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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. The primary treatment method is surgery. Especially during the twentieth century, a mastectomy was usually performed. However, as time progressed and as technology improved, the extent of mastectomies has varied. Less invasive mastectomies are employed today in comparison to those in the past, as the unnecessarily mutilating methodology proved to not enhance survival. Nowadays, it is expected for women to undergo breast-conserving surgery, such as radiotherapy instead of mastectomy, since the results are comparable.[1]

Portrait of William Stewart Halsted

Introduction

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For hundreds of years, escharotic materials and cautery were used to treat breast cancer. It was not until late 1890 that William Halsted, a prominent American surgeon, devised a novel operation for breast cancer known as radical mastectomy. The operation was considered "radical" because it involved the removal of not only the breast but also the removal of lymph nodes and muscles in the surrounding area. Despite the downside of disfigurement, this procedure was standard in treating breast cancer for almost 70 years before less aggressive surgery was introduced.

Radical Mastectomy

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Halsted and Meyer were the first to publish research on 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.[2] Willy Meyer also published research on radical mastectomy from his interactions with New York patients in December 1894.[3] For the first time, patients were cured of their diseases. Physicians had finally found an effective treatment for breast cancer; radical mastectomy became the revolutionary solution.

The Halsted-Meyer Theory

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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.[4]

 
Radical Mastectomy

Features of Radical Mastectomy

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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.[2][5] 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.[2][3]

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.[2] 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.[5][6][7][8][9][10][11]

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.[12] 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.[12] 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

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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.[13] 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.[14] 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.[15] The radical mastectomy was subsequently extended by a number of surgeons such as Sugarbaker and Urban to include removal of internal mammary lymph nodes.[16][17] 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.[18] 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.[19] 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.[20] 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

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Pectoralis Major
 
Pectoralis Minor

The Patey-Dyson Mastectomy

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Breast Anatomy

Up until the first half of the 20th century, the idea that breast cancer spread centrifugally was accepted. It was not until J.H. Gray published his study in 1940 that the belief that extended radical mastectomies were necessary was challenged.[21] 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.[22] 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".[22]

The Madden-Auchincloss Mastectomy

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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.[22] 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.[23] Another doctor, Hugh Auchincloss also presented data in favor of the modified radical mastectomy preserving the pectoralis minor.[24] 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.[25] 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.[26] His findings showed that survival rates following delayed axillary dissection were on part with or even better than following preventative lymph node dissection.[26]

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

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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.[27] 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.[28] 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

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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.[29] 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.[30] 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.[31] 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.

New Mastectomies

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The mastectomy operation is constantly being modified as part of the trend towards a less invasive but equally as effective traditional mastectomy.

Skin-Sparing Mastectomy

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A skin-sparing mastectomy is either a simple or modified radical mastectomy in which the surgical skin excision must include the nipple-areola complex, the biopsy site, and allow for access to the axilla for possible dissection.[32] Freeman was the first to perform a skin-sparing mastectomy on two patients with benign breast cancer.[33] Toth and Lappert followed suit and showed that great preoperative planning of the incisions was necessary in order to maximize skin preservation.[32]

Some benefits of skin-sparing mastectomy are that it reduces post-mastectomy disfigurement, allows for the reconstruction of the breast with a potentially more natural-looking contour, results in less residual scarring, and reduces the area necessary on myocutaneous flaps.[34]

