Extended Radical Mastectomy Research Articles

Reverse Abdominoplasty for Mastectomy Defect Closure in Advanced Breast Cancer.

Breast cancer patients with locally advanced breast cancer who require radical mastectomy are left with large chest wall defects. This poses a significant reconstructive challenge as many high-risk patients require timely postmastectomy adjuvant therapy. While the reverse abdominoplasty technique is commonly used for aesthetic improvement of the anterior trunk, it can be also be effectively used for closure of extensive mastectomy defects in this patient population. We conducted a retrospective cohort study of all consecutive patients who underwent an extensive radical mastectomy followed by immediate closure with the reverse abdominoplasty technique at a single tertiary cancer center from June 2017 to July 2022. Patients who had concurrent skin grafting or breast mound flap reconstruction were excluded. Demographic, medical, oncologic, and reconstructive data were collected. Six patients were treated with reverse abdominoplasty for 9 chest wall defects after surgical excision of locally advanced breast cancer. The median tumor size was 10.7 cm (range, 6.7-10 cm) and the median mastectomy weight was 865.7 g (range, 356.4-1247.7 g). On average, the operation length was 191 minutes (range, 86-257 minutes) and the postoperative length of stay was 2.2 days (range, 1-5 days). All patients underwent systemic adjuvant therapy and the median time from surgery to initiation of therapy was 44.5 days (range, 32-75 days). Reverse abdominoplasty is a simple and safe technique to reliably close large defects after locally advanced breast cancer excision. It has a short operative time, hospital stay, and turnaround time to initiation of adjuvant therapy.

Radically extended modified mastectomy of t4b-dn0-3m0 primary inflammatory breast cancer as a tool to minimize the risk of recurrence

Introduction. Breast cancer (BC) is an important public health problem. These are BC patients in young age, hereditary (BRCA-associated) BC patients, inflammatory BC patients, synchronous cancer patients etc. In case of a large size of tumor or diffuse form of BC we often need to use extended surgery techniques in order to perform it radically and minimize a risk of recurrence. The aim of the study to evaluate the effectiveness of surgery approaches in inflammatory BC patients. Materials and research methods. Тhe first stage of our research was to evaluate extended surgical treatment using techniques by Handelhail and Beck on the risk of local recurrence. The study included 39 patients with breast cancer T4b-dN0-3M0 who in the period from 2014 to 2019 received complex treatment at National Cancer Institute of Ukraine. Besides neo- and adjuvant chemotherapy, an extended radical mastectomy using a technique by Handelhail and Beck was performed in 19 patients. In 20 patients a traditional (Madden) modified radical mastectomy was done. Results. When studying the data of a group of 20 patients we received a very high percentage of recurrence. Recurrences were classified as locoregional if they occurred in the ipsilateral breast or the axillary or supraclavicular lymph nodes, and as distant metastasis, if they occurred at any other site. Radical extended modified mastectomy consisted in the removal of the mammary gland and adjacent skin along the perimeter with subcutaneous tissue at a distance of 2-3 cm outward from the macroscopic edges of the gland, subclavian-axillary-subscapularis lymphadenectomy. The resulting defect was closed using a technique by Handelhail and Beck. The use of extended surgery made it possible to improve recurrence-free survival.

SURGICAL TREATMENT FOR BREAST CANCER AND AXILLARY METASTASES: HISTORICAL PERSPECTIVE

Breast cancer (BC) is the most common malignancy to affect females. The first suggestions of BC and its treatment date back to Ancient Egypt, 1500-1600 B.C. Throughout history, the management of BC has evolved from extensive radical mastectomy towards less invasive treatments. Radical mastectomy was introduced by W.S. Halsted in 1894, involving the resection of the breast, regional lymph nodes, pectoralis major and minor. Despite its mutilating effect, it had been the main surgical approach to BC patients until 1948, when Patey and Dyson proposed its modified form that conserved pectoralis major and minor and the level III of axillary lymph nodes. The latter was associated with less postoperative morbidity and improved quality of life. The idea of limited breast tissue resection was introduced in the 1970s by Umberto Veronesi and led to further minimizations of surgery in BC patients until breast conservation became the standard of care for early-stage disease. In the 1990s, intraoperative lymphatic mapping and the concept of sentinel lymph node (SLN) biopsy (SLNB) have been developed. SLNB has replaced axillary lymph node dissection (ALND) to be the standard procedure for axillary staging in patients with clinically node-negative BC. Many women have since been spared ALND, including those with negative SLNB or with SLNs involved with micrometastases (0.2-2 mm in size). In the last decade, evidence gathered from new clinical trials suggests that ALND may be safely omitted even in BC patients with 1 or 2 positive SLNs if adjuvant radiotherapy is delivered.

