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Surgical evaluation of carcinoma of the breast with axillary metastases
Surgical Evaluation of Carcinoma of the Breast with Axillary Metastases WILLIAM B. HUTCHINSON, M.D., LAWRENCE B. KIRXLUK, M.D. AND HERMAN R. ANSINGH, M.D., Seattle, Wusbington
T work
NE Iast decade has produced some exceIIent
on carcinoma of the breast. MacDonaId’s [I] predeterminism, Lees and Park’s [2] statistical evidence that the treatment of carcinoma of the breast does not aIter the surviva1 rate and McWhirter’s [3] cIaims after simpIe mastectomy and radiation have made a11 good surgeons think. This may at times discourage the casua1 genera1 surgeon, causing him to hasten, compromise or Iessen the exceIIence of his technic in performing radica1 mastectomy. Our desire in this paper is to give the cIinica1 surgeon who performs the Iaborious task of a good radica1 mastectomy encouragement and justification for this extensive operation. Radica1 mastectomy has been our mode of treatment, and we consider it a good one. It is not the purpose of this paper to argue the merits of one type of treatment or another. We do not deny that there is a great difference in survival time in patients with carcinoma of the breast, based on a host of variabIes. We present our resuIts over the past twenty years with radica1 mastectomy performed upon private patients who had positive axiIIary Iymph nodes demonstrabIe at origina surgery. We pIan to examine how we are succeeding in cIearing the Iymphatic spread in the axiIIa and how we are possibIy contributing to the Iongevity of the patient by preventing further spread of the disease. MATERIALS
AND
METHODS
The case materia1 of this study is 175 patients with histologically proved axiIIary node metastases that were found among 342 private patients operated upon for carcinoma of the breast from 1942 through 1961. ExcIuded were one maIe patient, seven patients who underwent simpIe mastectomies
and ten patients with positive internal mammary nodes and positive axiIIary nodes, who received treatment other than radicaI mastectomy, OnIy one patient was lost to foIIow-up study. This Ieft us with a tota of 156 patients with carcinoma of the breast with axihary node metastases who were treated with radical mastectomy. In contrast to more seIected series, our indications for radica1 mastectomy in the patient with cIinicaIIy paIpabIe axihary nodes were generous which ailowed more patients the benefit of good operative treatment. Such liberal seIection will reduce the long-term favorable results in any series. However, the criteria of operability so we11estabIished originahy by Haagensen and Stout were our guide [4]. Al1 patients underwent biopsy and frozen section, folIowed immediateIy in the vast majority by radical mastectomy. The breast and axillary contents were carefuhy studied in the pathoIogic department of the Swedish HospitaI. We know that the incidence of finding invoIved nodes is high and have accordingly divided our series into patients with more than three invoIved nodes and patients with three involved nodes or Iess to evaluate more accurately radica1 mastectomy in the treatment of operabIe breast cancer, AI1 cases in our series with axiIIary metastatic spread wouId faI1 into Butcher’s type III and IV classification [j]. A11 but three patients had primary wound cIosures. No prophyIactic radiation, oophorectomy, adrenalectomy or hormone therapy was used prior to 1952. From 1952 through rg6r a11patients with involved axillary nodes were treated at the Tumor Institute of the Swedish HospitaI with postoperative radiation of 4,000 r over a period of four weeks directed at the retrosterna1, supra-, infraand retrocIavicuIar space and upper anterior axilla above the surgica1 Iimits. OnIy nine of these patients were treated with oophorectomy alone or with adrenaIectomy and eIeven patients with hormones since 1952; it wouId seem a rather insignificant number in this selected series to be of any statistica vaIue. We realize
Carcinoma
of Breast with Axillary
Metastases
TABLE I:\ FIVE YEAR SURVIVAL
_
I 1948~~19jZ
‘9433’947
1043 IOj’
19j3-1957
Involvement
1 TotaI ~Per ceut I Total / Cases Alive I Cases
Percent ~~‘I-cad C:rscts ~ Alive ! C:IWS
Per cent Alive
Total
I’<,rccllt Alive
~~ -~
~ I I I
Over-all Three nodes or less. Alore than three nodes.
