[dr. urban:] primary treatment of breast cancer succeeds when the tumor and its regional lymph-node metastasis are destroyed or removed completely in the absence of systemic spread. appropriate surgery for specific clinical settings should be based, we believe, on gross pathological and anatomical extent of disease present, and should aim to achieve optimal local control while interfering least with physical appearance and function of the patient. many factors are involved in this problem. perhaps we may start off best with the survey of the salvage of untreated breast cancer. let me have the first slide please. as you see here, this is a slide from middlesex hospital in london, by julian blum.
he demonstrated that approximately 18 percent of patients with primary breast cancer survived after the, clinical onset of their disease at five years. this is not very good but we must accept this salvage rate and consider it in evaluating results of therapy. can we have the next slide please. this next slide explains a paradox which all of us have been aware of, and had difficulty in explaining. this is that after a delay of a year or so, the salvage rate of breast cancer doesn't seem to be very much different from that in the group that is picked up early. the reason for this is shown in this slide. in the first year the grade one lesions survive very nicely, but the high grade lesions, the more aggressive lesions,
die off rapidly, so at the end of the year, we have an entirely different set-up in that the more aggressive tumors have been weeded out of our material. the low-grade tumors certainly survive longer and all of them would survive longer with therapy, obviously. in the last sixty years, the salvage rate of breast cancer has improved, probably two- or three-fold, and this is due mainly to the fact that we are getting patients at an earlier stage when the disease is more confined to the breast, and less likely to have spread beyond the confines of the breast and the regional nodes.
this slide demonstrates the salvage rate obtained in a representative group of patients by radical mastectomy supplemented by x-ray therapy. as you see, when the disease is confined to the breast, salvage rate is very satisfactory. as the nodes are involved from the lowermost level of the axilla to the upper level, the salvage drops. since there is more possibility or probability of systemic spread as the local extension of disease progresses. this leads us to probably the most important factor in increasing our salvage rate at present, and this is early diagnosis. next slide please. one of the means of detecting the early patient is to entertain a constant suspicion
of any persistent mass in the breast, whether it appears benign or malignant clinically. in our clinic at memorial hospital we found that roughly eleven percent of the patients who underwent local excision for either indefinite or clinically benign disease proved to have carcinoma on frozen section. these patients did a lot better than the patients who came in with clinically obvious cancer of the breast. next slide please. to pursue this a bit further, we're not going to find the early lesions unless we look for them. physical examination is absolutely essential; we can't depend solely on mammography or any other laboratory technique. the mere careful examination of the patient is most important. this slide demonstrates a patient who on the right appears completely symmetrical.
however, on elevating the arms, tensing the pectoral sheath, an obvious deformity in the left breast is apparent. now, we can't depend upon the age of the patient to help us to decide whether to do a biopsy or not. here are two patients who are on the ward service at memorial at the same time. one was eighty, the other eighteen. both of them had cancer of the breast. next please. the clinical appearance of a lesion can very often be misleading and this necessitates surgical biopsy for any persistent mass, whether it appears benign or malignant.
this...we'll show you a few representative slides here, go over them quickly please, and these are nipple lesions which should be easily diagnosed but actually are very difficult to diagnose. the first one is a patient with an intraductal papilloma coming through the duct and appearing on the surface of the nipple. the next which looks very similar, is a patient with early paget's disease of the nipple. the next please. the next slide is a representative picture of eczema of the nipple with a typical weeping, crested lesion of the nipple and areola. and the next slide which looks very similar, actually proved to be paget's when biopsy was taken.
so that even when we can see these lesions on the surface, we really cannot have any confidence in our clinical ability to diagnose them accurately. not only is it difficult to diagnose from clinical examination, we also have difficulty even when we have the specimen apparent in the operating room. this lesion, which appears rather mean, proved to be a benign intraductal pathol mitosis tissue in the breast. and the next slide which looks very similar is a gelatinous carcinoma. so by all means forget any pride in your ability to make a definite clinical diagnosis of a breast lesion.
