Is Modified Radical Mastectomy Adequate for Axillary Lymph Node Dissection? T. NEMOTO, THOMAS L. DAO
The effectiveness of axillary dissection by modified radical mastectomy was assessed by a comparison of the total axillary nodes removed by this operation to that by radical mastectomy. In a series of 121 consecutive radical mastectomies performed during the period of 1964 to 1969, we found that the number of axillary nodes removed ranged from 3 to 63 with a median of 22 and a mean of 23.4 per patient. In a subsequent series of 111 consecutive modified radical mastectomies performed between 1969 and 1973, the total axillary nodes removed ranged from 6 to 77 with a median of 24 and mean of 25.7 nodes in each mastectomy specimen. These results strongly suggest that axillary dissection in modified radical mastectomy is as complete as that in the Halsted radical mastectomy.
T RADITIONALLY, surgical treatment of breast cancer combines local extirpation of the tumor with the removal of the regional lymph nodes en bloc. Any less procedure than this radical approach has often been considered as inadequate for curative treatment. In recent
years, modified radical mastectomy has been employed by many surgeons2-4 as a preferable method of treatment for breast cancer, but opponents say that this procedure cannot effectively remove all the axillary lymph nodes because of the preservation of the pectoral muscles. In a recent report, Hultborn et al.1 claimed that from 1-10 additional nodes were left behind by modified radical mastectomy. In that study, a modified radical mastectomy was first performed by one surgeon, and this was followed by a radical mastectomy performed by another surgeon to remove the pectoral muscles and any lymph nodes that were not removed. These authors therefore Submitted for publication June 9. 1975.
From the Department of Breast Surgery and Breast Cancer Research Unit, Roswell Park Memorial Institute, Buffalo, New York
concluded that a complete axillary dissection was impossible to achieve by modified radical mastectomy. In this paper, we report that modified radical mastectomy is as efficient as the conventional radical mastectomy so far as the completeness of the dissection of the axillary lymph nodes is concerned. Material and Method Modified radical mastectomy has been employed as a standard curative operative procedure for women with breast cancer since 1969, by the Breast Department of Roswell Park Memorial Institute. A total of 109 women underwent modified radical mastectomies between 1969 and 1973 and they are the subject of this analysis. A total of 121 radical mastectomies performed in the same department between 1964 and 1969 will serve as the standard for the comparison. In the modified operation, the entire mammary gland is removed with pectoral fascia. Between the two pectoral muscles, the interpectoral fat pad is dissected from neurovascular supply to the pectoralis major. This fat pad containing lymph nodes is submitted separately for the pathological study. On entering the axilla, the pectoralis minor is transsected from the coracoid process to facilitate the exposure of the axilla. A complete axillary dissection is carried out up to the highest point.
722
Vol. 182
-
MODIFIED RADICAL MASTECTOMY
No. 6
TABLE 4. Skin Recurrences
TABLE 1. Comparison of Total Axillarv Nodes Recovered
Number of Patients Number of Mastectomies Axillary Nodes per Patient
Median Mean Range
Radical
Modified Radical
Mastectomy
Mastectomy
121 121
109 111
22 23.4 3-63
24 25.7 6-77
TABLE 2. Recurrence Free Survival Radical Mastectomy Modified Radical Negative Positive Negative Year nodes nodes nodes 1 50/53(.94)* 52/68(.76) 42/45(.93) 2 48/53(.91) 39/68(.57) 31/33(.93) 3 45/53(.85) 31/68(.46) 24/26(.92) 4 45/53(.85) 27/68(.40) 16/19(.84) 5 44/53(.83) 26/68(.38) 7/10(.70) *Recurrence free survivors/total (%).
Mastectomy Positive nodes
49/64(.77) 38/54(.70) 23/41(.56) 19/33(.58) 13/24(.54)
723
Year 1 2 3 4 5
Radical Mastectomy Positive nodes nodes 1/53 10/68 1/53 5/68 0/53 1/68 0/53 0/68 1/53 0/68
Negative
Modified Radical Mastectomy Positive Negative nodes nodes 2/45 7/64 0/33 1/54 0/26 3/41 0/19 0/33 0/10 1/24
in either group (P = 0.44 for node negative group and P = 0.58 for node positive group). The data also show that composition of patients by age is similar in both groups (Table 3). No difference was noted in the extent of nodal metastasis in those two groups. Table 4 summarizes the data on the frequency of skin recurrences in these two groups of patients. The results show that the incidence of local recurrence is about the same whether the surgical procedure is a Halsted radical or a modified radical mastectomy.
The removed axillary contents are thoroughly Discussion examined by the clearing method described by Pickren.5 All axillary nodes, large and small, can be readily idenThe efficacy of the modified radical mastectomy must tified by this method. At least 4 to 5 sections were made be measured by the curative achievement over a sufflifrom each lymph node for histologic examination. cient period of time. In this series, the duration of followup for most of the patients is still too short to allow Result any definitive conclusion. However, the analysis of In 121 patients treated by radical mastectomy, the recurrence-free survival and the incidence of skin recurnLumber of axillary nodes removed ranged from 3 to 63 rence thus far has failed to show a significant difference with a median of 22 and a mean of 23.4 per patient (Table between the modified radical mastectomy and the Hal1). sted radical mastectomy. Our study clearly shows that In contrast, among the women undergoing modified modified radical mastectomy can remove axillary lymph radical mastectomy, total number of axillary nodes re- nodes as completely as radical mastectomy. moved ranged from 6 to 77 with a median of 24 and a Involvement of pectoral muscles by tumors occurs mean of 25.7 nodes in each mastectomy specimen. The only in advanced breast cancers and the removal of pecdifference in numbers of axillary nodes removed by radi- toral muscles perhaps is not an essential part of a curative cal or modified radical mastectomies was not statistically mastectomy.6 Our clinical experience demonstrates that significant by t-test (P = 0.104). a satisfactory surgical exposure of the axilla and a comFive-year survival followup is available for 121 radical plete axillary dissection can be accomplished without mastectomy patients. Modified radical mastectomy removing the pectoralis major. series is more recent and the evaluation of disease recurrence somewhat less complete. The results, as shown References in Table 2, disclose that the recurrence free survival in 1. Hultoborn, A., Hulten, B., Roos, B., et al.: Effectiveness of Axillary these two groups is comparable. Statistical analysis was Lymph Node Dissection in Modified Radical Mastectomy with done in both node negative and positive groups by BresPreservation of Pectoral Muscles. Ann. Surg. 179:269, 1974. low life table test and no significant difference was found 2. Madden, J. L., Kandalaft, S., and Bourque, R.A.: Modified Radical TABLE 3. Age
anid Nodall Sttitus
Radical Mastectomy Modified Radical Mastectomy 650 >50 0 nodes 1-3 nodes 4+ nodes
41 80 53 34 34
38 71 45 30 34
Mastectomy. Ann. Surg., 175:624, 1972. 3. Nemoto, T.: Survey of Surgeons Regarding the Treatment of Early Breast Cancer. N.Y. State J. Med., 73:1901, 1973. 4. Patey, D. H. and Dyson, W. H.: The Prognosis of Carcinoma of the Breast in Relation to the Type of Operation Performed. Br. J. Cancer, 2, 7, 1948. 5. Pickren, J. W.: Lymph Node Metastasis in Carcinoma of the Female Mammary Gland. Roswell Park Memorial Institute, Bulletin 1:79, 1956. 6. Pickren, J. W., Rube, J., and Aurchincloss, H., Jr.: Modification of Conventional Radical Mastectomy. Cancer, 18:942, 1965.
The effectiveness of axillary dissection by modified radical mastectomy was assessed by a comparison of the total axillary nodes removed by this operation to that by radical mastectomy. In a series of 121 consecutive radical mastectomies performed during the period of 1964 to 1969, we found that the number of axillary nodes removed ranged from 3 to 63 with a median of 22 and a mean of 23.4 per patient. In a subsequent series of 111 consecutive modified radical mastectomies performed between 1969 and 1973, the total axillary nodes removed ranged from 6 to 77 with a median of 24 and mean of 25.7 nodes in each mastectomy specimen. These results strongly suggest that axillary dissection in modified radical mastectomy is as complete as that in the Halsted radical mastectomy.
T RADITIONALLY, surgical treatment of breast cancer combines local extirpation of the tumor with the removal of the regional lymph nodes en bloc. Any less procedure than this radical approach has often been considered as inadequate for curative treatment. In recent
years, modified radical mastectomy has been employed by many surgeons2-4 as a preferable method of treatment for breast cancer, but opponents say that this procedure cannot effectively remove all the axillary lymph nodes because of the preservation of the pectoral muscles. In a recent report, Hultborn et al.1 claimed that from 1-10 additional nodes were left behind by modified radical mastectomy. In that study, a modified radical mastectomy was first performed by one surgeon, and this was followed by a radical mastectomy performed by another surgeon to remove the pectoral muscles and any lymph nodes that were not removed. These authors therefore Submitted for publication June 9. 1975.
From the Department of Breast Surgery and Breast Cancer Research Unit, Roswell Park Memorial Institute, Buffalo, New York
concluded that a complete axillary dissection was impossible to achieve by modified radical mastectomy. In this paper, we report that modified radical mastectomy is as efficient as the conventional radical mastectomy so far as the completeness of the dissection of the axillary lymph nodes is concerned. Material and Method Modified radical mastectomy has been employed as a standard curative operative procedure for women with breast cancer since 1969, by the Breast Department of Roswell Park Memorial Institute. A total of 109 women underwent modified radical mastectomies between 1969 and 1973 and they are the subject of this analysis. A total of 121 radical mastectomies performed in the same department between 1964 and 1969 will serve as the standard for the comparison. In the modified operation, the entire mammary gland is removed with pectoral fascia. Between the two pectoral muscles, the interpectoral fat pad is dissected from neurovascular supply to the pectoralis major. This fat pad containing lymph nodes is submitted separately for the pathological study. On entering the axilla, the pectoralis minor is transsected from the coracoid process to facilitate the exposure of the axilla. A complete axillary dissection is carried out up to the highest point.
