Journal of Surgical Oncology 9:487-492 (1977)

Radical Mastectomy for Operable Breast Cancer ..................................................................................... ...................................................................................... H. FREUND, M.D., A. L. DURST, M.D., F.A.C.S., N. B. GROVER, Ph.D., G. KOMISSAR, Ph.D., I. PETERBURG, M.D., and N. J. SALTZ, M.D.,F.A.C.S. The experience with radical mastectomy in the treatment of 152 cases of operable breast cancer at the Hadassah University Hospital has been analyzed. An overall 5 year survival of 75% and a 10 year survival of 62% are reported and compared with results from other methods of treatment. Based on the exmielleiitsurvival rates achieved and the low incidence of local recurrence (9.8%), the present study su,%geststhat radical mastectomy is still the most suitable surgical procedure in the treatment of operable breast cancer.

............................................................................................ ............................................................................................ Key words: radical mastectomy, breast cancer

INTRODUCTION In the early 1950s, the Halsted-Meyer radical mastectomy was introduced at the Idadassah University Hospital in Jerusalem as the operation of choice for operable breast cancer. In recent years alternative, less extensive operations have been employed, leading to a controversy, not yet settled, as to the proper treatment for operable breast cancer l(Crile, 1974,1975; Hayward, 1974b). This controversy and the ensuing confusion have prompted us to examine our own experience in the field, and the results are presented below. CLINICAL MATERIAL During the period 1959-1968,213 women with breast cancer were operated on at the Hadassah University Hospital in Jerusalem. Of the 184 women available for follow-up, From the Department of Surgery, Hadassah University Hospital; Department of Experimental Medicine and Cancer Research, Hebrew University-Hadassah Medical School, Jerusalem; and the Computer Science Department, Technion, Haifa, Israel Address reprint requests to Herbert Freund, M.D., Department of Surgery, Hadassah University Hospital, P.O. Box 499, Jerusalem, Israel.

487

0 1977 Alan R. Liss, Inc., 150 Fifth Avenue, New York, NY 10011

488

Freund et al.

32 underwent palliative simple mastectomy only, because of advanced tumor or old age. The present report is an analysis of the 152 women with breast cancer treated by the classical Halsted-Meyer radical mastectomy and followed for a period of at least 5 years. Patient selection for surgery was based on the Columbia clinical classification, according to which there were 9 6 women in stage A, 37 in stage B, and 17 in stage C. Radical mastectomy was performed on patients in stages A and B only; exceptions were made where the disease seemed to be of limited extent, although classified formally as stage C. The operative technique, while performed by various staff members and residents, was uniform.

RESULTS Of the 152 women in this survey, 104 were still alive at the conclusion of the study. Survival was calculated according t o the modification by MacComb (1967) of the BerksonGage presentation of end results and is illustrated graphically in Fig. 1. In stage A the survival is 84% at 5 years and 72% at 10 years; the corresponding figures for stage B are 66% and 59%. The attrition as a function of time is similar for the 2 stages. The total number of patients in stage C is too small to justify drawing general conclusions, but the sharp drop in mortality observed after 5 years should be noted. 100

a

$

10

10 0

~

1

1

2

3

~

L

1

5

6

’

7

8

~

~

~

1

~

~

9 10 11 1 2 1 3 1 1 1 5 16

VEARS AFTER MASTECTOMY Fig. 1. Cumulative percentage of survivors in 152 women with breast cancer stages A, B, and C, treated by radical mastectomy and followed for at least 5 years.

In this series of 152 radical mastectomies, there were 18 instances of local recurrence in 15 patients (9.8%): 12 in the chest wall (7.9%) and 6 in the axilla (3.9%); there were no parasternal recurrences (Table I). Chest wall recurrence occurred mainly during the first 2 years after surgery, 75% of the patients dying within 2 years of its appearance. Of the 6 patients with axillary recurrence (3 also had chest wall recurrence) half died within 1 year

1

’

489

Radical Mastectomy for Operable Breast Cancer TABLE I. Local Recurrences bv Stage

Stage A

B C Total

No. of cases

No. of cases

96 39 17 152

6 3 3 12

Chest wall Mean interval (years) Operation- Recurrencerecurrence death

% 6.2

1.7 11.6 1.9

No. of cases

%

3 2 1 6

3.1 5.1 5.9 3.9

3.0 2.3 1.0 2.3

2.1 3.0 3.0 2.8

Axilla Mean interval (years) Operation- Recurrencerecurrence death

6.0 3.0 6.0 5.0

3.0 1.0 >1 2.0

of its detection. Thus, although axillary recurrence occurs later in the disease than chest

wall recurrence, the outcome is n o better, both carrying a grave prognosis (Table I). At the conclusion of this study, 100 patients were without any signs of metastases or recurrences. There were 52 patients (34.2%) with a total of 110 metastatic sites, including the 18 local recurrences already discussed (Fig. 2). Half of the metastases occurred within the first 2 years after surgery, most of them during the second postoperative year. Pathologically involved lymph nodes were found at the initial surgery in 57% of these cases, compared t o only 33% in women with no metastases ( p < 0.01). Average survival folllowing the occurrence of metastases was 1-2 years, being quite independent of whether they appeared early or late after surgery.

