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PubMed1997

Locoregional recurrence of breast cancer following mastectomy: always a fatal event? Results of univariate and multivariate analysis.

PURPOSE: The outcome of patients with local-regional breast cancer recurrence after mastectomy often is described as fatal. However, certain subgroups with favorable prognoses are thought to exist. To determine these favorable subgroups, we analyzed prognostic factors for their influence on postrecurrence survival by univariate and multivariate analysis. METHODS AND MATERIALS: Between 1979 and 1992, 145 patients with their first isolated locoregional recurrence of breast cancer following modified radical mastectomy without evidence of distant metastases were treated at the Department of Radiation Oncology of the University of Wurzburg. Thirty-nine percent of patients (n = 67) had had postmastectomy radiotherapy, representing 7% of patients who had received routine postmastectomy irradiation at our institution. Systemic adjuvant hormonal therapy had been applied in 24% and systemic chemotherapy in 19% of patients. Several combinations were used. Treatment of recurrences consisted of surgical tumor excision in 74%, megavoltage irradiation in 83%, additional hormonal therapy in 41%, and chemotherapy in 12% of patients, employing different combinations. Local control in the recurrent site was achieved in 86%. Median follow-up for patients alive at the time of analysis was 8.9 years after recurrence. We tested different prognostic factors, including prior treatment and treatment of recurrence, for their influence on postrecurrence survival, using univariate and multivariate analysis. RESULTS: Eighty-two of the 145 patients (57%) developed distant metastases within the follow-up period. Metastases-free rate was 42% at 2 years and 36% at 10 years following recurrence. With development of distant metastases, the survival rate deteriorated. Recurrences appeared within the first 2 years from primary surgery in 56% of patients, and in 89% within 5 years. Overall, 2-year and 5-year survival rates following local-regional recurrence were 67% and 42%, respectively. Univariate analysis revealed statistically significant worsening of survival rates for pT3 + 4 primary tumors, primary axillary lymph node involvement, tumor grading 3 + 4, lymphatic vessel invasion, blood vessel invasion, tumor necrosis, negative estrogen (ER) and progesterone (PR) hormonal receptor status, postmastectomy chemotherapy and hormonal therapy, short time to recurrence (< 1 year), combined recurrences and supraclavicular site of recurrence, non-scar recurrence, size of the largest recurrent nodule > 5 cm, multiple recurrent nodules, no surgical excision of recurrence, small target volume of irradiation, chemotherapy for recurrence, and no local control within the recurrence site. The 2-year and 5-year survival rates ranged from 68% to 94%, and from 33% to 65%, respectively, in the favorable subgroups compared to 2-year and 5-year survival rates ranging from 20% to 59% and 0% to 35%, respectively, in the unfavorable subgroups. Multivariate analysis showed that site of recurrence and number of recurrent nodules have the strongest influence on postrecurrence survival, but time to recurrence, age at time of recurrence, local control in recurrent site as well as primary pT and axillary status, and the presence of tumor necrosis in the primary tumor specimen showed additional independent influences on survival. Thus, we identified a highly favorable subgroup of patients with a single chest wall or axillary recurrent nodule (in a patient aged > 50 years), a disease-free interval of > or = 1 year, pT1-2N0 primary tumor, and without tumor necrosis, and whose recurrence is locally controlled. This group (12 patients) had 5- and 10-year survival rates of 100% and 69%, respectively. CONCLUSION: We conclude that locoregional recurrence of breast cancer following mastectomy is not always a sign of systemic disease. Our data support previous findings, that subgroups with favorable prognosis exist and they still have a chance for cure, demanding comprehensive local treatment. (ABSTR

Analysis of Variance↗

PubMed2003

Mastectomy without drain at pectoral area: a randomized controlled trial.

