A Comparison of Modified Radical Mastectorry to Radical Mastectomy in the Treatment of Operable Breast Cancer R. ROBINSON BAKER, ALBERT C. W. MONTAGUE, J. NORRIS CHILDS
From the Departments of Surgery and Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
This study compares the results of modified radical mastectomy (144 cases) to radical mastectomy (188 cases) in the treatment of operable breast cancer. Two hundred five patients had Stage I breast cancer, 60 had Stage II disease and 67 had Stage III disease (TNM System). There was no statistically significant difference in five year survival when the results of a radical mastectomy were compared to a modified radical mastectomy at any stage of disease. There was no statistically significant difference in the incidence of local recurrence in patients with Stage I and Stage II disease when the results of a radical mastectomy were compared to modified radical mastectomy. Those patients with Stage III disease who were treated by a modified radical mastectomy had a statistically significant higher incidence of local recurrence (chest wall and axilla) in comparison to patients treated by radical mastectomy. We have concluded that a modified radical mastectomy is the treatment of choice in patients with Stage I and Stage II diseases. In patients with Stage III disease, a radical mastectomy provides a better chance of local control of the disease but offers no increased chance of survival.
This retrospective study was undertaken to examine the relative efficacy of a modified radical mastectomy versus a radical mastectomy in the treatment of breast cancer. It represents an analysis of 332 patients who were treated for breast cancer at The Johns Hopkins Hospital between the years 1969 and 1972. One hundred forty-four patients were treated by modified radical mastectomy, and 188 had a radical mastectomy. These procedures were performed by 25 staff and resident surgeons. The selection of one operative procedure or the other was not related to the stage of the disease, but rather to the conviction of the surgeon as to optimal means of therapy.
A LTHOUGH THE TREATMENT of breast cancer
Clinical Material
remains controversial, the trend among surgeons is toward more conservative procedures. Albert et al.1, Lazaro et al.4 and Neomoto6 report a significant increase in recent years in the use of modified radical mastectomy in the treatment of breast cancer and a significant decrease in the use of radical mastectomy. This decline in the number of radical mastectomies has occurred because of an increasing awareness that failures in the treatment of breast cancer are usually related to the presence of occult systemic metastases rather than inadequate local treatment and also because of a conviction among some surgeons, at least, that an adequate axillary lymph node dissection can be completed without excision of the pectoralis major muscle.
Age Of the 144 patients undergoing modified radical mastectomy, 18% were under 45 years of age, 42% of the patients ranged in age from 45 to 55 years and 40% of the patients were 56 years or older. Twentyone per cent of the 188 patients treated by radical mastectomy were less than 45 years of age, 32% ranged in age from 45 to 55 years and 47% were 56 years of age or older.
Presented at the Annual Meeting of the Southern Surgical Association, December 4-6, 1978, Hot Springs, Virginia. Reprint requests: R. Robinson Baker, M.D., Department of
Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland. Submitted for publication: December 7, 1978.
Menopausal Status Forty-seven per cent of the patients treated by modified radical mastectomy were premenopausal or perimenopausal (within 2 years of menopause), and 53% of the patients were 2 or more years postmenopausal. In the group of patients treated by radical mastectomy, 44% of these patients were premenopausal or perimenopausal, and 56% were postmenopausal.
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TABLE 1. Histologic Types of Tumors Correlated with Operative Procedures
Modified Radical Mastectomy
Ann. Surg. * May 1979
involved and in one case the exact number of nodes not determined in the surgical pathology laboratory. Forty-six of the 114 (40%) patients treated by radical mastectomy had histologic evidence of axillary lymph node metastases. Twenty-two of these patients had one to three nodes involved, and 11 had four or more nodes involved. In 13 patients the exact number of nodes containing metastatic tumor was not determined in the surgical pathology laboratory. Sixty-three per cent of the patients treated by modified radical mastectomy and 62% of the patients treated by radical mastectomy with clinical Stage II and Stage III disease had histologic evidence of axillary lymph node metastases. Of the 33 patients undergoing a modified radical mastectomy, 11 had one to three nodes containing metastatic tumor and 17 had four or more nodes involved. In five cases, the exact number of nodes was not determined. Eleven of the 46 patients undergoing radical mastectomy had one to three nodes involved, and 14 patients had four or more nodes containing metastatic breast cancer. Although all of the remaining 21 patients had axillary lymph node metastases, the exact number could not was
Radical Mastectomy
Histologic Types
No.
%
No.
