Modified radical mastectomy and lymphocyte subsets of regional lymph nodes

Whether or not regional lymph nodes in tumor-bearing hosts possess special immunological properties, still remains an important problem in the management of breast cancer. Regional lymph node cells from 22 patients with breast cancer were immunologically studied using monoclonal antibodies, OKT-3, 4, 8, OK-M 1, Leu-7, and laser flow cytometry. Among these patients, 13 early cancer patients underwent modified radical mastectomy (Auchincloss operation or Patey operation) and 9 underwent standard radical mastectomy (resection of breast, pectoralis major muscle and axillary dissection). More helper T lymphocytes defined by OKT-4 were found in regional lymph nodes in modified radical mastectomy patients in comparison with standard radical mastectomy patients. In patients given the modified operations, NK activity defined by OK-M 1 or Leu-7 were significantly increased, especially in lateral axillary lymph nodes. Also, OK-M 1 lymphocytes and Leu-7 lymphocytes were increased in lymph nodes without metastasis rather than those with metastasis. These findings suggest that regional lymph nodes may have defence mechanisms against the spread of tumor cells in early cancer patients.     

Resectable breast cancer: axillary dissection sparing pectoralis muscles and nerves

In breast cancer surgery, axillary dissection is currently considered an essential step. Nevertheless, procedures commonly used include the resection of the pectoralis minor muscle and/or pectoralis nerves. Since 1984 we have performed axillary dissection by sparing both the pectoralis muscles and their nerves. In this paper we present the surgical technique. The comparison of the two groups with clinical N0 N1a assessment, the former of 103 patients submitted to this kind of surgical procedure, the latter (108 women) treated by resection of the pectoralis minor muscle, showed that the mean number of dissected lymph nodes in both procedures was superimposable.     

Complete axillary lymph node dissection for stage I-II carcinoma of the breast

We reviewed the complete axillary dissection specimens of 136 patients with stage I-II breast cancer to clarify the distribution of axillary lymph node metastases in this disease. Our series included 71 patients undergoing axillary dissection as part of a modified radical mastectomy (MRM) and 65 patients undergoing axillary dissection in conjunction with conservative surgery of the breast and definitive postoperative breast radiotherapy (CAD). These two groups of patients were comparable according to age, menopausal status, tumor size, and clinical stage. In all patients the pectoralis minor muscle was excised and all axillary tissue removed. Each specimen contained a median of 23 lymph nodes. The axillary levels (I, II, III) were determined according to the relationship of axillary tissue to the pectoralis minor muscle (lateral, inferior, medial). Thirty-nine percent of the lymph nodes were contained in level I, 41% in level II, and 20% in level III. There were no significant differences noted in the number of lymph nodes or in the distribution of lymph nodes according to axillary level between dissections performed as part of the MRM or those done as a single procedure (CAD). Sixty-five patients (47.8%) had one or more positive lymph nodes in their axillary specimen. The clinical and pathologic stage was determined and compared for all patients. Among patients judged to have a clinically negative axilla, 37.6% had histologically positive lymph nodes (clinical false-negative rate). For patients with a clinically positive axilla, 11.1% had, histologically, no evidence of metastatic disease (clinical false-positive rate). When the distribution of lymph node metastases according to axillary level was studied, it was found that 29.2% of lymph node-positive patients (or 14.0% of all patients) had metastases only to level II and/or III of the axilla, with level I being negative (skip metastases). This incidence of skip metastases was greater among clinically node-negative than among clinically node-positive patients, but was not related to the size or location of the primary tumor in the breast. In addition, it was found that 20.0% of lymph node-positive patients (or 9.6% of all patients) were converted from three or fewer to four or more positive nodes by analysis of lymph nodes contained in levels II and III. This conversion from three or fewer to four or more positive nodes was due primarily to information contained in level II, with level III contributing to a smaller degree.(ABSTRACT TRUNCATED AT 400 WORDS)     

