An en bloc internal mammary lymph node dissection was added to the standard radical mastectomy in the 1960s (37). This technique became popular and is the operation commonly referred to as the extended radical mastectomy. Extended radical mastectomy did not enhance overall survival rates, because only 3% to 5% of patients with negative axillary nodes will have involvement of internal mammary nodes (38). Locally destructive surgery is not justified, based on current understanding of the biologic behavior of breast cancer. Radical mastectomy is no longer an indicated procedure, except in the most unusual circumstances, with extensive pectoralis involvement by direct tumor extension.
In contrast to radical mastectomy, modified radical mastectomy preserves the pectoralis major muscle (39,40) (Fig. 40.2B). The breast is removed in a manner similar to that of radical mastectomy, but neither the axillary lymph node dissection nor the skin excision is as extensive. Consequently, there is no need for skin grafting. There are no differences in survival rates between radical and modified radical mastectomy, but the latter procedure has a better functional outcome and a superior cosmetic result (41). Modified radical mastectomy has replaced radical mastectomy in the United States and is an alternative to breast conserving surgery and axillary dissection for some patients.
Total Mastectomy Total mastectomy involves removal of the entire breast, nipple, and areolar complex without resection of the underlying muscles or intentional excision of axillary lymph nodes. Low-lying lymph nodes in the upper outer portion of the breast and low axilla often are excised. Total mastectomy has local control rates comparable with those of radical or modified radical mastectomy but has a higher risk of axillary recurrence. In the past, regional recurrence would occur in at least 15% to 20% of patients treated with total mastectomy alone. With the addition of sentinel lymph node biopsy, which selects patients who are lymph node negative, local recurrence rates should be lowered in patients with total mastectomy and node negative disease compared to those in the past with unknown axillary status.
More patients have early small cancers and others are undergoing prophylactic mastectomy for genetic mutations and for other high-risk lesions. Patients may elect to undergo a skin-sparing mastectomy (SSM) with nipple–areolar complex (NAC) removal that leaves a skin envelope to accommodate the breast reconstruction, as well as providing a nipple-sparing mastectomy (NSM) with preservation of the NAC. Both of these procedures are being studied for their potential utility and safety in various clinical situations. Retrospective series show that performing NSM does not impact survival, although a prospective randomized trial has not been performed (42).
McWhirter developed the combination of total mastectomy followed by radiation (43). Many advocated adjuvant radiation therapy used in combination with various operative procedures. Studies claiming improvements in overall survival usually are ﬂawed by the use of historical controls and inaccurate preoperative staging. Classic trials, both prospective randomized and historical control studies, showed that adjuvant radiation therapy improves local control but not overall survival rates (44–47). In a prospective randomized trial performed by the National Surgical Adjuvant Breast Project (NSABP), the roles of postoperative radiation therapy and axillary treatment were examined. Patients were randomly assigned to either total mastectomy, radical mastectomy, or total mastectomy with radiation therapy. This trial showed no difference in survival among the three treatment arms, whereas radiation therapy and axillary treatment improved local and regional control. Twenty-five-year follow-up data continue to support these conclusions (48).
Three randomized control studies from the 1990s showed that postmastectomy radiation therapy reduced the risk of local–regional failure by 20% and produced an absolute sur