Selecting variations in extent of surgical procedure for breast cancer.

Abstract

Most breast cancers arise in multicentric areas of the breast parenc hyma and exist as silent innocuous in-situ entities for many years before the infiltrating stage develops. Most of the lymphatic drainage extends to the axillary lymphatic nodes but some to the internal mammary lymph node chain. Risk of spread to the internal mammary nodes increases as the primary tumor approaches the sternal margin as the size of the primary tumor increases and when axillary nodes are also involved. The primary operation should remove all disease present. Aggressive primary surgery and radiation therapy will salvage those without generalized disease. Systemic therapy should be reserved for those with systemic disease. Uninvolved regional lymph nodes do not add to the immune protective mechanism. Modified radical mastectomy in which axillary nodes are removed is adequate for early cases. Histological study at time of operation is essential. Only patients with negative axillary nodes do well with this less complete operation. More complete axillary dissection is preferable when disease is present in the axilla. Radical mastectomy is best for most infiltrating breast cancers. When metastases are found in the axillary nodes supervoltage radiation therapy is also given because of the risk of spread to the internal mammary lymph chain. Extended radical mastectomy which includes en bloc excision of the internal mammary nodes has been used for patients with a high risk of spread to these nodes. Almost 800 patients have been so treated with an operative mortality of less than .5%. Of these 33% had metastases to these nodes and 47% also had axillary node involvement. Of those with negative axillary involvement 15% had positive internal mammary nodes; this was found highest when the primary tumor was on the inner side of the breast. 5 years after surgery 500 patients 47% with axillary involvement and 30% with internal mammary involvement were evaluated. 72.4% were alive 65.8% were disease-free and 7% had local recurrence. 41% with involvement of both nodal areas were clinically disease free. Of 315 evaluated at 10 years 52% were clinically disease-free. Of 98 patients with internal mammary node metastases 27 were clinically disease-free and 28 survived at 10 years. Palliative mastectomies were done on 37 considered inoperable. With added radiation therapy local control was obtained in 29. In only 5 of 14 treated with radiation alone was local control obtained. Of the total 51 inoperable patients 21% were alive at 5 years and 14% were free of disease. None survived 10 years.