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Evolution Of Surgical Management Of Breast CancerClinical information-series on the breast cancer for the healthcare providers and community, is prepared by Women's Health & Education Center (WHEC). The ancient documentation of historical aspects of breast cancer and the development of thoughts regarding its biology, pathophysiology and the concepts to rational treatment indicates that this disease has always been the relatively common and virulent entity that we know today. As the Renaissance philosophy of enlightenment and learning spread throughout Europe in the 15th and 16th centuries, many of the principles that eventually led to the modern era of breast cancer treatment were developed or rediscovered. One of the first surgical attempts to allow healing by direct union of the incised skin edges following mastectomy was recorded by Van der Mullen in 1698. Benjamin Bell (1749-1806), surgeon to the Edinburgh Royal Infirmary, not only advocated a radical operation for all breast tumors but also emphasized the importance of early diagnosis. These principles of treatment of breast carcinoma remained the standard in Scotland for the next century. The purpose of this document is to give the healthcare professionals various surgical treatments available to manage breast cancer. Various modern treatment modalities are also discussed. The surgeon has become an integral part of a multidisciplinary team who manages patients with breast carcinoma. This team includes the diagnostic radiologist, radiation oncologist, medical oncologist, and pathologist. Our resolute purpose must always be to promote the best interest of each individual patient, and not those of surgery, radiotherapy or chemotherapy. Two major advances that paved the way for an effective operation for breast carcinoma were the discovery and development of general anesthesia and the dissemination of the germ theory of disease and principles of antisepsis. The evolution of a standardized, effective, and widely accepted operation for the treatment of breast carcinoma culminated with the efforts of William Stewart Halsted (1852-1922). The major contribution that Halsted made in this area was his advocacy of the routine removal of the pectoralis major muscle (in addition to entire breast) and meticulous clearing of the axillary tissue. It ultimately became known as the radical mastectomy. The most effective modality for detecting breast carcinoma in its earliest forms, when treatment promises to be most successful, had its beginnings as early as 1913. The increasing use of mammography in the United States during the 1980s resulted in substantial changes in the techniques used by surgeons to diagnose breast carcinoma. Standard open surgical biopsies could no longer be performed on the progressively smaller and non-palpable lesions detected by mammography. Needle localization biopsy with specimen radiography evolved as the most common method to accurately localize and sample non-palpable mammographically detected breast lesions. The basic flaw in the theory of local disease origin was quickly manifested by the fact that surgery alone did not consistently yield high rates of cure, regardless of how extensive the procedure or early the diagnosis. Although survival at 3 years appeared to show an improvement over that with earlier procedures, longer follow-up revealed steadily diminishing rates. The efforts of many surgeons to extend the scope of the radical mastectomy indicated their recognition of its inadequacy as the sole treatment for breast carcinoma (1). The evident shortcomings of surgical treatment of breast carcinoma led some to consider using less extensive procedures in conjunction with other modalities to spare patients unnecessary tissue loss. Radiation therapy was one of the first adjunctive modalities applied to breast carcinoma for this purpose. The one common thread found in virtually all recent studies on the surgical treatment of breast carcinoma are that the type and extent of local and regional treatment do not substantially affect survival. Patients with breast cancer have some potential for systemic dissemination from the earliest phases of disease development. The greatest promise for an effective cure must therefore lie in systemic treatment. Cytotoxic chemotherapy became popular in the late 1950s and has since become a mainstay of adjuvant systemic therapy following surgical treatment, and as such has demonstrated better survival than surgery alone. Advances in molecular biology have led to the discovery of oncogenes, which offer the opportunity of perhaps manipulating the process of malignancy to prevent it altogether. Adoptive immunotherpy is another form of systemic treatment involving the application of the lymphokine-interleukin-2 to active "killer" lymphocytes with antitumor activity. The surgeon's role has evolved to diagnosing and ensuring the removal of all clinically evident disease so as to maximize the efficacy of radiation and systemic therapy. The soundest prediction of future progress must come from a realistic view of the past. The significant contributions of investigators for breast cancer management in the 20th century established the outcome results for conservative surgical techniques to be equivalent to those of radical approaches with regard to disease-free and overall survival. Thus the procedure to be completed and the anatomic site to receive irradiation for stages 0, I, and II disease depend on the location of the primary neoplasm in the breast, the presence or absence of axillary metastases, phenotype of the index cancer, and the growth characteristics of the index tumor (eg, extension