乳腺癌保留皮肤改良根治并即刻假体再造与传统改良根治术的疗效比较

目的 比较乳腺癌保留皮肤改良根治并即刻假体再造和传统改良根治术的治疗效果.方法 对2004年1月至2008年12月手术治疗的530例0～Ⅲa期女性乳腺癌患者病例资料进行回顾性分析.530例中,91例行乳腺癌保留皮肤改良根治并即刻假体再造,439例行传统改良根治术.通过比较两组患者术后并发症、局部复发率、远处转移率、病死率的差异,评价乳腺癌保留皮肤改良根治并即刻假体重建与传统改良根治术的疗效.结果 即刻假体再造组随访患者84例,中位随访时间35个月,局部复发率2.4%,远处转移率8.3%,病死率6.0%;改良根治组随访患者439例,中位随访时间36个月,局部复发率3.3%,远处转移率9.5%,病死率6.5%.随访期间两组复发率、转移率、病死率的差异均无统计学意义(P＞0.05).即刻假体再造组术后美观效果随访12个月,医生和患者评估的良好率分别为93%、87%.结论 乳腺癌保留皮肤改良根治并即刻假体再造可以达到和传统改良根治术相当的疗效,并可显著改善患者术后乳房外形美观及生活质量.

Abstract：

Objective To compare the therapy efficiency of immediate implanting breast reconstruction after skin sparing mastectomy and modified radical mastectomy in breast cancer. Methods The data of 530 female patients with early of stage 0 to Ⅲ a breast cancer was retrospectively analyzed, from January 2004 to Decembet 2008. Among the patients,91 patients operated with skin sparing mastectomy and immediate implanting breast reconstruction ( Group of immediate implanting reconstruction), and 439 patients were with modified radical mastectomy (Group of modified radical mastectomy ). By comparing complications, local recurrence, distant metastases and mortality rates between the two groups, the research was done to evaluate the therapy efficiency. Results In the group of immediate implanting reconstruction,84 patients completed follow-up with the median follow-up time of 35 months ( 14-72 months) while the local recurring rate was 2. 4%, distant metastasis rate was 8. 3% and mortality rate was 6. 0%. In the group of modified radical mastectomy, 398 patients completed follow-up with the median follow-up time of 36 months ( 12-74 months) while the local recurring rate was 3.3%, distant metastasis rate was 9. 5% and mortality rate was 6. 5%. Therefore there was no obvious statistic difference between the two groups in local recurring rate, distant metastasis rate and mortality rate (P ＞ 0. 05 ). Evaluation of aesthetic results was done in the 84 patients after immediate implanting reconstruction for 12 months which was 93% as good or excellent by surgeons while 87% by patients. Surgeons and patients were both satisfied with the breast appearance. Conclusions For patients with early stage breast cancer, combining standard postoperative therapy, skin sparing mastectomy and immediate implanting reconstruction could achieve the same effect as the traditional modified radical mastectomy, while reconstruction would bring about better appearance and higher quality of life.     

Attempt for modified radical mastectomy in the treatment of early breast cancer]

Until five years ago the Aichi Cancer Center had adopted the standard radical mastectomy where breast, major and minor pectoral muscles, and axillary adipose tissues were resected en bloc. In case tumor was found at the inner half or the center of the breast, parasternal lymph node dissection was concomitantly carried out. Recently, however, we begin to perform Auchincloss by which major and minor pectoral muscles can be conserved, as an attempt for modified radical mastectomy. In some cases, furthermore, breast conserving operation is made. The reasons why we changed the operation methods are: 1) Due to the advancement of diagnostic imaging and widespread self examination, percentage of early breast cancer has considerably increased. 2) Postoperative adjuvant therapy, especially adjuvant endocrine therapy, has remarkably progressed.     

Inflammatory carcinoma of the breast. A therapeutic approach followed by improved survival.

Disappointing results of radical mastectomy for treatment of inflammatory breast carcinoma led to its abandonment and the use of alternative therapeutic methods without improvement of survival rates. Results of radical mastectomy combined with other therapeutic modalities have not been fully evaluated so far. In a series of nine patients with proven inflammatory breast carcinoma and no distant metastases, two underwent radiotherapy, oophorectomy, and adrenalectomy (group A) and seven underwent preoperative irradiation, radical mastectomy, postoperative irradiation, and chemotherapy (group B). There were no local recurrences in either group. Group A patients survived five and eight months (mean, 6.6+/-2.1) and patients of group B survived 45.5+/-26.2 months (p less than 0.05). Results show no rational basis for withholding radical mastectomy, but suggest that improved survival may be obtained when radical mastectomy is an integral part of a rational sequential therapeutic schedule.     