OBJECTIVES: Mastectomy is still one of the standard alternative procedures for the management of female breast cancer. Axillary node dissection is also performed to establish the accurate staging. After operation, the axilla must be drained because of lymphatic leakage. Whether the raw surface at the pectoral area should be drained or not is an interesting controversial point. The authors conducted a randomized controlled trial to compare outcomes after modified radical mastectomy (MRM) with and without drainage at the pectoral area. METHODS: Sixty patients who agreed to be treated with MRM and had given their consent were enrolled. Mastectomy was performed to remove the breast tissue proper by scalpel in order to minimize tissue injury. The axillary contents were removed by sharp instrument. After bleeding had stopped, patients were randomly allocated to one or other of 2 groups: group I (n = 30): only 1 drain was inserted at the axilla area; group II (n = 30): 2 conventional drains were inserted into the pectoral area and axilla area. The size of tube drain and negative suction pressure were constant in all cases. Volume of contents was recorded daily. Subcutaneous seroma or hematoma were carefully observed and confirmed by ultrasonography 3-5 days after operation. Overall drainage contents and complications were compared. RESULTS: The mean weight of breast tissue of group I was 632.1 g and group II 654.0 g (p = 0.81). Total drainage contents (median) from the two groups were 250 cm3 and 231 cm3 respectively (p = 0.796). Complications occurred in 1 case in group I and 2 cases in group II (p = 0.35). None of the above differences were statistically significant. CONCLUSION: Mastectomy by scalpel can be performed without drainage at the pectoral area. Overall complications in the conventional group and the group without drain did not differ significantly.

Adult↗

PubMed1996

Superiority of the microvascularly augmented flap: analysis of 50 transverse rectus abdominis myocutaneous flaps for breast reconstruction.

Our experience with 50 transverse rectus abdominis myocutaneous (TRAM) flap transfers was evaluated as to the types of TRAM flaps, indications for breast reconstruction with a TRAM flap, and complications. The TRAM flap was transferred as a free flap in 7 patients, a unipedicled flap in 14 patients, and a microvascularly augmented flap in 29 patients. Microvascular augmentation was performed through the contralateral inferior epigastric vascular system to the superiorly pedicled muscle in 10 patients who had undergone radical mastectomy and the ipsilateral inferior epigastric vascular system in 19 patients who had undergone modified radical mastectomy. In this series, the incidence of flap-site complications, including total flap loss, partial flap loss, and fat necrosis, was lowest in the microvascularly augmented flap group. Particularly, incidence of partial flap loss in the microvascularly augmented flap group was significantly lower than in the unipedicled flap group (p < 0.01). These outcomes demonstrated the superiority of the microvascularly augmented TRAM flap for breast reconstruction.

Fat Necrosis↗

PubMed2005

Postoperative loco-regional radiation therapy for breast cancer patients with four or more involved lymph nodes or extracapsular extension.

BACKGROUND: Post-mastectomy loco-regional radiation to the chest wall and draining lymphatics, combined with adjuvant chemotherapy and hormonal therapy, significantly improve survival in patients with node-positive breast cancer. However, the actual benefit of post-mastectomy radiotherapy and the desired extent of treatment are still debatable. OBJECTIVES: To examine the effect of postoperative loco-regional radiotherapy on local and regional recurrence and survival in breast cancer patients with four or more involved lymph nodes or extracapsular tumor extension. METHODS: This controlled clinical trial included 258 breast cancer patients with four or more involved nodes or ECE. Eighty-nine patients in the control group had modified radical mastectomy and received adjuvant chemotherapy with melphalan and 5FU, but no radiation therapy. The 169 patients in the study group (87 with MRM and 82 with lumpectomy and axillary dissection) received various adjuvant chemotherapy regimes and radiation therapy to the chest wall/breast, supraclavicular region and full axilla. RESULTS: With an average follow-up of more than 5 years, loco-regional radiation significantly reduced local and regional disease recurrence. The median disease-free survival was significantly longer in radiated patients (59.2 months and 63.3 months in the MRM and L+AXLND groups, respectively, vs. 28.4 months in the control group; P < 0.01). There was no difference in the rate of systemic recurrence and overall survival. The median overall survival was 71.2 and 67.5 months in the study groups (MRM and L+AXLND, respectively) and 70.5 months in the control group (P = 0.856). CONCLUSIONS: Radiotherapy to the breast/chest wall and to the draining lymphatics, in addition to surgery and adjuvant therapy, significantly reduced the risk of local and regional recurrence in high risk breast cancer patients with four or more involved lymph nodes or ECE.