33
~
39-3 57-I 34.6
7 26
41.3
58
45 29 16
3o ii “.’ 14.3 28
42.2 44.8 37i
‘1 130
4’ ’
00
j(l
-0
27 .I
.O
I TABLE TEN
YEAR
IB SURVIVAL
r948--Igp
1943-1947
1943~-1952
8’ _,__~_.
InvoIvement TotaI Cases
Over-a11 ......................................... ...................... Three nodes or Iess ...... More than three nodes .............................
33 7 26
i that this wiII infhmnce our survivaI degree in the period 1952 to 1957.
rates
to some
RESULTS
The data on our patients with axiIIary metastases have been divided in arbitrary groups in such a way as to eIucidate the benefits of radicaI mastectomy. These benefits are most readiIy demonstrated by cases in which fewer axiIIary nodes are invoIved. Thus the good that can be accompIished from radica1 mastectomy is not obscured by advanced cases that no treatment can aid. In support of the pIea for earIy diagnosis and treatment, our data give support to the theory that the smaIIer primary Iesion that has been present for a shorter period of time wiI1, over a reasonabIe interva1 in a Iarge series of cases, give more favorabIe resuIts. To understand the significance of the number of invoIved nodes in relation to prognoses, a carefu1 study was made by tabuIating the number of invoIved nodes and the surviva1 rates [6j. In some instances the tota number of patients in one group was too smaI1 to be of significance. For this reason, patients were
Per cent AIive
TotaI Cases
Pycczt
1~TotaI Cases
j Per cent ! Ahve
21.2
42.8 19.2
28
I
14.3
‘I
ii
54
~ 14.8 I
divided in groups with more than three invoIved nodes and with three invoIved nodes or Iess. TabIes IA and B show the five and ten year surviva1 for the years 1943 to 1947, 1948 to rg5z and 1953 to 1957. It is of interest to note the greater five year surviva1 in patients with three nodes or Iess invoked by metastatic disease (56 per cent) over those with more than three invoIved nodes (27.1 per cent). The ten year surviva1 rate is 45.9 per cent for those with three invoIved nodes or Iess and 14.8 per cent for those with over three invoIved nodes with demonstrabIe metastatic carcinoma. This indicates that the fewer Iymph nodes invoIved, the better is the chance for the patient to Iive. The regiona recurrence of carcinoma was noted in 17 percent of the patients which compares favorabIy with other reports [y]. Some series in arriving at this recurrence rate incIude onIy those patients who are foIIowed up for five years. It is our experience that as the time interva1 is extended from the date of operation, the percentage of regiona recurrences will increase. It is not unusua1 to find a patient with extensive metastases from carcinoma of
Hutchinson, FIVE
YEAR
TABLE
II
IN
PATIENTS
SURVIVAL
OPERABLE
BREAST RADICAL
CANCER
WITH TREATED
PRIMARY BY
MASTECTOMY
OverSCGCS
KiriIuk
No. of C&F%
alI Percentage
376 238 8.224
51.
Breast PIUS Involved AxiIla (Per cent)
-. Geisinger Memorial Hospital.. Lahey Clinic.. Mayo Clinic.. Johns Hopkins Hospital.. Haagensen (personal series). Present series..
.
_. _.
no
356 342
I 52.1 52. I 44.1 56.7
34.2 37.0 33.1 31.7 38.8 41.
