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PubMed1983

Early results of subcutaneous mastectomy with immediate silicone prosthetic implant for carcinoma of the breast.

Surgery for carcinoma of the breast is becoming less radical even to the extent of breast conservation. Subcutaneous mastectomy and implant offers itself as an alternative, retaining a breast shape and removing almost all breast tissue. Forty-four consecutive patients who had this procedure for breast carcinoma were studied with a follow-up of 5-44 months (mean 25.3 months). Only 4 patients (9 per cent) had local recurrences, i.e. recurrence in the skin flap or scar. This compares favourably with other series and other forms of treatment. Removal of the prosthesis was necessary in 10 patients due to local factors. The cosmetic result as assessed by the patients was almost universally pleasing. Twenty-six of 27 patients with prostheses in situ who were interviewed in person or by postal questionnaire were pleased with the results of their surgery. The absence of high recurrence rates locally and high patient acceptance makes this a definite surgical alternative.

Adult↗
PubMed1983

Central breast carcinoma treated by simultaneous mastectomy and latissimus dorsi flap reconstruction.

Simultaneous mastectomy with latissimus dorsi flap reconstructions have been performed on 15 women with primary central breast cancer and on 5 women with local recurrence after local excision and deep X-ray treatment. The indications and technique are discussed. There was no mortality and no initial morbidity. No prosthesis has become infected. One prosthesis has slipped laterally, requiring removal and re-insertion at the time of nipple reconstruction. In all patients an acceptable cosmetic result, as assessed by the patient and the surgeon, has been achieved. Follow-up is very brief, 1-18 months, but there is as yet no sign of local recurrence.

Adult↗
PubMed1985

Survival following local skin recurrence after mastectomy.

Seventy-three patients with breast cancer, treated by radical mastectomy, who subsequently developed a local skin recurrence without clinical evidence of disseminated disease, have been reviewed. There were significant differences between the survival of patients with single and multiple recurrences. Only 10 per cent of those with multiple lesions survived 5 years, and none was alive at 10 years, whereas 42 per cent of those with single lesions survived 5 years and 22 per cent were alive and well at 10 years' postrecurrence. Adequate local treatment of a single skin nodule may enable a subset of patients to survive without subsequent development of breast cancer metastases.

Breast Neoplasms↗
PubMed1985

Patterns of flap recurrence following mastectomy.

Flap recurrence after mastectomy is divisible into three distinct entities: spot recurrence, multiple spot recurrence and field change. Spot recurrence and multiple spot recurrence are usually controlled by local measures and are not associated with any particular characteristics of the primary tumour. The field change type of flap recurrence is difficult to control and is associated with aggressive primary tumours (grade III, node positive, oestrogen receptor negative) and a very poor prognosis. The appearance of field change type of flap recurrence is an indication for systemic therapy.

Breast Neoplasms↗
PubMed1986

Post-mastectomy breast reconstruction using the inflatable tissue expander.

Breast reconstruction following mastectomy has previously relied on the insertion of a silicone gel implant or the use of a myocutaneous flap. We report the use of an innovation, the inflatable tissue expander, for both immediate and delayed breast reconstruction in 26 patients where soft tissue cover was inadequate to permit the use of the silicone implant. By serial inflation of the tissue expander with saline, sufficient tissue cover was achieved for a second operative placement of a silicone prosthesis of appropriate volume to match the normal breast. To date, 10 patients undergoing delayed reconstruction and 5 of 16 patients with immediate reconstruction have had their final prosthesis inserted, while 3 women are satisfied with the result of the expandable implant and desire no further surgery. Only two technical complications have arisen with loss of the expander in one patient who had had recent radiotherapy and in another the tissue expander was placed much too high on the chest wall. Mechanical failure occurred in three cases where disruption of the seam led to sudden deflation in two and a slow leak from the injection port developed in one. One patient also attempted self-inflation leading to deflation of the tissue expander. The cosmetic results were subjectively and objectively very good with capsular distortion present in only one case. We feel that the inflatable tissue expander is simple and safe to use, may be used for immediate reconstruction without compromising the ablative surgery and should be a choice available to general surgeons for providing safe and cosmetically acceptable reconstructive surgery.

