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Total Mastectomy and Partial Axillary Dissection
Symposium on Surgical Techniques
Total Mastectomy and Partial Axillary Dissection
Blake Cady, M.D.
The standard operative procedure at the Lahey Clinic Foundation for carcinoma of the breast in stages A and B is, currently, total mastectomy and partial axillary dissection. The rationale for this has been described!' 2 and results chiefly from two factors: the decreasing size and much reduced axillary nodal involvement of carcinoma of the breast seen in the United States in recent years, and the realization that nodal involvement and local recurrence, while possibly creating problems in management, have little, if any, control over eventual patient survival and thus do not warrant excessive surgical measures for prevention during a period of decreasing incidence. Advances in the field of carcinoma of the breast in the near future will undoubtedly hinge on advances in tumor and host immunology in terms of predictive indexes by immunologic testing and development of immunologic alterations of disease course. In addition, greater appreciation of the concept of "risk factors"3 and perfection of early diagnostic techniques will lead to treatment of still earlier cancers, while further exploration of the usefulness and long-term results of local excision with or without radiation therapy may, in the future, alter drastically our currently "modern" concepts of proper therapy. Until much longer follow-up data about ultraconservative surgery and radiation are obtained, however, it is necessary to update our standard surgical approaches, as enough current information is available to indicate full confidence in muscle-preserving operations that also remove lower axillary lymph nodes for prognostic and therapeutic goals.
PROCEDURE Standard draping is utilized, with the arm wrapped and free for ease in moving the shoulder if necessary. Only horizontal elliptical incisions are utilized, to avoid unsightly vertical scars near the clavicle and shoulder (Fig. IA). These elliptical incisions may be shifted upward or downward to provide an adequate margin about biopsy incisions. Biopsy Surgical Clinics of North America- VoL 53, No.2, April 1973
313
314
BLAKE CADY
~~~ ~ /--"\ _\0~ ~ A
Usual
/
s~in incision
B
c Figure 1. A, Usual horizontal incision. The ellipse may be shifted up or down to accommodate lesions that are superior or inferior in the breast. B, Forceful vertical traction on the skin edge combined with vigorous downward traction by the surgeon's left hand displays the subcutaneous fascia. Knife dissection including this subcutaneous fascia with the breast specimen is then accomplished by extended knife motions with "feathering" of the knife blade. C, The pectoral fascia is dissected off the pectoralis muscle sharply so that bare muscle remains. The pectoral fascia best defines the deep extent of breast tissue.
incisions are always placed in such a way as to allow easy incorporation within a subsequent mastectomy incision. Thus, they are as central and as near the horizontal axis as is possible. Many biopsy incisions can be avoided completely by the use of needle aspiration biopsy (performed in the office) of all suspected carcinomas or discrete breast masses. Two thirds of all breast carcinomas have been proved pathologically before the patient enters the hospital, through my use of such aspiration techniques. By means of such office needle aspiration, considerable operating room time is saved. No inappropriate mastectomies from false-positive readings of the aspirate cytology have been encountered with our close association with the Laboratory of Pathology at the New England Deaconess Hospital. Obviously a "negative" breast aspiration cytology means nothing, and in the absence of gross cystic disease and cyst flUid, all breast masses are biopsied if aspirate cytology gives negative results. The intended elliptical incision is scored on the skin by knife blade without penetrating the dermis. In this way, no blood loss is incurred while a row of triple hook clamps is placed at 2 cm. intervals along the entire length of the upper side of the outlined incision. Then, with ex-
TOTAL MASTECTOMY AND PARTIAL AXILLARY DISSECTION
315
