(Part – 1)
I
History of Breast Surgery
Since hundreds of years, various types of mastectomies being done to control the disease but failed.
Modern era started in 1890 with Halstead procedure of Radical Mastectomy, also promoted same time by Willy Meyer (1894), on theory of disease involving Axillary nodes commonly by gradual spread through lymphatics.
Many changes in procedure came to excise only pectoralis minor and axillary dissection at later stage, but over all recurrence and survival for 5 years remains same (50%) local recurrence 20% with high morbidity -arm swelling, restricted movement etc.
Radical mastectomy + RT (1930) did improved survival but high morbidity
Extended Radical Mastectomy is of removing Internal Mammary nodes with axillary nodes more so in Inner quadrant cases (Samson Handley 1920). Urban (1950) did extensional clearance of Internal Mammary chain in block with high morbidity and no survival benefit.
PATEY and Dyson (1948) preferred to save pectoralis minor and advocated muscle sparing procedure but doubted the improvement of disease free survival till some systemic treatment is given.
Madden (1972) started muscle sparing procedure with proper clearance of Axilla. Crete (1975) suggested delayed axiliary clearance with same 5 years benefit.
– Simple mastectomy – developed by Kennedy and Metler (1964) – followed by RT (KAAC and JOHNSON 1969) with equal result to extended Radical or Radical and Modified Radical.
– Breast Conservative Surgery –
BERNARD FISHER (1970) said breast cancer is a systemic disease and suggested debulking the tumor mass with chemotherapy. Coincidence was Mammography in 1970’s to detect early cancer and change in total perspective in management and survival improvement in Breast Cancer
VERONES’s group – Milan Italy started lumpectomy / Axillary clearance and CT with comparable results with Mod Radical and Radical Mastectomies.
FISHER published follow up of 20 years with equal survival and hardly any morbidity.
New Mastectomies – Wide Excision (Lumpectomy) quadrantectomy + RT became popular depending on type and stage of the disease.
SKIN Sparing – Procedure – FREEMAN (1996) in selected cases with good preoperative planning and reconstruction. Some studies follow up of 3 years has shown no difference with other conventional mastectomies.
Indications – BRCA 1-2, Intra epithelial neoplasia.
Nipple Sparing Mastectomy – Intra operative RT with high complication of narcosis.
Prophylactic Risk Resection Mastectomies –
High risk patient BRCA 1-2 – 65% risk in BRCA till age 70 years MEIJERS HERLBOER et al (2010)
-Mastectomy does not eliminate the risk of Breast Cancer.
RECONSTRUCTION – Various procedure – TRAM / Transverse Rectus Abdominus myocutaneous) DIEP (Deep Infraephigastric perforator ) (GAP) Gluteal Artery Perforator)
Extended Radical Mastectomy V/s Simple Mastectomy +RT – 5 years follow up – (Copenhagen Breast Cancer Randomised study, H.Johansen et. al. Acta oncol (4) 633-668 208,1951-56 ) – 666 Cases 241 excluded , 25 years 5 year survival – No difference .
Grade I & II better survival
WYATT. J.P. et. all (1954) – St. Louis University, St. Louis Minnesota
60 patients- Int. Mammary deposits19 cases ( Internal mammary group) outer quadrant group – all have axillary deposits and 7 have Int. mammary deposits.
I b
HISTORY
Breast Cancer has been known since ancient time and because of it visible nature of lump, noticed well and documented in ancient literature. In only recent time with female joining the main stream and involved in social reforms that lump in breast is more commonly noticed and documented.
More then 1000 years BC Egyptian were the first to describe it as bulging tumor of Breast with NO CURE. HIPPOCRATE (460 BC) Father of Modern Medicine described four HUMORS – Blood, Phlegm, Yellow Bile and Black bile and said cancer was caused by black bile. Cancer Breast later bursts open to give black bile and named it as Cancer KARKINOS – a Greek word for CRAB.
GALEN (200 AD) also said about black bile and suggested some medicine .During this time Breast Cancer was described to involve whole Breast with No Cure.
FRANCOISDE IS BOESYLYIUS (1680) challenged the Humoral theory of Cancer
– and said it as a chemical process that transformed lymphatic fluid from Acidic to ACID.
– CLAUDE DESHAIES GENDRON (1730) in Paris – said Cancer developed when nerve and glandular tissue mixed with lymphatic vessels.
– BERNARDI NO RARRAZZINI’S (1713) – Breast Cancer in NUNS was due to lack of sex, causing decay of reproductive organs including Breast.
– FRIEDRICH HOFFMAN OF PRUSSIA said women with regular sex if developed cancer is because of Vigorous sex, leading to lymphatic blockage.
– GOVANANI MORGAGNI – Blamed curled milk
– JOHANES de GORTER – Pus mixed inflammation in Breast
– CLAUDE NICOLAS Le Cat from ROUEN blamed Depressive mental disorder.
