Mastectomy

Until the late 1970's, the treatment of breast carcinoma was extensive resection. The presenting tumours were often large, because many patients initially disregarded the painless lump. The moral philosophy of the time was against inaction and it took several studies to convince surgeons that limited resection, combined with the then more sophisticated chemotherapy and radiotherapy, conferred the same survival rates as radical excision. Patients now present earlier, having been educated on cancer awareness and self examination. Modern imaging modalities, including MRI, Ultrasound with direct tissue elasticity assessment, digital radiography with tailored image processing and feature extraction, have all improved the assesment prior to any surgery. Before these advances, the surgical aim was to remove all tissues that might be invaded, even though no extensive tumour spread was visible at the time of surgery. The lack of information meant that a pessimistic view was considered appropriate. The breast and underlying muscle were removed in an operation, which often involved the clearance of (draining) lymph tissue from the axilla. The absence of pectorals can be seen on chest films of patients with such previous radical mastectomies.

Radiotherapy after surgery was found to improve survival rates but was complicated by secondary changes in irradiated tissue. Both radical mastectomy and intense local radiotherapy with fibrosis can affect the function of the lymphatics of the arm. The result is oedema or induration in the arm on that side. Lymph node metastasis, if extensive, can produce similar swelling.