Adult↗
PubMed1987

Nipple preservation during mastectomy.

In a retrospective study of 100 patients with operable breast cancer, microscopic involvement of the nipple-areola complex was found in 16 cases. Each of these 16 cases occurred in patients with centrally situated tumours. In contrast, nipple involvement did not occur with peripherally situated tumours lying greater than 2 cm outside the areolar margin (P less than 10(-6), Fisher's exact test). Nipple involvement was more likely in patients with greater than or equal to 4 positive axillary nodes (P less than 0.01, chi 2 test). From this study it appears that nipple preservation may be undertaken during mastectomy for small peripheral tumours, provided the nipple is clinically normal, and frozen section analysis of the sub-nipple area is shown to be free from tumour invasion. These criteria for nipple preservation were satisfied in 20 patients out of a prospective series of 60. In this group, nipple preservation on the skin flap improved the cosmetic result of breast reconstruction in 35 per cent, and facilitated skin closure in 20 per cent. After a mean follow-up period of 50.4 months, nipple preservation was not associated with any significant excess of local recurrences.

Breast↗
PubMed1991

Perioperative blood transfusion does not promote recurrence and death after mastectomy for breast cancer. The Danish Breast Cancer Cooperative Group.

Several reports suggest that perioperative blood transfusion promotes recurrence and death after cancer surgery. We studied the effect of transfusion in 1599 patients who had mastectomy for carcinoma of the breast. In 228 transfused patients the disease recurred in 110 (48 per cent), compared with 647 (47 per cent) of 1371 non-transfused patients (P = 0.85). The 5-year recurrence-free survival rate was 0.54 in the transfused patients and 0.60 in the non-transfused group (P = 0.44). The transfused patients had a higher prevalence of risk factors than the non-transfused patients. Cox's multiple regression analysis confirmed that perioperative blood transfusion was of no importance. The study does not support the hypothesis that perioperative blood transfusion promotes recurrence after operation for breast cancer.

Adult↗
PubMed1992

Subcutaneous mastectomy with immediate reconstruction as treatment for early breast cancer.

Subcutaneous mastectomy and axillary dissection combined with immediate reconstruction was used to treat primary breast cancer in a consecutive series of 111 patients. Local recurrence occurred in 19 patients (17 per cent) during a mean follow-up of 30 (range 6-60) months. Complete control of local disease was achieved in all patients except one, who had terminal disease. Prophylactic radiotherapy was avoided for 83 per cent of patients, and good cosmetic results were obtained in 89 per cent. These results support the use of this technique in the treatment of early breast cancer.

Adult↗
PubMed1993

Randomized trial of laser scalpel for modified radical mastectomy.

The efficacy of a contact neodymium yttrium-aluminium-garnet laser scalpel was assessed during breast surgery. Forty consecutive women undergoing modified radical mastectomy were randomized to operation performed with a conventional or laser scalpel. The laser scalpel was associated with a significant reduction in mean operative blood loss (149 versus 421 ml; 95 per cent confidence interval of difference 176-368 ml, P < 0.001), but the mean operating time was longer (105 versus 80 min; 95 per cent confidence interval of difference 16-34 min, P < 0.001). No significant differences were found in the volume of postoperative wound drainage, incidence of axillary seroma, postoperative pain score or time to return of shoulder mobility. Use of a laser scalpel in breast surgery cannot be recommended.

Adult↗
PubMed1996

Breast conservation or mastectomy: treatment choice of women aged 70 years and older.

Fifty women aged 70 years and older with newly diagnosed carcinoma of the breast were prospectively studied after being offered a choice of four treatment options. Thirty-four of 38 patients who chose their own treatment had breast conservation; four opted for mastectomy. At 12-month follow-up only two women were unhappy with their choice of treatment. It is concluded that elderly women should be involved in deciding the treatment of their breast cancer.

