Journal of Surgical Oncology 50241-246 (1992)
Oncological Aspect of Immediate Breast Reconstruction in Mastectomy Patients MASAKUNI NOGUCHI, MU, WATARU FUKUSHIMA, MU, NAGAYOSHI OHTA, MU, NAOHIRO KOYASAKI, MD, MICHAEL THOMAS, PhD, ITSUO MIYAZAKI, MD, TETSUJIYAMADA, MD, AND MASAAKI NAKAGAWA, MD From The Operation Center (M.N.), Department of Surgery (11) (M.N., W.F., N.O., N.K., M.T., I.M.), Kanazawa University Hospital, School of Medicine, Kanazawa University; Department of Surgery, lshikawa Prefectural Central Hospital (T.Y., M.N.); and Hokuriku Breast Cancer Society (M.N., W.F., N.O., N. K., 1.M., T.Y., M.N.), Kanazawa, japan
In this study, we compared the relapse-free and overall survival of 83 patients who underwent mastectomy with immediate reconstruction (MIBR) using a musculocutaneous flap with or without silicone implant with those of 153 patients with breast cancer who underwent mastectomy without immediate reconstruction. In univariate analysis, the overall and/or relapse-free survival of reconstructed patients with four or more positive axillary lymph nodes or those with menopausal status were significantly inferior compared with those of nonreconstructed patients. In multivariate analysis, however, the immediate breast reconstruction did not appear to have a significant adverse influence on all patients, and on the subgroups stratified by menopausal status or axillary lymph node metastases. Therefore, it was concluded that MIBR using a musculocutaneous flap did not compromise the survival of patients with breast cancer. 0 1992 Wiley-Liss, Inc.
KEYWORDS: breast cancer, menopausal status, axillary lymph node metastases cerning the potential of the latter type of MIBR for comMastectomy with immediate breast reconstruction promising patient survival. We report here on the duration of survival in recon(MIBR) has become an accepted procedure in the treatstructed patients in comparison with a control population ment of breast carcinoma. The options for immediate without immediate reconstruction, correcting for the mabreast reconstruction include submuscular implants, such jor known prognostic factors of human primary breast as a silicone implant or tissue expander, and the use of cancer. autologous tissue, such as a latissimus dorsi musculocutaneous (LDM) flap with or without silicone implant, or MATERIALS AND METHODS transverse rectus abdominis musculocutaneous (TRAM) Patients and Treatment flap. The former type of MIBR is the simplest procedure. While the extent of mastectomy depended mainly on The latter is more complex and requires the transposition the local extent of cancer cells in order to provide the best of autologous tissue from the back or abdomen. A major of local control, the indication for breast reconstrucform concern in attempting MIBR has been the potential intion was at the patients’ request. After diagnosis was crease in tumor recurrence resulting from a compromise confirmed by excisional biopsy or aspiration needle biin the ablative surgical technique. Moreover, the presence of a bulky implant or autologous tissue has been regarded as a potential obstacle to detect local recurrence. While the former type of MIBR has no adverse influence Accepted for publication April 28, 1992. Address reprint requests to Dr. Masakuni Noguchi, The Operation on the natural history of surgically treated breast cancer Center, Kanazawa University Hospital, School of Medicine, [1,2], to our knowledge, there have been no data con- Kanazawa University, Takara-machi, 13-1, Kanazawa, 920, Japan.
INTRODUCTION
0 1992 Wiley-Liss, Inc.
