30 - General Principles of Mastectomy: From Halsted Radical Mastectomy and Modified Radical Mastectomy to Total (Simple) Mastectomy

Abstract

This chapter describes the evolution of breast cancer ideology and treatment, which resulted in advancement from the radical mastectomy to total (simple) mastectomy. The Halsted radical mastectomy, the first effective surgery in treating breast cancer, is now limited to treatment of locally advanced disease involving the pectoralis muscles. This technique was modified by Patey, Madden, and others as the modified radical mastectomy (MRM) to preserve the pectoralis major muscle and limit the degree of axillary lymph node dissection (ALND). Studies have shown comparable survival outcomes between the two types of mastectomy. The MRM became the standard treatment for women with stage I and II breast cancer in the 1970s; however, ALND was associated with significant side effects. The total mastectomy (TM) was developed to be utilized with less extensive nodal surgery, especially in patients with noninvasive breast cancer in order to focus on treating the local disease only. Evidence has demonstrated that survival rates after TM with or without radiation therapy are comparable to radical mastectomy. Adjuvant systemic treatment has been shown to significantly improve disease-free and overall survival in many patients with breast cancer depending on stage and subtype. Sentinel lymph node biopsy (SLNB) was developed to provide pathologic nodal assessment in patients with a clinically negative axilla. Today, TM coupled with SLNB has largely replaced the MRM. The technique of each type of mastectomy is described.