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Radical tumor excision and cosmetic balance in the surgical treatment of breast carcinoma: biquadrantectomy
Biomed & Pharmacother (1992) 46.401-404 Q Elsevier. Paris
tumor excision a
R Garofalo,
ica
R Borioni, R LLA Garofalo, G Lavanga, G Math6 European Hospital, Via Portuense. 696 Rome, Italy (Received
18 May 1992; accepted 30 July 1992)
Summary - The present trend in favor of conservative surgery is in contrast with histopathological findings of multicentric breast carcinoma, which may be responsible for the occurrence of relapses in spite of the use of radiation therapy. As a consequence, conservative surgery appears to be inadequate, especially when tumor size exceeds 2 cm. Therefore for tumors up to 4 cm in size, which are not adherent to the pectoral fascia, we propose the excision of two quadrants with concomitant operation on the contralateral breast resulting in a more symmetrical and therefore cosmetic effect. This is a more radical procedure than the removal of the one quadrant. breast
carcinoma
/ biquadrantectomy
R&urn6 - Excision tumorale radicale et pr6occupations esthltaques dans le traitement chirurgical du cancer du sein: la biquadrantectomie. La tendance actuelle en faveur d’une chirurvie conservatrice est en contradiction aver les donnPes histologiques quand on observe un carcinome multicentrique du sein susceptible de donner lieu ti des rechutes, malgrk E’usage d’uw radiothhe’rapie. En conskquence, la chirurgie cnn~ervatrice ne semble pas complStement adiquate, particuliPrement lorsque la taille de la tumeur d&passe 2 cm. Ainsi, pour les tumeurs atteignant jusqu’h 4 cm et non adhkentes au fascia pectoral, les auteurs suggkent l’excision dQ deux quadrants, avec intervention concomitante sur le sein controlat~ral. duns un but de symbrie. Cette me’thode comporte un avantage esthitique, et reprisente un traitement plus radical que l’ablation d’un quadrat ou l’excision tumorale, plus ou moins extensive. excision tumorale I esthitique I biquadrantectomie
Introduction The present trend in favor of conservative surgery, as shown by various international trials [3, 7, 8, 15, 181 is in contrast with the histopathological findings of multicentric breast carcinoma [6, 10, 14, 171, which may be responsible for the occurrence of relapses in spite of the use of radiation therapy (NSABP). On the other hand, from an anatomico-surgical viewpoint, breast tumor spreads not only by “starlike” infiltration but also via the lympnatic vessels directed upward to the sub-areolar plexus and then toward the axilla. As a consequence, conservative surgery is [ll], not fully adequate, especially when tumor size exceeds 2 cm. Therefore for tumors up to 4 cm in size, which are not adherent to the pectoral fascia, we suggest
the excision of two quadrants with concomitant operation on the contralateral breast which results in a more symmetrical and therefore cosmetic effect.
Biological prerequisites The incidence of multicentricity in breast carcinoma has been widely reported in the literature. The lack of uniformity in speciman preparation and studies is likely to be responsible for the disparate findings observed. However, the phenomenon cannot be disregarded since it is found in 10 to 74% of cases [6, lo]. Clinically, in nonappreciable breast tumors as well as in those up to 3 cm in size, the incidence of multicentric carcinoma is 40% in the absence of clinical or radiological signs of multicentricity [ 1, 171. In most
cases it is not easy to establish whether the multicentric lesions are intramammary motostases, tumor enlargement or independently developing carcinoma [ 131. Holland ef nl [ 121 used the Engan method [6] to investigate 282 mastectomy T 1-T2 samples of invasive, non-disseminated, carcinomas for which conservative surgery had been ~co~end~ and found that: a) the possibility of the presence of multicentric foci decreased with the increase of distance from the primary tumor and markedly diminished beyond 6 cm; b; the likelihood of residual carcinoma after surgery was directly related to the extent of surgical excision; c) the chances of the residual carcinoma being invasive or non-invasive were equal. Histologically, in~l~ating ductal carcirioma, lobular carcinoma in situ and infiltrating lobular carcinoma are markedly more multicentric than the other histotypes [5]. On the other hand, the size of the primary tumor is also a factor in the ficquenty of multicent~~ neoplams [lo].
