for Invasive Cancer 1 4

Tracy-Ann Moo and Rache M. Simmons

Abbreviations transection of the long thoracic and thoracodor- sal nerves, which was routinely performed at DCIS Ductal carcinoma in situ the time. NAC Nipple-areola complex By the mid-1900s, the modifi ed radical mastectomy, which spared the pectoral muscles, began to gain widespread support as a less Introduction morbid procedure that could achieve results equivalent to the radical mastectomy [ 3 – 6 ]. The The mastectomy procedure has evolved consider- modifi ed radical mastectomy would in subse- ably since the era of the radical mastectomy. In quent decades be replaced by the total or simple the late 1800s, Halsted and Mayer described the mastectomy, which eliminated the axillary radical mastectomy in individual reports on the dissection. However, around the treatment of . The radical mastec- same time, other groups advocated for a more tomy involved removal of the breast and pectoral extensive resection as a means of achieving muscles in conjunction with an axillary and greater local control, the extended radical mas- infraclavicular lymph node dissection [1 , 2]. At a tectomy [7 , 8]. The extended radical mastec- time when no effective adjuvant treatment tomy was a more morbid procedure removing existed, this en bloc resection provided the best not only the infraclavicular and axillary lymph rates of local control. The obvious drawbacks to nodes but also the supraclavicular and paraster- such a radical procedure included chronic lymph- nal lymph nodes. edema, as well as neurologic defi cits related to To address this growing dichotomy in surgical treatment options, the fi rst randomized trials in breast cancer treatment were conceived. These tri- T.-A. Moo , MD (*) als examined the debated approaches to local con- Department of , trol. As early as 1951, the Danish trial began to Memorial Sloan Kettering Cancer Center, enroll patients diagnosed with breast cancer to Evelyn H Lauder Breast Center , 300 East 66th street, 8th fl oor , New York , either simple mastectomy followed by radiation or NY 10065 , USA extended radical mastectomy [ 9]. In multiple e-mail: [email protected] reports from this, as well as other randomized con- R. M. Simmons , MD, FACD trolled trials, it became evident that there was no Department of Surgery , difference in survival between the two groups. In New York Presbyterian Hospital , the United States, the modifi ed radical mastectomy 425 East 61st street, 10th fl oor , New York , NY 10065 , USA had replaced the radical mastectomy as the stan- e-mail: [email protected] dard therapy for breast cancer by the 1980s [10 ].

A.I. Riker (ed.), Breast Disease: Comprehensive Management, 215 DOI 10.1007/978-1-4939-1145-5_14, © Springer Science+Business Media New York 2015 216 T.-A. Moo and R.M. Simmons

In the decades that followed, debate centered tectomy. There is some retrospective evidence on the treatment of breast cancer with breast con- demonstrating equivalent outcomes with breast- servation ( and radiation) vs. mastec- conserving surgery in select cases of multicentric tomy. Subsequent randomized controlled trials disease [15 – 17]. However, there are no pro- demonstrated equivalence of the two approaches spective, randomized trials that have addressed and have resulted in more women now being this issue and so for now the standard remains treated with breast-conserving surgery [11 – 14 ]. mastectomy. However, there are still instances in which mas- tectomy remains the procedure of choice. The choice of mastectomy technique largely depends Scenario 2 on the indication, tumor characteristics, and plans for reconstruction. Currently, several mastec- A 36-year-old female with a past medical history tomy techniques can be used including the simple of mantle radiation as a teenager for Hodgkin’s mastectomy, skin-sparing mastectomy, and the lymphoma presents with a new diagnosis of left nipple-areola-sparing mastectomy. breast cancer…

Prior chest wall radiation may be a contraindica- Indications for Mastectomy tion to breast-conserving surgery depending on the dose and radiation fi eld. In these cases, details • Presence of contraindications to breast- on prior radiation exposure are very important in conserving surgery determining the optimal surgical options of either – Multicentric disease breast conservation or mastectomy. – Previous chest radiation • Inability to achieve cosmetically acceptable result with lumpectomy Scenario 3 • Patient preference • Risk reduction of second ipsilateral or contra- A 54-year-old woman with scleroderma presents lateral breast cancer with a diagnosis of breast cancer… • Infl ammatory breast cancer Although most women will be candidates for Patients with active collagen vascular disease breast-conserving surgery, mastectomy is at times such as systemic lupus erythematosus or sclero- the more appropriate procedure. These situations derma may not be candidates for vary from the presence of an absolute contraindica- (therefore not candidates for breast conservation tion to breast conservation to patient preference. therapy) secondary to poor wound healing and subsequent complications.