to musculature of chest wall, skin, and axilla). Lesions in the lateral aspect of the breast drain principally through axillary lymphatic channels. Index tumor presentations in this location can be eradicated from the chest wall by using the modified radical mastectomy with sentinel lymph node biopsy (SLNB). This surgical procedure as a total mastectomy with preservation of the pectoralis minor/ major muscles and includes dissection of level I and II axillary lymph nodes. These laterally placed neoplasms with histologically positive axillary lymph node metastases may be associated with internal mammary or supracervical lymph node metastases in as many as 25% to 30% of patients. Radiation therapy and chemotherapy are used for "grave" presentations of the tumors: skin fixation, nodularity, greater than 20% of nodes dissected histologically involved, more than three histologically involved nodes, and chest wall tumor fixation (2). Centrally located lesions that are fixed to the pectoralis major fascia or high-lying (superiorly located) lesions that are fixed to this fascia may be treated with radical mastectomy or with a combination of radical mastectomy and peripheral lymphatic and chest wall irradiation when palpable axillary lymph node metastases smaller than 2 cm are evident. These centrally placed lesions commonly metastasize through lymphatics that parallel the course of the neurovascular bundle medial to the pectoralis minor muscle. This medial neurovascular bundle that contains the lateral pectoral nerve and innervates the pectoralis major muscle is preserved in the modified radical mastectomy to ensure function of the pectoralis major muscle after mastectomy. In the radical mastectomy procedure, this neurovascular bundle, associated lymphatics, and areolar tissue are respected en bloc with the specimen to accomplish adequate surgical extirpation of regional disease. For medially located neoplasms, the principal lymphatic drainage is through routes that course to lymph nodes near the ipsilateral internal mammary vessels. These medial lesions may be associated with metastasis to the internal mammary lymphatics in 10% to 30% of patients. The presence of pathologically positive axillary metastasis with an associated medial lesion escalates this incidence of internal mammary metastasis to greater than 50%. In the absence of clinically positive axillary metastases, medially located cancers may be adequately treated with segmental (partial) mastectomy or with modified radical mastectomy and peripheral lymphatic irradiation. Whether the surgeon chooses the conservation or radical approach depends on tumor size and characteristics, general medical status, patient choice, and desire for reconstruction. Regardless of the operative procedure selected, clearance of pathologically "free" margins about the neoplasm in three dimensions is paramount to enhancement of local and regional disease-free survival. Surgeons, should plan the operative procedure with the subjective of achieving, at minimum, 1-2 cm skin margins with subcutaneous and parenchymal margins of 2 to 3 cm in all directions from the index tumor, which can be accomplished with a radical, modified radical, or extended simple mastectomy. Patients with distant metastases, including supraclavicular lymph node metastases, are best treated with systemic chemotherapy with or without local and regional irradiation (3). Central and subareolar primary lesions – the classic Stewart elliptical skin incision is used for mastectomy. The Stewart incision is commonly preferred by plastic surgeons anticipating delayed reconstruction with myocutaneous flaps, especially when a contralateral simple mastectomy is planned for treatment of high-risk disease or as a prophylactic procedure. Furthermore, this technique is often the choice of oncologic surgeons when radiation to the chest wall is planned before reconstruction. Upper or lower inner quadrants lesions – minimal skin margins of 1 to 2 cm from the primary neoplasm are incorporated in a modified Orr incision that is slightly oblique from the transverse line with cephalad extension toward the axilla. Similar to the Orr and Stewart incisions, although somewhat more oblique, these incisions lend themselves to cosmetically satisfactory breast reconstruction results using myocutaneous or subpectoral augmentation breast implants. Upper inner quadrants lesions – are difficult to manage because of their anatomic location. Surgeons should recognize the inherent problems encountered with elevation of skin flaps that allow adequate surgical margins and provide cosmesis for wound closure and potential reconstruction. Surgeons should be able to develop a 1 to 2 cm margin for lesions that are in this quadrant, providing the lesion is not cephalad (infraclavicular). These lesions may be accessed through the modified Stewart incision. Surgeons should plan the cephalic portion of the incision for the superior flap such that adequate access to the pectoralis major and to the axillary contents is ensured. Lower outer quadrants lesions – these should have an incision design similar to those of the upper inner quadrant, with margins of 1 to 2 cm around the primary lesion and with maximum extension of the cephalad margin to provide access to flaps for dissection of the pectoralis major and the axillary contents. High-lying (infraclavicular) lesions – with large lesions (T2, T3, T4) that are high-lying infraclavicular, or fixed to the pectoralis major, incisions designed to provide a minimal 1 to 2 cm margin will necessitate skin grafting of the defect or coverage with myocutaneous flaps. The original Halsted and Meyer incisions, with subsequent modifications