simple mastectomy and radiation therapy for locally advanced ... - AJR

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locally advanced disease require high doses of irradiation. High-dose preoperative ir- radiation was first undertaken by Baclesse,3 but the results of this therapy.
OL.

No.

120,

s

SIMPLE FOR

MASTECTOMY AND RADIATION THERAPY LOCALLY ADVANCED BREAST CANCERS TECHNICALLY SUITABLE FOR RADICAL MASTECTOMY* By

GEORGE GILBERT

R. BROWN, M.D.,t JEAN-CLAUDE HORIOT, M.D., H. FLETCHER, M.D., EDGAR C. WHITE, M.D.,J and DAVID W. ANGE, M.D. HOUSTON,

TEXAS

I

RRADIATION alone is the only treatment for effective local control of unresectable breast cancer. It is usually palliative for inflammatory carcinoma, lesions fixed to the chest wall, massive disease in the axilla, multiple satellite nodules and extensive edema of the skin, since almost all patients will die from distant metastases. The choice of patients for resection of tumors technically suitable for a radical mastectomy must be based on rigid criteria. Without careful selection the incidence of recurrences locally and in the regional

In

lymph 1943,

nodes

is prohibitively

Haagensen

and

Stout9

the course of radical mastectomy

109

breast cancer. of their disease

All but 3 patients by years and

surgical

signs

*

From

the

t Radiotherapist, Radiotherapist, § Radiotherapist,

University

with escape of Texas

no

reviewed a

had died the 3 sur-

treatment at the conclusion M.

0.

Anderson

Hospital

and

which

are

greater

than

broken

capsule

nosis,

in

chest

wall

produced of

categorical

and

the

clinical

contraindica-

in diameter implies

a

high

recurrence.

confirmed

by

tients

breast

with

cm.

2.5

particular

mastectomy.

This

Spratt’s”

cancer

Chest

has

a poor

a

prog-

probability

of

was series of 704 patreated by radical

wall

correlation

recurrences

were

seen in 40 to 45 per cent of patients with heavily infested axillary lymph nodes. Although there is not a rigid correlation between results and the size of the primary tumor, accumulated data indicate that the larger the tumor size, the poorer the prognosis and the higher the incidence of local failures. In Spratt’s’ series, patients with tumors larger than 8 cm. had a local recurrence rate of 33 per cent. This essay will be directed to the features of the disease which determine the most

all. It that

St. David’s Hospital, Austin, Texas. Radiotherapy Service, Centre G. F. Leclerc, Head, Department of Radiotherapy.

Analysis

tions for radical mastectomy. He has related the incidence of local recurrences with various features of the disease, in particular the size ofclinically positive axillary lymph nodes. An axillary lymph node

vivors developed local recurrence and distant metastases shortly after years. The incidence of recurrences within the operative area was 47.7 per cent. Extensive surgical manipulations can throw clumps of tumor cells into the blood stream which may produce distant metastases. This is suggested in the study of Haagensen and Stout,9 since routinely a few patients would be expected to be alive at 5 years (io to i per cent) is difficult to

actually

metastases.

features of disease in this series of patients led Haagensen and Stout9 to define criteria for clinical operability. In his second edition of Diseases of the Breast,8 Haagensen described the grave

high.

patients having had for locally advanced

manipulations

distant

Tumor i)ijon,

Institute

at Houston,

Houston,

Texas.

France.

II Surgeon, #{182} Fellow, This tional

Heal, Department of Surgery. Department of Radiotherapy. investigation was supported by Public Cancer Institute.

Health

Service

Research

67

Grants

Nos.

CA-o#{244}294, CA-o64,

and

CA-oo99

from

the

Na-

68

Brown,

Horiot,

Fletcher,

effective modality of treatment for those patients, who have locally advanced disease still technically suitable for a radical mastectomy (Table i). The tumor may be more than cm. in diameter with or without skin attachment, or attached to the pectoralis muscle but not fixed to the chest wall. In addition, there may be satellite nodules in continuity with the tumor, at least one lymph node more than 2.5 cm. in diameter in the axilla, or multiple clinically positive axillary lymph nodes. The patient may

also have

icular lymph

clinically positive

White

surgical

Preoperative since reducing

in diameter

rads

to the

MANAGEMENT

Baclesse tients with

logical mass

with

OF

LOCALLY

Technically Radical Primary



Skin fixation Peripheral satellite

nodule(s)

Inflammatory fascia

fixation

Chest

wall

fixation

Node(s)

Size

Single

Number Location Supraclavicular Lymph

large

lymph

node

without

fixa-

tion or Multiple lymph nodes or Apical lymph node(s) Node(s)

Staging UICC

[TXTY]NZ * The worst feature placas the Adapted from: Fletcher, G. H.

patient in the appropriate Textbook of Radiotherapy,

nodes,

fixed

or not

Fixed

[T3[+][No, N1] [T1, T2, T5[+]]N2 [T1, T2, T,[+]]N,

T1[N,

lymph

fixed

Moveable

T[+]

Matted

Stage Late

T,[+], T.5[N0,

II

N, N,,

Stage III N2, N,]

Very

do not change Pennsylvania,

1973.

