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The Authors report the incidence of local relapsing in a group of 362 patients who underwent Patey's mastectomy from 1974 to 1985. The overall incidence was 9.6%. The predictive factors of major value were: presence of lymph node metastases, primary tumor size and grading.
The reasons that led to subcutaneous mastectomy in some initial stage breast cancer patients are reported. After removal of the mammary gland, this surgical technique provides for prosthetic reconstruction and should therefore be confined to women with initial stage cancer who for psychological or aesthetic reasons refuse more destructive operations. The technique is described and results obtained discussed, recalling that this type of non-destructive operation will be increasingly in demand in the future but needs preclinical diagnosis of the local disease and its systemic diffusion.
Forty-seven patients were treated for primary operable carcinoma of the breast and had subsequent pregnancies. Their ages varied from 22-45 years, the median age being 35 years. Each patient with negative nodes received only a radical mastectomy, and each patient who had metastases to the lymph nodes in addition received a course of radiation therapy. None of the patients received chemotherapy. Of the 30 patients who did not have metastases to the lymph nodes, 23 survived a 10-year period (77%). Of the 16 patients who manifested metastases to the lymph nodes, nine survived a 10-year period (56%). No detrimental effect of subsequent pregnancy could be demonstrated even among patients with positive axillary nodes. It is generally agreed that most metastases show up within a 3-year period before incurring a pregnancy. In this series there was no differences between those who delayed. Abortion could not be demonstrated to improve the survival rate; in fact, patients who had abortions did worse than those who did not. We conclude, accordingly, that pregnancy need not be avoided or terminated among those patients who are apparently free of recurrences or residual cancer after undergoing treatment for carcinoma of the breast. The decision to become pregnant and the medical conduct of the pregnant female are best determined by the stage of the cancer and how the malignant potential affects prognosis. Careful consultation should be sought with all support personnel, which should include the husband, spiritual leader, psychologist, etc., to discuss the potential for the patient's surviving and supporting the child.(ABSTRACT TRUNCATED AT 250 WORDS)
The demolition-reconstruction sequence in patients suffering from breast cancer may, in selected cases, be reduced to two surgical steps alone without compromising the radical nature of the surgery or the aesthetic result. The technical details of a protocol realisable in a short time that proposes on the one hand classical radical mastectomy (according to Patey or Madden) and on the other reconstruction by tissue expansion are described.
In a double-blind prospective clinical trial 75 consecutive patients undergoing mastectomy were randomly allocated to one of three groups. Twenty-five patients received perioperative anti-thromboembolic therapy with sodium heparin and 25 with calcium heparin. The remaining 25 patients were given anti-embolism stockings but no heparin. The total postoperative blood loss and period of drainage did not differ between the two groups given heparin, but a total of 10 of these 50 patients suffered haemorrhagic complications in the form of severe bruising or haematoma postoperatively. Of the patients given no heparin, none suffered haemorrhagic complications and the blood loss following the first 24-hour postoperative period was significantly less than in the groups given heparin.
After underlining the serious psychological consequences of radical mastectomy for carcinoma and the importance of breast reconstruction for the patient's complete recovery, the paper briefly reviews the main reconstruction techniques employed in restoring breast volume which is essentially achieved by inserting an artificial prosthesis below a myocutaneous skin flap often taken from the great dorsal. Some mention is also made of recently developed alternative techniques.
Breast reconstruction has been playing an increasing role in breast cancer therapy at The University of Texas M. D. Anderson Cancer Center. Our goal is not only to correct cosmetic deformity but also to allow mastectomy patients to wear normal clothing and function as normally as possible in society. Reconstruction is now available to most women who request it. The most commonly used techniques, in our institution, are tissue expansion, use of the latissimus dorsi flap, and use of the transverse rectus abdominis musculocutaneous (TRAM) flap. Each has advantages and disadvantages, with the choice of method depending on individual circumstances. In most cases, successful breast reconstruction can be achieved.
Nipple-areolar necrosis is a known and expected complication in a small percentage of patients undergoing subcutaneous mastectomy, especially with concomitant mastopexy or in smokers. Impending ischemia or congestion of the areola can often be ameliorated by simple maneuvers such as suture release. When full-thickness necrosis occurs, conservative management with essential debridement, dressings, and careful wound hygiene alone will often yield a surprisingly good result, requiring little or no revisional surgery.
After pointing out the need for reconstruction of the nipple-areola complex and the restoration of symmetry between the two breasts after radical mastectomy for cancer, the paper briefly examines the techniques currently available for the achievement of these "finishing touches" that usually take longer then the primary and fundamental breast reconstruction.
A case of nipple recurrence presenting 17 years after subcutaneous mastectomy for carcinoma is presented. The tumour had become less well differentiated but did not appear to have metastasized. This case highlights the problems of follow-up that will accompany the use of treatments that preserve part of the breast.
