Modified radical mastectomy
A surgical procedure that removes the breast, surrounding tissue, and nearby lymph nodes that are affected by cancer.
The purpose for modified radical mastectomy is the removal of breast cancer (abnormal cells in the breast that grow rapidly and replace normal healthy tissue). Modified radical mastectomy is the most widely used surgical procedure to treat operable breast cancer. This procedure leaves a chest muscle called the pectoralis major intact. Leaving this muscle in place will provide a soft tissue covering over the chest wall and a normal-appearing junction of the shoulder with the anterior (front) chest wall. This sparing of the pectoralis major muscle will avoid a disfiguring hollow defect below the clavicle. Additionally, the purpose of modified radical mastectomy is to allow for the option of breast reconstruction , a procedure that is possible, if desired, due to intact muscles around the shoulder of the affected side. The modified radical mastectomy procedure involves removal of large multiple tumor growths located underneath the nipple and cancer cells on the breast margins.
The highest rates of breast cancer occur in Western countries (more than 100 cases per 100,000 women) and the lowest among Asian countries (10–15 cases per 100,000 women). Men can also have breast cancer, but the incidence is much less when compared to women. There is a strong genetic correlation since breast cancer is more prevalent in females who had a close relative (mother, sister, maternal aunt, or maternal grandmother) with previous breast cancer. Increased susceptibility for development of breast cancer can occur in females who never breastfed a baby, had a child after age 30, started menstrual periods very early, or experienced menopause very late.
In the United States, there were approximately 175,000 cases of breast cancer in 1999 with more than 43,000 deaths. Breast cancer accounts for 30% of all cancer diagnosed in American women and for 16% of all cancer deaths. Breast cancer is a worldwide public health problem since there are approximately one million new cases diagnosed annually. A woman's lifetime risk of developing breast cancer is one in eight. The incidence rose
The surgeon's goal during this procedure is to minimize any chance of local/regional recurrence; avoid any loss of function; and maximize options for breast reconstruction. Incisions are made to avoid visibility in a low neckline dress or bathing suit. An incision in the shape of an ellipse is made. The surgeon removes the minimum amount of skin and tissue so that remaining healthy tissue can be used for possible reconstruction. Skin flaps are made carefully and as thinly as possible to maximize removal of diseased breast tissues. The skin over a neighboring muscle (pectoralis major fascia) is removed, after which the surgeon focuses in the armpit (axilla, axillary) region. In this region, the surgeon carefully identifies vital anatomical structures such as blood vessels (veins, arteries) and nerves. Accidental injury to specific nerves like the medial pectoral neurovascular bundle will result in destruction of the muscles that this surgery attempts to preserve, such as the pectoralis major muscle. In the armpit region, the surgeon carefully protects the vital structures while removing cancerous tissues. After axillary surgery, breast reconstruction can be performed, if desired by the patient.
Modified radical mastectomy is a surgical procedure to treat breast cancer. In order for this procedure to be an operable option, a definitive diagnosis of breast cancer must be established. The first clinical sign for approximately 80% of women with breast cancer is a mass (lump) located in the breast. A lump can be discovered by monthly self-examination or by a health professional who can find 10–25% of breast cancers that are missed by yearly mammograms (a low radiation x ray of the breasts). A biopsy can be performed to examine the cells from a lump that is suspicious for cancer. The diagnosis of the extent of cancer and spread to regional lymph nodes determines the treatment course (i.e., whether surgery, chemotherapy, or radiation therapy, either singly or in combinations). Staging the cancer can estimate the amount of tumor, which is important not only for diagnosis but for prognosis (statistical outcome of the disease process). Patients with a type of breast cancer called ductal carcinoma in situ (DCIS), which is a stage 0 cancer, have the best outcome
Persons affected with breast cancer must undergo the staging of the cancer to determine the extent of cancerous growth and possible spread (metastasis) to distant organs. Patients with stage 0 disease have noninvasive cancer with a very good outcome. Stages I and II are early breast cancer, without lymph node involvement (stage I) and with node positive results (stage II). Persons with stage III disease have locally advanced disease and about a 50% chance for five-year survival. Stage IV disease is the most severe since the breast cancer cells have spread through lymph nodes to distant areas and/or other organs in the body. It is very unlikely that persons with stage IV metastatic breast cancer survive 10 years after diagnosis.
