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.
-
Anatomy markings prior to mastectomy.
-
Superior flap dissection.
-
Superior flap dissection up to the pectoralis muscle facia.
-
Lifting the breast off the pectoralis muscle with the facia in the specimen.
-
Entering the axilla at the lateral boder of pectoralis major muscle.
-
Preserving the axillary vein and the thoracodorsal nerve (along with the thoracodorsal vascular bundle) to the latissimus dorsi and serratus anterior in the axillary dissection.
-
Drain placement and skin closing after mastectomy.