I
the breast who has had no IocaI skin recurrence suddenIy bIossom out with skin recurrences immediateIy prior to death. The casua1 foIIowup examination wiI1 sureIy overlook this type of skin recurrence. Considering the fact that a11 these patients had invoIved axiIIary nodes, we beIieve that wider skin excision and skin graft are not indicated. There were no operative deaths in this series. The average hospitaIization was seven days. In the three year period of 1943 through 1946, thirty-one patients were operated upon. Of these, eight were Iiving for more than fifteen years and seven for more than seventeen years. Of those seven Iiving for seventeen years, a11 are free of disease at present. Their primary Iesions were Iocated in different parts of the breast, and four of them had more than three invoIved axiIIary nodes. We have carefuIIy reviewed the microscopic sIides; at present we wish to make no statement other than that a11 these seven cases were cIassified as reIativeIy we11 differentiated carcinoma simpIex. COMMENTS
Series of patients with untreated carcinoma of the breast show five and ten year surviva1 figures of 20 and 5 per cent, respectiveIy [8,9]. The poor prognoses and high rate of IocaI recurrence before axiIlary dissection became recognized as an essentia1 part of the procedure are historica [IO]. The question as to whether we are doing any better with radica1 mastectomy in patients with axiIIary spread was studied. The majority of patients dying from breast cancer die of osseous, puImonary, cerebral or other distant metastases. We Iearned from this review that radicaI mastectomy wiI1 reduce secondary metastatic spread from the
and Ansin,ah
axiIIary Iymph nodes in those patients in whom metastatic spread is minima1 and apparentIy confIned to the axiIIa. In many instances axiIIary nodes are found to harbor metastases onIy after carefu1 sectioning of the axiIIary contents and even then metastatic disease is sometimes overIooked [or]. From our previous studies we know that approximateIy 50 per cent of those patients with demonstrabIe axiIIary node invoIvement wiI1 have demonstrabIe positive interna mammary nodes [12]. We therefore are submitting about one fourth of a11 our patients to unnecessary radica1 mastectomy. The prognoses after radica1 mastectomy in patients with positive axiIIary nodes can be expected to be far better if we excIude any of those patients (50 per cent) who have invoIved interna mammary nodes. This was expressed in our uncorrected surviva1 figures for the five year period 1952 to 1957 in which the uncorrected five year surviva1 rate was 48.5 per cent. It was in this period that we foIIowed up those patients with known positive interna mammary nodes. Ten patients had invoIved interna mammary nodes on whom radica1 mastectomy was not performed. If we had performed radica1 mastectomy, the hve year surviva1 wouId have been 41. I per cent which we consider our correct figure. We did not excIude in these mortaIity figures eighteen patients who died of diseases other than carcinoma. The figures frequentIy reported in the Iiterature for five year surviva1 in patients with invoIved axiIIary nodes averages 38 per cent [13]. (TabIe II.) It is of interest to the cIinician to be abIe to predict before surgery how many nodes wiI1 histoIogicaIIy be invoIved if one or more axiIIary Iymph nodes are palpabIe and thought to be cIinicaIIy positive. The significance of this in reIation to the patients’ uItimate prognoses was studied. Fifty per cent of our patients with actua1 invoIved axiIIary nodes were thought to be cIinicaIIy negative for abnormaIities. In those instances in which paIpabIe nodes were present, there was a 65 per cent incidence of patients with more than three invoIved nodes and a 35 per cent incidence of patients with three invoIved nodes or Iess. Therefore, even in those patients in whom nodes are cIinicaIIy paIpabIe, one third wiI1 have a reIativeIy good prognosis. Patients with more than three involved nodes have
C:arcinoma
of Breast
with Axillary
ai,out half the life expectancy of those with three involved nodes or less. ‘I‘ho~c advocating forms of routine treatment other than radical mastectomy wiI1 argue that a 56 per cent five year surviva1 means nothing more than ~4 per cent of the patients died of the di~case. Flowever, a figure of 56 per cent is nlore significant if we postuIate that of those patients with invoIved asillary nodes, approximnteIv one half will have positive interna mam&~ry nodes. nlany of those dying of carcinoma also have invoIved interna mammary nodes indicating a more diffuse initia1 spread of carcinoma. This theory finds support in the observation of a 46.4 per cent ten year surviva1 rate for patients with three invoIved nodes or Iess, supporting our contention