A multivariate analysis of en bloc extended radical mastectomy versus conventional radical mastectomy in operable breast cancer

We made clinical trials of en bloc extended radical mastectomy (EXT) of a new type in 118 patients from 1980 through 1985. Conventional radical mastectomies (RDL) were also performed in 105 patients from 1973 through 1985. A multivariate analysis was performed to compare the results of EXT and RDL. As the result, the 5-year survival rates of 91 +/- 2.6% and 83 +/- 3.7% were achieved for the EXT and RDL groups, respectively (Cox P value for comparison of survival curves = 0.16). Adjusted Cox regression analysis revealed a significantly favorable result of EXT (P = 0.03). This difference was most remarkable in patients with one to three metastatic axillary lymph nodes, although it was not statistically significant because of too small number of patients available (P = 0.18). The results are thus not definite, but suggest that EXT may be advantageous over RDL especially in patients with a few metastatic axillary lymph nodes.     

A multivariate analysis of en bloc extended radical mastectomy versus conventional radical mastectomy in operable breast cancer.

We made clinical trials of en bloc extended radical mastectomy (EXT) of a new type in 118 patients from 1980 through 1985. A variety of conventional radical mastectomies (RDL) were also performed in 105 patients from 1973 through 1985. A multivariate analysis was performed of the results to compare EXT and RDL. The result showed the 5-year survival rates of 91 +/- 2.6% and 83 +/- 3.7% were achieved for the EXT and RDL groups, respectively (Cox P value for comparison of survival curves = 0.16). Adjusted Cox regression analysis revealed a significantly favourable result of EXT (P = 0.05). This difference was most remarkable in patients with one to three metastatic axillary lymph nodes, although it was not statistically significant because of too small a number of patients available (P = 0.18). The results are thus not definite, but suggest that EXT may be advantageous over RDL especially in patients with a few metastatic axillary lymph nodes.     

Factors contributing to improved local control after mastectomy in patients with breast cancer aged 40 years or younger

Long-term local control rates were studied in a series of 659 patients with invasive breast cancer aged 40 years or younger, who underwent mastectomy in general hospitals in the southern part of the Netherlands between 1988 and 2005. During a median follow-up time of 6.0 years, 34 patients developed a local recurrence in the chest wall without previous or simultaneous evidence of distant disease. The 5- and 10-year actuarial local recurrence rates for the total group were 5.6% (95% confidence interval [95% CI], 3.5–7.7%) and 7.3% (95% CI, 4.7–9.9%), respectively. A multivariate analysis showed that patients receiving radiotherapy (hazards ratio [HR], 0.29; 95% CI, 0.10–0.96) or adjuvant systemic treatment (HR 0.23; 95% CI, 0.08–0.65) had a significantly lower risk of local recurrence. It is concluded that excellent local control rates can be obtained with mastectomy in young women with breast cancer, especially in those who receive adjuvant systemic treatment and/or radiotherapy.     

Patterns of care analysis among women with ductal carcinoma in situ in North Carolina

BACKGROUND: Ductal carcinoma in situ (DCIS) of the breast comprises approximately 25% of new breast cancer cases. The aim of this study was to delineate patterns of care for women with DCIS as related to age, tumor characteristics, and race/ethnicity. Further study goals included the identification of predictors of breast-conserving surgery (BCS), adjuvant radiation, and/or hormonal therapy, as well as breast reconstruction after mastectomy. METHODS: The North Carolina Cancer Registry was queried for primary DCIS treated in 1998 and 1999 (n = 1,893). Logistic regression analysis was performed to define the determinants of patterns of care. RESULTS: Thirty-five percent of the women in this study sample underwent mastectomy. Positive predictors of mastectomy included young age (age <50 y vs 70+; odds ratio [OR], 1.55; 95% confidence interval [CI], 1.13-2.11) and larger tumor size (>2 mm vs 0-1 mm; OR, 2.43; 95% CI, 1.63-3.60). Approximately 48% of women who underwent BCS received adjuvant radiation therapy. Factors associated with receiving radiation therapy after BCS include younger age (age <50 vs 70+; OR, 2.12; 95% CI, 1.49-3.03). Approximately 19% of women who underwent BCS received adjuvant hormonal therapy. Positive predictors of receiving adjuvant hormonal therapy after BCS included age of 50 to 60 years versus 70+ (OR, 2.16; 95% CI, 1.36-3.44) and the receipt of radiation therapy (OR, 3.60; 95% CI, 2.55-5.06). Approximately 28% of women who underwent mastectomy received breast reconstruction surgery. Positive predictors of breast reconstruction after mastectomy included age younger than 50 years versus 70+ years (OR, 47.36; 95% CI, 19.45-115.32). African American race was associated negatively with receipt of breast reconstruction after mastectomy (OR, .46; 95% CI, .26-.84). CONCLUSIONS: Treatment strategies for primary surgical therapy for DCIS vary significantly by age. Inconsistencies exist surrounding the use of adjuvant radiation therapy after BCS in women with DCIS. Variations in approaches to reconstructive surgery after mastectomy may be related to age, ethnicity, and/or economic constraints.     