Music intervention improves the physical and mental status for patients with breast cancer

Background:Breast cancer is the most familiar cancer and the major cause of the cancer death in women worldwide. The breast cancer patients may suffer from severe mental and physical trauma. At present, there are few studies on the music therapy for patients with breast cancer. The objective of our paper is to assess the effect of music intervention on mental and physical state of breast cancer patients.Methods:The experiment will be implemented from June 2021 to June 2022 at Jinan Central Hospital. The experiment was granted through the Research Ethics Committee of Jinan Central Hospital (no.08847765). The inclusion criteria requires that the age of female patients ranges from 25 to 65 years old, and the pathological diagnosis of breast cancer requires radical mastectomy (containing extensive radical mastectomy and modified radical mastectomy). Patients who do not like to listen to music or have severe debilitating diseases or are allergic to the sound will be excluded. Patients in the intervention group are given music intervention, and in control group, patients do not receive any information about the music therapy in the period of this study. The primary outcome is quality of life, psychological distress. The secondary outcomes are the heart rate, blood pressure, as well as Visual Analog Scale (VAS).Results:Table 1 will illustrate the postoperative outcomes after music interventions between groups.Conclusion:Music intervention can improve the mental and physical health of the breast cancer patients.Trial registration:This study protocol was registered in Research Registry (researchregistry6168).

Present and changing trends in surgical modalities and neoadjuvant chemotherapy administration for female breast cancer in Beijing, China: A 10-year (2006-2015) retrospective hospitalization summary report-based study.

BackgroundThis study was conducted to describe present and changing trends in surgical modalities and neoadjuvant chemotherapy (NACT) in female breast cancer patients in China from 2006 to 2015.MethodsData of 44 299 female breast cancer patients from 15 tertiary hospitals in Beijing were extracted from hospitalization summary reports. Surgeries were categorized into five modalities: breast‐conserving surgery (BCS), simple mastectomy (SM), modified radical mastectomy (MRM), radical mastectomy (RM), and extensive radical mastectomy (ERM).ResultsIn total, 38 471 (86.84%) breast cancer patients underwent surgery: 22.64% BCS, 8.22% SM, 63.97% MRM, 4.24% RM, and 0.93% ERM. Older patients (> 60) underwent surgery more frequently than younger patients (< 60). The proportion of patients who underwent BCS was highest in the age ≥ 80 (39.24%) and < 40 (28.69%) subgroups and in patients with papillary carcinoma (35.48%), and lowest in the age 60‐ subgroup (18.17%) and in patients with Paget's disease (19.05%). SM was most frequently performed in patients with Paget's disease (29.00%), and MRM for ductal (64.99%), and lobular (63.78%) carcinomas. During the study period, the proportion of patients who underwent MRM dropped by 29.04%, SM and BCS increased from 15.78% and 30.83%, respectively, and NACT increased in all subgroups, particularly in patients with lymph node involvement (26.72%).ConclusionsSurgical modalities varied significantly by age and histologic group. The use of BCS and SM increased dramatically, while MRM declined significantly. The proportion of patients treated with NACT has increased significantly, especially in patients with lymph node involvement.