%
Infiltrating duct CA Infiltrating lobular CA Lobular CA-in situ Medullary CA Tubular CA Papillary CA Colloid CA
114 13 2 5 3 4 3
78 11
150 20 0 7 2 1 8
79 10
Clinical Stage Preoperative staging was accomplished by the TNM system. Two hundred five patients had Stage I disease; 91 of these patients were treated by modified radical mastectomy and 114 by radical mastectomy. Sixty patients had Stage II disease; 22 of these patients were treated by modified radical mastectomy and 38 by radical mastectomy. Sixty-seven patients had Stage III disease; 31 ofthese patients were treated by modified radical mastectomy and 36 by radical mastectomy.
Operative Procedures In all patients undergoing a modified radical mastectomy, the pectoralis major muscle was preserved, the pectoralis minor muscle was either divided or retracted to expose the upper portion of the axilla. In some cases a complete axillary dissection was performed; in others the intrapectoral group of lymph nodes (Rotter's nodes) were not excised and the dissection did not extend beyond the lateral border of the pectoralis minor muscle. The majority of modified radical mastectomies were performed through a transverse incision. The radical mastectomy was a more constant procedure, similar to that described by Halsted; this operation was performed through a vertical incision in the majority of cases. The amount of skin excised and type of closure, either with or without a skin graft, were not included in the analysis of either group of patients.
Histology The histologic types of the tumors removed correlated with the operative piocedures are reviewed in Table 1. Of the 91 patients with Stage I disease treated by modified radical mastectomy, 26 (28%) had histologic evidence of axillary node metastases. Twenty of these patients had one to three nodes containing metastatic tumor, five had four or more nodes
be determined.
Adjuvant Therapy None of the patients in this series received adjuvant chemotherapy. Postoperative irradiation was employed as a surgical adjuvant in a small percentage of patients with histologic evidence of axillary lymph node metastases. Seventeen patients treated by modified radical mastectomy received postoperative irradiation directed to the chest wall and the lymph nodes in the axilla, supraclavicular fossa and internal mammary chain (Stage I disease, seven patients; Stage II, four; Stage III, six). Seven patients treated by radical mastectomy received postoperative irradiation (Stage I, three; Stage III, four). Results Twenty-one of the 144 patients treated by modified radical mastectomy were lost to follow-up, six within the first 24 months. Thirty-three of the 188 patients undergoing radical mastectomy were lost to follow-up, four within the first 24 months. These patients who were lost to follow-up were included in the analysis of 5-year survival by a life table method. The 5-year survivorship calculated by life table methods10 of the patients treated by modified radical mastectomy compared to radical mastectomy according to stage of disease are presented in Figures 1, 2 and 3. The test of significance was made by a log rank test (Mantel-Haenzel x2).10 There was no statistically
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FIG. 1. Survival rate of patients with Stage I breast cancer paring a modified radical mastectomy to radical mastectomy.
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significant difference in the five year survival between those patients treated by modified radical mastectomy versus those treated by radical mastectomy in any clinical stage of disease. A local recurrence was defined as a recurrence on the ipsilateral chest wall between the clavicle superiorly, the costal margin inferiorly, the midportion of the sternum medially and the latissimus dorsi muscle laterally. Any other type of recurrence was classified as distant metastasis. The incidence of local recurrence correlated with the stage of disease and operative procedure is presented in Table 2. There was no statistically significant difference in the incidence of local recurrence when the results of modified radical mastectomy were compared with those of radical mastectomy in patients with Stage I and Stage II disease. A statistically significant greater incidence of local recurrence was present in patients with Stage III disease who were treated by modified radical mastectomy compared to radical mastectomy. The sites of local recurrence correlated with the stage of disease and type of operative procedure are presented in Table 3. Chest wall recurrence was defined as either recurrence in the skin flaps or within the soft tissues of the chest wall. The majority of local recurrences either on the chest wall or within the axilla in patients treated by modified radical mastectomy occurred in those patients with histologic evidence of lymph node metastases in the axillary contents removed at the operation. This included six of 12 patients with Stage I disease, two of two patients
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FIG. 2. Survival rate of patients with Stage II breast cancer paring a modified radical mastectomy to radical mastectomy.
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with Stage II disease and ten of 12 patients with Stage III disease (average number of nodes involved was eight). Four of 17 patients with a local recurrence who were treated by radical mastectomy had histologic evidence of axillary lymph node metastases in the operative specimen. Three patients with a local recurrence on the chest wall were treated by irradiation and survived for five years or more without further evidence of disease.
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BAKER, MONTAGUE AND CHILDS
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TABLE 2. Incidence of Local Recurrence Correlated wvith Stage of Disease and Type of Operative Procedure
Operation
No. Patients
Modified radical Radical
91 114
Modified radical Radical
22 38
Modified radical Radical
31 36
No. with Local Recurrence
Statistical Significance
Stage I 12 10
xI = 1.03 (n.s.)