Axilla↗

PubMed1977

[Surgical treatment of the mammary carcinoma according to stage (author's transl)].

Improvement of the results of treatment was achieved only when an increased number of patients were diagnosed in stage I. The prerequisite for limitation of radical surgery is histomorphologic classification of the stages. The central axillary group of lymph nodes appears to be representative of lymph node involvement. Differentiated methods of operations range from local excision to mastectomy in case of precancer. In histologic stage I, modified radical mastectomy; is the treatment of choices; operations with further limitations are recommended only within the scope of controlled studies. In stage II, the classical ablation is still the safest procedure.

Axilla↗

PubMed1989

Adjuvant CMFVP versus melphalan for operable breast cancer with positive axillary nodes: 10-year results of a Southwest Oncology Group Study.

Four hundred forty-one women with operable breast cancer with histologically positive axillary nodes were randomized to receive either combination cyclophosphamide (60 mg/m2 orally everyday for 1 year); fluorouracil (300 mg/m2 intravenously [IV] weekly for 1 year); methotrexate (15 mg/m2 IV weekly for 1 year); vincristine (0.625 mg/m2 IV for 10 weeks); prednisone (30 mg/m2 orally days 1 to 14, 20 mg/m2 days 15 to 28, 10 mg/m2 days 29 to 42) (CMFVP) or single-agent melphalan (L-PAM) (5 mg/m2 orally every day for 5 days every 6 weeks for 2 years) chemotherapy after a modified or radical mastectomy between January 1975 and February 1978. Patients were stratified according to menopausal status and number of positive nodes (one to three, more than three nodes) before randomization. Seventy-eight patients were ineligible, most (56) because they were registered more than 42 days from surgery. Maximum duration of follow-up is 12 years, with a median of 9.8 years. The treatment arms were balanced with respect to age, menopausal status, and number of positive nodes. Among eligible patients, disease-free survival and survival were superior with CMFVP (P = .002, .005, respectively). At 10 years, 48% of patients treated with CMFVP remain alive and disease-free and 56% remain alive, compared with 35% alive and disease-free and 43% alive on the L-PAM arm. Disease-free survival and survival were significantly better with CMFVP compared with L-PAM only in premenopausal patients and patients with four or more positive nodes. Both regimens were well tolerated, although toxicity was more severe and more frequent with CMFVP. We conclude that after 10 years of follow-up, adjuvant combination chemotherapy with CMFVP is superior to single-agent L-PAM in patients with axillary node-positive primary breast cancer. The major advantage is in premenopausal women and in patients with more than three positive axillary nodes.

Age Factors↗

PubMed1986

Breast reconstruction according to pTNM: our experience.

Reconstruction of the breast after radical mastectomy has become an integral part of the treatment and rehabilitation of the patient with breast cancer. Any variants of radical mastectomy are the mainstay of the treatment of the majority of patients with breast cancer. We prefer modified radical mastectomy according to the Madden-Auchincloss technique, because the breast reconstruction after this procedure is easier from the anatomic point of view. The three major questions raised in regard to breast reconstruction are: what patient is eligible for breast reconstruction; when should the breast reconstruction be performed; how should the goals of breast reconstruction be realised? There are two basic elements in our therapeutic choice in this field: collaboration of the patient, the evaluation of pTNM.

Adult↗

PubMed1981

Primary reconstruction of the breast by free myocutaneous gluteal flap.

