Clinical Practice Guidelines for Modified Radical Mastectomy of Breast Cancer: Chinese Society of Breast Surgery (CSBrs) Practice Guidelines 2021
Breast cancer remains a significant health concern worldwide, and in China, the proportion of patients with early-stage breast cancer undergoing mastectomy exceeds 70%. Among these, the Auchincloss operation is the major surgical technique for patients with axillary lymph node-positive breast cancer. To standardize the clinical application of modified radical mastectomy, the Chinese Society of Breast Surgery (CSBrS) organized domestic experts to conduct literature retrieval and expert discussions on the theoretical basis and technical details of this procedure. The guidelines were developed with reference to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, evaluating related evidence and combining it with clinical accessibility. These guidelines aim to provide a reference for breast surgeons in clinical practice.
Level of Evidence and Recommendation Strength
The guidelines adhere to a standardized level of evidence and recommendation strength. The voting committee for this guideline comprised 81 members, including 66 breast surgeons (81.5%), four oncologists (4.9%), four radiologists (4.9%), one pathologist (1.2%), one gynecologist (1.2%), two radiation therapists (2.4%), and three epidemiologists (3.7%). The target audience for these guidelines is clinicians specializing in breast diseases in China.
Recommendations
Recommendation 1: Indications
The guidelines outline specific indications for modified radical mastectomy:
1.1 Early breast cancer not suitable for breast-sparing surgery (Level of Evidence: I, Recommendation Strength: A) 1.2 Axillary lymph nodes positive (Level of Evidence: I, Recommendation Strength: A) 1.3 Clinical evaluation suitable for R0 resection (Level of Evidence: I, Recommendation Strength: A)
Recommendation 2: Incision Design
The preferred incision design is the horizontal Stewart incision (Level of Evidence: I, Recommendation Strength: A). For patients with difficulty using a horizontal incision, the “S” incision or the “parallelogram method” is recommended to reduce skin tension while keeping the incision relatively concealed.
Recommendation 3: Free Skin Flap Layer
The free skin flap should be isolated in the superficial fascia of breast tissue (Level of Evidence: I, Recommendation Strength: A).
Recommendation 4: Free Skin Flap Range
The free skin flap range generally includes:
- Upper boundary: 1 to 2 cm below the clavicle
- Lower boundary: at the level of the costal arch
- Medial boundary: at the parasternal line
- Lateral boundary: at the latissimus dorsi leading edge (Level of Evidence: I, Recommendation Strength: A)
Recommendation 5: Axillary Lymph Node Dissection
Axillary lymph node cleaning should be performed up to level II. If there is obvious level II or III lymph node metastasis, level III cleaning is necessary (Level of Evidence: I, Recommendation Strength: A).
Discussion
The guidelines provide a comprehensive discussion on the historical context and evolution of modified radical mastectomy. In 1948, Patey et al. first reported retaining the pectoralis major muscle and removing only the pectoralis minor muscle during Halsted radical surgery to preserve the better appearance and function of the chest wall. In 1951, Auchincloss et al. proposed retaining both the pectoralis major and minor muscles, known as improved radical surgery. The Auchincloss method achieves R0 resection and reduces the injury of pectoral innervation nerves, making it widely used in clinical practice.
The expert committee discussed various aspects of the Auchincloss operation, including incision design, the layer and range of free skin flap, tissues to be removed and retained, surgical techniques, and the management of complications. A consensus was reached, and detailed surgical procedures and precautions are provided in the appendix.
Regarding the treatment of pectoral fascia, traditional surgical procedures require its removal to prevent tumor metastasis through fascial lymphatic vessels and to remove tumor cells shed during surgery. However, there is no evidence that removing the pectoral fascia improves local control. Considering that its removal does not have many adverse effects, the experts recommended removing the pectoralis major fascia after discussion. The second and third intercostal arteries near the sternum have internal thoracic arteries, which should be ligated or coagulated. Multiple small perforating vessels from the pectoralis major muscle are a factor in post-operative hemorrhage and should be fully stanched.
In 1955, Berg divided axillary lymph nodes into three levels based on the upper and lower margins of the pectoralis minor muscle. The outside edge of the pectoralis minor muscle is level I, the area between the lower and upper edge is level II, and the area within the pectoralis minor muscle on the edge (subclavian area) is level III. The experts agreed that for patients with lymph node metastasis at level II, at least ten or more lymph nodes should be removed to complete accurate pathology N staging.
During axillary lymph node dissection, attention should be paid to protecting the thoracic dorsal nerve accompanying the thoracic dorsal artery and the long thoracic nerve running close to the chest wall. Injury to the former leads to latissimus dorsi atrophy, while injury to the latter leads to serratus anterior atrophy, affecting the quality of life. The intercostal brachial nerve, responsible for sensation in the medial upper arm, should be retained during the operation. If it is adhered to the lymph node, it can be excised considering the safety of the tumor.
Common post-operative complications of modified radical resection include hemorrhage, incision infection, necrosis of the skin flap, subcutaneous hydrops, skin paresthesia, and edema of the affected upper limb. Adequate intra-operative hemostasis and continuous post-operative negative pressure drainage can reduce post-operative hemorrhage, subcutaneous hydrops, and lymphedema of the affected upper limb. Lymphedema of the upper extremity after modified radical surgery has attracted increasing attention. The main cause is the obstruction of upper extremity lymphatic reflux, with axillary lymph node dissection and radiotherapy being the main inducements. High-risk factors include obesity, post-operative infection, and the formation of axillary seroma. Measures to prevent upper extremity lymphedema include reducing the formation of axillary seroma, avoiding post-operative infection, improving precise radiotherapy techniques, scientifically guiding upper extremity function exercise, reducing excessive weight bearing on the affected side, and avoiding induced factors of upper extremity venipuncture on the affected side. Severe upper extremity lymphedema must be treated with a combination of treatments and even surgery.
Conclusion
The Chinese Society of Breast Surgery (CSBrS) practice guidelines for modified radical mastectomy of breast cancer provide a comprehensive and standardized approach to this surgical procedure. The guidelines cover indications, incision design, free skin flap layer and range, axillary lymph node dissection, and the management of complications. By adhering to these guidelines, breast surgeons can improve clinical outcomes and reduce post-operative complications for patients undergoing modified radical mastectomy.
doi.org/10.1097/CM9.0000000000001412
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