– LORENZ HEISTER – Childlessness
– MANY OTHERS – Sedentary life style
– HENRI Le DRAN ( French 1757) – Surgical removal with excision of lymph nodes from axilla.
– CLAUDE NICOLAS Le Cat – Surgical Excision is the only method of treat of Breast Cancer
This theory led to the – Radical Mastectomy concept for Breast Cancer management in 20th Century.
19th / 20th Century
Mid Nineties – Surgery became best option of treatment because of better anaesthesia, asepsis, blood transfusion etc.
WILLIAM HALSTEAD (New York) – postulated radical mastectomy as Gold standard of treatment with reasonable good result, lasted for next 100 years.
This continued till 1950’s, but complications led to women’s non acceptability.
GEORGE BEATSON (1895- Scottish Surgeon) – discussed removing ovaries from one of the Cancer Breast resulted in shrinking of the tumor.
Many started Radical mastectomy and oophrectomy with better results.
– CHARLES HUGGIN (1952) – started removing adrenal gland as some oestrogen is formed in Adrenals.
– ROLF LEFTI AND HERBERT OLIVECRONAD – started removing pituitary another site of oestrogen production.
DEVELOPMENT OF THE SYSTEMIC THEORY
GEORGE CRILE (1955) – Breast Ca, is a generalized disease though seen in Breast but present in whole body.
BERNARD FISHER (1976) – Suggested capability of cancer to metastasis to other parts, published results of Breast conservative surgery + RT/CT and found as effective as Mastectomy.
By 1995, only 10% of Ca Breast women had mastectomies, because of many developments like –
– Mammogram for early detection
– Hormonal treat
– Isolation of Breast Gene BRCA 1and 2
and – Biological therapies
II
Breast Lymphatic drainage and Lymph Nodes
Lymphatic anatomy is not very well understood inspite of numerous studies for decades and factors are beyond our control. (J.Am. Coll. Surg-2001, May, 192(3) 399-409). Tanis, P.J. et.al.
Axilla – drain breast lymphatic principally, direct course to nodes, not through subareolar plexus.
– Sentinel nodes – primary node getting lymphatics from Breast.
– Intra dermal Injection of dye may not reflect the drainage of tumor in the Breast tissue inside.
Because of large false negative rates, sentinel node result gives doubts to Axillary dissection decision on its result.
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Current Breast Lymphatic System is derived mainly by anatomist SAPPEY (1850).
Lymphatic passes from anterior surface directly to Axilla or through parenchyma in radial fashion to axilla. Most to one node called sentinel but may also drain to other nodes bypassing sentinel nodes.
Management of the lymph nodes in Ca-Breast
Since Halstead mastectomy (early 1902) till 1970, axillary clearance was an important part of any mastectomy.
Its therapeutic values remained doubtful but in Invasive cases, because of its prognostic significance.
Sentinel Node Biopsy (SNB) important before axillary dissection, but for large false negative cases – 5% to 10%.
Site of Injection questioned from dermal, subareolar, paritumoral, or periareolar. In any case false negative remain same (5 to 10%).( Dye- Blue dye+ Hydrogen peroxide , Ultra marine Indocynine )
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– Lymphatics are AVALVULAR. In skin starts from dermal area – 20-70 micro mm, drain to large lymphatics (300micro mm) deep in Breast tissue contain VALVE. These lymph collecting vessels have smooth muscle layer and are identified as Lymphatics.
– Lymphatic from Breast as Lymph collectors branched into peripheral region from large collecting vessel and drain into one lymph node (90%-SLN).
– Nipple/ areola – radial net work of lymphatic draining to bigger lymphatic vessels and directly to Axillary nodes.
Internal Mammary – collecting from breast tissue (deep and medially) – lymphatic drain along the intercostals vessels into Internal Mammary nodes deep to parietal pleura. Superficial lymphatic drainage from Breast has no connection to deep perforator lymphatics draining into Internal mammary.
TURNER WARWICK (1959) – performed photographic and radiological studies following – Injection of Prussian blue or radioisotope gold (An 198) during surgery, and found lymphatic passed direct to axilla or Internal mammary, bypassing sub areolar plexus.
TARIS and UREN (May 2007) – No constant route through subareolar plexus.
Ca-Breast and role of Lymph node
Lymph Node – Immunological organ filters lymph fluid, fight infection by T and L cells
Breast – Primary Node – Axilla
– Secondary – Supraclavicular
+
Int. Mammary
(Filter lymphatus of bad guys)
– Axillary lymph node dissection improves survival but not a guarante that disease has not spread elsewhere
– Supra clavicular nodes and Internal Mammary nodes – are involved in
20 to 30% of cases with axillary node involvement.
– Number of nodes involved also a predictor factor
– Lymphatics do not always drain systematically to group-1 to group-3 – May be group-3 initially by passing group-1.
Massage – MARISA WEISS M.