It is also imperative to assess the degree of cancerous spread to lymph nodes within the armpit region. Of primary importance to stage determination and regional lymph node involvement is identification and analysis of the sentinel lymph node. The sentinel lymph node is the first lymph node to which any cancer would spread. The procedure for sentinel node biopsy involves injecting a radioactively labeled tracer (technetium 99) or a blue dye (isosulphan blue) into the tumor site. The tracer or dye will spread through the lymphatic system to the sentinel node, which should be surgically removed and examined for the presence of cancer cells. If the sentinel node and one or two other neighboring lymph nodes are negative, it is very likely that the remaining lymph nodes will not contain cancerous cells, and further surgery may not be necessary.
Once a breast lump (mass) has been identified by mammography or physical examination , the patient should undergo further evaluation to histologically (studying the cells) identify or rule out the presence of cancer cells. A procedure called fine-needle aspiration allows the clinician to extract cells directly from the lump for further evaluation. If a diagnosis cannot be established by fine-needle biopsy, the surgeon should perform an open biopsy (surgical removal of the suspicious mass). Preparation for surgery is imperative. The patient should plan for both direct care and recovery time after modified radical mastectomy. Preparation immediately prior to surgery should include no food or drink after midnight before the procedure. Post-surgical preparation should include caregivers to help with daily tasks for several days.
After breast cancer surgery, women should undergo frequent testing to ensure early detection of cancer recurrence. It is recommended that annual mammograms, physical examination, or additional tests (biopsy) be performed annually. Aftercare can also include psychotherapy since mastectomy is emotionally traumatic. Affected women may be worried or have concerns about appearance, the relationship with their sexual partner, and possible physical limitations. Community-centered support groups usually made up of former breast cancer surgery patients can be a source of emotional support after surgery. Patients may stay in the hospital for one to two days. For about five to seven days after surgery, there will be one or two drains left inside to remove any extra fluid from the area after surgery. Usually, the surgeon will prescribe medication to prevent pain. Movement restriction should be specifically discussed with the surgeon.
There are several risks associated with modified radical mastectomy. The procedure is performed under general anesthesia, which itself carries risk. Women may have short-term pain and tenderness. The most frequent risk of breast cancer surgery (with extensive lymph node removal) is edema, or swelling of the arm, which is usually mild, but the presence of fluid can increase the risk of infection. Leaving some lymph nodes intact instead of removing all of them may help lessen the likelihood of swelling. Nerves in the area may be damaged. There may be numbness in the arm or difficulty moving shoulder muscles. There is also the risk of developing a lump scar (keloid) after surgery. Another risk is that surgery did not remove all the cancer cells and that further treatment may be necessary (with chemotherapy and/or radiotherapy). By far, the worst risk is recurrence of cancer. However, immediate signs of risk following surgery include fever, redness in the incision area, unusual drainage from the incision, and increasing pain. If any of these signs develop, it is imperative to call the surgeon immediately.
If no complications develop, the surgical area should completely heal within three to four weeks. After mastectomy, some women may undergo breast reconstruction (which can be done during mastectomy). Recent studies have indicated that women who desire cosmetic reconstructive surgery have a higher quality of life and better sense of well-being than those who do not utilize this option.
Morbidity and mortality rates
The outcome of breast cancer is very dependent of the stage at the time of diagnosis. For stage 0 disease (5–10% of the cases), the five-year survival is 99%. For stage I (early/lymph node negative), which comprises 40–45% of total cases, the five-year survival is 85–95%. For stage II (early/lymph node positive), which comprises 35–40% of total cases, the five-year survival decreases to 65–75%. For stage III disease (locally advanced), which accounts for 10–15% of total cases, the five-year survival is 45–50%. Women with stage IV (metastatic) breast cancer account for about 7% of total cases; the five-year survival is 20–30%. Less than 1% of these women survive past 10 years.
There are no real alternatives to mastectomy. Surgical requirement is clear since mastectomy is recommended for tumors with dimensions over 2 in (5 cm). Additional treatment (adjuvant) is typically recommended with chemotherapy and/or radiation therapy to destroy any remaining cancer during surgery. Modified radical mastectomy is one of the standard treatment recommendations for stage III breast cancer.
Noble, John. Textbook of Primary Care Medicine, 3rd edition. St. Louis: Mosby, Inc., 2001.
Townsend, Courtney. Sabiston Textbook of Surgery, 16th edition. St. Louis: W. B. Saunders Company, 2001.
Fiorica, James. "Prevention and Treatment of Breast Cancer." Obstetrics and Gynecology Clinics 28 no. 4 (December 2001).
American Cancer Society. (800) ACS-2345. http://www.cancer.org. .
Laith Farid Gulli, MD
Nicole Mallory, MS, PA-C