Download Modified Radical Mastectomy

Modified Radical Mastectomy
Valerie L. Staradub, MD, and Monica Morrow, MD
urgical management options for breast cancer include
modified radical mastectomy (MRM), MRM with
immediate reconstruction, and breast conservation
therapy (BCT). Absolute contraindications to BCT include tumor presence in more than one breast quadrant,
diffuse suspicious or indeterminate calcifications seen on
mammography and contraindications to radiation therapy,
such as first or second trimester of pregnancy or history
of radiation therapy to the breast field for previous
breast cancer or as part of treatment for another condition, such as Hodgkin's disease. 1 Relative contraindications include sufficiently large tumor-to-breast ratio
to preclude acceptable cosmesis and collagen vascular
disease. The incidence of these contraindications varies
with tumor stage. In our experience, 10% of w o m e n with
stage I breast cancer and 28% of w o m e n with stage II
breast cancer had contraindications to B e T . 2 In w o m e n
with contraindications to BCT, MRM is medically necessary. For all others, there is no survival difference
between the procedures, and patient preference should
be the deciding factor. We have observed that approximately 20% of w o m e n who are candidates for BCT opt to
undergo MRM. Nationally, MRM remains the most common treatment for patients with stage I and II breast
cancer. 3-5 In some situations, MRM is not an appropriate
first-line treatment modality, and the patient should be
referred for neoadjuvant chemotherapy; these include
metastatic breast cancer and locoregionally advanced
carcinoma. 6-7 In addition, patients presenting with stage
IV carcinoma are surgical candidates only if they develop
local complications that cannot be controlled with systemic therapy.
MRM always includes removal of the breast tissue, the
nipple-areolar complex, and the ipsilateral axillary lymph
nodes. Variations of the procedure, including removal of
the pectoralis minor muscle or division of its tendon to
S
facilitate axillary exposure, have been described, sq~ In
our experience, these are rarely, if ever, necessary, and the
technique that we describe keeps the pectoralis minor
intact. The original descriptions of MRM included removal of the pectoralis major fascia, because this structure was thought to be a barrier to the lymphatic spread
of tumor. Subsequent studies have shown that lymphatic
vessels penetrate the pectoral fascia and that this fascia
may be preserved when needed to facilitate implant
reconstruction, as long as care is taken to meticulously
remove all of the breast tissue superficial to the fascia.
MRM is an extremely safe operation with a very- low
operative mortality rate. This is true even in the elderly
population, for which the mortality rate from breast
surgery of all types is less than 2%. 11-14
Patient Positioning and Preparation
1"he patient is positioned supine on the operating table
with the ipsilateral arm abducted 90 ~ on an arm board.
The arm board is padded to prevent subluxation of the
shoulder with brachial plexus stretch. The patient is
positioned at the edge of the table on the operative side;
it may be helpful to place a folded sheet under the
ipsilateral shoulder.
The axilla is shaved if necessary, and a standard
surgical preparation is done. The breast preparation
should extend below the mframammary crease, across
the midline, and to the supraclavicular fossa in the event
that extra skin mobilization is needed to allow closure.
The entire ipsilateral arm is prepped to the wrist, the arm
board is covered with a Mayo stand cover, and the arm is
draped with an impervious stockinet. The field drapes
are brought underneath the ipsilateral shoulder so that
the entire arm is in the operative field.
From the Lynn Sage Comprehensive Breast Center, Department of Surgery,
Northwestern University Medical School, Chicago, IL.
Address reprint requests to Monica Morrow, MD, Director, Lynn Sage
Comprehensive Breast Center, Northwestern Memorial Hospital, 251 E. Huron
St., Gaiter 13-174, Chicago, IL 60611.
Copyright 9 2000 by WB. Saunders Company
1524-153X/00/0202-0005510.00/0
doi: 10.1053/otgn.2000.7066
118
Operative Techniques in General Surgery, Vol 2, No 2 (June), 2000: pp 118-126