Comparative risk of leptomeningeal disease after resection or stereotactic radiosurgery for solid tumor metastasis to the posterior fossa

OBJECT: The authors tested the hypothesis that patients with metastatic posterior fossa lesions (MPFLs) treated with resection have a higher risk of leptomeningeal disease (LMD) than those with MPFLs treated with stereotactic radiosurgery (SRS). METHODS: Between 1993 and 2004, 379 patients with MPFLs were treated with resection or SRS at The University of Texas M. D. Anderson Cancer Center. The authors' primary study outcome was the incidence of LMD, as diagnosed with cerebrospinal fluid cytological analysis and/or neuroimaging. RESULTS: Resection was performed in 260 patients, whereas 119 patients underwent SRS. The median patient age was 56 years, 51% of patients were male, and 93% had a Karnofsky Performance Scale score>or=70. The most common primary cancers were those of the lung, breast, and kidney, as well as melanoma. Leptomeningeal dissemination of cancer occurred in 33 patients: 26 in the resection group and 7 in the SRS group (resection group: rate ratio [RR] 2.06, 95% confidence interval [CI] 0.89-4.75, p=0.09). Piecemeal tumor resection (137 cases) was associated with a significantly higher risk of LMD than en bloc resection (123 cases; RR 3.4, 95% CI 1.43-8.12, p=0.006) or SRS (RR 3.37, 95% CI 1.41-8.04, p=0.006), and there was no significant difference in the risk for LMD between en bloc resection and SRS (en bloc resection: RR 0.98, 95% CI 0.34-2.81, p=0.98). The multivariate RR and significance associated with piecemeal resection, however, were consistent, with a strong effect (RR 2.45, 95% CI 1.19-5.02, p=0.02) and no indication of biases associated with tumor size, location, or cystic/necrotic appearance. CONCLUSIONS: There is an increased risk of LMD after piecemeal resection of an MPFL. This increase, although clinically and statistically significant, is not as alarming as previously reported and is absent when en bloc removal is achieved. Further assessment of the role of resection in a controlled prospective setting is warranted.     

The significance of regional lymph node dissection in the surgical management of breast cancer

The results of an analysis done on the regional lymph node metastases of 300 patients with operable breast cancer, who were treated in the Department of Surgery (II), Kanazawa University Hospital from 1973 to early 1988 are reported herein. It was found that the metastases of the axillary and internal mammary lymph nodes were closely related to the survival of patients, but they were hardly diagnosed before the operation. Only the dissection of these lymph nodes proved useful for providing the prognostic information. Moreover, in a retrospective study comparing the en bloc extended radical mastectomy versus the other types of mastectomy, the extended radical mastectomy was seen to greatly improve the survival of patients with 3 or less than 3 metastatic axillary lymph nodes. Thus, the extended radical mastectomy provides the maximum diagnostic and prognostic information, and gives the best chance of loco-regional control of the disease. The anterior chest deformity created by the extended radical mastectomy, however, should be avoided in those patients without internal mammary involvement. We therefore propose the modified extended mastectomy as a staging operation.     

Intraoperative implantation radiation therapy plus lumpectomy for carcinoma of the breast

The preponderance of evidence indicates that lumpectomy plus radiation therapy produces the same survival as modified radical mastectomy in patients with early breast cancer and further suggests that the local failure rate may be lower in the patients who undergo irradiation. In this series, patients were treated with immediate implantation of the tumor bed with iridium Ir 192. There have been two recurrences in the breast from 110 breast cancers (44% had a clinical stage greater than T1, and 41% had axillary-node involvement) in 107 patients followed up for four to 52 months (25.8 +/- 13.3 months [mean +/- SD]). These preliminary data suggest that local treatment failure can be minimized by aggressive, immediate intraoperative implantation of the tumor bed with iridium Ir 192.     