Scenario 1 Scenario 4 A patient presents following a workup demonstrat- ing a 1 cm mass within the upper outer quadrant of A 29-year-old woman at 14 weeks gestation pres- the right breast, with an additional area of micro- ents with right breast invasive ductal carcinoma… calcifi cations within the right lower inner quad- rant. Core needle biopsy of both suspicious areas demonstrates invasive ductal carcinoma in the As radiation therapy cannot be given to patients upper outer quadrant and ductal carcinoma in situ during pregnancy, breast conservation may not (DCIS) in the lower inner quadrant. be a feasible option during early pregnancy. This depends on the stage of gestation and whether This patient has multicentric disease, for which or not radiation therapy can be timely adminis- the current recommended treatment is mas- tered after delivery in relation to chemotherapy, 14 Mastectomy for Invasive Breast Cancer 217 if indicated. Some women will simply prefer to of resection are the clavicle superiorly, the lateral have a mastectomy as defi nitive treatment during border of the sternum medially, the inframam- pregnancy. mary crease inferiorly, and the anterior border of the latissimus dorsi laterally.

Scenario 5 Simple Mastectomy A 39-year-old female with a BRCA gene mutation (Non-Skin-Sparing) is recently diagnosed with a right invasive ductal carcinoma and presents to your offi ce desiring The simple mastectomy is well suited for those bilateral … patients who will not have immediate reconstruc- tion. In this type of mastectomy, most of the skin Mastectomy may be a better option for the patient is removed. On completion, the incision is who is found to have a BRCA gene mutation, as expected to lie fl at against the chest wall without they are certainly at a very high risk of a new pri- leaving excess amounts of tissue at the medial mary and contralateral breast cancer. Increasingly and lateral limits of the incision. This allows common is the election of bilateral mastectomies proper positioning of prosthesis and limits poten- in this population. tial discomfort resulting from redundant skin. The simple mastectomy removes all the breast parenchyma with the nipple-areola complex and Scenario 6 the skin, leaving just enough skin to close the wound without undo tension. The most com- A 65-year-old woman presents with infl ammatory monly used incision is the Stewart elliptical inci- breast cancer… sion, which extends medially from the sternum to the latissimus laterally and will encompass most The treatment of infl ammatory breast cancer tumors located central and laterally. Depending mandates a mastectomy. This occurs after the on the position of the tumor, the Stewart incision completion of neoadjuvant chemotherapy, with a can also be placed obliquely as in the modifi ed modifi ed radical mastectomy being the procedure Stewart or Orr incision (Fig. 14.1 ). These oblique of choice in this scenario. incisions can be placed with the medial aspect

