Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ionc20 Acta Oncologica ISSN: 0284-186X (Print) 1651-226X (Online) Journal homepage: https://www.tandfonline.com/loi/ionc20 Total Mastectomy with Special Reference to Surgical Technique, Extent of Axillary Dissection and Complications S. Watt-Boolsen, K. Jacobsen & M. Blichert-Toft To cite this article: S. Watt-Boolsen, K. Jacobsen & M. Blichert-Toft (1988) Total Mastectomy with Special Reference to Surgical Technique, Extent of Axillary Dissection and Complications, Acta Oncologica, 27:6, 663-665, DOI: 10.3109/02841868809091765 To link to this article: https://doi.org/10.3109/02841868809091765 Published online: 07 Aug 2009. Submit your article to this journal Article views: 397 View related articles
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Total Mastectomy with Special Reference to Surgical Technique, Extent of Axillary Dissection and ComFull Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ionc20
Acta Oncologica
Total Mastectomy with Special Reference to Surgical Technique, Extent of Axillary Dissection and Complications
S. Watt-Boolsen, K. Jacobsen & M. Blichert-Toft
To cite this article: S. Watt-Boolsen, K. Jacobsen & M. Blichert-Toft (1988) Total Mastectomy with Special Reference to Surgical Technique, Extent of Axillary Dissection and Complications, Acta Oncologica, 27:6, 663-665, DOI: 10.3109/02841868809091765
To link to this article: https://doi.org/10.3109/02841868809091765
Published online: 07 Aug 2009.
Submit your article to this journal
Article views: 397
View related articles
FROM THE SURGICAL DEPARTMENT K, ODENSE UNIVERSITY HOSPITAL, DK-5000 ODENSE C, DENMARK.
TOTAL MASTECTOMY WITH SPECIAL REFERENCE TO SURGICAL TECHNIQUE, EXTENT OF AXILLARY
DISSECTION AND COMPLICATIONS
Abstract Total mastectomy and partial axillary dissection as advised in
the DBCG (Danish Breast Cancer Cooperative Group) protocols was performed in 104 consecutive females with operable primary invasive breast cancer, aged 34-82 years, median 47 years. The glandular removal was complete as assessed by microscopic examination of side resection planes and deep fascia of the surgical specimen. The number of removed axillary lymph nodes ranged from 1 to 28, median 8. The mortality was zero. There were no general complications. Wound complications comprised seroma (47.1 %), flap margin necrosis (5.8%) and infection (1.9%). The pitfalls in securing total mastectomy are discussed as is the extent of axillary dissection for staging purposes. Further- more, the problem of axillary dissection and axillary irradiation in node positive patients is considered.
Key words: Breast cancer, modified radical mastectomy, axil- lary dissection, complications.
The surgeon’s role in operable primary invasive breast cancer has changed considerably within the last decade in accordance with the fundamental changes in the under- standing of the biology of breast cancer. The Halstedian dogma that operable breast cancer is a locoregional dis- ease has lost adherents with a still increasing speed, whereas the understanding of breast cancer as a systemic disease is increasingly accepted. Accordingly, the sur- geon’s role has been redefined in the sense that the extent of surgery is not decisive in determining the final outcome of breast cancer. Logically, this has lead to breast con- serving operations in patients who previously would have had some form of mastectomy. If the available results of breast conserving operations as to locoregional control and survival can be upheld on long-term, it is most likely that the ratio between breast-conserving operations and mastectomy will increase. However, mastectomy will for the time being be the operation most often applied in
operable breast cancer. Which one of the many modifica- tions of radical mastectomy should be employed, depends upon the aims of mastectomy.
The aims of mastectomy were reconsidered during the preparation of the DBCG (Danish Breast Cancer Cooper- ative Group) 82- protocols, dealing with operable primary breast cancer. Recognizing the systemic nature of the disease, the aims were defined as firstly to obtain local control, secondly to secure staging, and thirdly to mini- mize functional and cosmetic sequelae to the operation. These requirements were considered fulfilled by the modi- fied radical mastectomy described by Cady (2).
The present paper deals with technical problems in mastectomy and the extent of axillary dissection. Further- more, the perioperative complications are accounted for.