tremely vigorous upward retraction on groups of three triple hooks by the assistants combined with forceful countertraction by the operator on the specimen side of the incision, the dermis is cut through. With continued forceful retraction, the subcutaneous fascia is placed on the stretch and displayed. This stretched fascia is used as a guide to dissection so that with wide continuous knife motions, this fascia is included with the specimen as it is followed to the usual limits of mastectomy dissection (Fig. IB). By utilizing the knife blade as both cutting edge and an angled, beveled, scraping edge, the ramifications of the dissected fascia can be accommodated most easily. This "feathering" of the knife blade between strictly "on edge" cutting and sharply angled scraping permits unusual versatility in such long sweeping knife motions for flap dissections. The pectoralis fibers just below the clavicle, the midline presternal fascia, the rectus abdominis fascia at the costal margin, the serratus anterior fascia along the anterolateral chest, and the latissimus fibers laterally serve as the usual landmarks of the extent of dissection of flaps. The triple hook clamps are shifted to the lower flap skin edge as the means of obtaining vigorous retraction after completion of the upper flap. After development of the flaps, which with the help of vigorous retraction can be done quite rapidly, a row of hemostats is placed at 2 cm. intervals across the entire medial edge of the incised pectoral fascia. Clustering the handles of these clamps between the fingers of the surgeon's left hand for forceful upward traction, the entire pectoral fascia with its extension across the serratus anterior laterally is dissected off sharply with the same feathering knife motions (Fig. 1 C). A completely bare muscle surface should remain after such dissection; if filamentous sheets of gray fascia cover the muscle, it indicates incomplete removal of fascia, and, of course, if lobules of fat remain, this indicates that none of the pectoral fascia was removed. Complete stripping of the pectoral fascia is important since this tissue most clearly defines the deepest limits of breast tissue. Additionally, flap adherence to muscle is more rapid, and postoperative problems of fluid accumulation are decreased. As the pectoral fascia is stripped off muscle from medial to lateral, the separation becomes easier near the lateral border of the pectoralis major muscle. At this point, the weight of the breast simplifies retraction, and the fascial attachment to muscle is less. When the actual rolled edge of pectoralis major is defined, blunt dissection beneath the fascia is possible, exposing the interpectoral area and the fascia overlying the pectoralis minor. This, in turn, is incised in the depth of the interpectoral area and sharply stripped laterally while the pectoralis major is retracted medially and upward. About two thirds of the distance up the lateral edge of the pectoralis minor a small cluster of nerves and vessels, which supply the pectoralis major, are encountered (Fig. 2A). These are carefully preserved by dividing the laterally directed tiny veins and reflecting the small vessels and nerves medially. As this fascial dissection continues just below the pectoralis minor, the fibers of the serratus anterior are seen. At this point, a finger may be inserted and directed posteriorly between the serratus fibers medially and the axillary packet of fat and lymphatic structures surrounded by deep fascia laterally. The entire medial
316
BLAKE CADY
Nerve supply to Pect. mojo m.
Figure 2. A, Demonstration of the completed mastectomy and final steps in partial axillary resection. The axillary "packet" of fat and lymphatic tissue runs toward the axillary apex beneath the pectoralis minor muscle. The anatomic limits of this axillary packet are displayed. B, A clamp is placed across the thin wedge of axillary tissue at the level of the mid pectoralis minor muscle. This tissue is divided and tied to prevent lymphatic leakage and defines the medial extent of the partial axillary dissection. C, A demonstration of the small amount of residual axillary lymphatic tissue remaining after completion of the partial axillary dissection. Approximately 2 to 3 cm. separates the fingertips, one on the tie at the upper end of the axillary resection and one at the junction of the clavicle and the first rib marking the extreme apex of the axilla or the usual medial extent of a radical axillary dissection.