Anatomic prerequisites Breast carcinoma spreads by direct infiltration and lymphatic progression. The observation that malignant anatomy is not the anatomy of the organs but that of the lymphatic system (Moyniha, 1908) is pertinent to breast cancer. According to Haagensen lymphatic spreading affects [ 1I], (fig 1). the central sub-areolar area; the lymphatic vessels directed from the sub-areolar region to axillary sites and particularly the collecting vessels flowing along the lateral margin of the pectoralis major muscle; the transpectoral and retropectoral accessory lymphatic vessels; the lymphatic directed to the internal mammary artery. As a consequence, it seems reasonable that surgery involves not only the axillary lymph nodes but also the drained intraparenchymal lymphatic vessels.
Local relapses In stage I or stage II breast carcinoma, extensive tumor excision is accompanied by a significant risk of local relapse within 10 years, occurring in 6-i6% of cases 12, 3, 7, 8, 151. The most commonly affected are the younger premenopausal patients with small breasts [2, 31. Local relapse
Fig 1. Lymphatic system of the breast.
after conservative surgery is more likely to occur when the tumor is larger than 2 cm, with unfavorable histologic grading and early carcinomatous lymphangitis. It usually affects the same quadrant as the primary tumor or the neighbouring glandular parenchyma and in most cases is histologically similar lo the primary tumor [9]. Relapsing negatively affects long-term survival and the appearance of metastases [3] and, at any rate, must be regarded as a failure as far as cosmetic outcome is concerned.
Two-quadrant excision is aimed at obtaining the most radical excision compatible with satisfactory cosmetic results, while reducing the possibility 0; local relapse. Technically, it involves a large resection of the affected mammary hemiparenchyma, that includes a large portion of the sub-aureolar region (greater than the slice resulting from classic single-quadrant removal), the fascia and the iateral margin of the pectoralis major muscle with its main lymphatic vessels, the pectoralis minor muscle and I, II and II level lymph nodes (fig 2). The latter are reached through a separate incision, when necessary. Reconstruction is carried out by flapping and remodeling of the residual mammary parenchyma. Simultaneously, a second team operates upon the
403 tion, two-quadrant excision must be regarded as a valid therapeutic alternative, taking into account the anatomico-surgical and biological prerequisites which provide the basis for the correct therapeutic approach to breast cancer.
References Anton HW, Guhr A, Muller A, Abel U (1987) Multi~ent~e~ty in breast carcinoma. In: Breast Diseases. (Kubli F, van Fournier D, Junkermann H, Bauer M, Kaufmann M, eds) Springer-Verlag, Berlin Heidelberg, p 48 Chauvet B, Reynaud-Bougnoux A, Calais G, et al f 1990) Prognostic significance of breast relapse after conservative treatment in node-negative early breast cancer. Int J Radiat Oncol Biol Phys 19, 1125 Chauvet B, Lemseffer A, Le pechoux C et al (1990) Predisposing factors for local recurrence after conservative treatment of breast cancer. Ann kzdiol33. 306 Cody HS, Laughlin EH, Trill0 C, Urban JA (1991) Have changing treatment patterns affected oucome for operable breast cancer? Ann Surg 213, 297 Conte~r? G, Rn’resse J, Fontaine F, Petit JY (1977) Les disstminations intramammaires des carcinomes du sein. Bull Cancer 64, 5 Egan RL (1982) Multicentric breast carcinoma. Clinical-radiographic-pathologic whole organ studies and 1O-years survival. Cancer 49, 1123 Fisher B, Bauer M, Margolese R et al (1985) Five-
Fig 2. Morphology of biquadrantectomy.
contralateral breast to achieve symmetry, thus avoiding prolongation of surgery. The classic indication of two-quadrant excision is T2 for which conservative surgery is not advisable since it entails a high percentage of recurrence. In the case of large breasts, two-quadrant excision may also be indicated for tumors less than 2 cm in size, as good cosmetic results can be obtained. However, radical surgery is more effective than single-quadrant excision. We believe it is useful to administer chemotherapy in addition to radiation therapy immediately before and after surgery as well as during the operation, so as to avoid the effects of possible intraoperative spreading.