that radicaI mastectomy, at Ieast in patients with few invoIved axiIIary nodes, sign&cantIy aids in irradication of the disease. In reviewing our statistica data with reference to the eflicacy of routine prophylactic radiation treatment postoperatively, we find that the surviva1 rate of the 1953 to 1957 group was very sIightIy proIonged. This trend we beIicve has continued. There is no evidence however that a so-caIIed cure increase could be noted. During the year 1961 we have discontinued prophylactic radiation therapy. We beIieve that a Iarge percentage of patients are submitted to severe forms of treatment without good evidence that a “cure” has been accomplished and that the paIIiative effect of radiation is just as we11 accompIished when recurrences first appear [r4]. No one wiI1 refute the fact that simpIe mastectomy could not provide a five year surviva1 of 56 per cent in a group of patients who had three invoIved nodes or Iess. It is therefore our contention that good axiIIary dissection provides a substantial percentage of these patients the benefits of a cure by remova of a11 the disease present in the breast as we11 as the axiIIa. We contend that carcinoma may spread from a metastatic noduIe or a metastatic node. This source of spread can be eIiminated onIy by radica1 dissection. Patients in whom the disease is Iimited to the breast and axiIIa are given the opportunity for cure. Therefore, as a routine method of treatment for carcinoma of the breast, we consider radica1 mastectomy as a superior routine operative procedure. It is obvious that in a given case it is not possibIe and probabIy not desirabIe to determine
853
hletastases
whether positive asiIlary nodes esist or not. I$‘e disagree with the use of any tc~chnic dcsigned to determine at opera&on ~1hether asillary nodes contain carcinoma with radical surgery dependent on the findings. lZ:e disagree with those who use this method in other adjacent anatomic areas to guide them in their decision of radica1 surgery or a compromise form of treatment. At one time we beIiel;ed this to be desirable, but subsequent foIlo\v-up observation proved this technic hazardous when positive nodes were encountered [ 151. Statistical data accumuIated through carefu1 CIassification and foIIow-up study are essential and invaIuabIe. Nevertheless when one begins to appIy this information too rigidiv to the individuaJ patient, he encounters d;fJicuJties such as in the tumor host compfex, a factor we know so IittIe about. Four of the seven patients Iiving more than seventeen years may very we11 have faIIen into the rejection category. The strict appIication of rigid criteria of operabiIity might have denied these people what time proved to be exceIIent therapv. SUMMARY
One hundred fifty-six patients with carcinoma of the breast with histoIogicaIIy, proved metastases to the axiIIary nodes for which they were treated by radica1 mastectomy were studied over a period of twenty years, from 1942 through 1962. A comparison of the five and ten year surviva1 rates of this series with those of others shows a favorable trend in improvement of the figures over the years. A breakdown of this series according to the number of invoIved axiIIary nodes shows a significantIy better prognosis for those with fewer invoIved nodes. We beIieve that these findings shouId encourage the clinician and surgeon who treat patients with carcinoma of the breast. RadicaI mastectomy may in certain instances prevent or retard further spread of the disease if it has spread to the axiIIa, resuIting in five year surviva1 rates of 56 per cent for those patients with three invoIved nodes or Iess and 27.1 per cent for those with more than three invoIved nodes. We postuIate that if those patients who demonstrate metastases to the interna mammary nodes are excIuded, radical mastectomy
Hutchinson,
KiriIuk
8. NATHANSON, I. T. and WELCH, C. E. Life expectancy and incidence of maIignant disease. I. Carcinoma of the breast. Am. J. Cancer, 28: 40,
may aIter the mortaIity to a significant degree in patients with invoIved axiIIary nodes.
1936. 9. DALAND, E. M. Untreated cancer of the breast. Surg. Gynec. @ Obst., 44: 264, 1927. IO. HALSTED, W. S. The resuhs of operations for the cure of cancer of the breast performed at the Johns Hopkins HospitaI from June 1889 to January 1894. Ann. Surg., 20: 497, 1894. II. SAPHIR, 0. and AMROMIN, G. D. Obscure axillary lymph node metastases in carcinoma of the breast. Cancer, I: 238, 1948. 12. HUTCHINSON, W. B. IntercostaI dissection and radica1 mastectomy. Arch. Surg., 66: 440, 1953. 13. POLLOCK, R. S. The surgica1 treatment of carcinoma of the breast. S. Clin. Nortb America, 42:
REFERENCES I. MACDONALD, I. BioIogicaI
man
cancer.
Surg.
and Ansingh
predeterminism in huGynec. ti Obst., 92: 443,
1951.