surface of this axillary packet is separated easily by blunt finger dissection. At the bottom of this cleavage lies the long thoracic nerve, and it can be dissected out of the fascia sharply and carefully preserved as it lies just anterior to the subscapular muscle (Fig. 2A). Attention to the superior dissection of this axillary packet is focused on sharp dissection of the fascial and adipose tissue overlying the axillary vein. No attempt is made to strip the vein closely, and areolar tissue is deliberately left in place for protection of the vein. All venous tributaries are carefully exposed, clamped, cut, and ligated promptly to prevent inadvertent tearing of the axillary vein. Just below the vein, the subscapular ves-
TOTAL MASTECTOMY AND PARTIAL AXILLARY DISSECTION
317
sels and the adjoining thoracodorsal nerve are exposed (Fig. 2A). The axillary lymphatic packet, surrounded by the thin deep fascia, is carefully stripped from the anterior surface of the subscapular vessels and thoracodorsal nerve. This entire process is feasible with forceful medial and upward retraction of both pectoral muscles (Fig. 2A). What remains now is the axillary packet, separated medially from the chest wall and superiorly from the axillary vein, posteriorly from the subscapular muscle, thoracodorsal, and long thoracic nerve, but attached to the residual axillary apex tissue (Fig. 2A). This thin wedge of the lymphatic-rich axillary tissue is clamped, divided, and tied with appropriate caution to avoid the long thoracic nerve which lies at the extreme posterior aspect (Fig. 2B). The ligature prevents excessive lymphatic leakage postoperatively. The level of this axillary lymphatic division is the mid pectoralis minor. After this lymphatic division, and by replacing structures in their normal alignment, one can demonstrate that the only axillary tissue remaining is the extreme apex, a small 2 cm. to 3 cm. cone of tissue no longer than the distal one half of the fifth finger (Fig. 2C). The average number of lymph nodes dissected out of this excised axillary packet by the pathology department is 20, which substantiates the extensive lymphatic resection. The specimen is rapidly cleared from the anterior border of the latissimus muscle and the attachments to the lower serratus fibers. The field is washed thoroughly to remove blood clots after all bleeders have been tied. If the horizontal elliptical incision is closed as is, it will frequently produce a "dog ear" of tissue directly beneath the axilla which will be cosmetically unsightly as well as functionally irritating from constant rubbing against the medial part of the upper arm. This "dog ear," about 4 to 5 cm. long, is resected before closure, which carries the incision posterior to the posterior axillary line but cinches up the tissue sufficiently to provide a flat scar that is acceptable and out of the way of usual feminine attire. Plastic suction catheters are placed medially and laterally. The amount of fluid aspirated through these after operation is recorded each day, and catheters are removed on the fifth day if the aspirate is minimal, or somewhat later if fluid production continues. Postoperatively, patients are allowed full range of motion and are seen by physiotherapists before discharge, to ensure proper shoulder motion. Patients are usually discharged on the sixth day but are seen 1 week later for assessment of fluid accumulation. Any fluid present is removed by repeated needle aspiration. Only rarely is the persistence of fluid such as to require open drainage. Radiation therapy is utilized only to reduce local recurrences in selected high-risk groups defined by pathologic findings. These groups are: (1) diffuse carcinoma with extensive lymphatic permeation, (2) stage A (CCC*) cases with more than three lymph nodes involved by metastases in the axilla, and (3) stage B (CCC) cases where any axillary metastases are recorded. ·Columbia Clinical Classification
318
BLAKE CADY
Patients with stage C (CCC) disease are not operated on until the completion of preoperative radiation therapy and complete reassessment of occult metastatic disease after a 6 to 8 week delay period by the usual methods as well as by total body bone scan. Our definition of stage C includes all cases with primar lesions more than 6 cm. in dia--r. tl izing preoperative ra iation therapy in t is group at high risk for local recurrence provides excellent protection. In fact, the majority of these patients never come to surgery because either their tumor entirely disappears or they have evidence of metastatic disease if carefully assessed.
REFERENCES 1. Cady, B.: Changing patterns of breast cancer. Arch. Surg. 104:266-269 (March) 1972. 2. Cady, B.: Modern management of breast cancer: a point of view. Arch. Surg. 104:270-275 (March) 1972. 3. Wynder, E.L.: Identification of women at high risk for breast cancer. Cancer 24:1235-1240 (Dec.) 1969. Lahey Clinic Foundation 605 Commonwealth Avenue Boston, Massachusetts 02215
Total Mastectomy and Partial Axillary Dissection
Blake Cady, M.D.
