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Radical mastectomy
Radical
Mastectomy
GRANTLEY W. TAYLOR, M.D., Weston, Massachusetts From tbe Department of Surgery, Massachusetts Hospital, Boston, Massachusetts.
General
ROM THE
1890’s untiI recent years, radicaI has been virtuahy unchahenged as the method of treatment for breast carcinoma. Progress has been made in defining the criteria of operabiIity. AnciIIary therapies, such as preoperative and postoperative radiation therapy, and hormona1 adjuvants and abIations, have been appraised and evaIuated. In the course of the years, fairIy accurate knowIedge has accumuIated in regard to the statistica1 efficacy of the operation; great progress has been made in understanding of the variations in the Iife history of the disease, and in paIIiation of inoperabIe or recurrent cases. Recent years have introduced severa new approaches to the problem: concept of predeterminism, with its inevitabIe impIication of therapeutic anarchy; progress in radica1 radiotherapy cuIminating in the McWhirter program; and the extended radicaIism of DahIUrban and others. Waiting to be Iversen, evaIuated, there is aIso a new adjuvant in the form of chemotherapy employed in conjunction with the radica1 operation. We are here concerned with a review and restatement of the roIe and effectiveness of the orthodox radica1 mastectomy, as a base Iine for evaIuation of the newer heresies. CertainIy unti1 the variant approaches have been given the test of time, and their efficacy documented and statisticaIIy supported, we must continue to place our major reIiance upon cIassic radica1 mastectomy in the treatment of breast cancer, and to treach the residents the indications, contraindications and technic of this operation.
F mastectomy
MATERIAL AND METHODS Operability. Haagensen and Stout authoritativeIy defined criteria of operabiIity which American
Journal
of Surgery.
Volume
106,
September
1963
396
had been assumed and accepted in genera1 by most surgeons even before this formulation. CertainIy, every effort must be made to determine whether or not operation offers a possibiIity or probability for cure before it is undertaken, The presence of remote metastases precIudes cure by a IocaI operation; the more thoroughIy these metastases are sought, the greater the number of cases wiI1 be found in which operation is contraindicated. The IocaI extent of disease and its mode of growth wiI1 give an indication of its degree of maIignancy, its duration, and the possibiIity of compIete remova at operation. Thus, the criteria of inflammatory growth, fixation, skin noduIes or uIceration, supracIavicuIar metastases, muItipIe Iarge or fixed axiIIary metastases, or edema of the arm, demonstrate incurabiIity by radicaI operation. Interpretation of these characteristics of growth and extent may vary from surgeon to surgeon, and the aggressive and eager operator may offer operation in patients from whom a cautious, timid or more experienced surgeon will turn away. On the assumption that there is an orderIy progression in time from a stage of IocaI disease favorabIe for cure to a stage hopeIessIy inoperabIe, educationa efforts are directed to the public and profession in earIy and prompt detection, with the hope of increasing the number of cases favorable for cure. Great care must be exercised in comparing operabiIity percentages between one hospita1 or surgeon and another. The community exercises a seIection; those reporting a high percentage of operabiIity may be the ones to whom favorabIe cases are referred. Greater discrimination in seIection of cases for operation results in a lower percentage of operabiIity, whereas a better educated pubhc and profession wiI1 discover a greater number of patients in a potentiaIIy curabIe stage.