INTRAOPERATIVE PHOTODYNAMIC THERAPY IN PATIENT WITH STAGE IIIC BREAST CANCER (8 YEARS WITHOUT RECURRENCE)

The article presents a clinical observation of the patient of 38 y.o. with cancer of the left breast stage IIIC урТ4bN3М0L1V1. On the 1 st step of the treatment the patient had 2 courses of CAF neoadjuvant chemotherapy, on the 2 nd step – extended radical mastectomy on the left with intraoperative photodynamic therapy and closure of the defect with ТRАМ-flap, on the 3 rd step – continuation of the chemotherapy (8 courses), on the 4 th step – radiation therapy to the chest wall on the left and zones of regional lymph drainage, targeted therapy with herceptin a (1 year). Four years later a silicone implant was inserted into the left breast. Corrective surgery (reduction mammoplasty on the right side) was performed in april, 2017. Currently, the patient has remission of the disease of the left breast, the period of remission accounts for 8 years.

Nursing of integrated traditional Chinese and western medicine for patients with extended radical mastectomy

Nursing of integrated traditional Chinese and western medicine for patients with extended radical mastectomy

乳腺癌乳房切除术后放射治疗的疗效分析

目的：总结乳腺癌乳房切除术后的放疗效果，并探讨相关预后影响因素。材料与方法：2005年1月至2012年12月共有241例入组，中位年龄51岁，最小27岁，最大75岁。0期1例，IA期11例，IIA期51例，IIB期41例，IIIA期82例，IIIB期3例，IIIC期42例，IV期10例。全组患者均接受乳房切除术，其中改良根治术210例，根治术29例，扩大根治术2例。除3例不详，其余患者均接受术后化疗，其中有50例接受新辅助化疗。全组患者均接受放射治疗，中位剂量50 Gy (30~60 Gy)，照射部位包括同侧胸壁、淋巴引流区(锁骨上和/或内乳)，147例照射同侧胸壁、锁骨上和内乳(61.0%)，47例照射胸壁和锁骨上(19.5%)，39例未照射胸壁，仅照射锁骨上和/或内乳(16.2%)，6例仅照射胸壁(2.5%)，2例照射胸壁和内乳(0.8%)。结果：中位随访5.5年(0~10年)，全组5年OS为87.5%。单因素分析显示肿瘤分期是影响OS的重要因素(P = 0.002)，I、II期的5年OS为95.9%，III、IV期的5年OS为81.0%。LRR有14例(5.8%)，DM是主要失败原因，有49例(20.3%)。死亡36例，均死于肿瘤。结论：仅5.8%的复发，提示乳房切除术后的放射治疗仍是乳腺癌术后规范治疗标准，5年OS接近国内外先进水平。 Objective: To summarize the outcome of radiotherapy in breast cancer after mastectomy, and to explore the relevant prognostic factors. Material and Methods: From January 2005 to December 2012, a total of 241 women who had undergone mastectomy were analyzed. The median age was 51 years old, with minimum 27 years old and maximum 75 years old. The pathological stage 0 were 1 case, IA of 11 cases, IIA of 51 cases, IIB of 41 cases, IIIA of 82 cases, IIIB of 3 cases, IIIC of 42 cases, IV of 10 cases, which performed in all patients by using AJCC 7th. All patients underwent mastectomy, which 210 cases of modified radical mastectomy, 29 cases of radical mastectomy, and 2 cases of extended radical mastectomy. In addition to three cases were unknown, the remaining patients received postoperative chemotherapy, while 50 patients received neoadjuvant chemotherapy. All patients were treated with radiation therapy, the median dose 50 Gy (30 - 60 Gy), irradiated sites included ipsilateral chest wall, lymph drainage area (supraclavicular and/or internal mammary). 147 cases were treated with chest wall, ipsilateral supraclavicular and internal mammary nodes irradiation (61.0%), 47 cases were treated with chest wall and supraclavicular irradiation (19.5%), 39 cases were treated with non-irradiated chest wall, only supraclavicular and/or internal mammary nodes (16.2%), 6 cases were only irradiated to chest wall (2.5%), two cases to chest wall and internal mammary irradiation (0.8%). Results: The median follow-up was 5.5 years (0 - 10 years), the 5-year OS was 87.5%. Univariate analysis showed that tumor stage was an important factor affecting the OS, 5-year OS of the pathological stage I and II was 95.9% while the OS of stage III and IV was 81.0% (P = 0.002). LRR in 14 cases (5.8%), whereas DM was the main causes of failure, which included 49 cases (20.3%). 36 patients died, all died of cancer. Conclusions Only 5.8% patients have locoregional recurrence, suggesting that radiation therapy after mastectomy is still the standard treatment in breast cancer. 5-year OS is approaching the world advanced level.

