Mastectomy for Invasive Breast 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 lymph node dissection. However, around the treatment of breast cancer. 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 Breast Surgery , 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 (lumpectomy 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 radiation therapy 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 mastectomies… 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.