Material and Methods
The series comprised 104 consecutive females with op- erable primary invasive breast cancer, who had total mas- tectomy and partial axillary dissection (2) with primary wound closure in a continuous 12-month period at the Department of Surgery, Odense University Hospital. The patients were aged 34-82 years, median 47 years.
A macroradical mastectomy was performed in general anaesthesia according to Cady (2) as to the glandular tissue. The pectoral fascia was stripped, whereas neither the major nor the minor pectoral muscle was removed. The axillary dissection was modified according to Cady (2), comprising removal of the central axillary lymph nodes involving level I and partially level 11. A suction
Presented at the DBCG meeting, Copenhagen, January 22-23, 1988.
663
664 S . WATT-BOOLSEN, K . JACOBSEN AND M . BLICHERT-TOFT
drain was placed in the axilla and exteriorised through a stab wound in the caudal skin flap in the frontal axillary line. The drain was usually removed after 3 to 5 days, when the secretion had decreased to 40 ml within the last 24 h. A physical training programme for shoulder-arm movements was started from day 1 or 2.
The glandular mastectomy was always supplemented with macroradical resection of muscle in case of deep fascia invasion. In patients above the age of 70 years, but in poor general condition, the axillary dissection was limited to comprise removal of only the lowest axillary lymph nodes, unless nodes at a higher level were macro- scopically involved.
Mortality was defined as death within the first 30 post- operative days. General complications or events were clinically diagnosed. Haematoma was defined as accumu- lation of blood in the operative field needing surgical evacuation or removal by aspiration. Wound infection was defined as accumulation of pus needing debridement. Seroma was explicitly looked for and diagnosed by the demonstration of fluctuation and verified by puncture and aspiration of more than 10 ml.
To assess whether or not total mastectomy had been accomplished, tissue sections from the side resection planes and the deep fascia of the mastectomy specimen was microscopically examined.
Results
Total mastectomy had been accomplished in all patients as assessed by microscopic examination. The number of removed lymph nodes ranged from 1 to 28, median 8. The intraoperative blood loss ranged from 150 to 1800 ml, median 700 ml.
Mortality was zero. There were no general complica- tions, such as pneumonia, deep vein thrombosis, pulmo- nary embolism or cardiac failure.
Wound complications comprised seroma (47.1 %), flap margin necrosis (5.8%) and infection (1.9%). Patients with seroma had from I to 7 , median 3, punctures and aspirations, before cessation of seroma formation. Nei- ther flap necrosis nor wound infection was related to the development of seroma formation (data not shown). Wound dehiscence and major or total flap necrosis as well as haematomas did not occur.
Lesion of the long thoracic nerve or the thoracodorsal nerve was not observed. Dysesthesia on the inner side of the upper arm was a common finding, since the intercos- tobrachial nerves were usually sacrificed.
Discussion
Although the employed mastectomy and partial axillary dissection is rather straightforward to perform, the train- ing of surgical trainees has demonstrated certain intra- operative pitfalls.
The problem most often met with is the dissection of the skin flaps. The identification of the superficial layer of the superficial fascia may be difficult as is keeping the plane of dissection just superficial to this fascia. A deli- cate technique is required to achieve total glandular mas- tectomy, remembering that the glandular tissue cranially may reach the clavicle, laterally the deltoideopectoral fossa and caudally below the inframammary sulcus. The trainees tend to make the skin incision too deep and to commence the dissection underneath the superficial fas- cia. The problem of identifying this fascia can be over- come by slightly stretching the skin during incision, look- ing for the fascia, and not to deepen the incision further than required to incise the fascia plane. It is of the utmost importance to put the fascia under stretch when dissecting the skin flaps and to realize that the flaps may be very thin in skinny patients and thicker in obese ones.
Deviations from the correct plane of dissection occur in both directions. While a too superficial dissection may devascularize the skin flap and probably account for the marginal flap necrosis, it will not result in incomplete glandular mastectomy. On the other hand, a too deep dissection may result in subtotal glandular mastectomy by leaving glandular tissue on the skin flaps or peripherally to the flaps. The latter is caused by ceasing the dissection before the true periglandular area is reached. The trainee should be warned of this fault. We advocate routine mi- croscopic examination of selected tangential sections of the deep fascia of the mastectomy specimen as well as of side resection planes to assess the completeness of glan- dular mastectomy.
