The Landmark Series: Mastectomy Trials (Skin-Sparing and Nipple-Sparing and Reconstruction Landmark Trials)
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CONTINUING EDUCATION– BREAST ONCOLOGY
The Landmark Series: Mastectomy Trials (Skin-Sparing and Nipple-Sparing and Reconstruction Landmark Trials) Leisha C. Elmore, MD1, Jill R. Dietz, MD2, Terence M. Myckatyn, MD1, and Julie A. Margenthaler, MD1 Department of Surgery, Washington University School of Medicine, St. Louis, MO; 2Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 1
ABSTRACT Despite advances in medical therapy, the foundation of breast cancer treatment is surgery. The landscape of operative intervention for breast cancer has shifted toward less invasive techniques, resulting in improved cosmesis and lower morbidity while maintaining oncologic integrity. In this article, we review the body of literature contributing to landmark advances in mastectomy for the treatment of breast cancer.
The surgical management of breast cancer began with mastectomy, which continues to be a standard treatment in the modern era. William Halsted originally developed the concept of radical mastectomy in 1894. The Halsted radical mastectomy consisted of removal of the breast, pectoralis muscles, and axillary lymph nodes; however, this procedure, which remained the standard of care for nearly a century, was associated with significant morbidity. Over the last 50 years, the surgical management of breast cancer has seen many significant changes, marked by a trend towards less invasive operative techniques. This paradigm shift has resulted in improved morbidity and patient-reported outcomes without compromise to oncologic safety. This article reviews the pre-eminent studies that serve as the foundation for changes in the surgical approach to mastectomy. It is important to note that there are limited high-quality, large-scale experimental trials evaluating
Ó Society of Surgical Oncology 2020 First Received: 18 May 2020 Accepted: 8 August 2020 J. A. Margenthaler, MD e-mail: [email protected]; [email protected]
mastectomy technique, therefore we also included the landmark observational studies that have contributed to evolution of the operative technique of mastectomy. NATIONAL SURGICAL ADJUVANT BREAST AND BOWEL PROJECT (NSABP) B-04 The first documented practice-changing trial was a randomized trial conducted by the National Surgical Adjuvant Breast and Bowel Project (NSABP).1,2 The NSABP B-04 trial compared the previous standard of radical mastectomy with total (simple) mastectomy. While the study had important implications for the management of the axilla, we will focus specifically on the results relevant to the changes in mastectomy technique. Study Design and Results The trial began accrual in 1971, concluded in 1974, and enrolled 1079 women from 34 institutions with clinically negative axillary nodes and randomized them to receive a radical mastectomy, total mastectomy without axillary dissection and with regional irradiation, or total mastectomy alone. An additional 586 women with clinically positive axillary nodal disease were randomized to radical mastectomy or total m
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