2. LEES, J. C. and PARK, W. W. AbsoIute curability of cancer of the breast. Surg. Gynec. ti Obst., 93: 129, 195’. 3. MCWHIRTER, R. SimpIe mastectomy and radiotherapy in the treatment of breast cancer. &it. J. Radiol., 28: 128, 1955. 4. HAAGENSEN, C. D. and STOUT, A. P. Cancer of the breast; criteria for operability. Ann. Surg., I 18: 859, 1943. 5. BUTCHER, H. R., JR. Effectiveness of radical mastectomy for mammary cancer. Ann. Surg., 154: 383. 1961. 6. HULTBORN, K. A. and TORNBERG, B. Mammary carcinoma. Acta radiol. (suppl.), 196: I, 1960. 7. KLINGER, H. M. and BUFFINGTON, R. Breast carcinoma. Arch. Surg., 84: 439, 1962.
839. 1962. 14. PATERSON, R.
Breast cancer; vaIue of postoperative radiotherapy. J. Fat. Radiologists, IO: 175, 1959.
15. HUTCHINSON, W. B. and KIRILUK, L. B. Internal
mammary node investigation in carcinoma the breast. Am. J. Surg., 92: 151, 1956.
854
of
T work
NE Iast decade has produced some exceIIent
on carcinoma of the breast. MacDonaId’s [I] predeterminism, Lees and Park’s [2] statistical evidence that the treatment of carcinoma of the breast does not aIter the surviva1 rate and McWhirter’s [3] cIaims after simpIe mastectomy and radiation have made a11 good surgeons think. This may at times discourage the casua1 genera1 surgeon, causing him to hasten, compromise or Iessen the exceIIence of his technic in performing radica1 mastectomy. Our desire in this paper is to give the cIinica1 surgeon who performs the Iaborious task of a good radica1 mastectomy encouragement and justification for this extensive operation. Radica1 mastectomy has been our mode of treatment, and we consider it a good one. It is not the purpose of this paper to argue the merits of one type of treatment or another. We do not deny that there is a great difference in survival time in patients with carcinoma of the breast, based on a host of variabIes. We present our resuIts over the past twenty years with radica1 mastectomy performed upon private patients who had positive axiIIary Iymph nodes demonstrabIe at origina surgery. We pIan to examine how we are succeeding in cIearing the Iymphatic spread in the axiIIa and how we are possibIy contributing to the Iongevity of the patient by preventing further spread of the disease. MATERIALS
AND
METHODS
The case materia1 of this study is 175 patients with histologically proved axiIIary node metastases that were found among 342 private patients operated upon for carcinoma of the breast from 1942 through 1961. ExcIuded were one maIe patient, seven patients who underwent simpIe mastectomies
and ten patients with positive internal mammary nodes and positive axiIIary nodes, who received treatment other than radicaI mastectomy, OnIy one patient was lost to foIIow-up study. This Ieft us with a tota of 156 patients with carcinoma of the breast with axihary node metastases who were treated with radical mastectomy. In contrast to more seIected series, our indications for radica1 mastectomy in the patient with cIinicaIIy paIpabIe axihary nodes were generous which ailowed more patients the benefit of good operative treatment. Such liberal seIection will reduce the long-term favorable results in any series. However, the criteria of operability so we11estabIished originahy by Haagensen and Stout were our guide [4]. Al1 patients underwent biopsy and frozen section, folIowed immediateIy in the vast majority by radical mastectomy. The breast and axillary contents were carefuhy studied in the pathoIogic department of the Swedish HospitaI. We know that the incidence of finding invoIved nodes is high and have accordingly divided our series into patients with more than three invoIved nodes and patients with three involved nodes or Iess to evaluate more accurately radica1 mastectomy in the treatment of operabIe breast cancer, AI1 cases in our series with axiIIary metastatic spread wouId faI1 into Butcher’s type III and IV classification [j]. A11 but three patients had primary wound cIosures. No prophyIactic radiation, oophorectomy, adrenalectomy or hormone therapy was used prior to 1952. From 1952 through rg6r a11patients with involved axillary nodes were treated at the Tumor Institute of the Swedish HospitaI with postoperative radiation of 4,000 r over a period of four weeks directed at the retrosterna1, supra-, infraand retrocIavicuIar space and upper anterior axilla above the surgica1 Iimits. OnIy nine of these patients were treated with oophorectomy alone or with adrenaIectomy and eIeven patients with hormones since 1952; it wouId seem a rather insignificant number in this selected series to be of any statistica vaIue. We realize
Carcinoma
of Breast with Axillary
Metastases
TABLE I:\ FIVE YEAR SURVIVAL
_
I 1948~~19jZ
‘9433’947
1043 IOj’
19j3-1957
Involvement
1 TotaI ~Per ceut I Total / Cases Alive I Cases
Percent ~~‘I-cad C:rscts ~ Alive ! C:IWS
Per cent Alive
Total
I’<,rccllt Alive
~~ -~
~ I I I
Over-all Three nodes or less. Alore than three nodes.