NO of

40

I'

recurrency silos

32 30

-

20

-

10-

0-1

1-2

LOCAL

4

5

2-3

3-4

4-5

5-7

1

2

AXILLARY L.N.

1

SECOND BREAST

1

2

BONES

4

10

2

1

3

6

2

LW€R

3

5

2

1

1

1

1

LUNGS

5

4

5

1

4

2

4

BRAIN

3

6

1

1

3

2

1

21

32

13

4

13

15

a

7-10

>10

y w r s after masfecfomy 2

2

1

2

1

1

1

4

Fig. 2. Appearance and site of 110 local recurrences and metastases in 52 women with radical mastectomy.

490

Freund et al.

DISCUSSION The survival rates in the present series compare favorably with those in other published studies of patients undergoing radical mastectomy (Butcher, 1969 a,b; Getzen and Rifferburgh, 1972; Haagensen, 1974; Payne et al., 1970; Wise et al., 1971; Donegan, 1974; Hayward, 1974a): 72% for 10 year survival in stage A is essentially the same as that in the literature (70%), whereas the 59% 10 year survival in stage B is somewhat better than the average 30-50% usually observed. The results of different treatment modalities are presented in Table 11, our results being rather better. TABLE 11. Results of Various Treatment Modalities: 10 Year Survival Rates (’%)

Modality Local excision Simple mastectomy Simple mastectomy Simple mastectomy and irradiation Modified radical mastectomy Modified radical mastectomy Modified radical mastectomy and irradiation Extended radical mastectomy Radical mastectomy

Source

No. of cases

Clinical stage A B C

Hayward (1974b) Miller (1969) Donegan (1974) McWhirter (1955)

310 212 111 1,781

69 40 50 54

23 26 43

22 0 24

Handley and Thackray (1969)

143

61

25

14

Payne e t al. (1970)

220

78

13

-

Williams and Stone (1969)

142

59

46

19

Dahl-Iversen and Tobiassen (1969) Present study

417

59

21

29

152

12

59

46

-

The local recurrence rate of 9.8% reported here is well within the range accepted in the literature after radical mastectomy and is considerably below the 2 0 4 0 % observed by Miller (1969) and inKaae and Johansen (1969)in patients undergoing simple mastectomy; it is even somewhat less than the 12-24% found by Handley and Thackray (1969) after modified radical mastectomy. The liberal policy adopted for the selection of candidates for operation, based as it was on the conviction that staging criteria are not absolute and that considerable palliative benefit can be achieved by surgical ablation of reasonably well localized tumors proved to be correct as concerns our small group of stage C patients, having results in a 10 year survival rate of 46%. Looking at these results critically, one may maintain that no appreciable benefit can be claimed for radical mastectomy as compared t o less mutilating surgical procedures. This is true only as regards stage A patients with clinically and pathologically uninvolved axillary lymph nodes: In such cases, a modified radical mastectomy or even a simple mastectomy may be as effective (Delarue et al., 1969; Payne et al., 1970). Clinical assessment of lymphatic metastases is inaccurate, however, with an average error in the literature of 34% (Atkins et al., 1972; Butcher, 1969b; Haagensen, 1974; Johnstone, 1972;

Radical Mastectomy for Operable Breast Cancer

491

McLaughlin and Coe, 1973; Rimsten et al., 1974) and in the present study, 39%. Patients with mammary carcinoma cannot safely be treated by local surgery because we now know that in more than half the cases there are multiple impalpable foci in the breast, which local excision does not remove, and that in an equal proportion there are axillary metastases, which will also be left untreated if a procedure other than radical mastectomy is performed; in either case, the prognosis would be very grave. It seems to us, therefore, that until accurate sampling of the state of the axillary nodes can be achieved, radical mastectomy will remain the technique of choice for operable breast cancer. If, on the other hand, the condition of the nodes can be determined by pectoral node histology while performing simplle mastectomy, as suggested by the Cardiff-St. Mary’s trial (Forrest et al., 1974), then reliable staging is perhaps possible during surgery. If this is indeed the case, then conservative local therapy by simple mastectomy alone would be sufficient and safe for patients with uninvolved nodes, while for those with proved lymph node involvement, radical mastectomy should be performed, probably supplemented by systemic therapy.

ACKNOWLEDGMENTS

This investigation was supported in part by a grant from the Israel Cancer Association.

REFERENCES Atkin: