Mastectomy.docx

Mastectomy
INTRODUCTION
Mastectomy (complete removal of the tissue of the breast) is one option for the surgical
treatment of breast cancer and the only surgical option for breast cancer risk reduction.
This topic will address the types, indications, techniques, and complications of mastectomy.
Breast-conserving therapy for breast cancer and the surgical management of regional lymph
nodes in breast cancer patients are reviewed separately.
SURGICAL ANATOMY
The mature adult breast lies between the second and sixth ribs in the vertical axis and between
the sternal edge and the midaxillary line in the horizontal axis. Breast tissue also projects into the
axilla as the axillary tail of Spence. The breast is comprised of three major elements: skin,
subcutaneous tissue, and breast tissue.
The superficial pectoral fascia envelops the breast and is continuous with the superficial
abdominal fascia (of Camper). The undersurface of the breast lies on the deep pectoral fascia,
covering the pectoralis major and serratus anterior muscles. Connecting these two fascial layers
are fibrous bands (the Cooper suspensory ligaments) that represent a natural means of support for
the breast.
INDICATIONS FOR MASTECTOMY
Breast conservation contraindicated or unsuccessful — The criteria that preclude breast
conservation are presented here briefly and addressed in detail elsewhere.
 Inflammatory breast cancer (IBC). For patients with IBC, the standard of care is
neoadjuvant chemotherapy followed by modified radical mastectomy and
postmastectomy radiation therapy, even if the patient has a complete clinical response to
neoadjuvant chemotherapy.
 Multicentric disease with two or more primary tumors in separate quadrants of the breast.
However, ongoing research is assessing techniques that could permit breast conservation
for selected multicentric diseases with a satisfactory cosmetic outcome.
 Diffuse suspicious microcalcifications on mammography such that the extent of disease
is not clearly evident.
 A history of prior therapeutic radiation that included a portion of the affected breast,
which, with the addition of whole breast radiation therapy (WBRT), would result in an
excessively high total radiation dose to the chest wall. This includes patients who had
prior breast radiation as well as those who received chest wall radiation for other reasons,
such as mantle radiation for Hodgkin's lymphoma.
Ongoing studies are assessing partial breast irradiation alternatives to WBRT for these
patients, which could permit breast conservation.

 Pregnancy is an absolute contraindication to the use of breast irradiation; however, it may
be possible to perform breast-conserving surgery in the third trimester, deferring breast
irradiation until after delivery.
 Inability to clear persistently positive resection margins after reasonable attempts at
reexcision.
 Large tumor size in relation to breast size, although neoadjuvant systemic treatment has
the potential to downstage large tumors and improve the chances for successful breast-
conserving surgery. Insufficient response to neoadjuvant chemotherapy or endocrine
therapy requires mastectomy.
Patient preference — Some patients may choose to have a mastectomy rather than breast-
conserving therapy for various reasons, including a desire to avoid postoperative radiation,
further screening, or biopsies.
When both breast-conserving surgery and mastectomy are clinically and oncologically
acceptable, patients should be presented with the advantages and disadvantages of both
approaches. This should include discussion of cosmetic concerns because breast-conserving
surgery may result in unacceptable cosmetic results if the patient has a small amount of breast
tissue. Discussion should also include a realistic risk assessment of the likelihood of a recurrence
or second primary as studies have shown that many women grossly overestimate this risk.
Careful review of the risks and benefits of both options, including the long-term complications of
mastectomy, the limitations and complications of breast reconstruction, and the absence of a
survival benefit from mastectomy, is critical to optimal shared decision making.
Breast cancer risk reduction — For women without a personal history of cancer who have a
BRCA1/2 pathogenic variant, bilateral prophylactic (or preventative) mastectomy reduces the
risk of developing cancer by more than 90 percent.
Similarly for patients who have been diagnosed with unilateral breast cancer and carry a
deleterious BRCA1 or BRCA2 mutation, a contralateral prophylactic mastectomy may be an
option [1].
Bilateral or contralateral prophylactic mastectomy may also benefit patients with mutations in
other breast cancer susceptibility genes [2]. However, the decision about whether or not to
undergo such surgery is based on patient preference, given that effective screening is available.

