Caldwell B Esselstyn, Jr, MD
Selective surgery for breast cancer In recent years, both in this country and abroad, there has been an evaluation of alternatives to the standard radical mastectomy in the treatment of operable breast cancer. During the past 18 years, a selective surgical treatment of breast cancer has evolved, mainly under the leadership of George Crile, Jr, MD. The essence of this approach is a high degree of individualization of therapy, which includes the technique of biopsy and type of operation together with an appreciation of the patient's desires.
Caldwell B Esselstyn, Jr, MD, FACS, is a member of the staff, department of general surgery, Cleveland Clinic Foundation. He received his MD degree from Case Western Reserve University School of Medicine, Cleveland. Dr Esselstyn is a diplomate of the American Board of Surgery. He was a speaker at the 1975 AORN Congress.
730
Biopsy. A standard biopsy to most surgeons is either excisional or incisional under general anesthesia. If negative, the patient will awaken with her breast; if positive, she will have had a radical mastectomy. In the past three years, we at the Cleveland Clinic have adopted a staged biopsy and primary operation for several reasons: 1. less time under anesthesia 2. less total trauma, which theoretically lessens immune suppression at a time when tumor cells may be circulating in greater numbers from manipulation and dissection in or near the cancer' 3. allows the biopsy site to heal with less chance for internal or external spillage or implantation of tumor cells at primary surgery 4. permits a more accurate evaluation of the pathology and lessens the chance of the infrequent, but tragic, mastectomy for benign disease 5. eliminates the anxious period for the woman with a lump in her breast, who may have to have general anesthesia without knowing whether the breast will be removed 6. allows the surgeon, in conference with the patient, to select the most appropriate operation based on the biopsy.2 The first step in a staged biopsy is
AORN Journal, November 1975, Vol22, No 5
usually aspiration biopsy, performed as a n office procedure with an 18- or 20-gauge needle. A Papanicolaou-type spread is made.3 The technique requires pathologists who are familiar with cytologic techniques. No false positives have occurred where clinical and cytological diagnoses agree that carcinoma is present. Negative aspirations are followed by an open biopsy. For larger tumors or cancer in advanced stages, a Vim-Silverman needle biopsy provides a greater amount of tissue. Immunology. Fundamental to the concept of selective surgical treatment of breast cancer is recognition of hostresistance factors inherent in the immune system. This concept is supported by the fact that patients with immune deficiency syndromes have an increased incidence of cancer. The same phenomenon is seen in patients who are receiving immunosuppressive therapy, particularly €or organ transplantation. Experimentally, there are animal studies defining the role of regional lymph nodes in decreasing metastases or reimplantation of cancer.* More recently, studies from our laboratory and other investigators have shown cytotoxic interaction between axillary lymphocytes and breast cancer cells in women, especially when the axillary nodes were not involved with tumor.5 Assuming that host defense is an integral part of tumor therapy, it becomes important to conserve uninvolved nodes as well as t o remove completely the primary cancer. Simple and modified radical mastectomy. Following confirmation of malignancy, the breast is removed with a transverse elliptical incision from the sternum to the tip of the axillary hairline. Flaps are purposely cut thick. Pectoralis fascia is removed with the specimen. With the breast
Breast cancer stages Stage I: The tumor is confined to the breast. There may be early signs of skin involvement such as dimpling or nipple retraction, but there are no signs of axillary or distant rnetastases. Stage II: The primary tumor is as in stage I, but there are movable, suspicious nodes in the ipsilateral axilla. Stage 111: The primary tumor is infiltrating the skin or chest wall, or the axillary nodes are matted or fixed. Stage IV: Distant metastases are present. Marcus A Krupp, Milton J Chatton, Current Medical Diagnosis & Treatment (Los Altos, Calif: Lange Medical Publications, 1975) 401.
