Surgical resection was the principal therapy for breast cancer for centuries. However, over the past 30 years, as therapeutic interventions have been modified and outcomes have been studied, aggressiveness of the procedures has substantially been reduced. Currently, large chest wall resections and reconstructions are offered only to select patients with locoregional disease. This chapter evaluates the indications and contraindications for this operation, discusses procedural technique, and reviews the complications.
William S. Halsted is often credited with evolution and advancement of the radical mastectomy. He thought that breast cancer advanced locally and then spread to regional lymph nodes prior to reaching distal sites.1 Therefore, extirpation of the breast cancer required a complete en bloc excision of the skin, both pectoral muscles, and all levels of lymph nodes of the axilla (I, II, III) and lower neck, and sacrifice of the thoracodorsal artery, vein, and nerve together with the long thoracic nerve.2–5
Today, with the advent of early detection and neoadjuvant therapies, surgeons perform major procedures, such as the Halsted mastectomy and large chest wall resections, sparingly (<2%). Cytoreduction through radiotherapy and chemotherapy permits the treatment of breast cancer patients with less aggressive surgical procedures. However, the oncologic surgeon will face certain presentations of advanced disease and locoregional recurrence in which a chest wall resection would be appropriate, such as an isolated chest wall or solitary lymph node recurrence;6-9 curative treatment for removing a locally advanced primary cancer; and palliation, with the goal of treating pain, drainage, ulceration, or continued growth.6,7,10,11
A number of contraindications exist for extensive chest wall resection. Definitive contraindications include systemic disease and multifocal recurrence. Other features that are suggestive of a poor prognosis with a large resection are short disease-free interval, poor pulmonary function, and additional high operative risk factors6,7 (Table 157-1). Specifically, studies confirm that age less than 35 years, disease-free interval less than 2 years, and positive lymph nodes at first diagnosis are poor prognostic factors.8,9,12-16
Indications and Contraindications
Currently, with the major advances made in breast cancer treatment and perioperative management, more appropriate patients can be selected to undergo major chest wall resections instead of less discriminatory measures, as was done in Halsted's day. In addition, recent surgical developments, including procedures related to flap reconstruction with improvements in anesthesia, antibiotics, tissue augmentation technology, and intensive care, have allowed more acceptable morbidity and mortality rates related to chest wall resections.10,17