2 4
x2 = .039 (n.s.)
Stage II
Stage III 12 3
x2 = 8.84 p = .0088
All of these patients were initially treated by modified radical mastectomy, and none of these patients had evidence of axillary lymph node metastases. In the small. group of patients treated by postoperative irradiation there was no significant effect on survival or the incidence of local recurrence. Five of the 17 patients treated by modified radical mastectomy and one of seven patients treated by a radical mastectomy subsequently developed a local recurrence after postoperative irradiation. Discussion Although the number of modified radical mastectomies is increasing in comparison to radical mastectomies to treat patients with breast cancer, the relative effectiveness of a modified radical mastectomy compared to a radical mastectomy has never been evaluated in a prospective clinical trial. This retrospective study compares a similar group of patients as regards age, menopausal status and histologic type of resected tumor. The incidence of axillary lymph node metastases in patients with Stage I disease is lower in patients treated by modified radical mastectomy compared to radical mastectomy. Although this difference is not statistically significant (x2 = 3.66), it is close to significance and indicates that a slightly more favorable group of patients were treated by modified radical mastectomy compared to radical mastectomy. Patients treated by modified radical mastectomy also had fewer nodes involved with metastatic tumor, another more favorable prognostic sign. The presence of axillary lymph node metastases and the number of axillary lymph nodes involved can only be determined, however, by pathologic staging and cannot be employed to compare results based on clinical staging. If the patient had clinical Stage I or Stage II disease, this study demonstrates that a modified radical mastectomy is as effective as a radical mastectomy in the control
Ann. Surg. * May 1979
of local disease. Similar results have been reported by Delarue et al.2, Neomoto and Dao7 and Papatestas and Lesnick.8 The majority of local recurrences encountered in patients with Stage I and Stage II disease occurred either in the skin flaps or on the chest wall rather than in the axillary lymph nodes. Seventy-nine per cent of patients with a local recurrence subsequently developed evidence of distant metastases
within a relatively short period of time, indicating that in the majority of cases local recurrences were the first manifestation of systemic disease and probably occurred as a result of circulating tumor cells implanting in the skin flaps or muscles of the chest wall. This retrospective study also demonstrates no significant difference in 5-year survival when patients treated by a modified radical mastectomy are compared to those treated by radical mastectomy. These findings are similar to those reported by Donegan et al.3, Meyer et al.5, Patey9 and Robinson et al.1" On the basis of our results and also those of other investigators cited, we have concluded that a properly performed modified radical mastectomy which extends beyond the lateral border of the pectoralis minor muscle is the treatment of choice in patients with Stage I and Stage II breast cancer. It is less deforming than a radical mastectomy, and subsequent reconstruction is considerably easier to accomplish. The incidence of lymphedema of the arm is less in comparison to that with a radical mastectomy. Also, the modified radical mastectomy appears to be superior to a simple mastectomy particularly in premenopausal women. The presence of axillary lymph node metastases can only be determined if the nodes are excised. At the present time, adjuvant chemotherapy is indicated in premenopausal patients if there is histologic evidence of axillary lymph node metastases; adjuvant chemotherapy is not indicated if there is no histologic evidence of axillary lymph node metastases in patients with Stage I and Stage II disease. TABLE 3. Sites of Local Recurrences Correlated with Stage of Disease and Type of Operation
Operation Modified radical Radical
Modified radical Radical Modified radical Radical
Chest Wall Recurrence
Stage I 12 10 Stage II 2 4 Stage III 7 3
Axillary Nodal Recurrence 1 2 1
7 0