Analysis of 6 cases of stromal sarcoma of the breast

OBJECTIVE To investigate the clinical and pathological characteristics, diagnosis and treatment of stromal sarcoma of the breast （SSB）. Methods： The clinical and pathological data of 6 patients with SSB treated between 1954 and 2007 were retrospectively analyzed.
METHODS The clinical and pathological data of 6 patients with SSB treated between 1954 and 2007 were retrospectively analyzed.
RESULTS All patients were female and one was menopausal. The median age of the patients was 39 years old （range, 20-55）. All cases had a history of a palpable mass. The tumor rapidly augmented in a short time period in 3 patients. One patient had discontinuous pain and 3 patients had masses located in the upper outer quadrant of the breast. The median tumor radius was 6.0 cm （range, 3-15 cm）. According to the AJCC breast cancer staging standard （6th edition）, 1 case was of stage ⅡA, 2 cases were of stage ⅡB, 2 cases were of stage ⅢB and one case couldn＇t be staged. Four patients were initially treated by excising the tumor and then undergoing mastectomy or modified radical mastectomy after recurrence. Radical mastectomy was suitable for those with pectoralis major muscle involvement. Two patients received simple mastectom）~ 2 patients underwent radical mastectomy and another 2 patients received modified radical mastectomy. After surgery, all patients were identified as SSB through pathology, with focal ossification in one case and mucinous degeneration in another one case. Four patients who underwent axillary lymph node dissection did not have lymph node metastases. Three patients received chemotherapy after surgery. After a median follow-up time of 36.5 months （8-204 months）, 4 patients had recurrence after local excision and 3 patients had recurrence more than 2 times with a median time to recurrence of 2.5 months （1 to 4 months） after surgery. One patient had lung metastases at 7 months after the initial surgery and the other 5 patients were alive without disease at the end of the follow-up period.
CONCLUSION SSB is difficult to diagnose preoperatively and is characterized by its tendency to .recur locally. To obtain negative margins, wide local excision or mastectomy must be performed. Axillary lymph node dissection is not mandatory. The roles of adjuvant chemotherapy and radiotherapy have still been controversial.     

Analysis of 6 Cases of Stromal Sarcoma of the Breast

OBJECTIVE To investigate the clinical and pathological characteristics,diagnosis and treatment of stromal sarcoma of the breast(SSB).Methods:The clinical and pathological data of 6 patients with SSB treated between 1954 and 2007 were retrospectively analyzed.METHODS The clinical and pathological data of 6 patients with SSB treated between 1954 and 2007 were retrospectively analyzed.RESULtS Atl patients were female and one was menopausal.The median age of the patients was 39 years old(range,20-55).All cases had a history of a palpable mass.The tumor rapidly augmented in a short time period in 3 patients.One patient had discontinuous pain and 3 patients had masses located in the upper outer quadrant of the breast.The median tumor radius was 6.0 cm(range,3-15 cm).According to the AJCC breast cancer staging standard(6th edition),1 case was of stage ⅡA,2 cases were of stage ⅡB,2 cases were of stage ⅢB and one case couldn't be staged.Four patients were initially treated by excising the tumor and then undergoing mastectomy or modified radical mastectomy after recurrence.Radical mastectomy was suitable for those with pectoralis major muscle involvement.Two patients received simple mastectomy, 2 patients underwent radical mastectomy and another 2 patients received modified radical mastectomy,After surgery,all patients were identified as SSB through pathology,with focal ossification in one case and mucinous degeneration in another one case.Four patients who underwent axillary Iymph node dissection did not have lymph node metastases.Three patients received chemotherapy after surgery. After a median follow-up time of 36.5 months(8-204 months),4 patients had recurrence after local excision and 3 patients had recurrence more than 2 times with a median time to recurrence of 2.5 months(1to 4 months) after surgery.One patient had lung metastases at 7months after the initial surgery and the other 5 patients were alive without disease at the end of the follow-up period.CONCLUSION SSB is difficult to diagnose preoperatively and is characterized by its tendency to recur locally.To obtain negative margins,wide local excision or mastectomy must be performed.Axillary lymph node dissection is not mandatory.The roles of adjuvant chemotherapy and radiotherapy have still been controversial.     

