Clinical Practice Guidelines for Modified Radical Mastectomy of Breast Cancer: Chinese Society of Breast Surgery (CSBrS) 2021 Guidelines
In China, over 70% of patients with early-stage breast cancer undergo mastectomy—and for those with cancerous axillary (underarm) lymph nodes, the Auchincloss operation is the most common surgical technique. To standardize how this procedure is performed, the Chinese Society of Breast Surgery (CSBrS) brought together 81 experts—including breast surgeons, oncologists, radiologists, and epidemiologists—to create evidence-based guidelines. These rules help ensure safe, effective care for breast cancer patients while balancing clinical practicality. Here’s what you need to know:
Why These Guidelines Exist
Modified radical mastectomy (MRM) removes the entire breast and nearby lymph nodes but spares key chest muscles (unlike older “Halsted radical” surgery). The Auchincloss variation—first proposed in 1951—goes a step further by keeping both the pectoralis major and minor muscles, which preserves chest function and appearance. But without clear standards, surgical techniques varied widely. The CSBrS guidelines aim to fix that by synthesizing research, expert input, and real-world feasibility.
Key Recommendations (Simplified)
The guidelines use a grading system (Level I evidence = strongest data; Recommendation A = high confidence) to outline best practices:
1. Who Needs This Surgery?
MRM is recommended for:
- Early-stage breast cancer where breast-conserving surgery (BCS) isn’t an option (e.g., large tumors, multiple lesions).
- Patients with positive axillary lymph nodes (cancer has spread to underarm nodes).
- Cases where doctors can achieve R0 resection (complete removal of all visible tumor).
2. Incision Design
Surgeons should prefer a horizontal Stewart incision—it’s less visible and reduces skin tension. If that’s not possible (e.g., large tumors), an “S” shape or “parallelogram” cut works too.
3. How to Lift the Skin
The skin is separated from the breast tissue in the superficial fascia (a thin layer just below the skin). This preserves blood flow and reduces skin damage.
4. How Far to Lift the Skin
The skin flap (the area of skin separated from the breast) should extend:
- 1–2 cm below the collarbone (upper boundary).
- To the ribcage (lower boundary).
- To the middle of the chest (parasternal line, medial boundary).
- To the edge of the latissimus dorsi (a large back muscle, lateral boundary).
5. Lymph Node Dissection
Doctors typically remove level II axillary lymph nodes (nodes under the pectoralis minor muscle). If there’s obvious cancer in level II or III (nodes near the collarbone), level III nodes are also removed. At least 10 nodes must be taken to accurately stage the cancer.
The Science Behind the Choices
Surgical History
Older radical surgeries removed the pectoralis muscles, causing severe chest deformity. The Patey technique (1948) saved the pectoralis major; Auchincloss (1951) saved both muscles. This reduces nerve damage and improves quality of life—critical for long-term recovery.
Pectoral Fascia: To Remove or Not?
Traditional surgery removed the pectoralis fascia (the thin layer covering chest muscles) to prevent cancer spread. But experts found no evidence that removing it improves survival. Still, they recommend taking the pectoralis major fascia because it doesn’t cause harm.
Nerve Protection
During lymph node dissection, surgeons must protect two key nerves:
- Thoracic dorsal nerve: Controls the latissimus dorsi (back muscle). Damage causes muscle atrophy.
- Long thoracic nerve: Controls the serratus anterior (chest muscle). Damage leads to shoulder weakness.
The intercostobrachial nerve (which senses feeling in the inner arm) should also be saved unless it’s attached to cancerous nodes—removing it causes numbness.
What Patients Should Know About Recovery
Common complications include:
- Bleeding/infection: Prevented by careful surgical hemostasis (stopping blood flow) and post-op care.
- Skin flap necrosis: Death of skin tissue from poor blood flow—minimized by proper skin flap technique.
- Lymphedema: Swelling in the arm from blocked lymph flow. Risk factors include obesity, infection, and fluid buildup (seroma).
To reduce lymphedema risk:
- Avoid blood draws or IVs in the affected arm.
- Don’t lift heavy objects with that arm.
- Do gentle arm exercises to improve lymph flow.
Severe lymphedema may need compression garments, physical therapy, or surgery.
Who These Guidelines Are For (and Who They’re Not)
The rules are only for breast disease specialists in China. They’re not a substitute for personalized medical advice—patients should always discuss treatment with their care team. The CSBrS also notes that the guidelines don’t resolve medical disputes or replace clinical judgment.
Where to Find More
The full surgical procedure and committee details are available in the appendix (http://links.lww.com/CM9/A478). The original study was published in the Chinese Medical Journal (2021) by authors from the Henan Breast Cancer Center at Zhengzhou University’s Affiliated Cancer Hospital.
For more on breast cancer surgery standards, you can reference the NCCN Clinical Practice Guidelines (https://www.nccn.org/professionals/physician_gls/f_guidelines.asp) or the CSBrS’s 2018 expert consensus.
These guidelines represent a big step toward safer, more consistent breast cancer care in China. By standardizing techniques like the Auchincloss operation, doctors can improve outcomes while honoring patients’ quality of life.
doi:10.1097/CM9.0000000000001412
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