A30 Session 9: Women’s Health : Breast cancer cryoablation

The surgical management of breast cancer has seen a radical evolution over the past several decades, characterized by equal or improved outcomes with significantly less morbidity. Eradication of the primary tumor has progressed from radical mastectomy (and extended radical mastectomy), through modified radical mastectomy, to lumpectomy. These changes have been facilitated by a multitude of factors, including improvements in technology and screening, better-quality and more widely used adjuvant therapies, and countless patients participating in multi-institutional prospective, randomized trials. The next, seemingly inevitable, step in the evolution of breast cancer therapy would be the replacement of lumpectomy, at least for a select group of patients, with non-surgical methods for destroying the tumor. Cryoablation has emerged as an alternative to surgery for tumors of the skin, prostate, kidney, liver and bone, and given recent advances in breast imaging, and our ability to target non-palpable lesions, it seems logical that breast cancer would be an ideal clinical target. However, adoption of cryoablation for breast cancer has proven challenging, with several obstacles still to overcome. This presentation will review the clinical experience to date with breast cancer cryoablation and some of the hurdles to its clinical implementation.

Internal Mammary Sentinel Lymph Node Biopsy: Minimally Invasive Staging and Tailored Internal Mammary Radiotherapy

Internal mammary lymph node (IMLN) metastasis has a similar prognostic importance as axillary lymph nodal involvement in breast cancer patients. Even though TNM staging has incorporated the internal mammary sentinel lymph node biopsy (IM-SLNB) concept since the 6th edition of the American Joint Committee on Cancer, IMSLNB has not been performed routinely and has remained a subject of discussion. In fact, accurate staging could not be achieved by depending on the status of the axillary sentinel lymph node alone, which might lead to under-stage and under-treatment. The recent studies of Caudle et al. and Gnerlich et al. showed again that IM-SLNB was a minimally invasive technique for the efficient evaluation of the status of internal mammary sentinel lymph nodes (IMSLN) with high safety and feasibility. Gnerlich et al. reported no complications in their study, and Caudle et al. found only two intraoperative surgical complications, but both were resolved smoothly. In our current study, there is no pneumothorax on postoperative chest radiography and no postoperative bleeding. IM-SLNB had made a more accurate lymph node staging and improved the decision making of the adjuvant radiotherapy of the IMLN, and even adjuvant systemic therapy in some cases. Caudle et al. suggested that IM-SLNB should be performed in patients who revealed IM-SLN drainage by preoperative lymphoscintigraphy. Even though the success rate of IM-SLNB has reached 72–100 %, the visualization rate of IM-SLN was low (mean 13 %; range 0–37 %), which has been the restriction for both clinical study and daily practice of IM-SLNB to date. In the retrospective analysis of Caudle et al., only 71 cases (8.8 %) of 808 patients (from 1998 to 2011) underwent IM-SLNB according to preoperative lymphoscintigraphy. In order to improve the preoperative visualization rate of IM-SLN, we established a modified technology, which could significantly improve the preoperative visualization rate of the IM-SLN (70.2 %, 203/289, the latest data). With the combination of the intraoperative c-probe, the detection rate of IM-SLN could reach 77.2 % (223/289; p 0.05). The algorithm of our study is shown in Figs. 1 and 2. In the study, all patients who determined IMLN map ? (hotspot on lymphoscintigraphy and/or detected intraoperative cprobe) underwent IM-SLNB. We found the site of IMSLNs concentrated in the second and third intercostal space (85.4 %, 176/206). The involvement rate of IM-SLN was 8.8 % (17/193) when the axillary lymph nodes (ALN) were negative, and 23.3 % when the ALN were positive. These results were in accordance with the form study of extended radical mastectomy, which could reflect the accuracy of IM-SLNB indirectly. The IMLN metastases related significantly to the status of ALN. In the study of Veronesi et al., IMLN were positive in 29.1 % of patients with ALN metastases and only 9.1 % with negative ALN (p 0.001). Gnerlich et al. also confirmed that the number of the positive ALN was the only independent predictor of IM-SLN metastases. Similarly, Caudle et al. showed that 91 % (10/11) of patients with IM-SLN metastases were ALN positive. Current research of SLNB (both axillary and internal mammary) was limited to patients with clinically negative ALN. As IMLN metastases are Society of Surgical Oncology 2014

Thoracoscopic Internal Mammary Lymph Node Dissection: A Video Demonstration

Internal mammary lymph node (IMN) metastasis in breast cancer is a well-established prognostic factor of similar importance to axillary lymph node status. Although randomized controlled trials in the 1970s failed to show a survival benefit of IMN dissection during extended radical mastectomy, they did demonstrate diminished survival of patients with IMN metastasis.1,2 The 2011 National Comprehensive Cancer Network Clinical Practice Guidelines recommend radiotherapy to the IMN chain that is clinically or pathologically positive. However, the direct contribution of IMN irradiation to improved survival is still controversial, while it may contribute to the increased risk of relevant cardiac mortality.3-5 Thoracoscopic internal mammary node dissection is a novel minimally invasive technique to assess and treat IMN metastasis. It ensures that the whole IMN chain is excised for histological evaluation, and therefore, no further irradiation of these regional nodes is needed. This procedure is indicated in the following instances: operable invasive breast cancer; all medial or central tumors; lateral tumors with involved axillary lymph nodes; primary internal mammary lymphatic drainage detected by lymphoscintigraphy; and no contraindications to thoracoscopic surgery, including the inability to tolerate single-lung ventilation and extensive pleural adhesion. Thoracoscopic internal mammary node dissection is a feasible procedure designed to provide simultaneous assessment and management of IMN metastasis. However, a larger study cohort with long-term follow-up is required to verify its safety and clinical significance.

Breast Axillary Lymph Node Metastasis

The surgical management of breast cancer has evolved over the years from extensive radical mastectomy to breast conservation surgery. Until the introduction of the sentinel lymph node biopsy (SLNB), all patients with invasive breast cancer would undergo complete axillary lymph node dissection (ALND) and thus be at risk of suffering from its associated high morbidity. SLNB has become the standard of care and represented significant progress toward reducing the invasive procedures for the management of the axilla. The most recent clinical trials (NSABP-B32 and ACOSOG Z0011) performed in patients that underwent SLNB support this procedure as an accurate predictor of the risk of further axillary node involvement and of breast cancer recurrence. Additionally, the ACOSOG Z0011 trial challenged the standard of practice in the management of the axilla, in which ALND is mandated for all the patients with a positive sentinel node. A similar outcome was demonstrated for a selected group of patients (treated with breast conserving surgery and radiotherapy) with positive SLNB then followed by ALND or SLNB only. In light of these results, the role of ALND in the current management of breast cancer is being reevaluated for specific patient subpopulations. In this special issue, this timely subject is provocatively reviewed in addition to other relevant topics, such as the controversial meaning of the presence of micrometastasis and isolated tumor cells in the SLN in relation to local recurrence and overall survival and the feasibility of performing SLNB after neoadjuvant treatment and transaxillary breast augmentation. Despite the advances in the lymphatic mapping and in the intraoperative methods for SLN analysis, the accurate identification of tumor cells in this node continues to be a challenge in clinical practice, and significant false-negative results in SLNB are still observed. In a research study published in this issue, a preferential cellular distribution of the malignant cells in the SLN is reported, suggesting that the pathological analysis directed to this area may contribute to a more precise identification of nodal metastasis. Additional progress in this direction involves the development of molecular markers, which would tackle not only the misdiagnosed SLN-negative patients but also the ones with low risk of recurrence that are unnecessarily submitted to SLNB. In this sense, the Bayesian-based nomogram developed by Westover et al. is proposed to be particularly useful, especially in cases where the SLNB assessment is predicted to be less sensitive. This nomogram would also lead to the identification of high-risk individuals for recurrence, based on the calculation of residual axillary disease risk, despite a negative SLNB. Several new reports, mostly based on gene expression profiling, have suggested that the different rates of recurrence can be due to the distinct molecular types of breast cancer. The development of a genomic signature that effectively discriminates patients by lymph node status, as the one proposed by Ellsworth et al., could stratify patients based on their need of surgical evaluation of the lymph nodes, sparing the ones in which disease will probably be limited to its primary site. The assessment of specific tumor markers in the lymph nodes is also discussed in this special issue, including a review of the prognostic and/or predictive implications of lymph node metastasis in tumors with elevated levels of CXCR4 (a protein chemokine receptor) and VEGF-C (a vascular endothelial cellular growth factor). From the Halsted radical mastectomy to the commercial gene expression profiling tests, axillary lymph node management and recurrence prediction are still evolving topics for patients with breast cancer. The continued improvement of molecular tumor profiling and bioinformatics from larger and better defined patient cohorts will certainly provide answers to many challenging questions regarding the axillary metastatic process. The clarification of this complex molecular mechanism and the identification of novel and integrative molecular markers that can reliably predict lymph node involvement that will affect risk of recurrence and survival will continue to form the basis of the contemporary approach for breast cancer management, where an early prediction of axillary metastasis and a personalized cancer treatment can be achieved. Luciane R. Cavalli Rachel E. Ellsworth Christoph Klein Giuseppe Viale