Aged↗
PubMed2004

Cytokeratin-positive cells in sentinel lymph nodes in breast cancer are not random events: experience in patients undergoing prophylactic mastectomy.

BACKGROUND: The incidence of immunohistochemistry (IHC)-detected epithelial cell displacement in sentinel lymph node (SLN) biopsy is unknown. In the current study, we address this question by examining the pattern of SLN involvement in patients undergoing prophylactic mastectomy (PM) at Memorial Sloan-Kettering Cancer Center (New York, NY). METHODS: Between January 1999 and January 2003, 5275 patients underwent SLN biopsy. Unilateral or bilateral PM with SLN biopsy was performed in 143 (2.7%) patients, representing 163 PM cases. RESULTS: Occult carcinoma was identified in 13 of 163 (8.0%) PM specimens. Two patients with occult invasive carcinoma had positive SLNs (hematoxylin and eosin). In the remaining 150 PM cases without occult carcinoma (130 patients), 89% underwent IHC analysis of the SLNs. Of these 130 patients, 43 (33%) had one or more prior biopsies in their "cancer-free" breast, a median of 43 days (range, 3-314 days) before PM. A total of 310 SLNs were examined by IHC (mean, 2.3 lymph nodes per PM case). Only 1 of 130 (0.8%) patients without occult carcinoma had an IHC-positive SLN. This patient had Stage IIIC carcinoma of the contralateral breast. IHC-positive SLNs were not identified in any of the 43 patients with a history of prior biopsy. Therefore, only 1 IHC-positive SLN was detected in 310 (0.3%) lymph nodes examined. CONCLUSIONS: IHC-positive cells in SLNs are rare in the absence of cancer and are not the result of previous breast instrumentation. Although the prognostic significance of IHC-positive cells remains controversial, the current study suggests that they are not random events.

Adult↗
PubMed2004

Contralateral prophylactic mastectomy. Predictors of significant histologic findings.

BACKGROUND: Women with unilateral breast carcinoma are at increased risk for developing contralateral breast carcinoma (CBC). The authors sought to identify predictors of malignant or moderate to high-risk histologic findings in contralateral prophylactic mastectomy (CPM) specimens, and to determine the efficacy of CPM. METHODS: The authors performed a retrospective review of 239 patients with unilateral early-stage breast carcinoma who underwent CPM. The number of CBCs expected if the contralateral breast had been left intact was calculated based on CBC rates observed in the Surveillance, Epidemiology, and End Results (SEER) database and on life-table analysis by family history. RESULTS: In the current study, 11 patients (4.6%) had occult contralateral malignancies (4 invasive carcinomas and 7 ductal carcinomas in situ) and 44 (18.4%) patients had moderate to high-risk pathology (8 lobular carcinoma in situ, 11 atypical lobular hyperplasia, 25 atypical ductal hyperplasia). At 1846 patient-years of follow-up, only 1 patient (0.4%) developed a new CBC compared with 11 expected cancers based on SEER data. One CBC was observed among 140 patients with a family history of breast carcinoma, compared with 16 expected cancers based on life-table analysis adjusted for adjuvant therapy. The determinants of significant findings at CPM were invasive lobular histology, estrogen and progesterone receptor positivity, additional ipsilateral moderate to high-risk pathology, and age > 40 years at cancer diagnosis. CONCLUSIONS: CPM was associated with a low risk of subsequent development of breast carcinoma. Evaluation of histologic findings in the ipsilateral breast may help to predict the likelihood of significant disease in the contralateral breast and assist in risk stratification.

Adult↗
PubMed2005

Skin-sparing mastectomy and immediate reconstruction is an acceptable treatment option for patients with high-risk breast carcinoma.