still attached to the axillary tail and with the pectoral muscles well retracted, the axillary fat is carefully explored. If nodes are stony hard and obviously involved, a modified radical mastectomy is done, sparing the muscles. If there is not clear-cut evidence of involvement, one or two of the most prominent low axillary nodes are removed for frozen section. If these are negative, only a simple mastectomy is performed. If they are positive, an axillary dissection is done. Apical nodes are not removed, for with their dissection, the chance for lymphedema is increased but cure is not. If the apex is obviously involved, we agree with Haagensen that radiation therapy is preferable to radical surgery.6 Partial mastectomy. Partial mastectomy is not to be confused with the term lumpectomy, a deplorable term connoting a simple enucleation of cancer. Partial mastectomy implies a removal of the primary cancer to-
AORN Journal, November 1975, V a l 22, No 5
73 1
gether with overlying skin, 3 cm of breast tissue around the cancer, and pectoralis fascia. The incision, except in medially placed lesions, terminates in the axilla so that the nodes can be evaluated in the same way as in mastectomy. If the nodes are involved, the axilla is dissected in continuity. Unless the breast is large, partial mastectomy is limited to lesions peripherally placed and 2 cm or less in diameter. Candidates should not have a strong family history of breast cancer, and xeromammography should rule out other suspicious areas in the breast to be operated. If previous biopsy suggests a diffuse lobular or interductal cancer, a mastectomy is performed. Results. A review of 624 consecutive patients treated in the manner outlined and followed for 5 to 15 years revealed a crude five-year survival rate of 58% in all stages. The five-year survival rate of patients with operable cancers in Stage I and Stage I1 was 71%. Proof of the prognostic validity of staging is the five-year survival rate of % for Stages 111 and IV. Fifty-seven patients in Stages I and I1 who were followed for 5 to 15 years had a partial mastectomy, and most of them have done well. Obviously their high survival rate reflects selection of favorable cases. However, it becomes more meaningful when the patients are matched by size of tumor and involvement of nodes with a similar number of patients treated by total mastectomy with or without axillary dissection. After partial mastectomy, the five-year survival rate was 77% compared to 7Wo in the more conventionally treated group. Conclusion. Until the biological mechanisms of breast cancer are more fully understood, surgery remains at best a macroscopic approach to a microscopic disease. Its goal should be
732
maximal survival with minimal morbidity.
0
Notes 1. B Fisher, E R Fisher, “Experimentalstudies of factors influencing hepatic metastases. 111. Effect of surgical trauma with special reference to liver injury,” Annals of Surgery, 150 (1959) 731-744. 2. G Crile, Jr, “Breast cancer and informed consent,” Cleveland Clinic Quarterly (1972) 57-59. 3. J Zajicek, et al, “Aspiration biopsy of mammary tumor in diagnosis and research. A critical review of 2,200 cases,” Acta Cytology, 11 (1967) 169- 175. 4. G Crile, Jr, “The effect on metastasis of removing or irqdiating regional nodes of mice,” Surgery, Gynecology & Obstetrics, 126 (1968) 1270-1271; B Fisher, E R Fisher, “Studies concerning the regional lymph node in cancer. II. Maintenance of immunlty,” Cancer, 29 (1972) 1496-1501. 5. S D Deodhar, G Crile, Jr, C Esselstyn, Jr, “Study of the tumor cell-lymphocyte interaction in patients with breast cancer,“ Cancer, 29 (1972) 1321-1325. 6. C D Haagensen, Diseases of the Breast, 2nd ed (Philadelphia: W B Saunders, Co, 1971). 7. G Crile, Jr, “Partial mastectomy for cancer of the breast,” Surgery, Gynecology & Obstetrics, 136 (1973) 929-933.
ICS annual meeting The annual meeting of the International College of Surgeons, United States Section, will be Dec 5 to Dec 9 at the Sheraton Waikiki Hotel, Honolulu. Special sessions have been arranged for nurses and paramedics which are separate from the overall surgical program. However, registrants may attend any of the surgical lectures at no fee. There is no registration fee, but advance registrations are necessary and may be made with William Houser, 1516 N Lake Shore Dr, Chicago, 111 60610.