Mastectomy Techniques

There are several techniques by which a mastec- tomy can be performed. The procedure involves the removal of the entire breast parenchyma with varying degrees of skin, with or without removal of the nipple-areola complex. The choice of tech- nique depends largely on the size of the breast and whether or not immediate reconstruction is planned. Incision choice is often dictated by the technique as well as the size and shape of the breast and to some extent surgeon and patient preference. The choice of incision also depends on the existence of previous biopsy or lumpec- tomy incisions and whether or not the tumor is adherent to the skin. In all techniques, the limits Fig. 14.1 Oblique elliptical incision for simple mastectomy 218 T.-A. Moo and R.M. Simmons directed cephalad to encompass tumors in the Skin-Sparing Mastectomy upper inner quadrant and lower outer quadrant of the breast. They can also be positioned so that the The skin-sparing mastectomy as described by medial aspect is pointing caudad to encompass Toth and Lappert [ 18] achieves removal of all tumors located in the lower inner quadrant or breast parenchyma with the nipple-areola upper outer quadrant. The incision should encom- complex and minimal skin excision (fi gure 14.2 ). pass any previous lumpectomy scars and any area This technique is well suited for patients who of the skin that is adherent to the tumor. are having immediate tissue or implant An incision is made through the dermis and reconstruction. the skin is elevated using penetrating skin hooks. A dissection plane is developed in the avascular plane between the breast parenchyma and the Nipple-Areola-Complex-Sparing subcutaneous tissue ensuring preservation of the Mastectomy subcutaneous vasculature. The dissection pro- ceeds utilizing electrocautery as necessary or First described in the 1960s by Freeman [ 19 ] with a scissors or knife depending on surgeon as the subcutaneous mastectomy, the nipple- preference. The mastectomy skin fl aps are then areola- complex (NAC)-sparing mastectomy created, allowing removal of all breast was intended to achieve an improved cosmetic parenchyma while leaving a layer of subcutane- result by preserving the NAC. This procedure ous fat. Acceptable fl ap thickness varies by was initially performed selectively at very few patient and amount of subcutaneous fat present. institutions, as there were concerns for oncologic Skin fl aps should not be so thin as to compromise outcomes as well as appropriate selection crite- blood supply and lead to skin necrosis. However, ria. In women undergoing prophylactic mastec- creating fl aps that are too thick will leave behind tomy, nipple-areola-sparing mastectomy is well breast tissue that may lead to an increased risk of accepted as a safe procedure. There remains con- tumor recurrence. troversy regarding its use in women with invasive Once the skin fl aps have been dissected supe- cancer. However, an increasing body of evidence riorly to the clavicle, inferiorly to the inframam- supports nipple-areola-sparing mastectomy in mary fold, medially to the sternal border, and select patients. This includes women who have laterally to the latissimus dorsi, the breast is small (<3.5 cm), peripherally located tumors that removed from the pectoralis major muscle. are >2 cm from the nipple, a negative and Elevation of the breast from the pectoralis major have not been treated with neoadjuvant chemo- is usually performed with electrocautery. The therapy [ 20 – 23]. Frozen sections are routinely superior margin of the breast is grasped and sent in patients with invasive cancer or DCIS to retracted caudad, while the pectoralis fascia is confi rm a negative nipple margin before proceed- removed with the breast leaving the underlying ing with nipple-areola-sparing mastectomy. In pectoralis major muscle intact. At times when the our experience, the overall rate of nipple involve- tumor is abutting or invading the pectoralis mus- ment was 10.6 % [24 ]. cle, this area of muscle can be removed with the There are several incisions that can be used for specimen. Perforating vessels should be con- the NAC-sparing mastectomy, including the trolled with electrocautery, clips, or ties. As the inframammary fold, various lateral incisions, dissection progresses inferolaterally, care is taken vertical incision, and an incision that incorpo- to preserve the fascia of the serratus muscle. rates a reduction mastectomy (Fig. 14.3 ). The Toward the axillary tail, the lateral mammary choice of incision is largely predetermined by the branches entering the breast are ligated and size of the breast as well as the extent of ptosis. A divided. The breast is divided at the axilla, which well-placed incision facilitates removal of all is recognized by visualization of the clavipec- breast parenchyma within the boundaries of a tra- toral fascia. ditional mastectomy. In women who present with 14 Mastectomy for Invasive Breast Cancer 219

ab

cd

Fig. 14.2 Skin-sparing mastectomy incisions: (a ) peri-areolar, (b ) reduction, (c ) tennis racquet, (d ) modifi ed ellipse small, non-ptotic , this can be done simple mastectomy or skin-sparing mastectomy. through an inframammary incision. However, in The use of a knife, scissors, or electrocautery the larger ptotic breast, a variation of the lateral depends on surgeon preference. As progress is or vertical incision is better suited for performing made along the fl ap, a lighted retractor may be an oncologically safe procedure with survival of useful to ensure adequate retraction and fl ap the breast skin. thickness. The nipple is dissected from the under- Once the skin incision has been made, fl aps lying duct tissue sharply; this may be done with are raised in the usual fashion. The creation of or without nipple tumescence. We have found skin fl aps for the nipple-areola-sparing mastec- that insertion of a 2-0 silk stitch through the nip- tomy is often more challenging than with the ple allows the assistant to elevate the nipple, 220 T.-A. Moo and R.M. Simmons

