Skin Metastasis in Post-Operative Irradiated Breast Cancer

Abstract

THE appearance of single or multiple metastatic skin nodules secondary to breast cancer is disquieting not alone to the patient but to the informed clinician because of his knowledge that it is a manifestation of a terminal process. Since the advent of intensive fractionated high voltage x-irradiation and its rather universal utilization, one might expect from theoretical considerations to encounter secondary skin deposits in breast cancer, irradiated post-operatively, less frequently than formerly, or at least to have their appearance delayed. Nevertheless they have continued in my clinic with disquieting frequency, so that it seemed of importance to survey them in an attempt to establish the chronological relationship, if any, between the kind of x-irradiation and the appearance of the metastatic skin nodule. In a period of fourteen years (1923 to 1936, inclusive), 407 cases of pathologically proven breast cancer were operated upon at the Boston City Hospital. They constituted 0.3 per cent of the surgical admissions for that period. Of these breast cancers, 255, or 62.6 per cent, were treated post-operatively by x-ray. Single or multiple skin nodules appeared in 54 of these 255 cases, or in 21.1 per cent. In 22 cases, or 41.7 per cent, skin metastases appeared on an average of 8.14 months after operative interference, which was frankly incomplete. In 32 cases, or 58.3 per cent, skin metastases appeared on an average of 14.6 months following the classical radical resection. There were 10 of these cases, however, that had palpable axillary and supraclavicular glands before operation and should not have been subjected to the radical operation. Skin metastases did not appear for an average of 18.5 months in the 22 cases without palpable nodes that were operated upon radically. These figures closely parallel those of Ackland (1). On the face of it, these statistics indicate that the appearance time of skin metastasis in this group of breast cancers treated post-operatively by x-rays was directly related to the extent of the growth at the time of operation. There was no evidence that the kind of tumor influenced the appearance time of skin metastases. It was clear, however, that skin metastasis appeared with relative promptness following incomplete or injudicious surgery. Paradoxically, it would seem, in our reputedly enlightened age, 20 of the 22 frankly incomplete operations in the group were done since 1929. The x-ray treatment was given on the average about four months after operation, not early enough perhaps but at least an improvement over the group reported earlier (2), in which in one-half the cases x-ray therapy was not instituted for more than ten months following surgery. The majority of the cases showing secondary skin nodules had adequate x-ray therapy as judged by the mode of the era in which they were treated. The earlier ones were not irradiated in as thoroughgoing a fashion as is our wont to-day.