The principle aim of the partial axillary dissection was to remove lymph nodes for staging purposes. This is accomplished by excising the central axillary lymph nodes ( I , 3 , 6). A drawback, however, is the need for axillary irradiation in node positive patients, since level 111- and most of level 11-nodes are not removed ( 1 ) . Larson et al. (4), investigating breast cancer patients undergoing axil- lary surgery prior to full axillary irradiation, reported that the risk of arm oedema at 6 years was 28%, if more than 10 nodes had been removed, and 9%, if only one to 10 nodes had been removed. The radical solution to this dilemma is to do a complete axillary dissection, thus obviating the need for axillary irradiation in node positive patients. Another option is to restrict the dissection to comprise only removal of level I-nodes ( I ) and irradiate node positive patients. This should significantly reduce the risk of arm oedema following irradiation (4), but prob- ably increase the rate of false negative nodal staging (5).
The type and frequency of complications in the present series are consistent with the recent report by Tejler & Aspegren (7), employing the same type of mastectomy. In our study, seromas developed in 47.1 %. In the report just quoted, seromas occurred in 34.8 % of 194 patients, oper- ated by one of seven experienced surgeons. Among these surgeons, the seroma frequency vaned from 18 to 74%. It
SURGICAL ASPECTS OF
was concluded that the surgeon in a n unknown way was a factor associated with the development of seroma. W e cannot confirm this interesting observation, since the vast majority of our operations were performed by one sur- geon (SWB) and the remainder b y various trainees. How- ever, we d o know from a n ongoing investigation that the exudate is inflammatory in origin, and that serorna pa- tients thus may have a prolonged acu te inflammatory phase. Hypothetically, this may be caused by otherwise minor variations in surgical technique.
Although the present series did not show a relation between seroma and other wound complications, seroma may postpone the initiation of radiation therapy. If only for this reason, it is important t o fur ther investigate the causes of seroma development in o rde r to diminish its occurrence.
REFERENCES 1. BOOVA R. S., BONANNI R. and ROSATO F. E.: Patterns of
axillary nodal involvement in breast cancer. Predictability of level one dissection. Ann. Surg. 196 (1982), 642.
2.
3 .
4.
5.
6.
7.
MASTECTOMY 665
Acta Oncologica
Total Mastectomy with Special Reference to Surgical Technique, Extent of Axillary Dissection and Complications
S. Watt-Boolsen, K. Jacobsen & M. Blichert-Toft
To cite this article: S. Watt-Boolsen, K. Jacobsen & M. Blichert-Toft (1988) Total Mastectomy with Special Reference to Surgical Technique, Extent of Axillary Dissection and Complications, Acta Oncologica, 27:6, 663-665, DOI: 10.3109/02841868809091765
To link to this article: https://doi.org/10.3109/02841868809091765
Published online: 07 Aug 2009.
Submit your article to this journal
Article views: 397
View related articles
FROM THE SURGICAL DEPARTMENT K, ODENSE UNIVERSITY HOSPITAL, DK-5000 ODENSE C, DENMARK.
TOTAL MASTECTOMY WITH SPECIAL REFERENCE TO SURGICAL TECHNIQUE, EXTENT OF AXILLARY
DISSECTION AND COMPLICATIONS
Abstract Total mastectomy and partial axillary dissection as advised in
the DBCG (Danish Breast Cancer Cooperative Group) protocols was performed in 104 consecutive females with operable primary invasive breast cancer, aged 34-82 years, median 47 years. The glandular removal was complete as assessed by microscopic examination of side resection planes and deep fascia of the surgical specimen. The number of removed axillary lymph nodes ranged from 1 to 28, median 8. The mortality was zero. There were no general complications. Wound complications comprised seroma (47.1 %), flap margin necrosis (5.8%) and infection (1.9%). The pitfalls in securing total mastectomy are discussed as is the extent of axillary dissection for staging purposes. Further- more, the problem of axillary dissection and axillary irradiation in node positive patients is considered.
