Almost all the trials comparing full complete removal of the breast tissue, that is mastectomy, compared to breast conservation where only part of the breast containing the tumour, that is lumpectomy or breast conservation, followed by radiotherapy, all trials comparing these two procedures have revealed a higher local recurrence in the lumpectomy radiotherapy group compared to a fully mastectomy. In fact, the first trial showing the benefit of breast conservation by Professor Umberto Veronesi in the famous Milan-1 trial, started in Milan, revealed 8% local recurrence in the quadrantectomy group compared to only 2% in the radical mastectomy group after twenty years of follow-up. Subsequently all other trials have also confirmed that there is high local regional recurrence in the lumpectomy radiotherapy group compared to mastectomy.
So we are offering skin and, if possible, skin and nipple sparing mastectomy in ladies with early breast carcinoma where the skin is normal and the nipple is not involved. If the nipple has an ulcer or Paget's disease or nipple retraction we can remove the nipple and still perform a skin sparing mastectomy.
What are the differences between skin sparing mastectomy and radical mastectomy?
In the radical mastectomy the entire breast tissue, along with the skin over the tumour and the nipple areola, are removed whereas in a skin sparing mastectomy, which is offered in selected cases where the tumour is away from the skin envelope and away from the nipple areola, we preserve the native skin of the mammary gland, the breast, and this gives a better result in terms of appearance and quality of life. The lady looks at her own body with her own native skin of the breast, as well as the nipple areola, and she feels better. So quality of life is better in ladies who have undergone treatment for breast cancer by skin and nipple sparing mastectomy.
Classically it has been used for tumours less than 3cm in size or ladies who have diffuse tumour in the form of ductal carcinoma in situ, or DCIS, with diffused microcalcification shown on the mammogram. In those ladies it has offered excellent results. If the tumour is away from the nipple we can certainly preserve the nipple. If it is only a 2mm tumour without any diffuse microcalcification, without any evidence on imaging, like mammogram or MRI, of the diffuse nature of the disease then perhaps it will not be an appropriate treatment – it will be overkill. However, we can certainly avoid radiotherapy if the lady does not want radiotherapy or she has some medical condition which precludes the use of radiotherapy such as scleroderma or other autoimmune diseases involving skin – there radiotherapy has a severe radiation reaction. Or if there has been radiotherapy given to the chest area due to prior lymphoma in childhood or early age then, again, it is not suitable for a second dose of radiotherapy.
The third situation would be where radiotherapy cannot be given to a tumour which was initially treated by lumpectomy and radiotherapy and now the lady has developed a new tumour in the same breast. Conventionally we do not offer radiotherapy again to the same breast and therefore breast conservation after breast conservation is not a possibility. The second recurrence in the breast is usually treated by mastectomy. So skin sparing is a better option of mastectomy where the tumour is away from the skin and away from the nipple.
We are performing this procedure through a lateral crease incision which is not very popular. Most surgeons perform a skin sparing mastectomy by a periareolar incision where an incision is made around the areola and breast tissue is removed. However, in our approach we are performing this procedure through a lateral mammary crease incision where we place the incision at the lateral mammary crease and then approach the breast tissue, raising a thick flap, about 1-1.5cm thick from the skin. We have performed some research in this area and found that there is a clear plane of breast tissue separated from the subcutaneous fat and this plane is called the premammary fascial plane. We found that the premammary fascia is located 1.8cm or so in the upper outer quadrant from the skin and in the lower inner quadrant it is about 1.2-1.3cm away. So if we raise a flap about 1cm in thickness we should be safe in removing almost all the breast tissue.