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PRIMARY TREATMENT OF BREAST CANCER GEORGE CRILE, JR., M.D. Cleveland Hospital Department of General Surgery Cleveland, Ohio

Ishall not discuss the role of the conventional Halsted type of radical mastectomy in the treatment of breast cancer because there is now widespread agreement that this radical operation is obsolete and that there is no indication for its use.* The modified radical mastectomy (or simple mastectomy with low and central axillary dissection) has replaced the radical operation as the most frequently used operation. This has been a boon to women who, when the operation is performed through a transverse incision and with thick skin flaps, no longer have deformities visible in ordinary clothes and no longer have uncomfortable chest walls. Moreover, if the operation is properly done and radiation is not given, they rarely have postoperative area edema. Although the modified radical mastectomy is the simplest and most effective way to treat breast cancer, there remain a large number of women who simply do not want to lose a breast. This article discusses alternatives to mastectomy and the possibilities of successful reconstruction of the breast after mastectomy. PARTIAL MASTECrOMY For the past 24 years we have used partial mastectomy (segmental resection) to treat selected patients with small cancers located in the periphery of the breast. If the cancers were in the outer quadrant, the axilla was explored and when any node seemed involved they were removed. If no involvement appeared, the lower nodes were removed for histological study. In about 15% of the cases, radiation was given. If the tumor appeared multicentric (10% of the cases) mastectomy was advised. *A poll of New Jersey surgeons in 1971 showed that 83% of the surgeons favored radical mastectomy and only 15% modified radical. In 1977 a similar poll showed only 37% doing radical and 60% favoring modified radical mastectomy. A poll in Ohio in 1970 showed only 63% were doing radical mastectomy, and it is estimated that today the proportion has dropped to 15%.17,18

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TABLE I. CLEVELAND CLINIC 1957 THROUGH 1970 Material and staging (Manchester) 894 previously untreated breast cancers 7 10 operable, stages I and II 175 inoperable, stages III and IV 9 inoperable, stages I and II (infirmity)

79% 20% 1%

TABLE II. CLEVELAND CLINIC 1957 THROUGH 1970 Treatment of operable stages I and II Radical mastectomy Modified radical Simple mastectomy Partial mastectomy Cobalt (adjuvant)

4/710 = 347/7 10 = 27 1/7 10 = 88/7 10 = 138/7 10 =

0.5%S 49.0% 38.0% 12.0% 19.0%

Until 1971 only 12% of the patients with operable breast cancer were treated by partial mastectomy. Most of the rest underwent modified radical mastectomy, usually with radiation or with radiation only to the internal mammary chain. The results of this treatment are summarized in the tables. In spite of the fact that only 0.5% of the patients were treated by radical mastectomy, their survival rate at both five and 10 years was a little higher than that reported after radical mastectomy by the Cancer Registry and the National Surgical Adjuvant Breast Project.1 Since 1970 we have performed more partial mastectomies-35% of the 213 patients operated on in 1971 and 1972. Although these 74 patients included a number of Stage II cancers with extensive axillary involvement treated palliatively by partial mastectomy and radiation, and a number of old or debilitated patients who were not considered to be fit for mastectomy, the five year survival rate was 76%. Twelve patients died of cancer and six of other causes. LOCAL EXCISION AND RADIATION

We have followed with interest reports from Dr. Pierquin of Paris and Drs. Levene and Hellman in Boston who have excised cancers of the breast and then inserted hollow guide needles into the involved area. Into these are then inserted seeds of radioactive iridium set in plastic and spaced

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TABLE III. FIVE-YEAR SURVIVAL 1957-1970 885 Patients treated Crude-all stages Stages I and II (operable) Stages III and IV (inoperable) Lost, (counted as dead) Local recurrence

518/885 = 59% 502/710 = 71% 16/175 = 9% 8/885 = 1% 44/710 = 6%

TABLE IV. 10-Y EAR SURVIVAL 1957-1965

Stages I and II (operable) Lost before 10 years If all lost lived Local recurrence

