Bernard Fisher reflects on a half-century's worth of breast cancer research.
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Antineoplastic Agents, Hormonal↗
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Results for “Mastectomy, Modified Radical”
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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↗
TRAM flaps: a reconstructive option after bilateral nipple-sparing total mastectomy.
BACKGROUND: Transverse rectus abdominis musculocutaneous (TRAM) flaps have commonly been used as a reconstructive option after total mastectomy or modified radical mastectomy, but they can also serve as an appropriate alternative after bilateral nipple-sparing total mastectomy. In this study, performed from 1992 to 2002, 16 patients underwent TRAM flap breast reconstruction after bilateral nipple-sparing total mastectomy. METHODS: The indications for bilateral nipple-sparing total mastectomy all involved benign breast disease; these patients were evaluated using a health outcomes study and the aesthetic evaluations of four judges using postoperative photographs. One patient had free flaps and 15 patients received pedicled flaps. Eleven patients had secondary reconstruction with bilateral TRAM flaps after implant removal, and five patients underwent immediate reconstruction with bilateral TRAM flaps. RESULTS: Patients reported satisfactory physical and emotional functioning after the surgery without any significant detrimental effects on quality of life. Follow-up ranged from 3 to 90 months (median follow-up, 21 months). The cosmetic outcome of the reconstructed breast after bilateral nipple-sparing total mastectomy yielded fair to excellent results in the majority (80 percent) of patients. CONCLUSIONS: Bilateral nipple-sparing total mastectomy remains an option for women with symptomatic breast conditions or with a high risk of familial breast cancer. Autologous tissue remains a reasonable alternative for reconstruction after bilateral nipple-sparing total mastectomy in the appropriately selected patient. To date, all patients in the study have remained free of breast cancer (range, 2 to 21 years).
Adult↗
Natural history of node-negative breast cancer: a study of 826 patients with long-term follow-up.
PURPOSE: We were interested in examining the long-term outcome of patients with node-negative breast cancer to address the following questions: (1) Is node-negative breast cancer a disease that is curable by local modalities? (2) Are there predictors of disseminated disease in node-negative breast cancer? (3) Are there subgroups of tumors that have different times to recurrence? METHODS: From 1927 to 1984, 826 women with node-negative breast cancer were treated at the University of Chicago. Patients underwent either a radical or extended radical mastectomy (83%) or a modified radical mastectomy (13%). RESULTS: Follow-up evaluation ranged from 9 to 523 months (43.6 years); the mean follow-up period of survivors is 162 months (13.5 years). On multivariate analysis, the strongest predictor of outcome and time to relapse was pathologic tumor size. Patients with tumors less than 2 cm had a 20-year disease-free survival (DFS) rate of 79% and a median time to recurrence of 48 months as compared with patients with tumors greater than 2 cm, who had a survival rate of 64% (P < .001) and a median time to recurrence of 37 months (P = .01). CONCLUSION: With extended follow-up evaluation, node-negative breast cancer is a curable disease. Size is the strongest predictor of dissemination and rate of relapse. These data suggest that given the natural history of node-negative breast cancer, analysis of clinical trials with short follow-up periods can be misleading, since it may identify those patients whose tumors have a greater virulence but not necessarily a greater likelihood to metastasize.
Actuarial Analysis↗
[Patey's radical mastectomy in combined treatment of breast cancer].
The late results of treatment of operable patients with breast carcinoma are analysed. The frequency of local recurrences and metastases in the subclavicular lymph nodes and distal organs are compared according to the method of operative intervention. It is emphasized that purposeful exposure to radiation makes it possible to achieve similar results in Patey's, Halsted's, and Urban-Holdin's operations. From the functional standpoint, however, conservative radical mastectomy surpasses radical and extended radical mastectomy considerably. All this allows Patey's operation in combination with irradiation to be recommended for wide introduction into therapeutic practice at oncological institutions of the Soviet Union.
Adult↗
[Treatment of breast cancer].