Key words: Breast cancer, modified radical mastectomy, axil- lary dissection, complications.
The surgeon’s role in operable primary invasive breast cancer has changed considerably within the last decade in accordance with the fundamental changes in the under- standing of the biology of breast cancer. The Halstedian dogma that operable breast cancer is a locoregional dis- ease has lost adherents with a still increasing speed, whereas the understanding of breast cancer as a systemic disease is increasingly accepted. Accordingly, the sur- geon’s role has been redefined in the sense that the extent of surgery is not decisive in determining the final outcome of breast cancer. Logically, this has lead to breast con- serving operations in patients who previously would have had some form of mastectomy. If the available results of breast conserving operations as to locoregional control and survival can be upheld on long-term, it is most likely that the ratio between breast-conserving operations and mastectomy will increase. However, mastectomy will for the time being be the operation most often applied in
operable breast cancer. Which one of the many modifica- tions of radical mastectomy should be employed, depends upon the aims of mastectomy.
The aims of mastectomy were reconsidered during the preparation of the DBCG (Danish Breast Cancer Cooper- ative Group) 82- protocols, dealing with operable primary breast cancer. Recognizing the systemic nature of the disease, the aims were defined as firstly to obtain local control, secondly to secure staging, and thirdly to mini- mize functional and cosmetic sequelae to the operation. These requirements were considered fulfilled by the modi- fied radical mastectomy described by Cady (2).
The present paper deals with technical problems in mastectomy and the extent of axillary dissection. Further- more, the perioperative complications are accounted for.
Material and Methods
The series comprised 104 consecutive females with op- erable primary invasive breast cancer, who had total mas- tectomy and partial axillary dissection (2) with primary wound closure in a continuous 12-month period at the Department of Surgery, Odense University Hospital. The patients were aged 34-82 years, median 47 years.
A macroradical mastectomy was performed in general anaesthesia according to Cady (2) as to the glandular tissue. The pectoral fascia was stripped, whereas neither the major nor the minor pectoral muscle was removed. The axillary dissection was modified according to Cady (2), comprising removal of the central axillary lymph nodes involving level I and partially level 11. A suction
Presented at the DBCG meeting, Copenhagen, January 22-23, 1988.
663
664 S . WATT-BOOLSEN, K . JACOBSEN AND M . BLICHERT-TOFT
drain was placed in the axilla and exteriorised through a stab wound in the caudal skin flap in the frontal axillary line. The drain was usually removed after 3 to 5 days, when the secretion had decreased to 40 ml within the last 24 h. A physical training programme for shoulder-arm movements was started from day 1 or 2.
The glandular mastectomy was always supplemented with macroradical resection of muscle in case of deep fascia invasion. In patients above the age of 70 years, but in poor general condition, the axillary dissection was limited to comprise removal of only the lowest axillary lymph nodes, unless nodes at a higher level were macro- scopically involved.
Mortality was defined as death within the first 30 post- operative days. General complications or events were clinically diagnosed. Haematoma was defined as accumu- lation of blood in the operative field needing surgical evacuation or removal by aspiration. Wound infection was defined as accumulation of pus needing debridement. Seroma was explicitly looked for and diagnosed by the demonstration of fluctuation and verified by puncture and aspiration of more than 10 ml.
To assess whether or not total mastectomy had been accomplished, tissue sections from the side resection planes and the deep fascia of the mastectomy specimen was microscopically examined.
Results
Total mastectomy had been accomplished in all patients as assessed by microscopic examination. The number of removed lymph nodes ranged from 1 to 28, median 8. The intraoperative blood loss ranged from 150 to 1800 ml, median 700 ml.
Mortality was zero. There were no general complica- tions, such as pneumonia, deep vein thrombosis, pulmo- nary embolism or cardiac failure.
Wound complications comprised seroma (47.1 %), flap margin necrosis (5.8%) and infection (1.9%). Patients with seroma had from I to 7 , median 3, punctures and aspirations, before cessation of seroma formation. Nei- ther flap necrosis nor wound infection was related to the development of seroma formation (data not shown). Wound dehiscence and major or total flap necrosis as well as haematomas did not occur.