临床腋淋巴结阳性乳腺癌患者行全腋窝淋巴结清扫的应用探讨

背景与目的:临床腋淋巴结阳性乳腺癌患者常规行全腋窝淋巴结清扫,本研究探讨改良根治术时采用改进L3组淋巴结清扫方式的临床应用及意义.方法:322例临床腋淋巴结阳性的乳腺癌患者中,154例采用改进的L3组淋巴结清扫方式,168例行常规Auchinclos改良根治术,对两种手术方式所用时间和术后不良反应进行比较,同时随访观察患者的无病生存率.结果:两种手术方式所用手术时间、术后不良反应差异无统计学意义(P＞0.05),行改进术式患者腋下淋巴结总数及L3组淋巴结数较常规术式多,两组差异有统计学意义(P＜0.05),L3组淋巴结未转移患者5年无病生存率为68.6％,L3组淋巴结转移患者5年无病生存率为35.7％,差异有统计学意义(P＜0.05).结论:对临床腋淋巴结阳性乳腺癌患者行L3组淋巴结清扫具有一定的临床应用价值,采用改进的淋巴结清扫方式,便于L3组淋巴结的清扫.     

Low risk of locoregional recurrence of primary breast carcinoma after treatment with a modification of the Halsted radical mastectomy and selective use of radiotherapy

BACKGROUND: The purpose of the current study was to evaluate the locoregional recurrence rate after treatment of patients with operable breast carcinoma with a modification of the Halsted radical mastectomy and the selective use of radiotherapy and to identify risk factors for locoregional recurrence. METHODS: Between 1979-1987, 691 consecutive patients underwent mastectomy after a negative biopsy of the axillary apical lymph nodes. The median age of the patients was 59 years (range, 26-89 years). The clinical tumor size was < 2 cm in 72 patients, 2-5 cm in 387 patients, and >5 cm in 169 patients; 16 patients had a T4 tumor. Surgery was comprised of a modification of the Halsted radical mastectomy, including at least part of the pectoralis major muscle and the entire pectoralis minor muscle, in 573 patients; 303 patients had positive axillary lymph nodes. Adjuvant radiotherapy to the chest wall and regional lymph nodes was given to 74 patients, whereas an additional 414 patients underwent irradiation to the internal mammary and medial supraclavicular lymph nodes. The median follow-up was 91 months. RESULTS: The actuarial overall survival rate was 82% at 5 years and 63% at 10 years. The 10-year chest wall and regional lymph node control rates, including patients with prior distant failures, were 95% and 94%, respectively. The only two significant prognostic factors for locoregional recurrence on multivariate analysis were lymph node status and pathologic tumor size. CONCLUSIONS: Excellent locoregional control can be achieved with a modified technique of radical mastectomy in patients with negative apical biopsy and the selective use of comprehensive radiotherapy. These results may serve as a reference outcome for comparison with other locoregional treatment strategies.     

Management of operable breast cancer: the surgeon's view.

There is no ideal single operation for breast cancer. In planning the choice of surgery for breast cancer, one must be aware of its multicentric origin, and of the regional spread from the breast to the axillary and internal mammary lymph nodes. The scope of the surgical attack should be correlated with the clinical pathologic extent of disease in the individual patient with the aim of removing all disease present, while preserving appearance and function to the utmost. The main goal remains removal of all disease from the breast and its regional nodes. Three distinct operative procedures have been utilized--modified radical mastectomy--total mastectomy with axillary dissection, radical mastectomy, and extended radical mastectomy. In all instances, the appropriate operation is applied to the individual, with the concept of removing most efficiently all disease present in the breast and regional nodes. With this plan of therapy, a 10 year survival rate of 61% with a local recurrence rat of 7.7% has been attained in a group of 565 patients with 40% axillary node involvement. These data are crude and uncorrected for age, intercurrent disease and for those lost to follow-up. The best salvage has been attained in the so-called "minimal" breast cancers--95% well 10 years following modified radical mastectomy. The extended radical mastectomy has been superior to the radical mastectomy when axillary node disease is present. In the more complete operation, 54% 10 year survival has been attained in patients with axillary node metastases, compared with only 33% attained in those treated by the conventional radical mastectomy. Adjuvant radiation therapy is applied to the adjacent regional nodes, when indicated. Adjuvant multi-chemotherapy is in its infancy and still to be evaluated. It should be used as a supplement to adequate primary surgical treatment, and should not be used as a crutch for inadequate primary surgery.     

