From radical to nipple sparing mastectomy: Techniques, indications and safety

Abstract

The role of surgery in the management of breast cancer has continuously evolved over the last 100 years. William Halsted pioneered in breast cancer management by establishing that the primary goal of surgery was to treat the disease and prolong survival by containing the loco-regional spread with radical resections; his radical mastectomy was widely used for almost 100 years. Thanks to the results of well-designed randomized control trials that began in the 1970s, the treatment goal for the management of breast cancer shifted in a different direction, and the role of surgery altered dramatically. As a result, the extreme “one size fits all” radical mastectomies were gradually replaced by a more “tailor-made” less invasive modified technique, but without compromising the prognosis and survival. Eventually, the correct and timely resection of the tumour in a way that minimized morbidity, without causing unnecessary harm and burden to the patient, became the basic goal of breast surgery. Conservation of the breast and acceptable cosmesis became the main purpose of breast surgery and the gold standard for early stage breast cancer. Notwithstanding, approximately 20-30% of women with breast cancer undergo mastectomy. Nevertheless, the face of mastectomy has altered during the last three decades and what used to be a simple, and unfortunately often mutilating removal of the cancerous breast lesion, has become a sophisticated, often technically demanding, and definitely quality-of-lifeoriented part of the multidisciplinary process. In this review, we present the historical evolution of mastectomy while analyzing the indications, technical points and safety of each approach. In the “Halsted” radical mastectomy, the breast was removed along with the overlying skin and both pectoralis muscles, together with complete en bloc resection of the regional lymph nodes. In the 1940s, a less radical procedure was proposed by Patey: a modification of the radical mastectomy where the pectoralis major was preserved, followed a few years later by a less radical approach that preserved both pectoral muscles. This modified technique subsequently became the gold standard procedure in the USA in the 1970s and remains, to date, the current conventional form of mastectomy. In the 1950s, silicone implants were introduced to breast surgery. Given the prolonged survival for many patients, breast reconstruction became a reality. In 1991, Toth and Lambert described a new form of mastectomy (the skin sparing mastectomy) where the breast was removed from well-planned incisions in a way that most of the skin, particularly the inframammary fold, was preserved in order to allow immediate reconstruction and better cosmetic results. Eventually, a new form of SSM where the nipple areola complex (NAC) was also preserved emerged as a surgical option in order to further improve the cosmetic outcome of mastectomy in selected patients. In conclusion, mastectomy still remains necessary for a high percentage of breast cancer patients, though radical mastectomy is rarely used nowadays. The main indications for mastectomy are extensive or multicentric disease, contraindication, failure or recurrence after breast conserving surgery (BCS), locally advanced and inflammatory cancer, risk reduction, and if the patient so chooses. Skin-sparing mastectomy is a safe option offering better cosmetic results for patients with an indication for mastectomy and immediate reconstruction, provided that the skin is not involved and there is no inflammatory cancer. Nipple-sparing mastectomy can be applied safely in carefully selected patients, providing them with even better cosmetic results. Riskreducing mastectomy should be performed when indicated in a way that provides the patient optimal quality of life.