Modified Radical Mastectomy and Simple Mastectomy

Abstract

Introduction: The surgical techniques used in mastectomy are in constant evolution because of advancement in knowledge and the needs of patients.

Methodology: Literature review of different types of mastectomy.

Results: Halsted radical mastectomy (RM), the first effective surgery in treating breast cancer, was later modified by Patey, Madden, and others to preserve the pectoralis major muscle. Studies showed comparable survival outcomes between the two types of mastectomy. The modified radical mastectomy (MRM) became the standard treatment for women with stage I and II breast cancer in the 1970s. However, the axillary lymph node dissection (ALND), a part of modified radical mastectomy, was associated with significant side effects. Hence, the simple mastectomy (SM) was developed to spare the ALND and focus on treating the local disease only. Studies showed that survival after SM with or without radiation was comparable to those with RM.

Recently, adjuvant systemic treatment has been shown to significantly improve disease-free and overall survival in patients with node-positive breast cancer, which requires nodal staging to guide therapy. Sentinel lymph node biopsy (SLNB) was invented to provide adequate pathologic nodal status in clinically negative axilla. Today, SM coupled with SLNB has largely replaced the MRM.

Additional modifications to mastectomy by sparing the skin and the nipple areolar complex further increased its popularity.

Discussion: The evolution of surgical treatment of breast cancer is governed by the principles of controlling the local disease and providing adequate pathology with minimal adverse effects. The validity of any new procedure requires confirmation.

Keywords

modified radical mastectomy, simple mastectomy, contralateral prophylactic mastectomy, prophylactic mastectomy, irradiation

Modified Radical Mastectomy

Historical Evolution of the Surgical Technique

The rationale for the Halsted radical mastectomy was largely to achieve local and regional control of the breast cancer. The mastectomy techniques invented by Halsted’s predecessors in surgery and pathology allowed him to achieve unprecedented success in obtaining this objective without the availability of irradiation or chemotherapy. The techniques now known as the Halsted radical mastectomy and the modified radical mastectomy are an evolution of these methods, which used varying degrees of breast extirpation and lymphatic dissection ( Table 31.1 ).

TABLE 31.1

Historical Development of Modified Radical Mastectomy

Study	Year	Surgery
Moore ^a	1867	Segmental breast resection, selective axillary dissection
Volkmann ^b	1875	Total breast extirpation, with removal of pectoralis major fascia, preservation of pectoralis major muscle
Gross ^c	1880	Total mastectomy and complete axillary dissection
Banks ^d	1882	Modified radical mastectomy, with pectoralis preservation
Sprengel ^e	1882	Total mastectomy and selective axillary dissection
Kuster ^f	1883	Total mastectomy and routine axillary dissection
Halsted ^g	1894	Radical mastectomy
Meyer ^h	1894	Radical mastectomy
Murphy ⁱ	1912	Radical mastectomy, modified by pectoralis preservation
McWhirter ^j	1948	Modified radical mastectomy with radiotherapy
Patey ^k	1948	Modified radical mastectomy with resection of pectoralis minor
Madden ^l	1965	Modified radical mastectomy with pectoralis preservation

a Data from Moore CH. On the influence of inadequate operations on the theory of cancer. R Med Chir Soc Lond. 1867;1:244.

b Data from Volkmann R. Geschwülste der mamma (36 Fälle) Beitrage zur Chirurgie. Leipsig; 1895:310.

c Data from Gross SW. A Practical Treatment of Tumors of The Mammary Gland Embracing Their Histology, Pathology, Diagnosis and Treatment. New York: Appleton; 1880.

d Data from Banks WM. On free removal of mammary cancer with extirpation of the axillary glands as a necessary accompaniment. BMJ. 1882;2:1138.

e Data from Sprengel.

f Data from Küster E. Zur behandlung des brustkrebses verhandlungen der deutschen gesellschaft für Chirurgie. Leipsig; 1883:288.

g Data from Halsted.

h Data from Meyer.

i Data from Murphy.

j Data from McWhirter.

k Data from Patey and Dyson and Patey.

l Data from Madden et al. and Madden.

