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PubMed2004

Post-mastectomy chylous fistula: anatomical and clinical implications.

A chylous fistula after a modified radical mastectomy is a rare occurrence; however, major anatomical variations in the termination of the thoracic duct may occur, rendering it susceptible to injury. High output chylous fistulae are difficult to manage and have local, metabolic, and immunologic complications with a mortality rate varying from 12.5-50%. Herein such a case of postmastectomy chylous fistula and its management are discussed. A 56-year-old postmenopausal woman with invasive duct carcinoma of the left breast underwent modified radical mastectomy with complete axillary clearance (Level I, II, III nodes). The operative procedure was uneventful. On the commencement of a normal diet, however, the patient started exuding milky fluid from the axillary drain and analysis of the fluid revealed biochemical features compatible with chyle. After 2 weeks of failed conservative management, the axilla was re-explored. A continuous flow of clear fluid was observed originating from a single major lymphatic trunk inferior to the axillary vein in the region of the former Level II nodes. The leak was controlled by the application of multiple mass ligatures using 2-0 silk suture. A part of the pectoralis major muscle was rotated and sutured over the area of the leak as additional reinforcement. Suturing a muscle flap over the leak has been described previously and functions theoretically by causing fibrosis. The chylous fistula in the present case was managed successfully with mass ligatures and muscle flap reinforcement.

Chyle↗
PubMed2003

Skin-sparing mastectomy. specialty bias and worldwide lack of consensus.

BACKGROUND: Skin-sparing mastectomy (SSM) is a variation of modified radical mastectomy (MRM) optimized for reconstruction. The authors attempted to determine SSM attitudes and biases within different specialties and countries throughout the world. METHODS: The authors polled 11,485 individuals via e-mail, including members of surgical, medical, and breast oncology societies, about SSM. Respondents were directed to a survey website where data were directly entered into a database. RESULTS: Among 1027 respondents, 19 said their knowledge was insufficient to attempt the survey. Surveys were completed by 1008 respondents (8.8%) from 52 countries, comprising 436 (43.3%) surgeons, 376 (37.3%) medical oncologists, 146 (14.5%) radiation oncologists, and 50 (5.0%) individuals from other fields. Of the respondents, 61.9% stated that SSMs are performed at their institution. However 19.1% of these believed that SSM leaves the nipple and areola intact. This perception was higher outside the U.S. (P < 0.0001). Despite knowledge by 77.8% that SSM does not have a higher local disease recurrence rate than MRM, 25.3% of these individuals did not believe the literature. This was most prevalent among radiation oncologists (48.5%), as was the belief that SSM is contraindicated in patients with ductal carcinoma in situ and invasive breast carcinoma (23.3%). CONCLUSIONS: Despite a developing body of literature, there was variation in opinion among specialties and a lack of understanding of SSM. Many physicians were not familiar with the literature. Among those who were, skepticism was highest among radiation oncologists. Although these results were indicative of only those responding, education about SSM is needed across specialties and in other countries if the procedure is to be widely accepted.

Breast Neoplasms↗
PubMed2004

The effect of ethnicity on immediate reconstruction rates after mastectomy for breast cancer.