AORN Journal, November 1975,Vol22, NO 5
Selective surgery for breast cancer In recent years, both in this country and abroad, there has been an evaluation of alternatives to the standard radical mastectomy in the treatment of operable breast cancer. During the past 18 years, a selective surgical treatment of breast cancer has evolved, mainly under the leadership of George Crile, Jr, MD. The essence of this approach is a high degree of individualization of therapy, which includes the technique of biopsy and type of operation together with an appreciation of the patient's desires.
Caldwell B Esselstyn, Jr, MD, FACS, is a member of the staff, department of general surgery, Cleveland Clinic Foundation. He received his MD degree from Case Western Reserve University School of Medicine, Cleveland. Dr Esselstyn is a diplomate of the American Board of Surgery. He was a speaker at the 1975 AORN Congress.
730
Biopsy. A standard biopsy to most surgeons is either excisional or incisional under general anesthesia. If negative, the patient will awaken with her breast; if positive, she will have had a radical mastectomy. In the past three years, we at the Cleveland Clinic have adopted a staged biopsy and primary operation for several reasons: 1. less time under anesthesia 2. less total trauma, which theoretically lessens immune suppression at a time when tumor cells may be circulating in greater numbers from manipulation and dissection in or near the cancer' 3. allows the biopsy site to heal with less chance for internal or external spillage or implantation of tumor cells at primary surgery 4. permits a more accurate evaluation of the pathology and lessens the chance of the infrequent, but tragic, mastectomy for benign disease 5. eliminates the anxious period for the woman with a lump in her breast, who may have to have general anesthesia without knowing whether the breast will be removed 6. allows the surgeon, in conference with the patient, to select the most appropriate operation based on the biopsy.2 The first step in a staged biopsy is
AORN Journal, November 1975, Vol22, No 5
usually aspiration biopsy, performed as a n office procedure with an 18- or 20-gauge needle. A Papanicolaou-type spread is made.3 The technique requires pathologists who are familiar with cytologic techniques. No false positives have occurred where clinical and cytological diagnoses agree that carcinoma is present. Negative aspirations are followed by an open biopsy. For larger tumors or cancer in advanced stages, a Vim-Silverman needle biopsy provides a greater amount of tissue. Immunology. Fundamental to the concept of selective surgical treatment of breast cancer is recognition of hostresistance factors inherent in the immune system. This concept is supported by the fact that patients with immune deficiency syndromes have an increased incidence of cancer. The same phenomenon is seen in patients who are receiving immunosuppressive therapy, particularly €or organ transplantation. Experimentally, there are animal studies defining the role of regional lymph nodes in decreasing metastases or reimplantation of cancer.* More recently, studies from our laboratory and other investigators have shown cytotoxic interaction between axillary lymphocytes and breast cancer cells in women, especially when the axillary nodes were not involved with tumor.5 Assuming that host defense is an integral part of tumor therapy, it becomes important to conserve uninvolved nodes as well as t o remove completely the primary cancer. Simple and modified radical mastectomy. Following confirmation of malignancy, the breast is removed with a transverse elliptical incision from the sternum to the tip of the axillary hairline. Flaps are purposely cut thick. Pectoralis fascia is removed with the specimen. With the breast
Breast cancer stages Stage I: The tumor is confined to the breast. There may be early signs of skin involvement such as dimpling or nipple retraction, but there are no signs of axillary or distant rnetastases. Stage II: The primary tumor is as in stage I, but there are movable, suspicious nodes in the ipsilateral axilla. Stage 111: The primary tumor is infiltrating the skin or chest wall, or the axillary nodes are matted or fixed. Stage IV: Distant metastases are present. Marcus A Krupp, Milton J Chatton, Current Medical Diagnosis & Treatment (Los Altos, Calif: Lange Medical Publications, 1975) 401.