After biopsy confirmation of breast carcinoma, women who were scheduled to undergo a modified radical mastectomy had demographic data collected, goniometric measurements of shoulder flexion and abduction, and functional evaluation of the ipsilateral shoulder performed, and upper extremity circumferential measurements at five levels determined. Patients were then randomly assigned either to a group that received immediate postoperative physical therapy or to one that did not. Results represent the combination of data from a pilot study and this subsequent study following appropriate statistical analysis. Sixty-four women in the treatment group showed a statistically significant increase in shoulder range of motion in both abduction and flexion as compared to 51 women who received no physical therapy. The treated group also had fewer problems with five of the six upper extremity functional tasks that were assessed. There were no significant differences between the groups for length of hospital stay, postoperative complications, or upper extremity edema. The authors conclude that early physical therapy intervention makes a significant contribution to return to normal function without increasing the incidence of postoperative complications or prolonging hospital stay.
Prophylactic procedures to prevent disease in women at high risk for breast cancer should be considered only when the benefits of prophylaxis outweigh its costs. The rational prophylactic use of mastectomy in these circumstances must await answers to several questions. First, accurate estimates of the true risk associated with these lesions must be obtained, as current estimates are imprecise and potentially biased. Second, large ongoing trials of breast cancer screening and treatment may provide effective methods of distinguishing those women at exceptionally high risk in whom such procedures may be warranted. Finally, the question of conservative surgery as an acceptable treatment for breast cancer must be settled; otherwise, the prophylactic procedure may be more invasive and disfiguring than the treatment of the disease it seeks to prevent.
Three cases of Paget's disease of the nipple are presented occurring in women treated for carcinoma of the breast with subcutaneous mastectomy and primary silicone reconstruction. These cases represent a 0.5% incidence of this problem in 584 women similarly treated over fourteen years. A suggested method of management is outlined.
Immediate reconstruction of the breast has become an integral part of treatment of breast cancer during the last years. Several studies have reported that breast cancer patients who undergo immediate reconstruction have the same survival rates as unreconstructed patients and that reconstruction does not adversely affect the natural course of breast cancer. Since 1983 immediate reconstruction has been performed in 87 patients at our institution. It has been demonstrated that the psychological trauma has been dramatically reduced and that many patients will accept mastectomy almost with a sense of relief, when immediate reconstruction can be offered.
Arm volumes of 360 patients with breast cancer were determined by a new optoelectronic technique. About 42% developed swelling of the arm after modified radical mastectomy which varied from mild (edema-volume 150-400 ml), moderate (400-800 ml), to severe (more than 800 ml) lymphatic edema. Lymphscintigraphy and computer tomography of the arms was also studied in different grades of lymphatic edema. Two years after operation and telecobalt-irradiation, one half of the patients without arm edema showed marked signs of a decreased capacity of lymphatic transport. In patients with severe lymphatic edema, the dynamic as well as the static evaluation of the lymphscintigrams revealed delayed transport, lack of radioisotope accumulation in the axillary region and notable congestion in the upper arm and forearm. Computerized tomography displayed a shift of fluid volume in the epifascial and subfascial tissue compartments and detected progressive structural changes in the soft tissue. Moderate edema not only increased the epifascial but also the subfascial compartments. In severe postmastectomy arm lymphedema, however, expansion of the epifascial space was paradoxically sometimes associated with a decrease in the subfascial compartment.
Necessity of breast reconstruction after mastectomy has been increasing in recent years. For better reconstruction, we preserve a nipple-areolar complex (NAC) by transplanting it temporarily onto the lower abdominal wall and retransplant it to the restored breast mound in a subsequent operation. Indications for NAC preservation are as follows: (1) by palpation the tumor is found to be smaller than 3.0cm in diameter without apparent regional and distant metastasis, (2) neither abnormal nipple discharge nor nipple retraction is observed, (3) tumor is remote more than 3.0cm from the areolar margin, (4) no abnormal shadows are seen below the nipple and areola in the mammogram, (5) no microscopic extension of the cancerous cells is detected beneath the resected NAC. We have performed 18 transplantations using this procedure with good cosmetic results. There were no recurrent cases due to NAC preservation. It is concluded that this technique for preserving the NAC by autotransplantation is easy to perform and useful for breast reconstruction because of low risk of recurrence and better cosmetic results.
The approach to subcutaneous mastectomy is presented, with emphasis on individualization of surgical technique. The operation is based on breast size as well as nipple-areolar complex location. Reconstructive alternatives include a mammary prosthesis, tissue expander, and autologous tissue.
Over the last few decades the psychosocial problems following mastectomy have become well recognized and surgical treatment for breast cancer has become less mutilating. For women with small cancers a number of equally effective treatments are available and involving the patient in the choice of treatment appears to reduce morbidity.