if a mass persists in a breast, persists through a period, take it out to prove its characteristic and to rule out carcinoma. now one of the best illustrations of the importance of early diagnosis comes from clinical data supplied by cancer detection clinics. in this chart from the minneapolis cancer detection clinic as well as from the strang clinic in new york, we see that if you look at the bottom two lines, the salvage rate of patients who are asymptomatic and in whom carcinoma of the breast was detected on routine examination, and the patient is then subjected to surgery,
salvage rate of five years was 85 percent; the nodal involvement was only 30 percent. this is what we can expect to obtain in general practice if all individuals concerned would all cooperate: the patient, local physician, surgeon, radiologist. now even though we would like to get the early patients, i don't think we can be too choosy when we have a situation like this. here's a patient who many would consider inoperable, with an ulcerated tumor of the breast, edema of the skin of the breast, large nodes in the axilla. however, we were unable to find any evidence of systemic disease,
neck was clear, and we decided to do a radical mastectomy on this patient. she proved to have an medullary carcinoma, all the nodes were negative, they're inflammatory. the edema was caused by obstruction of the drainage by mechanical pressure of the tumor and she is now fifteen years post-op free of disease. so i don't think that we do the best we can with our patients by being over-selective in considering operability. may i have the next slide please? now in considering the technique of primary therapy,
we'll devote most of our discussion to surgery, surgical therapy. this is our anatomical set-up. we can attack the breast tumor, its regional lymph node metastases, and the breast itself which, from which the tumor arises. unfortunately we still do not have a good technique for dealing with systemic blood-borne metastasis. this again emphasizes the importance of early diagnosis. now here is our anatomical set-up... the lymphatics of the breast drain to the axilla
and to the internal mammary areas. approximately three-quarters of the lymphatic drainage goes to the axilla and about one-quarter to the internal mammary chain. from either of these depots, further drainage extends into the base of the neck where the lymphatics drain into the large vessels behind the head of the clavicle. now, there are roughly three categories of patients with cancer of the breast to be considered for the various surgical attacks. number one would be the in-situ, or intraductal non-infiltrating cancers which are confined to the breast and in which there is almost no risk of regional node involvement.
these patients do perfectly well with a modified radical. essentially this consists of a complete simple mastectomy plus a low axillary dissection. now, the great majority of patients are patients with early infiltrating breast cancers which arise in the upper outer portion of the breast. in these patients, the main risk of further spread is to the axilla, and these patients we believe should be treated, ideally, by radical mastectomy. finally, we have a small group of patients in whom there is a high risk of internal mammary spread. primarily those with lesions arising in the center and medial portion
of the breast, and we personally prefer to do an extended radical on these patients, and treat the internal mammary area just as we do the axilla in performing a radical mastectomy. now this represents a patient with a very early paget's of the nipple. with a set-up like this, particularly when no induration is palpable beneath the nipple in the duct system, the great likelihood is that we are dealing with early paget's in the nipple and a non-infiltrating microscopic intraductal carcinoma in the underlying duct system.
these patients almost never have axillary node metastasis and these patients do perfectly well, in our experience, when they are treated by the modified approach. the big advantage of doing a simple with a low axillary dissection on these optimal patients, with practically no risk of axillary metastasis, is the physical appearance following the surgery. this patient still has the pectoral muscles and obviously has a better physical appearance and slightly improved functional result than would occur following radical mastectomy.
to prove that this is not an an inadequate therapy for these optimal lesions, we now have some 75 patients who underwent this procedure, again for very early lesions, all of whom are free of disease, many over five years. now this procedure is primarily indicated for the in-situ, non-infiltrating cancers of the breast, particularly when they are microscopic in size. with a bulky tumor, there is a chance that you might miss the infiltrating area in the breast and on this basis, this patient probably should have a radical mastectomy. if you look over the slide, you see that all these lesions are lesions
where we ordinarily don't find nodal involvement. now so much for the modified approach. these patients do very well, and again, these patients are only found when all means at, utilizing all measures for early diagnosis are utilized. mammography, cancer detection clinics, self-examination, and so forth. now, the great majority of patients would be treated, in our experience, or should be treated in our experience, by a radical mastectomy. and this patient demonstrates the result of an adequate radical operation with thin flaps,
complete cleaning out of the axillary content of the neurovascular bundle apparent beneath the skin in the axilla. only through such radical surgery will we get good results. unfortunately very often, or too often, we see a patient with a lesion, with an operation, of this sort referred into the clinic for post-operative x-ray therapy with a note saying that so-and-so has had a radical mastectomy, would you please radiate the breast, and the chest wall, and the axilla. well, this patient has not had an adequate radical, she hasn't even had a complete simple and this sort of surgery is to be condemned.