RadicaI Mastectomy Diagnosis. WhiIe cIinica1 diagnosis is fairIy accurate for the experienced, there is stiI1 a considerabIe possibility of error. PathoIogic verification is desirable in a11 cases. Needle or aspiration biopsy is chiefly usefu1 in the advanced or inoperabIe case, to insure documentation of the diagnosis. WhiIe delay of a few days between incisional or excisiona biopsy may not be demonstrably hazardous, it seems wiser to be prepared to proceed at once with a radica1 operation after frozen section examination of the suspected tissue. Great care shouId be exercised to avoid contamination of the radica1 operative fieId, and the wound of exploration shouId be carefuIIy isoIated; potentiaIIy contaminated gloves, instruments and drapes shouId be discarded. Operation. SurgicaI texts and Iiterature present innumerabIe descriptions of the operative technic of radica1 mastectomy. Numerous incisions are described, the principa1 deviations from the origina HaIsted operation being the transverse axiIIary incision and the transverse incision of Stewart. There is rather general agreement that skin flaps shouId be thin, and and that gentIe handling wideIy undercut, and punctilious hemostasis are desirabIe. Sharp dissection is recommended by almost a11 authors, and actuaIIy practiced by many. The extent of skin removal varies, and some surgeons invariabIy employ grafts in effecting closure. Certainly grafting is preferabIe to cIosure with excessive tension, which contributes to necrosis of skin edges. Drainage by soft rubber drains or suction catheters is almost invariabIy empIoyed, aIong with firm dressings to obIiterate dead space. Temporary partia1 immobilization of the arm tends to minimize accumuIations of Iymph and serum. Mortality and Complications. OriginaIIy a significant mortaIity was associated with the operation. This has been IargeIy obviated with the genera1 improved safeguards of recent appraisa1 of years, with better preoperative risks, improved anesthesia and earIy mobiIization in the postoperative period. PuImonary embolism and coronary disease stir1 take their toI1. Postoperative sepsis and pneumonia have been minimized by antibiotic therapy and earIy ambulation. Persistent drainage and necrosis of skin margins stiI1 occasionaIIy complicate the convaIescence. Impaired shoulder and arm functions are rare and usuaIIy respond to exercises and instruction.
Lymphedema of the Arm. Lymphedema of the arm is an occasiona compIication. DaIand reported IO per cent in a series from the PondviIIe HospitaI. Our own Massachusetts Genera1 HospitaI recent series, 1943 to 1932, noted this compIication in 5 per cent of the “cured” cases. Most of the patients with this complication had probIems of wound healing, either repeated reaccumuIations of serum, or sepsis or both. Postoperative x-ray therapy appeared to be impIicated in many cases. Elevation, massage, rest and pressure bandages m.ay be heIpfu1 in controIIing or reducing the sweIIing. RESULTS
In a recent series at the Massachusetts Genera1 HospitaI [I] the operabiIity was 81 per cent. Eight hundred ninety-five persons were subjected to radica1 mastectomy. The postoperative mortaIity was 0.7 per cent (two patients). Causes of death were coronary thrombosis and cerebrovascuIar accident. Among the patients who were operated upon, axiIIary lymph node metastases were present in 54 per cent. After five years, 48 per cent of the patients operated upon were living and free from evidence of recurrent disease. Those without axiIIary metastases presented 6g per cent “cures”; those with axiIIary metastases presented 32 per cent “cures.” Forty-five deaths occurred from intercurrent disease in patients free from recurrence when last seen. These are inconcIusive. Recurrence in the operative field was noted in 127 cases (27 per cent of the faiIures, or 14 per cent of a11 operated cases). This is usuaIIy interpreted as due to fauIty estimation of operabiIity, or error of technic. Radiation therapy postoperativeIy was not used routineIy, and when it was empIoyed it was principaIIy in those patients in whom the or pathologist beIieved that the surgeon operative findings augured a bad prognosis. Radiation and hormone administrations were the chief measures empIoyed for the recurrent and inoperabIe cases. It is we11 recognized that five years is not an end point, and that a number of recurrences a.nd deaths from cancer takes pIace after a five year period. It is, however, reasonabIe to use the five year freedom from disease as a baseline for comparing the efficacy of different methods of treatment. Many authors report
397
TayIor resuh on the basis of five year survivors, yieIds a higher figure.
contraindications to operation, gratifying saIvage rate, and morbidity.
which
a
there is a minimum
SUMMARY REFERENCE
The classic radicaI mastectomy alone, or combined with postoperative radiation therapy, is appIicable to a high percentage of patients suffering from cancer of the breast. If the operation is restricted to patients without
TAYLOR, G. W. and ROGERS, W. P. Cancer of the breast: end results of treatment by radicaI mastectomy at the Massachusetts Genera1 HospitaI, x943-1952. Tr. New England S. Sot., 42: 153, 1961.