33
~
39-3 57-I 34.6
7 26
41.3
58
45 29 16
3o ii “.’ 14.3 28
42.2 44.8 37i
‘1 130
4’ ’
00
j(l
-0
27 .I
.O
I TABLE TEN
YEAR
IB SURVIVAL
r948--Igp
1943-1947
1943~-1952
8’ _,__~_.
InvoIvement TotaI Cases
Over-a11 ......................................... ...................... Three nodes or Iess ...... More than three nodes .............................
33 7 26
i that this wiII infhmnce our survivaI degree in the period 1952 to 1957.
rates
to some
RESULTS
The data on our patients with axiIIary metastases have been divided in arbitrary groups in such a way as to eIucidate the benefits of radicaI mastectomy. These benefits are most readiIy demonstrated by cases in which fewer axiIIary nodes are invoIved. Thus the good that can be accompIished from radica1 mastectomy is not obscured by advanced cases that no treatment can aid. In support of the pIea for earIy diagnosis and treatment, our data give support to the theory that the smaIIer primary Iesion that has been present for a shorter period of time wiI1, over a reasonabIe interva1 in a Iarge series of cases, give more favorabIe resuIts. To understand the significance of the number of invoIved nodes in relation to prognoses, a carefu1 study was made by tabuIating the number of invoIved nodes and the surviva1 rates [6j. In some instances the tota number of patients in one group was too smaI1 to be of significance. For this reason, patients were
Per cent AIive
TotaI Cases
Pycczt
1~TotaI Cases
j Per cent ! Ahve
21.2
42.8 19.2
28
I
14.3
‘I
ii
54
~ 14.8 I
divided in groups with more than three invoIved nodes and with three invoIved nodes or Iess. TabIes IA and B show the five and ten year surviva1 for the years 1943 to 1947, 1948 to rg5z and 1953 to 1957. It is of interest to note the greater five year surviva1 in patients with three nodes or Iess invoked by metastatic disease (56 per cent) over those with more than three invoIved nodes (27.1 per cent). The ten year surviva1 rate is 45.9 per cent for those with three invoIved nodes or Iess and 14.8 per cent for those with over three invoIved nodes with demonstrabIe metastatic carcinoma. This indicates that the fewer Iymph nodes invoIved, the better is the chance for the patient to Iive. The regiona recurrence of carcinoma was noted in 17 percent of the patients which compares favorabIy with other reports [y]. Some series in arriving at this recurrence rate incIude onIy those patients who are foIIowed up for five years. It is our experience that as the time interva1 is extended from the date of operation, the percentage of regiona recurrences will increase. It is not unusua1 to find a patient with extensive metastases from carcinoma of
Hutchinson, FIVE
YEAR
TABLE
II
IN
PATIENTS
SURVIVAL
OPERABLE
BREAST RADICAL
CANCER
WITH TREATED
PRIMARY BY
MASTECTOMY
OverSCGCS
KiriIuk
No. of C&F%
alI Percentage
376 238 8.224
51.
Breast PIUS Involved AxiIla (Per cent)
-. Geisinger Memorial Hospital.. Lahey Clinic.. Mayo Clinic.. Johns Hopkins Hospital.. Haagensen (personal series). Present series..
.
_. _.
no
356 342
I 52.1 52. I 44.1 56.7
34.2 37.0 33.1 31.7 38.8 41.
