Extended Radical Mastectomy Research Articles

A CASE OF SQUAMOUS CELL CARCINOMA OF THE BREAST

A case of squamous cell carcinoma of the breast diagnosed by preoperative needle aspiration biopsy cytology is reported. A 59-year-old woman was found having an about 7.5×7.5cm hard tumor with skin reddness in the right breast. Needle aspiration cytology revealed atypical keratinized cells. These findings are the routine diagnostic feature of squamous cell carcinoma. Right extended radical mastectomy was carried out. Fine needle aspiration biopsy cytology is also available for preopatative diagnosis of squamous cell carcinoma of the breast.

Mastectomy from the perspective of a medical oncologist.

An increasing awareness of breast cancer and the increased use of mammography fortunately is resulting in a marked increase in the diagnosis of early breast cancer. Many of these lesions are characterized by intraductal breast cancer (ductal carcinoma in situ) and/or lesions smaller than 1 cm. Before the era of mammography, approximately 3-5% of new breast cancer cases involved ductal carcinomas in situ. More recent series suggest that such lesions can account for up to 25% of all new breast cancer cases. Breast conservation therapy is of particular importance to this population of patients with breast cancer. Breast conservation therapy is defined as excision of the primary breast tumor and adjacent breast tissue followed by radiation. This is referred to as lumpectomy, tumorectomy, segmental mastectomy, and quadrantectomy. Surgeons have participated in a series of clinical studies which that provided us with the progressive concept that breast cancer is not only a local but a systemic disease. These studies have shown that a modified radical mastectomy is as effective as a radical or extended radical mastectomy for the management of breast cancer. Subsequently, patients with Stage I or II breast cancer, in which the tumor size was 4 cm or smaller, appeared to do equally well when treated with either total mastectomy or lumpectomy with radiation therapy. Lumpectomy followed by radiation therapy resulted in a 5-year survival rate of 85%, compared with 76% for total mastectomy. The probability of a radiated breast remaining free of tumor at 8 years after the operation was 90%, compared to 61% for those who did not receive radiation therapy after lumpectomy. Subsequent observations indicate that lumpectomy followed by breast radiation and adjuvant chemotherapy in women with positive nodes was appropriate treatment for Stages I and II breast cancer. This manuscript describes the contraindications and indications for conservative surgery for breast cancer and the role or perioperative chemotherapy. Improved imaging techniques will allow clinicians to diagnose breast cancer at an earlier stage of its evolution and demand even more stringent conservation approaches to its management. Simple or total mastectomy and lumpectomy with radiation therapy remain viable options for the management of patients with early stage breast cancer.

Radical mastectomy with parasternal node dissection or radiation to the parasternal region for breast cancer of medial or central location.

In order to establish a therapeutic approach for primary breast cancer of medial and central origin, we reviewed 183 patients who had been treated by one of the following three modalities at the Second Department of Surgery, Osaka University Medical School between January, 1965 and December, 1980. Group A (n = 70): standard radical mastectomy alone; Group B (n = 34): standard radical mastectomy followed by postoperative irradiation to the parasternal and supraclavicular regions, and; Group C (n = 62): extended radical mastectomy that included removal of the parasternal lymph nodes. The background factors of the three groups were not significantly different. The overall survival five and ten years following surgery in the three groups were 91 percent and 79 percent in group A, 82 percent and 67 percent in group B, and 82 percent and 70 percent in group C, respectively, showing no significant difference in overall survival among the three groups. When the patients were classified according to the extent of axillary lymph node involvement, there was no difference in survival among the three treatments in patients who had less than three lymph node metastases in the axilla. However, treatment of the parasternal lymph nodes improved survival in the patients who had more than four lymph node metastases in the axilla. Parasternal lymph node involvement definitely worsened the prognosis, showing it to be a good prognostic factor. Thus, extended radical mastectomy should be considered for patients with breast cancer of medial or central location, when extended axillary lymph node involvement is found.