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Our experience with Stage III breast cancer has been considerably different in comparison to that with Stage I and Stage II disease. Although there was no significant difference in survival between patients treated by modified radical mastectomy compared to radical mastectomy, there was an increased incidence of local recurrence in patients treated by a modified radical mastectomy, particularly if axillary lymph node metastases were present. There was also a difference in the pattern of local recurrence. Those patients treated by radical mastectomy had recurrence confined to the chest wall. In contrast, patients treated by modified radical mastectomy had local recurrences on the chest wall and in the axilla. We believe these axillary nodal recurrences are due to inadequate dissection of the axillae which contain multiple nodal metastases. If a modified radical mastectomy is performed in a patient with Stage III breast cancer, the dissection should be continued beneath and medial to the pectoralis minor muscle, and the intrapectoral group of nodes (Rotter's nodes) should also be excised. On the basis of this study, we have concluded that Stage III breast cancers should not be treated solely by modified radical mastectomy unless a complete axillary lymph node dissection, which includes Rotter's nodes as well as the nodes beneath and medial to the pectoralis minor muscle, is performed. The radical mastectomy provides better exposure of the axilla and should be considered as an alternate procedure in some patients with Stage III disease. If a limited axillary node dissection is performed and axillary lymph node metastases are demonstrated in the operative specimen, the modified radical mastectomy should be combined with adjuvant chemotherapy in premenopausal patients and postoperative irradiation in postmenopausal patients. Although the great majority of treat-
DISCUSSION DR. CHARLES ECKERT (Albany, New York): I rise primarily to discuss the method of evaluation of treatment measures employed in mammary cancer. Over the years it has been extraordinarily difficult to demonstrate differences in life expectancy between different methods of treatment, so one cannot be surprised that in the present study there was no difference in live expectancy between modified radical and radical mastectomy. The reason for this is not entirely clear, but one obvious reason is the presence of micrometastases that are undiscoverable preoperatively. Unfortunately, we have inadequate means to control these micro metastases. This is likely the main problem to be solved if the results of treatment of breast cancer are to be improved. A more searching method of comparison of different operations is the ability to achieve local control of disease. The frequency of local recurrence has long been known to be primarily dependent on the clinical stage of disease, and secondarily dependent on the method of treatment. To a lesser extent, perhaps, the results
557
ment failures in patients with Stage III disease are due to distant metastases which are present prior to operation surgical treatment should not be undertaken in these patients unless it has an excellent chance of eliminating disease within the area of surgical resection.
Acknowledgment The authors would like to thank Professor David B. Duncan for his assistance and guidance in the statistical analyses.
References 1. Albert, A., Belle, S. and Swanson, G. M.: Recent Trends in the Treatment of Primary Breast Cancer. Cancer, 41:2399, 1978. 2. Delarue, N. C., Anderson, W. D. and Starr, J.: Modified Radical Mastectomy in Individualized Treatment of Breast Cancer. Surg. Gynecol. Obstet., 129:79, 1969. 3. Donegan, W. L., Sugarbaker, E. D., Handley, R. S. and Watson, F. R.: Proceedings of the Sixth National Cancer Conference. Philadelphia, J. B. Lippincott Co., pp. 135- 143, 1970. 4. Lazaro, E. J., Rush, B. R. Jr. and Swaminathan, A. P.: Changing Attitudes in the Management of Cancer of the Breast. Surgery, 84:441, 1978. 5. Meyer, A. C., Smith, S. S. and Potter, M.: Carcinoma of the Breast: A Clinical Study. Arch. Surg., 113:364, 1978. 6. Neomoto, K.: Changing Treatment of Breast Cancer: A Survey of Surgeons. Breast, 4:16, 1978. 7. Neomoto, T. and Dao, T. L.: Is Modified Radical Mastectomy Adequate for Axillary Lymph Node Dissection? Ann. Surg., 182:722, 1975. 8. Papatestas, A. E. and Lesnick, G. J.: Treatment of Carcinoma of the Breast by Modified Radical Mastectomy. Surg. Gynecol. Obstet., 140:22, 1975. 9. Patey, D. H.: A Review of 146 Cases of Carcinoma of the Breast Operated upon Between 1930 and 1943. Br. J. Cancer, 21:260, 1967. 10. Petro, R., Pike, M. C., Armitage, P. et al.: Design and Analysis of Randomized Clinical Trials Requiring Prolonged Observation of Each Patient. 11. Robinson, G. N., Van Heerden, J. A. V., Payne, W. S. et al.: The Primary Surgical Treatment of Carcinoma of the BreastA Changing Trend Toward Modified Radical Mastectomy. Mayo Clin. Proc., 51:433, 1976.