Internal mammary node metastasis in breast cancer: Predictive models to determine status & management algorithms

Aim Internal mammary node (IMN) metastases are an important prognostic factor in breast cancer. However due to difficulty of access, most surgeons ignore these nodes, hence adjuvant treatment decisions may be compromised. Through mathematical modeling based on large datasets this study aims to estimate the current rate of IMN and sentinel node metastasis. Methods Models were created to estimate the current rate of axillary and IM sentinel node metastasis. Data from historical extended radical mastectomy series were analyzed to project contemporary rates of IMN metastasis. This information was coupled with derived models and contemporary datasets: a single-institution breast lymphoscintigraphy database (1992–2007) to establish lymphatic anatomy; and the Surveillance, Epidemiology and End-Results (SEER) registries in the US (2000–2003). Results Rates of IMN metastasis and positive sentinel nodes were estimated and models derived to assist with predicting IMN status in patients. If high definition peritumoral lymphatic mapping were available, the predicted rates of positive sentinel nodes in the axilla (AN) and internal mammary chain (IMN) would be equal. We predicted the overall rate of IMN metastasis is ∼39% the rate of positive sentinel AN. Conclusion Simplified models and algorithms can predict IMN status.

Extended radical mastectomy versus simple mastectomy followed by radiotherapy in primary breast cancer. A fifty-year follow-up to the Copenhagen Breast Cancer randomised study

From November 1951 to December 1957, 666 consecutive patients with untreated primary breast cancer admitted to the Radium Center in Copenhagen were randomised before their operability was evaluated into two groups, simple mastectomy with postoperative radiotherapy or extended radical mastectomy. Following physical examination 241 of the patients were excluded, primarily due to tumours deemed inoperable due to clinical criteria (n =107) and due to poor general condition (n =69). Twenty-five years results of disease-free free survival and fifty years results of survival are presented, showing no difference between the two groups. Patients with clinical stage I did significantly better than patients with stage II-III tumours. Patients with grade I tumours had a better survival than patients with grade II-III. The breast cancer associated mortality was lower in premenopausal patients compared to postmenopausal patients. An excess mortality due to breast cancer was evident up to 20–25 years following the primary diagnosis.