Efficacy of Internal Mammary Node Dissection in the Treatment of Breast Cancer

The present study compares clinical and pathological findings and survival data from 410 patients who have undergone extended radical mastectomies in our hospital during the 20 years from 1967 with those derived from 261 who underwent mastectomies without dissections of the internal mammary nodes, in order to determine the value of additional internal mammary node dissection following standard radical mastectomy. Extended radical mastectomy was used in 289 of 361 (80.1%) patients with medial tumors, and in 121 of 310 (39.0%) with lateral tumors. Metastases to the internal mammary nodes were found in 18.5% (76) of all patients, in 20.4% (59) of the patients with medial tumors and in 14.0% (17) of those with lateral tumors. Of the patients with medial tumors, internal mammary node metastases were found in seven of 44 (15.9%) at TNM Stage I, and the rate of metastases rose with advances in stage. Internal mammary node metastases alone, without those to the axillary nodes, were found in 14 patients (4.8%) with medial tumors and in two with lateral tumors. The 10-year survival rate in patients with medial tumors and metastases to the internal mammary nodes only was 67.0%, which was as good as that in patients with metastases to the axillary nodes only. In conclusion, extended radical mastectomy was valuable in the treatment of relatively early medial breast cancer at TNM Stages I and II.

SIGNIFICANCE OF CLINICOPATHOLOGIC DETAILS AND PROGNOSES IN MEDIALLY LOCATED BREAST CANCER

Surgically treated breast cancers were grouped by location of the primary tumor, and 172 medial (M) and 214 lateral (L) groups were retrospectively analyzed. No significant difference was found in background factors such as age, T-factor, stage, and axillary lymph node involvement. Ten-years cumulative survival rate in group M was 57.1% which was significantly poorer than that in group L. In group M follow-up results were compared for operative procedure (extended radical and radical) by stages, and significantly poorer prognosis was noted in stage II cancers undergone extended radical mastectomy. No significant differences were found in other stages. The mean age was significantly younger in extended radical mastectomy cases. No significant difference was seen in the tumor diameter. Lymph node involvement tended to occur in extended radical mastectomy cases, in which adjuvant therapies were more frequently performed in these cases. From these findings, careful selection of operative procedure appears important in medial breast cancers, namely, modified radical mastectomy with dissection of internal mammary node and extended radical mastectomy considered to be reasonable in stage I cancers and stage III cancers, respectively. However in stage II cancers, factors indicating malignant potentials of cancers should be take into account in determining operative procedure and adjuvent therapies.

CASE OF BREAST CANCER ASSOCIATED WITH A PITUITARY ADENOMA

We report a case of breast cancer associated with a pituitary adenoma. The patient was a 44-year-old woman. She noticed signs of acromegaly about 22 years ago. At the age of 43, she found a painless mass of the left breast, and consulted our hospital. A diagnosis of breast cancer associated with acromegaly was made. After intra-arterial chemotherapy, extended radical mastectomy and partial hypophysectomy were performed sequentially. The breast cancer was in stage IIIb (T4bn0M0, scirrhous type), and was estrogen receptor positive. No recurrence was noted as of 2 years after surgery. The pituitary adenoma was eosinophilic.It is unknown if the development and growth of breast cancer is accelerated by human growth hormone. The incidence of breast cancer in persons with acromegaly may be more than expected.

PROGNOSIS OF BREAST CANCERS AS ASSESSED BY LOCATIONS WITH REFERENCE TO THE SIGNIFICANCE OF PARASTERNAL AND SUPRACLAVICULAR LYMPH NODE DISSECTION FOR ADVANCED BREAST CANCER DEVELOPED IN THE INNER AREA

To study the prognosis of breast cancers occupying different locations and the significance of parasternal (Ps) and supraclavicular (Sc) lymph node dissection for advanced breast cancer developed in the inner area of the breast.Regardless of the locations, breast cancer patients having undergone radical mastectomy as a rule during 1975-1982 were subjected, and survival rates by locations were studied. In patients group with inner breast cancer in T2 or severe after 1983 who received Ps dissection; and in patients group with advanced inner one after 1987 who received intrammamary infusion of activated carbon particle adsorbing aclarubicin (ACR-CH) followed by Ps and Sc dissection, the value of Ps and Sc dissection was evaluated.A comparison of survival rates by locations revealed that the prognosis in cancers developed in the inner area was significantly poorer compared to those in the outer area. Cancers in the inner area predominantly involved Ps and/or Sc recurrence, which might cause the declined survival rate. Possible contribution of Ps dissection to increase survival rate might be reasonable in only 2 Ps metastasis-positive cases, which accounted for about 4% of 49 Ps dissection cases. Therapeutic results with ACR-CH infusion followed by extended radical mastectomy (Ps, Sc) were currently favorable and further improvement in survival rate with this method can be expected.