year results of a randomized clinical trial comparing
Conclusion Conservative surgery in breast carcinoma, in spite of associated treatment, entails the risk of local relapse which subsequently affects outcome, also from a cosmetic viewpoint. However, conservative surgery must adopt a more aggressive surgical approach which could lead to a ten-year survival rate exceeding 90% for stage I and 70% for stage II tumors; the rate of local recurrences being quite low (O-3.2%) [4, 16, 181. It is therefore evident that, when it is feasible (Tl in large breasts) or necessary (T2) to resort to radical excision, conservative surgery should be able to yield the same results. In this connec-
9
10
11 12
total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engt J Med 312, 665 TisBsr B, Redmond C. Poisson R et al (1989) Eightyear results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 320, 822 Fisher ER, Sass R, Fisher B et al (1986) Pathologic findings from the National Surgical Adjuvant Breast Projed. II. Relation of local breast recurrence to multicentricity. Cancer 57. 17 17 Gallager HS, Martin JE (1969) The study of mammary carcinoma by mammography and whole organ sections. Early observations. Cancer 23, 855 Haagensen CD (1971) Disease of the breast. WB Saunders, Philadelphia Holland R, Veling SHJ, Mravunac M, Hendrics JHCL (1985) Histologic multifocality of Tis, Tl-2 breast carcinomas. Cancer 56, 979
404 13 Kalbfleisch H, Thomas C (1985) Histological study on multicentricity of breast carcinoma by means of wholeorgan sections. In: Early Breast Cancer. (J Zander, J Balker, eds) Springer-Verlag, Bedin Heidelberg, p 20 14 Lesser ML, Rosen PP, Kinne W (1982) Multicentricity and bilaterality in invasive breast carcinoma. Surgery 91, 234 15 Recht A, Silen W, Schnitt SJ et 01 (1988) Time course of local recurrence following conservative surgery and radiotherapy for early stage breast cancer. Znt .I Radiat Oncol Biol Phys 15, 255
16 Schottenfeld D, Nash AG, Robbins GF, Beattie EJ (1976) Ten-year results of the treatment of primary operable breast carcinoma. Cancer 38, 1001 17 Schwartz GF, Patchessfsky AS, Feig SA et al (1380) Multicentricity of non-palpable breast cancer. Cancer 45, 2913 18 Veronesi U, Zucali R, Luini A, Belli F, Crispino S, Merson M (1985) Conservative treatment of breast cancer with the QU.A.RT techniqae. Ir.: &‘rly Breast Cancer (Zander J, Baltzer J, eds) SpringerVerlag, Berlin Heidelberg, p 264
tumor excision a
R Garofalo,
ica
R Borioni, R LLA Garofalo, G Lavanga, G Math6 European Hospital, Via Portuense. 696 Rome, Italy (Received
18 May 1992; accepted 30 July 1992)
Summary - The present trend in favor of conservative surgery is in contrast with histopathological findings of multicentric breast carcinoma, which may be responsible for the occurrence of relapses in spite of the use of radiation therapy. As a consequence, conservative surgery appears to be inadequate, especially when tumor size exceeds 2 cm. Therefore for tumors up to 4 cm in size, which are not adherent to the pectoral fascia, we propose the excision of two quadrants with concomitant operation on the contralateral breast resulting in a more symmetrical and therefore cosmetic effect. This is a more radical procedure than the removal of the one quadrant. breast
carcinoma
/ biquadrantectomy
R&urn6 - Excision tumorale radicale et pr6occupations esthltaques dans le traitement chirurgical du cancer du sein: la biquadrantectomie. La tendance actuelle en faveur d’une chirurvie conservatrice est en contradiction aver les donnPes histologiques quand on observe un carcinome multicentrique du sein susceptible de donner lieu ti des rechutes, malgrk E’usage d’uw radiothhe’rapie. En conskquence, la chirurgie cnn~ervatrice ne semble pas complStement adiquate, particuliPrement lorsque la taille de la tumeur d&passe 2 cm. Ainsi, pour les tumeurs atteignant jusqu’h 4 cm et non adhkentes au fascia pectoral, les auteurs suggkent l’excision dQ deux quadrants, avec intervention concomitante sur le sein controlat~ral. duns un but de symbrie. Cette me’thode comporte un avantage esthitique, et reprisente un traitement plus radical que l’ablation d’un quadrat ou l’excision tumorale, plus ou moins extensive. excision tumorale I esthitique I biquadrantectomie
Introduction The present trend in favor of conservative surgery, as shown by various international trials [3, 7, 8, 15, 181 is in contrast with the histopathological findings of multicentric breast carcinoma [6, 10, 14, 171, which may be responsible for the occurrence of relapses in spite of the use of radiation therapy (NSABP). On the other hand, from an anatomico-surgical viewpoint, breast tumor spreads not only by “starlike” infiltration but also via the lympnatic vessels directed upward to the sub-areolar plexus and then toward the axilla. As a consequence, conservative surgery is [ll], not fully adequate, especially when tumor size exceeds 2 cm. Therefore for tumors up to 4 cm in size, which are not adherent to the pectoral fascia, we suggest
the excision of two quadrants with concomitant operation on the contralateral breast which results in a more symmetrical and therefore cosmetic effect.