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Antineoplastic Agents↗
[Surgical treatment of breast cancer in elderly women--analysis of 244 patients].
From April 1964 to December 1981, 244 patients, women over 60 years old, with unilateral breast cancer were treated by surgery in our hospital. In this series, 15 patients (6.1%) had Stage I, 131 (53.6%) Stage II, 82 (33.6%) Stage III and 16 (6.6%) unstaged lesions. Of these patients, 3 were treated by extended radical mastectomy (ERM), 140 by standard radical mastectomy (SRM), 49 by modified radical mastectomy (MRM) and 52 by total mastectomy (TM). Except 52 cases by TM, axillary lymph node metastasis rate in 192 patients of this series was 49.3%. The 5- and 10-year survival rates were 33.3% in ERM group, 53.4% and 39.5% in SRM group, 70.8% and 48.5% in MRM group, and 73.4% and 55.3% in TM group, respectively. The overall 5-and 10-year survival rates were 62.1% and 45.6%. In Stage I, II patients, the 5-and 10-year survival rates of TM group were much higher than those of SRM and MRM groups (P less than 0.01), but in Stage III, the 5- and 10-year survival rates of MRM group were higher than those of other groups (P less than 0.05). Noticeably, the 5- and 10-year survival rates of SRM group in Stage I approximately III were not satisfactory. Our data show that the postoperative radiotherapy or chemotherapy was ineffective in elderly patients with breast cancer.
Aged↗
[Established and new surgical procedures in the therapy of breast cancer].
The established surgical procedure in the treatment of mammary cancer today is, without any doubt the modified radical mastectomy (Patey, Dyson). The adjuvant radiation therapy, following modified radical mastectomy, could not improve the all over survival of mammary cancer patients. Within the last years the breast conserving surgical procedures went more and more into the field of interest, especially of the patients. That is the reason, why these treatment-schedules should be considered very carefully according to thorough oncological principles. The radiation therapy within the conserving treatment is necessary as primary treatment in addition to surgery.
Breast↗
Submuscular breast reconstruction--indications and techniques.
We review the care and treatment of 93 patients who underwent submuscular breast reconstruction in our service between 1975 and 1980. The indications and clinical situations in which submuscular reconstruction has been useful include: following simple mastectomy; following modified radical mastectomy; following subcutaneous mastectomy (immediate or delayed reconstruction); in standard augmentation mammaplasty in selected patients; and with unusual, unsatisfactory, or dangerous preexisting breast conditions. Unusual indications include unsatisfactory subcutaneous placement with capsule formation after subcutaneous mastectomy; use of unsatisfactory or dangerous implants such as Ivalon and Etheron; and replacement of the old-fashioned Cronin gel implants with fixation patches. Submuscular placement has also been used to advantage in patients with excessively scarred, tenuous skin. Technical modifications in the submuscular implantation technique are detailed. We have used subserratus-subpectoral placement in most instances. Technical tips to keep the implant in a low position by division of the serratus attachments and limitations of upward dissection are detailed. Clinical studies on the upward migration of implants and pressures developed under the serratus and pectoralis muscles as measured by manometer are also detailed.
Breast↗
[Paget's disease of the breast].
Paget's disease of the nipple is a rare lesion that is not always associated with underlying breast cancer. The authors report three cases of Paget's disease; in two of the three patients examined, the disease became evident following the appearance of an erythematous and erosive lesion on the nipple and areola, but no clinical evidence of an underlying nodule. In both cases diagnosis was made by integrating cytological tests by apposition of the nipple with mammography. In the third case the disease became manifest following the onset of a lesion on the nipple and areola with the characteristics of chronic eczema in association with a retroareolar nodule, measuring 3 cm, with the mammographic characteristics of an infiltrating carcinoma. All three patients were treated by radical mastectomy modified according to Madden.
Aged↗
A descriptive study of pulmonary complications after postoperative radiation therapy in node-positive stage II breast cancer.
