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The possibilities of treatment and considerations with regard to time and location of correctly organized treatment of post-mastectomy lymphatic edemas are reviewed. Dangers and misunderstandings are pointed out.
Adjuvant therapy after total mastectomy and axillary clearance in postmenopausal women with breast cancer and axillary node metastasis was assessed; chemo-endocrine therapy (cyclophosphamide, methotrexate, fluorouracil, prednisone, and tamoxifen; CMFp + T) was compared with endocrine therapy (prednisone and tamoxifen; p + T), and with no adjuvant treatment in 463 patients aged less than or equal to 65 years. Endocrine therapy was compared with no adjuvant therapy in 320 patients aged 66-80 years. At median follow-up of 36 months, disease-free survival was significantly longer in CMFp + T patients than in p + T or control patients; p + T also significantly increased disease-free survival. There were no significant differences in overall survival between the randomised groups. In analyses of patterns of first failure, chemo-endocrine therapy reduced local, regional, and distant relapses, whereas endocrine therapy reduced local and regional recurrences only.
The authors relate the observation of a 42 years old woman with antecedents of mastodynia from several years and numerous operations for fibroadenoma. During the follow-up a sub-cutaneous mastectomy is realized owing to the discovery of clustered calcifications on mammographic study, which reveals a bilateral lobular in situ carcinoma. They talk over surgical procedures in this form of carcinoma.
A cutaneous angiosarcoma developed in a mastectomy scar four years after post operative irradiation. Clinical and histological data are presented. The authors believe that radiotherapy was determinant in the genesis of this rare type of tumour.
Controlling seroma formation by the use of closed suction drainage and flap attachment to the chest wall lowered the incidence of seroma formation after mastectomy and axillary dissection below that in other reports. The presumed advantage would be fewer seroma-associated complications, such as infection, impaired shoulder motion and lymphedema.
Interest in breast-conserving treatment of mammary carcinoma has increased tremendously in recent years, as breast cancer is being detected at an earlier stage than previously, especially in regions where screening is practised. In the present report it is argued that the breast-conserving procedure is still an experimental method which should be performed only within the framework of clinically controlled studies. An uncritical use of the method could render its improvement difficult and prevent an accurate assessment of its possibilities for cure. A short description is given of a recently started Danish multicentric study in which the result of breast-conserving therapy, randomly, is weighed against the result of mastectomy. The preliminary experience of the method obtained in the Odense Centre is submitted. Since 1979 a total of 44 patients have had breast-conserving therapy for mammary carcinoma. Their median age was 47 years, range 30-69 years. About 10% had stage II cancer. So far, local recurrences in the breast have not been observed within the follow-up period, 5-48 months, but one case of axillary recurrence. Metastatic disease has not been demonstrated.
Breast cancer is the leading form of cancer and a common chronic illness in women. The prevention, diagnosis and management of the disease involves a need for information, support and ongoing physical care which can best be coordinated by a primary care provider. This article reviews current surgical and adjuvant therapies and their side effects. The role of the nurse practitioner in monitoring and meeting mastectomy patients' needs during and after treatment is also discussed.
The Authors review the indications for mammary reconstruction following mastectomy, and add a new series of procedures after considering the oldest ones. They point out the possible post operative complications and evaluate the result of a reconstruction which can prove useful both cosmetically and psychologically.
In the medical literature we found published four cases of irradiation induced chondrosarcoma of the scapula. We present a fifth one and report about a 63 year old female patient. She underwent a left radical mastectomy for breast cancer. Pre- and postoperatively a local irradiation of 140,00 Gy was applied. After a disease free interval of 18 years a large tumor in the left scapula was histologically confirmed as a chondrosarcoma. All criterias of Cahan for an irradiation induced sarcoma are fulfilled.
The accurate determination of sex steroid receptors at the time of mastectomy (MX) for breast carcinoma is important for the determination of subsequent therapy of patients who develop metastases in inaccessible sites. The estrogen (E) and progesterone (P) receptor (R) proteins are heat labile, and measured levels may be vulnerable to alterations once the tumor is devascularized. To evaluate potential differences in ER and PR determinations in tumor tissue acquired at biopsy as compared with tumor from the MX specimen, quantitative analyses of ER (21 patients) and PR (17 patients) were performed on dual samples acquired from the initial biopsy (BX) and the subsequent MX specimen. Receptor concentrations were determined both by sucrose density gradient analysis and titration analysis, and results were expressed as fmol/mg cytosol protein. ER values were classified as receptor-rich (greater than 10 fmol/mg), intermediate (3 to 10 fmol/mg), or receptor-poor (less than 3 fmol/mg); PR values greater than 3 fmol/mg were considered positive. ER BX values were found to be rich or intermediate in 18 patients. When compared with BX values, MX ER values were quantitatively unchanged in 11 patients, lower (MX less than BX) in four patients, and higher in three patients (MX greater than BX). In no patient was the BX ER rich or intermediate and the concomitant MX ER poor. In two patients the PR value was "positive" at BX but "negative" at MX. Accordingly, malignant tissue from a pre-MX biopsy specimen is preferred for receptor analysis although it is apparent that tumor tissue from a properly handled MX specimen is satisfactory for the determination of ER status for clinical purposes.
