MRM PDF

Modified Radical Mastectomy
Pornchai O-charoenrat MD PhD
Professor
Division of Head, Neck & Breast Surgery
SIRIRAJ HOSPITAL
THAILAND
Modified Radical Mastectomy (MRM)
Rationale
Indications
Techniques
Special considerations
Rationale
Indications
Techniques
Mastectomy
‘Surgical Removal of the Breast’
Radical mastectomy – removal of the breast, pectoralis
major and minor m. and Level I-III axillary nodes
Modified radical mastectomy – removal of breast and

Level I or Level I and II nodes
Simple mastectomy – removal of breast
Skin-sparing mastectomy – mastectomy with removal of

nipple-areolar complex, but with preservation of the
rest of the breast skin
NSABP-B04 Study
Dissatisfaction with results after radical
mastectomy
Less radical surgery might be just as
effective as the more extensive operations
To determine whether patients who received

local or regional treatments other than
radical mastectomy would have outcomes
similar to those achieved with radical
mastectomy
Radical Mastectomy Offers No
Advantage
Fisher et al. NEJM 2002

Advantages over radical mastectomy
Good postoperative cosmetic appearance
Maintain motor activity in the arm
Low rate of postoperative arm edema
Easy postoperative breast reconstruction

Patey: removal of pectoralis minor muscle

to allow Level III node dissection
Madden and Auchincloss: preservation of

both pectoralis major and minor; only
level I-II dissection
Higher chance of medial pectoral nerve preservation
Reduce arm swelling
Rationale
Indications
Techniques
Patient Selection and
Evaluation
History and physical examination
Mammography
Histological assessment of the

resected breast specimen
Assessment of the patient’s needs and

expectations
Absolute Indications for
Mastectomy
= Absolute contraindications for BCT
• Multicentricity or diffuse malignant-
appearing microcalcifications
• Persistent positive margins after reasonable
surgical attempts
• History of prior therapeutic irradiation to
the breast region
• Pregnancy (first or second trimester)
Relative Indications for
Mastectomy
Large tumor in a small breast

Tumor size (> 4-5 cm)
Breast size (large or pendulous breasts)
History of collagen vascular disease
(scleroderma or active SLE)
Multifocality
? Indications for Mastectomy
Prophylactic mastectomy for familial or

high risk women
Cost and inconvenience of irradiation
Attitude of patient/relatives/friends
Because the doctors say so

Because the doctors say so
29 percent of patients had been offered only

the option of a mastectomy
All were from a metropolitan area
70 percent had more than a high-school
education
62 percent reported an annual family income
of more than $30,000
More than 90 percent had health insurance
Clauson et al. Cancer 2002
Rationale
Indications
Techniques
Skin Incision
‘Total mastectomy with en bloc

removal of breast tissue, pectoralis
fascia, nipple/areolar complex, axillary
lymphatics, and overlying skin near
the tumor with a 2-cm margin’
Preservation of pectoralis major muscle

Anatomic Boundaries of MRM
Lateral - anterior margin of latissimus

dorsi muscle
Medial - midline of the sternum
Superior - subclavius muscle
Inferior - caudal extension of the breast

2 to 3 cm inferior to the inframammary
fold
Rationale
Indications
Techniques
Special Considerations
Level III dissection
Intercostobrachial nerve
Drain or no drain
Seroma formation
Drain or no drain
Seroma formation
Randomized clinical trial comparing level II
and level III axillary node dissection in
addition to mastectomy for breast cancer
Tominaga et al. Br J Surg 2004

Drain or no drain
Seroma formation
Long term results of a randomised
prospective study of preservation of
the intercostobrachial nerve
Freeman et al. EJSO 2003

Long term results of a randomised
prospective study of preservation of
the intercostobrachial nerve