are dependent on the technical excellence with which a procedure is applied. Dr. Baker's report indicates that patients with signs of locally advanced disease have a significantly higher recurrence rate with modified radical mastectomy than with traditional radical mastectomy. Now, the type of modified radical mastectomy to be employed enters into this discussion, even though, as previously stated, this is of secondary importance in overall control of the disease, as compared with stage. Nevertheless, using the same stage of disease-namely, locally advanced disease-we are able to draw conclusions regarding the effectiveness of different operative procedures. Most of us believe the so-called Auchincloss operation to be an inadequate procedure, whereas with the Patey operation complete removal of axillary lymph nodes is possible. Since we do not know the numbers of each operation that were used in this study, we really do not have a valid comparison between radical and modified radical mastectomy. On the basis of this report it would seem wise to use radical mastectomy in patients with Stage III, or locally advanced disease. I
From the Departments of Surgery and Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
This study compares the results of modified radical mastectomy (144 cases) to radical mastectomy (188 cases) in the treatment of operable breast cancer. Two hundred five patients had Stage I breast cancer, 60 had Stage II disease and 67 had Stage III disease (TNM System). There was no statistically significant difference in five year survival when the results of a radical mastectomy were compared to a modified radical mastectomy at any stage of disease. There was no statistically significant difference in the incidence of local recurrence in patients with Stage I and Stage II disease when the results of a radical mastectomy were compared to modified radical mastectomy. Those patients with Stage III disease who were treated by a modified radical mastectomy had a statistically significant higher incidence of local recurrence (chest wall and axilla) in comparison to patients treated by radical mastectomy. We have concluded that a modified radical mastectomy is the treatment of choice in patients with Stage I and Stage II diseases. In patients with Stage III disease, a radical mastectomy provides a better chance of local control of the disease but offers no increased chance of survival.
This retrospective study was undertaken to examine the relative efficacy of a modified radical mastectomy versus a radical mastectomy in the treatment of breast cancer. It represents an analysis of 332 patients who were treated for breast cancer at The Johns Hopkins Hospital between the years 1969 and 1972. One hundred forty-four patients were treated by modified radical mastectomy, and 188 had a radical mastectomy. These procedures were performed by 25 staff and resident surgeons. The selection of one operative procedure or the other was not related to the stage of the disease, but rather to the conviction of the surgeon as to optimal means of therapy.
A LTHOUGH THE TREATMENT of breast cancer
Clinical Material
remains controversial, the trend among surgeons is toward more conservative procedures. Albert et al.1, Lazaro et al.4 and Neomoto6 report a significant increase in recent years in the use of modified radical mastectomy in the treatment of breast cancer and a significant decrease in the use of radical mastectomy. This decline in the number of radical mastectomies has occurred because of an increasing awareness that failures in the treatment of breast cancer are usually related to the presence of occult systemic metastases rather than inadequate local treatment and also because of a conviction among some surgeons, at least, that an adequate axillary lymph node dissection can be completed without excision of the pectoralis major muscle.
Age Of the 144 patients undergoing modified radical mastectomy, 18% were under 45 years of age, 42% of the patients ranged in age from 45 to 55 years and 40% of the patients were 56 years or older. Twentyone per cent of the 188 patients treated by radical mastectomy were less than 45 years of age, 32% ranged in age from 45 to 55 years and 47% were 56 years of age or older.
Presented at the Annual Meeting of the Southern Surgical Association, December 4-6, 1978, Hot Springs, Virginia. Reprint requests: R. Robinson Baker, M.D., Department of
Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland. Submitted for publication: December 7, 1978.
Menopausal Status Forty-seven per cent of the patients treated by modified radical mastectomy were premenopausal or perimenopausal (within 2 years of menopause), and 53% of the patients were 2 or more years postmenopausal. In the group of patients treated by radical mastectomy, 44% of these patients were premenopausal or perimenopausal, and 56% were postmenopausal.
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TABLE 1. Histologic Types of Tumors Correlated with Operative Procedures
Modified Radical Mastectomy
Ann. Surg. * May 1979
involved and in one case the exact number of nodes not determined in the surgical pathology laboratory. Forty-six of the 114 (40%) patients treated by radical mastectomy had histologic evidence of axillary lymph node metastases. Twenty-two of these patients had one to three nodes involved, and 11 had four or more nodes involved. In 13 patients the exact number of nodes containing metastatic tumor was not determined in the surgical pathology laboratory. Sixty-three per cent of the patients treated by modified radical mastectomy and 62% of the patients treated by radical mastectomy with clinical Stage II and Stage III disease had histologic evidence of axillary lymph node metastases. Of the 33 patients undergoing a modified radical mastectomy, 11 had one to three nodes containing metastatic tumor and 17 had four or more nodes involved. In five cases, the exact number of nodes was not determined. Eleven of the 46 patients undergoing radical mastectomy had one to three nodes involved, and 14 patients had four or more nodes containing metastatic breast cancer. Although all of the remaining 21 patients had axillary lymph node metastases, the exact number could not was
Radical Mastectomy
Histologic Types
No.
%
No.
