Endoscopic Mastectomy: What does the Future Hold?

“Endoscopic breast surgery is associated with minimal scarring and postoperative pain and it appears that wound complications are rare events.”

There have been significant advances in the surgical management of breast cancer since 1891 when Halsted proposed that a radical surgical approach to breast cancer management was the key to successful treatment of the disease [1]. In 1948, Patey and Dyson reported a less radical approach to mastectomy by preserving the pectoralis major muscle and the overlying skin [2]. Another significant milestone was the introduction of breast-conservation surgery (BCS), and randomized, controlled trials have demonstrated that the result of BCS combined with radiotherapy is comparable to mastectomy [3]. Skin sparing and subcutaneous mastectomy was introduced subsequently and, at the same time, there has been evolutionary changes in breast reconstruction surgery including silicone implant, autologous pedicle flap and, more recently, free perforator flap reconstruction.

“Endoscopic surgery has been carried out extensively in many surgical conditions and has gained acceptance as an alternative and less invasive approach to open surgery.”

The quest for a less invasive approach in the surgical management of breast cancer continued with the prime aim of complete removal of cancer and preservation or restoration of the patients' body image.

Endoscopic surgery has been carried out extensively in many surgical conditions and has gained acceptance as an alternative and less invasive approach to open surgery. In breast cancer treatment, this approach has been gaining popularity in Asian countries, such as Japan, Korea and China, over the last decade. The main reason for this is that women in this part of the world have small breasts and BCS can lead to obvious breast asymmetry and inadequate resection margin; therefore, subcutaneous mastectomy and reconstruction using endoscopic approach has become increasingly popular even in early-stage breast cancer. The main indications for endoscopic mastectomy include extensive ductal carcinoma in situ as well as early invasive breast cancer (T1/T2) in patients with small breasts in whom BCS may lead to obvious deformity or in patients who do not wish to undergo radiotherapy and, therefore, opt for mastectomy. It is also suitable for risk-reducing mastectomy in patients with a strong family history of breast cancer with proven BRCA1/BRCA12 mutation.

The procedure is performed by making a small incision (∼2.5 cm) in the axilla, which is used for sentinel node biopsy (open or endoscopic). Through the same opening, an endoscope is inserted and the breast tissue and pectoral fascia is separated from the pectoralis major muscle under the direct vision. The view is very clear and authors use ClearGlide™ (Datascope®, NJ, USA) vessel harvesting system to perform this part of the operation. Depending on the size and location of tumor and the breast size, an additional periareolar incision is made in order to perform the superficial dissection of mammary tissue from the overlying skin as well as more controlled dissection of breast ducts from the nipple. This is achieved by creating subcutaneous tunnels endoscopically under direct vision and dividing the bridging tissue using bipolar diathermy scissors or harmonic scalpel. Most centers perform this procedure without the use of CO₂ insufflations, although CO₂ has been used in order to create the working space during dissection. It is essential that the specimen is delivered intact through the periareolar wound and appropriately orientated to ensure adequate histological analysis is carried out with particular emphasis on the resection margins. Reconstruction of breast can be carried out simultaneously or at a later date and the commonly practiced method of reconstruction is the use of an expandable implant, although autologous latissimus dorsi flap can also be used. The reason for the use of expander implant is that it can be deployed in the submuscular plane through the small axillary incision with relative ease. Dissection and creation of the submuscular pocket is also carried out endoscopically. Adjuvant treatment in a form of chemotherapy, hormonal therapy or radiotherapy is advised, based on the individual characteristics of the tumor.

The concerns expressed about the endoscopic approach in breast cancer surgery include safety considerations regarding the adequacy of tumor clearance, locoregional disease control and long-term survival. Currently, the evidence in the published literature is based on eight case series [4–11] and one nonrandomized controlled trial [12], with a total of 242 patients recruited in these trials and a maximum mean follow-up duration of 28 months. There are no published reports on any randomized, controlled trials and, therefore, there is a lack of level 1 evidence in support of this technique.

