radical mastectomy and radiotherapy and found that the overall survival rates were similar.[32] Once again, a less invasive mastectomy proved to result in similar outcomes to the more prevalent invasive mastectomy, thus turning the tide in favor of "reduced" mastectomies.

Breast Conservation

Mammography
Radiotherapy

During the 1970s, the debate between extended and reduced mastectomies came to a head when Bernard Fisher cited evidence supporting the claim that breast cancer was a systemic disease from the beginning, and that, in most cases, distant metastases were present well before diagnosis. Thus, extended mastectomies were useless. On the other hand, Fisher also gathered evidence that debulking the tumor mass might prompt the body to kill remaining tumor cells by immunologic and other mechanisms in combination with systemic cytotoxic agents.[33] As these ideas circulated and the use of mammography to identify small lesions and permit diagnosis of breast cancer at an earlier age became more widespread, surgeons became inspired to experiment with breast conservation treatments combined variably with elective axillary dissection, radiotherapy, and chemotherapy. Veronesi's group was the first to publish a study on the value of a conservative procedure in patients with breast cancer. More specifically, the study compared the radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast.[34] Later on, Fisher also conducted a study in which he compared total mastectomy and segmental mastectomy both with and without radiation in the treatment of breast cancer.[35] The findings of these two studies were revolutionary as they confirmed that conservative breast surgery is equivalent to mastectomy as a treatment for breast cancer. Thus, mastectomy appeared to result in unnecessary mutilation. Nowadays, patients with stage I or II breast cancer will be treated with a lumpectomy or a quadrantectomy, followed by whole breast irradiation. For breast cancers that are more advanced or cases such as inflammatory breast cancer, intraepithelial neoplasia not responsive to breast-conserving surgery, or local recurrence after breast conserving surgery, mastectomy is necessary. 

Modern Mastectomies

Modern mastectomies focus on effectively removing the tumor while preserving tissue to maintain cosmetic appearance. In cases where significant portion of tissue cannot be saved, breast reconstruction is an option made available to patients. There are several benefits of breast reconstruction, including reduction of anxiety, facilitation of wardrobe flexibility, improvement of body image, and sexual responsiveness. Either preserving the nipple or reconstructing it along with the breast contour reconstruction gives the patient a sense of completeness, more similar to the preoperative state.[36] The following mastectomies attempt to conserve much of the natural breast.

Skin-Sparing Mastectomy (SSM)

The skin-sparing mastectomy can be identified by the circular scar where the nipple would be.

Conserving skin facilitates breast reconstruction, which relies substantially on the amount of breast skin remaining. Bromley S. Freeman hailed the modern era of skin preservation with his skin-sparing mastectomy on two patients with benign breast cancer in Mayo Clinic. Toth and Lappert first reported a detailed account of the considerable preoperative planning of incision to maximize skin preservation. The operation involved removing the breast gland, nipple-areola complex, biopsy scar, and skin overlying the cancer.[37]

The SSM is approached with caution as there are some concerns regarding oncological safety since residual breast tissue remains in the preserved skin. However, residual breast tissue was found even in 23% of cases with conventional mastectomy. In addition, studies following up post surgery suggest no significant difference in recurrence or survival rates between patients that underwent skin-sparing mastectomy with reconstruction and those that had conventional mastectomy.[38][39] It has been found that the procedure is appropriate in certain cases. For instance, a high prevalence of residual disease in the skin is associated with a skin flap thickness greater than 5mm.[40] Another study indicates that it would be oncologically safe to perform SSM in class T1 and T2 tumors because skin involvement is usually small.[41] Skin-sparing Mastectomy has several benefits including a reduced post-mastectomy deformity, improved breast shape after reconstruction, minimal residual scarring, and reduced need for contralateral breast surgery to attain symmetry.[39]

Common complications of SSM include skin necrosis, infection, and hematoma.[38] Rates of infection are variable but generally occur in 3%–19% of cases [52–57]. Skin flap necrosis occurs in about 10.7% of cases without risk factors.[42] About 65% of patients experience reduced skin sensitivity.[43] SSM and other forms of mastectomy result in similar surgical and oncological outcomes, but skin flap ischemia is more common after SSM and is associated with a number of risk factors. Smoking is the most notable risk factor for ischemia among other factors such as previous breast irradiation, diabetes, and high BMI.[44]

