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Total mastectomy with axillary dissection
Total Mastectomy with Axillary Dissection A Modified Radical Mastectomy
Daniel F. Roses, MD,* New York, New York Matthew N. Harris, MD, New York, New York Stephen L. Gumport, MD, New York, New York
Until recently, the classic radical mastectomy was generally regarded as the procedure of choice for operable carcinoma of the breast. However, dissatisfaction with the morbidity and patients’ concern about resulting cosmetic deformity prompted many surgeons to seek a different approach without compromising the scope of a “cancer operation.” A modification of this procedure which preserves the pectoralis major muscle was described by Patey and Dyson [I] in 1948 and more recently by Handley and Thackray [2] and Papatestas and Lesnick[3]. One of the criticisms of these procedures has been the possible failure of adequate removal of all the lymph nodes at the apex of the axilla [4]. The present report describes a technic that we believe insures a thorough axillary lymph node dissection with preservation of the pectoralis major muscle as well as the contour of the axilla. It may also permit subsequent reconstructive surgery after an appropriate disease-free interval. Total mastectomy with complete axillary dissection is suggested for the following clinical situations: (1) clinically nonpalpable invasive breast carcinoma discovered by mammography; (2) a small primary cancer (generally less than 1.5 cm in diameter); (3) a freely movable carcinoma in the upper outer quadrant of the breast with no clinically positive axillary nodes and with no apparent involvement of the pectoralis major muscle at surgery; (4) intraductal carcinoma with minimal invasion; and (5) histologically favorable invasive lesions, such as tubular, medullary, colloid, adenoid cystic, and papillary carcinomas. The procedure has been adapted from our experience with 180 axillary lymph node dissections for melanoma and has been utilized in thirty-six patients with carcinoma of the breast to date. From the Tumor Service, Department of Surgery, New York University Medical Center, New York, New York. Reprint requests should bs addressed to Daniel F. Roses, MD, Department of Surgery, New York University Medical Center, 566 First Avenue, New York, New York 10016. Junior Faculty Clinical Fellow, American Cancer Society. l
674
Method
The methods of incision and development of the skin flaps are identical to those utilized in the usual radical mastectomy. A transverse or oblique incision with the most lateral extension below the hair-bearing area of the axilla is preferred; of course this depends upon the laation of the lesion. The flaps are raised above the level of the superficial fascia. With sharp dissection, the thin anterior fascia of the pectoral& major muscle and the overlying breast is removed, starting medially at the midsternal line and superiorly at the clavicle and continuing to the free edge of the muscle laterally and the rectus sheath inferiorly. (Figure 1.) At this point, the pectoralis major muscle is clearly identified at its insertion into the humerus. Using blunt dissection, a separation is made between the clavicular and sternal fibers of the pectoralis major muscle, which is then divided at its tendinous insertion into the humerus. The muscle is then retracted medially with the use of noncrushing clamps or stay sutures, thus exposing the lateral axillary contents. (Figure 2.) Gentle traction on the breast facilitates this exposure. The fascia overlying the axillary vein is opened, and the lower leaf of the axiilary vein sheath is swept inferiorly. The dissection is extended to the lateral border of the pectoralis minor muscle, which is divided at its insertion at the coracoid process. The pectoralis minor muscle is allowed to retract inferiorly and medially, completely exposing the remainder of the axilla. (Figure 3.) The branches of the axillary vein and artery are divided and ligated to the level of the thoracoacromial vessels and lateral pectoral nerve, which emerge medially to the pectoralis minor muscle. The lateral pectoral nerve is preserved, as it is one of the major innervations of the pectoralis major muscle. The pectoral branches of the thoracoacromial vessels may be sacrificed so that clear access can be obtained to the apex of the axilla. The apical tissue is tagged to identify this portion of the specimen for the pathologist. The axillary contents are then dissected free from the chest wall, commencing at the apex of the axilla and proceeding inferiorly. (Figure 4.) The pectoralis minor muscle is divided at its origins on the chest wall, thereby including it in the specimen along with the interpectoral fascia and Rotter’s nodes. The intercostobrachial nerve(s) is sacrificed. The long thoracic and thoracodorsal nerves are identified and usually preserved. The thoracodorsal vessels are sacrificed, and the fascia over the serratus anterior and
The American Journal of Surgery
Modified Radical Mastectomy
Clavicle
l i
Figure 1. Breast and anterior fascia of pectoral/s mabr muscie removed to free edge of muscle.
