When is a modified radical mastectomy indicated?

Updated: Jun 18, 2021
  • Author: Nafisa K Kuwajerwala, MD; Chief Editor: Erik D Schraga, MD  more...
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Answer

Answer

There are a few contraindications to breast conservation for which a mastectomy is recommended. According to the National Comprehensive Cancer Network guidelines, [8] indications for mastectomy include the following:

  • Prior radiation therapy to the breast or chest wall

  • Radiation therapy contraindicated by pregnancy (except patients in the third trimester who can receive radiation postpartum)

  • Inflammatory breast cancer

  • Diffuse suspicious or malignant-appearing microcalcifications

  • Widespread disease that is multicentric, located in more than one quadrant, and cannot be removed through a single incision with negative margins

  • A positive pathologic margin after repeat re-excision and suboptimal cosmetic outcome

Relative indications for mastectomy include the following:

  • Active connective tissue disease involving skin (eg, scleroderma, lupus)

  • Tumors greater that 5 cm in diameter

  • Focally positive margin

A consensus statement from an international expert panel specified that following maximal disease response to chemotherapy (in HER-2–normal patients) or chemotherapy and dual (pertuzumab and trastuzumab) anti–HER-2 treatment (in HER-2–positive patients), inflammatory breast cancer should be treated with modified radical mastectomy, including skin, breast, and axillary-node resection. [9]  A study by Partain et al indicated that modified radical mastectomy and partial/complete chemotherapeutic response by distant disease are independent factors for improved overall survival in de novo stage IV inflammatory breast cancer, with the hazard ratio for the mastectomy procedure being 0.52. [10]

Patients who are younger than 35 years of age or premenopausal with known BRCA1/2 mutations have an increased risk of local recurrence. Prophylactic bilateral mastectomy may be considered for risk reduction.


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