%
Infiltrating duct CA Infiltrating lobular CA Lobular CA-in situ Medullary CA Tubular CA Papillary CA Colloid CA
114 13 2 5 3 4 3
78 11
150 20 0 7 2 1 8
79 10
Clinical Stage Preoperative staging was accomplished by the TNM system. Two hundred five patients had Stage I disease; 91 of these patients were treated by modified radical mastectomy and 114 by radical mastectomy. Sixty patients had Stage II disease; 22 of these patients were treated by modified radical mastectomy and 38 by radical mastectomy. Sixty-seven patients had Stage III disease; 31 ofthese patients were treated by modified radical mastectomy and 36 by radical mastectomy.
Operative Procedures In all patients undergoing a modified radical mastectomy, the pectoralis major muscle was preserved, the pectoralis minor muscle was either divided or retracted to expose the upper portion of the axilla. In some cases a complete axillary dissection was performed; in others the intrapectoral group of lymph nodes (Rotter's nodes) were not excised and the dissection did not extend beyond the lateral border of the pectoralis minor muscle. The majority of modified radical mastectomies were performed through a transverse incision. The radical mastectomy was a more constant procedure, similar to that described by Halsted; this operation was performed through a vertical incision in the majority of cases. The amount of skin excised and type of closure, either with or without a skin graft, were not included in the analysis of either group of patients.
Histology The histologic types of the tumors removed correlated with the operative piocedures are reviewed in Table 1. Of the 91 patients with Stage I disease treated by modified radical mastectomy, 26 (28%) had histologic evidence of axillary node metastases. Twenty of these patients had one to three nodes containing metastatic tumor, five had four or more nodes
be determined.
Adjuvant Therapy None of the patients in this series received adjuvant chemotherapy. Postoperative irradiation was employed as a surgical adjuvant in a small percentage of patients with histologic evidence of axillary lymph node metastases. Seventeen patients treated by modified radical mastectomy received postoperative irradiation directed to the chest wall and the lymph nodes in the axilla, supraclavicular fossa and internal mammary chain (Stage I disease, seven patients; Stage II, four; Stage III, six). Seven patients treated by radical mastectomy received postoperative irradiation (Stage I, three; Stage III, four). Results Twenty-one of the 144 patients treated by modified radical mastectomy were lost to follow-up, six within the first 24 months. Thirty-three of the 188 patients undergoing radical mastectomy were lost to follow-up, four within the first 24 months. These patients who were lost to follow-up were included in the analysis of 5-year survival by a life table method. The 5-year survivorship calculated by life table methods10 of the patients treated by modified radical mastectomy compared to radical mastectomy according to stage of disease are presented in Figures 1, 2 and 3. The test of significance was made by a log rank test (Mantel-Haenzel x2).10 There was no statistically
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FIG. 1. Survival rate of patients with Stage I breast cancer paring a modified radical mastectomy to radical mastectomy.
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significant difference in the five year survival between those patients treated by modified radical mastectomy versus those treated by radical mastectomy in any clinical stage of disease. A local recurrence was defined as a recurrence on the ipsilateral chest wall between the clavicle superiorly, the costal margin inferiorly, the midportion of the sternum medially and the latissimus dorsi muscle laterally. Any other type of recurrence was classified as distant metastasis. The incidence of local recurrence correlated with the stage of disease and operative procedure is presented in Table 2. There was no statistically significant difference in the incidence of local recurrence when the results of modified radical mastectomy were compared with those of radical mastectomy in patients with Stage I and Stage II disease. A statistically significant greater incidence of local recurrence was present in patients with Stage III disease who were treated by modified radical mastectomy compared to radical mastectomy. The sites of local recurrence correlated with the stage of disease and type of operative procedure are presented in Table 3. Chest wall recurrence was defined as either recurrence in the skin flaps or within the soft tissues of the chest wall. The majority of local recurrences either on the chest wall or within the axilla in patients treated by modified radical mastectomy occurred in those patients with histologic evidence of lymph node metastases in the axillary contents removed at the operation. This included six of 12 patients with Stage I disease, two of two patients
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FIG. 2. Survival rate of patients with Stage II breast cancer paring a modified radical mastectomy to radical mastectomy.
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with Stage II disease and ten of 12 patients with Stage III disease (average number of nodes involved was eight). Four of 17 patients with a local recurrence who were treated by radical mastectomy had histologic evidence of axillary lymph node metastases in the operative specimen. Three patients with a local recurrence on the chest wall were treated by irradiation and survived for five years or more without further evidence of disease.
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FIG. 3. Survival rate of patients with Stage III breast cancer commodified radical mastectomy to radical mastectomy.
paring a
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TABLE 2. Incidence of Local Recurrence Correlated wvith Stage of Disease and Type of Operative Procedure
Operation
No. Patients
Modified radical Radical
91 114
Modified radical Radical
22 38
Modified radical Radical
31 36
No. with Local Recurrence
Statistical Significance
Stage I 12 10
xI = 1.03 (n.s.)