In contrast to the Halsted radical mastectomy, the modified radical mastectomy defines a surgery of complete breast removal, with the inclusion of the tumor, overlying skin, and axillary lymphatics, with preservation of the pectoralis major muscle. Preservation of the pectoralis major muscle provides for better cosmesis of the chest wall.

In 1894, Halsted and Meyer independently reported their individual techniques for the successful therapy of breast carcinoma with radical mastectomy. The initial clinical experience by Halsted suggested that the pectoralis major muscle was removed concomitantly with the axillary node dissection. The pectoralis minor muscle was transected only for technical expediency during the axillary dissection and was thereafter reapproximated to close the posterior superior axillary space. Soon after, however, Halsted advocated Meyer’s concept of the routine resection of both muscles. This method, once advocated by both Halsted and Meyer, became the state-of-the-art operative procedure for decades in treating cancer of the breast.

However, both American and British surgeons began to develop more conservative procedures. By 1912, Murphy had abandoned the Halsted radical mastectomy in favor of preserving both pectoral muscles. This practice was based on the experiences of Bryant of London, who acknowledged only one case of recurrent breast carcinoma in the pectoral muscles in patients followed over a 40-year clinical review period. Furthermore, the practice by Grace to perform only the simple mastectomy in certain patients went unchallenged until the widely acclaimed reports of the modified radical mastectomy by McWhirter, Patey and Dyson, and Patey in the 1940s. This paradigm shift to focus on surgery with muscle preservation has continued since the 1960s. In 1972, 30% of patients with breast cancer were treated with modified radical mastectomy and 50% with radical mastectomy. By 1981, only 3% received radical mastectomy, and 73% had modified radical mastectomy. The Consensus Development Conference on the treatment of breast cancer in 1979 stated that the modified radical mastectomy was the standard of treatment for women with stages I and II breast cancer during that period of time. Any other local or regional treatment developed thereafter must be compared with results of modified radical mastectomy.

Retrospective Studies of the Modified Radical Mastectomy

Multiple retrospective clinical studies were conducted to evaluate the survival outcomes after modified radical mastectomy and are summarized in Table 31.2 . These series clearly demonstrated that the rate of survival decreased as the tumor size increased and the lymph node metastases became evident. In these nonrandomized, retrospective studies, there appeared to be no survival benefit obtained by a complete axillary dissection to include level 3 nodes or removal of the pectoralis minor muscle (Patey vs. Auchincloss-Madden techniques). Although a rigorous statistical comparison was not applied, the survival rates at 5 and 10 years after the modified radical mastectomy were clearly affected by the initial stage of the disease (i.e., stage I vs. stage II), and the survival rates deteriorated with longer follow-up.

TABLE 31.2

Results of Retrospective Clinical Trials of Patients Treated With Modified Radical Mastectomy Alone ^a

Study	Location/Affiliation	Technique	No. of Patients	Disease Stage	ABSOLUTE SURVIVAL (%)
Study	Location/Affiliation	Technique	No. of Patients	Disease Stage	5-yr	10-yr
Handley Thackray, 1969 ^b	United Kingdom	Patey	77	I	75	61
			58	II	57	25
Delarue, 1969 ^c,d	Toronto	Madden	75	I	61.8	—
			25	II	51.4	—
Madden, 1972 ^e,f	New York City	Madden	94	I	81.6	63
				II	32.4	17
Robinson, 1976 ^g	Mayo Clinic	Madden	280	I	81	—
				II	54	—
Meyer, 1978 ^h	Rockford, Illinois	Madden	175	I–III	74	43
Baker, 1979 ^d,i	Johns Hopkins University	Patey	91	I	90	—
			22	II	72	—
			31	III	45	—
Leis, 1980 ^j,k	New York Medical College	Patey	397	I	—	72.2
			333	II	—	40.2
Nemoto, 1980 ^d,l	American College of Surgeons	Mixed	8906	I	65.1	—
			7832	II	35.1	—
Hermann, 1985 ^d,m	Cleveland Clinic	Madden	358	I	73	56
			211	II	55	28

a Includes some patients treated with radical mastectomy with equivalent results.