by Greenough, Rodman, and Gray are mostly used for treatment of primary lesions of T2, T3, and T4 size. Limited skin excision can be defined as excision of the nipple / areola complex, the skin around the biopsy site, and the skin within 1 to 2 cm of the tumor margin. This technique usually sacrifices 5% to 10% of the breast skin, which is either approximated primarily or closed with an autogenous myocutaneous flap that is used to replace the breast volume. Dog-ears do not occur with this technique, because the limited skin removal does not initiate skin contracture with closure. Wide skin excision is routinely used with every radical and modified mastectomy. A mastectomy with wide skin excision is often inclusive of an excision in excess of 30% to 50% of the breast skin. This is removed as an ellipse, usually measured 10 cm (width) by 20 cm (length), and is closed primarily. The elliptical excision facilitates removing the dog-ears that are technically created by the wide skin removal and subsequent tension of excessive tissue at the terminal points of skin closure. Standards of practice have sequentially evolved as follows: The skin-sparing mastectomy has been used primarily for patients with AJCC – TNM stages 0, I, and early II disease requiring mastectomy when eligible for immediate autogenous breast reconstruction (4). It is a general consensus the indications for skin-sparing techniques are: The rapid advances in understanding of the fundamental biology of breast cancer in the 20th and early 21st centuries, together with advances in surgical techniques following the advent and application of the vascularized myocutaneous flaps (TRAM and latissimus), have provided viable options for reconstruction after mastectomy. Breast reconstruction is performed to correct anatomic abnormalities, and for this reason, it is a functional procedure. Routine consideration of breast reconstruction at the time of mastectomy can now be scientifically defended for patients with stages 0, I, and IIa. This subset of patients describes more than 70% of the patients who are undergoing mastectomy at present. As the safety of breast reconstruction has been demonstrated in careful studies, there is no more reason to deny breast cancer patients reconstruction than there is to deny any other cancer patients reconstruction. There is no data to suggest that immediate reconstruction interferes with surgical treatment by either spreading the cancer, hiding a local recurrence, or adversely affecting the survival. It is now recognized that essentially all local recurrences are harbingers of systemic disease and that recurrences can exist only within breast tissue. The only remaining breast tissue following a mastectomy is either in the breast skin or in breast tissue that was not removed with the mastectomy. After a reconstruction, what would have been a chest wall recurrence becomes a skin recurrence, only because the skin is physically separated from the chest wall by the reconstruction. Recurrences are never seen within the substance of an autogenous flap, because the fat and muscle of the flap are inhospitable to the transplantation of the breast cancer (5). Although the potential harmful effects on local recurrence or survival have not materialized, there should be concern about the effect of breast reconstruction on adjuvant therapy. It is important biologically to begin chemotherapy within 28 to 40 days of extirpative therapy, so the reconstruction must be primarily healed during the first month. Chemotherapy can be started while there is still a surface wound that has not yet epithelialized, but it cannot be started in the face of necrotic tissue, seromas, or infection. When it is known in advance that the patient will undergo chemotherapy, the choices of reconstructions should include only flaps that are well vascularized and known to heal primarily as the first choice. Implants can be used, but if the implants have problems with seroma or infections, it may be necessary to remove the implant to correct the healing problem and allow the chemotherapy to progress. When radiation is planned, tissue expander and implant reconstruction should not be used, because unsatisfactory firmness is inevitable when implants are radiated. Only autogenous flaps offer satisfactory solutions in these patients, and it is preferable to complete the reconstruction at the time of mastectomy. Radiation is usually performed because the margin of tumor-resection at the chest wall is suspected or because the tumor is large and aggressive. In either case, the reason for tumor recurrence or poor patient survival is the stage of the disease, not the reconstruction. Whether immediate reconstruction should be performed at all in stages IIb and III is more of a social decision than a medical decision. The survival in these patients will not be as good as that in most patients, but it will not be affected by an autogenous reconstruction. Early in the 20th century, the surgeon was alone in taking responsibility for breast cancer treatment, when the only treatment was the radical mastectomy. Today, there is support from several disciplines, and the surgical oncologist should be the leader of this coordinated effort. Helping the patient choose among these sophisticated treatment options requires the efforts and mutual cooperation of both the surgical oncologist and the reconstructive surgeon. Contemporary oncology practice guided by phase II/ III clinical trials have directed our understanding of breast cancer treatment to allow new combinations of chemotherapy, reconstruction, and radiation that were not realized a generation earlier. |
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