Lesion of the long thoracic nerve or the thoracodorsal nerve was not observed. Dysesthesia on the inner side of the upper arm was a common finding, since the intercos- tobrachial nerves were usually sacrificed.
Discussion
Although the employed mastectomy and partial axillary dissection is rather straightforward to perform, the train- ing of surgical trainees has demonstrated certain intra- operative pitfalls.
The problem most often met with is the dissection of the skin flaps. The identification of the superficial layer of the superficial fascia may be difficult as is keeping the plane of dissection just superficial to this fascia. A deli- cate technique is required to achieve total glandular mas- tectomy, remembering that the glandular tissue cranially may reach the clavicle, laterally the deltoideopectoral fossa and caudally below the inframammary sulcus. The trainees tend to make the skin incision too deep and to commence the dissection underneath the superficial fas- cia. The problem of identifying this fascia can be over- come by slightly stretching the skin during incision, look- ing for the fascia, and not to deepen the incision further than required to incise the fascia plane. It is of the utmost importance to put the fascia under stretch when dissecting the skin flaps and to realize that the flaps may be very thin in skinny patients and thicker in obese ones.
Deviations from the correct plane of dissection occur in both directions. While a too superficial dissection may devascularize the skin flap and probably account for the marginal flap necrosis, it will not result in incomplete glandular mastectomy. On the other hand, a too deep dissection may result in subtotal glandular mastectomy by leaving glandular tissue on the skin flaps or peripherally to the flaps. The latter is caused by ceasing the dissection before the true periglandular area is reached. The trainee should be warned of this fault. We advocate routine mi- croscopic examination of selected tangential sections of the deep fascia of the mastectomy specimen as well as of side resection planes to assess the completeness of glan- dular mastectomy.
The principle aim of the partial axillary dissection was to remove lymph nodes for staging purposes. This is accomplished by excising the central axillary lymph nodes ( I , 3 , 6). A drawback, however, is the need for axillary irradiation in node positive patients, since level 111- and most of level 11-nodes are not removed ( 1 ) . Larson et al. (4), investigating breast cancer patients undergoing axil- lary surgery prior to full axillary irradiation, reported that the risk of arm oedema at 6 years was 28%, if more than 10 nodes had been removed, and 9%, if only one to 10 nodes had been removed. The radical solution to this dilemma is to do a complete axillary dissection, thus obviating the need for axillary irradiation in node positive patients. Another option is to restrict the dissection to comprise only removal of level I-nodes ( I ) and irradiate node positive patients. This should significantly reduce the risk of arm oedema following irradiation (4), but prob- ably increase the rate of false negative nodal staging (5).
The type and frequency of complications in the present series are consistent with the recent report by Tejler & Aspegren (7), employing the same type of mastectomy. In our study, seromas developed in 47.1 %. In the report just quoted, seromas occurred in 34.8 % of 194 patients, oper- ated by one of seven experienced surgeons. Among these surgeons, the seroma frequency vaned from 18 to 74%. It
SURGICAL ASPECTS OF
was concluded that the surgeon in a n unknown way was a factor associated with the development of seroma. W e cannot confirm this interesting observation, since the vast majority of our operations were performed by one sur- geon (SWB) and the remainder b y various trainees. How- ever, we d o know from a n ongoing investigation that the exudate is inflammatory in origin, and that serorna pa- tients thus may have a prolonged acu te inflammatory phase. Hypothetically, this may be caused by otherwise minor variations in surgical technique.
Although the present series did not show a relation between seroma and other wound complications, seroma may postpone the initiation of radiation therapy. If only for this reason, it is important t o fur ther investigate the causes of seroma development in o rde r to diminish its occurrence.
REFERENCES 1. BOOVA R. S., BONANNI R. and ROSATO F. E.: Patterns of
axillary nodal involvement in breast cancer. Predictability of level one dissection. Ann. Surg. 196 (1982), 642.
2.
3 .
4.
5.
6.
7.
MASTECTOMY 665
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