Biological prerequisites The incidence of multicentricity in breast carcinoma has been widely reported in the literature. The lack of uniformity in speciman preparation and studies is likely to be responsible for the disparate findings observed. However, the phenomenon cannot be disregarded since it is found in 10 to 74% of cases [6, lo]. Clinically, in nonappreciable breast tumors as well as in those up to 3 cm in size, the incidence of multicentric carcinoma is 40% in the absence of clinical or radiological signs of multicentricity [ 1, 171. In most
cases it is not easy to establish whether the multicentric lesions are intramammary motostases, tumor enlargement or independently developing carcinoma [ 131. Holland ef nl [ 121 used the Engan method [6] to investigate 282 mastectomy T 1-T2 samples of invasive, non-disseminated, carcinomas for which conservative surgery had been ~co~end~ and found that: a) the possibility of the presence of multicentric foci decreased with the increase of distance from the primary tumor and markedly diminished beyond 6 cm; b; the likelihood of residual carcinoma after surgery was directly related to the extent of surgical excision; c) the chances of the residual carcinoma being invasive or non-invasive were equal. Histologically, in~l~ating ductal carcirioma, lobular carcinoma in situ and infiltrating lobular carcinoma are markedly more multicentric than the other histotypes [5]. On the other hand, the size of the primary tumor is also a factor in the ficquenty of multicent~~ neoplams [lo].
Anatomic prerequisites Breast carcinoma spreads by direct infiltration and lymphatic progression. The observation that malignant anatomy is not the anatomy of the organs but that of the lymphatic system (Moyniha, 1908) is pertinent to breast cancer. According to Haagensen lymphatic spreading affects [ 1I], (fig 1). the central sub-areolar area; the lymphatic vessels directed from the sub-areolar region to axillary sites and particularly the collecting vessels flowing along the lateral margin of the pectoralis major muscle; the transpectoral and retropectoral accessory lymphatic vessels; the lymphatic directed to the internal mammary artery. As a consequence, it seems reasonable that surgery involves not only the axillary lymph nodes but also the drained intraparenchymal lymphatic vessels.
Local relapses In stage I or stage II breast carcinoma, extensive tumor excision is accompanied by a significant risk of local relapse within 10 years, occurring in 6-i6% of cases 12, 3, 7, 8, 151. The most commonly affected are the younger premenopausal patients with small breasts [2, 31. Local relapse
Fig 1. Lymphatic system of the breast.
after conservative surgery is more likely to occur when the tumor is larger than 2 cm, with unfavorable histologic grading and early carcinomatous lymphangitis. It usually affects the same quadrant as the primary tumor or the neighbouring glandular parenchyma and in most cases is histologically similar lo the primary tumor [9]. Relapsing negatively affects long-term survival and the appearance of metastases [3] and, at any rate, must be regarded as a failure as far as cosmetic outcome is concerned.
Two-quadrant excision is aimed at obtaining the most radical excision compatible with satisfactory cosmetic results, while reducing the possibility 0; local relapse. Technically, it involves a large resection of the affected mammary hemiparenchyma, that includes a large portion of the sub-aureolar region (greater than the slice resulting from classic single-quadrant removal), the fascia and the iateral margin of the pectoralis major muscle with its main lymphatic vessels, the pectoralis minor muscle and I, II and II level lymph nodes (fig 2). The latter are reached through a separate incision, when necessary. Reconstruction is carried out by flapping and remodeling of the residual mammary parenchyma. Simultaneously, a second team operates upon the
403 tion, two-quadrant excision must be regarded as a valid therapeutic alternative, taking into account the anatomico-surgical and biological prerequisites which provide the basis for the correct therapeutic approach to breast cancer.