CHOICE OF MASTECTOMY
Types of mastectomy used in modern breast surgery include modified radical mastectomy
(MRM), simple (total) mastectomy, skin-sparing mastectomy (SSM), and nipple-areolar sparing
mastectomy (NSM). Radical mastectomy is a legacy procedure that is rarely indicated.
Following mastectomy, breast reconstruction can commence at the same time ("immediate") or
after the completion of cancer treatment ("delayed"). The timing of the planned reconstruction
has important implications on the choice of mastectomy techniques [3].
A modified radical mastectomy is a procedure in which the entire breast is removed, including
the skin, areola, nipple, and most axillary lymph nodes, but the pectoralis major muscle is spared.
Historically, a modified radical mastectomy was the primary method of treatment for breast
cancer. [1, 2] As the treatment of breast cancer evolved, breast conservation has become more
widely used. [3, 4] However, mastectomy still remains a viable option for women with breast
cancer
Indications
It currently remains the patient’s choice to undergo breast conservation or mastectomy with or
without reconstruction. The European Organization for Research and Treatment of Cancer 10801
trial found no significant difference in the 20-year overall survival rate between women who
underwent breast-conserving surgery and radiation and those who were treated with modified
radical mastectomy, for stage 1 or 2 breast cancer. Overall survival at 20 years was 44% in the
breast-conserving surgery group and 39% in the modified radical mastectomy group. Time to
distant metastasis also did not differ significantly between the two groups, although the study did
find that the 10-year locoregional recurrence of cancer was higher in the breast-conserving group
than in the mastectomy patients (20% vs 12%, respectively). [7]
There are a few contraindications to breast conservation for which a mastectomy is
recommended. According to the National Comprehensive Cancer Network guidelines, [8]
indications for mastectomy include the following:
 Prior radiation therapy to the breast or chest wall
 Radiation therapy contraindicated by pregnancy (except patients in the third trimester
who can receive radiation postpartum)
 Inflammatory breast cancer
 Diffuse suspicious or malignant-appearing microcalcifications
 Widespread disease that is multicentric, located in more than one quadrant, and cannot be
removed through a single incision with negative margins
 A positive pathologic margin after repeat re-excision and suboptimal cosmetic outcome.

Relative indications for mastectomy include the following:
 Active connective tissue disease involving skin (eg, scleroderma, lupus)
 Tumors greater that 5 cm in diameter
 Focally positive margin
A consensus statement from an international expert panel specified that following maximal
disease response to chemotherapy (in HER-2–normal patients) or chemotherapy and dual
(pertuzumab and trastuzumab) anti–HER-2 treatment (in HER-2–positive patients),
inflammatory breast cancer should be treated with modified radical mastectomy, including skin,
breast, and axillary-node resection. [9] A study by Partain et al indicated that modified radical
mastectomy and partial/complete chemotherapeutic response by distant disease are independent
factors for improved overall survival in de novo stage IV inflammatory breast cancer, with the
hazard ratio for the mastectomy procedure being 0.52. [10]
Patients who are younger than 35 years of age or premenopausal with known BRCA1/2
mutations have an increased risk of local recurrence. Prophylactic bilateral mastectomy may be
considered for risk reduction.
Contraindications
There are very few contraindications to a modified radical mastectomy. For patients who present
with metastatic disease, the primary mode of treatment remains systemic therapy. Mastectomy is
currently not the standard of care for patients with metastatic disease. Additional
contraindications involve patients who are unable to receive general anesthesia.
Technical Considerations
Best Practices
There has been recent national debate over the indication for axillary lymph node dissection.
Current indications for a level I or II axillary dissection in patient undergoing a mastectomy
include the following:
 Preoperative diagnosis of positive axillary lymph node metastasis on fine-needle
aspiration or core biopsy
 Prior inadequate axillary lymph node dissection
 Positive intraoperative sentinel lymph node biopsy
 Failed mapping for a sentinel lymph node biopsy
 Clinically suspicious nodes at the time of surgery
 Neoadjuvant chemotherapy (outside clinical trials)
 Axillary local recurrence.