Solitary renal allografts from pediatric cadaver donors less than 2 years of age transplanted into adult recipients

BACKGROUND: Transplantation of solitary pediatric renal allografts from donors 2 years of age or younger into adult recipients is controversial. METHODS: Between 1998 and 2001, 15 solitary renal allografts from pediatric donors 2 years of age or younger were transplanted into adult recipients. Thirty-three en bloc renal allografts transplanted between 1994 and 2001 were used for comparison. En bloc kidneys were considered for separation if they measured greater than or equal to 6 cm in length. Renal function (creatinine clearance [CrCl]) was estimated using the Cockroft-Gault formula. RESULTS: Two-year graft survival for the solitary and en bloc groups were 93% and 77%, respectively (P =0.405). Five grafts were lost because of arterial thrombosis (four en bloc and one solitary). Ureteral complications occurred in three grafts in the en bloc group. One-year postoperative CrCl of the surviving solitary (n=14) and en bloc (n=26) grafts were 51.4+/-26.2 mL/min and 55.1+/-27.5 mL/min (P >0.05), respectively. Donor weight and kidney length were greater in the solitary group (14.3+/-3.5 kg and 6.3+/-0.4 cm, respectively) compared with the en bloc group (10.8+/-2.6 kg and 5.9+/-0.3 cm, respectively) (P =0.001 and P <0.001). CONCLUSIONS: Separation of en bloc pairs into solitary allografts can be considered when the graft measures greater than or equal to 6 cm in length and donor weight is greater than or equal to 14 kg. The transplantation of solitary pediatric kidneys into adult recipients is successful, and the majority of pediatric en bloc allografts can be separated before transplantation.     

保留乳头乳晕复合体乳腺癌根治即刻胸大肌包裹假体植入乳房重建

目的 探讨保留乳头乳晕复合体(NAC)的乳腺癌改良根治术即刻胸大肌包裹假体植入乳房重建的可行性.方法 对28例0、I、II期乳腺癌行保留皮肤的乳腺癌改良根治术后,即刻于胸大肌后方植入硅胶假体重建乳房,并根据冰冻切片结果决定是否保留NAC.结果 28例早期乳腺癌均保留了NAC,术后随访2～18个月(中位随访期:15个月),外观良好,双侧乳房对称,优良率达96.5%;均无局部复发或远处转移,无明显术后并发症.结论 保留NAC的乳腺癌改良根治术后用硅胶假体行即刻乳房重建,能达到满意的乳房美容效果,是治疗早期乳腺癌安全可行的方法.     

Effect of preoperative chemotherapy on mastectomy for locally advanced breast cancer

Mastectomy is frequently performed after intensive chemotherapy for locally advanced breast cancer. The effects of preoperative chemotherapy on the postoperative course and the timing of subsequent adjuvant therapy, however, have not been defined. We therefore reviewed the perioperative course of 54 patients undergoing mastectomy after combination (CAMFPT) chemotherapy for stage IIIA,B (IIIA - 25 pts; IIIB noninflammatory - 5 pts; IIIB inflammatory-24 patients) breast cancer. A median of 7 cycles (6 months) of chemotherapy was administered preoperatively. Mastectomy was performed a median of 20 days after last chemotherapy; white blood cell count (WBC) and platelet counts returned to normal limits preoperatively. Total mastectomy with or without axillary node dissection was performed in 53 patients, and a Halsted radical mastectomy in 1 patient. Negative margins on breast and/or axillary tissue were achieved in 47 patients (87.0%). Postoperative complications included skin flap necrosis in 8 patients (14.8%), seroma formation in 5 patients (9.3%), and wound infection in 1 patient (1.9%). Median operative blood loss (550 cc), hospital stay (8 days), and duration of wound catheter drainage (6 days) were comparable to published reports for modified radical mastectomy without preoperative chemotherapy. Systemic chemotherapy was resumed a median of 16 days after mastectomy, and radiotherapy started a median of 33 days after mastectomy. These findings indicate that intensive preoperative chemotherapy does not increase the hospital course or the postoperative complications of mastectomy for locally advanced breast cancer. In view of the current interest in treatment of stage I and II breast cancer with preoperative chemotherapy, this information may be useful in their management as well.     