This study was conducted to assess the frequencies of symptomatic pulmonary complications following adjuvant postoperative radiotherapy using different treatment techniques in patients with Stage II node-positive breast cancer. During 1991-1993, 177 patients were referred to the Radiotherapy Department of Stockholm Söder Hospital; 144 after modified radical mastectomy and 33 after partial mastectomy. The records of these patients were studied retrospectively for clinically diagnosed radiotherapy-induced lung complications 1-7 months after treatment. Thirty-three of 138 patients (24%) irradiated after modified radical mastectomy developed pulmonary complications and 20 (14%) of these were diagnosed as severe, i.e. needing medical treatment with corticosteroids. No statistically significant difference could be found between the different electron energies used for treating the chest wall and the frequency of respiratory side-effects. Eighteen of 33 patients completed the prescribed treatment after partial mastectomy. Nine of these 18 patients (50%) developed pulmonary complications and 4 (22%) developed severe reactions. Fifteen patients received alternative treatments. With the techniques used after partial mastectomy the median central lung distance was 32 mm among the patients who experienced respiratory side-effects compared with 25 mm among the patients who were not affected (p = 0.03). This study identifies acute/subacute pulmonary side-effects as a clinically significant problem. Prospective follow-up with lung function tests, identification of risk factors, and individual lung dose volume histograms is warranted to assess the long-term implications.
Adult↗
Breast carcinoma and surgical treatment. Results from randomized studies.
Few randomized studies including a sufficient number of patients comparing different methods of loco-regional treatment have been performed on operable breast carcinoma. This review summarizes the findings after total mastectomy with or without lymph-node dissection and/or radiotherapy. There was no difference in survival or local recurrence rates between extended radical mastectomy and radical mastectomy or mastectomy plus loco-regional radiotherapy. The results after radical mastectomy with or without loco-regional radiotherapy are the same as after modified radical mastectomy. Simple mastectomy plus loco-regional radiotherapy offers the same prospects of survival as modified or radical mastectomy with or without loco-regional radiotherapy. In some studies loco-regional radiotherapy after various forms of total mastectomy reduced loco-regional recurrences, but did not affect overall survival. Preoperative radiotherapy seems to enhance survival prospects after modified radical mastectomy, but only time will tell if this effect will be sustained.
Breast Neoplasms↗
Influence of mastectomy techniques on estrogen and progesterone receptor analysis in carcinoma of the breast.
Gradual tumor tissue devascularization during mastectomy is thought to decrease estrogen (ER) and progesterone (PgR) receptor activity. To determine whether or not hormone receptor values could be influenced by different mastectomy techniques, 62 patients with carcinoma of the breast had a Tru-cut needle (Baxter Healthcare Corporation) biopsy (premastectomy sample) and underwent modified radical mastectomy (postmastectomy sample) either before (group 1, 40 patients) or after (group 2, 22 patients) axillary lymph node dissection. When the two surgical procedures were compared in 33 patients in whom it could be assessed, no significant tendency (p = 0.51 for ER and p = 0.36 for PgR) for the postmastectomy sample to have hormone receptors levels less than samples taken at biopsy was detected. Overall, in the two groups (44 assessable patients), comparison with respect of each patient, between premastectomy and postmastectomy samples showed that the variations in either ER or PgR receptor values, determined by immunoenzymatic assays, were not statistically significant (p = 0.32 for ER and p = 0.21 for PgR). The current results indicated the relative stability of steroid receptors during the two modified radical mastectomy procedures and suggested that a systematic reference determination of hormone receptors on biopsy before modified radical mastectomy is unnecessary.
Aged↗
Adjuvant chemotherapy with doxorubicin-containing regimen for 326 stage II breast cancers: 15-year results.