I
the breast who has had no IocaI skin recurrence suddenIy bIossom out with skin recurrences immediateIy prior to death. The casua1 foIIowup examination wiI1 sureIy overlook this type of skin recurrence. Considering the fact that a11 these patients had invoIved axiIIary nodes, we beIieve that wider skin excision and skin graft are not indicated. There were no operative deaths in this series. The average hospitaIization was seven days. In the three year period of 1943 through 1946, thirty-one patients were operated upon. Of these, eight were Iiving for more than fifteen years and seven for more than seventeen years. Of those seven Iiving for seventeen years, a11 are free of disease at present. Their primary Iesions were Iocated in different parts of the breast, and four of them had more than three invoIved axiIIary nodes. We have carefuIIy reviewed the microscopic sIides; at present we wish to make no statement other than that a11 these seven cases were cIassified as reIativeIy we11 differentiated carcinoma simpIex. COMMENTS
Series of patients with untreated carcinoma of the breast show five and ten year surviva1 figures of 20 and 5 per cent, respectiveIy [8,9]. The poor prognoses and high rate of IocaI recurrence before axiIlary dissection became recognized as an essentia1 part of the procedure are historica [IO]. The question as to whether we are doing any better with radica1 mastectomy in patients with axiIIary spread was studied. The majority of patients dying from breast cancer die of osseous, puImonary, cerebral or other distant metastases. We Iearned from this review that radicaI mastectomy wiI1 reduce secondary metastatic spread from the
and Ansin,ah
axiIIary Iymph nodes in those patients in whom metastatic spread is minima1 and apparentIy confIned to the axiIIa. In many instances axiIIary nodes are found to harbor metastases onIy after carefu1 sectioning of the axiIIary contents and even then metastatic disease is sometimes overIooked [or]. From our previous studies we know that approximateIy 50 per cent of those patients with demonstrabIe axiIIary node invoIvement wiI1 have demonstrabIe positive interna mammary nodes [12]. We therefore are submitting about one fourth of a11 our patients to unnecessary radica1 mastectomy. The prognoses after radica1 mastectomy in patients with positive axiIIary nodes can be expected to be far better if we excIude any of those patients (50 per cent) who have invoIved interna mammary nodes. This was expressed in our uncorrected surviva1 figures for the five year period 1952 to 1957 in which the uncorrected five year surviva1 rate was 48.5 per cent. It was in this period that we foIIowed up those patients with known positive interna mammary nodes. Ten patients had invoIved interna mammary nodes on whom radica1 mastectomy was not performed. If we had performed radica1 mastectomy, the hve year surviva1 wouId have been 41. I per cent which we consider our correct figure. We did not excIude in these mortaIity figures eighteen patients who died of diseases other than carcinoma. The figures frequentIy reported in the Iiterature for five year surviva1 in patients with invoIved axiIIary nodes averages 38 per cent [13]. (TabIe II.) It is of interest to the cIinician to be abIe to predict before surgery how many nodes wiI1 histoIogicaIIy be invoIved if one or more axiIIary Iymph nodes are palpabIe and thought to be cIinicaIIy positive. The significance of this in reIation to the patients’ uItimate prognoses was studied. Fifty per cent of our patients with actua1 invoIved axiIIary nodes were thought to be cIinicaIIy negative for abnormaIities. In those instances in which paIpabIe nodes were present, there was a 65 per cent incidence of patients with more than three invoIved nodes and a 35 per cent incidence of patients with three invoIved nodes or Iess. Therefore, even in those patients in whom nodes are cIinicaIIy paIpabIe, one third wiI1 have a reIativeIy good prognosis. Patients with more than three involved nodes have
C:arcinoma
of Breast
with Axillary
ai,out half the life expectancy of those with three involved nodes or less. ‘I‘ho~c advocating forms of routine treatment other than radical mastectomy wiI1 argue that a 56 per cent five year surviva1 means nothing more than ~4 per cent of the patients died of the di~case. Flowever, a figure of 56 per cent is nlore significant if we postuIate that of those patients with invoIved asillary nodes, approximnteIv one half will have positive interna mam&~ry nodes. nlany of those dying of carcinoma also have invoIved interna mammary nodes indicating a more diffuse initia1 spread of carcinoma. This theory finds support in the observation of a 46.4 per cent ten year surviva1 rate for patients with three invoIved nodes