The standard operative procedure at the Lahey Clinic Foundation for carcinoma of the breast in stages A and B is, currently, total mastectomy and partial axillary dissection. The rationale for this has been described!' 2 and results chiefly from two factors: the decreasing size and much reduced axillary nodal involvement of carcinoma of the breast seen in the United States in recent years, and the realization that nodal involvement and local recurrence, while possibly creating problems in management, have little, if any, control over eventual patient survival and thus do not warrant excessive surgical measures for prevention during a period of decreasing incidence. Advances in the field of carcinoma of the breast in the near future will undoubtedly hinge on advances in tumor and host immunology in terms of predictive indexes by immunologic testing and development of immunologic alterations of disease course. In addition, greater appreciation of the concept of "risk factors"3 and perfection of early diagnostic techniques will lead to treatment of still earlier cancers, while further exploration of the usefulness and long-term results of local excision with or without radiation therapy may, in the future, alter drastically our currently "modern" concepts of proper therapy. Until much longer follow-up data about ultraconservative surgery and radiation are obtained, however, it is necessary to update our standard surgical approaches, as enough current information is available to indicate full confidence in muscle-preserving operations that also remove lower axillary lymph nodes for prognostic and therapeutic goals.
PROCEDURE Standard draping is utilized, with the arm wrapped and free for ease in moving the shoulder if necessary. Only horizontal elliptical incisions are utilized, to avoid unsightly vertical scars near the clavicle and shoulder (Fig. IA). These elliptical incisions may be shifted upward or downward to provide an adequate margin about biopsy incisions. Biopsy Surgical Clinics of North America- VoL 53, No.2, April 1973
313
314
BLAKE CADY
~~~ ~ /--"\ _\0~ ~ A
Usual
/
s~in incision
B
c Figure 1. A, Usual horizontal incision. The ellipse may be shifted up or down to accommodate lesions that are superior or inferior in the breast. B, Forceful vertical traction on the skin edge combined with vigorous downward traction by the surgeon's left hand displays the subcutaneous fascia. Knife dissection including this subcutaneous fascia with the breast specimen is then accomplished by extended knife motions with "feathering" of the knife blade. C, The pectoral fascia is dissected off the pectoralis muscle sharply so that bare muscle remains. The pectoral fascia best defines the deep extent of breast tissue.
incisions are always placed in such a way as to allow easy incorporation within a subsequent mastectomy incision. Thus, they are as central and as near the horizontal axis as is possible. Many biopsy incisions can be avoided completely by the use of needle aspiration biopsy (performed in the office) of all suspected carcinomas or discrete breast masses. Two thirds of all breast carcinomas have been proved pathologically before the patient enters the hospital, through my use of such aspiration techniques. By means of such office needle aspiration, considerable operating room time is saved. No inappropriate mastectomies from false-positive readings of the aspirate cytology have been encountered with our close association with the Laboratory of Pathology at the New England Deaconess Hospital. Obviously a "negative" breast aspiration cytology means nothing, and in the absence of gross cystic disease and cyst flUid, all breast masses are biopsied if aspirate cytology gives negative results. The intended elliptical incision is scored on the skin by knife blade without penetrating the dermis. In this way, no blood loss is incurred while a row of triple hook clamps is placed at 2 cm. intervals along the entire length of the upper side of the outlined incision. Then, with ex-
TOTAL MASTECTOMY AND PARTIAL AXILLARY DISSECTION
315
