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A Technique for Partial Mastectomy
Symposium on Surgical Techniques
A Technique for Partial Mastectomy
Caldwell B. Esselstyn, Jr., M.D.
Operations less than mastectomy for carcinoma of the breast are not new. Adair1 in this country, PorriW in England, and Muskatallio6 in Scandinavia reported early results of operations less than mastectomy, and more recently, Wise et al. 8 in England, and Crile et al. 4 in this country have published their results. The term partial mastectomy has often been labeled "lumpectomy," a deplorable term, and much confusion exists concerning the proper technique of partial mastectomy and its application. The purpose of this article is to discuss the selection of patients for partial mastectomy and to review the fundamental techniques of the procedure. Biopsy For the past 4 years, the majority of our patients who have been candidates for breast cancer surgery have a diagnostic biopsy performed by needle aspiration in the office. 2 If the biopsy specimen is negative, an open biopsy is performed. Rarely is any further surgery done immediately following the frozen section. Permanent sections of the biopsy are evaluated, and recommendations for subsequent surgery are then based on the pathology, size, location, family history, and personal desires of the patient.5 Selection of Candidates for Partial Mastectomy Patients who desire a partial mastectomy must be fully informed that they have the same chance of developing a second new cancer in that breast as they do of developing a new primary cancer in the opposite breast.3 Patients who have no family history of breast cancer or have a lesion less than 2.5 em which is not centrally located, and whose biopsy specimen is not suggestive of extensive intraduct or lobular carcinoma in situ or multicentricity, are acceptable candidates if they object to mastectomy. Less acceptable are patients who do not meet these criteria but for esthetic reasons refuse mastectomy. Another less than ideal group are the elderly or infirm whose systemic illness precludes a mastectomy; a partial mastectomy becomes a From the Department of General Surgery, The Cleveland Clinic Foundation and The Cleve· land Clinic Educational Foundation, Cleveland, Ohio
Surgical Clinics of North America- Vol. 55, No.5, October 1975
1065
1066
CALDWELL
B.
EssELSTYN, JR.
mandatory substitute. Occasionally their debility requires that the operation be performed under local anesthesia.
Operative Technique Following proper positioning of the patient, the skin is marked in a diamond shape to obtain 1.5 to 2 em of skin clearance of the biopsy site (Fig. 1). The incision for the superior flap is made only through the skin down to the breast fat. The scalpel is then immediately beveled in a lateral direction away from the specimen to insure at least 2.5 to 3 em of normal breast tissue beyond the tumor. This incision is carried down to the pectoralis fascia (Fig. 2). Dissection is now carried inferiorly on the muscle with removal of the pectoralis fascia (Fig. 3). This is continued until the operator's fingers can be inserted beneath the entire specimen that is to be removed (Fig. 4). For deep lying tumors a segment of pectoralis muscle should be included to insure safe and clear inferior margins. Once the tumor is cleared inferiorly, a similar incision is made along the lower skin margin, again beveling the knife away from the tumor to insure a safe margin (Fig. 5). With the tumor between thumb and fingers, the lesion may now be completely removed, or as is often my personal preference, an in continuity axillary dissection may be performed (Figs. 6 and 7). This clears all axillary tissue below the axillary vein while preserving the long thoracic and thoracodorsal nerves (Fig. 8). The axillary dissection may be included in the treatment of all lateral quadrant lesions, even if high or low. In medial quadrant partial mastectomies axillary dissection is not done. A layered closure is fashioned using vacuum drainage (Fig. 9). The cosmetic result of the skin closure with continuous fine nylon minimizes the scar (Fig. 10).
Figure 1. The incisional pattern.
A
TECHNIQUE FOR PARTIAL MASTECTOMY
Figure 2.
1067
Cutting laterally away from the tumor down to pectoralis fascia
Figure 3. Dissection inferiorly along the pectoralis muscle. Note that the pectoralis fascia is removed with the specimen.
1068
CALDWELL
B.
ESSELSTYN, JR.
Figure 4. The operator's fingers checking inferior clearance of the tumor specimen.
Figure 5. Incising the skin on the lower border of the specimen.
A
TECHNIQUE FOR PARTIAL MASTECTOMY
Figure 6. muscle.