subscapularis muscles is included in the specimen. The lateral axillary tissue is also tagged for orientation of the specimen by the pathologist. After removal of the specimen and thorough irrigation of the wound, the transected sternal portion of the pectoralis major muscle is sutured to the clavicular portion of this muscle near the insertion into the humerus. (Figure 5.) The reconstruction is done without tension using O-O chromic catgut mattress sutures. This restores muscular continuity and preserves the lateral axillary contour. Large, soft Hemova@ suction catheters are placed so that they do not impinge upon any neurovascular structures. The catheters exit via lateral stab wounds. The skin is closed with interrupted 4-O Tevdek@ sutures, and a light dressing is applied. Comments Several studies present conflicting data, suggesting either success or failure in achieving an effective axillary dissection when the pectoralis major muscle is preserved in surgery for breast carcinoma. In a study by Hultborn et al [5], injections of lg8Au into the breast parenchyma and lymphography via the lymphatics of the hand were utilized to compare the effectiveness of standard mastectomy and modified radical mastectomy in clearing axillary lymph nodes. The authors concluded that complete axillary lymph node dissection was impossible without sacrificing the pectoral muscles. However, the pectoralis minor muscle was severed from the coracoid process in
voluma 134, Nommber 1977
*
7.
Figure 2. CIavicuiar and sternal &ions of pectoraiis major muscle separated and sternal portion divided.
fewer than half of the modified radical procedures used in their study. Caceres, Lingan, and Delgado [6] performed a modified radical mastectomy followed by a second stage procedure which transformed the initial operation into a radical mastectomy in fifty consecutive patients. Lymph nodes were recovered
675
Roses, Harris, and Gumport
Sternal portion ot pectoralis major muscle
Pectoralis minor muscle ‘\\
Figure 3. Pectoralis minor muscle has been divided at its insertion.
Pectoraliamajor
Thorecodonal
nerve
Longlhoracicnewe
Figure 4. Axillary contents and pectoraik minor nwsck dissected from chest wall.
in the second stage in thirty-six patients, particularly behind the pectoralis minor muscle and at the apex. They concluded that “modified” radical mastectomy was an inadequate operation for clearing the axilla. However, the “modified” procedure used in their study always preserved both pectoral muscles. Nemoto and Dao [ 71 compared the total number of
676
axillary nodes removed in a comparable series of radical and modified radical mastectomies. Their data suggested that the axillary dissection in the modified radical procedure was as complete as in a radical mastectomy. It should be emphasized that in the modified radical procedure used in their study, the pectoralis minor muscle was transected at the
The American Journal of Surgery
Modified Radical Mastectomy
Figure 5. Pectoralis major muscle reconstructed restoring axillary contour. Hemovac catheters placed and wound closed.
coracoid process. We believe that this is essential to achieve an adequate axillary dissection if the pectoralis major muscle is to be preserved and the interpectoral fascia and nodes are to be included in the specimen. The anatomic region of greatest concern to critics of the Patey type of modified radical mastectomy is the apex of the axilla, the area between the medial border of the pectoralis minor muscle and the subclavius muscle. We believe that in individual instances, when the surgeon selects a modified radical procedure to be the preferred operative therapy, division of the pectoralis major muscle between the clavicular and sternal portions greatly facilitates access to the apex. Previous descriptions of the modified radical mastectomy have not included this measure, although we have used it in axillary lymph node dissections for melanoma [8]. Further access may be achieved by flexing the shoulder joint and having an assistant hold the arm vertically so that the elbow joints upward during the dissection of the apex, as described by Chretien et al [9]. The operation described herein, when used in selected patients, encompasses the objective of total removal of the breast and the regional lymphatic network except for the communicating lymphatics coursing through the pectoralis major muscle. We believe that this operation should be referred to as “total mastectomy with complete axillary lymph node dissection.” The more frequently used term, “modified radical mastectomy,” may connote any of a wide range of procedures, all being less extensive than the standard radical mastectomy.