tremely vigorous upward retraction on groups of three triple hooks by the assistants combined with forceful countertraction by the operator on the specimen side of the incision, the dermis is cut through. With continued forceful retraction, the subcutaneous fascia is placed on the stretch and displayed. This stretched fascia is used as a guide to dissection so that with wide continuous knife motions, this fascia is included with the specimen as it is followed to the usual limits of mastectomy dissection (Fig. IB). By utilizing the knife blade as both cutting edge and an angled, beveled, scraping edge, the ramifications of the dissected fascia can be accommodated most easily. This "feathering" of the knife blade between strictly "on edge" cutting and sharply angled scraping permits unusual versatility in such long sweeping knife motions for flap dissections. The pectoralis fibers just below the clavicle, the midline presternal fascia, the rectus abdominis fascia at the costal margin, the serratus anterior fascia along the anterolateral chest, and the latissimus fibers laterally serve as the usual landmarks of the extent of dissection of flaps. The triple hook clamps are shifted to the lower flap skin edge as the means of obtaining vigorous retraction after completion of the upper flap. After development of the flaps, which with the help of vigorous retraction can be done quite rapidly, a row of hemostats is placed at 2 cm. intervals across the entire medial edge of the incised pectoral fascia. Clustering the handles of these clamps between the fingers of the surgeon's left hand for forceful upward traction, the entire pectoral fascia with its extension across the serratus anterior laterally is dissected off sharply with the same feathering knife motions (Fig. 1 C). A completely bare muscle surface should remain after such dissection; if filamentous sheets of gray fascia cover the muscle, it indicates incomplete removal of fascia, and, of course, if lobules of fat remain, this indicates that none of the pectoral fascia was removed. Complete stripping of the pectoral fascia is important since this tissue most clearly defines the deepest limits of breast tissue. Additionally, flap adherence to muscle is more rapid, and postoperative problems of fluid accumulation are decreased. As the pectoral fascia is stripped off muscle from medial to lateral, the separation becomes easier near the lateral border of the pectoralis major muscle. At this point, the weight of the breast simplifies retraction, and the fascial attachment to muscle is less. When the actual rolled edge of pectoralis major is defined, blunt dissection beneath the fascia is possible, exposing the interpectoral area and the fascia overlying the pectoralis minor. This, in turn, is incised in the depth of the interpectoral area and sharply stripped laterally while the pectoralis major is retracted medially and upward. About two thirds of the distance up the lateral edge of the pectoralis minor a small cluster of nerves and vessels, which supply the pectoralis major, are encountered (Fig. 2A). These are carefully preserved by dividing the laterally directed tiny veins and reflecting the small vessels and nerves medially. As this fascial dissection continues just below the pectoralis minor, the fibers of the serratus anterior are seen. At this point, a finger may be inserted and directed posteriorly between the serratus fibers medially and the axillary packet of fat and lymphatic structures surrounded by deep fascia laterally. The entire medial
316
BLAKE CADY
Nerve supply to Pect. mojo m.
Figure 2. A, Demonstration of the completed mastectomy and final steps in partial axillary resection. The axillary "packet" of fat and lymphatic tissue runs toward the axillary apex beneath the pectoralis minor muscle. The anatomic limits of this axillary packet are displayed. B, A clamp is placed across the thin wedge of axillary tissue at the level of the mid pectoralis minor muscle. This tissue is divided and tied to prevent lymphatic leakage and defines the medial extent of the partial axillary dissection. C, A demonstration of the small amount of residual axillary lymphatic tissue remaining after completion of the partial axillary dissection. Approximately 2 to 3 cm. separates the fingertips, one on the tie at the upper end of the axillary resection and one at the junction of the clavicle and the first rib marking the extreme apex of the axilla or the usual medial extent of a radical axillary dissection.