邻近受侵器官一并切除的肾癌根治术

目的探讨肾癌根治术邻近受侵器官一并切除的可行性及临床意义。方法对24例肿物直接侵犯至周围器官的肾癌患者施行邻近受侵器官一并切除的手术，其中左肾连同结肠脾曲、部分降结肠切除7例，部分胰体、胰尾、脾脏切除者5例，单纯连同脾脏切除者3例；右肾连同结肠肝曲切除4例，肝右后叶部分切除者4例，十二指肠降部部分切除1例。24例中部分腰大肌切除5例，合并结肠系膜部分切除者7例。术后9例行免疫治疗。结果本组24例无手术死亡，住院期间无严重并发症出现。术后21例获随访，随访时间3～240个月，1、3、5、8年生存率分别为90．5％（19／21）、42．9％（9／21），33．3％（7／21）及19．0％（4／21）。结论对丁局限于周围器官受侵的肾癌，外科手术切除仍然是首选。患者条件允许时，将邻近受侵器官一并扩大切除，能达到肾癌根治切除的要求，在有一定普通外科经验的条件下，手术较为安全。有可能延长生存时间，并为后续的系统性治疗创造有利条件。     

Breast cancer and regional lymph node dissections

Regional lymph node metastases were evaluated in 289 patients with operable breast cancer. The metastases of the axillary and internal mammary lymph node were shown to be closely related to the survival of patients, but the status of these nodes was shown to be impossible to estimate before the operation. Thus, axillary and internal mammary node dissections seem to be very important in order to attain an acceptable amount of information for staging of certain breast cancer patients. Due to the radicality of operations including internal mammary node dissection, the use of modified extended mastectomy is proposed as the staging operation. In this manner, the anterior chest deformity created by an extended radical mastectomy can be avoided and the pectoralis major muscle spared in patients without internal mammary lymph node involvement. Also found in this study, was some evidence of the beneficial use of en bloc extended radical mastectomy for the survival of a selected group of patients.     

Extent of chest wall invasion and survival in patients with lung cancer.

BACKGROUND: The long-term survival after operation of patients with lung cancer involving the chest wall is known to be related to regional nodal involvement and completeness of resection, but it is not known whether the depth of chest wall involvement or the type of resection (extrapleural or en bloc) affects either the rate of local recurrence or survival. METHODS: We retrospectively reviewed the Memorial Sloan-Kettering Cancer Center experience between 1974 and 1993 of 334 patients undergoing surgical exploration for lung cancer involving the chest wall or parietal pleura. RESULTS: Of 334 patients who underwent exploration, 175 had apparently complete (R0) resections, 94 had incomplete (R1 or R2) resections, and 65 underwent exploration without resection. The overall 5-year survival of R0 patients was 32%, of R1 or R2 patients 4%, and of patients undergoing exploration without resection 0%. In the patients undergoing R0 resections, the extent of chest wall involvement was limited to the parietal pleura in 80 patients, and extended into the ribs or soft tissues in 95. The 5-year survival of R0 patients with T3 N0 M0 disease was 49%, T3 N1 M0 disease 27%, and T3 N2 M0 disease 15% (p < 0.0003). Independent of lymph node involvement, a survival advantage was observed in R0 patients if the chest wall involvement was limited to parietal pleura only, rather than invading into the chest wall musculature or ribs. CONCLUSIONS: Survival of patients with lung cancer invading the chest wall after resection with curative intent is highly dependent on the extent of nodal involvement and the completeness of resection, and much less so on the depth of chest wall invasion.     

Anaplastic (undifferentiated) thyroid carcinoma (ATC)

BACKGROUND: Old age, reduced general condition and far advanced tumor stage associated with poor prognosis induced the belief that, apart from verifying the diagnosis of anaplastic thyroid carcinoma (ATC) by biopsy, no additional surgery would be justified. However, in some cases, an ultraradical approach was recommended in order to improve the quality of life and survival. METHODS: These are the results of a retrospective analysis involving 120 patients subjected to restricted radical surgery (excising as much as possible of the tumor and local metastases, foregoing ultraradical removal of vital organs such as esophagus, larynx and trachea). RESULTS: Irrespective of the surgical approach used, 6+/-2% of the patients were alive after 5 years (median survival time: 3.1 months). Patients without tumor residues (R0-resections; extending to soft tissue only; Kaplan-Meier estimate - cumulative survival 15+/-5%) had a significantly better prognosis than patients with tumor residues (R1/R2-resections; no patient survived 5 years; P<0.001). Tumor morphology (spindle cells, giant cells, mixed cells) or differentiated parts of the tumor as well as lymph-node involvement had no statistically significant impact on the prognosis. CONCLUSIONS: In ATC, the objective should be to remove as much of the carcinoma as possible (in the ideal case, a thyroidectomy); if lymph nodes are affected, neck dissection should be the goal, if possible (restricted radical approach, improving quality of life). Ultraradical surgery to include segmental resection of larynx, trachea or esophagus do not seem to be indicated, as prolonged survival is questionable and quality of life is certainly diminished.     

