Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана

CamillaGomes andJasmineM.Wong

Radical mastectomy, which refers to removal of the entire breast, chest wall muscles and full axillary lymph node dissection, prevailed for much of the twentieth century based on the observation that many patients developed local recurrence prior to manifestation of distant metastasis of death from breast cancer. This surgi­cal practice changed with the publication of several randomized controlled trials demonstrating equal survival rates in patients undergoing breast conserving surgery and patients undergoing radical or modied radical mastectomy [1–3]. One of the milestone prospective trials supporting breast conserving surgery, commonly referred to as NSABP B-04, was published in the 1980s. This trial compared radical mastectomy to less extensive surgery in patients with clinically node-negative and node-positive disease, and after 25years of follow up showed no signicant differ­ences in long-term outcomes between the clinically node-negative patients who underwent radical mastectomy and those who underwent total mastectomy with or without radiotherapy, or between the clinically node-positive patients who under­went radical mastectomy and those who underwent total mastectomy with radio­therapy [4]. In addition to several clinical trials focusing on operative management of breast cancer, we now also have increased understanding about tumor biology, as well as increased availability to targeted systemic therapies thereby improved precision.

Mastectomy is indicated in patients with inammatory breast cancer, those with multicentric disease (two or more primary tumors in separate quadrants of the breast) that would result in a poor cosmetic outcome due to too great of volume resection of the breast, those with diffuse suspicious microcalcications on mam­mography such that extent of disease is not well demarcated, or extensive non-mass enhancement on breast MRI.Additionally, those with a history of prior radiation therapy to a portion of the affected breast which would lead to high total radiation dose to that area with repeat radiation, persistently positive margins after attempts at re-excision, and for those who have large tumor extent with relation to breast size would be recommended for mastectomy. Mastectomy may also be indicated due to patient preference or for risk reduction in patients who carry a known mutation that puts them at elevated risk of developing breast cancer. Neoadjuvant chemotherapy, when indicated based on presentation with locally advanced cancer or tumor biol­ogy, can help facilitate breast conservation in patients who initially require mastec­tomy. However, if NAC does not adequately decrease tumor volume relative to the natural breast size, mastectomy may still be indicated.

sentinel lymph node biopsy or axillary dissection, include locally advanced breast cancer, multicentric breast cancer (in more than one quadrant), large tumor relative to the size of the breast such that lumpectomy would compromise nal cosmesis, extensive ductal carcinoma in situ (DCIS), or patient preference for mastectomy. Additionally, patients who are not candidates for breast-conserving therapy due to contraindication to radiation therapy may also undergo simple mastectomy. This may include those with previous history of chest wall irradiation (either after previ­ous breast-conserving therapy or for another reason such as lymphoma), those with severe skin disorders, and those with severe pulmonary dysfunction.

The incision for a SSM, which is often planned with the plastic surgeon, consists of a small ellipse, that can be oriented obliquely or vertically, or a circular incision that includes the nipple-areolar complex, depending on the location of the tumor and type of planned reconstruction. It is also important to consider the presence of scars after excisional biopsy or prior surgical intervention. One of the most critical

components of this procedure is ap dissection to be used for reconstruction. Given the oncologic nature of these resections, the goal of a skin ap is to achieve the perfect balance of total excision of the breast tissue while preserving the skin and underlying subcutaneous fat to create a well-vascularized skin envelope for subse­quent breast reconstruction. Very thin aps are associated with a higher incidence of skin necrosis, and do not increase oncological safety.

One of the most feared complications associated with SSM is ap necrosis, espe­cially in cases where reconstruction is performed with expanders and/or prosthesis, as this may cause failure of the procedure. Flap necrosis occurs when the aps are too thin, thereby devascularizing the skin aps and can lead to prolonged wound care needs, delay adjuvant therapy, compromise aesthetic results, and need for implant removal due to infection in addition to patient distress and nancial loss [5]. This risk is higher in patients who are smokers, as nicotine is a direct vasoconstric­tor that affects the skin. More commonly, infection, often presenting as a cellulitis or infection of the uid surrounding the implant, can occur post operatively and can result in the need for antibiotics (oral or intravenous), expander or implant removal, and similarly can delay adjuvant therapies and lead to additional patient distress.