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Introduction

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The Radical Mastectomy Procedure

The radical mastectomy, as described by William Halsted.

The Radical Mastectomy as performed by Halstead is a surgery for breast cancer. The procedure involves removing all the breast tissue, overlying skin, the pectoralis muscles, and all the axillary lymph nodes. This procedure 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 ococured at a much later stage. -Skin was removed because the disease often involved the skin; in fact, the skin was often ulcerated on presentation [2, 4]. The pectoralis muscles were removed not simply because the chest wall was often involved, but because it was considered essential to remove the transpectoral lymphatic pathways that run directly through the pectoralis major to Rotter's nodes between the pectoralis major and pectoralis minor. At that time, it was also considered anatomically impossible to do a complete axillary dissection without removing the pectoralis muscles [2, 3].

Halsted achieved a three-year local recurrence rate of 3% and locoregional recurrence rate of 20% with no perioperative mortality. Compared to the 50-80% local recurrence rates of other prominent European doctors of the time, Halsted's accomplishment was undeniable. 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. Five-year survival was 40%—twice that of untreated patients [2]. However, morbidity after the operation was great, because the large wounds were left to heal by granulation, lymphedema was near universal, and arm movement was severely restricted (due to pectoralis muscle removal and damage to axilla nerves). For these reasons, chronic pain was also an important sequela. Over a century ago, surgeons were faced with large breast cancers that seemed to require drastic treatment to have some chance of cure: patients’ quality of life was not a consideration [4–10]. Nevertheless, thanks to Halsted and Meyer, at last, it became possible to cure breast cancer in some cases, and systematic knowledge of the disease began to accumulate, standardized treatments started being applied, and controlled long-term studies would eventually be conducted.

Pre Halstead treatments

In 460 BC, Hippocrates described breast cancer as a humoral disease. This humoral theory of oncogenesis was embraced by the influential Roman physician Galen and remained an unchallenged standard through the Middle Ages for over 1,300 years. 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 of paramount significance because he recognized that cancer at its earliest phase of development is a local disease that could be surgically removed.

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.

Despite Petit's publication, many surgeons were reluctant to perform a radical surgery even towards the end of the 19th century. 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.

Post Halstead treatments

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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. The following mastectomies attempt to conserve much of the natural breast.

Skin-Sparing Mastectomy (SSM)

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.

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. 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. Another study indicates that it would be oncologically safe to perform SSM in class T1 and T2 tumors because skin involvement is usually small. Skin-sparing Mastectomy has several benefits including a reduced postmastectomy deformity, improved breast shape after reconstruction, minimal residual scarring, and reduced need for contralateral breast surgery to attain symmetry.

Common complications of SSM include skin necrosis, infection, and hematoma. 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. About 65% of patients experience reduced skin sensitivity. 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.

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

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.

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.

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. 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.

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.

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.

Reconstructive Surgery After Mastectomy

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. 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.

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.

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.

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

Note

http://ovidsp.tx.ovid.com/sp-3.24.1b/ovidweb.cgi?WebLinkFrameset=1&S=BDPLFPKDPCDDJDHJNCHKLHIBEIOCAA00&returnUrl=ovidweb.cgi%3fMain%2bSearch%2bPage%3d1%26S%3dBDPLFPKDPCDDJDHJNCHKLHIBEIOCAA00&directlink=http%3a%2f%2fovidsp.tx.ovid.com%2fovftpdfs%2fFPDDNCIBLHHJPC00%2ffs047%2fovft%2flive%2fgv039%2f00000658%2f00000658-190707000-00001.pdf&filename=THE+RESULTS+OF+RADICAL+OPERATIONS+FOR+THE+CURE+OF+CARCINOMA+OF+THE+BREAST.%2a.&navigation_links=NavLinks.S.sh.22.1&link_from=S.sh.22%7c1&pdf_key=FPDDNCIBLHHJPC00&pdf_index=/fs047/ovft/live/gv039/00000658/00000658-190707000-00001&D=ovft&link_set=S.sh.22%7C1%7Csl_10%7CresultSet%7CS.sh.22.23%7C0

https://www.ncbi.nlm.nih.gov/pubmed/17861990?dopt=Abstract