BACKGROUND: Multiple factors may influence whether patients undergo immediate breast reconstruction along with mastectomy for breast cancer. The authors investigated whether ethnicity was an independent predictor of immediate breast reconstruction. METHODS: The authors identified 1004 patients who underwent mastectomy for breast cancer during the period 2001-2002. The rates of immediate reconstruction among different ethnicities were evaluated using the chi-square test. Logistic regression was used to adjust for covariates, including age and disease stage. Medical records were analyzed to identify factors that influenced each patient's decision for or against immediate breast reconstruction. RESULTS: Three hundred seventy-six women (37.5%) underwent immediate breast reconstruction: This included 20.2% of African-American women, compared with 40.0% of white women, 42.0% of Hispanic women, 42.2% of Asian women, and 10.0% of Middle Eastern women (P < 0.001). The unadjusted odds ratio (OR) for immediate reconstruction for African-Americans versus whites was 0.38 (95% confidence interval [95% CI], 0.23-0.63; P < 0.001). After multivariate analysis, this disparity persisted, with an adjusted OR of 0.34 (95% CI, 0.18-0.62; P = 0.001). Asian women had lower rates of immediate reconstruction compared with white women (adjusted OR, 0.50; 95% CI, 0.24-1.04; P = 0.06). Hispanic women did not have immediate reconstruction rates that differed significantly from white women. Middle Eastern women had lower rates of immediate reconstruction compared with white women (adjusted OR, 0.08; 95% CI, 0.02-0.38; P = 0.002), but they had a corresponding increase in the rate of delayed reconstruction. In a stepwise analysis of the decision pathway to immediate reconstruction, it was found that African-American women were less likely to be offered referrals for reconstruction, were less likely to accept offered referrals, were less likely to be offered reconstruction, and were less likely to elect reconstruction if it was offered. CONCLUSIONS: African-American women underwent immediate breast reconstruction at significantly lower rates compared with white women, Hispanic women, and Asian women. After adjusting for covariates, including age and disease stage, African-American women and Asian women had lower rates of reconstruction compared with white women. The factors that contribute to these differences warrant further study.

Black or African American↗
PubMed2005

Breast MRI findings after modified radical mastectomy and transverse rectus abdominis myocutaneous flap in patients with breast cancer.

PURPOSE: To evaluate the MRI findings in breast cancer patients who had undergone a modified radical mastectomy (MRM) and a transverse rectus abdominis myocutaneous (TRAM) flap. MATERIALS AND METHODS: MRI was performed on 20 patients who had been diagnosed with breast cancer and had undergone an MRM and TRAM flap. The results were examined in terms of MRI's ability to detect the flap and assess possible postoperative changes and recurrence. In addition, MRI images of the opposite breast were analyzed. Follow-up examinations were carried out on 11 patients, and all changes were assessed. RESULTS: The flap was clearly visualized by MRI in all of the patients. The signal intensity of the flap was equivalent to that of fat. The contact zone between the TRAM flap and the mastectomy site was enhanced after contrast infusion. Postoperative changes, such as skin thickening (n=20), edema (n=2), fluid collection (n=3), hematoma (n=1), and fat necrosis (n=3), were detected. In two patients, artificially inserted fat tissue was identified. On the MRI of the opposite breast, enhancing lesions were detected in seven patients. In one patient with this finding, ductal carcinoma in situ was diagnosed. On the follow-up MRI, a decrease in skin thickening, fat necrosis, and hematoma was detected. CONCLUSION: MRI is an effective method for lesion detection and evaluation of postoperative changes after MRM and TRAM flap, as well as for evaluation of the opposite breast.

Adult↗
PubMed1977

Radical mastectomy for operable breast cancer.

The experience with radical mastectomy in the treatment of 152 cases of operable breast cancer at the Hadassah University Hospital has been analyzed. An overall 5 year survival of 75% and a 10 year survival of 62% are reported and compared with results from other methods of treatment. Based on the excellent survival rates achieved and the low incidence of local recurrence (9.8%), the present study suggests that radical mastectomy is still the most suitable surgical procedure in the treatment of operable breast cancer.

Axilla↗
PubMed1983

Mastectomy in the management of patients with inflammatory breast cancer.

Inflammatory carcinoma of the breast is rare and lethal. Since the early 1940s, operation except for biopsy has been contraindicated in patients with inflammatory breast cancer. Results with radiotherapy alone and with radiotherapy and chemotherapy are reviewed. Results of treating patients with initial chemotherapy and debulking surgery in patients who respond to chemotherapy are presented. Mastectomy may be safely performed in selected patients with inflammatory breast cancer. Local control will improve quality of life. By removing the breast and residual tumor after chemotherapy and/or radiotherapy, fungation, ulceration, and some of the clinical and psychological problems of uncontrolled local disease may be avoided. Mastectomy should be performed only in patients who responded well to preoperative therapy. Patients who do not respond to chemotherapy should be treated with radiotherapy and should not undergo operation. This approach has not been detrimental to survival or to ultimately achieving local control of the disease.