208/453 = 46% 14/453 = 3% 222/453 = 49% 30/453 = 7%

a centimeter apart. These give a uniform field of radiation and provide a booster in the area most apt to have microscopic deposits of cancer. This is supplemented by high voltage radiation therapy specially designed, through the use of wedges and computerized dosimetry, to give uniform radiation throughout the breast. If the use of the bolus is avoided, the skin reaction tends to be minimal .34 At the Cleveland Clinic we have treated 50 patients in this way, but it is too early to assess the results. All that we know is that the morbidity is low, the treatment is not too uncomfortable, and that the patients to date are grateful for having had their breasts preserved. The incidence of local recurrence in the hands of others has been low. This form of treatment seems to be particularly helpful in patients with small cancers located so near the nipple that they could not be excised without sacrificing the nipple. LOCAL RECURRENCE

In 1971 and 1972 the incidence of local recurrence or new cancers five years after partial mastectomy, with or without conventional external irradiation and with or without axillary dissection, was 13%. Six of the 11 patients who had local recurrences were living and five had died of cancer. These results differ from local recurrence after total mastectomy and axillary dissection because at least two of the recurrences appeared to be new tumors and all could be treated by mastectomy or axillary dissection and the recurrence controlled. Thus, although a local recurrence after total

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mastectomy usually signifies disseminated disease, a recurrence after partial mastectomy may still be localized and curable.5 THE ROLE OF NODES

Many studies have shown that it makes no difference in terms of survival whether axillary nodes are removed or irradiated. And if nodes are not palpably involved it makes no difference whether they are removed at the time of mastectomy or whether axillary dissection is delayed until nodes become palpable and are then removed. Our observations show the same thing. Cases in which the surgeon could feel no involvement of nodes were divided into two groups, 28 in one and 24 in the other. In one, the surgeon removed the nodes at the time of the mastectomy and the pathologist found occult cancer in the nodes. In the other, patients who had occult involvement that appeared later were then operated on. The survival of the latter group was slightly (but not significantly) better than those who had axillary dissection at the time of mastectomy. 1 RECONSTRUCTION OF THE BREAST AFTER MASTECrOMY

Although most patients with small tumors can be treated by partial mastectomy or by a combination of lumpectomy, iridium implant, and irradiation, there remains a group whose tumors are large and who would have more chance of local recurrence were modified radical mastectomy done. If the patient does not wish to run that risk and yet does not want to be deformed by mastectomy, she should consider having her breast rebuilt after mastectomy. She should make this desire clear to the surgeon so he will make a transverse incision and cut the skin flaps loose and thick. Moreover, if the tumor does not involve the nipple, he can remove the nipple as a skin graft and bank it on the abdomen or thigh until a prosthesis can restore the contour of the breast. The nipple is then grafted back in place. RADIATION ALONE AS INITIAL TREATMENT

Since there are now so many choices of surgery or combinations of surgery and irradiation for the treatment of breast cancer and because all of these treatments offer comparable rates of survival in properly selected patients,6'5 it is essential for the surgeon to explain the pros and cons of each method. The final decision, of course, is the patient's. Usually, she

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makes a reasonable choice. Even when the recommended operation is steadfastly refused, excellent results can be obtained by irradiation. We have seen several patients who refused the mastectomy that we urged and were treated instead by irradiation. Some of these have done well. This experience is confirmed by the Curie Foundation in Paris, whose report of 514 patients treated primarily by irradiation and followed for five, 10, or more years appeared in 1978.16 Patients with apparently localized tumors 3 cm. or less in diameter were treated by lumpectomy and irradiation. Those with larger tumors or with apparent involvement of nodes were treated by irradiation alone. If the tumors did not respond satisfactorily, mastectomy was done later. Two thirds of the patients still had their breasts, and 51% were alive at 10 years, the same proportion as after radical surgery. (At the Curie Institute, where only one third of the patients were treated by mastectomy, the 10-year survival rates for each stage were 1% higher than after radical mastectomies at the Memorial Hospital, New York.16) Similar results have been reported in this country by Prosnitz and his associates. 15 SUMMARY

