Chapter 76: Mastectomy and Breast Reconstruction

HISTORICAL PERSPECTIVE

Mastectomy has been utilized in the surgical management of patients with breast cancer for centuries. It was William Stewart Halsted who popularized the technique of radical mastectomy after his initial publication in the mid-1890s.¹ Halsted believed that breast cancer spread from the primary tumor in the breast parenchyma to the regional lymph node basins and then to distant sites. He felt that this sequential progression of spread could be halted if all of the breast tissue, skin, chest wall musculature, and regional lymphatics were resected. In addition to the extensive chest wall resection, the Halsted radical mastectomy included removal of the level I, II, and III axillary lymph nodes. Halsted’s initial publication reported a 5-year survival rate of 40% and a local-regional control rate of 73%. The extended radical mastectomy was introduced to include internal mammary nodal dissection based on retrospective comparisons showing improved survival with the more extensive procedure. A multinational randomized trial was initiated in the 1960s to compare survival rates with the Halsted radical mastectomy versus the extended radical mastectomy.² The trial did not show any difference in survival outcomes between the two surgical procedures, however it was underpowered and patients were not staged and selected for participation based on imaging studies. Subsequent studies failed to confirm any survival advantage with the extended radical mastectomy and this procedure was largely abandoned in favor of radiation to the regional nodes.

In 1943, Haagensen and Stout first introduced the criteria for inoperability of patients with advanced breast cancer who would not be expected to have a survival benefit from the radical mastectomy.³ These included inflammatory carcinoma, evidence of satellite skin nodules or extensive edema of the skin of the breast, ulceration or fixation of the tumor to the chest wall, and fixed axillary lymph nodes. They suggested that operative management of patients with these findings was not beneficial and did not result in local-regional control or long-term survival. It was not until the introduction of effective systemic therapies and the incorporation of radiation into the local-regional management of breast cancer that survival outcomes improved in patients with locally advanced disease. Multidisciplinary management of patients with advanced breast cancer remains the standard of care today.

Although some surgeons began to explore less radical approaches to the surgical management of breast cancer in the early 1900s, the Halsted radical mastectomy remained as a standard well into the 1970s even for patients with early-stage breast cancer. The modified radical mastectomy was introduced as an alternative to radical mastectomy and included removal of the breast and level I, II, and III axillary lymph nodes but preserved the pectoralis major muscle. Murphy and colleagues⁴ were proponents of preservation of the pectoralis muscles during mastectomy as early as 1912. Patey and Dyson⁵ modified the technique of radical mastectomy for patients with early-stage breast cancer by preserving the pectoralis major and removing the pectoralis minor ...