THE DIAGNOSIS OF INTERNAL MAMMARY LYMPH NODE METASTASES IN BREAST CANCER

An information on internal mammary lymph node (IMN) status is important for estimating prognosis and/or selecting treatment of breast cancer. In this study, an efficacy of lymphoscintigraphy and sonography as preoperative examination of IMN status was evaluated in 71 patients in which presence or absence of IMN metastases was histologically confirmed. The overall accuracies of lymphoscintigraphy and sonography were 67% and 90%, respectively. On the other hand, when the locations of metastatic IMN were evaluated in patients who underwent extended radical mastectomy, the metastatic incidence was 97% at the first and/or second intercostal space. Therefore, we conclude that a biopsy of IMN at the first and second intercostal space is practical and useful to provide the information of IMN status.

Lymph node metastasis within the pectoralis major muscle in breast cancer—A case report—

We report herein, a case of a 75 year old woman with breast cancer in whom lymph node metastasis within the pectoralis major muscle was found. The breast mass measured 10 X 6 cm, and its overlying skin was red and edematous, suggesting inflammatory carcinoma. An extended radical mastectomy was performed and the lesion was histologically confirmed to be solid-tubular carcinoma with regional lymph node involvement. In the pectoralis major muscle, where lymph nodes do not usually exist, one positive metastatic lymph node and another metastatic lymph node-like nodule were histopathologically confirmed. To our knowledge, no other such case has ever been reported, yet the possibility of lymph nodes existing in the pectoralis major muscle, albeit rare, should nevertheless be considered in the treatment of breast cancer.

A CASE OF SPINDLE CELL CARCINOMA OF THE MAMMARY GLAND

Spindle cell carcinoma of the mammary gland has been categorized into so-called carcinosarcoma in the former general rule for mammary cancer and rarely found in Japan. In addition to already reported domestic 13 cases, we report a case of the disease together with a review of the literature. A 35-year-old woman had a large tumor approximately 10×9cm in size ranging her whole right breast. Right extended radical mastectomy was carried out uner a suspesion of nonepitherial tumor. Histological examination as well as findings from immunological tissue stain indicated a spindle cell carcinoma. Although we can not draw any clear findings from a comparative review between Japan and European/American patients because of too small number of its reports, the common finding may be that mammary spindle cell carcinoma appears as a slightly larger tumor but has similar natures including prognosis to those of regular type breast carcinomas.

Simple Mastectomy with Postoperative Irradiation Versus Extended Radical Mastectomy in Breast Cancer: A twenty-five-year follow-up of a randomized trial

From November 1951 to December 1957, all patients with untreated breast cancer admitted to the Radium Centre in Copenhagen were randomized before their operability was evaluated into two groups, if the patients were operable, viz. simple mastectomy with postoperative x-ray treatment or extended radical mastectomy. Twenty-five-year results are presented, showing no difference in survival or recurrence-free survival of the operable patients. Histological grading was performed in nearly all cases. Patients with grade 1 tumours had a better survival than grades 2 and 3, but there was no difference in survival between the two treatment groups, when histological grading was taken into account. Histological node positive patients had more grades 2 and 3, tumours, whereas node negative patients had more grade 1 than grades 2 and 3 tumours. Premenopausal women had a significantly better survival than postmenopausal in all stages.

The significance of regional lymph node dissection in the surgical management of breast cancer.

The results of an analysis done on the regional lymph node metastases of 300 patients with operable breast cancer, who were treated in the Department of Surgery (II), Kanazawa University Hospital from 1973 to early 1988 are reported herein. It was found that the metastases of the axillary and internal mammary lymph nodes were closely related to the survival of patients, but they were hardly diagnosed before the operation. Only the dissection of these lymph nodes proved useful for providing the prognostic information. Moreover, in a retrospective study comparing the en bloc extended radical mastectomy versus the other types of mastectomy, the extended radical mastectomy was seen to greatly improve the survival of patients with 3 or less than 3 metastatic axillary lymph nodes. Thus, the extended radical mastectomy provides the maximum diagnostic and prognostic information, and gives the best chance of loco-regional control of the disease. The anterior chest deformity created by the extended radical mastectomy, however, should be avoided in those patients without internal mammary involvement. We therefore propose the modified extended mastectomy as a staging operation.