242
Noguchi et al.
opsy, mastectomy with immediate breast reconstruction (MIBR) was discussed with the patients. Generally, women with locally advanced disease were not offered MIBR, but in some patients with histologically conf m e d internal mammary lymph node metastases, the latissimus dorsi musculocutaneous (LDM) or transverse rectus abdominis musculocutaneous (TRAM) flap was performed to repair the chest wall defect after extended radical mastectomy rather than for breast reconstruction. Since the aim of this study was to evaluate the influence of the LDM or TRAM flap on breast cancer prognosis, those patients were included in the study. The LDM flap was recommended for thin or young women or those with a lower abdominal midline scar, whereas the TRAM flap was recommended for those with large breasts or who did not have an abdominal scar. The LDM flap with silicone was implanted in some patients in this early series, but abandoned because of frequent capsular contructure. From April 1982 through March 1991,83 patients underwent mastectomy with immediate breast reconstruction (MIBR) (group A). Procedures included modified radical mastectomy in 63, radical mastectomy in 10, and extended radical mastectomy in 10. The methods of MIBR included the LDM flap alone in 8, the LDM flap with silicone implant (Dow-Corning, Midland, MI) in 15, and the TRAM flap alone in 60.No patient was reconstructed with the submuscular implant alone. In our operation, the pectoralis major muscle was dissected at the distal portion, reflected upward during axillary dissection and internal mammary biopsy, then sutured onto the upper part of the LDM or TRAM flap for breast reconstruction. Since the pectoralis major muscle is placed just beneath a thin skin flap, it will not camouflage a local recurrence. During the same period, 153 patients underwent various radical mastectomies without breast reconstruction (group B). The mastectomy included modified radical mastectomy in 63, radical mastectomy in 18 and extended radical mastectomy in 72. Thus, the axillary lymph nodes were dissected in all the patients, of whom 85 patients underwent extended radical mastectomy. The internal mammary lymph nodes from 97 of the patients treated by modified or radical mastectomy were biopsied. Postoperatively patients received a variety of preventive chemoendocrine therapies: patients with negative axillary nodes or 1-3 positive axillary nodes underwent only mild chemotherapy, such as oral medication with 5-flUOrOuracil ( 100 mg/day) , cyclophosphamide (50 mglday), and tamoxifen (20 mg/day) for 2 or 3 years, whereas those with 4 or more positive axillary nodes were given intensive chemotherapy such as six cycles of cyclophosphamide (500 mg/m2), doxorubicin (50 mg/m’), and 5-fluorouracil (500 mg/m’) (CAF) therapy with tamoxifen (20 mg/day) for 2 or 3 years. They were followed up until death or through March 1991. In this study, however, patients with stage 4 breast cancer, bilateral breast
cancer, and male breast cancer, as well as those given breast-conserving treatment, were excluded.
Statistical Methods Group comparisons were performed for qualitative parameters, using the chi-square test, and for quantitative parameters using the two sample Student’s test. The duration of overall or relapse-free survival was calculated as the interval from surgery until death from breast cancerrelated causes or to recurrence, respectively. Patients who had died without recurrence, were censored at death. In a univariate study, the overall and relapse-free survival in both groups were studied by the Kaplan-Meier method, and a log-rank test was employed to assess the statistical significance. Then, in a multivariate study, Cox’s regression test was used to examine whether MIBR compromised patient survival by adjusting the relevant prognostic factors such as age, menopausal status, clinical stage, tumor size, histological type, and axillary and internal mammary lymph node metastases. Multivariate analysis showed that patients with unknown internal mammary node status were included in the group with negative internal mammary nodes, since the univariate analysis revealed no significant differences in relapsefree or overall survival.
