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PubMed2001

Outpatient mastectomy: clinical, payer, and geographic influences.

OBJECTIVE: To determine (1) the use of outpatient services for all surgical breast procedures for breast cancer and (2) the influence of payer and state on the use of outpatient services for complete mastectomy in light of state and federal length-of-stay managed care legislation. DATA SOURCES: Healthcare Cost and Utilization Project representing all discharges from hospitals and ambulatory surgery centers for five states (Colorado, Connecticut, Maryland, New Jersey, and New York) and seven years (1990-96). STUDY DESIGN: Longitudinal, cross-sectional analyses of all women undergoing inpatient and outpatient complete mastectomy (CMAS), subtotal mastectomy (STMAS), and lumpectomy (LUMP) for cancer were employed. Total age-adjusted rates and percentage of outpatient CMAS, STMAS, and LUMP were compared. Independent influence of state and HMO payer on likelihood of receiving an outpatient CMAS was determined from multivariate models, adjusting for clinical characteristics (age < 50 years, comorbidity, metastases, simple mastectomy, breast reconstruction) and hospital characteristics (teaching, ownership, urban). PRINCIPAL FINDINGS: In 1993, 1 to 2 percent of CMASs were outpatient in all states. By 1996, 8 percent of CMASs were outpatient in Connecticut, 13 percent were outpatient in Maryland, and 22 percent were outpatient in Colorado. In comparison, LUMPs were 78 to 88 percent outpatient, and by 1996, 43 to 72 percent of STMASs were outpatient. In 1996, women were 30 percent more likely to receive an outpatient CMAS in New York, 2.5 times more likely in Connecticut, 4.7 times more likely in Maryland, and 8.6 times more likely in Colorado compared to New Jersey. In addition, women with Medicare, Medicaid, or private commercial insurance were less likely to receive an outpatient CMAS compared to women with an HMO payer. CONCLUSIONS: LUMP is an outpatient procedure, and STMAS is becoming primarily outpatient. CMAS, while still primarily inpatient, is increasingly outpatient in some states. Although clinical characteristics remain important, the state in which a woman receives care and whether she has an HMO payer are strong determinants of whether she receives an outpatient CMAS.

Adult↗

PubMed1987

Malignant fibrous histiocytoma of the breast with axillary lymph node involvement.

This case history describes a 70-year-old female patient with a malignant fibrous histiocytoma (MFH) of the breast with secondary involvement of the skin and axillary lymph node metastases. We think that in the case of a MFH of the breast a radical or modified radical mastectomy should be pursued instead of a simple mastectomy.

Aged↗

PubMed2005

Phyllodes tumor of borderline malignancy: seven year follow up with immunohistochemical study.

The patient was 80 years old when she initially presented with a left breast mass. Originally, a needle biopsy showed benign stromal and ductal cells. Five years later, the breast mass increased in size and a core needle biopsy showed a biphasic intraductal papillomatous tumor with cellular stroma. Eighteen months later, another biopsy was taken from the breast mass, revealing a well-developed phyllodes tumor (PT) of borderline malignancy. One month later, a simple mastectomy was performed for this 87-year-old woman. Histolopathologic and immunohistochemical studies, including estrogen and progesterone receptors, Ki-67 and p53, performed on tissues from the different biopsy specimens confirmed the progressive transition of the tumor in a 7 year period. An increase in mitotic activity was noted in the later samples. Similarly, percentages of p53- and Ki-67-positive cells were much higher in the stromal and ductal cells of the later samples compared to the original specimen. These findings support the notion that Ki-67 and p53 immunohistochemical staining may be used as simple and practical markers for the evaluation of the malignant potential of PT.

Aged↗

PubMed1993

Treatment of intraductal breast cancer--noncomedo type.

The treatment of intraductal breast carcinoma, ranging from local incision alone to modified radical mastectomy, remains controversial. Seventy-nine patients were treated for intraductal breast carcinoma, noncomedo type at our institution from 1975 to 1991. There were 78 females and one male with a mean age of 58 years and a range from 32 to 90 years. Clinical presentation included a palpable mass in 25 patients, abnormal mammogram in 60 patients, and nipple discharge in 12 patients. Treatment consisted of local excision in 19 patients, simple mastectomy in 25 patients, and modified radical mastectomy in 35 patients. Twenty-five patients underwent simultaneous prophylactic contralateral mastectomy. Choice of treatment was determined by physician preference and no differences were seen in family history, parity, nipple discharge, history of fibrocystic disease, presence of palpable lymph nodes, tumor size, tumor location, patient age, or mammographic findings. Forty-five patients had multicentric tumors on final pathology. One patient demonstrated an axillary lymph node metastasis following modified radical mastectomy raising the question of undetected invasive carcinoma. All patients were free of disease at last evaluation and no differences in survival were noted between different treatment groups with a mean follow up of 5 years. We conclude that local excision is an appropriate option for treatment of intraductal breast carcinoma noncomedo type.