b Data from Handley RS, Thackray AC. Conservative radical mastectomy (Patey’s operation). Ann Surg . 1969;170:880.

c Data from Delarue NC, Anderson WD, Starr J. Modified radical mastectomy in the individualized treatment of breast carcinoma. Surg Gynecol Obstet. 1969;129:79.

d TNM classification.

e Data from Madden et al.

f Manchester classification.

g Data from Robinson et al.

h Data from Meyer et al.

i Data from Baker et al.

j Data from Leis HP Jr. Modified radical mastectomy: definition and role in breast cancer surgery. Int Surg. 1980;65:211.

k Columbia Clinical Classification.

l Data from Nemoto T, Vana J, Bedwani RN, et al. Management and survival of female breast cancer: Results of a national survey by the American College of Surgeons. Cancer. 1980;45:2917.

m Data from Hermann RE et al.

Further analysis of these series also demonstrated survival rates for operable breast cancer as a function of the status of the axillary lymph nodes at the time of modified radical mastectomy ( Table 31.3 ). Survival was not only inversely related to the presence of a positive lymph node but also decreased proportionate to the number of positive lymph nodes. Similarly, the local and regional recurrence rates after modified radical mastectomy were affected by the stage of disease at the time of treatment ( Table 31.4 ).

TABLE 31.3

Five- and 10-Year Survival Rates as a Function of Axillary Nodal Status After Modified Radical Mastectomy

Study and Year	Clinic or Study Group	No. of Patients	SURVIVAL RATE FOR PATIENTS WITH NEGATIVE NODES		SURVIVAL RATE BY NUMBER OF POSITIVE NODES
			SURVIVAL RATE FOR PATIENTS WITH NEGATIVE NODES		ANY		1–3		≥4
			5-yr	10-yr	5-yr	10-yr	5-yr	10-yr	5-yr	10-yr
Handley and Thackray, 1969 ^a	United Kingdom	135	75	57	61	25	NA	NA	NA	NA
Madden, 1972 ^b	New York City	94	82	63	32	17	NA	NA	NA	NA
Robinson, 1976 ^c	Mayo Clinic	339	80 ^g(93)		48 ^g(55)		61 ^g(72)		37 ^g(42)
Nemoto, 1980 ^d	American College of Surgeons	24,136	71.8		40.4		63.1–58.8 ^h		51.9–22.2 ^h
Hermann, 1985 ^e	Cleveland Clinic	564	78	62	55	28	66	41	47	25
Martin, 1986 ^f	Mayo Clinic	208	87	74	—	56	NA	NA	NA	NA

NA, Not available.

a Data from Handley RS, Thackray AC. Conservative radical mastectomy (Patey’s operation). Ann Surg 170:880, 1969.

b Data from Madden et al.

c Data from Robinson et al.

d Data from Nemoto T, Vana J, Bedwani RN, et al. Management and survival of female breast cancer: results of a national survey by the American College of Surgeons. Cancer. 1980;45:2917.

e Data from Hermann et al.

f Data from Martin JK et al. Is modified radical mastectomy really equivalent to radical mastectomy in treatment of carcinoma of the breast? Cancer. 1986;57:510.

g Determinate survival.

h Range inclusive of number of positive nodes.

TABLE 31.4

Local and Regional 5- and 10-Year Recurrence Rates of Various Sites in Retrospective Studies After Modified Radical Mastectomy

Study and Year	Clinic or Study Group	No. of Patients	Disease Stage	SITE (%)
Study and Year	Clinic or Study Group	No. of Patients	Disease Stage	Chest Wall Scar or Operative Field	Axilla
Delarue, 1969 ^a	Toronto General ^g(Canada)	43	I	0	0
		32	II	12.5	—
		25	III	15	—
Madden, 1972 ^b	New York City ^h	94	I–III	10	0
Handley, 1976 ^c	United Kingdom ^h	77	A ⁱ	10	1.8
		58	B	22.6	0.1
		8	C	63.6	9.1
Baker, 1979 ^d	Johns Hopkins ^g	91	I	13.2	1.1
		22	II	9.1	4.5
		31	III	22.6	22.6
Leis, 1980 ^e	New York Medical College ^h	116	0	0	0
		397	I	5	0.08
		333	II	13.8	0.08
Crowe, 1991 ^f	Case Western	917	LN–	6.5	2.7
		475	LN+	9	8.4

LN–, Lymph node negative; LN+, Lymph node positive.