398
Mastectomy
GRANTLEY W. TAYLOR, M.D., Weston, Massachusetts From tbe Department of Surgery, Massachusetts Hospital, Boston, Massachusetts.
General
ROM THE
1890’s untiI recent years, radicaI has been virtuahy unchahenged as the method of treatment for breast carcinoma. Progress has been made in defining the criteria of operabiIity. AnciIIary therapies, such as preoperative and postoperative radiation therapy, and hormona1 adjuvants and abIations, have been appraised and evaIuated. In the course of the years, fairIy accurate knowIedge has accumuIated in regard to the statistica1 efficacy of the operation; great progress has been made in understanding of the variations in the Iife history of the disease, and in paIIiation of inoperabIe or recurrent cases. Recent years have introduced severa new approaches to the problem: concept of predeterminism, with its inevitabIe impIication of therapeutic anarchy; progress in radica1 radiotherapy cuIminating in the McWhirter program; and the extended radicaIism of DahIUrban and others. Waiting to be Iversen, evaIuated, there is aIso a new adjuvant in the form of chemotherapy employed in conjunction with the radica1 operation. We are here concerned with a review and restatement of the roIe and effectiveness of the orthodox radica1 mastectomy, as a base Iine for evaIuation of the newer heresies. CertainIy unti1 the variant approaches have been given the test of time, and their efficacy documented and statisticaIIy supported, we must continue to place our major reIiance upon cIassic radica1 mastectomy in the treatment of breast cancer, and to treach the residents the indications, contraindications and technic of this operation.
F mastectomy
MATERIAL AND METHODS Operability. Haagensen and Stout authoritativeIy defined criteria of operabiIity which American
Journal
of Surgery.
Volume
106,
September
1963
396
had been assumed and accepted in genera1 by most surgeons even before this formulation. CertainIy, every effort must be made to determine whether or not operation offers a possibiIity or probability for cure before it is undertaken, The presence of remote metastases precIudes cure by a IocaI operation; the more thoroughIy these metastases are sought, the greater the number of cases wiI1 be found in which operation is contraindicated. The IocaI extent of disease and its mode of growth wiI1 give an indication of its degree of maIignancy, its duration, and the possibiIity of compIete remova at operation. Thus, the criteria of inflammatory growth, fixation, skin noduIes or uIceration, supracIavicuIar metastases, muItipIe Iarge or fixed axiIIary metastases, or edema of the arm, demonstrate incurabiIity by radicaI operation. Interpretation of these characteristics of growth and extent may vary from surgeon to surgeon, and the aggressive and eager operator may offer operation in patients from whom a cautious, timid or more experienced surgeon will turn away. On the assumption that there is an orderIy progression in time from a stage of IocaI disease favorabIe for cure to a stage hopeIessIy inoperabIe, educationa efforts are directed to the public and profession in earIy and prompt detection, with the hope of increasing the number of cases favorable for cure. Great care must be exercised in comparing operabiIity percentages between one hospita1 or surgeon and another. The community exercises a seIection; those reporting a high percentage of operabiIity may be the ones to whom favorabIe cases are referred. Greater discrimination in seIection of cases for operation results in a lower percentage of operabiIity, whereas a better educated pubhc and profession wiI1 discover a greater number of patients in a potentiaIIy curabIe stage.