Most of the patients diagnosed as having cancer of the breast in an early stage survive for a longer period and deserve to be socially rehabilitated by reconstruction. The main obstacle for primary reconstruction is delay in discovery of local recurrence. Standard, radical mastectomy with primary reconstruction by a distant thick flap or free myocutaneous gluteal flap is justified, because modified radical mastectomy has been an accepted method and permits primarily the local thick flap cover or the pectoral major muscle. We have done primary reconstruction in two cases (secondary in one case) with success, utilizing the microvascular surgical technique. This autogenous tissue transfer is the most physiological method and we believe that it is the procedure of choice. Postoperative follow-up studies by muscle biopsy, xerography and thermography have shown the satisfactory results without local recurrence.

Adult↗

PubMedDate not supplied

History of surgery for breast cancer: radical to the sublime.

The historic milestones that have brought the surgical management of breast cancer to its current state are recounted. The Halsted radical mastectomy, once considered the ideal cancer operation, no longer has a place in the routine management of patients with breast cancer. Breast conservation in the form of segmental mastectomy, axillary node dissection, and radiation is often chosen over the modified radical mastectomy, popular in the 1980s. Axillary lymphadenectomy, shown to be of questionable therapeutic value in breast cancer, is certainly of prognostic significance. Studies are ongoing to establish the validity of the less-invasive sentinel node biopsy in determining axillary nodal status. Perhaps the most significant change in today's approach to breast cancer is the reliance on well-controlled prospective studies to evaluate outcome and determine the appropriate surgical procedure.

Breast Neoplasms↗

PubMed1994

Natural History and Management of Isolated Local-Regional Recurrence Following Mastectomy.

The average incidence of isolated local-regional recurrence following modified radical mastectomy is 10% to 20%, but it can be as low as 5% or as high as 40%, depending on the presence or absence of various risk factors. One of the objectives of this article is to discuss how to evaluate the risk of locoregional failure. In addition, although the average overall survival rate following recurrence is approximately 40% at 5 years and 25% at 10 years, individual patient survival varies considerably and depends on a number of fairly well-documented prognostic features that are also discussed here. The unfortunate reality is that control of an isolated local-regional recurrence for the duration of life is not frequently achieved. Even with optimal irradiation, 50% of all patients will die with uncontrolled local-regional disease. The quality of life for patients with uncontrolled disease is often very poor, and some examples are shown here. For this reason, local-regional recurrence should be avoided. The way to avoid (or at least minimize) local-regional recurrence is to give postoperative irradiation to those who are at high risk for local-regional recurrence following mastectomy. This author considers the risk to be "high" when it reaches 25% to 30%.

Journal Article↗

PubMed1985

[Objective measurement of lymphedema after mastectomy].

A new optic-electronic method for measuring arm volume was used on 275 women before and after mastectomy for carcinoma of the breast. Two weeks after modified radical mastectomy, an increase of over 150 ml in arm volume over the preoperative value was recorded in 12% of patients. Lymphoedema was demonstrated on average 19.3 months after the operation and telecobalt treatment in 42% of 200 women so treated; in 17% it was of moderately severe to severe degree (over 400 ml). In patients with severe lymphoedema a 15-day period of treatment reduced the oedema volume on average by 383 ml (62.1%). The described optic-electronic volumetric method makes it possible to obtain an objective comparison of swelling of the arm and thus early recognition and treatment of lymphoedema, as well as providing a means of assessing the effectiveness of any treatment.

Adult↗

PubMed1985

Bilateral breast cancer. Risk reduction by contralateral biopsy.

