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Early experience with the modified transverse incision for mastectomy is presented. A 'fish-shaped' incision, by adding two triangles at the lateral tip, decreases the amount of excess skin and prevents the 'dog ear' deformity, makes up the difference in the length of the transverse edges depending on the location of the tumour and provides easy access to the axilla.
Eighty-five breast cancer patients who had been operated for mastectomy and were currently undergoing adjuvant or therapeutic chemotherapy were included in the study. Patients were divided into two matching groups of 50 (A) and 35 (B) subjects; group A was treated with CT and thymostimulin Serono and group B with CT alone. The difference between the two groups in relation to first-degree (24% vs 57%) and second-degree leucopenia (8% vs 14%), in addition to the difference in relation to infections and the regularity of chemotherapy cycles confirmed the value of immunotherapy with thymostimulin during chemotherapy for breast cancer.
The author analyzes some causes preventing the development of reconstruction of the breast after mastectomy, mentions the reasons for reconstruction and reflects on contraindications of this operation. He demonstrates a case of bilateral reconstruction of the breasts by means of a TRAM flap.
Breast reconstruction after mastectomy can make an important contribution to the quality of life of women with breast cancer. Reconstruction eliminates the need for a cumbersome external prosthesis, allows greater freedom in the selection of clothing styles, and makes a woman more comfortable undressing in front of others. Reconstruction also reduces anxiety and depression and helps a woman regain a sense of wholeness and femininity. Advances in breast reconstruction include improved types of implants, use of autogenous tissues, and refinements in nipple reconstruction. This article summarizes the "state of the art" in breast reconstruction, the various surgical techniques available, their indications, advantages, and potential drawbacks.
Breast reconstruction is widely used in patients who have undergone mastectomy for breast cancer. The paper underlines that reconstruction is often performed by the general surgeon who has become an expert in this type of plastic surgery. The Authors present their own clinical data, and describe the indications and techniques used, and the results obtained. In conclusion, it is stressed that ideally the same surgeon should be experienced in oncology and plastic surgery.
The indications, technique and complications of salvage mastectomy in 25 patients with local recurrence after breast-conserving therapy for carcinoma of the breast have been reviewed. Two patients required myocutaneous flaps to repair the defect, and six patients (24%) suffered wound infection or breakdown. Subsequent local relapse occurred in a total of five patients, two of whom died with uncontrolled chest wall skin nodules.
To define the role of radiotherapy in the treatment of supraclavicular lymph node (SCN) metastasis after initial surgery for breast cancer, a retrospective review of 55 patients with ipsilateral SCN metastasis after (extended) radical mastectomy was undertaken. In most cases, SCN metastasis is a manifestation of the systemic dissemination, because 87% of the patients developed second recurrence in 2 years after radiotherapy to SCN. However, the response to radiotherapy closely related to the survival after radiotherapy. 3 year-survival of the patients showing complete response was 42% while of the patients showing partial response was 9%. Six out of 34 mastectomized patients with sole SCN metastasis survived more than 3 years without evidence of recurrence following radiotherapy to SCN. It can be suggested that radiotherapy to SCN metastasis is not always palliative treatment, and has potency to improve the prognosis of the mastectomized patients. The prognostic factor of the patients with SCN metastasis was also referred. The time interval from initial surgery until SCN recurrence (disease free interval) has prognostic significance, because it indicates the natural course of each tumor. Presence of metastasis other than SCN at the time of first recurrence and poor response to radiotherapy predict worse prognosis.
Today there are many types of reconstruction available for the patient with a post-mastectomy deformity. Experience with all the types enables the surgeon to select the one that is appropriate to the particular reconstruction. The TRAM flap method is one which has proven to be an excellent method in selected cases. It is one that can result in the reconstruction of an attractive breast, yet be done with an acceptable risk of surgical complication.
Total mastectomy and immediate reconstruction using the latissimus dorsi myocutaneous flap with nipple preservation has been performed in 87 women. The palpable tumours were all more than 3 cm from the nipple. No recurrence in the preserved nipple was seen in 63 women who underwent the procedure for tumour recurrence after previous radiotherapy. Nipple recurrence occurred in 3 out of 24 women (12%) where the indication was multifocal disease and no radiotherapy was given. This non-irradiated group should either not have the nipple preserved or should undergo postoperative electron field therapy to the nipple-areolar complex.
Average charge of $6,160 was billed to Metropolitan Life Insurance Company for 807 modified radical mastectomies during 1988. The average physicians' fees were $2,090. Length of hospital stay averaged 4.3 days across the country. The charges varied by as much as 92 percent between states. Among the 19 states included in the study, New York and California reported the highest average total charges ($7,870 and $7,290) and Iowa and Minnesota reported the lowest average charges ($4,100 and $4,620). On average, hospital expense comprised 66 percent of the total charges and ancillary fees accounted for almost three-fourths of the hospital bill.
With the object of investigating the occurrence of pain and dysaesthesiae in the scar following mastectomy, 120 were interviewed by a standard questionnaire in a prospective study. These women had commenced postoperative control or treatment in the Department of Oncology in the University Hospital of Aarhus consecutively during a one-year period. One hundred and ten of these women were interviewed again one year later. In 92% of the patients with scar pain and dysaesthesiae, these appeared within the first three months postoperatively. At the first interview, 42 patients (35%) had scar pain and 15 of these (13%) experienced constant scar pain. One year later, 25 patients (23%) still had scar pain and 13 patients (12%) had experienced persistent scar pain throughout the entire year. Two of the patients (8%) with scar pain had constant pain while, at the second interview, 14 patients (56%) reported that the scar pain lasted for seconds. Twenty-seven patients (23%) had dysaesthesiae at the first interview while 29 patients experienced these continually one year after operation. Both the intensity and the duration of the scar pain diminished with the elapse of time. This held also true where dysaesthesiae were concerned but was not so marked.
In a comparative study 38 patients with secondary unilateral lymphatic oedema after mastectomy were investigated with regard to the efficacy of intermittent compression treatment using uni- or multichamber systems (Jobst and Lymph-a-mat respectively). Although both machines significantly reduce oedema, there is no difference between their reduction capacities.
To assess the effect of perioperative factors on the incidence of postoperative wound complications, the authors retrospectively analyzed 101 patients who had undergone modified radical mastectomy. These factors included age, body weight, operative techniques, estimated blood loss, wound-catheter drainage, extent of axillary dissection, nodal involvement, and length of hospital stay. Complications included seroma (10.9%), wound infection (8.9%), wound necrosis (5%), hematoma (3%), lymphedema (2%), and pneumothorax (1%). The logistic regression method was used to analyze the data. When electrocautery was used to create the skin flaps, the probability of a wound complication was .462, a 44% increase over that calculated for the cold-knife technique (P = .05). A prolonged hospitalization accompanied the occurrence of a wound complication. No other factors reached statistical significance.
Mastectomy remains the treatment of reference for breast cancer. Pre or post-operative radiotherapy was the only adjuvant therapy possible for many years. This series of 2166 cases, treated between 1960 and 1973, analyses the survival, loco-regional recurrence rate, metastases and complications as a function of initial UICC staging and the type of treatment chosen. With follow up periods ranging from 15 to 25 years, we have shown that the clinical course is marked by recurrences for metastases occurring principally between the 2nd and 5th year, and that the number of events occurring beyond 10 years is still considerable. This study justifies the long term surveillance of patients. The results of current therapies need to be assessed in relation to historical data with a sufficiently long follow up, in order to confirm their efficacy.
Eighteen patients with gynaecomastia were mastectomised over the last three years (September 1984 to September 1987) using a technique of modified subcutaneous mastectomy. This modification utilizes an axillary flat flap to fill in the defect resulting from excision of the breast tissue. All our patients had a very satisfactory post-operative cosmetic result. The frequent complications of breast excision, such as doughnut deformity, nipple necrosis, nipple flattening, inversion or loss of sensation, were not encountered in our series. The operative technique is described in detail, steps and a representative result are shown.
Reported is the case of a 54-year-old female manifesting the Stewart-Treves syndrome (a postmastectomy angiosarcoma.) The patient had developed an angiosarcoma in her lymphoedematous right shoulder and lower neck develop ten years after a radical mastectomy for a papillo-tubular adenocarcinoma of the right mammary gland. Radiologically, a well-enhanced tumor was revealed by computed tomography, which angiographically had more stains and tumor vessels than usual for a mammary carcinoma and less than usually seen in a cavernous hemangioma. Histologically, this tumor showed less of a luminal differentiation than a conventional angiosarcoma and resembled a fibrosarcoma. Computed tomography and angiography were found useful in achieving a diagnosis and the subsequent therapy for this Stewart-Treves syndrome.
A review of 198 cases of breast reconstruction done at the time of mastectomy for carcinoma of the breast shows an extremely low morbidity. The technique of using a tissue-expander prosthesis enables immediate breast reconstruction without any fear of impairing prognosis, of spreading disease, or of impeding adjuvant therapy.
To investigate the nature and origin of postmastectomy seroma, the concentration of IgG, the number of leucocytes, granulocytes and lymphocytes in the drain fluid and seroma aspirates was studied in breast cancer patients after mastectomy. The composition of the fluid and aspirates and the time-related changes of the investigated criteria suggested that 1) seroma is not an accumulation of serum, but an exudate, 2) the exudate is an element in an acute inflammatory reaction, i.e. the first phase of wound repair, and 3) seroma formation reflects an increased intensity and a prolongation of this phase. By paying attention to factors influencing the duration and intensity of the first phase of wound repair, it should be possible to reduce the occurrence of seroma.