RESULTS Characteristics of Patients Table I shows the characteristics of patients and tumors possible related to prognosis in both groups. There were 83 patients in group A and 153 in group B. For univariate and multivariate analyses, three age ranges were selected: S 3 5 years, 36-50 years, and a 5 1 years. The average age and menopausal status were significantly different between the two groups. Clinical stage was classified according to the TNM classification [3]. Three ranges of tumor size were analyzed: 6 2 cm, 2.1-5.0 cm, and 2 5 . I cm. Histological types were classified according to the Histological Classification of Breast Cancer proposed by the Japan Breast Cancer Society [3], a modification of the Histological Typing of the World Health Organization (WHO) [4]. Axillary and internal mammary lymph node metastases were histologically confirmed, and three ranges of axillary lymph node metastases were analyzed: negative axillary nodes, 1-3 positive axillary nodes, and 4 or more positive nodes. Clinical stage, tumor size, histological type, and axillary and internal mammary lymph node metastases were not significantly different (Table I). Outcome of Patients As of March 1991, five patients had died from disease recurrence, three were alive with recurrence, and 75 were alive without recurrence in group A. No one died from unrelated disease in group A. In group B, 10 patients died
Immediate Breast Reconstruction
TABLE 11. Outcome of Patients With and Without Immediate Breast Reconstruction
TABLE I. Characteristics of Patients With and Without Immediate Breast Reconstruction After Mastectomy* Group A" (n = 83) Age
c 35 years 36-50 years 3 51 years Menopausal status Re Post Clinical stage TIS Stage I Stage 2 Stage 3 Tumor size S 2.0 cm 2.1-5.0 cm 3 5.1 cm Histological type Noninvasive carcinoma' Invasive ductal carcinoma Special type of invasive carcinoma AX 0 1-3 >3 IM Positive Negative Unknown Follow-up time (month) (Mean tSE)
10 58 15
Group B' (n 153)
7
243
P
< 0.01
64 82
Group A" (n = 83)
Outcome Alive without recurrence Alive with recurrence Died of disease Died of unrelated disease
75 (90%) 3 (4%) 5 (6%) 0
Group Bb = 153)
(n
129 (84%) 7 (5%) 10 (7%) 7 (5%)
~~
67 16
66 87
< 0.01
3 18 48 14
8 38 74 33
NS
30
68 75
NS
44 9
10
3 75
NS
5
8 I27 18
48 20 15
85 39 29
NS
10
18 I06 29 58 f 3
NS
48 25 41 ? 2
aGroup A: Patients who underwent mastectomy with immediate breast reconstruction. 'Group B: Patients who underwent mastectomy without breast reconstruction.
Univariate Analyses of Relapse-Free and Overall Survival
< 0.01
*AX, axillary lymph node metastases; IM, internal mammary lymph node metastases; NS, not statistically significant. "Group A: Patients who underwent mastectomy with immediate breast reconstruction. hGroup B: Patients who underwent mastectomy without breast reconstruction. 'Noninvasive carcinoma included non invasive ductal carcinoma, in situ lobular carcinoma, and Paget's disease in this study.
from disease recurrence, seven were alive with recurrence, and 129 were alive without recurrence. The other seven patients died from unrelated disease in group B (Table 11). By contrast, with regard to the type of recurrence, there were distant metastases alone in four and regional lymph node recurrence followed by distant metastases in 4 patients of group A. No recurrence related to the musculocutaneous flap was found except for one patient who developed multiple skin metastases on the TRAM flap, but these were probably signs of systemic disease. Among group B patients, there were distant metastases alone in 9, and regional lymph node recurrence followed by distant metastases in 8.
Five-year relapse-free and overall survival rates were 90% and 9296, respectively, in group A, and 86% and 92% in group B, respectively. There were no significant differences in relapse-free and overall survival rates between groups A and B (Tables 111, IV) (Figs. 1, 2). In postmenopausal patients, however, the overall and relapse-free survival of reconstructed patients were significantly inferior compared with those of nonreconstructed patients. Also, in patients with four or more positive axillary lymph nodes, the overall survival of reconstructed patients was significantly inferior compared with those of nonreconstructed patients (Tables 111, IV). However, a number of prognostic factors were different and interrelated between the two groups. Especially, group A included some postmenopausal patients with advanced breast cancer, in which the LDM or TRAM flap was performed to repair the chest wall defect after extended radical mastectomy rather than for breast reconstruction.
Multivariate Analysis on Overall and Relapse-Free Survival The prognostic variables were analyzed by Cox's multivariate analysis for relative importance and independence. The important independent factors affecting relapse-free as well as overall survival were confirmed to be axillary lymph node metastases, whereas the age, menopausal status, clinical stage, tumor size, histological type, and internal mammary node metastases did not appear to be independent factors in this series. Furthermore, the immediate breast reconstruction did not appear to have a significant adverse influence on the all patients (Table V) and on the subgroups stratified by menopausal status or axillary lymph node metastases.