Although survival from primary breast cancer has improved with earlier diagnosis and treatment, the management of the opposite breast is still in question. The risk factors for bilaterality are known, and preoperative mammography is occasionally helpful, but identification of early second breast cancer is very limited. Contralateral biopsy may provide a reasonable answer to the problem. During a 5-year period, 62 elective contralateral biopsies were performed in patients having mastectomies for primary breast cancer. This consisted of either a mirror image biopsy or, more commonly, a biopsy of the upper outer quadrant. Thirteen patients had simultaneous contralateral cancers, of whom two had clinically overt bilateral cancers and 11 (18%) had clinically occult malignancy. Seven of these 11 had both radiologically and clinically normal breasts. Thus, 11.3% had radiologically and clinically occult cancer demonstrated by biopsy. Surgical management consisted of total mastectomy with low axillary dissection for noninvasive cancers and modified radical mastectomy for invasive cancers. Pathologic findings of the dominant breast cancer and the contralateral lesion were: bilateral, noninvasive: three patients; invasive, noninvasive: (seven patients), and invasive, invasive: three patients. Although follow-up is short (median of 40 months), 82% of the patients who had clinically occult second-breast cancer remain free of disease. During a previous 8-year period, 37 of 500 primary breast cancer patients (7.4%) developed metachronous (33) or synchronous (4) second-breast primary cancers primarily diagnosed clinically or radiologically. Of these, 35 were invasive and two noninvasive cancers; 41% had nodal metastases. A selected "favorable group," 28 of these patients who were free of disease 3 years after their first cancer, was analyzed. The analysis showed that only 10 (36%) were surviving free of disease at 7 years; 25% were free of disease at 10 years. Although the incidence of clinically-recognized, second-primary breast cancer is relatively low, development of a second invasive cancer severely impairs patient survival. Contralateral biopsy would appear useful to identify patients with early invasive or preinvasive cancer in the second breast, which appears normal after clinical observation or mammography. It provides opportunity to reduce the risk of invasive cancer in that breast, as well as to provide important diagnostic and prognostic information.

Biopsy↗

PubMed1983

Considerations of cost and effectiveness in the choice of mastectomy.

Operable breast cancer may be managed equally well by a number of different regimens of mastectomy and/or radiotherapy. This paper examines the financial and morbidity costs, together with the node sampling efficacy, of three commonly employed techniques: simple mastectomy; total mastectomy with node biopsy or limited node excision; and modified radical mastectomy. Adjuvant radiotherapy (and/or chemotherapy) can only be applied rationally if node sampling is effective. Simple mastectomy cannot achieve this. Total mastectomy, providing that a node sample is obtained, is effective, and is probably the cheapest option. Total axillary clearance runs the risk of increased morbidity (and financial cost), while not necessarily guaranteeing more effective node sampling. Much of the cost and morbidity of mastectomy may be reduced by a limited but rational radiation policy.

Breast Neoplasms↗

PubMed2006

Effect of prevailing local treatment options of breast cancer on survival outside controlled clinical trials: experience of a specialist breast unit in North India.

BACKGROUND: This study aimed at analyzing different treatments of breast cancer (BC) prevalent in the region, their effect on patients' survival, and discusses the most suitable method within available resources. METHODS: The study was set up at a tertiary care hospital in north India. We retrospectively reviewed data of 473 female BC patients who attended the departments of Surgical Oncology and Radiotherapy from January 1997 to December 1999. Patients with cTNM stage IV and inoperable stage III were included; those who defaulted or were lost to follow-up were excluded. Out of 473 patients, 372 were selected. The selected patients were divided into groups on the basis of place and type of local treatment they received: (1) local excision only, (2) standard breast conservation therapy (BCT), (3) total mastectomy (TM) + axillary lymph node dissection + radiotherapy (RT), and (4) modified radical mastectomy (MRM) + RT. Data regarding recurrence and survival were analyzed in December 2005. Minimum follow-up was 6 years. RESULTS: Overall recurrence rates were significantly higher in patients operated elsewhere (P <0.0001). Of 194 operated at our Breast Unit, 25 (14.6%) of 171 MRM patients and none of 23 BCT had recurrence. Of 178 patients operated elsewhere, 44 (100%), 6 (42.9%), 41 (41%), and 8 (40%) developed recurrence in groups 1, 2, 3, and 4 respectively. Overall survival was significantly better in patients with MRM at our unit versus TM outside (93.6% vs. 80%). CONCLUSIONS: Several types of treatment from improper local excision alone, BCT, TM, to a carefully done MRM are prevalent here. Properly done, MRM yields significant local control with survival benefit and appears to remain the gold standard in management of our BC patients.

Adult↗

PubMed1983

Changing practice in the surgical treatment of breast cancer. The national perspective.