unless one depends completely on x-ray therapy, there's no place for such surgery in treating breast cancer. this is a representive slide showing the sort of salvage rate we can expect with the use of radical mastectomy in the average group of patients. these thousand patients were treated at memorial hospital between 1945 and '48, and as you see the overall group, 50 percent were free of disease, 57 percent alive at five years. now in the third box down, this is the group which was picked up by local excision of a clinically indefinite or benign lesion, and in this group we,
our salvage rate is almost 70 percent free of disease and close to 75 percent alive at five years. this is actually what we should obtain if all of us were on the ball, the patient included. unfortunately, many patients included in this series were quite advanced and this is what brings down the survival rate in the overall group. we did not include our modified radicals in this evaluation. they're in the bottom box. as you see they are all free of disease, all in uninfiltrating lesions.
now to get to our third surgical effort, the extended radical. we would apply this to patients who have a high risk of internal mammary spread, and we essentially would remove the breast, the axillary content, the internal mammary chain, all in continuity, and attempt to do an en bloc excision of this entire area. this slide demonstrates the, a plotting of the location of the internal mammary nodes in a series of patients explored by darl eveson and his group in copenhagen and as you see, the nodes lie pretty much between the undersurface of the ipsilateral margin of the sternum and the costochondral junction. the dotted line is the area which we resect in removing this area.
we did some baseline studies in an effort to decide which patients would be most suitable for this extended approach. this patient demonstrates a parasternal recurrence in the second inner space there is a mound of cancer coming out of the chest in the intercostal space next to the sternum. we believe this represents an outgrowth of an internal mammary node metastasis, and we use this as an indirect index of frequency of internal mammary spread. on this slide we broke down a study of a thousand patients into the various quadrants of the breast and evaluated the incidence of parasternal recurrence
as the first sign of recurrent cancer. in the overall group, five percent of the patients showed a parasternal recurrence as a first sign of recurrent cancer. this material is based on data on patients treated between 1945 and '48 before the advent of [?] therapy. the sectors next to the sternum, a and c, showed a particularly high incidence, 17 and 20 percent, whereas the outer quadrants, f and g, showed only two percent incidence of parasternal recurrence.
again demonstrates the five year salvage in the same group of patients, and again we have a better salvage rate for the outer-quadrant lesions than for the parasternal lesions. the worst salvage rate when the axillary nodes were negative was for sector a, in the extreme upper inner portion of the breast. only 54 percent of patients with negative axilla survived at five years. sector e is interesting, the subareola area, in that these patients did very well when the axilla was negative and they did very poorly when the axilla was involved.
eighty-four percent salvage with a negative axilla, only 19 percent with a positive axilla and we have found that, by and large, with an infiltrating lesion beneath the areola, if the axilla is involved, about 60 percent have internal mammary involvement. when the axilla is negative, we almost never find anything in the internal mammary. so we have a baseline to compare results to the extended radical. and from studying this material we decided to apply the extended radical mastectomy mainly to patients whose lesions arose in sectors a, b, c, d, and e.
very few in the outer quadrants. next please. this is the technique that we use. here you see, we perform our skin excision just as one would do this for a radical mastectomy. we go at least four cm from the nearest margin of the tumor. we keep our dissection in the flaps outside of the superficial fascia which separates the breast parenchyma from the subcutaneous fat, and we develop our flaps to the clavicle above the costal margin, below the sternum medially, and latissimus muscle laterally.
in the inferior portion of the breast, we preserve the rectus sheath from the level of the sixth inner space inferiorly in order to avoid a diastasis recti. there is very, there is really no proof that the rectus sheath acts as a lymphatic spread to the abdomen and the liver particularly. we expose the muscle over the sixth rib, and cut through the rectus muscle over the sixth, over the fifth inner space. in the upper margin of the wound, we split the pectoralis major muscle
between its two normal heads, the clavicular and the sternal head, through the normal plane. this is found most easily beneath the head of the clavicle, medially. after finding this area, dissect the two muscle bundles through the anatomical separation. we then transect the tendon of the muscle from its attachment on the humerus. here, we now cut through the clavipectoral sheath which is attached to the coracobrachialis muscle laterally, cut through the tendon of the minor muscle, which is enveloped by the sheath, and its attachment to the coracoid,
and cut it from its attachment to the subclavian muscle medially. this is then reflected downward and gives you a very nice approach to the axillary field. in performing, performing the extended radical, after developing our fields and isolating the operative area, we open the first inner space by exposing this area. by reflecting the sternal portion of the pectoralis major muscle downward. this exposes the first inner space just beneath the head of the manubrium, the arch of manubrium and the first rib. the pectoralis muscle is isolated by running a finger
beneath the muscle where it is reflected over the chest wall lateral to its parasternal attachment. the finger above goes through the first inner space level down below... traverses the fifth, fourth, and third inner space levels. and this isolates and mobilizes the muscle, and delineates the parasternal attachment, which corresponds roughly to the costal cartilages. now the segment of chest wall which was isolated in that manner, is now resected from the chest wall by cutting through the first inner space just beneath the first rib
and the arch of the manubrium, transecting the internal mammary vessels beneath the arch of the manubrium, cutting through the parietal pleura at this level. doing the same thing inferiorly, cutting through the two branches of the internal mammary vessels, just above the sixth rib, then splitting the sternum with a lebsche knife, splitting it approximately one-third in from its ipsilateral margin. this creates a trap door in the chest wall. then, we use a heavy shears and cut through the ribs and intercostal soft parts, just at the level of the costochondral junctions.