Breast Neoplasms↗
PubMed1984

Lateral pectoralis nerve: the need to preserve it in the modified radical mastectomy.

The preservation of the medial pectoralis nerve is classical and compulsory in the Patey Modified Radical Mastectomy, which innervates the clavicular and sternal insertions of the pectoralis major muscle. The lateral pectoralis nerve innervates the lower third, and the costo-abdominal insertions of the pectoralis major muscle. The tight relationship of this nerve with the pectoralis minor muscle makes it impossible to resect the muscle without damaging the nerve. The lesion of this nerve causes fibrosis, atrophy and shortening of the pectoralis major muscle, limitations of the shoulder movements, and a certain degree of skeletonization of the chest wall. Routine removal of the pectoralis minor muscle, as seen in Patey's type operation, with sectioning of the lateral pectoralis nerve, and the above mentioned sequela, is not recommended since it destroys the cosmetic result which is the main objective of the surgery. In naming these structures we prefer Moosman's proposal, because it is easier to remember, it adapts better to our surgical training, and it denotes course location and distribution. We encourage the preservation of the pectoralis minor muscle, and the lateral pectoralis nerve in the modified radical mastectomy, following the Scanlon's proposal in the hope of maintaining a cosmetic aspect and an appropriate base for the reconstructive surgery.

Esthetics↗
PubMed1992

Oncological aspect of immediate breast reconstruction in mastectomy patients.

In this study, we compared the relapse-free and overall survival of 83 patients who underwent mastectomy with immediate reconstruction (MIBR) using a musculocutaneous flap with or without silicone implant with those of 153 patients with breast cancer who underwent mastectomy without immediate reconstruction. In univariate analysis, the overall and/or relapse-free survival of reconstructed patients with four or more positive axillary lymph nodes or those with menopausal status were significantly inferior compared with those of nonreconstructed patients. In multivariate analysis, however, the immediate breast reconstruction did not appear to have a significant adverse influence on all patients, and on the subgroups stratified by menopausal status or axillary lymph node metastases. Therefore, it was concluded that MIBR using a musculocutaneous flap did not compromise the survival of patients with breast cancer.

Adult↗
PubMed1989

Breast conservation versus mastectomy: psychological considerations.

From the available evidence it is clear that mastectomy is associated with a substantial psychological and psychiatric morbidity. To date there is no convincing evidence that counseling can prevent this morbidity, but monitoring of women's psychological adjustment can lead to early detection and effective treatment of their problem. The use of immediate or delayed implantation or reconstruction appears to reduce the psychiatric morbidity in those women who are particularly concerned about their appearance at the time of surgery. Psychiatric morbidity is further increased when adjuvant chemotherapy is used and when treatment results in persistent arm pain and swelling. A shorter course of adjuvant chemotherapy and reduction of surgery within the axilla could reduce psychiatric morbidity. The role of radiotherapy is still unclear, but in some studies a link has been found between the amount of radiotherapy given, adverse effects, and psychiatric morbidity. In women undergoing breast conservation the reduction in body image problems is offset by greater anxiety about recurrence and depression caused by radiotherapy. Exploring and allowing choice when a patient has a strong preference for breast conservation or mastectomy appears to reduce morbidity. But attention still needs to be paid to the early recognition and treatment of psychological problems in patients with breast cancer, and guidelines are provided.

Aftercare↗
PubMed1987

Surgical complications and follow-up evaluation of 163 patients with subcutaneous mastectomy.

One hundred sixty three prophylactic subcutaneous mastectomies were performed during a six-year period in high-risk situations. All cases were evaluated for immediate surgical complications and followed up for at least five years. The postoperative complications following subcutaneous mastectomy with and without simultaneous reduction of skin were hematoma, infection, necrosis of the nipple area, pain, and impaired sensitivity. The most significant long-term complication was moderate to severe capsule formation. Despite these problems most women were satisfied with the procedure which was performed because of their increased risk of breast cancer.