DISCUSSION Although it is generally accepted that mastectomy and regional dissection can achieve better local-regional control in the majority of patients with operable breast cancer, the loss of a breast after mastectomy has significant
244
Noguchi et al.
TABLE 111. Overall 5-YearSurvival Rates by the Univariate Analysis of Mastectomy Patients With and Without Immediate Reconstruction* Group A" (n = 83)
Group Bb (n = 153)
92 t 3%
92 t 3%
NS
Menopausal status Pre Post
97 t 2% 69 t 17%
92 2 4% 92 2 3%
NS < 0.01
80 t 13% 97 t 3% 85 t 10%
83 f 15% 94 f 4% 91 2 4 %
NS
100% 100% 95 2 5% 7 0 2 13%
100% 96 2 4% 93 t 4% 84 2 8%
NS
100% 89 t 7% 7 4 t 16%
94 2 4% 96 2 3% 52 f 18%
NS
100% 91 t 4 % 100%
100% 92 2 3% 83 2 1 1 %
NS
98 2 2% 89 2 6% 73 2 10%
NS
35 years 36-50 years 3 51 years 5
Clinical stage TIS Stage 1 Stage 2 Tumor size < 2.0 cm 2.1-5.0 cm 2 5.1 cm Histological type Noninvasive carcinoma lnvasive ductal carcinoma Special type of invasive carcinoma AX 0 1-3 >3 IM Positive Negative Unknown
Group A" (n = 83)
Group Bh (n = 153)
P
All cases
9024%
8623%
NS
Menopausal status Pre Post
93 2 4 % 79 2 1 1 %
83 2 6 % 88 2 4 %
3:2) IM (Negative or unknown:O/Positive: 1) Breast reconstruction (A:O/B: 1)
Overall
Relapse-free
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
Oncological Aspect of Immediate Breast Reconstruction in Mastectomy Patients MASAKUNI NOGUCHI, MU, WATARU FUKUSHIMA, MU, NAGAYOSHI OHTA, MU, NAOHIRO KOYASAKI, MD, MICHAEL THOMAS, PhD, ITSUO MIYAZAKI, MD, TETSUJIYAMADA, MD, AND MASAAKI NAKAGAWA, MD From The Operation Center (M.N.), Department of Surgery (11) (M.N., W.F., N.O., N.K., M.T., I.M.), Kanazawa University Hospital, School of Medicine, Kanazawa University; Department of Surgery, lshikawa Prefectural Central Hospital (T.Y., M.N.); and Hokuriku Breast Cancer Society (M.N., W.F., N.O., N. K., 1.M., T.Y., M.N.), Kanazawa, japan
In this study, we compared the relapse-free and overall survival of 83 patients who underwent mastectomy with immediate reconstruction (MIBR) using a musculocutaneous flap with or without silicone implant with those of 153 patients with breast cancer who underwent mastectomy without immediate reconstruction. In univariate analysis, the overall and/or relapse-free survival of reconstructed patients with four or more positive axillary lymph nodes or those with menopausal status were significantly inferior compared with those of nonreconstructed patients. In multivariate analysis, however, the immediate breast reconstruction did not appear to have a significant adverse influence on all patients, and on the subgroups stratified by menopausal status or axillary lymph node metastases. Therefore, it was concluded that MIBR using a musculocutaneous flap did not compromise the survival of patients with breast cancer. 0 1992 Wiley-Liss, Inc.