改良乳腺癌根治术保留胸前神经的方法及临床意义

目的：探讨在改良乳腺癌根治术中保留胸前神经的方法和临床意义.方法：将68例拟行改良乳腺癌根治术的患者随机分为两组,保留胸前神经组和不保留胸前神经组各34例.保留胸前神经组手术时分开胸大肌暴露并保留胸内、外侧神经,不保留胸前神经组则不保留胸内、外侧神经.其余手术操作相同.术后12个月用彩超测量胸大肌厚度,并与对侧比较.结果：保留胸前神经组无重度胸大肌萎缩,不保留胸前神经组重度萎缩26例（76.5%）.经统计学检验,保留胸前神经组重度胸大肌萎缩情况较不保留胸前神经组明显减少（P＜0.01）.结论：改良乳腺癌根治术中保留胸前神经能减少术后胸大肌萎缩.     

保留乳头乳晕复合体乳腺癌根治术的肿瘤学风险及适应证

保留乳头乳晕复合体（nipple—areolacomplex，NAC）的乳腺癌改良根治术是在保留胸肌的改良根治术的基础上，进一步保留乳头、乳晕，其具有保乳手术良好的效果，同时又达到改良根治术的较低的复发率，可望作为Ⅰ、Ⅱ期乳腺癌手术治疗的常规选择术式。该术式的缺陷在于保留NAC带来的残留癌的风险，因此术前结合NAC浸润相关因素，准确预测NAC受累风险，从而制定恰当的手术适应证是关键。本文就保留NAC的乳腺癌改良根治术的肿瘤学风险及适应证进行综述：     

Extended neck dissection

From the time Crile described radical neck dissection in 1906, this surgical procedure became popular in the management of metastatic cancer in the neck. Over the past two decades, the modified neck dissection has been effectively utilized for conservation of function and cosmesis while achieving the same oncologic goals. However, there are several instances where the above standard procedures are not adequate for resection of malignant tumors. Although there is a definite trend toward conservation procedures, extended neck dissection is often necessary especially in patients with N2 and N3 disease. Apart from the standard structures removed in radical neck dissection, the other structures removed in extended neck dissection include skin, the digastric muscle, hypoglossal nerve, vagus nerve, sympathetic chain, ramus mandibularis, carotid artery, tracheo-esophageal nodes, etc. Over the past seven years, we have performed 40 extended neck dissections. All the patients had N2 or N3 disease in the neck. Nine patients had unknown primaries. Thirteen patients had their primary tumors in the oral cavity and 11 in the laryngopharynx. Five patients had primary tumor in the salivary glands and two patients had metastatic melanoma. Patients who underwent extensive skin excision had pectoralis myocutaneous flap reconstruction. All patients received postoperative radiation therapy. One patient died of cardiac problems 4 weeks after operation. Local control was achieved in 70%. The most difficult region for local control was the disease behind the mastoid process, and the most difficult problems were patients with involvement of the subdermal lymphatics. Our data suggests that there are definite situations where extended neck dissection is indicated with satisfactory local control of the nodal disease.     