RadicaI Mastectomy Diagnosis. WhiIe cIinica1 diagnosis is fairIy accurate for the experienced, there is stiI1 a considerabIe possibility of error. PathoIogic verification is desirable in a11 cases. Needle or aspiration biopsy is chiefly usefu1 in the advanced or inoperabIe case, to insure documentation of the diagnosis. WhiIe delay of a few days between incisional or excisiona biopsy may not be demonstrably hazardous, it seems wiser to be prepared to proceed at once with a radica1 operation after frozen section examination of the suspected tissue. Great care shouId be exercised to avoid contamination of the radica1 operative fieId, and the wound of exploration shouId be carefuIIy isoIated; potentiaIIy contaminated gloves, instruments and drapes shouId be discarded. Operation. SurgicaI texts and Iiterature present innumerabIe descriptions of the operative technic of radica1 mastectomy. Numerous incisions are described, the principa1 deviations from the origina HaIsted operation being the transverse axiIIary incision and the transverse incision of Stewart. There is rather general agreement that skin flaps shouId be thin, and and that gentIe handling wideIy undercut, and punctilious hemostasis are desirabIe. Sharp dissection is recommended by almost a11 authors, and actuaIIy practiced by many. The extent of skin removal varies, and some surgeons invariabIy employ grafts in effecting closure. Certainly grafting is preferabIe to cIosure with excessive tension, which contributes to necrosis of skin edges. Drainage by soft rubber drains or suction catheters is almost invariabIy empIoyed, aIong with firm dressings to obIiterate dead space. Temporary partia1 immobilization of the arm tends to minimize accumuIations of Iymph and serum. Mortality and Complications. OriginaIIy a significant mortaIity was associated with the operation. This has been IargeIy obviated with the genera1 improved safeguards of recent appraisa1 of years, with better preoperative risks, improved anesthesia and earIy mobiIization in the postoperative period. PuImonary embolism and coronary disease stir1 take their toI1. Postoperative sepsis and pneumonia have been minimized by antibiotic therapy and earIy ambulation. Persistent drainage and necrosis of skin margins stiI1 occasionaIIy complicate the convaIescence. Impaired shoulder and arm functions are rare and usuaIIy respond to exercises and instruction.
Lymphedema of the Arm. Lymphedema of the arm is an occasiona compIication. DaIand reported IO per cent in a series from the PondviIIe HospitaI. Our own Massachusetts Genera1 HospitaI recent series, 1943 to 1932, noted this compIication in 5 per cent of the “cured” cases. Most of the patients with this complication had probIems of wound healing, either repeated reaccumuIations of serum, or sepsis or both. Postoperative x-ray therapy appeared to be impIicated in many cases. Elevation, massage, rest and pressure bandages m.ay be heIpfu1 in controIIing or reducing the sweIIing. RESULTS
In a recent series at the Massachusetts Genera1 HospitaI [I] the operabiIity was 81 per cent. Eight hundred ninety-five persons were subjected to radica1 mastectomy. The postoperative mortaIity was 0.7 per cent (two patients). Causes of death were coronary thrombosis and cerebrovascuIar accident. Among the patients who were operated upon, axiIIary lymph node metastases were present in 54 per cent. After five years, 48 per cent of the patients operated upon were living and free from evidence of recurrent disease. Those without axiIIary metastases presented 6g per cent “cures”; those with axiIIary metastases presented 32 per cent “cures.” Forty-five deaths occurred from intercurrent disease in patients free from recurrence when last seen. These are inconcIusive. Recurrence in the operative field was noted in 127 cases (27 per cent of the faiIures, or 14 per cent of a11 operated cases). This is usuaIIy interpreted as due to fauIty estimation of operabiIity, or error of technic. Radiation therapy postoperativeIy was not used routineIy, and when it was empIoyed it was principaIIy in those patients in whom the or pathologist beIieved that the surgeon operative findings augured a bad prognosis. Radiation and hormone administrations were the chief measures empIoyed for the recurrent and inoperabIe cases. It is we11 recognized that five years is not an end point, and that a number of recurrences a.nd deaths from cancer takes pIace after a five year period. It is, however, reasonabIe to use the five year freedom from disease as a baseline for comparing the efficacy of different methods of treatment. Many authors report
397
TayIor resuh on the basis of five year survivors, yieIds a higher figure.
contraindications to operation, gratifying saIvage rate, and morbidity.
which
a
there is a minimum
SUMMARY REFERENCE
The classic radicaI mastectomy alone, or combined with postoperative radiation therapy, is appIicable to a high percentage of patients suffering from cancer of the breast. If the operation is restricted to patients without
TAYLOR, G. W. and ROGERS, W. P. Cancer of the breast: end results of treatment by radicaI mastectomy at the Massachusetts Genera1 HospitaI, x943-1952. Tr. New England S. Sot., 42: 153, 1961.
398