BACKGROUND: Skin-sparing mastectomy (SSM) followed by immediate reconstruction is an effective treatment option for patients with early-stage breast carcinoma, but its use in patients with more advanced disease is controversial. METHODS: A retrospective review was performed that included 38 consecutive patients with high-risk breast carcinoma who underwent SSM and immediate reconstruction (between July 1996 and January 2002). Tumor characteristics, type of reconstruction, margin status, timing of adjuvant therapy, postoperative complications, and incidence of recurrence were evaluated. RESULTS: High-risk patients (Stage IIA [n=4 patients] Stage IIB [n=23 patients] Stage IIIA [n=8 patients] and Stage IIIB [n=3 patients]) underwent immediate reconstruction after SSM with the use of a transverse rectus abdominis myocutaneous flap (n=31 patients), a latissimus dorsi myocutaneous flap plus an implant (n=3 patients), or tissue expanders with subsequent implant placement (n=4 patients). The median follow-up was 52.9 months (range, 27.5-92.0 months), and the median time to recurrence has not yet been reached at the time of last follow-up. The median interval from surgery to the initiation of postoperative adjuvant therapy was 38 days (range, 25-238 days). Local recurrence was seen in 1 patient (2.6%), systemic recurrence in was seen in 10 patients (26.3%), and both local and distant metastases in were seen in 2 other patients (5.3%). CONCLUSIONS: SSM with immediate reconstruction appeared to be an oncologically safe treatment option for high-risk patients with advanced stages of breast carcinoma. In addition to the aesthetic and psychological benefits of performing SSM with immediate reconstruction, local recurrence rates and disease-free survival were favorable when combined with the use of radiation therapy and adjuvant chemotherapy, as indicated.

Adult↗
PubMed2006

Selective use of sentinel lymph node surgery during prophylactic mastectomy.

BACKGROUND: Patients with invasive cancer identified at the time of prophylactic mastectomy (PM) will require axillary lymph node dissection for staging; therefore, many surgeons advocate sentinel lymph node (SLN) surgery at the time of PM. The current study investigates the invasive cancer rate in PM and evaluates factors associated with invasive cancer to guide SLN surgery use. METHODS: Patients undergoing PM at the M. D. Anderson Cancer Center between January 2000 and July 2005 were identified from a prospective database. Clinical, radiographic, and pathologic data were collected. RESULTS: A total of 409 patients (436 PM cases) were identified; 382 underwent contralateral PM (CPM) and 27 underwent bilateral PM (BPM). Cancer was identified in 22 of 436 PM cases (5%). Of these, 14 patients (64%) had ductal carcinoma in situ (DCIS). Only 8 patients (1.8%) had invasive cancer, with a mean tumor size of 5 mm (range, 2-9 mm). There was no difference in the occult cancer rate between CPM and BPM. No cases of invasive cancer were identified in the 23 patients with BRCA mutations. Significantly increased risk of invasive cancer in the PM breast was seen in postmenopausal patients (3.7%; P = .007), patients age >60 years (7.5%; P = .008), and patients with history of invasive lobular carcinoma (9.7%; P = .0002) or lobular carcinoma in situ (LCIS) (7.7%; P = .008). CONCLUSIONS: The frequency of cancer in PM is very low and the majority represents DCIS. Therefore, routine use of SLN surgery in all patients undergoing PM is not warranted. However, patients at higher risk for whom SLN surgery should be considered include older women and patients with a history of lobular cancer or LCIS.

Adult↗
PubMed2006

African-American race is associated with a poorer overall survival rate for breast cancer patients treated with mastectomy and doxorubicin-based chemotherapy.

BACKGROUND: African-American (AA) race has been associated with a worse outcome in breast cancer. It is unclear whether this is due to biological factors, socioeconomic factors, or both. METHODS: The records from 2 independent cohorts of breast cancer patients treated on institutional protocols with mastectomy and adjuvant (n = 1456) or neoadjuvant (n = 684) doxorubicin-based chemotherapy were retrospectively reviewed. RESULTS: The adjuvant (Adj) chemotherapy cohort included 1142 Caucasian (CA), 186 Hispanic (HI), and 128 (AA) patients. The neoadjuvant (Neo) chemotherapy protocols included 448 CA, 114 HI, and 122 AA patients. In both groups, AA patients had later-stage tumors (Adj P = .017; Neo P = .051), a higher rate of estrogen receptor (ER)-negative disease (Adj P = .054; Neo P = .039), and a worse 10-year actuarial overall survival rate than CA or HI patients (Adj, 52%, 62%, and 62%, respectively, P = .009; Neo, 40%, 50%, and 56%, respectively, P = .015). In multivariate analyses, AA race remained independently associated with a poorer overall survival rate in both cohorts (Adj, hazard ratio = 1.39, P = .018; Neo, hazard ratio = 1.37, P = .02). CONCLUSIONS: The data suggest that AA race is associated with less favorable biological tumor features, such as an increased likelihood of ER-negative disease, than those found in CA and HI patients. Such differences in tumor biology, as well as previously described socioeconomic factors, likely contribute to the lower rate of survival in the AA breast cancer population.