This study documents changes in surgical treatment of breast cancer using data from the National Hospital Discharge Survey. All discharge records for women aged 25 years and older who received a mastectomy and had a diagnosis of breast cancer were selected for analysis. The proportion of such women discharged who received a radical mastectomy declined precipitously from 49% in 1972-1974 to 14% in 1978-1980. The proportion of women discharged who received modified radical mastectomies increased concomitantly from 29% in 1972-1974 to 64% in 1979-1980. Further, these changes in surgical practice were observed in all regions of the United States and for both small and large hospitals. The average length of hospital stay for discharged women treated surgically for breast cancer declined from 11.8 to 10.3 days between 1972-1974 and 1978-1980. About one third of this decline can be attributed to the shift toward less extensive operations.

Adult↗

PubMed1999

Racial differences in the presentation and surgical management of breast cancer.

BACKGROUND: African American women are seen with more advanced breast cancers, are less likely to be treated with breast-conserving surgery, and generally have poorer prognoses than white women. There are a myriad of potential causes for these phenomena. The purpose of this study was to measure racial differences in the surgical treatment of breast cancer among women with comparable health care access and delivery. METHODS: The Breast Cancer Registry of the Department of Surgery at Henry Ford Hospital was accessed for all patients between January 1, 1990, and December 31, 1997 for whom data on race, tumor characteristics, stage, and treatment specifics were available. Socioeconomic information was collected with use of 1990 census block data. Proportions of women who received each treatment were compared for African Americans and whites with use of the relative risk (RR) and 95% confidence intervals (CI). We used multiple logistic regression to obtain estimates of the relative risk, controlling for potential confounding factors. RESULTS: Of the 1699 patients in the database, 1250 had sufficient information for analysis. A total of 8.7% of African American women were diagnosed with late-stage disease (i.e., stage III or IV) compared with 7.9% of whites. Nevertheless, African American women had a lower frequency of stage I disease (30.5% vs 36.2%) and a higher frequency of stage II disease (36.8% vs 31.4%). Overall and adjusted risk estimates for age, tumor stage, marital status, median income, and type of insurance revealed no substantive or statistically significant differences between African American and white patients. The adjusted RR for local excision was 1.39 (95% CI 0.78 to 2.49), for lumpectomy and axillary dissection RR 0.92 (95% CI 0.66 to 1.29), for simple mastectomy RR 0.84 (95% CI 0.41 to 1.72), and for modified radical mastectomy RR 1.00 (95% CI 0.73 to 1.36). CONCLUSIONS: In this setting of equal access to health care, African American women still have higher frequencies of stage II disease, although the frequencies for late-stage disease are similar. Nevertheless, no surgical differences were found in this population, even after the effects of socioeconomic indicators and stage at diagnosis were controlled for Survival differences between African American and white women are unlikely to be explained by differences in treatment.

Aged↗

PubMed1999

Charges for partial, radical mastectomy vary by region.

Data Library: Breast cancer survival rates are going up, largely due to early detection and diagnosis. Surgery remains a mainstay of treatment, most often by a modified radical mastectomy but increasingly by the less drastic partial mastectomy, or lumpectomy. This MetLife analysis of charges and utilization for radical and partial mastectomy reveals some noteworthy geographic variations.

Benchmarking↗

PubMed1985

Psychological outcome of lumpectomy versus mastectomy in the treatment of breast cancer.

Forty-six patients who underwent modified radical mastectomy were compared 14 months after surgery with 21 patients who underwent lumpectomy and radiation; all patients had stage I or II breast cancer. Lumpectomy patients reported less of a loss of feelings of attractiveness and femininity, were less self-conscious about their appearance, received more emotional support from friends, and were more open about their surgery and sexual feelings after surgery. Unlike the mastectomy patients, they saw their spouses' sexuality as enhanced after surgery. Lumpectomy patients were not less anxious or less depressed but showed better overall adaptation to their surgery and less functional change.

Adaptation, Psychological↗