Primary non-hodgkin’s lymphoma of the breast: Report of a case with special reference to 380 cases in the Japanese literature

A 52-year-old Japanese woman presented with a mass in the left breast. A tumor 2.9 cm in diameter was found in the D area on ultrasonography. An ipsilateral swollen axillary lymph node was detected. Invasion of the tumor to the pectoralis major muscle was seen. Based on a diagnosis of malignant lymphoma by fine needle aspiration cytology, radical mastectomy with ipsilateral axillary lymph node dissection was performed. Malignant diffuse large B-cell type lymphoma was diagnosed histologically according to the World Health Organization classification, and the clinical stage was II E by the Ann Arbor staging system. Four courses of adjuvant chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) were subsequently performed. The patient is free of recurrence 7 years after surgery. Up to 2002, 380 cases of primary breast non-Hodgkin's lymphoma had been documented in the Japanese literature. When the tumor size was bigger than 4.5 cm, the outcome was poor. Regarding treatment methods, we showed that only enucleation of the tumor is necessary and axillary dissection is not necessary. In our case, we thought that the prognosis was good despite the large tumor and axillary lymph node metastasis, and that we could omit axillary dissection.     

Breast-conserving treatment for breast cancer in Stockholm, Sweden, 1977 to 1981

Since 1977 patients living in Stockholm with Stage I breast cancer fulfilling specific criteria are offered breast-conserving treatment. The treatment includes a partial mastectomy and a low-axillary dissection followed by radiotherapy, 5000 rad, to the remaining breast. Between 1977 and 1981, 262 patients underwent the breast conserving therapy. One hundred eighty-six patients had pathologic Stage I tumors. Radiotherapy was given to 158 of those patients. During the follow-up time (6 months to 5 years), 4 of 186 patients had recurrence to the breast. Two of those had not received radiotherapy. Recurrent tumor in regional lymph nodes occurred in 4/186, and distant metastases in 10/186 patients. Six patients have died of their disease. The cosmetic results were favorable overall, but often impaired when surgical complications occurred. A comparison between these results and those obtained in similar patients treated with modified radical mastectomy with a low-axillar dissection followed by radiotherapy to the remaining breast seems to be an alternative treatment to modified radical mastectomy. Longer follow-up time is needed before final conclusions can be drawn.     

The preservation of minor pectoralis muscle in axillary dissection for breast cancer: functional and cosmetic evaluation.

We have evaluated, in two groups of 50 patients each submitted to axillary dissection for breast cancer (10 mastectomies and 90 conservative procedures), the advantage of the preservation of the minor pectoralis muscle. This muscle was preserved in one group and removed in the other. Whereas in the immediate postoperative period complications (shoulder pain, functional impairment, quantity or duration of serum drainage from the axilla) were the same in the two groups, at longer follow-up (more than 6 months after surgery) the patients whose pectoralis minor muscle was preserved showed a reduction in the incidence of partial atrophy and fibrosis of the pectoralis major muscle. Patients treated with conservation of the pectoralis minor muscle showed this atrophy in 6% of cases vs 54% observed in the other patients. This fact may be related to disruption of the pectoral nerves, which are in close contact with the pectoralis minor during their course from the brachial plexus to the pectoralis major muscle.     

带蒂胸大肌肌皮瓣移植在头颈癌放疗后手术中的运用

目的:探讨头颈癌放疗后因肿瘤复发进行挽救性手术,带蒂胸大肌肌皮瓣修复手术切除后软组织缺损的可行性和价值。方法:7例头颈部恶性肿瘤进行了根治性放疗后局部复发或颈淋巴结转移,通过手术切除病灶,颈淋巴结清扫,同侧带蒂胸大肌肌皮瓣移植修复软组织缺损创面。结果:7例移植的带蒂胸大肌肌皮瓣全部成活,有2例出现切口裂开,愈合困难。结论:在头颈癌放疗后手术中,带蒂胸大肌肌皮瓣移植是修复手术切除后软组织缺损的有效方法。     

乳腺导管原位癌26例疗效分析

目的 通过对导管原位癌(DCIS)的疗效分析,探讨对DCIS的合理治疗方法。方法 回顾性分析1992年1月—200l年12月间我院收治的26例DCIS,中位随访时间42(12—112)个月,随诊资料完整者22例。26例中,全乳切除3例,全乳切除加腋淋巴结清扫23例。术后接受辅助化疗8例,接受辅助放疗1例。结果 26例中失访3例,1例死于糖尿病。余22例均生存5年以上,无因DCIS死亡的病例,有1例为胸壁局部复发。23例行腋淋巴结清扫切除之淋巴结全部没有转移,3例出现上肢水肿。结论 DCIS系非侵袭性癌,缺乏转移能力,推荐采用不加淋巴结清扫的保乳手术。     