Female↗
PubMed1990

Aesthetic refinements in prophylactic mastectomy with immediate reconstruction.

Immediate reconstruction of more than 1000 breasts was performed on high-risk patients on whom a prophylactic mastectomy was done. The mastectomy removes as much breast tissue as possible while leaving sufficient skin, and possibly the nipple-areola complex, to enable immediate reconstruction. The creation of symmetrical, well-balanced muscle pockets for the implant is the most important factor in producing satisfactory results in these cases.

Breast↗
PubMed1996

Time distribution of the recurrence risk for breast cancer patients undergoing mastectomy: further support about the concept of tumor dormancy.

PURPOSE: To gather information on metastatic growth from the time-distribution of first treatment failure in breast cancer patients undergoing mastectomy alone. METHODS: The risk of recurrence at a given time after surgery was studied utilizing the cause-specific hazard function. Recurrence was categorized as first treatment failure at any site, local-regional recurrence, distant metastases, and contralateral tumor. The risk distribution was assessed relative to tumor size, axillary lymph node involvement, and menopausal status. RESULTS: A total of 1173 patients treated between 1964 and 1980 with mastectomy alone and no adjuvant therapy were studied. The hazard function for first failure presented an early peak at about 18 months after surgery, a second peak at about 60 months and then a tapered plateau-like tail extending up to 15 years. A similar risk pattern was detectable for both local recurrence and distant metastases, while the curve of contralateral breast tumors showed a near flat plateau. The risk of early local-regional and distant recurrences was much lower for tumors less than 2 cm in diameter than for larger tumors; the risk of late recurrence was similar for small and large primaries. Node-positive patients showed peaks four to five times higher than node-negative patients. Sub-dividing node-positive patients into 1-3 and > 3 node-positive subsets did not substantially change the general picture of tumor recurrence. The hazard functions for premenopausal and postmenopausal patients were virtually superimposable. CONCLUSIONS: The multipeak hazard curve suggests that the process resulting in overt clinical metastases may have discrete features. Primary tumor size could affect in different ways early and late metastases, while axillary node status should be related to the risk level, not to the risk pattern, and menopausal status does not seem to significantly affect the hazard distribution. Moreover, contralateral breast tumors, occurring at constant risk throughout the time, should be considered as second primary cancers. These findings could be reasonably explained by a tumor dormancy hypothesis, which assumes that micrometastases may be in different biological steady states, most of which do not imply tumor growth. Tumor or microenvironment changes could induce metastatic growth after given mean transition times from surgery and originate a discrete pattern of the hazard function.

Adult↗
PubMed1983

Psychosocial and physical outcomes of primary breast cancer therapy: mastectomy vs excisional biopsy and irradiation.

Thirty-eight patients treated for primary breast cancer as part of a prospective randomized clinical trial were questioned retrospectively as to their psychosocial adaptation to treatment. Twenty patients had received mastectomy and eighteen had received excisional biopsy plus radiation of the intact breast. Aside from body image concerns, there were no marked psychosocial differences detected between these groups. Previous studies emphasizing serious psychological problems in mastectomy patients and fewer such problems in nonmastectomy patients may be influenced by biases that are not present in a randomized study design.

Adult↗
PubMedDate not supplied

Presentation, treatment, and outcome of local recurrence afterskin-sparing mastectomy and immediate breast reconstruction.

BACKGROUND: The local recurrence (LR) rate with skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) has been reported as comparable to the LR rate after conventional mastectomy. However, limited data are available on the prognostic significance and management of LR following SSM. METHODS: A prospective database maintained at the University of Texas M. D. Anderson Cancer Center identified 437 SSMs performed for 372 invasive T1/T2 breast cancers between 1986 and 1993. RESULTS: Twenty-three LRs were identified, with a LR rate of 6.2% (23/372). Twenty-two of these (96%) presented as palpable skin-flap masses. The median time to recurrence was 25 months (range, 3 to 98 months). Fourteen patients were treated with a combination of surgery and systemic therapy. Resection of the reconstructed breast was performed in only three patients. Complete local control of the recurrent disease was achieved in 17 patients (74%). Nine patients (39%) developed distant metastatic disease. At a median follow-up of 26 months, 14 of 23 patients (61%) are alive without evidence of disease, and 7 (30%) have died from breast cancer. CONCLUSIONS: Because LR rate with SSM is low and likelihood of local control and survival is high, SSM and IBR is an acceptable treatment option for early stage breast cancer.