Preservation of the
Intercostobrachial Nerve
Oncological safe
Alteration in sensation or presence of pain
cannot be solely attributed to preservation or
sacrifice of the ICBN
Some patients whom had nerve sacrifice had
normal sensation and yet many with nerve
preservation did not
No clear difference in pain
Drain or no drain
Seroma formation
Drain or No Drain
Following MRM, standard practice involves

insertion of suction drains deep to
mastectomy flaps and in the axilla
Drains are left in situ until fluid drainage is
less than 40-50 ml/day usually 6-14 days
after operation
Despite the use of suction drains, seromas
requiring aspiration still occur in 10-52
percent of patients
Randomized clinical trial of no wound
drains and early discharge in the
treatment of women with breast cancer
Suturing of flap to muscle and avoiding wound drainage can be

performed to facilitate early discharge with no associated
increase in surgical or psychological morbidity.
Purushotham et al. Br J Surg 2002

Mastectomy without Drain at Pectoral Area
: a Randomized Controlled Trial
Sixty patients underwent MRM

Randomized to
Group I: only 1 drain was inserted at the
axilla area
Group II: 2 drains were inserted into the
pectoral area and axilla area
No differences in total drainage contents

and complications
Puttawibul et al. J Med Assoc Thai. 2003

Drain or no drain
Seroma formation
Methods to Reduce Seroma
Formation
External compression dressing
(circumferential chest wrap of two 6-inch Ace
bandages, held in place by circumferential
Elastoplast bandage)
vs. Standard front-fastening Surgibra
Fails to decrease postoperative drainage and

may increase the incidence of seroma
formation after drain removal
O’Hea et al. Am J Surg 1999
Formation
Fibrin glue -Prospective randomized trials
significantly decrease the duration and

quantity of serosanguinous drainage
Moore et al. J Am Coll Surg 2001
no significant benefit on axillary lymphatic

drainage, drain removal time, or seroma
formation Berger et al. Breast Cancer Res Treat 2001
Ulusoy et al. Breast J. 2003
Formation
Immobilization of the affected arm
5-day period of arm immobilization is NOT
associated with decreased drainage and
seroma in comparison with arm mobilization
after the second postop. day
Petrek et al. Arch Surg 1990
No impact on the postoperative drainage

volume and duration and is associated with
discomfort and shoulder stiffness.
Christodoulakis et al. EJSO 2003
Formation
Octreotide
prospective randomized controlled trial
261 consecutive patients
Treatment group: 0.1 mg octreotide s.c.
3 times a day for 5 days
Control group: no treatment
Decreased amount and duration of seroma
Carcoforo et al. J Am Coll Surg 2003

Conclusion
Patients with breast cancers should be
informed of options available during
treatment planning
MRM remains an important tool for

locoregional control of breast cancer
Various methods to reduce postoperative

complications remain inconclusive

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Modified Radical Mastectomy

Pornchai O-charoenrat MD PhD

Modified radical mastectomy – removal of breast and

Simple mastectomy – removal of breast

Skin-sparing mastectomy – mastectomy with removal of

To determine whether patients who received

Fisher et al. NEJM 2002

Advantages over radical mastectomy

Good postoperative cosmetic appearance

Maintain motor activity in the arm

Low rate of postoperative arm edema

Easy postoperative breast reconstruction

Patey: removal of pectoralis minor muscle

Madden and Auchincloss: preservation of

Histological assessment of the

Assessment of the patient’s needs and

Large tumor in a small breast

Prophylactic mastectomy for familial or

Cost and inconvenience of irradiation

Because the doctors say so

29 percent of patients had been offered only

‘Total mastectomy with en bloc

Preservation of pectoralis major muscle

Lateral - anterior margin of latissimus

Superior - subclavius muscle

Inferior - caudal extension of the breast

Level III dissection

Level III dissection

Tominaga et al. Br J Surg 2004

Level III dissection

Freeman et al. EJSO 2003

Freeman et al. EJSO 2003

Level III dissection

Following MRM, standard practice involves

Suturing of flap to muscle and avoiding wound drainage can be

Purushotham et al. Br J Surg 2002

Sixty patients underwent MRM

No differences in total drainage contents

Puttawibul et al. J Med Assoc Thai. 2003

Level III dissection

Fails to decrease postoperative drainage and

significantly decrease the duration and

no significant benefit on axillary lymphatic

No impact on the postoperative drainage

Decreased amount and duration of seroma

Carcoforo et al. J Am Coll Surg 2003

MRM remains an important tool for

Various methods to reduce postoperative

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