then we tuck this outward. there is still in continuity with the overlying pectoral muscles and breast. next slide. now the defect in the chest wall is repaired. first we suture the mediastinal pleura to the interior periosteum of the sternum to close off the mediastinum and act as a hemostatic measure. then we insert an underwater catheter through the fifth inner space laterally. now the defect in the chest wall is stabilized and diminished in size through the use of stay sutures,
which run from the cut surface of the sternum to the opposing rib margins. we usually put a, what corresponds to a vertical matrasuture, here and use heavy dermalon sutures. these permanent stay sutures i, we believe lessen the tendency toward loosening of this repair of the chest wall. now, after stabilization of the chest wall defect, we then apply a graft of sterile ox fascia to the defect in the chest wall. this is tacked down with interrupted dermalon, and then after the redundant margins are trimmed, it is smoothed down with a running, continuous locked, fine chromic catgut suture.
in our experience, this material has proven quite satisfactory. it is much more convenient than using the patient's own fascia lata. probably the fascia lata is a bit more durable and lasting. however, this seems to afford a practical means of closing the defect. following closure of the chest wall, we now complete the radical mastectomy in the usual manner, usually preserving the long thoracic nerve and sacrificing the thoracodorsal. we ordinarily can obtain primary closure.
if the flaps are somewhat tight we will, we prefer to undermine the flaps across the midline, to mobilize them rather than using a free graft. we use constant suction beneath the flaps, using a hemovac or similar mechanism and have the underwater catheter come out through the lateral flap and attach to an underwater bottle. this catheter draining the chest cavity is removed two days post-operatively we ordinarily apply a wraparound dressing on the patient following this procedure, and this demonstrates a practical manner of holding the patient, supported on an arm board,
while the dressing is wrapped about. this slide shows in a diagrammatic fashion the relationship between the tumor in the breast, the lymphatic strain in this tumor, and the regional nodes in the axilla as well as in the internal mammary areas. we can do a true en bloc excision of this whole area by this means. here is a typical patient who was operated on fifteen years ago. she had a lesion beneath the right areola. you can see some deviation of her nipple and a mark in the skin from the aspiration biopsy incision.
this shows the specimen removed from this patient, demonstrating the tumor mass adjacent to the areola. the next slide shows the undersurface of the specimen which has already been cleared in the pathology laboratory. however, it gives us a good idea of the extent of chest wall excision. you see the sternal margin, the second, third, fourth, and fifth costal cartilages. shows the patient with some added deformity in the depression next to the sternum. this patient was one of our early patients at that time we inserted the fascia on the inside of the chest wall
and obtained good support but added deformity. we now apply the fascia on the outside and avoid this depression next to the sternum. this patient had a positive node in the internal mammary area and a positive node in the axilla, and is now fifteen years free of disease. this slide shows the operative field following removal of the specimen and closure of the chest wall defect with a fascia lata graft. you see the axillary vessels and nerves up above, underwater catheter draining the chest running down below thin flaps. this is the specimen removed from this patient,
again demonstrating the in-continuity en bloc principle and showing the internal mammary vessels apparent beneath the parietal pleura of the chest resection. this is a patient, corresponding to the previous specimen, with very little added deformity as compared with a classical radical mastectomy. here is another patient whose primary lesion arose in a second inner space next to the sternum, necessitating a rather unorthodox skin incision. we used the usual elliptical incision with a right-angle extension going across the midline encompassing the tumor area and wound up with a t-type closure.