TWO CASES OF OCCULT BREAST CANCER

Two cases of occult breast cancer that we encountered are reported inaddition to the discussion on the literature. Case 1 was a 57-year-old woman who visited our department because she moted masses in the left axillary and supraclavicular fossae. When the mass in the left axillary fossa was examined via biopsy, it was diagnosed as metastatic adenocarcinoma. Because a mammogram showed very small calcification, but a possible malignant tumor in other organs was clinically denied, she was diagnosed as breast occult cancer. This patient underwent extended radical mastectomy of the left breast; the tumor was defined as T0, N3, M0 and stage IIIb. Case 2 was a 64-year-old woman who visited our department with the main complaint of an egg-sized painless mass in the left axillary fossa. Because the mass was diagnosed as metastatic adenocarcinoma via biopsy, her whole body was examined, a nd a mass, measuring about 2cm in diameter, was detected in the left thyroid lobe. While we were thinking of a possibility of breast occult cancer, we undetook operation based on suspected thyroid adenocarcinoma. Because that tumor was found to be benign goiter during operation, total mastectomy was performed at the same time. Her breast tumor was histopathologically defined as medullary tubular carcinoma with infiltration to a very limited extent.

Prognostic value of hormone receptors in breast cancer.

The aim of this study was to establish the role of estrogen receptor (ER) and progesterone receptor (PgR) as prognostic indicators for early recurrence and survival. In all, among breast cancer patients, 166 patients who had undergone radical or extended radical mastectomy were studied. These patients were treated with adjuvant chemotherapy alone for 2-3 years after surgery. No patients had adjuvant endocrine therapy. Local recurrence and/or distant metastases were treated by endocrine therapy and/or chemotherapy. The relapse-free interval was not different between the ER-positive and ER-negative patients. The postrelapse survival curve was significantly different between the two groups. There was no significant difference in the relapse-free interval and the postrelapse survival curve between the PgR-positive and PgR-negative patients. These results suggest that ER is a good predictor of the response to endocrine therapy given after relapse, but not of early recurrence.

Management of inflammatory carcinoma of the breast with combined modality therapy including intraarterial infusion chemotherapy as an induction therapy. Long-term follow-up results of 28 patients.

Twenty-eight patients with inflammatory breast cancer were treated with combined modality therapy consisting of (1) intraarterial infusion chemotherapy (IA chemotherapy) through the internal thoracic artery and subclavian artery, (2) surgical ablation, (3) extended radical mastectomy, and (4) adjuvant chemotherapy in that order. The IA chemotherapy included Adriamycin (n = 14) and mitomycin C plus 5-Fluorouracil (n = 14) were used. The response rate of the primary breast lesions to IA chemotherapy was as high as 83%, and complete necrosis of the tumor was histologically documented in 43% of the cases. The median interval from the initiation of IA chemotherapy to surgery was 7 weeks. Toxicity was acceptable and every patient completed the treatment. The 5- and 10-year disease-free survival rates were 59% and 53%, respectively. These results suggest that IA chemotherapy is a very useful induction therapy for inflammatory breast cancer in terms of excellent local effects and the short time required for therapy before surgery.

Primary surgical treatment of breast cancer.

An unexpected rise in breast cancer mortality has been reported for 1984 and 1985 in white women below 50 years of age in the United States. During the preceding 10 years, there had been a progressive drop of approximately 1% in breast cancer mortality for each successive year. This recent increase in mortality occurred despite the increased use of adjuvant chemotherapy; it is most likely a direct result of the current tendency to downgrade the need for adequate primary therapy. Several recent prospective randomized studies that evaluated the relative efficacy of mastectomies of varying extent have shown a direct relationship between local control and long-term survival. They also demonstrated that specific operative procedures were most effective for the appropriate clinicopathological stage of disease. Stage I cancers can be treated effectively by modified mastectomy, but radical mastectomy is superior for control of stage II and stage III disease. Inner-quadrant cancers are most effectively managed by extended radical mastectomy, which includes excision of the internal mammary nodes. Excellent surgical technique was employed in all studies, which included observed follow-up of 10-20 years. Optimal local control and long-term survival were achieved by the appropriate operative procedure.