In an attempt to reduce oedema of the arm after mastectomy, patients were provided with an elastic sleeve which was worn for a period of between 1 week and up to 6 months. A statistically significant mean relative decrease of 17% in the volume of oedema was achieved. Subsequent treatment by intermittent pneumatic compression for 10 days produced a further significant mean relative decrease of 18%. When the sleeve was worn for 6 months after this treatment there was no significant increase in arm volume--that is, no relapse.
Immediate reconstruction offers an adjunct to the standard modified radical mastectomy for carcinoma of the breast in highly selected patients. It provides early reestablishment of breast form with a low complication rate and high patient satisfaction. There has been no evidence to date that immediate reconstruction affects the natural course of the primary breast cancer.
The American Cancer Society estimates that more than a hundred thousand American women develop breast cancer every year. Mastectomy is the treatment of choice. While this surgery performs a gratifying service by saving a woman's life, her appreciation is muted by the price she must pay--the loss of a breast and permanent disfigurement. Within the value system of American culture, that price is a considerable one. This paper will attempt to interpret that cost.
Breast reconstruction after mastectomy is discussed with emphasis on present surgical techniques and results achieved. The deformity is defined and the goals outlined. Contra-indications, indications, evaluation of the patient and proper choice of reconstructive procedures and implantable materials are reviewed as well as complications and restrictions. Selective illustrations demonstrate some of the clinical experience of patients treated at Memorial-Sloan Kettering Cancer Center.
The mutilating effect of surgery for cancer of the breast has left many women needful of reconstruction to restore the body contour and self-image. Reconstruction involves replacement of the three elements that have been lost: breast mass, skin, muscle and nipple-areolar complex. Methods for accomplishing this have been devised and are in common use. Because of the increased predisposition to malignancy in the remaining breast and the difficulty in achieving symmetry in both breasts, the remaining breast must be considered, with subcutaneous mastectomy being the most appropriate course in most cases. Patient acceptance has been excellent.
The correlation of staging criteria for mammary carcinoma with the curability of primary and recurrent local and regional lesions was assessed by follow-up after 1,259 consecutive radical mastectomies performed in women under age 70 between 1927 and 1978. Using a staging scheme revised in the light of our experience, the incidence of recurrence by 20 years was 34% +/- 2.7% for pathological stage I, 65% +/- 2.6% for stage II, and 83% +/- 2.5% for stage III. Recurrence after 20 years was observed in one of 178 patients. After treatment of local recurrence, three of 51 patients survived 20 years. By restriction of entry into clinical or pathological stages I and II, currently employed revisions of staging criteria appear to increase survival in all stages, while placing patients with possibly curable lesions in stages III and IV.
In an attempt to reduce the oedema developing after mastectomy in 39 breast cancer patients, a number of physiotherapy techniques were applied in various combinations over 6 months. The techniques included massage, isometric exercises and an elastic sleeve. In the first week of the daily treatment a decrease of 11-13% in the volume of oedema was recorded, but in the next 3 weeks the benefit achieved declined sharply. To maintain the reduction in volume of the swollen arm, an elastic sleeve was applied. During the 4 weeks that the sleeve was worn there was no significant increase in volume. There was a correlation between an objective reduction in the volume of the arm and the patient's rating of the improvement.
The controversy about the best treatment for primary breast cancer will be settled only when properly designed clinical trials are completed. Most surgeons would rather await the results of such trials than participate in them. Prominent among the reasons for this view is the belief that an adequate cancer operation can seldom be performed with appropriate cosmetic preservation of the breast and, therefore, the trial of an unproven operation is not justified, because nothing can be gained. The poor cosmetic result is often owing to lack of experience with segmental mastectomy. From experience with 400 patients in the National Surgical Adjuvant Breast Project (NSABP) protocol has emerged an appreciation of the technical points that permit adequately wide local excision with minimal cosmetic loss. The results should stimulate both patients and surgeons to consider appropriate clinical trials for primary breast cancer surgery. This paper considers the causes of cosmetic failure and suggests the means of overcoming them.