早期乳腺癌的保乳综合治疗疗效分析

目的　评价早期乳腺癌保乳综合治疗的疗效。方法　保乳组 92例 ,行保留乳房的肿瘤切除加腋窝淋巴结清扫术 ;对照组 60例 ,行乳癌改良根治术。术后给予放疗、全身化疗和 /或内分泌治疗。结果　平均随访 5 7个月 ,保乳组中无局部复发病例 ,3年生存率为 97.2 % ,5年生存率为 89.3 % ,远隔脏器转移率为 6.5 % ;对照组局部复发 2例 ,3年生存率为 97.5 % ,5年生存率为90 .1% ,远隔脏器转移率为 5 .0 % ,两组各指标对比无明显差异 (P >0 .0 5 )。结论　早期乳腺癌采用保乳综合疗法 ,可以达到与根治术相似的治疗效果 ,可作为首选方法     

Local Control Following Single-Dose Intraoperative Radiotherapy Prior to Surgical Excision of Early-Stage Breast Cancer

Background

Multiple partial breast radiotherapy techniques are available. We have previously presented the technical details of our procedure of delivering partial breast irradiation with a single fraction of intraoperative radiotherapy (IORT) targeting the tumor in situ prior to partial mastectomy. This study details our completed, single-institution trial.

Materials and Methods

An IRB-approved, DSMB-monitored phase II trial was performed with the following inclusion criteria: women age ≥48, ultrasound-visible invasive ductal cancers <3 cm, clinically negative axillary nodes. IORT was delivered using mobile electron irradiator, at least a 1.5-cm radial and 1-cm deep margin; patients received 15 Gy and immediately underwent partial mastectomy. Ipsilateral breast recurrence was classified as true/marginal, elsewhere in the breast or nodal basin. Kaplan-Meier methods were used to estimate survival functions and exact 95% confidence intervals are reported.

Results

Between 2003 and 2007, 71 women underwent IORT (median follow-up: 3.5 years). For patients with tumor-involved or close margins, additional therapy was required: 7 patients, total mastectomy; 11, whole breast radiation. Four women experienced invasive ipsilateral breast failures (1 new primary, 3 margin recurrences) for a 3-year local control rate of 49 of 53 (94.8%; 95% confidence interval 92.4% [95% CI] 84.2–98.3%), actuarial three-year in breast recurrence was 8% (95% CI 2–18%), and breast cancer-specific survival was 100%.

Conclusions

Intraoperative radiotherapy delivered to an in situ tumor is feasible, but our local control rate at 3.5 years is concerning. Possible changes to this technique to improve local control rates include better preoperative imaging (MRI), routine intraoperative ultrasound, and improved IORT delivery (larger cone, increased dose).     

A randomized prospective trial of radical (Halsted) mastectomy versus modified radical mastectomy in 311 breast cancer patients.

This study reports the results of a prospectively randomized trial for treatment of carcinoma of the breast comparing standard (Halsted) radical mastectomy to a modified radical mastectomy. Three hundred eleven patients with primary operable carcinoma of the breast were entered in a surgical and adjunctive chemotherapy trial in Alabama between 1975 and 1978. A total of 91 surgeons participated (all Diplomats of the American Board of Surgery and Members of the American College of Surgeons). All operative reports, pathology and therapy were reviewed by referees. Histologically node positive patients were randomized after operation to receive melphalan or C.M.F.(cytoxan, methotrexate, and 5-FU) for 1 year. After a median follow-up of 5.5 years, there was no significant difference in disease-free survival or in overall survival between the two groups. There was a trend toward improved 5-year survival rates in the radical mastectomy group compared to the modified radical mastectomy group (84% vs. 76%, p = 0.14). There was also an increased incidence of local wound recurrence in those patients receiving modified radical mastectomy, but the differences were not statistically significant (p = 0.09). Longer follow-up will be necessary to evaluate these results more fully.