or Iess, supporting our contention that radicaI mastectomy, at Ieast in patients with few invoIved axiIIary nodes, sign&cantIy aids in irradication of the disease. In reviewing our statistica data with reference to the eflicacy of routine prophylactic radiation treatment postoperatively, we find that the surviva1 rate of the 1953 to 1957 group was very sIightIy proIonged. This trend we beIicve has continued. There is no evidence however that a so-caIIed cure increase could be noted. During the year 1961 we have discontinued prophylactic radiation therapy. We beIieve that a Iarge percentage of patients are submitted to severe forms of treatment without good evidence that a “cure” has been accomplished and that the paIIiative effect of radiation is just as we11 accompIished when recurrences first appear [r4]. No one wiI1 refute the fact that simpIe mastectomy could not provide a five year surviva1 of 56 per cent in a group of patients who had three invoIved nodes or Iess. It is therefore our contention that good axiIIary dissection provides a substantial percentage of these patients the benefits of a cure by remova of a11 the disease present in the breast as we11 as the axiIIa. We contend that carcinoma may spread from a metastatic noduIe or a metastatic node. This source of spread can be eIiminated onIy by radica1 dissection. Patients in whom the disease is Iimited to the breast and axiIIa are given the opportunity for cure. Therefore, as a routine method of treatment for carcinoma of the breast, we consider radica1 mastectomy as a superior routine operative procedure. It is obvious that in a given case it is not possibIe and probabIy not desirabIe to determine
853
hletastases
whether positive asiIlary nodes esist or not. I$‘e disagree with the use of any tc~chnic dcsigned to determine at opera&on ~1hether asillary nodes contain carcinoma with radical surgery dependent on the findings. lZ:e disagree with those who use this method in other adjacent anatomic areas to guide them in their decision of radica1 surgery or a compromise form of treatment. At one time we beIiel;ed this to be desirable, but subsequent foIlo\v-up observation proved this technic hazardous when positive nodes were encountered [ 151. Statistical data accumuIated through carefu1 CIassification and foIIow-up study are essential and invaIuabIe. Nevertheless when one begins to appIy this information too rigidiv to the individuaJ patient, he encounters d;fJicuJties such as in the tumor host compfex, a factor we know so IittIe about. Four of the seven patients Iiving more than seventeen years may very we11 have faIIen into the rejection category. The strict appIication of rigid criteria of operabiIity might have denied these people what time proved to be exceIIent therapv. SUMMARY
One hundred fifty-six patients with carcinoma of the breast with histoIogicaIIy, proved metastases to the axiIIary nodes for which they were treated by radica1 mastectomy were studied over a period of twenty years, from 1942 through 1962. A comparison of the five and ten year surviva1 rates of this series with those of others shows a favorable trend in improvement of the figures over the years. A breakdown of this series according to the number of invoIved axiIIary nodes shows a significantIy better prognosis for those with fewer invoIved nodes. We beIieve that these findings shouId encourage the clinician and surgeon who treat patients with carcinoma of the breast. RadicaI mastectomy may in certain instances prevent or retard further spread of the disease if it has spread to the axiIIa, resuIting in five year surviva1 rates of 56 per cent for those patients with three invoIved nodes or Iess and 27.1 per cent for those with more than three invoIved nodes. We postuIate that if those patients who demonstrate metastases to the interna mammary nodes are excIuded, radical mastectomy
Hutchinson,
KiriIuk
8. NATHANSON, I. T. and WELCH, C. E. Life expectancy and incidence of maIignant disease. I. Carcinoma of the breast. Am. J. Cancer, 28: 40,
may aIter the mortaIity to a significant degree in patients with invoIved axiIIary nodes.
1936. 9. DALAND, E. M. Untreated cancer of the breast. Surg. Gynec. @ Obst., 44: 264, 1927. IO. HALSTED, W. S. The resuhs of operations for the cure of cancer of the breast performed at the Johns Hopkins HospitaI from June 1889 to January 1894. Ann. Surg., 20: 497, 1894. II. SAPHIR, 0. and AMROMIN, G. D. Obscure axillary lymph node metastases in carcinoma of the breast. Cancer, I: 238, 1948. 12. HUTCHINSON, W. B. IntercostaI dissection and radica1 mastectomy. Arch. Surg., 66: 440, 1953. 13. POLLOCK, R. S. The surgica1 treatment of carcinoma of the breast. S. Clin. Nortb America, 42:
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