surface of this axillary packet is separated easily by blunt finger dissection. At the bottom of this cleavage lies the long thoracic nerve, and it can be dissected out of the fascia sharply and carefully preserved as it lies just anterior to the subscapular muscle (Fig. 2A). Attention to the superior dissection of this axillary packet is focused on sharp dissection of the fascial and adipose tissue overlying the axillary vein. No attempt is made to strip the vein closely, and areolar tissue is deliberately left in place for protection of the vein. All venous tributaries are carefully exposed, clamped, cut, and ligated promptly to prevent inadvertent tearing of the axillary vein. Just below the vein, the subscapular ves-
TOTAL MASTECTOMY AND PARTIAL AXILLARY DISSECTION
317
sels and the adjoining thoracodorsal nerve are exposed (Fig. 2A). The axillary lymphatic packet, surrounded by the thin deep fascia, is carefully stripped from the anterior surface of the subscapular vessels and thoracodorsal nerve. This entire process is feasible with forceful medial and upward retraction of both pectoral muscles (Fig. 2A). What remains now is the axillary packet, separated medially from the chest wall and superiorly from the axillary vein, posteriorly from the subscapular muscle, thoracodorsal, and long thoracic nerve, but attached to the residual axillary apex tissue (Fig. 2A). This thin wedge of the lymphatic-rich axillary tissue is clamped, divided, and tied with appropriate caution to avoid the long thoracic nerve which lies at the extreme posterior aspect (Fig. 2B). The ligature prevents excessive lymphatic leakage postoperatively. The level of this axillary lymphatic division is the mid pectoralis minor. After this lymphatic division, and by replacing structures in their normal alignment, one can demonstrate that the only axillary tissue remaining is the extreme apex, a small 2 cm. to 3 cm. cone of tissue no longer than the distal one half of the fifth finger (Fig. 2C). The average number of lymph nodes dissected out of this excised axillary packet by the pathology department is 20, which substantiates the extensive lymphatic resection. The specimen is rapidly cleared from the anterior border of the latissimus muscle and the attachments to the lower serratus fibers. The field is washed thoroughly to remove blood clots after all bleeders have been tied. If the horizontal elliptical incision is closed as is, it will frequently produce a "dog ear" of tissue directly beneath the axilla which will be cosmetically unsightly as well as functionally irritating from constant rubbing against the medial part of the upper arm. This "dog ear," about 4 to 5 cm. long, is resected before closure, which carries the incision posterior to the posterior axillary line but cinches up the tissue sufficiently to provide a flat scar that is acceptable and out of the way of usual feminine attire. Plastic suction catheters are placed medially and laterally. The amount of fluid aspirated through these after operation is recorded each day, and catheters are removed on the fifth day if the aspirate is minimal, or somewhat later if fluid production continues. Postoperatively, patients are allowed full range of motion and are seen by physiotherapists before discharge, to ensure proper shoulder motion. Patients are usually discharged on the sixth day but are seen 1 week later for assessment of fluid accumulation. Any fluid present is removed by repeated needle aspiration. Only rarely is the persistence of fluid such as to require open drainage. Radiation therapy is utilized only to reduce local recurrences in selected high-risk groups defined by pathologic findings. These groups are: (1) diffuse carcinoma with extensive lymphatic permeation, (2) stage A (CCC*) cases with more than three lymph nodes involved by metastases in the axilla, and (3) stage B (CCC) cases where any axillary metastases are recorded. ·Columbia Clinical Classification
318
BLAKE CADY
Patients with stage C (CCC) disease are not operated on until the completion of preoperative radiation therapy and complete reassessment of occult metastatic disease after a 6 to 8 week delay period by the usual methods as well as by total body bone scan. Our definition of stage C includes all cases with primar lesions more than 6 cm. in dia--r. tl izing preoperative ra iation therapy in t is group at high risk for local recurrence provides excellent protection. In fact, the majority of these patients never come to surgery because either their tumor entirely disappears or they have evidence of metastatic disease if carefully assessed.
REFERENCES 1. Cady, B.: Changing patterns of breast cancer. Arch. Surg. 104:266-269 (March) 1972. 2. Cady, B.: Modern management of breast cancer: a point of view. Arch. Surg. 104:270-275 (March) 1972. 3. Wynder, E.L.: Identification of women at high risk for breast cancer. Cancer 24:1235-1240 (Dec.) 1969. Lahey Clinic Foundation 605 Commonwealth Avenue Boston, Massachusetts 02215