Development and Trends of Surgical Modalities for Breast Cancer in China: A Review of 16-Year Data

Surgery is the most important treatment for nonmetastatic breast cancer; however, the utilization of modern surgical techniques in management of breast cancer in mainland China has not been reported. The medical records of 5887 consecutive breast cancer patients treated surgically in the past 16 years were reviewed retrospectively; the utilization of different surgical modalities and associated clinical outcomes were analyzed. Median age of all patients was 50 (range 16-92). About 1015 patients were staged as 0-I, 3569 stage II, 517 stage III, and 786 cases could not be staged. Extensive radical mastectomy (ERM), radical mastectomy (RM), modified radical mastectomy (MRM), simple mastectomy (SM), and breast-conserving surgery (BCS) were used in 8%, 27.2%, 55.7%, 1.5%, and 6.3% of patients, respectively. In addition, 1.3% of patients received breast reconstruction. The proportion of early-stage breast cancer increased, and the surgery patterns varied. MRM gradually replaced ERM and RM. The prevalence of BCS began to increase from the mid-1990s and currently represents about 12%. The prevalence of reconstruction also increased and now accounts for 5%. Age, pathologic pattern, and TNM staging affected the choice of surgery modalities markedly. Although patients receiving RM/ERM had worse survival than those receiving BCS/MRM, the survival outcomes of these four groups were similar in the early-stage population. MRM remains the most-used surgical modality in operable breast cancer, although the utilization of BCS for early-stage disease has increased rapidly in last decade. Reconstruction following mastectomy as an alternative to BCS is available. Breast-conserving therapy (BCT) and MRM provide similar local controls and long-term survival for breast cancer. Selection of appropriate candidates for a certain surgery requires an assessment of the patient's age and clinical and pathological characteristics of the tumor.

Breast cancer subpopulation with high risk of internal mammary lymph nodes metastasis: analysis of 2,269 Chinese breast cancer patients treated with extended radical mastectomy

The selective treatment of internal mammary lymph nodes (IMNs) in breast cancer is controversial. The purpose of this research was to determine the subpopulation patients with high risk of internal mammary lymph nodes metastasis who received extended radical mastectomy without any preoperative treatment from 1956 to 2003 in China. 1,679 Chinese patients were underwent extended radical mastectomy (ERM) between 1956 and 2003. Four individual variables were selected (tumor site, tumor size, the number of ALNs involvement, patient age),then classified by following standards: tumor site(lateral, central, medial),tumor size(T1:<or=2 cm; T2:2 < T <or= 5 cm, T3:>5 cm), ALNs(0,1-3,4-6, >or=7), age(<or=35 y, 36-50 y, >50 y). Chi-square and binary logistic regression were used to analysis relationship of these variable and IMMs. The four individual variables were significantly associated with IMNs metastasis using univariate analysis. However, three individual variables except for tumor size independently impact the IMNs metastasis using multivariate analysis. The incidence of IMNs metastasis in patients with 4-6 and >or=7 positive ALNs was 28.1%, 41.5%. Within subgroup patients with medial tumor and positive ALNs, the incidence of IMNs metastasis was 23.6% for patients with 1-3 positive ALNs, and 47.5% for 4-6 positive ALNs, 38.7% for patients with >or=7 positive ALNs. The incidence of IMNs metastasis was 25.4% for patients with T3 tumor and younger than 35 y. Patients with following conditions had high risk of IMNS metastasis: (1) patients with 4 or more positive ALNs. (2) patients with medial tumor and positive ALNs.(3) patients with T3 tumor and younger than 35 y. (4) patients with T2 tumor and positive ALNs.(5) patients with T2 tumor and medial tumor .The incidences of IMNS metastasis for those patients were more than 20%.

Evidence-Based Risk Factors for Seroma Formation in Breast Surgery

Seroma is a common problem in breast surgery. The aim of this systematic review was to identify risk factors for seroma formation. Articles published in English were obtained from searches of Medline and additional references were found in the bibliographies of these articles. Risk factors were graded according to the quality and strength of evidence and to the direction of association. One meta-analysis, 51 randomized controlled trials, 7 prospective studies and 7 retrospective studies were identified. There was no risk factor supported by strong evidence, but there was moderate evidence to support a risk for seroma formation in individuals with heavier body weight, extended radical mastectomy as compared with simple mastectomy, and greater drainage volume in the initial 3 days. On the other hand, the following factors did not have a significant influence on seroma formation: duration of drainage; hormone receptor status; immobilization of the shoulder; intensity of negative suction pressure; lymph node status or lymph node positivity; number of drains; number of removed lymph nodes; previous biopsy; removal of drains on the fifth postoperative day versus when daily drainage volume fell to minimal; stage; type of drainage (closed suction versus static drainage); and use of fibrinolysis inhibitor. In contrast, sentinel lymph node biopsy reduced seroma formation. Evidence was weak, or unproven, for other factors that were commonly cited in the literature. Although a number of factors have been correlated with seroma formation, strong evidence is still scarce. However, there is evidence showing that sentinel lymph node biopsy reduces seroma formation.