  1. ^ Fisher, Bernard; Jeong, Jong-Hyeon; Anderson, Stewart; Bryant, John; Fisher, Edwin R.; Wolmark, Norman (2002-08-22). "Twenty-Five-Year Follow-up of a Randomized Trial Comparing Radical Mastectomy, Total Mastectomy, and Total Mastectomy Followed by Irradiation". New England Journal of Medicine. 347 (8): 567–575. doi:10.1056/NEJMoa020128. ISSN 0028-4793. PMID 12192016.
  2. ^ a b c d Halsted, William S. (1894-11-01). "I. The Results of Operations for the Cure of Cancer of the Breast Performed at the Johns Hopkins Hospital from June, 1889, to January, 1894". Annals of Surgery. 20 (5): 497–555. doi:10.1097/00000658-189407000-00075. ISSN 0003-4932. PMC 1493925. PMID 17860107.
  3. ^ a b W. Meyer, “An improved method of the radical operation for carcinoma of the breast,” New York Medical Record, vol. 46, pp. 746–749, 1894.
  4. ^ Zurrida, Stefano; Bassi, Fabio; Arnone, Paolo; Martella, Stefano; Castillo, Andres Del; Martini, Rafael Ribeiro; Semenkiw, M. Eugenia; Caldarella, Pietro (2011-06-05). "The Changing Face of Mastectomy (from Mutilation to Aid to Breast Reconstruction)". International Journal of Surgical Oncology. 2011: 980158. doi:10.1155/2011/980158. ISSN 2090-1402. PMC 3263661. PMID 22312537.
  5. ^ a b HALSTED, WILLIAM STEWART (1913-02-08). "Developments in the Skin-Grafting Opertion for Cancer of the Breast". JAMA: The Journal of the American Medical Association. 60 (6): 416. doi:10.1001/jama.1913.04340060008004. ISSN 0002-9955.
  6. ^ Riddell, V. H. (2017-04-21). "The Technique of Radical Mastectomy: With Special Reference to the Management of the Skin Short Case and the Prevention of Functional Disability". British Journal of Cancer. 4 (3): 289–297. doi:10.1038/bjc.1950.27. ISSN 0007-0920. PMC 2007674. PMID 14783660.
  7. ^ Neumann, Charles G.; Conway, Herbert (1948-01-01). "Evaluation of skin grafting in the technique of radical mastectomy in relation to function of the arm". Surgery. 23 (3): 584–590. ISSN 0039-6060. PMID 18906044.
  8. ^ Bard, Morton (2017-04-21). "The sequence of emotional reactions in radical mastectomy patients". Public Health Reports. 67 (11): 1144–1148. doi:10.2307/4588308. ISSN 0094-6214. JSTOR 4588308. PMC 2030852. PMID 12993982.
  9. ^ Parker, Joe M.; Russo, P. E.; Oesterreicher, D. L. (1952). "Investigation of Cause of Lymphedema of the Upper Extremity After Radical Mastectomy". Radiology. 59 (4): 538–545. doi:10.1148/59.4.538. PMID 12983584.
  10. ^ JR, VON RONNEN (1955-01-01). "[Spontaneous rib fractures after radical mastectomy]". Journal Belge de Radiologie. 38 (4): 525–534. ISSN 0302-7430. PMID 13331884.
  11. ^ W. T. Fitts Jr., J. G. Keuhnelian, I. S. Ravdin, and S. Schor, “Swelling of the arm after radical mastectomy. A clinical study of its causes,” Surgery, vol. 35, no. 3, pp. 460–464, 1954.
  12. ^ a b Townsend, Courtney; Abston, Sally; Fish, Jay (1985). "Surgical Adjuvant Treatment of Locally Advanced Breast Cancer". Annals of Surgery. 201 (5): 604–610. doi:10.1097/00000658-198505000-00009. PMC 1250769. PMID 3994434.
  13. ^ Carey, J.M.; Kirklin, J.W. (1952-10-01). "Extended radical mastectomy: a review of its concepts". Proceedings of the Staff Meetings. Mayo Clinic. 27 (22): 436–440. ISSN 0092-699X. PMID 13004011.
  14. ^ Schachter, Karen; Neuhauser, Duncan (1981). Surgery for breast cancer. DIANE Publishing. ISBN 9781428924581.
  15. ^ Handley, R. S.; Thackray, A. C. (1954-01-09). "Invasion of Internal Mammary Lymph Nodes in Carcinoma of the Breast". British Medical Journal. 1 (4853): 61–63. doi:10.1136/bmj.1.4853.61. ISSN 0007-1447. PMC 2093179. PMID 13106471.
  16. ^ Sugarbaker, E. D. (1953-09-01). "Radical mastectomy combined with in-continuity resection of the homolateral internal mammary node chain". Cancer. 6 (5): 969–979. doi:10.1002/1097-0142(195309)6:5<969::aid-cncr2820060516>3.0.co;2-5. ISSN 0008-543X. PMID 13094645.