ab

d c

Fig. 14.3 Nipple-areola-complex-sparing incisions: (a ) inframammary, (b ) lateral, (c ) vertical, (d ) reduction which facilitates dissection of the underlying dissection of the superior aspect away from the ductal tissue. chest wall. If the mastectomy has been per- Once the ductal tissue is removed, the nipple formed through an inframammary incision, is inverted and an additional nipple margin is then separation of the breast parenchyma begin- taken and sent for frozen section. After the skin ning at the inframammary crease and progress- fl aps have been created, removal of the breast ing superiorly toward the clavicle is more from the chest wall including the pectoral fas- feasible. cia with the specimen must be accomplished. Often this dissection is most easily done by beginning at the lateral aspect of the breast and Management of the Axilla proceeding medially and inferiorly until the breast is completely removed up to the sternum. The mastectomy procedure (non-skin-sparing, The breast can then be delivered through the skin-sparing, or nipple-areola-sparing) can be incision and refl ected cranially to facilitate combined with either a sentinel lymph node 14 Mastectomy for Invasive Breast Cancer 221 biopsy for staging of the axilla or a formal axil- combination of antibiotics, aspiration, or debride- lary lymph node dissection. ment. Particularly in the presence of a foreign body The mastectomy incision may also provide (tissue expander or implant), careful attention must access to the axilla for dissection or sentinel be paid to the expedient administration of intrave- lymph node biopsy. In those instances where the nous antibiotics. Infectious complications are gen- incision does not allow axillary access, a small erally handed in conjunction with the plastic counterincision in the axilla can be made or a lat- surgeon when an expander or implant is present. eral extension can be added to the primary inci- Seroma formation is the most common complica- sion. In cases where there is a preexisting incision tion after mastectomy, reported in 10–30 % of on the breast, the mastectomy incision is designed patients [26 , 27 ]. While small fl uid collections to incorporate the previous incision. If it is not without evidence of infection may be observed, possible to include the previous incision, the area larger symptomatic seromas require aspiration and can be excised separately as long as this can be sometimes placement of a drainage catheter. done without compromising the blood supply to Nipple-sparing mastectomy has particular the intervening skin bridge. considerations. The presence of occult metastasis In the case of a patient with a positive axilla, a detected on permanent pathology should be modifi ed radical mastectomy is performed which treated with resection of the nipple. Partial or combines a simple mastectomy, skin-sparing complete nipple necrosis may also occur, requir- mastectomy, or nipple-areola-sparing mastec- ing debridement of the nipple. tomy in an en bloc resection with the axillary lymph node dissection. Considerations for the Plastic Surgeon Complications Currently, the treatment of breast cancer with Complications of mastectomy include early and mastectomy includes the proper screening and late events. In the early postoperative period, one selection of patients for breast reconstructive sur- must be vigilant for ongoing bleeding and hema- gery. While some patients will decline recon- toma formation, a complication reported in less struction for various reasons, most will meet a than 5 % of patients [25 ]. The use of closed suc- plastic surgeon in advance of their operation in tion drainage will often allow early detection of order to better understand their options for recon- ongoing bleeding, and a fi rm swelling on the chest struction. Once the decision to proceed with mas- wall usually indicates subsequent hematoma for- tectomy has been made, the patient should be mation. This is often accompanied by complaints referred to plastic and reconstructive surgery for of increased pain from the patient. In these situa- consultation. Communication between the breast tions, the patient should be evaluated by the sur- surgeon and plastic surgeon is important for opti- geon and a decision made whether to attempt mal surgical planning. Decisions on mastectomy compression or immediate evacuation. Flap isch- technique as well as incision are often made with emia or necrosis may also be seen in the early the input of the patient, breast surgeon, and plas- postoperative period and are often managed with tic surgeon. watchful waiting and delayed debridement of nonviable tissue. Large areas of skin loss requir- ing debridement may necessitate split-thickness skin grafts or rotational fl aps for coverage. References Late complications include infection and seroma formation. Manifestations of infections 1. Halsted WS. I. The results of operations for the cure of cancer of the breast performed at the Johns Hopkins include superfi cial cellulitis, wound drainage, and hospital from June, 1889, to January, 1894. Ann Surg. skin breakdown. This may be treated with a 1894;20(5):497–555. 222 T.-A. Moo and R.M. Simmons

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