Internal mammary lymph nodes: results of surgical methods of staging and treatment

Purpose: The elective treatment of internal mammary lymph nodes (IMNs) in breast cancer is controversial. Previous randomized trials have not shown a benefit to the extended radical mastectomy or elective IMN irradiation overall, but a survival benefit has been suggested by some for subgroups of patients with medial tumors and positive axillary lymph nodes. The advent of effective systemic chemotherapy and potential for serious cardiac morbidity have also been factors leading to the decreased use of IMN irradiation during the past decade. The recent publishing of positive trials testing postmastectomy radiation that had included regional IMN irradiation has renewed interest in their elective treatment. The purpose of this study is to critically review historical and new data regarding IMNs in breast cancer.Methods and Materials: The historical incidence of occult IMN positivity in operable breast cancer is reviewed, and the new information provided by sentinel lymph node studies also discussed. The results of published randomized prospective trials testing the value of elective IMN dissection and/or radiation are analyzed. The data regarding patterns of failure following elective IMN treatment is studied to determine its impact on local-regional control, distant metastases, and survival. A conclusion is drawn regarding the merits of elective IMN treatment based on this review of the literature.Results: Although controversial, the existing data from prospective, randomized trials of IMN treatment do not seem to support their elective dissection or irradiation. While it has not been shown to contribute to a survival benefit, the IMN irradiation increases the risk of cardiac toxicity that has effaced the value of radiation of the chest wall in reducing breast cancer deaths in previous randomized studies and meta-analyses. Sentinel lymph node mapping provides an opportunity to further evaluate the IMN chain in early stage breast cancer. Biopsy of “hot” nodes may be considered in the future to select patients who are most likely to benefit from additional regional therapy to these nodes.Conclusions: Irradiation of the IMN chain in conjunction with the chest wall and supraclavicular region should be considered only for those with pathologically proven IMNs with the goal of improving tumor regional control.

The pattern of lymphatic metastasis of breast cancer and its influence on the delineation of radiation fields

The delineation of radiation fields should cover the clinical target volume (CTV) and minimally irradiate the surrounding normal tissues and organs. This study was designed to explore the pattern of lymphatic metastasis of breast cancer and indications for radiotherapy after radical or modified radical mastectomy and to discuss the rational delineation of radiation fields. Between September 1980 and December 2003, 78 breast cancer patients receiving extended radical mastectomy in the Margottini model and 61 cases with complete data were analyzed to investigate the internal mammary lymphatic metastatic status. Between March 1988 and December 1988, 46 patients with clinical negative supraclavicular nodes received radical mastectomy plus supraclavicular lymph node dissection. The supraclavicular lymph nodes and axillary lymph nodes were labeled as S and levels I, II, or III, respectively, and examined pathologically. Between January 1996 and April 1999, 412 patients who had radical or modified radical mastectomy underwent the pathologic examination of axillary or levels I, II, or III nodes. The incidence of internal mammary lymph node metastasis was 24.6%. It was 36.7% for the patients with positive axillary lymph nodes and 12.9% for the patients with negative axillary lymph nodes. All the metastatic internal mammary lymph nodes were located at the first, second, and third intercostal spaces. Skipping metastasis of the supraclavicular and axillary lymph nodes was observed in 3.8% and 8.1% of patients, respectively. According to our data, we suggest that the radiation field for internal mammary lymph nodes should exclude the fourth and fifth intercostal spaces, which may help to reduce the radiation damage to heart. It is unnecessary to irradiate the supraclavicular lymph nodes for the patients with negative axillary level III nodes, even with positive level I and level II nodes.

The Breast: Comprehensive Management of Benign and Malignant Diseases

The Breast: Comprehensive Management of Benign and Malignant Diseases