Indications for skin-sparing mastectomy are BRCA1/2 mutation, ductal carcinoma, local reoccurring breast cancer after conservative treatment, and early-stage breast cancer.[45]

Contraindications include skin involvement by tumor, inflammatory carcinomas, and locally advanced carcinomas. Relative contraindications are smoking, adjuvant radiotherapy, previous irradiation, and high body mass index.[45]

Nipple-Sparing Mastectomy (NSM)

The nipple-sparing mastectomy (NSM) is an extension of the skin-sparing mastectomy. It involves removing the breast glands affected by cancer while leaving the full breast skin and nipple intact. Breast reconstruction may also be done during the procedure to provide a natural look.[46]

Freeman made this technique known through an operation for fibrocystic changes in the breast, as delineated in his 1962 report. He used the term "subcutaneous mastectomy" to describe the procedure, which is still known today. Hinton was one of the first to report NSM for breast cancer in the British Journal of Surgery in 1984. He compared two groups of women with mostly early stage breast cancer- one of which had undergone SCM and the other, simple mastectomies. The results indicated no statistical difference between the two groups in local recurrence, disease-free survival, and overall survival.[47] In a recent study, Didier showed NSM patients have a high level of satisfaction with the outcome as opposed to feeling mutilated after a mastectomy. It was found that the cosmetic results had a positive impact on the patient's satisfaction with femininity and body image. [48]

Nipple-Sparing Mastectomy should only be performed on carefully selected patients, using good clinical assessment with modern imaging techniques. The procedure is most suitable for small to medium breasts and may be indicated to treat DCIS and LCIS, and BRCA1 / BRCA2 mutation carriers.[49]

Contraindications for NSM are carcinoma affecting the area within 2 cm from the base of the nipple, inflammatory carcinoma, pathologic discharge from the nipple, and Paget's disease. Relative contraindications are similar to SSM, such as previous radiotherapy, active smoking, diabetes, and obesity.[50]

Reconstructive Surgery After Mastectomy

DIEP breast reconstruction

Autologous transplants, implants, or a combination of both are used in reconstructive surgery after mastectomy. The autologous breast reconstruction, in which the patient's own body tissue is used in the reconstruction, makes use of pedicle-based and free flaps. Latissimus dorsi flaps and transverse rectus abdominis myocutaneous (TRAM) flaps are commonly used as local pedicle flaps. The muscle tissue is left partially attached to its original blood source by a thin layer and merely transposed. Common free flaps include free TRAM flaps, deep inferior epigastric perforator (DIEP), and gluteal artery perforator (GAP) flaps. In a free flap, tissue is transplanted from one part of the body to another for reconstruction.

The Latissimus dorsi flap was first introduced for chest wall reconstruction by d'Este in 1912. Schneiders adapted the transplantation in 1977 to reconstruct the breast in a patient that had undergone radical mastectomy. The wound was reported to heal uneventfully.[51] The flap is often used in conjunction with implants to improve results.

The DIEP flap is a technique where skin and tissue from the abdomen is used to recreate the breast. This flap may be preferred over the TRAM procedure, which has a risk of hernia. The procedure preserves abdominal muscle since only the skin is used. However, operating time is longer for DIEP flaps than for other reconstructions.[52]

Example of a breast implant

The free TRAM flap involves cutting out fat, skin, blood vessels, and muscle from the lower abdomen to rebuild the breast. The blood vessels in the flap are reattached to the vessels in the chest using microsurgery. On the other hand, pedicled TRAM flaps leave blood vessels of the flap attached to their original blood supply in the abdomen. The tissues are moved under the skin up to the chest. One risk with the pedicled TRAM is not providing enough blood circulation to the tissue, as the blood supply is often weaker than reattaching vessels in the free flap procedure. [53]

Expanders and breast prostheses may be used for breast reconstruction. The development of the anatomical expander implants allow for better breast form, symmetry, and a single reconstructive procedure.[54]

The breast reconstruction procedure largely depends on the patient's case and the experience of the plastic surgeon.

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