References Anton HW, Guhr A, Muller A, Abel U (1987) Multi~ent~e~ty in breast carcinoma. In: Breast Diseases. (Kubli F, van Fournier D, Junkermann H, Bauer M, Kaufmann M, eds) Springer-Verlag, Berlin Heidelberg, p 48 Chauvet B, Reynaud-Bougnoux A, Calais G, et al f 1990) Prognostic significance of breast relapse after conservative treatment in node-negative early breast cancer. Int J Radiat Oncol Biol Phys 19, 1125 Chauvet B, Lemseffer A, Le pechoux C et al (1990) Predisposing factors for local recurrence after conservative treatment of breast cancer. Ann kzdiol33. 306 Cody HS, Laughlin EH, Trill0 C, Urban JA (1991) Have changing treatment patterns affected oucome for operable breast cancer? Ann Surg 213, 297 Conte~r? G, Rn’resse J, Fontaine F, Petit JY (1977) Les disstminations intramammaires des carcinomes du sein. Bull Cancer 64, 5 Egan RL (1982) Multicentric breast carcinoma. Clinical-radiographic-pathologic whole organ studies and 1O-years survival. Cancer 49, 1123 Fisher B, Bauer M, Margolese R et al (1985) Five-
Fig 2. Morphology of biquadrantectomy.
contralateral breast to achieve symmetry, thus avoiding prolongation of surgery. The classic indication of two-quadrant excision is T2 for which conservative surgery is not advisable since it entails a high percentage of recurrence. In the case of large breasts, two-quadrant excision may also be indicated for tumors less than 2 cm in size, as good cosmetic results can be obtained. However, radical surgery is more effective than single-quadrant excision. We believe it is useful to administer chemotherapy in addition to radiation therapy immediately before and after surgery as well as during the operation, so as to avoid the effects of possible intraoperative spreading.
year results of a randomized clinical trial comparing
Conclusion Conservative surgery in breast carcinoma, in spite of associated treatment, entails the risk of local relapse which subsequently affects outcome, also from a cosmetic viewpoint. However, conservative surgery must adopt a more aggressive surgical approach which could lead to a ten-year survival rate exceeding 90% for stage I and 70% for stage II tumors; the rate of local recurrences being quite low (O-3.2%) [4, 16, 181. It is therefore evident that, when it is feasible (Tl in large breasts) or necessary (T2) to resort to radical excision, conservative surgery should be able to yield the same results. In this connec-
9
10
11 12
total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engt J Med 312, 665 TisBsr B, Redmond C. Poisson R et al (1989) Eightyear results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 320, 822 Fisher ER, Sass R, Fisher B et al (1986) Pathologic findings from the National Surgical Adjuvant Breast Projed. II. Relation of local breast recurrence to multicentricity. Cancer 57. 17 17 Gallager HS, Martin JE (1969) The study of mammary carcinoma by mammography and whole organ sections. Early observations. Cancer 23, 855 Haagensen CD (1971) Disease of the breast. WB Saunders, Philadelphia Holland R, Veling SHJ, Mravunac M, Hendrics JHCL (1985) Histologic multifocality of Tis, Tl-2 breast carcinomas. Cancer 56, 979
404 13 Kalbfleisch H, Thomas C (1985) Histological study on multicentricity of breast carcinoma by means of wholeorgan sections. In: Early Breast Cancer. (J Zander, J Balker, eds) Springer-Verlag, Bedin Heidelberg, p 20 14 Lesser ML, Rosen PP, Kinne W (1982) Multicentricity and bilaterality in invasive breast carcinoma. Surgery 91, 234 15 Recht A, Silen W, Schnitt SJ et 01 (1988) Time course of local recurrence following conservative surgery and radiotherapy for early stage breast cancer. Znt .I Radiat Oncol Biol Phys 15, 255
16 Schottenfeld D, Nash AG, Robbins GF, Beattie EJ (1976) Ten-year results of the treatment of primary operable breast carcinoma. Cancer 38, 1001 17 Schwartz GF, Patchessfsky AS, Feig SA et al (1380) Multicentricity of non-palpable breast cancer. Cancer 45, 2913 18 Veronesi U, Zucali R, Luini A, Belli F, Crispino S, Merson M (1985) Conservative treatment of breast cancer with the QU.A.RT techniqae. Ir.: &‘rly Breast Cancer (Zander J, Baltzer J, eds) SpringerVerlag, Berlin Heidelberg, p 264