SURGICAL TREATMENT OF EARLY BREAST CANCER

This brief review defines the various surgical procedures for breast cancer, which are under dispute by laymen and some surgeons, because of lack of controlled comparative studies and differences in classification of stages of breast cancer. The simplest procedure, tylectomy or lumpectomy, consists of resection of the local lesion only. Simple mastectomy refers to removal of the involved mammary gland and pectoral fascia, perhaps with some easily accessible lymph nodes. Modified radical mastectomy consists of total mastectomy with dissection of the axillary contents. Radical mastectomy, the classical Halsted operation, is removal of breast, subcutaneous tissues, pectoral muscles, axillary contents, followed by skin graft. The extended radical mastectomy also involves resection of parasternal lymph nodes and supraclavicular tissues. For metastases, some physicians prefer irradiation, some chemotherapy and some ovariectomy with hormone therapy. 2 comparative studies cited show no difference in survival rates between radical mastectomy and radical mastectomy with irradiation or between radical mastectomy with irradiation and wide local excision with irradiation.

A CASE OF DOUBLE CARCINOMA OF THE BILIARY TRACT RESECTED 14 YEARS AFTER EXTENDED RADICAL MASTECTOMY

The present paper reports a case of double cancer of the biliary tract, i.e., the gallbladder and the lower portion of the common bile duct, developing 14 years after extended radical mastectomy for left breast cancer. A 79-year-old woman with the chief complaints of jaundice and epigastric pain was admitted to the department of surgery of our hospital under the diagnosis of obstructive jaundice. After a detailed examination, the patient underwent surgery for suspected cancer in the lower portion of the common bile duct and the gallbladder. Histopathologically the tumor in the gallbladder was tubular adenocarcinoma while that in the lower portion of the common bile duct was poorly differentiated cacinoma. As no continuity was noted between the two tumors, and lymph node metastasis was negative, the case was diagnosed as double cancer of the biliary tract. The breast cancer was scirrhous carcinoma located in the AC region with negative lymph node metastasis. Thus, this was a case of asynchronous triple cancer of the breast, gallbladder and common bile duct. Double cancer of the biliary tract is comparatively rare, and an association with carcinoma of other organs has been reported in only one case with concurrent gastric cancer. The authors report the extremely rare case of triple cancer involving the breast, and present a reveiw of the literature on cancer developing in other organs after surgery for breast cancer.

Survey of the management of primary breast cancer in Western Australia.

A postal survey of all general surgeons in Western Australia was undertaken in order to document their current attitudes towards the management of primary breast cancer. The commonest surgical procedure preferred for stages I and II breast cancer was a modified radical mastectomy, although a substantial number (31%) of surgeons favour breast conserving procedures for primary tumours less than 2 cm in size. Few (3%) surgeons still perform a classical radical or extended radical mastectomy. There is a wide diversity of practices regarding pre-operative investigations and postoperative management. Although many surgeons (68%) use aspiration cytology to determine the histologic nature of breast lumps, the majority (62%) do not use mammography to monitor the contralateral breast. After breast conserving surgery, 60% of surgeons would not refer their patients for adjuvant radiotherapy and over 33% would not favour the use of adjuvant systemic therapy for women with stage II breast cancer. It is concluded that the wide diversity in the pattern of management reflects uncertainty regarding the best approach to this disease.

Five year results of radical mastectomy for breast cancer, by a sternal splitting, intrapleural en bloc resection of the internal mammary lymph nodes.

A new operative method of extended radical mastectomy enables complete resection of the axillary and internal mammary lymph nodes. In this paper, we present the histological analysis of the internal mammary involvement, and the estimated 5 year survival rate, of 100 patients with breast cancer of Stage I, II or III, who underwent this operation. The incidences of axillary and internal mammary involvements were 41 per cent and 17 per cent, respectively. The metastases in the internal mammary lymph node chain were located from just below the supraclavicular vein to the third intercostal space along the internal mammary vessels. The types of lymphatic invasion observed in the internal mammary chain were lymph node metastases in 88 per cent, metastatic lesion in the lymphoid tissue in 29 per cent and cancer cell emboli in the lymphatic channel in 71 per cent. The overall estimated 5 year survival rate was 90.5 per cent. Where there was internal mammary involvement, the estimated 5 year survival rates for those with no axillary lymph node metastasis, those with fewer than 3 metastatic axillary lymph nodes, and those with more than 4 metastatic axillary lymph nodes were 100 per cent, 80 per cent and 31.2 per cent, respectively. Although the assumption that more aggressive surgical removal of the primary lesion and the regional lymphatic spread gives a higher cure rate has not been proved, this extended radical mastectomy with adjuvant chemoendocrine therapy seems to give a higher 5 year survival rate for patients with internal mammary involvement.