From modified radical mastectomy to infra-radical mastectomy: a phase I study for surgical de-escalation focusing on pathological analyses

Veronique Jossa; Fabrice Olivier; Eric Lifrange; André Crevecoeur; Audrey Courtois; Michel Coibion; Guy Jerusalem

doi:10.21037/gs-21-48

From modified radical mastectomy to infra-radical mastectomy: a phase I study for surgical de-escalation focusing on pathological analyses

Gland Surg. 2021 Jun;10(6):1931-1940. doi: 10.21037/gs-21-48.

Authors

Veronique Jossa¹, Fabrice Olivier², Eric Lifrange³, André Crevecoeur⁴, Audrey Courtois², Michel Coibion⁵, Guy Jerusalem⁶

Affiliations

¹ Anatomo-Pathology Department, CHC Montlegia, Liege, Belgium.
² Medical Oncology Department, University Hospital of Liege, Liege, Belgium.
³ Senology Department, University Hospital of Liege, Liege, Belgium.
⁴ Center of Senology, Liege, Belgium.
⁵ Gynecology Department, CHC Montlegia, Liege, Belgium.
⁶ Medical Oncology Department, CHU Liège and Liège University, Liege, Belgium.

Abstract

Background: Despite that breast conservative therapy became the standard of care in breast cancer, modified radical mastectomy, a large mutilating surgery, is still required for an important number of patients. In order to improve the quality of life and the psychological aspects of a surgery involving the femininity of woman, we developed a new less invasive procedure called infra-radical mastectomy. It aims to save the neckline of patients by the maintenance of the peripheral skin-fatty flap that constitutes the base for implantation of the breast. This phase I study analyzed the feasibility of this procedure using outcome of anatomo-pathological analyses as primary endpoint.

Methods: Between March 2015 and July 2017, all women with operable breast cancer without signs of lymph node invasion were invited to participate in the study in the 2 participating institutions. After a water-assisted dissection of the peri-glandular space, an enucleation of the breast was performed by a cold knife which represents the infra-radical mastectomy. A peri-glandular re-excision (PGR) of the skin and the fat tissue surrounding the gland was then achieved to obtain an MRM. This PGR underwent a careful pathological examination (10 samples per patient). Moreover, the tissue volume and the skin surface of the PGR were quantified.

Results: A total of 53 patients (median age: 60 years) were prospectively recruited. The pathological analysis of peri-glandular biopsies revealed none residual invasive carcinoma, 1% of biopsies contained focal ductal carcinoma in situ (DCIS) and 0.4% atypical hyperplasia corresponding to 4 and 2 patients respectively. These 4 patients with residual DCIS were preoperatively diagnosed with extensive DCIS. On average after an infra-radical mastectomy, 37% of the volume and 53% of the skin surface of a complete modified radical mastectomy were sparred.

Conclusions: The evaluation of biopsies from peri-glandular tissue suggests that infra-radical mastectomy should be further evaluated except for patients diagnosed with extensive DCIS which must be excluded of this infra-radical approach. Additional work is needed to evaluate cosmetic outcome and impact on quality of life, the need of radiotherapy and the oncological long-term outcome.

Keywords: Modified radical mastectomy (MRM); breast cancer; conservative treatment.