Vdume 134, November 1977
Summary
A technic for total mastectomy with complete axillary dissection has been described. The procedure utilizes division of the pectoralis major muscle between its clavicular and sternal portions, perservation of its innervation, and reconstruction after completion of the dissection. The pectoralis minor muscle is resected. This modification facilitates a thorough axillary dissection, particularly at the apex, while preserving the cosmetic and functional benefits of the Patey operation. References 1. Patey DH, Dyson WH: The prognosis of carcinoma of the breast in relation to the type of operation performed. l3r J Cancer 2: 71, 1948. 2. Handley RS. Thackray AC: Conservative radical mastectomy (Patey’s operation). Ann Surg 157: 182, 1963. 3. Papatestas AE, Lesnick GJ: Treatment of carcinoma of the breast by modified radical mastectomy. Surg Gynecol Obsfet 140: 22, 1975. 4. Haagensen CD: The choice of treatment for operable carcinoma of the breast. Surgery 76: 685, 1974. 5. Hultborn A, Hulten L, Roos 6, Rosencrantz M, Rosengren B, Ahren C: Effectiveness of axillary lymph node dissection in modified radical mastectomy with preservation of pectoral muscles. Ann Surg 179: 269, 1974. 6. Caceres E, Lingan M, Delgado P: Evaluation of dissection of the axilla in a modified radical mastectomy. Surg Gyneco/ O&et 143: 395.1976. 7. Nemoto T, Dao TL: Is modified radical mastectomv adeauate for axillary lymph node dissection? Ann Surg 185 722; 1975. 8. Harris MN, Gumport SL. Maiwandi H: Axillarv lvmoh node dissection for melanoma. Surg Gyneco/ bb&ei 135: 936, 1972. 9. Chretien PB, Ketcham AS, Hoye RC, Sample WF: Axillary dissection with preservation of the pectoralis major muscle. Ann surg 17: 554, 1971.
677
Daniel F. Roses, MD,* New York, New York Matthew N. Harris, MD, New York, New York Stephen L. Gumport, MD, New York, New York
Until recently, the classic radical mastectomy was generally regarded as the procedure of choice for operable carcinoma of the breast. However, dissatisfaction with the morbidity and patients’ concern about resulting cosmetic deformity prompted many surgeons to seek a different approach without compromising the scope of a “cancer operation.” A modification of this procedure which preserves the pectoralis major muscle was described by Patey and Dyson [I] in 1948 and more recently by Handley and Thackray [2] and Papatestas and Lesnick[3]. One of the criticisms of these procedures has been the possible failure of adequate removal of all the lymph nodes at the apex of the axilla [4]. The present report describes a technic that we believe insures a thorough axillary lymph node dissection with preservation of the pectoralis major muscle as well as the contour of the axilla. It may also permit subsequent reconstructive surgery after an appropriate disease-free interval. Total mastectomy with complete axillary dissection is suggested for the following clinical situations: (1) clinically nonpalpable invasive breast carcinoma discovered by mammography; (2) a small primary cancer (generally less than 1.5 cm in diameter); (3) a freely movable carcinoma in the upper outer quadrant of the breast with no clinically positive axillary nodes and with no apparent involvement of the pectoralis major muscle at surgery; (4) intraductal carcinoma with minimal invasion; and (5) histologically favorable invasive lesions, such as tubular, medullary, colloid, adenoid cystic, and papillary carcinomas. The procedure has been adapted from our experience with 180 axillary lymph node dissections for melanoma and has been utilized in thirty-six patients with carcinoma of the breast to date. From the Tumor Service, Department of Surgery, New York University Medical Center, New York, New York. Reprint requests should bs addressed to Daniel F. Roses, MD, Department of Surgery, New York University Medical Center, 566 First Avenue, New York, New York 10016. Junior Faculty Clinical Fellow, American Cancer Society. l
674
Method
