Definition & Overview
A radical mastectomy is the surgical process of removing the entire breast as treatment for breast cancer or large-sized tumours. It also involves the removal of the underlying chest muscles as well as the lymph nodes of the axilla or the armpit.
Up until the mid-1970s, this procedure was commonly performed on women suspected of having a malignant lump of tissues in their breasts. Removing the entire breasts and its associated parts are said to help prevent the spread of cancer to other parts of the body. However, due to the advent of newer surgical techniques and increasing awareness on the nature of this particular disease, radical mastectomy is offered only in extreme cases. This procedure is also known as the Halsted radical mastectomy, named after William Stewart Halsted, the surgeon who performed it for the first time in the United States and advocated its efficacy.
Who Should Undergo and Expected Results
A radical mastectomy can be recommended for patients diagnosed with:
- Advanced stages of carcinoma or cancer of the breast - This procedure is especially indicated if cancer cells have spread beyond the breast tissue and has affected the underlying chest wall. Because the disease is not contained or localised in just one part of the breast, patients do not qualify for skin-sparing or tissue-sparing surgical procedures.
- Tumours that are more than 5cm in diametre and are located deep within the breast and adjacent to the chest wall.
- Tumours that are less than 5cm in diametre but are located in the outer parts of the breast, with indications of spreading to nearby lymph nodes.
A radical mastectomy is considered a major surgical procedure and is performed in a hospital setting. Patients would need to rest for several weeks after the surgery. The affected arm is placed on a sling to minimise movement and reduce the chances of reopening the wound. Patients are also advised to participate in a physical rehabilitation programme to encourage healing and avoid muscle atrophy. Since the procedure grossly alters the chest anatomy, patients are also encouraged to attend support groups or seek professional help to address ensuing psychological and mental stress.
A radical mastectomy has a high success rate in removing identified diseased cells. As in any type of cancer, the survival rate of patients also depends on the stage of cancer when the procedure was performed. Patients may also need to undergo adjuvant cancer treatments like chemotherapy or radiation therapy following this procedure to increase their chances of being cancer-free.
How is the Procedure Performed?
The patient is placed in a supine position with arms outstretched and elevated. General anaesthesia is then administered. The patient’s chest area is cleansed in preparation for the procedure. Using a scalpel, the surgeon then makes an elliptical incision in the breast, cutting around the nipple and areola area. The surgeon then proceeds to evaluate and assess the underlying breast tissue. The breast tissue is then dissected through the pectoralis muscle and the tissue is separated from underlying musculature, the skin, and lymph vessels. The whole breast tissue is then removed and samples are sent to the pathology laboratory for evaluation.
The surgeon then makes an incision into the fascia, separating the pectoralis major and pectoralis minor muscles in the process. Any remaining breast tissue is then removed. The surgeon dissects the pectoralis major muscle and also exposes the pectoralis minor muscle. By removing the attachment of this muscle from its tendons, the axilla is exposed. The lymph nodes and its associated fat tissues are excised and removed. Throughout the process, the nerves and blood vessels are carefully identified and preserved, as much as possible. Blood vessels that need to be cut are ligated or sutured shut. Gauze soaked with sterile saline solution is then placed within the axilla. The surgeon proceeds to remove the pectoral muscles completely. Once all the necessary tissues are completely removed and the surgeon is certain that no bleeding will occur, the surgical site is irrigated with sterile saline solution.
If indicated, a breast reconstruction procedure can be performed after the removal of diseased tissue. A sterile tissue expander is placed in the pocket or space left behind by the procedure. The expander is filled with saline solution to inflate the area and reduce the hollow appearance.
Since the procedure entails the removal of the entire breast, the surgeon may need to cover the surgical site with grafted skin. Typically, the graft is harvested from other parts of the body, like the abdomen or the back, to cover the extensive wound.
The surgeon will then place drain tubes before covering the wound. One tube is placed in the axilla and the other on the chest wall. Sterile dressings are then placed over the surgical site.
Possible Risks and Complications
As a major surgical procedure requiring general anaesthesia and a huge incision, a radical mastectomy is commonly associated with the following risks and complications:
- Excessive bleeding – This can occur during and after surgery and is a major concern in this procedure.
- Infection at the surgical site
- Nerve damage - Patients often complain of tingling and numbness in the affected part due to possible nerve damage. The loss of sensation could predispose the patient to accidental cuts and burns.
- Muscle weakening and atrophy, especially if patients do not undergo proper physical therapy after the procedure.
- Seroma- The interruption of fluid flow in the lymph vessels could lead to seroma or the accumulation of fluid at the surgical site.
- Phantom breast pain - Most patients report phantom breast pain, which is akin to what amputees go through when they lose one or more limbs. This condition is characterised by throbbing pain and pressure, with the sensation of the removed breast still being there.
Depression - The procedure has a considerable impact on the mental status of the patient, often causing depression. Adding to the mental stress is the disfigurement that results from the procedure, which some patients may have difficulty overcoming.
Christian MC, McCabe MS, Korn EL, Abrams JS, Kaplan RS, Friedman MA. The National Cancer Institute audit of the National Surgical Adjuvant Breast and Bowel Project Protocol B-06. N Engl J Med. 1995 Nov 30. 333(22):1469-74.
Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011 Feb 9. 305(6):569-75.