Mastectomies remove all breast tissue in addition to a skin ellipse with nipple (A) and frequently the axillary tail image. Skin-sparing (B) and nipple-sparing (C) mastectomies may also be performed.

The deep margin of a mastectomy is the pectoralis muscle fascia image. The anterior “margins” are below the skin flaps image. The base of the nipple image is a margin for nipple-sparing mastectomies.


Surgical Procedure

  • Mastectomy is intended removal of all breast tissue

  • In some women, breast epithelium is present in subcutaneous tissue or axillary tissue beyond the typical extent of the breast

  • Therefore, all breast epithelial cells may not be removed by mastectomy

    • Prophylactic mastectomies reduce risk of breast cancer by 90%

    • Rarely, breast cancers arise in residual breast tissue


  • Majority of women can be successfully treated with breast-conserving therapy (BCT) and radiation therapy

    • Rate of local recurrence is higher with BCT, but survival is similar

    • Women with potentially surgically curable disease (DCIS, small node-negative invasive carcinomas) may have a greater benefit from mastectomy as cancer may recur at a higher stage

  • Mastectomy may be preferred procedure in some cases

    • Extensive carcinoma or multiple carcinomas that cannot be removed with cosmetically acceptable results

    • Centrally located carcinomas

    • Skin or chest wall involvement; many patients will be treated 1st with neoadjuvant chemotherapy

    • Patients with high risk of subsequent carcinoma (e.g., BRCA germline mutation carriers)

    • Patients not eligible for radiation due to previous treatment or collagen vascular disease

    • Patient choice

Types of Mastectomy

  • Simple

    • Removes breast tissue and skin ellipse including nipple

    • Small amount of muscle may be removed if carcinoma is close to deep margin

    • Axillary dissection is not performed

      • However, some lower lymph nodes may be present; lateral tissue should always be examined for nodes

  • Radical

    • Removes breast tissue, skin ellipse (including nipple, pectoralis major, and minor muscles), and axillary lymph nodes

    • Currently performed rarely except for carcinomas that invade into chest wall

    • Modified radical mastectomy is a simple mastectomy (without removal of muscle) and axillary dissection

  • Skin-sparing

    • Removes breast tissue and nipple with small amount of surrounding skin

  • Nipple-sparing

    • Removes breast tissue

    • Does not remove nipple or skin

    • May be appropriate for carcinomas at least 2 cm from nipple with limited amounts of DCIS

    • Base of nipple is a margin that must be sampled separately and submitted by the surgeon

  • Subcutaneous

    • Removes 85-90% of breast tissue

    • Does not remove nipple or skin; flaps are usually thick

    • Similar to nipple-sparing mastectomy but removes less breast tissue

      • Most common indication is gynecomastia in men

  • Prophylactic

    • Removes breast tissue and skin ellipse including nipple

    • Performed for risk reduction; no known carcinoma is present in the breast at time of surgery

    • Occult invasive carcinomas are found in 3-15% of cases; generally < 1 cm

Lymph Node Sampling with Mastectomy

  • Sentinel node biopsy

    • Sentinel nodes are identified by dye or radioactive tracer

    • Average number of nodes is 2, but more may be identified in some patients

    • Metastases are most often found at the pole of the node stained with blue dye

  • Axillary dissection

    • Extent of dissection may include levels I, II, or III

    • Surgeon should indicate extent of dissection

    • Ideally, at least 10 nodes should be found

      • If fewer nodes are present, additional examination of specimen &/or submission of tissue should be considered

  • Intramammary nodes

    • Nodes may be present within the breast and are usually located in upper outer quadrant

    • Typically not the sentinel node


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Jul 6, 2016 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on Mastectomies

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