Late

:LateT N5]:TN :TN5 category.

2nd edition,

and and

TN5 TN5

Multiple features Lea & Febiger,

in one

category

Philadelphia,

the

category.

\OL.

io,

No.

Simple

I

1\Iastectom II

TABLE BREAST RESULTS

OF

PATIENTS

IRRADIATION ASPIRATION

(January 1948-December Analysis February Size

of Primary

Lesion

cm.

NED NED




ings cers.

1972

13

yr.)

(6Io

years 5 years 5 years

mass

is

mass

I

Number

of Patients

47

NED=

no evidence of disease; 1D intercurrent From: Fletcher, G. H., Textbook of Radiotherapy, Lea & Febiger, Philadelphia, Pennsylvania, 1973.

disease. 2nd

edition,

SIMPLE

In

MASTECTOMY

AND

rate

alone,

failure.

Two

treated

with

of

of

30

17

(8

12

patients

per

cent) (17

had per

the

small

the

breast

is

compartment.

central

in

palpated

the the

the

one

with

the

and

the

most

sig-

seems

log-

a minimum

the large masses and excision of or

then

is rarely and the

region. From radiobiology,

anoxic

manipulation, mastectomy

breast,

Disease area

whenever

of cells with

canlargest

lymph

It

of surgical

by large nodes.

simple retroThis

leaves for radiotherapeutic management only microscopic disease in the skin of the chest wall and the intercostal !ymphatics

/

local cent)

simple mastectomy followed had a local failure. A tumor dose of 4,250 roentgens in 3 or weeks was given in the 2 series. This dose is not adequate to control large breast tumors. At the M. D. Anderson Hospital (MDAH), since 1948, some patients with very been

in

find-

advanced the

McWhirter1#{176}

1955,

survival

radiation

by

clinical

IRRADIATION

reported a crude per cent for locally advanced breast cancer treated with simplc mastectomy and radiotherapy. The features of the disease are not detailed and regional control rates are not included in the report. In 1961, Atkins and Horrigan1 reported on a series of patients treated for locally advanced cancer by irradiation alone versus simple mastectomy and irradiation. Of 20 patients who could have had a simple mastectomy but were treated with iryear

results.

typical

number to remove,

pectoral

percentage of control of very large masses could be obtained using longer treatment times than the conventional 4 to 6 weeks.2 However, only 3 of32 patients with lesions 6 cm. or more in diameter and with skin disturbance were cured of their cancer.4

the

occurs

usually

nificant ical

worthwhile

shows

supraclavicular of modern in

largest Total

the early 19605 of patients treated

and central axilla. in the subclavicular

in the standpoint

5 26

In series

showed

usually

the low palpable

2

irradiation. of a small I

69

Cancer

in patients with locally With some exceptions,

mass

by Palpation

Dimension

years years

by

this way Figure

in

1967)

Estimated

in Greatest

IN

BIOPSY

Breast

in

analysis

CARCINOMA

AN

Radiation lowed

PREOPERATIVE WITH

and

irradiation

large lesions in pendulous breasts treated by simple mastectomy

have fol-

I. As a rule the largest mass is the primary tumor, the next largest occurs in the axillary lymph nodes and then in the supraclavicular nodes. The supraclavicular lymph nodes, if palpable, are usually i to 2 cm. in diameter. (Reproduced, with permission of Lea & Febiger Co., Philadelphia, Pennsylvania.7)

FIG.

Brown,

70

1’Ietcher,

Horiot,

and subclinical disease in the axilla, supraclavicular area, and internal mammary chain lymph nodes. This study is limited to the patients treated at MDAH since 1955 with special emphasis on those treated from January 1964 through December 1969. The first Co6#{176} unit was acquired in 1954 with additional Co6#{176} units becoming available during the period of through 1963. Because of the number of patients to be treated, approximately one-third of the patients who had a simple mastectomy were treated with 250 kv. alone and onethird received combined treatment with 250 kv. and Co6#{176} to minimize the severity of the skin reaction which resulted from kilovoltage treatment alone. One-third of the patients were treated with Co6#{176} alone. Patients treated from January 1955 through December 1963 received 4,000 to 4,500 rads to the chest wall and 4,400 to 5,000 rads to the axilla, usually without boost therapy. Improved techniques were developed including better dosimetry and boost therapy to the scar and to palpable axillary nodes. The “boosts” were given with Co60, Cs’37, or the electron beam. All patients treated from January I, 1964 through 1969 had their basic therapy with Co60, utilizing well-established techniques. Contours of the chest wall are taken and isodose curves are derived for bolus and nonbolus treatment. The appropriate tumor dose levels are selected to deliver ,ooo rads, generally 1955

at 2,000

midaxis. rads

to the after an

scar

Additional treatment tumor dose) may

and

a surrounding

be

strip

(i,ooo delivered

to

of tissue

rads tumor dose, when there is increased risk of chest wall recurrence, 5,000

i.e. tumors invading muscle, skin invasion, satellite nodules, or multiple axillary lymph node involvement. The tumor dose to the central axilla is 5,000 rads with an additional I ,000 to 2,000 rads to palpable lymph nodes through an appositional portal. The skin reaction on the chest wall can be controlled by the number of bolus treatments given and/or by the tumor dose level chosen in the isodose distribution curves.