The methods of incision and development of the skin flaps are identical to those utilized in the usual radical mastectomy. A transverse or oblique incision with the most lateral extension below the hair-bearing area of the axilla is preferred; of course this depends upon the laation of the lesion. The flaps are raised above the level of the superficial fascia. With sharp dissection, the thin anterior fascia of the pectoral& major muscle and the overlying breast is removed, starting medially at the midsternal line and superiorly at the clavicle and continuing to the free edge of the muscle laterally and the rectus sheath inferiorly. (Figure 1.) At this point, the pectoralis major muscle is clearly identified at its insertion into the humerus. Using blunt dissection, a separation is made between the clavicular and sternal fibers of the pectoralis major muscle, which is then divided at its tendinous insertion into the humerus. The muscle is then retracted medially with the use of noncrushing clamps or stay sutures, thus exposing the lateral axillary contents. (Figure 2.) Gentle traction on the breast facilitates this exposure. The fascia overlying the axillary vein is opened, and the lower leaf of the axiilary vein sheath is swept inferiorly. The dissection is extended to the lateral border of the pectoralis minor muscle, which is divided at its insertion at the coracoid process. The pectoralis minor muscle is allowed to retract inferiorly and medially, completely exposing the remainder of the axilla. (Figure 3.) The branches of the axillary vein and artery are divided and ligated to the level of the thoracoacromial vessels and lateral pectoral nerve, which emerge medially to the pectoralis minor muscle. The lateral pectoral nerve is preserved, as it is one of the major innervations of the pectoralis major muscle. The pectoral branches of the thoracoacromial vessels may be sacrificed so that clear access can be obtained to the apex of the axilla. The apical tissue is tagged to identify this portion of the specimen for the pathologist. The axillary contents are then dissected free from the chest wall, commencing at the apex of the axilla and proceeding inferiorly. (Figure 4.) The pectoralis minor muscle is divided at its origins on the chest wall, thereby including it in the specimen along with the interpectoral fascia and Rotter’s nodes. The intercostobrachial nerve(s) is sacrificed. The long thoracic and thoracodorsal nerves are identified and usually preserved. The thoracodorsal vessels are sacrificed, and the fascia over the serratus anterior and
The American Journal of Surgery
Modified Radical Mastectomy
Clavicle
l i
Figure 1. Breast and anterior fascia of pectoral/s mabr muscie removed to free edge of muscle.
subscapularis muscles is included in the specimen. The lateral axillary tissue is also tagged for orientation of the specimen by the pathologist. After removal of the specimen and thorough irrigation of the wound, the transected sternal portion of the pectoralis major muscle is sutured to the clavicular portion of this muscle near the insertion into the humerus. (Figure 5.) The reconstruction is done without tension using O-O chromic catgut mattress sutures. This restores muscular continuity and preserves the lateral axillary contour. Large, soft Hemova@ suction catheters are placed so that they do not impinge upon any neurovascular structures. The catheters exit via lateral stab wounds. The skin is closed with interrupted 4-O Tevdek@ sutures, and a light dressing is applied. Comments Several studies present conflicting data, suggesting either success or failure in achieving an effective axillary dissection when the pectoralis major muscle is preserved in surgery for breast carcinoma. In a study by Hultborn et al [5], injections of lg8Au into the breast parenchyma and lymphography via the lymphatics of the hand were utilized to compare the effectiveness of standard mastectomy and modified radical mastectomy in clearing axillary lymph nodes. The authors concluded that complete axillary lymph node dissection was impossible without sacrificing the pectoral muscles. However, the pectoralis minor muscle was severed from the coracoid process in
voluma 134, Nommber 1977
*
7.
Figure 2. CIavicuiar and sternal &ions of pectoraiis major muscle separated and sternal portion divided.
fewer than half of the modified radical procedures used in their study. Caceres, Lingan, and Delgado [6] performed a modified radical mastectomy followed by a second stage procedure which transformed the initial operation into a radical mastectomy in fifty consecutive patients. Lymph nodes were recovered
675
Roses, Harris, and Gumport
Sternal portion ot pectoralis major muscle
Pectoralis minor muscle ‘\\
Figure 3. Pectoralis minor muscle has been divided at its insertion.