Staging is TNM unless otherwise noted.

a Data from Delarue NC, Anderson WD, Starr J. Modified radical mastectomy in the individualized treatment of breast carcinoma. Surg Gynecol Obstet. 1979;129:79.

b Data from Madden et al.

c Data from Handley.

d Data from Baker et al.

e Data from Leis HP Jr. Modified radical mastectomy: definition and role in breast cancer surgery. Int Surg. 1980;65:211.

f Data from Crowe JP et al.

g Five-year recurrence rates.

h Ten-year recurrence rates.

i Columbia Clinical Classification.

Support for limiting the level of lymph node dissection was demonstrated by Madden and colleagues using the Auchincloss technique, which questioned the need to completely dissect the axillary contents. Madden et al. reported a local recurrence rate of 10%. Auchincloss found that the apical nodes (level 3) should be removed if clinically involved because of the high rate of recurrence if these nodes were found to be positive and not subsequently removed. However, if these level 3 nodes were clinically negative, complete axillary dissection was unnecessary because mastectomy with excision of levels 1 and 2 and pectoralis preservation had control and survival rates identical with more radical approaches. Furthermore, if Rotter nodes were not involved, clearance of these interpectoral nodes was found to be unnecessary. Further retrospective studies by Dahl-Iversen and Tobiassen, Handley, Hermann, and Nemoto and Dao confirmed similar survival results between the classic radical mastectomy and the modified radical mastectomy and that these two procedures were equal in the recovery of axillary lymph nodes.

Baker and associates of Johns Hopkins University compared the results of modified radical mastectomy with radical mastectomy in the treatment of operable breast cancer. For 205 patients with stage I cancer, 60 with stage II disease, and 67 with stage III disease (based on the tumor, node, metastasis [TNM] system), there were no statistically significant differences in 5-year survival when the results of the radical mastectomy were compared with those of the modified radical mastectomy. Furthermore, no statistically significant differences in incidence of locoregional recurrence were evident in patients with stages I and II disease when the results of the two surgical procedures were compared. In contrast, individuals with stage III disease treated with modified radical mastectomy had a statistically significant ( p = . 002) higher incidence of local recurrence (chest wall and axilla) compared with patients treated with radical mastectomy. Baker and colleagues concluded that modified radical mastectomy is the treatment of choice in patients with TNM stages I and II disease. For patients with stage III disease, the radical mastectomy provided a greater probability of locoregional control of disease but did not enhance survival.

Crowe and coworkers reported a 16-year experience of locoregional recurrence in a series of 1392 patients treated for operable breast cancer with modified radical mastectomy. They found that most cases of locoregional recurrence occurred within the first 3 years of treatment. Among patients with locoregional recurrence, distant metastases had developed in 64%. Large size of tumor and positive nodes were associated with rapid, locoregional recurrence. Furthermore, the incidence of developing distant failure was associated with the time of locoregional recurrence. In summary, the size and nodal status of the original cancer, as well as the length of the locoregional disease-free interval, were found to directly affect the likelihood of developing metastasis.

These and other observations support the conclusion that extirpation of the pectoralis major muscle is not essential to provide locoregional control of stages I and II disease (Columbia Clinical Classification A and B). It must be noted that neither procedure was adequate for achieving locoregional control of TNM stage III breast cancer or Columbia Clinical Classification C and D tumors (see Section XV). In properly selected patients with stages I and II disease, these retrospective analyses for the modified radical procedure show survival and control rates comparable to the more radical procedure. Chapters 50 and 51 contain comprehensive discussion of local, regional, and systemic complications that may ensue with the modified radical mastectomy.