White

and

.Angc

j *NARV,

I74

Although the optimum skin reaction at completion of treatment is a uniform pigmentation with dry desquamation, an increased reaction (i.e. brisk ervthema and patchy moist desquamation) is desirable when there is high risk ofdermal lymphatic involvement or if there is a question of residual

tumor.

of boltis treatment

In

these

instances,

is increased. will be necessary skin

factory

reactions

the

Additional to obtain if chest

use

boltis satis-

wall

treat-

ment is given with to 6 mev. accelerators. The use of bolus may also vary depending upon the chest wall contour. If the soft tissues

of

the

number

is

the

chest

wall

are

of treatments

generally

very

irregular,

given

with

bolus

reduced.

RESULTS

OF AND

SIMILE

MASTECTOMY

IRRADIATION

Table III shows that 90 per cent of local and/or regional recurrences will have appeared by 3 years after treatment. Therefore, the control rates shown in Table Iv for the chest wall and regional lymphatic

areas

with

will

not

a minimum

of3

be significantly

years

follow-up

altered

with

longer

follow-up.

The can

the

of

correlated lesion

mary

of

incidence

be

as well

axillary

chest

with

wall the

as the

lymph

recurrences

size size

nodes.

of

the

and

pri-

number

Patients

with

lesions less than 3 cm. in diameter had no recurrences (0/30). Those patients with lesions from 3 to 5 cm. in diameter had 10 per cent recurrences (3/’29) and those with lesions more than cm. in diameter had i6 per cent recurrences (13/79). Peati d’orange present chest were

or in

40

marked patients

skin and

wall recurrences (20 chest wall recurrences

dimpling 8 of these

per cent). There in

12

per cent) with axillary nodes larger than 2 cm. in diameter conforms with Haagensen’s data.8 patients

was had

(24

of

52

lymph which

The chest wall failure rate was 1 2 per cent in 103 patients treated prior to January

chest only

1964

with

minimum

tumor

doses

wall below 5,ooo rad5. Since of 86 patients (4.6 per cent)

to

the

1964, have

\OL.

No.

110,

Simple

i

Mastectomy

and

Radiation

CUMULATIVE

SIMPLE

MASTECTOMY

(January 1955-December Analysis January

Sites

Chest Wall Axilla Supraclavicula Parastern al Cumulative Twenty-seven

*

the

time

had

first

a chest

with

of 189

recurrence

wall

signs

treated

from

is considered.

had

one with

associated

1955

If there

recurrence.

recurrences

grave

30 1969

tO

were

6

67

78

had

a local-regional

recurrence.

simultaneous

The

patients

or more advanced

of

the local

disease.

The the

failure rate was i 2 per cent prior to January 1964. The minimum tumor dose to the axilla was less than 5,000 rads. Boost therapy had not been given, although there was palpable in

axillary period

disease

at

the

conclusion

of

therapy

in

l

IABLE

CARCINOMA

LATE

STAGE

I.OCAL

III

UICC

CONTROL*

(Unlimited Follow_up) (January I55-l)ecember Analysis January 1972

I96)

Free of I)isease After Simple Mastectomy and Irradiation (lesion technically suitable for radical mastectomy)

Sites of Recurrences

January

1955-

l)ecember

Chest Wall Axilla Supraclavicular Parasternal

1963

103

patients

88% 88% 93% 99%

(91/103)

(

January 1964December 1969 86 patients 95% 99% 99%

1/103)

(96/103)

(82,’86) (8/86) (8/86) (86/86)

Ioo%

(102/103)

recurrences,

only

pstieflt

may

Survival (Modified

have

a recurrence

rates: life

table

method)

in more 10

than

one

location.

48

92.5 If there the

site

I00 were

closest

several

to the

sites

chest

of failure,

wall

only

is listed.

every these and

patient with axillary recurrence. In patients the lymph nodes were large multiple prior to treatment. Since 1964, there has been I axillary recurrence. Treatment has consisted of ,ooo rads to the axilla plus i,ooo or 2,000 rads given through

a

small

appositional

portal

de-

pending upon the initial size of the lymph node and its status at the end of weeks of treatment. Since 1967, low clinically positive axillary lymph nodes have been removed at the time of simple mastectomy. There were 7 supraclavicular failures prior to 1964 of which 2 were recurrences of initially clinically positive lymph nodes. The tumor dose was only 4,400 rads with no boost to the lymph nodes which has shown to be inadequate therapy for dinically positive lymph nodes. Since 1964, there has been I supraclavicular failure. The supraclavicular region has been treated with #{231},ooo rads given dose, if there were no palpable nodes. A boost of 1,000 rads was given through a small field, if the lymph nodes have been clinically positive. COMPLICATIONS

The treated

complications with

in

the techniques

the used

86

patients since 1964

in Table v. Forty-nine patients had no complications, the asymptomatic apical pulmonary fibrosis which every paare shown

*