Breast Neoplasms↗

PubMed1997

[Effects of tobacco smoking on the incidence of flap necrosis after mastectomy].

One hundred and fifty-nine women undergoing mastectomy (simple or modified radical) were followed for the development of flap necrosis. The incidence of flap necrosis was found to 14%. The only significant risk factor for the development of flap necrosis was found to be smoking, which increased the risk by 4.9 times. The effects of nicotine and carbon monoxide, the two principal known detrimental factors in tobacco smoke, are described. Prophylactic efforts are advised.

Cicatrix↗

PubMed2000

Immediate free TRAM reconstruction in lumpectomy and radiation failure patients.

Local recurrence after lumpectomy and radiation therapy indicates failed breast conservation surgery. These patients often proceed to mastectomy and are candidates for autogenous breast reconstruction. Free transverse rectus abdominus muscle (TRAM) reconstruction in these patients is complicated by repeated axillary dissection and the use of irradiated tissue. Complication rates for pedicled TRAMs have been reported at 33 percent when used in irradiated tissue beds. We report our results using the free TRAM for breast reconstruction after lumpectomy and radiation failure. All patients within this study developed a local recurrence after lumpectomy and radiation therapy. All patients had undergone axillary dissection for staging at the time of their lumpectomy. Patient records were reviewed for patient age, total radiation dose, associated risk factors for TRAM failure, operative time, donor vessels used for anastomosis, status of the native thoracodorsal vessels at the time of surgery, and postoperative complications. Over a 7-year period, 16 TRAM patients had undergone previous breast conservation surgery. Of these 16 patients, 14 underwent reconstruction with a planned free TRAM after simple mastectomy. Average operating room time was 7 hours. There were no partial or total flap losses. Complications were seen in 14 percent of the overall group. Overall, we found that the free TRAM provided an excellent aesthetic result with a lower complication rate than previously reported for pedicled TRAM flaps in irradiated beds. The thoracodorsal vessels provided an adequate donor vessel in 93 percent of the cases. The free TRAM provides a superior alternative in immediate reconstruction in patients who have failed breast conservative surgery.

Age Factors↗

PubMed1986

Breast cancer: presentation and prognosis in the community hospital.

A retrospective analysis of all breast cancer primarily treated at this institution during the ten-year period from 1967 to 1977 revealed 336 cases; in 308 of these cases, complete follow-up of five or more years was available. Clinical staging using the TNM system (tumor, node, metastasis) showed stage I disease in 60 patients, stage II in 94, stage III in 105, and stage IV in 49. Pathologic classification of these 308 cases showed a high incidence of infiltrating ductal carcinoma (88%). Early in the study operative treatment consisted of radical mastectomy, with modified radical mastectomy being more common in the later years. Simple mastectomy was occasionally done palliatively. Adjuvant treatment using cyclophosphamide (Cytoxan), methotrexate, 5-fluorouracil, radiation, and/or hormonal manipulation was then given according to a set protocol. In general, five- and ten-year survival improved with this combined treatment. The mortality among patients with stage I infiltrating ductal carcinoma not given adjuvant therapy suggests the need for proper selection of patients in this group who should receive adjuvant chemotherapy because they are at increased risk.

Adenocarcinoma, Mucinous↗

PubMed2005

Invasive breast cancer following bilateral subcutaneous mastectomy in a BRCA2 mutation carrier: a case report and review of the literature.

BACKGROUND: Primary prevention of breast cancer through prophylactic mastectomy can reduce the risk of malignancy in high-risk individuals. No type of mastectomy completely removes all breast tissue, but a subcutaneous mastectomy leaves more tissue in situ than does a simple mastectomy. CASE PRESENTATION: We report a case of invasive breast cancer in a BRCA2-positive woman 33 years after bilateral subcutaneous mastectomy. To our knowledge, only one case of primary breast cancer after prophylactic mastectomy in a BRCA1-positive patient has been reported in the literature and none in BRCA2-positive individuals. CONCLUSION: Careful documentation and long follow-up is essential to fully assess the benefits and risks of preventive surgical procedures in BRCA1 and BRCA2 mutation carriers.

Journal Article↗

PubMedDate not supplied

[Carcinoma of the breast in the male. Clinicopathological study of 10 cases].

The carcinoma of the male breast is a rare lesion, being aproximatelly 100 times less frequent than in women. Of 1930 cases of mammary cancer seen at the Hospital of Oncology of the National Medical Center, I.M.S.S. during a period of 10 years we found 10 histologically proved cases of carcinoma of the male breast. Their microscopic appearence was that of an invasive ductal carcinoma. The surgical treatment consisted in radical mastectomy on six patients, supermastectomy is one case and simple mastectomy in other. Two patients received radio and chemotherapy. In three patients bilateral orchiectomy was done and in other two cases a bilateral adrenalectomy was performed. The results of the review of these cases are compared with other previously reported.