Prospective Trials for the Modified Radical Mastectomy

During the 1970s, two prospective randomized trials by Turner in Manchester, England, and by Maddox at the University of Alabama, Birmingham, compared the Halsted radical mastectomy with the modified radical mastectomy. The study by Turner and associates consisted of 534 patients with T ₁or T ₂(N ₀or N ₁) carcinoma of the breast and demonstrated that after a median follow-up of 5 years, there was no significant difference in disease-free survival, overall survival, or locoregional control rates ( Table 31.5 ).

TABLE 31.5

Manchester Trial Results: Overall Survival, Disease-Free Survival, and Local and Distant Disease-Free Survival Rates (%) for Radical and Modified Radical Mastectomy According to Clinical and Pathologic Stage at Entry

	No. of Patients Followed Up	Overall Survival (5-yr)	Disease-Free Local Recurrence (5-yr) ^a	Disease-Free of Distant Metastases (5-yr) ^a	Overall Disease-Free Survival (5-yr) ^a
All Cases
Radical	278	70	75	63	58
Modified	256	70	79	63	58
Clinical Stage I
Pathologic Stage I
Radical	119	80	85	79	69
Modified	108	79	90	79	71
Pathologic Stage II
Radical	52	57	57	52	39
Modified	49	62	74	62	57
Clinical Stage II
Pathologic Stage I
Radical	41	85	91	79	79
Modified	38	78	88	71	70
Pathologic Stage II
Radical	64	55	59	47	38
Modified	59	55	56	45	30

From Turner L, Swindell R, Bell WG, et al. Radical versus modified radical mastectomy for breast cancer. Ann R Coll Surg Engl. 1981;63:239-243.

a Figures indicate the percentages of patients not experiencing each event regardless of any other outcome.

The study by Maddox and associates compared modified radical mastectomy with radical mastectomy in 311 patients with stages I to III breast cancers. Patients with positive lymph nodes were randomized to receive chemotherapy. Results of this study demonstrated no significant difference in the 5-year disease-free survival rate but did show a significant decrease in local recurrence rates after the radical mastectomy ( Table 31.6 ). A trend toward improved overall survival after radical mastectomy versus modified radical mastectomy was evident after 5 years (84% vs. 76%, respectively) and became more evident after 10 years (74% vs. 65%, respectively; Fig. 31.1 ). Although there was no significant difference in the overall survival rate between the procedures in patients with smaller cancers, the ultimate survival rate for patients with T ₂or T ₃tumors was significantly better after the radical mastectomy ( Fig. 31.2 ).

TABLE 31.6

University of Alabama Prospective Randomized Trial to Compare the Halsted Radical Mastectomy With the Modified Radical Mastectomy: Local Recurrence Rates of the Two Techniques

Disease Stage	MODIFIED RADICAL MASTECTOMY						HALSTED RADICAL MASTECTOMY
	No. of Patients	%	LOCAL RECURRENCE				No. of Patients	%	LOCAL RECURRENCE
			5-yr		10-yr				5-yr		10-yr
			n	%	n	%			n	%	n	%
I	43	13.8	4	9.3	NA	NA	37	11.9	2	5.4	NA	NA
II	112	36	8	7.1	NA	NA	83	26.7	3	3.6	NA	NA
III	20	6.4	4	20 ^a	NA	NA	16	5.1	1	6.3 ^a	NA	NA
Total	175	56.2	16	9.1 ^b	20	11.4 ^c	136	43.7	6	4.4 ^b	8	5.8 ^c

NA, Not available.

Modified from Maddox WA, Carpenter JT Jr, Laws HL, et al. A randomized prospective trial of radical (Halstead) mastectomy versus radical modified mastectomy in 311 breast cancer patients. Ann Surg. 1983;198:207-212; and Maddox WA, Carpenter JT Jr, Laws HL, et al. Does radical mastectomy still have a place in the treatment of primary operable breast cancer? Arch Surg. 1987;122:1317-1320.

a p = nonsignificant.

b p = .09.

c p = .04.