Transpectoral anterior approach to the axilla for lymph node dissection in association with mastectomy preserving both pectoral muscles and their neurovascular bundles

In Patey's mastectomy, which is still the most common operation for breast cancer, axillary node dissection (AND) is performed through the base of the axilla after retracting the pectoralis major muscle and excising the pectoralis minor muscle (some surgeons preserve the latter). This has the disadvantage of inadequate exposure of the axilla and the risk of damage to the neurovascular bundles supplying the pectoral muscles, which in the long run may lead to atrophy of these muscles. A transpectoral anterior approach to the axilla for AND in association with mastectomy was attempted in 115 cases to obviate the above-mentioned disadvantages. The approach included: 1) splitting of the pectoralis major between the clavicular and sternal fibers; 2) mobilization and swinging of the pectoralis minor into different directions by means of a sling to facilitate AND at selected levels. The major advantages of this approach were: 1) total preservation of both pectoral muscles with their neurovascular bundles maintained the normal anatomy and function of the shoulder; 2) the axilla was directly approached through the anterior wall instead of through the base; in this way the axillary contents were exposed almost at surface level; 3) the dissection plane could be limited to anterior to and below the axillary vein and the risk of postoperative lymphedema could thus be minimized; 4) change of position of the ipsilateral arm was not necessary; 5) the duration of surgery was reduced. Monoblock ablation of significant and suspected tissues, maintaining the normal anatomy and function of the shoulder, could be easily accomplished with this approach.     

一期静脉淋巴管吻合预防乳腺癌根治术后上肢淋巴水肿的临床研究

目的 观察乳腺癌根治术中一期行静脉淋巴管吻合术在预防术后患侧上肢淋巴水肿中的价值.方法 收集2010年3月-2013年5月华北理工大学附属唐山市肿瘤医院收治的90例乳腺癌需行根治术患者作为研究对象,应用区组随机化分组法将其均分为对照组与治疗组各45例,随机分配方案隐藏.两组均接受乳腺癌根治手术治疗,治疗组在此基础上一期行静脉淋巴管吻合术,对比两组患者手术时间、出血量、住院时间、术后并发症及腋窝淋巴结清扫数目上的差异,比较两组患者术后上肢淋巴水肿的发生率.结果 治疗组和对照组手术时间分别为(152.82±18.76) min、(78.92±10.33) min,出血量分别为(416.64±94.65)ml、(250.84±63.17) ml,差异均有统计学意义(t=-20.39,P=0.00,t=-4.48,P=0.00).治疗组和对照组平均住院时间分别为(14.91±5.44)d、(13.45 ±2.36)d,腋窝淋巴结清扫个数分别为(14.63±3.37)个、(14.37 ±3.18)个,发生术后并发症患者分别为9例(20.00％)和5例(11.11％),差异均无统计学意义(t=-0.47,P=0.64;t =0.75,P=0.46;x2 =1.35,P=0.38).与对照组相比,治疗组上肢淋巴水肿发生率更低(13.95％:40.91％),肿胀程度减轻,组间差异具有统计学意义(x2 =8.48,P =0.03).结论 乳腺癌根治术中一期行静脉淋巴管吻合术可以有效地转移淋巴分流至静脉循环,降低患侧上肢淋巴水肿的发生率,具有显著的预防作用.     

Extended radical operation of cancer of the rectum

Extended radical operation for rectal cancer included the high ligation of inferior mesenteric artery and the dissection of lateral lymph nodes. There was no significant difference between overall survival of extended operation and conventional operation, although in Dukes B cases, 5-year survival rate was significantly higher in extended operation than in conventional. Extended operation caused high incidence of postoperative urinary and sexual dysfunction compared with conventional operation. We conclude that extended radical operation must be performed only in those patients, when tumors locate in the lower part of the rectum and invade beyond the proper muscle layer.