still attached to the axillary tail and with the pectoral muscles well retracted, the axillary fat is carefully explored. If nodes are stony hard and obviously involved, a modified radical mastectomy is done, sparing the muscles. If there is not clear-cut evidence of involvement, one or two of the most prominent low axillary nodes are removed for frozen section. If these are negative, only a simple mastectomy is performed. If they are positive, an axillary dissection is done. Apical nodes are not removed, for with their dissection, the chance for lymphedema is increased but cure is not. If the apex is obviously involved, we agree with Haagensen that radiation therapy is preferable to radical surgery.6 Partial mastectomy. Partial mastectomy is not to be confused with the term lumpectomy, a deplorable term connoting a simple enucleation of cancer. Partial mastectomy implies a removal of the primary cancer to-
AORN Journal, November 1975, V a l 22, No 5
73 1
gether with overlying skin, 3 cm of breast tissue around the cancer, and pectoralis fascia. The incision, except in medially placed lesions, terminates in the axilla so that the nodes can be evaluated in the same way as in mastectomy. If the nodes are involved, the axilla is dissected in continuity. Unless the breast is large, partial mastectomy is limited to lesions peripherally placed and 2 cm or less in diameter. Candidates should not have a strong family history of breast cancer, and xeromammography should rule out other suspicious areas in the breast to be operated. If previous biopsy suggests a diffuse lobular or interductal cancer, a mastectomy is performed. Results. A review of 624 consecutive patients treated in the manner outlined and followed for 5 to 15 years revealed a crude five-year survival rate of 58% in all stages. The five-year survival rate of patients with operable cancers in Stage I and Stage I1 was 71%. Proof of the prognostic validity of staging is the five-year survival rate of % for Stages 111 and IV. Fifty-seven patients in Stages I and I1 who were followed for 5 to 15 years had a partial mastectomy, and most of them have done well. Obviously their high survival rate reflects selection of favorable cases. However, it becomes more meaningful when the patients are matched by size of tumor and involvement of nodes with a similar number of patients treated by total mastectomy with or without axillary dissection. After partial mastectomy, the five-year survival rate was 77% compared to 7Wo in the more conventionally treated group. Conclusion. Until the biological mechanisms of breast cancer are more fully understood, surgery remains at best a macroscopic approach to a microscopic disease. Its goal should be
732
maximal survival with minimal morbidity.
0
Notes 1. B Fisher, E R Fisher, “Experimentalstudies of factors influencing hepatic metastases. 111. Effect of surgical trauma with special reference to liver injury,” Annals of Surgery, 150 (1959) 731-744. 2. G Crile, Jr, “Breast cancer and informed consent,” Cleveland Clinic Quarterly (1972) 57-59. 3. J Zajicek, et al, “Aspiration biopsy of mammary tumor in diagnosis and research. A critical review of 2,200 cases,” Acta Cytology, 11 (1967) 169- 175. 4. G Crile, Jr, “The effect on metastasis of removing or irqdiating regional nodes of mice,” Surgery, Gynecology & Obstetrics, 126 (1968) 1270-1271; B Fisher, E R Fisher, “Studies concerning the regional lymph node in cancer. II. Maintenance of immunlty,” Cancer, 29 (1972) 1496-1501. 5. S D Deodhar, G Crile, Jr, C Esselstyn, Jr, “Study of the tumor cell-lymphocyte interaction in patients with breast cancer,“ Cancer, 29 (1972) 1321-1325. 6. C D Haagensen, Diseases of the Breast, 2nd ed (Philadelphia: W B Saunders, Co, 1971). 7. G Crile, Jr, “Partial mastectomy for cancer of the breast,” Surgery, Gynecology & Obstetrics, 136 (1973) 929-933.
ICS annual meeting The annual meeting of the International College of Surgeons, United States Section, will be Dec 5 to Dec 9 at the Sheraton Waikiki Hotel, Honolulu. Special sessions have been arranged for nurses and paramedics which are separate from the overall surgical program. However, registrants may attend any of the surgical lectures at no fee. There is no registration fee, but advance registrations are necessary and may be made with William Houser, 1516 N Lake Shore Dr, Chicago, 111 60610.
AORN Journal, November 1975,Vol22, NO 5