KEYWORDS: breast cancer, menopausal status, axillary lymph node metastases cerning the potential of the latter type of MIBR for comMastectomy with immediate breast reconstruction promising patient survival. We report here on the duration of survival in recon(MIBR) has become an accepted procedure in the treatstructed patients in comparison with a control population ment of breast carcinoma. The options for immediate without immediate reconstruction, correcting for the mabreast reconstruction include submuscular implants, such jor known prognostic factors of human primary breast as a silicone implant or tissue expander, and the use of cancer. autologous tissue, such as a latissimus dorsi musculocutaneous (LDM) flap with or without silicone implant, or MATERIALS AND METHODS transverse rectus abdominis musculocutaneous (TRAM) Patients and Treatment flap. The former type of MIBR is the simplest procedure. While the extent of mastectomy depended mainly on The latter is more complex and requires the transposition the local extent of cancer cells in order to provide the best of autologous tissue from the back or abdomen. A major of local control, the indication for breast reconstrucform concern in attempting MIBR has been the potential intion was at the patients’ request. After diagnosis was crease in tumor recurrence resulting from a compromise confirmed by excisional biopsy or aspiration needle biin the ablative surgical technique. Moreover, the presence of a bulky implant or autologous tissue has been regarded as a potential obstacle to detect local recurrence. While the former type of MIBR has no adverse influence Accepted for publication April 28, 1992. Address reprint requests to Dr. Masakuni Noguchi, The Operation on the natural history of surgically treated breast cancer Center, Kanazawa University Hospital, School of Medicine, [1,2], to our knowledge, there have been no data con- Kanazawa University, Takara-machi, 13-1, Kanazawa, 920, Japan.
INTRODUCTION
0 1992 Wiley-Liss, Inc.
242
Noguchi et al.
opsy, mastectomy with immediate breast reconstruction (MIBR) was discussed with the patients. Generally, women with locally advanced disease were not offered MIBR, but in some patients with histologically conf m e d internal mammary lymph node metastases, the latissimus dorsi musculocutaneous (LDM) or transverse rectus abdominis musculocutaneous (TRAM) flap was performed to repair the chest wall defect after extended radical mastectomy rather than for breast reconstruction. Since the aim of this study was to evaluate the influence of the LDM or TRAM flap on breast cancer prognosis, those patients were included in the study. The LDM flap was recommended for thin or young women or those with a lower abdominal midline scar, whereas the TRAM flap was recommended for those with large breasts or who did not have an abdominal scar. The LDM flap with silicone was implanted in some patients in this early series, but abandoned because of frequent capsular contructure. From April 1982 through March 1991,83 patients underwent mastectomy with immediate breast reconstruction (MIBR) (group A). Procedures included modified radical mastectomy in 63, radical mastectomy in 10, and extended radical mastectomy in 10. The methods of MIBR included the LDM flap alone in 8, the LDM flap with silicone implant (Dow-Corning, Midland, MI) in 15, and the TRAM flap alone in 60.No patient was reconstructed with the submuscular implant alone. In our operation, the pectoralis major muscle was dissected at the distal portion, reflected upward during axillary dissection and internal mammary biopsy, then sutured onto the upper part of the LDM or TRAM flap for breast reconstruction. Since the pectoralis major muscle is placed just beneath a thin skin flap, it will not camouflage a local recurrence. During the same period, 153 patients underwent various radical mastectomies without breast reconstruction (group B). The mastectomy included modified radical mastectomy in 63, radical mastectomy in 18 and extended radical mastectomy in 72. Thus, the axillary lymph nodes were dissected in all the patients, of whom 85 patients underwent extended radical mastectomy. The internal mammary lymph nodes from 97 of the patients treated by modified or radical mastectomy were biopsied. Postoperatively patients received a variety of preventive chemoendocrine therapies: patients with negative axillary nodes or 1-3 positive axillary nodes underwent only mild chemotherapy, such as oral medication with 5-flUOrOuracil ( 100 mg/day) , cyclophosphamide (50 mglday), and tamoxifen (20 mg/day) for 2 or 3 years, whereas those with 4 or more positive axillary nodes were given intensive chemotherapy such as six cycles of cyclophosphamide (500 mg/m2), doxorubicin (50 mg/m’), and 5-fluorouracil (500 mg/m’) (CAF) therapy with tamoxifen (20 mg/day) for 2 or 3 years. They were followed up until death or through March 1991. In this study, however, patients with stage 4 breast cancer, bilateral breast
cancer, and male breast cancer, as well as those given breast-conserving treatment, were excluded.