2 4
x2 = .039 (n.s.)
Stage II
Stage III 12 3
x2 = 8.84 p = .0088
All of these patients were initially treated by modified radical mastectomy, and none of these patients had evidence of axillary lymph node metastases. In the small. group of patients treated by postoperative irradiation there was no significant effect on survival or the incidence of local recurrence. Five of the 17 patients treated by modified radical mastectomy and one of seven patients treated by a radical mastectomy subsequently developed a local recurrence after postoperative irradiation. Discussion Although the number of modified radical mastectomies is increasing in comparison to radical mastectomies to treat patients with breast cancer, the relative effectiveness of a modified radical mastectomy compared to a radical mastectomy has never been evaluated in a prospective clinical trial. This retrospective study compares a similar group of patients as regards age, menopausal status and histologic type of resected tumor. The incidence of axillary lymph node metastases in patients with Stage I disease is lower in patients treated by modified radical mastectomy compared to radical mastectomy. Although this difference is not statistically significant (x2 = 3.66), it is close to significance and indicates that a slightly more favorable group of patients were treated by modified radical mastectomy compared to radical mastectomy. Patients treated by modified radical mastectomy also had fewer nodes involved with metastatic tumor, another more favorable prognostic sign. The presence of axillary lymph node metastases and the number of axillary lymph nodes involved can only be determined, however, by pathologic staging and cannot be employed to compare results based on clinical staging. If the patient had clinical Stage I or Stage II disease, this study demonstrates that a modified radical mastectomy is as effective as a radical mastectomy in the control
Ann. Surg. * May 1979
of local disease. Similar results have been reported by Delarue et al.2, Neomoto and Dao7 and Papatestas and Lesnick.8 The majority of local recurrences encountered in patients with Stage I and Stage II disease occurred either in the skin flaps or on the chest wall rather than in the axillary lymph nodes. Seventy-nine per cent of patients with a local recurrence subsequently developed evidence of distant metastases
within a relatively short period of time, indicating that in the majority of cases local recurrences were the first manifestation of systemic disease and probably occurred as a result of circulating tumor cells implanting in the skin flaps or muscles of the chest wall. This retrospective study also demonstrates no significant difference in 5-year survival when patients treated by a modified radical mastectomy are compared to those treated by radical mastectomy. These findings are similar to those reported by Donegan et al.3, Meyer et al.5, Patey9 and Robinson et al.1" On the basis of our results and also those of other investigators cited, we have concluded that a properly performed modified radical mastectomy which extends beyond the lateral border of the pectoralis minor muscle is the treatment of choice in patients with Stage I and Stage II breast cancer. It is less deforming than a radical mastectomy, and subsequent reconstruction is considerably easier to accomplish. The incidence of lymphedema of the arm is less in comparison to that with a radical mastectomy. Also, the modified radical mastectomy appears to be superior to a simple mastectomy particularly in premenopausal women. The presence of axillary lymph node metastases can only be determined if the nodes are excised. At the present time, adjuvant chemotherapy is indicated in premenopausal patients if there is histologic evidence of axillary lymph node metastases; adjuvant chemotherapy is not indicated if there is no histologic evidence of axillary lymph node metastases in patients with Stage I and Stage II disease. TABLE 3. Sites of Local Recurrences Correlated with Stage of Disease and Type of Operation
Operation Modified radical Radical
Modified radical Radical Modified radical Radical
Chest Wall Recurrence
Stage I 12 10 Stage II 2 4 Stage III 7 3
Axillary Nodal Recurrence 1 2 1
7 0
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MASTECTOMY TECHNIQUE COMPARISON
Our experience with Stage III breast cancer has been considerably different in comparison to that with Stage I and Stage II disease. Although there was no significant difference in survival between patients treated by modified radical mastectomy compared to radical mastectomy, there was an increased incidence of local recurrence in patients treated by a modified radical mastectomy, particularly if axillary lymph node metastases were present. There was also a difference in the pattern of local recurrence. Those patients treated by radical mastectomy had recurrence confined to the chest wall. In contrast, patients treated by modified radical mastectomy had local recurrences on the chest wall and in the axilla. We believe these axillary nodal recurrences are due to inadequate dissection of the axillae which contain multiple nodal metastases. If a modified radical mastectomy is performed in a patient with