Pectoraliamajor
Thorecodonal
nerve
Longlhoracicnewe
Figure 4. Axillary contents and pectoraik minor nwsck dissected from chest wall.
in the second stage in thirty-six patients, particularly behind the pectoralis minor muscle and at the apex. They concluded that “modified” radical mastectomy was an inadequate operation for clearing the axilla. However, the “modified” procedure used in their study always preserved both pectoral muscles. Nemoto and Dao [ 71 compared the total number of
676
axillary nodes removed in a comparable series of radical and modified radical mastectomies. Their data suggested that the axillary dissection in the modified radical procedure was as complete as in a radical mastectomy. It should be emphasized that in the modified radical procedure used in their study, the pectoralis minor muscle was transected at the
The American Journal of Surgery
Modified Radical Mastectomy
Figure 5. Pectoralis major muscle reconstructed restoring axillary contour. Hemovac catheters placed and wound closed.
coracoid process. We believe that this is essential to achieve an adequate axillary dissection if the pectoralis major muscle is to be preserved and the interpectoral fascia and nodes are to be included in the specimen. The anatomic region of greatest concern to critics of the Patey type of modified radical mastectomy is the apex of the axilla, the area between the medial border of the pectoralis minor muscle and the subclavius muscle. We believe that in individual instances, when the surgeon selects a modified radical procedure to be the preferred operative therapy, division of the pectoralis major muscle between the clavicular and sternal portions greatly facilitates access to the apex. Previous descriptions of the modified radical mastectomy have not included this measure, although we have used it in axillary lymph node dissections for melanoma [8]. Further access may be achieved by flexing the shoulder joint and having an assistant hold the arm vertically so that the elbow joints upward during the dissection of the apex, as described by Chretien et al [9]. The operation described herein, when used in selected patients, encompasses the objective of total removal of the breast and the regional lymphatic network except for the communicating lymphatics coursing through the pectoralis major muscle. We believe that this operation should be referred to as “total mastectomy with complete axillary lymph node dissection.” The more frequently used term, “modified radical mastectomy,” may connote any of a wide range of procedures, all being less extensive than the standard radical mastectomy.
Vdume 134, November 1977
Summary
A technic for total mastectomy with complete axillary dissection has been described. The procedure utilizes division of the pectoralis major muscle between its clavicular and sternal portions, perservation of its innervation, and reconstruction after completion of the dissection. The pectoralis minor muscle is resected. This modification facilitates a thorough axillary dissection, particularly at the apex, while preserving the cosmetic and functional benefits of the Patey operation. References 1. Patey DH, Dyson WH: The prognosis of carcinoma of the breast in relation to the type of operation performed. l3r J Cancer 2: 71, 1948. 2. Handley RS. Thackray AC: Conservative radical mastectomy (Patey’s operation). Ann Surg 157: 182, 1963. 3. Papatestas AE, Lesnick GJ: Treatment of carcinoma of the breast by modified radical mastectomy. Surg Gynecol Obsfet 140: 22, 1975. 4. Haagensen CD: The choice of treatment for operable carcinoma of the breast. Surgery 76: 685, 1974. 5. Hultborn A, Hulten L, Roos 6, Rosencrantz M, Rosengren B, Ahren C: Effectiveness of axillary lymph node dissection in modified radical mastectomy with preservation of pectoral muscles. Ann Surg 179: 269, 1974. 6. Caceres E, Lingan M, Delgado P: Evaluation of dissection of the axilla in a modified radical mastectomy. Surg Gyneco/ O&et 143: 395.1976. 7. Nemoto T, Dao TL: Is modified radical mastectomv adeauate for axillary lymph node dissection? Ann Surg 185 722; 1975. 8. Harris MN, Gumport SL. Maiwandi H: Axillarv lvmoh node dissection for melanoma. Surg Gyneco/ bb&ei 135: 936, 1972. 9. Chretien PB, Ketcham AS, Hoye RC, Sample WF: Axillary dissection with preservation of the pectoralis major muscle. Ann surg 17: 554, 1971.
677