Halsted advocated radical mastectomy (RM) to achieve locoregional control for breast cancer at the end of the 19th century, stemming from his theory of the sequential progression of breast cancer metastases from the primary tumor to regional lymphatics and on to distant sites.1 The RM and extended radical mastectomy (ERM) embodied the theory of aggressive local control, and emerged as mainstays of surgical treatment for breast cancer (Fig. 68-1). Nonetheless, as early as 1912, Murphy and other proponents of pectoralis muscle preservation began to challenge these techniques with modified radical mastectomy (MRM) and total mastectomy. They demonstrated adequate local control without the associated cosmetic and functional morbidities.2 Patey and Dyson later modified the Halsted technique for resection of small (T1 and T2) breast cancers, advocating level I, II, and III axillary dissection, preserving pectoralis major, and removing only the pectoralis minor muscle.3,4 Neoadjuvant chemotherapy further served to lessen the surgical approach required by greatly facilitating resectability. The criteria for breast cancer inoperability published by Haagensen and Stout were established before the wide acceptance and advances in chemotherapy and modern radiation techniques.5 Accordingly, criteria for the role of surgery in locally advanced breast cancer (LABC) are evolving, yet still remain largely reserved for palliation, comfort, hygiene, and wound management.6
Halsted radical mastectomy. From initial description of the surgical procedure as reported in 1894. (Reproduced with permission from Halsted W. The results of operations for the cure of cancer of the breast performed at the Johns Hopkins Hospital from June 1889 to January 1894. Ann Surg. 1894;5:497-555.)
The Halsted RM involves removal of all breast tissue, the pectoralis major and minor muscles, and level I, II, and III axillary and supraclavicular lymph node dissections. Since Haagensen and Stout's 1943 publication detailing the bleak results (5-year local recurrence and survival rates of 46% and 6%, respectively) achieved with RM as sole treatment for LABC, other studies emerged comparing less aggressive surgical approaches and radiotherapy, alone and in combination with surgery, to RM for the treatment of LABC.5 Baker and associates compared the results of MRM to RM in patients with operable breast cancer, citing no statistically significant differences in 5-year survival or incidence of local or regional recurrence between the 2 surgical modalities.7 Patients with stage III disease, however, demonstrated statistically significant higher incidences of axillary and chest wall recurrences when treated with MRM versus RM, leaving the authors to conclude that MRM is appropriate for early-stage breast cancer only. Likewise, MRM sparing the pectoralis major muscle using the Patey technique was demonstrated to yield as many axillary lymph nodes as RM. This suggested that MRM was comparable to RM and sufficient for locoregional control and prognostic determination for early-stage breast cancer.8
While surgical therapy appears imperative to effective management of LABC, RM does not ...