mrm

Modified Radical MastectomyModified Radical Mastectomy

Pornchai OPornchai O--charoenrat MD PhDcharoenrat MD PhD

ProfessorProfessorDivision of Head, Neck & Breast SurgeryDivision of Head, Neck & Breast Surgery

SIRIRAJ HOSPITAL SIRIRAJ HOSPITAL THAILANDTHAILAND

Modified Radical Mastectomy (MRM)Modified Radical Mastectomy (MRM)

�� RationaleRationale

�� IndicationsIndications

�� TechniquesTechniques

�� Special considerations Special considerations





�� Special considerationsSpecial considerations

MastectomyMastectomy

‘‘Surgical Removal of the BreastSurgical Removal of the Breast’’

Radical mastectomyRadical mastectomy –– removal of the breast, removal of the breast, pectoralispectoralis

major and minor m. and Level Imajor and minor m. and Level I--III axillary nodesIII axillary nodes

Modified radical mastectomyModified radical mastectomy –– removal of breast and removal of breast and

Level I or Level I and II nodesLevel I or Level I and II nodes

Simple mastectomySimple mastectomy –– removal of breastremoval of breast

SkinSkin--sparing mastectomysparing mastectomy –– mastectomymastectomy with removal of with removal of

nipplenipple--areolarareolar complex, but with preservation of the complex, but with preservation of the

rest of the breast skin rest of the breast skin

NSABPNSABP--B04 StudyB04 Study

�� DDissatisfactionissatisfaction withwith resultsresults afterafter radicalradical

mastectomymastectomy

�� LLessess radicalradical surgerysurgery mightmight bebe justjust asas

effectiveeffective asas thethe moremore extensiveextensive operationsoperations

�� TTo o determinedetermine whetherwhether patientspatients whowho receivedreceived

locallocal oror regionalregional treatmentstreatments otherother thanthan

radicalradical mastectomymastectomy wouldwould havehave outcomesoutcomes

similarsimilar toto thosethose achievedachieved withwith radicalradical

mastectomymastectomy

Radical Mastectomy Offers No Radical Mastectomy Offers No

AdvantageAdvantage

Fisher et al. NEJM 2002


Advantages over radical mastectomy

� Good postoperative cosmetic appearance

� Maintain motor activity in the arm

� Low rate of postoperative arm edema

� Easy postoperative breast reconstruction


PateyPatey: removal of : removal of pectoralispectoralis minor muscle minor muscle

to allow Level III node dissectionto allow Level III node dissection

Madden and Madden and AuchinclossAuchincloss: preservation of : preservation of

both both pectoralispectoralis major and minor; only major and minor; only

level Ilevel I--II dissectionII dissection�� Higher chance of medial pectoral nerve preservationHigher chance of medial pectoral nerve preservation

�� Reduce arm swellingReduce arm swelling

Patient Selection and Patient Selection and

Evaluation Evaluation

�� History and physical examination History and physical examination

�� MammographyMammography

�� Histological assessment of the Histological assessment of the resected breast specimen resected breast specimen

�� Assessment of the patientAssessment of the patient’’s needs and s needs and expectationsexpectations

Absolute Indications for Absolute Indications for


= Absolute contraindications for BCT = Absolute contraindications for BCT

•• MulticentricityMulticentricity or diffuse malignantor diffuse malignant--

appearing appearing microcalcificationsmicrocalcifications

•• Persistent positive margins after reasonable Persistent positive margins after reasonable

surgical attempts surgical attempts

•• History of prior therapeutic irradiation to History of prior therapeutic irradiation to

the breast regionthe breast region

•• Pregnancy (first or second trimester) Pregnancy (first or second trimester)

�� Large tumor in a small breast Large tumor in a small breast

�� Tumor size (> 4Tumor size (> 4--5 cm)5 cm)

�� Breast size (large or pendulous breasts) Breast size (large or pendulous breasts)

�� History of collagen vascular disease History of collagen vascular disease

(scleroderma or active SLE) (scleroderma or active SLE)

�� MultifocalityMultifocality

Relative Indications for Relative Indications for


�� Prophylactic mastectomy for familial or Prophylactic mastectomy for familial or

high risk womenhigh risk women

�� Cost and inconvenience of irradiationCost and inconvenience of irradiation

�� Attitude of patient/relatives/friendsAttitude of patient/relatives/friends

�� Because the doctors say soBecause the doctors say so

? Indications for Mastectomy? Indications for Mastectomy

� 29 percent of patients had been offered only

the option of a mastectomy

� All were from a metropolitan area

� 70 percent had more than a high-school

education

� 62 percent reported an annual family income

of more than $30,000

� More than 90 percent had health insurance

Because the doctors say soBecause the doctors say so

Clauson et al. Cancer 2002

Skin IncisionSkin Incision


‘‘Total mastectomy with Total mastectomy with en blocen blocremoval of breast tissue, removal of breast tissue, pectoralispectoralis

fascia, nipple/fascia, nipple/areolarareolar complex, axillary complex, axillary

lymphatics, and overlying skin near lymphatics, and overlying skin near

the tumor with a 2the tumor with a 2--cm margincm margin’’