In view of the startling advances in radiotherapeutic technics, we may be entering a new era in the treatment of breast cancer. For more than a century radical mastectomy was the standard treatment for breast cancer. Now the modified radical is widely accepted. If results in the centers in this country that use combinations of interstitial and external radiation prove to be as acceptable as those reported from centers in Europe and England, women will soon be able to choose between the ease and comfort of a modified radical mastectomy and the more complicated process of relying chiefly on radiotherapy. In any event, it is becoming more and more apparent that in most patients the breast can be saved without jeopardizing the chances of survival. REFERENCES 1. Crile, G., Jr.: Results of conservative treatment of breast cancer at 10 and 15 years. Ann. Surg. 181:26-30, 1975. 2. Pierquin, B., Baillet, F., and Wilson, J. F.: Radiation therapy in the management of primary breast cancer. Am. J. Roentgenol. 127:645-48, 1976. 3. Levene, M., Harris, J., and Hellman,

S.: Primary radiation therapy for operable carcinoma of the breast. Surg. Clin. N. Am. 58:767-76, 1978. 4. Levene, M., Harris, J., and Hellman, S.: Treatment of cancer of the breast by radiation therapy. Cancer 39:2840-45, 1977. 5. Calle, R., et al.: Conservative manageBull. N.Y. Acad. Med.

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7.

8. 9.

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ment of operable breast cancer. Cancer 12. Wise, L., Mason, A., and Ackerman, L.: Local excision and irradiation: An 42:2045-53, 1978. alternative method for the treatment of Forrest, A. et al.: The Cardiff-St. early mammary cancer. Ann. Surg. Mary's Trial. Br. J. Surg. 6/:766-69, /74:393-401, 1971. 1974. Kaae, S. and Johansen, H.: Simple ver- 13. Peters, V.: Cutting the gordian knot in early breast cancer. Ann. R. Coll. Phlys. sus radical mastectomy for primary Surg. Canad. 8:186-92, 1975.. breast cancer. In: Prognostic Factors in Breast Cancer: Tenoi'us Symposium, 14. Hayward, J.: Conservative surgery in the treatment of early breast cancer. Br. J. Ist, Cardiff, Wales, 1967, Forrest, A. P. Surg. 6/:770-71, 1974. M. and Kunkler, P. B., editors. Balti15. Prosnitz, L. et al.: Radiation therapy as more, Williams & Wilkins, 1968. initial treatment for early stage cancer of' Brinkley, D. and Haybittle, J.: Treatthe breast without mastectomy. Cancer ment of stage-II carcinoma of the female 39:917-23, 1977. breast. Lancet 2:1086-87, 1971. Bum, J.: Early breast cancer: The Ham- 16. Calle, R., Pilleron, J. P., Schlienger, P., and Vilcoq, J. R.: Conservative mersmith trial. Br. J. Surg. 61:762-65, management of operable breast cancer. 1974. Cancer 42:2045-53, 1978. Hamilton, T., Langlands, A., and Prescott, R.: The treatment of operable 17. Lazaro, E. J., Rush, Jr., B. F., and Swaminathan, A. P.: Changing attitudes cancer of the breast. A clinical trial in the in the management of cancer of the South-East Region of Scotland. Br. J. breast. Surgery 84:441-46, 1978. Surg. 61:758-61, 1974. Murray, J.: Cancer research campaign 18. Herman, R.: Discussion. Surgery 84: 446, 1978. breast study. Br. J. Surg. 6/:772-74, 1974.

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492 PRIMARY TREATMENT OF BREAST CANCER GEORGE CRILE, JR., M.D. Cleveland Hospital Department of General Surgery Cleveland, Ohio Ishall not discuss t...
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