Patients should be evaluated for an axillary lymph node dissection on a case-by-case basis.
Axillary dissection may not benefit patients with favorable tumor characteristics, elderly
patients, patients with multiple comorbidities, or patients for whom a full axillary dissection will
not influence the recommendation regarding systemic treatment.
Procedure Planning
Patients who undergo a mastectomy have the option for immediate or delayed reconstruction
using autologous tissue or implants. Prior to the mastectomy, patients should be referred to a
plastic surgeon. The decision for immediate or delayed reconstruction is made based on the need
for postmastectomy radiation and surgeon preference. [12]
Complication Prevention
Complications associated with a modified radical mastectomy include issues associated with
wound healing, such as hematoma, infection, dehiscence, chronic seroma, and skin necrosis. The
risk of skin necrosis often involves the superior flap and the wound edges. It is often treated with
only local debridement and wound care.
A randomized, controlled trial by Archana et al indicated that compared with electrocautery, the
use of the harmonic scalpel in modified radical mastectomy significantly reduces the incidence
of seromas found on initial postoperative follow-up (34.3% vs 21.7%, respectively), as well as
the mean total seroma drainage volume (937.5 mL vs 470 mL, respectively). [13] A
retrospective study by van Bastelaar et al indicated that following either a mastectomy and
sentinel node biopsy or a modified radical mastectomy, flap fixation using sutures or ARTISS
fibrin sealant lessened the need for postoperative seroma aspiration compared with a drain-only
approach. [14]
Similarly, in a study of patients who underwent mastectomy, including modified radical
mastectomy, de Rooij et al found that flap fixation using sutures significantly reduced
postoperative seroma aspiration compared with conventional wound closure. The investigators
reported that 7.3% of suture fixation patients underwent aspiration, compared with 17.5% of
those treated with conventional closure. [15]
Patients at a higher risk for postoperative complications are those with diabetes, smokers,
patients with a history of prior chest wall radiation, and patients with diffuse small vessel
disease. After an axillary dissection, along with the normal local healing issues, the alteration of
the regional lymphatic system puts patients at an increased risk of complications.
For patients undergoing sentinel lymph node biopsy prior to axillary dissection, there is a risk of
anaphylaxis related to the isosulfan blue contrast agent. The anesthesiologist and patient should
be aware of this rare complication, which often resolves intraoperatively. [16]

Patients who have undergone a completion axillary dissection have an increased risk of
developing lymphedema. [17] They also are at increased risk of numbness under the axilla or
even hypersensitization and chronic pain in that area. Patients are encouraged to ambulate the
arm early with stretching exercises to prevent decreased shoulder function and scarring of the
muscle, which can lead to cording and chronic pain syndromes.
Periprocedural Care
Equipment
The following equipment is needed to perform a modified radical mastectomy:
 Sterile gloves and gowns
 Sterile drapes
 Preoperative skin preparation supplies
 No. 15 blade
 Bovie electrocautery
 Sterile sponges
 Suction system
 Sterile irrigation solution (water and normal saline)
 Standard mastectomy tray
 Freeman face lift or skin hooks
 Richardson retractors
 Several types of sutures and ties, silks available for ties, nylon for drain sutures, Vicryl,
and Monocryl for skin closure
 Clips for the axillary dissection
 Drains for the axilla and chest wall under the mastectomy flaps (eg, Jackson-Pratt round
15-Fr).
Patient Preparation
Anesthesia
General anesthesia is used without a neuromuscular blocking agent for the mastectomy and
axillary dissection. If the patient is undergoing immediate breast reconstruction at the same time
as the mastectomy, a paralytic is often used after completion of the axillary lymph node
dissection.
A thoracic paravertebral block may also be used to provide both procedural and postprocedural
analgesic effects, leading to a reduction in postoperative pain both immediately and over the
following 24 hours. [18]
Positioning
Patients are placed in the operating room table in the supine position, with the arm at a 90-degree
angle from the body.