Stage III breast cancer, the dissection should be continued beneath and medial to the pectoralis minor muscle, and the intrapectoral group of nodes (Rotter's nodes) should also be excised. On the basis of this study, we have concluded that Stage III breast cancers should not be treated solely by modified radical mastectomy unless a complete axillary lymph node dissection, which includes Rotter's nodes as well as the nodes beneath and medial to the pectoralis minor muscle, is performed. The radical mastectomy provides better exposure of the axilla and should be considered as an alternate procedure in some patients with Stage III disease. If a limited axillary node dissection is performed and axillary lymph node metastases are demonstrated in the operative specimen, the modified radical mastectomy should be combined with adjuvant chemotherapy in premenopausal patients and postoperative irradiation in postmenopausal patients. Although the great majority of treat-
DISCUSSION DR. CHARLES ECKERT (Albany, New York): I rise primarily to discuss the method of evaluation of treatment measures employed in mammary cancer. Over the years it has been extraordinarily difficult to demonstrate differences in life expectancy between different methods of treatment, so one cannot be surprised that in the present study there was no difference in live expectancy between modified radical and radical mastectomy. The reason for this is not entirely clear, but one obvious reason is the presence of micrometastases that are undiscoverable preoperatively. Unfortunately, we have inadequate means to control these micro metastases. This is likely the main problem to be solved if the results of treatment of breast cancer are to be improved. A more searching method of comparison of different operations is the ability to achieve local control of disease. The frequency of local recurrence has long been known to be primarily dependent on the clinical stage of disease, and secondarily dependent on the method of treatment. To a lesser extent, perhaps, the results
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ment failures in patients with Stage III disease are due to distant metastases which are present prior to operation surgical treatment should not be undertaken in these patients unless it has an excellent chance of eliminating disease within the area of surgical resection.
Acknowledgment The authors would like to thank Professor David B. Duncan for his assistance and guidance in the statistical analyses.
References 1. Albert, A., Belle, S. and Swanson, G. M.: Recent Trends in the Treatment of Primary Breast Cancer. Cancer, 41:2399, 1978. 2. Delarue, N. C., Anderson, W. D. and Starr, J.: Modified Radical Mastectomy in Individualized Treatment of Breast Cancer. Surg. Gynecol. Obstet., 129:79, 1969. 3. Donegan, W. L., Sugarbaker, E. D., Handley, R. S. and Watson, F. R.: Proceedings of the Sixth National Cancer Conference. Philadelphia, J. B. Lippincott Co., pp. 135- 143, 1970. 4. Lazaro, E. J., Rush, B. R. Jr. and Swaminathan, A. P.: Changing Attitudes in the Management of Cancer of the Breast. Surgery, 84:441, 1978. 5. Meyer, A. C., Smith, S. S. and Potter, M.: Carcinoma of the Breast: A Clinical Study. Arch. Surg., 113:364, 1978. 6. Neomoto, K.: Changing Treatment of Breast Cancer: A Survey of Surgeons. Breast, 4:16, 1978. 7. Neomoto, T. and Dao, T. L.: Is Modified Radical Mastectomy Adequate for Axillary Lymph Node Dissection? Ann. Surg., 182:722, 1975. 8. Papatestas, A. E. and Lesnick, G. J.: Treatment of Carcinoma of the Breast by Modified Radical Mastectomy. Surg. Gynecol. Obstet., 140:22, 1975. 9. Patey, D. H.: A Review of 146 Cases of Carcinoma of the Breast Operated upon Between 1930 and 1943. Br. J. Cancer, 21:260, 1967. 10. Petro, R., Pike, M. C., Armitage, P. et al.: Design and Analysis of Randomized Clinical Trials Requiring Prolonged Observation of Each Patient. 11. Robinson, G. N., Van Heerden, J. A. V., Payne, W. S. et al.: The Primary Surgical Treatment of Carcinoma of the BreastA Changing Trend Toward Modified Radical Mastectomy. Mayo Clin. Proc., 51:433, 1976.
are dependent on the technical excellence with which a procedure is applied. Dr. Baker's report indicates that patients with signs of locally advanced disease have a significantly higher recurrence rate with modified radical mastectomy than with traditional radical mastectomy. Now, the type of modified radical mastectomy to be employed enters into this discussion, even though, as previously stated, this is of secondary importance in overall control of the disease, as compared with stage. Nevertheless, using the same stage of disease-namely, locally advanced disease-we are able to draw conclusions regarding the effectiveness of different operative procedures. Most of us believe the so-called Auchincloss operation to be an inadequate procedure, whereas with the Patey operation complete removal of axillary lymph nodes is possible. Since we do not know the numbers of each operation that were used in this study, we really do not have a valid comparison between radical and modified radical mastectomy. On the basis of this report it would seem wise to use radical mastectomy in patients with Stage III, or locally advanced disease. I