Preservation of Preservation of pectoralispectoralis major musclemajor muscle

Anatomic Boundaries of MRM

� Lateral - anterior margin of latissimusdorsi muscle

� Medial - midline of the sternum

� Superior - subclavius muscle

� Inferior - caudal extension of the breast 2 to 3 cm inferior to the inframammaryfold

Special ConsiderationsSpecial Considerations

�� Level III dissectionLevel III dissection

�� IntercostobrachialIntercostobrachial nervenerve

�� Drain or no drainDrain or no drain

�� SeromaSeroma formationformation

Randomized clinical trial comparing level II and level III axillary node dissection in addition to mastectomy for breast cancer

Tominaga et al. Br J Surg 2004

Long term results of a randomisedprospective study of preservation of the intercostobrachial nerve

Freeman et al. EJSO 2003

Preservation of the Intercostobrachial Nerve

Freeman et al. EJSO 2003

� Oncological safe

� Alteration in sensation or presence of pain

cannot be solely attributed to preservation or

sacrifice of the ICBN

� Some patients whom had nerve sacrifice had

normal sensation and yet many with nerve

preservation did not

� No clear difference in pain

Drain or No DrainDrain or No Drain

� Following MRM, standard practice involves insertion of suction drains deep to mastectomy flaps and in the axilla

� Drains are left in situ until fluid drainage is less than 40-50 ml/day usually 6-14 days after operation

� Despite the use of suction drains, seromasrequiring aspiration still occur in 10-52 percent of patients

Randomized clinical trial of no wound drains and early discharge in the treatment of women with breast cancer

Purushotham et al. Br J Surg 2002

Suturing of flap to muscle and avoiding wound drainage can be performed to facilitate early discharge with no associated increase in surgical or psychological morbidity.

Mastectomy without Drain at Pectoral Area Mastectomy without Drain at Pectoral Area

: a Randomized Controlled Trial : a Randomized Controlled Trial

�� Sixty patients underwent MRMSixty patients underwent MRM

�� Randomized to Randomized to

Group I: only 1 drain was inserted at the Group I: only 1 drain was inserted at the axillaaxilla area area

Group II: 2 drains were inserted into the Group II: 2 drains were inserted into the pectoral area and pectoral area and axillaaxilla areaarea

��No differences in total drainage contents No differences in total drainage contents and complicationsand complications

Puttawibul et al. J Med Assoc Thai. 2003

Methods to Reduce Methods to Reduce SeromaSeroma

FormationFormation

� External compression dressing(circumferential chest wrap of two 6-inch Ace bandages, held in place by circumferential Elastoplast bandage)

vs. Standard front-fastening Surgibra

�Fails to decrease postoperative drainage and may increase the incidence of seromaformation after drain removal

O’Hea et al. Am J Surg 1999


FormationFormation

� Fibrin glue -Prospective randomized trials

�significantly decrease the duration and quantity of serosanguinous drainage

�no significant benefit on axillary lymphatic drainage, drain removal time, or seromaformation

Berger et al. Breast Cancer Res Treat 2001 Ulusoy et al. Breast J. 2003

Moore et al. J Am Coll Surg 2001


FormationFormation

� Immobilization of the affected arm

�5-day period of arm immobilization is NOT

associated with decreased drainage and seroma in comparison with arm mobilization after the second postop. day

�No impact on the postoperative drainage volume and duration and is associated with discomfort and shoulder stiffness.

Petrek et al. Arch Surg 1990

Christodoulakis et al. EJSO 2003


FormationFormation

� Octreotide

�prospective randomized controlled trial

261 consecutive patients

�Treatment group: 0.1 mg octreotide s.c. 3 times a day for 5 days

Control group: no treatment

�Decreased amount and duration of seroma

Carcoforo et al. J Am Coll Surg 2003

ConclusionConclusion

�� Patients with breast cancers should be Patients with breast cancers should be informed of options available during informed of options available during treatment planningtreatment planning

�� MRM remains an important tool for MRM remains an important tool for locoregional control of breast cancerlocoregional control of breast cancer

�� Various methods to reduce postoperative Various methods to reduce postoperative complications remain inconclusivecomplications remain inconclusive

mrm

Documents