Adult↗
PubMed1996

Aggressive therapy for locoregional recurrence after mastectomy in stage II and III breast cancer patients.

BACKGROUND: To determine if aggressive treatment of locoregional recurrence affects survival, we retrospectively analyzed the clinical outcome of 69 breast cancer patients who developed locoregional disease as their first episode of recurrence following mastectomy and adjuvant chemotherapy. METHODS: Patients were identified from among 1,707 stage II and III breast cancer patients who enrolled in five different doxorubicin-based adjuvant chemotherapy protocols at The University of Texas M. D. Anderson Cancer Center from 1975 to 1986. Sixty-nine evaluable patients who had a locoregional recurrence as the first site of relapse after mastectomy formed the study group. Multifactorial analysis of clinical and histopathological characteristics of both the primary tumor and the subsequent recurrence was performed using a logistic regression method. Survival analysis was performed using an actuarial life-table method calculated from the date of registration into the adjuvant therapy protocols. RESULTS: Median follow-up was 6.6 years. Two factors significantly affected survival: recurrence of disease during or after adjuvant treatment of the primary and whether the patient was rendered disease free after recurrence. CONCLUSIONS: Stage II and III breast cancer patients who have locoregional recurrence after adjuvant chemotherapy and can be rendered disease free may have a better survival rate. Aggressive treatment of locoregional recurrence including complete surgical excision should be considered in this subgroup of patients.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1975

Modified radical mastectomy with preservation of the pectoralis major muscle.

A new technique of modified radical mastectomy for early breast cancer was devised with an express purpose of preserving pectoralis major muscle but still enabling radical removal of the regional lymphnodes. The pectoralis major muscle was transected at its midportion to expose the thoracic wall for radical dissection of axillar and subclavicular lymphnodes followed by resuturing of the muscle to preserve its continuity. The parasternal nodes can also be dissected if necessary. The pectoralis minor muscle is either resected or preserved. This procedure should be applied mainly in T1N0 and T1N1a (Stage I in the TNM staging system) which seems recently to be increasing rapidly in number and for which the radical mastectomy with resection of pectoralis major muscle is thought to be too excessive. The procedure proposed in the present communication offers advantage not only in functional but also cosmetic aspect by preserving the pectoralis major muscle while the radicality of the operation is retained. Although the number of cases thus treated is limited and the long-term follow up with survival rate is not yet available, the procedure seems to be of considerable value in selected patients.

Adult↗
PubMed1987

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.

Adult↗
PubMed1989

The acceptable delay between biopsy and radical mastectomy in breast cancer patients.

The effects on the prognosis of breast cancer, of the delay between biopsy and radical mastectomy were studied in 394 patients. No delay had been experienced by 148 cases (no delay group), no biopsy had been performed in 166 cases (no biopsy group) and 80 cases had experienced a delay of 1 day or longer after having had a biopsy taken at a different institution (delay group). The recurrence rate of the no delay group was 10.8 per cent (16/148), whereas that of the delay group was 18.8 per cent (15/80). The relapse free survival rate of the no delay group was superior to that of the delay group (Kaplan Meier's method: p less than 0.05). The delay group was further divided into two groups according to the duration of delay, namely: a group whose delay was less than 7 days and another whose delay was longer than 8 days. There was no significant difference between the relapse free survival rates of the no delay group and the less than 7 days group, however, a significant difference was observed between the no delay group and the longer than 8 days delay group (p less than 0.05). The acceptable delay between biopsy and radical mastectomy may therefore be concluded as less than 7 days.

Biopsy↗