Aged↗

PubMed1977

Reconstruction of the breast after mastectomy.

We have described our techniques for reconstruction of the breast after a simple mastectomy, a modified radical mastectomy, and a radical mastectomy. Inadequate skin cover must be relieved, preferably by transposition of a thoracoepigastric flap. Not only must a mound be created, but also a nipple-areola complex. The areola can be constructed by nipple-sharing techniques from the opposite breast or by the use of the labia minora and/or the labia majora. However, we advise preservation and banking of the nipple-areola (or areola) by the ablative surgeon, when possible. The remaining breast usually requires some modification to match the reconstructed one.

Breast↗

PubMed1997

[The surgical treatment of nonpalpable breast lesions].

Non-palpable breast lesions may be defined as suspected lesions for "occult" tumours and diagnosed during the course of screening or, occasionally, in asymptomatic women. Mammography is the main diagnostic instrument owing to its high sensitivity and specificity, although an increasingly important complementary role is played by ultrasound scan. The comparison of findings obtained provides elements for further evaluation. Moreover, mammography can be used to make a dynamic study of the breast over time in order to evaluate doubtful lesions that might change, especially in women of a child-bearing age and during the various phases of the menstrual cycle. The use of the metal repere allows the lesion to be identified and surgically removed. A total of 135 operations for breast pathologies were examined from 1 January 1994 to 30 April 1996, subdivided into 26 operations for benign pathologies and 109 for malignant pathologies. Of the latter 52 (47.7%) were modified radical mastectomies, 50 (45.9%) were quadrantectomies with axillary lymphadenectomy, 1 (0.9%) quadrantectomy, and 5 (5.5%) simple mastectomies. A total of 16 needle biopsies were performed of which 8 were benign and 8 malignant. The latter were treated using 2 modified radical mastectomies owing to the presence of an extensive intraductal component, 5 quadrantectomies with lymphadenectomy, and 1 simple quadrantectomy for a lobular carcinoma in situ. Kopans needle was also used as a repere and the stiffening cannula was used for an accurate, effective but economical exeresis. One of the 8 benign cases was complicated by an hematoma (12.5%). Neither the mammary gland nor the subcutis were sutured to avoid unsightly scars and uncertain images at later mammographic controls.

Biopsy, Needle↗

PubMed1987

Overview of randomized trials of postoperative adjuvant radiotherapy in breast cancer.

An overview of the mortality results of the mature trials in which radiotherapy was a randomized option after simple or radical mastectomy is presented. The principal aim of the overview was to study long-term survival, and recent trials, often including chemotherapy options, have not been included. A total of 7941 patients were entered into these trials and 4148 deaths occurred. No differences were found in survival in the first 10 years of follow-up, in trials employing either radical mastectomy or simple mastectomy. Follow-up information after 10 years came mostly from trials employing radical mastectomy with or without irradiation, and in these trials a significant excess of deaths was observed among patients given radiotherapy (P less than 0.001, all trials; P = 0.002, radical mastectomy trials only). Further data collection will be necessary to determine which causes of death are elevated.

Breast Neoplasms↗

PubMed1989

Changes in the surgical management of early breast cancer in England.

A questionnaire survey of consultant surgeons in England indicates that there has been a considerable change in opinion over the past few years concerning the management of early breast cancer; only 39.1% would now perform mastectomy, whereas 64.4% would perform conservative surgery. The most common forms of management are simple mastectomy and axillary clearance (21.9%); wide excision, axillary clearance plus radiotherapy (20.1%); and wide excision plus radiotherapy alone (16.9%). The majority of the surgeons would offer patients a choice of surgery, but only 52% had access to a breast care nurse.

Attitude of Health Personnel↗

PubMed1986

[Prognosis of breast cancer--20 years experience in radical mastectomy].

From 1958 to 1982, 1,035 patients with breast cancer were treated by operation in our hospital. The follow up rate was 100% and 804 were followed for more than 5 years. Radical mastectomy was performed in 695 of the 804 patients, the rest were treated by simple mastectomy, modified radical mastectomy and extended radical mastectomy. The 5, 10, 15 and 20 year survival rates were 71.8%, 58.2%, 48.8% and 41.8%. According to the UICC TNM classification, the 5, 10, 15 and 20 year survival rates of stage I were 84.5%, 77.0%, 58.3% and 75.0%, of stage II, 72.8%, 57.4%, 53.5% and 58.8%, and of stage III, were 55.3%, 44.7%, 36.5% and 8.0%, respectively.