1069
Completing removal of the specimen with a portion of attached pectoral
Figure 7. In continuity axillary dissection.
1070
CALDWELL
B.
ESSELSTYN, JR.
Figure 8. The completed partial mastectomy in continuity with axillary dissection.
Figure 9.
A layered closure with vacuum drainage.
A
TECHNIQUE FOR PARTIAL MASTECTOMY
Figure 10.
1071
Completion of the running monofilament suturing of the skin.
A properly performed partial mastectomy follows the basic tenets of cancer surgery, namely, an en bloc removal of the primary cancer with safe and adequate margins of normal tissue. The partial mastectomy is not to be confused with the term "lumpectomy," which connotes a simple enucleation of the cancer. It is a totally unacceptable cancer procedure.
REFERENCES 1. Adair, F. E.: The role of surgery and irradiation in cancer of the breast. J.A.M.A., 121:553559, 1943. 2. Crile, G., Jr.: Better use of aspiration biopsy in breast cancer. Consultant, 14:37-39, 1974. 3. Crile, G., Jr.: Multicentric breast cancer. The incidence of new cancers in the homolateral breast after partial mastectomy. Cancer,35:475, 1975. 4. Crile, G., Jr., Esselstyn, C. B., Jr., Hermann, R. E., Jr. and Hoerr, S. 0.: Partial mastectomy for carcinoma of the breast. Surg. Gynec. Obstet., 136:929-933, 1973. 5. Crile, G., Jr., Esselstyn, C. B., Jr., Hermann, R. E., and Hoerr, S. 0.: A new look at biopsy of the breast. Am. J. Surg., 126:117, 1973. 6. Muskatallio, S.: Treatment of breast cancer by tumor extirpation and roentgen therapy instead of radical operation. J. Fac. Radiol., 6:23-26, 1954. 7. Porritt, A.: Early carcinoma of the breast. Br. J. Surg., 51:214-216, 1974. 8. Wise, L., Mason, A. Y., and Ackerman, L. V.: Local excision and irradiation; an alternative method for the treatment of early breast cancer. Ann. Surg., 174:392-399, 1971. Department of General Surgery The Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, Ohio 44106
A Technique for Partial Mastectomy
Caldwell B. Esselstyn, Jr., M.D.
Operations less than mastectomy for carcinoma of the breast are not new. Adair1 in this country, PorriW in England, and Muskatallio6 in Scandinavia reported early results of operations less than mastectomy, and more recently, Wise et al. 8 in England, and Crile et al. 4 in this country have published their results. The term partial mastectomy has often been labeled "lumpectomy," a deplorable term, and much confusion exists concerning the proper technique of partial mastectomy and its application. The purpose of this article is to discuss the selection of patients for partial mastectomy and to review the fundamental techniques of the procedure. Biopsy For the past 4 years, the majority of our patients who have been candidates for breast cancer surgery have a diagnostic biopsy performed by needle aspiration in the office. 2 If the biopsy specimen is negative, an open biopsy is performed. Rarely is any further surgery done immediately following the frozen section. Permanent sections of the biopsy are evaluated, and recommendations for subsequent surgery are then based on the pathology, size, location, family history, and personal desires of the patient.5 Selection of Candidates for Partial Mastectomy Patients who desire a partial mastectomy must be fully informed that they have the same chance of developing a second new cancer in that breast as they do of developing a new primary cancer in the opposite breast.3 Patients who have no family history of breast cancer or have a lesion less than 2.5 em which is not centrally located, and whose biopsy specimen is not suggestive of extensive intraduct or lobular carcinoma in situ or multicentricity, are acceptable candidates if they object to mastectomy. Less acceptable are patients who do not meet these criteria but for esthetic reasons refuse mastectomy. Another less than ideal group are the elderly or infirm whose systemic illness precludes a mastectomy; a partial mastectomy becomes a From the Department of General Surgery, The Cleveland Clinic Foundation and The Cleve· land Clinic Educational Foundation, Cleveland, Ohio
Surgical Clinics of North America- Vol. 55, No.5, October 1975
1065
1066
CALDWELL
B.
EssELSTYN, JR.
mandatory substitute. Occasionally their debility requires that the operation be performed under local anesthesia.