Statistical Methods Group comparisons were performed for qualitative parameters, using the chi-square test, and for quantitative parameters using the two sample Student’s test. The duration of overall or relapse-free survival was calculated as the interval from surgery until death from breast cancerrelated causes or to recurrence, respectively. Patients who had died without recurrence, were censored at death. In a univariate study, the overall and relapse-free survival in both groups were studied by the Kaplan-Meier method, and a log-rank test was employed to assess the statistical significance. Then, in a multivariate study, Cox’s regression test was used to examine whether MIBR compromised patient survival by adjusting the relevant prognostic factors such as age, menopausal status, clinical stage, tumor size, histological type, and axillary and internal mammary lymph node metastases. Multivariate analysis showed that patients with unknown internal mammary node status were included in the group with negative internal mammary nodes, since the univariate analysis revealed no significant differences in relapsefree or overall survival.
RESULTS Characteristics of Patients Table I shows the characteristics of patients and tumors possible related to prognosis in both groups. There were 83 patients in group A and 153 in group B. For univariate and multivariate analyses, three age ranges were selected: S 3 5 years, 36-50 years, and a 5 1 years. The average age and menopausal status were significantly different between the two groups. Clinical stage was classified according to the TNM classification [3]. Three ranges of tumor size were analyzed: 6 2 cm, 2.1-5.0 cm, and 2 5 . I cm. Histological types were classified according to the Histological Classification of Breast Cancer proposed by the Japan Breast Cancer Society [3], a modification of the Histological Typing of the World Health Organization (WHO) [4]. Axillary and internal mammary lymph node metastases were histologically confirmed, and three ranges of axillary lymph node metastases were analyzed: negative axillary nodes, 1-3 positive axillary nodes, and 4 or more positive nodes. Clinical stage, tumor size, histological type, and axillary and internal mammary lymph node metastases were not significantly different (Table I). Outcome of Patients As of March 1991, five patients had died from disease recurrence, three were alive with recurrence, and 75 were alive without recurrence in group A. No one died from unrelated disease in group A. In group B, 10 patients died
Immediate Breast Reconstruction
TABLE 11. Outcome of Patients With and Without Immediate Breast Reconstruction
TABLE I. Characteristics of Patients With and Without Immediate Breast Reconstruction After Mastectomy* Group A" (n = 83) Age
c 35 years 36-50 years 3 51 years Menopausal status Re Post Clinical stage TIS Stage I Stage 2 Stage 3 Tumor size S 2.0 cm 2.1-5.0 cm 3 5.1 cm Histological type Noninvasive carcinoma' Invasive ductal carcinoma Special type of invasive carcinoma AX 0 1-3 >3 IM Positive Negative Unknown Follow-up time (month) (Mean tSE)
10 58 15
Group B' (n 153)
7
243
P
< 0.01
64 82
Group A" (n = 83)
Outcome Alive without recurrence Alive with recurrence Died of disease Died of unrelated disease
75 (90%) 3 (4%) 5 (6%) 0
Group Bb = 153)
(n
129 (84%) 7 (5%) 10 (7%) 7 (5%)
~~
67 16
66 87
< 0.01
3 18 48 14
8 38 74 33
NS
30
68 75
NS
44 9
10
3 75
NS
5
8 I27 18
48 20 15
85 39 29
NS
10
18 I06 29 58 f 3
NS
48 25 41 ? 2
aGroup A: Patients who underwent mastectomy with immediate breast reconstruction. 'Group B: Patients who underwent mastectomy without breast reconstruction.
Univariate Analyses of Relapse-Free and Overall Survival
< 0.01
*AX, axillary lymph node metastases; IM, internal mammary lymph node metastases; NS, not statistically significant. "Group A: Patients who underwent mastectomy with immediate breast reconstruction. hGroup B: Patients who underwent mastectomy without breast reconstruction. 'Noninvasive carcinoma included non invasive ductal carcinoma, in situ lobular carcinoma, and Paget's disease in this study.
from disease recurrence, seven were alive with recurrence, and 129 were alive without recurrence. The other seven patients died from unrelated disease in group B (Table 11). By contrast, with regard to the type of recurrence, there were distant metastases alone in four and regional lymph node recurrence followed by distant metastases in 4 patients of group A. No recurrence related to the musculocutaneous flap was found except for one patient who developed multiple skin metastases on the TRAM flap, but these were probably signs of systemic disease. Among group B patients, there were distant metastases alone in 9, and regional lymph node recurrence followed by distant metastases in 8.
Five-year relapse-free and overall survival rates were 90% and 9296, respectively, in group A, and 86% and 92% in group B, respectively. There were no significant differences in relapse-free and overall survival rates between groups A and B (Tables 111, IV) (Figs. 1, 2). In postmenopausal patients, however, the overall and relapse-free survival of reconstructed patients were significantly inferior compared with those of nonreconstructed patients. Also, in patients with four or more positive axillary lymph nodes, the overall survival of reconstructed patients was significantly inferior compared with those of nonreconstructed patients (Tables 111, IV). However, a number of prognostic factors were different and interrelated between the two groups. Especially, group A included some postmenopausal patients with advanced breast cancer, in which the LDM or TRAM flap was performed to repair the chest wall defect after extended radical mastectomy rather than for breast reconstruction.
Multivariate Analysis on Overall and Relapse-Free Survival The prognostic variables were analyzed by Cox's multivariate analysis for relative importance and independence. The important independent factors affecting relapse-free as well as overall survival were confirmed to be axillary lymph node metastases, whereas the age, menopausal status, clinical stage, tumor size, histological type, and internal mammary node metastases did not appear to be independent factors in this series. Furthermore, the immediate breast reconstruction did not appear to have a significant adverse influence on the all patients (Table V) and on the subgroups stratified by menopausal status or axillary lymph node metastases.
DISCUSSION Although it is generally accepted that mastectomy and regional dissection can achieve better local-regional control in the majority of patients with operable breast cancer, the loss of a breast after mastectomy has significant
244
Noguchi et al.
TABLE 111. Overall 5-YearSurvival Rates by the Univariate Analysis of Mastectomy Patients With and Without Immediate Reconstruction* Group A" (n = 83)
Group Bb (n = 153)
92 t 3%
92 t 3%
NS
Menopausal status Pre Post
97 t 2% 69 t 17%
92 2 4% 92 2 3%
NS < 0.01
80 t 13% 97 t 3% 85 t 10%
83 f 15% 94 f 4% 91 2 4 %
NS
100% 100% 95 2 5% 7 0 2 13%
100% 96 2 4% 93 t 4% 84 2 8%
NS
100% 89 t 7% 7 4 t 16%
94 2 4% 96 2 3% 52 f 18%
NS
100% 91 t 4 % 100%
100% 92 2 3% 83 2 1 1 %
NS
98 2 2% 89 2 6% 73 2 10%
NS
35 years 36-50 years 3 51 years 5
Clinical stage TIS Stage 1 Stage 2 Tumor size < 2.0 cm 2.1-5.0 cm 2 5.1 cm Histological type Noninvasive carcinoma lnvasive ductal carcinoma Special type of invasive carcinoma AX 0 1-3 >3 IM Positive Negative Unknown
Group A" (n = 83)
Group Bh (n = 153)
P
All cases
9024%
8623%
NS
Menopausal status Pre Post
93 2 4 % 79 2 1 1 %
83 2 6 % 88 2 4 %
3:2) IM (Negative or unknown:O/Positive: 1) Breast reconstruction (A:O/B: 1)
Overall
Relapse-free
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