Between 1975 and 1986, 326 patients with stage II breast cancer were treated with an adjuvant combination of doxorubicin, vincristine, cyclophosphamide, and 5-fluorouracil (AVCF) following regional therapy (232 modified radical mastectomy, 94 lumpectomies, 304 irradiations). The AVCF regimen consisted of 4-week cycles of doxorubicin (30 mg/m2 day 1, modified radical mastectomy), vincristine (1 mg/m2 day 2), 5-fluorouracil 400 (mg/m2), and cyclophosphamide (300 mg/m2) days 3-6. Two hundred twenty-four patients (pts) had six cycles and 102 pts 12 cycles; 90 pts also received 30 mg daily tamoxifen for 1 year after chemotherapy. As of March 1994, the median follow-up was 130 months (range 86-221). One hundred eighteen pts developed recurrences (7 local, 19 controlateral, 92 metastatic) and 104 died. Estimated disease-free survival (DFS) was 5 years, 76 +/- 5%; 10 years, 64 +/- 5%; 15 years, 54 +/- 9%. Overall survival (OS) was 5 years, 85 +/- 4%; 10 years, 70 +/- 5%; 15 years, 58 +/- 10%. Survival was affected by the number of involved lymph nodes (258 pts were N+), menopausal status (OS at 15 years: 53% for MP+ and 65% for MP-) and Scarff-Bloom-Richardson grading, but not by hormonal receptors, number of courses, or associated hormonotherapy. Minimal cardiac toxicity was induced by doxorubicin either during or subsequent to treatment completion.
Adult↗
[Radiotherapy of invasive breast cancer in the female].
In curative treatments irradiation following breast-conserving operations reduces the local recurrence rate. Stage-adapted regional lymphatic irradiation remains controversial and is recommended only for advanced cases. Combination with adjuvant systemic treatment is possible. Following modified radical mastectomy irradiation reduces locoregional recurrences and improves recurrence-free survival. Inflammatory breast cancer is treated by chemotherapy, irradiation and mastectomy. The prognosis regarding local recurrence after breast-conserving treatment is better than after modified radical mastectomy. In palliative treatments irradiation improves quality of life.
Breast Neoplasms↗
Surgical management of early stage invasive breast cancer: a practice guideline.
OBJECTIVES: To assess the available evidence on sentinel lymph-node biopsy, and to examine the long-term follow-up data from large randomized phase III trials comparing breast-conserving therapy with mastectomy in order to make recommendations on the surgical management of early invasive breast cancer (stages I and II), including the optimum management of the axillary nodes: for the breast--modified radical mastectomy or breast-conserving therapy; for the axilla--complete axillary node dissection, axillary dissection of levels I and II lymph nodes, sentinel lymph-node biopsy or no axillary node surgery. OUTCOMES: Overall survival, disease-free survival, local recurrence, distant recurrence and quality of life. EVIDENCE: MEDLINE, EMBASE, the Cochrane Library databases and relevant conference proceedings were searched to identify randomized trials and meta-analyses. Two members of the Practice Guidelines Initiative, Breast Cancer Disease Site Group (BCDSG) selected and reviewed studies that met the inclusion criteria. The systematic literature review was combined with a consensus process for interpretation of the evidence to develop evidence-based recommendations. This practice guideline has been reviewed and approved by the BCDSG, comprising surgeons, medical oncologists, radiation oncologists, pathologists, a medical sociologist, a nurse representative and a community representative. BENEFITS, HARMS AND COSTS: Breast-conserving therapy (lumpectomy with levels I and II axillary node dissection, plus radiotherapy) provides comparable overall and disease-free survival to modified radical mastectomy. Levels I and II axillary dissection accurately stages the axilla and minimizes the morbidity of axillary recurrence but is associated with lymphedema in approximately 20% of patients and arm pain in approximately 33%. Currently, there is insufficient data regarding locoregional recurrence and long-term morbidity associated with sentinel-node biopsy to advocate it as the standard of care. Breast-conserving therapy may offer an advantage over mastectomy in terms of body image, psychological and social adjustment but appears equivalent with regard to marital adjustment, global adjustment and fear of recurrence. RECOMMENDATIONS: Women who are eligible for breast-conserving surgery should be offered the choice of either breast-conserving therapy with axillary dissection or modified radical mastectomy. Removal and pathological examination of levels I and II axillary lymph nodes should be the standard practice in most cases of stages I and II breast carcinoma. There is promising but limited evidence to support recommendations regarding sentinel lymph-node biopsy alone. Patients should be encouraged to participate in clinical trials investigating this procedure. VALIDATION: A draft version of this practice guideline and a 21-item feedback questionnaire was circulated to 201 practitioners in Ontario. Of the 131 practitioners who returned the questionnaire, 98 (75%) completed the survey and indicated that the report was relevant to their clinical practice. Eighty (82%) of these practitioners agreed that the draft document should be approved as a practice guideline.