Operative Technique Following proper positioning of the patient, the skin is marked in a diamond shape to obtain 1.5 to 2 em of skin clearance of the biopsy site (Fig. 1). The incision for the superior flap is made only through the skin down to the breast fat. The scalpel is then immediately beveled in a lateral direction away from the specimen to insure at least 2.5 to 3 em of normal breast tissue beyond the tumor. This incision is carried down to the pectoralis fascia (Fig. 2). Dissection is now carried inferiorly on the muscle with removal of the pectoralis fascia (Fig. 3). This is continued until the operator's fingers can be inserted beneath the entire specimen that is to be removed (Fig. 4). For deep lying tumors a segment of pectoralis muscle should be included to insure safe and clear inferior margins. Once the tumor is cleared inferiorly, a similar incision is made along the lower skin margin, again beveling the knife away from the tumor to insure a safe margin (Fig. 5). With the tumor between thumb and fingers, the lesion may now be completely removed, or as is often my personal preference, an in continuity axillary dissection may be performed (Figs. 6 and 7). This clears all axillary tissue below the axillary vein while preserving the long thoracic and thoracodorsal nerves (Fig. 8). The axillary dissection may be included in the treatment of all lateral quadrant lesions, even if high or low. In medial quadrant partial mastectomies axillary dissection is not done. A layered closure is fashioned using vacuum drainage (Fig. 9). The cosmetic result of the skin closure with continuous fine nylon minimizes the scar (Fig. 10).
Figure 1. The incisional pattern.
A
TECHNIQUE FOR PARTIAL MASTECTOMY
Figure 2.
1067
Cutting laterally away from the tumor down to pectoralis fascia
Figure 3. Dissection inferiorly along the pectoralis muscle. Note that the pectoralis fascia is removed with the specimen.
1068
CALDWELL
B.
ESSELSTYN, JR.
Figure 4. The operator's fingers checking inferior clearance of the tumor specimen.
Figure 5. Incising the skin on the lower border of the specimen.
A
TECHNIQUE FOR PARTIAL MASTECTOMY
Figure 6. muscle.
1069
Completing removal of the specimen with a portion of attached pectoral
Figure 7. In continuity axillary dissection.
1070
CALDWELL
B.
ESSELSTYN, JR.
Figure 8. The completed partial mastectomy in continuity with axillary dissection.
Figure 9.
A layered closure with vacuum drainage.
A
TECHNIQUE FOR PARTIAL MASTECTOMY
Figure 10.
1071
Completion of the running monofilament suturing of the skin.
A properly performed partial mastectomy follows the basic tenets of cancer surgery, namely, an en bloc removal of the primary cancer with safe and adequate margins of normal tissue. The partial mastectomy is not to be confused with the term "lumpectomy," which connotes a simple enucleation of the cancer. It is a totally unacceptable cancer procedure.
REFERENCES 1. Adair, F. E.: The role of surgery and irradiation in cancer of the breast. J.A.M.A., 121:553559, 1943. 2. Crile, G., Jr.: Better use of aspiration biopsy in breast cancer. Consultant, 14:37-39, 1974. 3. Crile, G., Jr.: Multicentric breast cancer. The incidence of new cancers in the homolateral breast after partial mastectomy. Cancer,35:475, 1975. 4. Crile, G., Jr., Esselstyn, C. B., Jr., Hermann, R. E., Jr. and Hoerr, S. 0.: Partial mastectomy for carcinoma of the breast. Surg. Gynec. Obstet., 136:929-933, 1973. 5. Crile, G., Jr., Esselstyn, C. B., Jr., Hermann, R. E., and Hoerr, S. 0.: A new look at biopsy of the breast. Am. J. Surg., 126:117, 1973. 6. Muskatallio, S.: Treatment of breast cancer by tumor extirpation and roentgen therapy instead of radical operation. J. Fac. Radiol., 6:23-26, 1954. 7. Porritt, A.: Early carcinoma of the breast. Br. J. Surg., 51:214-216, 1974. 8. Wise, L., Mason, A. Y., and Ackerman, L. V.: Local excision and irradiation; an alternative method for the treatment of early breast cancer. Ann. Surg., 174:392-399, 1971. Department of General Surgery The Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, Ohio 44106