we've now done over 600 patients at the memorial hospital using this technique. we've had two post-operative deaths within thirty days of surgery. one patient dying of a stroke and the other of a perforated peptic ulcer. this operative mortality is actually less than the operative mortality of radical mastectomy in many clinics. it is only possible when very meticulous care is taken of patients, and this procedure should be done only under ideal circumstances. now because of our selection of patients, we have a relatively high incidence of internal mammary metastasis.
as you see on the chart, although only 48 percent of our patients had axillary metastasis, 33 percent had internal mammary disease. as a matter of fact, 15 percent of our patients with no metastasis in the axilla had internal mammary metastasis. if we had taken all comers our incidence of internal mammary spread would probably be somewhere around 12 percent only. it's all very well to take this out, but can you salvage these patients? actually this slide demonstrates that you can salvage as many patients who have internal mammary disease as you can patients with axillary disease. if you look at the third line, only axillary involvement, you see that we have 57 percent of patients free of disease
and 64 percent alive at five years. go down two more lines and we have practically the same salvage rate for patients with only internal mammary disease. when both areas were involved, we still had a fairly respectable salvage rate: 45 percent alive and 37 percent free of disease. in the overall group, where 54 percent of the patients had positive nodes, we had 70 percent surviving at five years. probably the most impressive figure is our low local recurrence rate, 7.3 percent. at ten years, we still have a fairly good salvage rate.
ten year figures are quite impressive but they are difficult to evaluate because of the many incidental factors which occur over a long period of time to these patients. it is of interest in this group of 175 patients that 13 of them developed a new cancer in the opposite breast. also that 15 of these patients died of other disease without evidence of breast cancer. they're all included in the figures. and as you see here, patients with internal mammary disease, we had 33 percent free of disease at ten years
and 22 percent of patients with both axillary and internal mammary were still free of the disease at ten years. despite the loss of patients to other diseases, 49 percent of the original group were alive at five years, and 45 percent, at ten years, excuse me, and 45 percent free of disease. now, when considering salvage rates, i think the important thing is to consider overall salvage rate. most statistics are based on selected series and we can select series that are particularly favorable.
or for some reason or another, select series which emphasize one of several factors involved in this problem. when we consider the overall approach, we find that the more adequate the primary therapy, the better the overall salvage rate. the importance of considering overall salvage rate is that it eliminates the bias of selection. now in this slide here, we see a series of statistics covering various clinics treating breast cancer mainly by radical mastectomy,
and comparing them with mcwhirter's material based upon the simple mastectomy and x-ray therapy. and roughly, the radical mastectomy series is anywhere from seven to nine percent better than the simple mastectomy series. the more recent statistics certainly show improved results, primarily because of better material involved in the series. the overall picture at the memorial clinic in new york city between '53 and '55 showed that in the overall group, we had over 54 percent alive at five years. this is despite a loss of two and a half percent to follow-up.
in our primary operable group, which comprised 88 percent of the overall group, a five-year salvage was 80, 80, 60 percent. and in the patients we considered inoperable who comprised twelve percent of the overall group, ten percent were inoperable because of demonstration of systemic disease and only two percent because of extensive local disease. in private practice more recently, the salvage rate is certainly better. again, mainly due to the fact that we have more favorable material. this is the overall picture of a series of patients treated between 1957 and '59,
and as you see in this group, the majority of patients were treated by radical mastectomy, 74 percent alive at five years. a good number treated by extended radical, 75 percent alive. the total group, 74.3 percent salvage at five years. in the inoperable group, which comprised only six percent of this group, no patients were alive at five years. they really were inoperable. in the overall group we had 70 percent five-year salvage,
and we believe this demonstrates the advantage of an aggressive approach, with liberal criteria of operability, and aggressive surgery. now to sum this all up, i think we could sum it up in this manner. that recent improvement in the salvage of primary breast cancer patients has been due to a combination of early diagnosis and continued aggressive surgical therapy, supplemented with x-ray therapy when indicated. early diagnosis obtained through professional and public awareness of the need for early detection provides more patients with localized disease, and less risk of systemic disease at the time of treatment.
this great potential for improvement afforded by early diagnosis should not be canceled by inadequate primary therapy. at present we believe the main aim in the primary therapy of breast cancer will be to accomplish the complete eradication of the primary tumor and its regional node metastasis by surgery and x-ray therapy.
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