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
*