Breast Neoplasms↗
Surgical treatment of early-stage breast cancer in the Department of Defense Healthcare System.
BACKGROUND: The choice between breast-conserving surgery and modified radical mastectomy in the treatment of women with early stage breast cancer in the Department of Defense Healthcare System may be influenced by demographic factors. STUDY DESIGN: The Department of Defense Automated Central Tumor Registry (ACTUR) was queried for women diagnosed with American Joint Committee on Cancer Stage I or II invasive breast carcinoma from January 1, 1986, to December 31, 1996. Univariate analysis and multivariate analysis were applied to the study variables. Year of diagnosis, age at diagnosis, tumor size, type of hospital, geographic region, and local availability of radiation therapy were evaluated with respect to the type of surgical treatment performed. Surgical treatment was either breast conservation therapy (BCT) or modified radical mastectomy. RESULTS: After excluding women for whom the data were incomplete (n = 308), 7,815 women were identified who met study criteria. There was a progressive increase in the use of BCT to treat tumors of all sizes from 16% to 47% over the 11 years of the study (p < 0.0001). BCT was more frequently used for smaller tumors (< 2cm), with an odds ratio of 2.46 (2.20-2.76, 95% CI). In 1996, 54% of women with T1 (< 2 cm) tumors were treated with BCT. Women treated with BCT were nearly the same age as those undergoing modified radical mastectomy (55.5 years versus 56.8 years, p < 0.0001). BCT was used at a slightly greater rate in medical centers than in community hospitals (31% versus 28%, p < 0.0001). Use of BCT varied among geographic regions from a low of 24% in the southwestern USA to a peak of 36% in the Northeast and 40% in hospitals outside of the continental United States (p < 0.0001). Local availability of radiation therapy did not influence choice of treatment. CONCLUSIONS: The use of BCT to treat early stage invasive breast carcinoma in the Department of Defense Healthcare System is increasing. But BCT is used less often to treat larger tumors. Regional differences in the use of BCT persist, even after controlling for other factors. Patient age and type of hospital (community versus academic center) appear to exert little influence on the choice of treatment. Local availability of radiation therapy did not seem to influence the choice of treatment. Our data suggest that efforts to promote the use of BCT should target the central and southwestern USA. Use of BCT should also be emphasized for women with larger tumors (> 2 cm).
Aged↗
Sternalis muscle: importance in surgery of the breast.
Mastectomy is a commonly performed surgery for carcinoma of breast. During surgery, pectoral fascia is removed and pectoralis major muscle is laid bare. Sternalis is a rare muscle encountered in the subcutaneous plane. We examined the operative records of 1,152 patients who underwent modified radical mastectomies between 1990 and 2000. Patients who underwent conservative breast surgery or radical mastectomy were excluded. Among 1,152 patients who underwent modified radical mastectomy, eight were identified as having sternalis, a subcutaneously placed muscle oriented craniocaudally. The thickness of the muscle varied. The muscle was spared in all patients. Sternalis is a rare muscle in the subcutaneous plane. It should not be mistaken for a mass on mammography. During surgery it is important to be aware of this rare entity and identify the muscle early so that the dissection plane is appropriate. The depth at which internal mammary nodes are irradiated may also vary in the presence of the muscle. In addition, it should not be mistaken for recurrence on follow-up.
Breast Neoplasms↗