  17. ^ Urban, J. A. (1964-03-01). "Surgical Excision of Internal Mammary Nodes for Breast Cancer". The British Journal of Surgery. 51 (3): 209–212. doi:10.1002/bjs.1800510311. ISSN 0007-1323. PMID 14129436. S2CID 5680572.
  18. ^ Dahl-Iversen, E.; Tobiassen, T. (1969-12-01). "Radical mastectomy with parasternal and supraclavicular dissection for mammary carcinoma". Annals of Surgery. 170 (6): 889–891. doi:10.1097/00000658-196912000-00006. ISSN 0003-4932. PMC 1387715. PMID 5352643.
  19. ^ PACK, GEORGE T. (1961-11-01). "Interscapulomammothoracic Amputation for Malignant Melanoma". Archives of Surgery. 83 (5): 694–699. doi:10.1001/archsurg.1961.01300170050010. ISSN 0004-0010. PMID 14483062.
  20. ^ "Super Radical Mastectomy". TheFreeDictionary.com. Retrieved 2017-04-02.
  21. ^ Gray, J. H. (2017-04-17). "Studies of the regeneration of lymphatic vessels". Journal of Anatomy. 74 (Pt 3): 309–335. ISSN 0021-8782. PMC 1252591. PMID 17104816.
  22. ^ a b c Patey, D. H.; Dyson, W. H. (2017-04-17). "The Prognosis of Carcinoma of the Breast in Relation to the Type of Operation Performed". British Journal of Cancer. 2 (1): 7–13. doi:10.1038/bjc.1948.2. ISSN 0007-0920. PMC 2007539. PMID 18863724.
  23. ^ Madden, J L; Kandalaft, S; Bourque, R A (1972-05-01). "Modified radical mastectomy". Annals of Surgery. 175 (5): 624–634. doi:10.1097/00000658-197205000-00002. ISSN 0003-4932. PMC 1355229. PMID 4555029.
  24. ^ "Modified radical mastectomy: Why not? - ScienceDirect". www.sciencedirect.com. Retrieved 2017-04-17.
  25. ^ Berg, John W. (1955-01-01). "The significance of axillary node levels in the study of breast carcinoma". Cancer. 8 (4): 776–778. doi:10.1002/1097-0142(1955)8:4<776::aid-cncr2820080421>3.0.co;2-b. ISSN 1097-0142. PMID 13240660.
  26. ^ a b Jr, CRILE G (1964-03-01). "Results of Simplified Treatment of Breast Cancer". Surgery, Gynecology & Obstetrics. 118: 517–523. ISSN 0039-6087. PMID 14130910.
  27. ^ Kennedy, C. S.; Miller, E. (1963-02-01). "Simple mastectomy for mammary carcinoma". Annals of Surgery. 157: 161–162. ISSN 0003-4932. PMID 14031938.
  28. ^ Kaae, S.; Johansen, H. (1965-01-01). "Simple Mastectomy Plus Postoperative Irradiation by the Method of Mcwhirter for Mammary Carcinoma". Progr. Clin. Cancer. 1. OSTI 4591011.
  29. ^ Fisher, Bernard (1977-07-01). "Biological and clinical considerations regarding the use of surgery and chemotherapy in the treatment of primary breast cancer". Cancer. 40 (S1): 574–587. doi:10.1002/1097-0142(197707)40:1+3.0.CO;2-O (inactive 2022-06-08). ISSN 1097-0142.{{cite journal}}: CS1 maint: DOI inactive as of June 2022 (link)
  30. ^ Veronesi, Umberto; Saccozzi, Roberto; Del Vecchio, Marcella; Banfi, Alberto; Clemente, Claudio; De Lena, Mario; Gallus, Giuseppe; Greco, Marco; Luini, Alberto (2010-01-13). "Comparing Radical Mastectomy with Quadrantectomy, Axillary Dissection, and Radiotherapy in Patients with Small Cancers of the Breast". New England Journal of Medicine. 305 (1): 6–11. doi:10.1056/nejm198107023050102. PMID 7015141. Retrieved 2017-04-19.
  31. ^ Fisher, Bernard; Bauer, Madeline; Margolese, Richard; Poisson, Roger; Pilch, Yosef; Redmond, Carol; Fisher, Edwin; Wolmark, Norman; Deutsch, Melvin (2010-01-13). "Five-Year Results of a Randomized Clinical Trial Comparing Total Mastectomy and Segmental Mastectomy with or without Radiation in the Treatment of Breast Cancer". New England Journal of Medicine. 312 (11): 665–673. doi:10.1056/nejm198503143121101. PMID 3883167. Retrieved 2017-04-19.
  32. ^ a b "Modified Skin Incisions for Mastectomy: The Need for Plastic... : Plastic and Reconstructive Surgery". LWW.
  33. ^ "SUBCUTANEOUS MASTECTOMY FOR BENIGN BREAST LESIONS WITH IMMED... : Plastic and Reconstructive Surgery". LWW.
  34. ^ Patani, Neill; Mokbel, Kefah (2008-10-01). "Oncological and aesthetic considerations of skin-sparing mastectomy". Breast Cancer Research and Treatment. 111 (3): 391–403. doi:10.1007/s10549-007-9801-7. ISSN 0167-6806. PMID 17965954. S2CID 3197120.
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