722
Vol. 182
-
MODIFIED RADICAL MASTECTOMY
No. 6
TABLE 4. Skin Recurrences
TABLE 1. Comparison of Total Axillarv Nodes Recovered
Number of Patients Number of Mastectomies Axillary Nodes per Patient
Median Mean Range
Radical
Modified Radical
Mastectomy
Mastectomy
121 121
109 111
22 23.4 3-63
24 25.7 6-77
TABLE 2. Recurrence Free Survival Radical Mastectomy Modified Radical Negative Positive Negative Year nodes nodes nodes 1 50/53(.94)* 52/68(.76) 42/45(.93) 2 48/53(.91) 39/68(.57) 31/33(.93) 3 45/53(.85) 31/68(.46) 24/26(.92) 4 45/53(.85) 27/68(.40) 16/19(.84) 5 44/53(.83) 26/68(.38) 7/10(.70) *Recurrence free survivors/total (%).
Mastectomy Positive nodes
49/64(.77) 38/54(.70) 23/41(.56) 19/33(.58) 13/24(.54)
723
Year 1 2 3 4 5
Radical Mastectomy Positive nodes nodes 1/53 10/68 1/53 5/68 0/53 1/68 0/53 0/68 1/53 0/68
Negative
Modified Radical Mastectomy Positive Negative nodes nodes 2/45 7/64 0/33 1/54 0/26 3/41 0/19 0/33 0/10 1/24
in either group (P = 0.44 for node negative group and P = 0.58 for node positive group). The data also show that composition of patients by age is similar in both groups (Table 3). No difference was noted in the extent of nodal metastasis in those two groups. Table 4 summarizes the data on the frequency of skin recurrences in these two groups of patients. The results show that the incidence of local recurrence is about the same whether the surgical procedure is a Halsted radical or a modified radical mastectomy.
The removed axillary contents are thoroughly Discussion examined by the clearing method described by Pickren.5 All axillary nodes, large and small, can be readily idenThe efficacy of the modified radical mastectomy must tified by this method. At least 4 to 5 sections were made be measured by the curative achievement over a sufflifrom each lymph node for histologic examination. cient period of time. In this series, the duration of followup for most of the patients is still too short to allow Result any definitive conclusion. However, the analysis of In 121 patients treated by radical mastectomy, the recurrence-free survival and the incidence of skin recurnLumber of axillary nodes removed ranged from 3 to 63 rence thus far has failed to show a significant difference with a median of 22 and a mean of 23.4 per patient (Table between the modified radical mastectomy and the Hal1). sted radical mastectomy. Our study clearly shows that In contrast, among the women undergoing modified modified radical mastectomy can remove axillary lymph radical mastectomy, total number of axillary nodes re- nodes as completely as radical mastectomy. moved ranged from 6 to 77 with a median of 24 and a Involvement of pectoral muscles by tumors occurs mean of 25.7 nodes in each mastectomy specimen. The only in advanced breast cancers and the removal of pecdifference in numbers of axillary nodes removed by radi- toral muscles perhaps is not an essential part of a curative cal or modified radical mastectomies was not statistically mastectomy.6 Our clinical experience demonstrates that significant by t-test (P = 0.104). a satisfactory surgical exposure of the axilla and a comFive-year survival followup is available for 121 radical plete axillary dissection can be accomplished without mastectomy patients. Modified radical mastectomy removing the pectoralis major. series is more recent and the evaluation of disease recurrence somewhat less complete. The results, as shown References in Table 2, disclose that the recurrence free survival in 1. Hultoborn, A., Hulten, B., Roos, B., et al.: Effectiveness of Axillary these two groups is comparable. Statistical analysis was Lymph Node Dissection in Modified Radical Mastectomy with done in both node negative and positive groups by BresPreservation of Pectoral Muscles. Ann. Surg. 179:269, 1974. low life table test and no significant difference was found 2. Madden, J. L., Kandalaft, S., and Bourque, R.A.: Modified Radical TABLE 3. Age
anid Nodall Sttitus
Radical Mastectomy Modified Radical Mastectomy 650 >50 0 nodes 1-3 nodes 4+ nodes
41 80 53 34 34
38 71 45 30 34
Mastectomy. Ann. Surg., 175:624, 1972. 3. Nemoto, T.: Survey of Surgeons Regarding the Treatment of Early Breast Cancer. N.Y. State J. Med., 73:1901, 1973. 4. Patey, D. H. and Dyson, W. H.: The Prognosis of Carcinoma of the Breast in Relation to the Type of Operation Performed. Br. J. Cancer, 2, 7, 1948. 5. Pickren, J. W.: Lymph Node Metastasis in Carcinoma of the Female Mammary Gland. Roswell Park Memorial Institute, Bulletin 1:79, 1956. 6. Pickren, J. W., Rube, J., and Aurchincloss, H., Jr.: Modification of Conventional Radical Mastectomy. Cancer, 18:942, 1965.