Breast Neoplasms↗

PubMed1994

Advantages of outpatient breast surgery.

This article outlines surgical, financial, and psychosocial advantages of outpatient, definitive breast cancer surgery. The analysis of 118 patients who underwent outpatient breast cancer surgery between January 1991 and December 1993--20 modified radical mastectomy, 90 lumpectomy and axillary dissection or axillary dissection alone, and 8 partial or simple mastectomy--revealed only three patients with minor complications requiring admission. Same-day discharge was safely accomplished by early morning admission and using recovery room time for postoperative education. Outpatient cost was $1572 compared with an average 3-day inpatient cost of $6282, for a potential savings of $4710, or 75%, per patient for modified radical mastectomy. Outpatient cost was $1080 compared with an average 2-day inpatient cost of $4907, for a potential savings of $3827, or 78%, per patient for lumpectomy with axillary node dissection. Patients have indicated a high level of satisfaction with ambulatory surgery and experienced faster healing and recovery at home within the family milieu.

Ambulatory Care↗

PubMed2005

Selective use of post-mastectomy flap irradiation in high-risk breast cancer patients.

The incidence of local recurrence after mastectomy can be reduced by chest wall radiotherapy. However, only a minority of patients are at substantial risk. No UK national guidelines exist for the use of mastectomy flap radiotherapy. This study evaluated a protocol, whereby only high-risk patients were treated with post-mastectomy flap radiotherapy; identified histologically by grade, vascular invasion and nodal status. All women treated by simple mastectomy for invasive breast cancer at the Nottingham Breast Unit from January 1993 to December 1995 were studied (n=292). Postoperative flap radiotherapy was given to 147 high-risk women (50.3%). Median follow-up was 76 months. Overall, 12 women (4.1%) developed a chest wall recurrence; six were single spot recurrences and the remaining six were either multiple spot (n=3) or field change (field change dermal invasion, n=3). The chest wall recurrence rate was 2.7% in those treated with radiotherapy. A low rate of local recurrence has been achieved with selective use of mastectomy flap radiotherapy.

Adult↗

PubMed2005

Satisfaction after contralateral prophylactic mastectomy: the significance of mastectomy type, reconstructive complications, and body appearance.

PURPOSE: Contralateral prophylactic mastectomy (CPM) is one option for reducing the risk of a second breast cancer in women with a personal and family history of breast cancer. Few data are available regarding satisfaction, psychological, and social function after CPM. The purpose of this research is to evaluate women's long-term satisfaction with CPM, factors influencing satisfaction, and psychological and social function after CPM. PATIENTS AND METHODS: This was a descriptive study of all women with a family history of breast cancer, known to be alive, who elected CPM at Mayo Clinic (Rochester, MN) between 1960 and 1993 (n = 621). Ninety-four percent of the women (n = 583) completed a study-specific questionnaire. RESULTS: A mean of 10.3 years after the procedure, the majority of women (83%) were satisfied with their CPM. A smaller number were neutral (8%) or dissatisfied (9%). Women who had a subcutaneous mastectomy had more problems with reconstruction, and fewer of these women were satisfied than women with simple mastectomy. Decreased satisfaction with CPM was associated with decreased satisfaction with appearance, complications with reconstruction, reconstruction after CPM, and increased level of stress in life. The majority of women experienced no change or favorable effects in self-esteem (83%), level of stress in life (83%), and emotional stability (88%). Satisfaction with body appearance, feelings of femininity, and sexual relationships were the most adversely affected with 33%, 26%, and 23% of the women responding negatively. CONCLUSION: Although most women are satisfied with CPM, each woman should weigh the benefits alongside the potential adverse effects.

Adaptation, Psychological↗

PubMed1978

Electromyography in the estimation of nerve lesions after surgical and radiation therapy for breast cancer.

EMG was performed on the upper extremity of the affected side in 55 breast cancer patients who had undergone mastectomy and postoperative radiotherapy. Radical mastectomy caused six latissimus pareses out of 26 patients and seven deltoideus pareses out of 49 patients. Simple mastectomy caused no pareses. As an early complication of radiotherapy five out of 16 patients developed slight EMG changes, most often in the biceps brachii muscle, but no clinical pareses were observed. In the follow-up group (at least 5 years after primary treatment) 18 out of 25 patients had varying EMG alterations. The relative frequency of EMG findings indicates an increasing number of neural changes caused by radiotherapy in the follow-up group. Severe pareses were infrequent as complications of radiotherapy. In neurography of the cutaneous branch of n. radialis a diminution of the amplitude of the sensory response was found one or two months after radiotherapy in the affected side. EMG proved to be useful in estimating both the early and late neural complications of primary treatment of breast cancer and in evaluating patients' capacity for work.

Breast Neoplasms↗