“The main indications for endoscopic mastectomy include extensive ductal carcinoma in situ as well as early invasive breast cancer…”

As far as the adequacy of tumor resection is concerned, the rate of involvement of resection margins reported in one nonrandomized study is 5% for endoscopic mastectomy (one in 21 patients) as compared with 8% margin involvement in subcutaneous mastectomy group (two in 25 patients). There has been no report of recurrence around the axillary or periareolar scars, which are equivalent to port sites in laparoscopic surgery.

With regard to the locoregional control, it appears that the procedure is safe in experienced hands and, to date, there is only one report of salvage mastectomy in all studies reported with no cancer-related mortality observed in any of these patients.

Between 1995 and 2007 in E Fukuma's group at the Kameda Medical Center, Japan, a total of 385 patients underwent endoscopy mastectomy. The local recurrence rate during this period has been 1.3% (five in 385 patients). From 1996, the same group commenced endoscopic BCS and until 2007 they had performed 966 such procedures. The local recurrence rate in this cohort of patients was 0.62% (six in 966 patients); there has not been any recurrence at the site of the nipple–areolar complex where the excised specimen is retrieved.

There is no report of any major perioperative complications associated with endoscopic, approach, although hematoma and hemorrhage can occur and one study reports 8.5% subcutaneous hemorrhage rate (seven in 82 patients), two of which settled without any surgical intervention [4]. There are also few reports of superficial skin burns due to the use of diathermy through a small opening incision. These complications can be attributed to the relative lack of experience and the learning curve associated with the new procedure.

The operation time for endoscopic mastectomy is longer than open mastectomy owing to the added set-up time and limited access, and this may affect scheduling of the operating lists. As far as the patient satisfaction and cosmetic outcome is concerned, most studies report a high rate of patient satisfaction with good to excellent cosmetic outcome. Capsular contracture is a major complication that can occur if the reconstructed breast is irradiated postoperatively; therefore, patients who are likely candidates for postoperative radiotherapy either are not offered this procedure or the reconstruction is deferred and performed as a second operation. We advocate the two-stage approach in patients diagnosed with invasive breast cancer.

Endoscopic breast surgery is associated with minimal scarring and postoperative pain and it appears that wound complications are rare events; moreover, there is evidence to support that the length of stay in hospital is shorter than open procedures. Endoscopic mastectomy is now an accepted alternative to open mastectomy in Japan, so much so that in 2002 the reimbursement of endoscopic breast surgery was agreed by the Japanese health authority. However, it has been very slow to take off in Europe and North America. We have commenced this procedure in the UK to test its feasibility in this part of the world and are offering it to patients who fulfill the entry criteria outlined above.

Training in performing the endoscopic surgery and following a sound oncological principles are of paramount importance for the success of this procedure. This procedure requires good hand–eye coordination, and previous experience in performing endoscopic surgery is essential. It is also important that the whole team involved in the care of a patient are familiar with this technique. Experience with the instruments and equipment is also important since some of them are not normally used in laparoscopic surgery. Adequate patient selection is the key to the success of the procedure.

We must learn from the past experience of the introduction of laparoscopic cholecystectomy with associated significant complications due to a lack of experience.

In order to safely disseminate the procedure, experts in performing the operation should oversee or monitor trained clinicians and the results of the procedure should be audited. Clinicians should be allowed to perform the procedure unsupervised only after the satisfactory outcomes have been achieved.

Conclusion & future perspective

Endoscopic breast surgery plays an important role in the management of patients with early breast cancer. It is suitable for patients with small-to-moderate-sized breasts and reconstruction can be performed immediately or at a second stage. The reports from single institution studies are very encouraging; however, level 1 evidence in support of this approach is lacking and there is a need for randomized, controlled trials to provide evidence for the safety and the efficacy of the technique. It is also essential that these patients are followed up for a long period of time in order to ensure that it is safe in a long run. Adequate training is essential for the success, so the future is bright.