Chief Medical Officer – Breast Cancer.Org
Node involvement a sign of tumor potentially nasty streak and higher risk of spreading to other parts of body and guide you to the best treatment. (Jan-27, 2016).
Axillary nodel sampling –
72 patient – nodes palpable – RM / MRM – done
18 (25%) – had upper axillary node II, III positive
32% – No clinically palpable nodes has upper II and III positive.
Medial quadrant lesions – has more tendency then lateral (50% v/s 20%)
– Larger the tumor – more % involvement of Axillary node
– 2cm tumor cases also have 14% axillary nodes involvement
– Nodal samplings – under stage the disease.
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Halstead Revisited
– Internal Mammary – node sampling – sentinel not done routinely
256 patients – Sentinel node biopsy based on – (1) Lymphoscintigraphy (2) Intraoperative gamma probe (3) Blue dye
Int. Mammary Sentinel
Using 10mci (370 MBq) 99mTc nano colloid injected peritumorally 4.5 to 10 ml patent blue V injected intradermally.
– If possible both Axillary / Internal Mammary Sentinel nodes – sampled.
Result – Axillary SENT – 95% + and Int. Mammary – 25.3% +
– Result of Lymphoscintigraphy successful in Int. Mammary only in 63%.
– Int. Mammary METS IN 26.8%
– 73% – Int Mamo positive While Axillary – Negative
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20% Follow Up – Radical Mastectomy V/S conservative surgery + AXILLARY Dissection + RT
2cm of less – 701 patients
– long term survival
– Recurrence – Average period
– Metastasis – Average period
– Death – Average
% results are similar in both groups
All over world 300,000 patient – Conservative treat each year with good result.
Mastectomy / Internal Mammary Nodes
Stage – I, 2cm tumor, age 40 years. site of tumor not important, Axillary Node(+) – Internal Mammary 29%.
9.1% Axillary Nodes negative had positive Internal Mammary.
10 years survival – 80.4% Axillary node negative.
30% – Axilla and Internal mammary both involved.
54% or 53% if one (+) other Negative .
Tumor size affects survival both group.
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European Journal of Cancer Vol 30, Issue-5, 1994, P-645-652
Neoadjuvant C.T. in premenopausal patient with too large tumor for Breast Conservative Surgery.
414- Premenopausal women T2-T3, N1 _ C.T. ( Cytoxan + Dxyrubicin + 5 -FU) + RT
OR
Four cycle of CT after R.T. /Surgery.
Significant survival in Neo adjuvant C.T. group
191- Neo Adjuvant group – 65% objection response > 50% regression followed by 4 cycle of C.T. –
III
Screening Programme
Mammography initially came as a type of revolution in early diagnosis of Ca Breast from 1947 to 1970, As a modern Mammography period. R.L.E. BORGHE made clear radiological findings to detect early Ca Breast. Popular after 1951 and thousands such studies all over USA/Europe as Screening, but with sceptical results compared to early detection and mortality in young patient 40 and below while significant in 59 years and above.
ECONOMY is the main problem
AMA/ American Cancer Society of Radiological and Obst-Gyanae Association – Mammography is very useful in early detection, but Breast Self Examination if done properly Catches Ca Breast early in high % with better survival.
80% of Breast lump are non cancerous
70% of Breast Cancer are detected by Self Examination
80% diagnosed have no family history
(WHY – Screening in High Risk Group)
TOXIC EFFECT – Radiation effect
– Causes Ca Breast – 10 times Radiation to Xray Chest
– High False positive (6%)
– Tight Compressor causes spread of tumour. 30% over diagnosis
– Mammogram positive — Biopsies – questionable tissue – High false positive / negative histopath report leading to many surgical family and personal problems.
–
Self Examination
Impact on early detection and Survival
B.S.E. thought to be a better alternative to the Mammography which could not prove its efficacy in mortality rate. Many studies with meta analysis show more women seeking medical advise and many more biopsies, but is not an effective method of reducing Breast Cancer mortality.
In High Risk group with positive BRCA mutation, screening should start at 25 years. 10 years before regular screening age for general population. MRI is preferred in such group then mammogram, but impact on mortality is uncertain.
Clinical Breast Examination + Mammography is no more effective then Mammography alone in reducing mortality. B.S.E. does not improve mortality.
– KEY RECOMMENDATIONS FOR PRACTICE (Screening)
– Teaching B.S.E. – no improvement in Mortality
– Regular Clinical Examination + Mammography – recommendation
– Mammography – 6 month/1 year – Average risk – 50 – 74 years
Average Risk 40-49 – optional
depends on many factors, personal, family, financial etc.
Average Risk over 74 – optional
AWARENESS AND KNOW YOUR BREAST
In USA and advance countries – mortality is declining by 2.2% because of social awareness, B.S.E. and Mammography and adjuvant therapies.
MAMMOGRAPHY – Risk, Benefits, Age, Local factors.