Adolescent↗
PubMed1990

Flow cytometric detection of multifocal DNA aneuploid cell populations in mastectomy specimens containing a primary breast carcinoma.

DNA flow cytometry was used to study the presence of DNA aneuploid cell populations in macroscopically normal glandular tissue in mastectomy specimens from 30 patients with breast cancer. In the 13 patients with a DNA diploid primary tumor, no DNA aneuploidy could be found in any of the 39 distant specimens assessed. However, DNA aneuploid cell populations were demonstrated in four of the 17 (23%) patients with a primary DNA aneuploid carcinoma and in seven out of 54 (13%) distant tissue samples (P = 0.02). In all cases the DNA index of the DNA aneuploid cells found in the distant samples was identical to that of the primary tumor. The replicate aneuploid DNA indices and histologic controls taken in parallel very strongly suggest that these distant DNA aneuploid cell populations are metastases.

Aged↗
PubMed2001

Do surgical oncologists achieve lower rates of local-regional recurrence in node positive breast cancer treated with mastectomy alone?

BACKGROUND AND OBJECTIVE: Adjuvant radiotherapy for node positive breast cancer postmastectomy has been recommended by two previously published randomized controlled trials (RCT). The local-regional recurrence rates in the control arms, however, were considered by some critics to be excessive (> 25% at 10 years). Inadequate surgery, as evidenced by the low number of axillary nodes reported, may have resulted in the high local-regional recurrence rates, allowing for the benefits seen with radiotherapy. Fellowship trained surgical oncologists might provide "better quality" surgery, resulting in lower recurrence rates and thus making adjuvant radiotherapy unnecessary. Our objective was to establish the local-regional control rate postmastectomy in node positive breast cancer patients operated on by surgical oncologists, and to determine if treatment recommendations from previous RCTs are generalizable. METHODS: Node positive stage IIb and IIIa breast cancer patients treated with mastectomy at the Medical College of Virginia Hospitals by surgical oncologists, without adjuvant radiotherapy, and entered into adjuvant chemotherapy trials between 1978 and 1993 were identified retrospectively. Pathology and follow-up records were reviewed. RESULTS: One hundred and thirty-seven patients were identified. A median of 18 axillary nodes was reported with a median of 4 positive nodes. The locoregional recurrence at 10-years was 27% (95% confidence interval, 19-35%). CONCLUSION: Despite some evidence of "better quality" surgery, there was no clinically significant difference in the local-regional recurrence rate in this case series compared to controls in two previous RCTs. Recommendations for postmastectomy radiotherapy should be considered for node positive breast cancers, even if operated upon by surgical oncologists.

Breast Neoplasms↗
PubMed1977

The survival of inoperable breast cancer treated with radiotherapy and radiotherapy followed by mastectomy.

Forty-five patients with locally advanced breast carcinoma were treated by radiotherapy. Twelve of them became operable and were operated. After 3 and 4 years in comparable clinical stage the rate of metastases in the nonoperated group was 78.6% and in the operated 75%. The survival after 3 and 4 years in comparable clinical stages was similar. In more advanced stages the survival was worse. Considering the trauma of mastectomy and the similar survival obtained in our material, an international trial should be performed to decide whether inoperable breast cancer becoming operable after radiotherapy should be operated.

Breast Neoplasms↗