Postoperative Care
A study by Ferreira Laso et al indicated that continuous infusion of local anesthetic following
modified radical mastectomy results in decreased pain and reduced analgesic use but has no
impact on rates of nausea and vomiting. The randomized, double-blind, placebo-controlled trial
involved 73 women who underwent modified radical mastectomy, including 34 who received
levobupivacaine for 48 hours postoperatively through a wound catheter and 39 who received a
placebo (saline).
Technique
Approach Considerations
There are several different techniques for a modified radical mastectomy, including simple or
total mastectomy, skin-sparing mastectomy, nipple sparing, sentinel lymph node biopsy, and/or
axillary lymph node dissection. This topic describes a simple mastectomy with an axillary lymph
node dissection.
Simple Mastectomy with an Axillary Lymph Node Dissection
The anatomy of the breast and its boundaries include the clavicle superiorly, the sternum
medially, the inframammary fold inferiorly, and the latissmus along the pectoralis major fascia
laterally. The total mastectomy involves removal of the entire mammary gland including the
nipple-areolar complex and pectoralis fascia.
In a simple mastectomy with no immediate reconstruction, the outline of the breast is marked
and the medial and lateral endpoints of the breast are marked. The breast is then pulled
downward and a horizontal line connecting the two endpoints is drawn to mark the upper
incision. The breast is then pulled up and a second line connecting the endpoints is drawn to
identify the lower incision. These lines form an ellipse around the nipple and can be adjusted to
include prior incisions. See the image below.
These markings are checked to confirm that there is adequate skin for closure with minimal
tension. The skin is then incised.
The next step is to make viable skin flaps that leave subcutaneous tissue and superficial
vasculature but do not compromise the need to remove the entire mammary gland. These flaps
are approximately 5 mm in thickness. The plane is identified by careful retraction with skin
hooks and adequate countertraction, allowing the surgeon to identify the avascular plane
(superficial breast fascia) between the breast and subcutaneous tissue. Either a knife, scissors,
harmonic scalpel, or electrocautery can be used, depending on the surgeon’s preference.
Tumescent solution of dilute epinephrine hydrochloride in lactated Ringer solution is commonly
used in association with liposuction. [20] The solution is infused into the avascular plane to
facilitate dissection and minimize blood loss during the surgery.

The flaps are raised to the borders of the breast as previously defined. The pectoralis fascia is
divided both superiorly and medially. The pectoralis fascia is removed with the breast; muscle
should only be removed when there is gross involvement. The dissection proceeds to the lateral
edge of the pectoralis. See the images below.
Depending on surgeon preference, the breast may now be completely removed or axillary
dissection may continue, allowing the breast to give gravity traction and assist with exposure.
The axillary lymph node dissection follows the borders of the axilla and includes level I and II
lymph nodes. The axilla is bordered by the axillary vein superiorly, the latissimus dorsi laterally,
pectoralis muscle medially, and the serratus muscle anteriorly.
When performing an axillary dissection with a simple mastectomy, a separate incision is not
required. However, if a skin-sparing mastectomy is performed, a separate incision may be
needed.
The axilla is first entered by opening the clavipectoral fascia.
The axillary vein is identified by locating the lateral border of the pectoralis major; the vein is
identified as it runs posterior to the pectoralis muscle with careful blunt dissection and retraction
inferiorly of the axillary contents. Once identified, lymphatics can be tied, clipped, or cauterized,
depending on surgeon preference.
After the vein is identified, careful steps are taken to preserve its branches; the thoracodorsal
bundle is identified as it runs in the axillary fat pad and then enters the latissimus dorsi. The long
thoracic nerve should be preserved; it runs medial to the thoracodorsal bundle and is identified
close to the chest wall posteriorly.
Once these nerves and vein are identified, the axillary contents are dissected off the
thoracodorsal bundle superiorly and medially up to the level of the axillary vein. The contents
are then retracted inferiorly, the medial attachments to the serratus muscle are divided, and the
specimen is handed off.
Once the axillary dissection is completed, two drains are placed: one in the axilla and one
anterior to the pectoralis muscle. Drains should be shortened to allow for placement of the drain
within a pocket for patient comfort and to avoid clotting in the tubing. The skin is then closed in
an interrupted or running fashion according to the surgeon’s preference.
Patients are normally discharged the next morning and drains are removed when the output is
less than 30 mL in a 24-hour period. Patients are encouraged to ambulate early and begin arm
stretches.

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