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... In women without axillary metastases, the 5-year survival has been 70 ± 10% in most studies (Mansfield, 1976). A survival rate 80°/, has been reported after both radical mastectomy (Haagensen et al., 1969; Payne et al., 1970) and modified radical mastectomy (Madden et al., 1972). Our present results indicate that in Stage I excellent results can be obtained also by simple mastectomy combined with irradiation to parasternal and supraclavicular nodes in those with medially located tumours. ...
110 consecutively diagnosed breast-cancer patients in all stages were included in a study to evaluate a selective surgical and radiotherapeutical treatment. The surgical treatment was total mastectomy and exploration of the axilla, with lymphnode biopsy and peroperative cytological examination. Axillary dissection was done only when this examination showed metastases. No radiotherapy was given to the axilla in patients with lateral cancers in the absence of metastases, or with limited metastasization (no periglandular growth, no growth in apical nodes). In medial and central cancers, radiotherapy was applied to the parasternal and supraclavicular nodes irrespective of axillary involvement. A staging system with a combined clinical and histopathological classification was used and formed the basis for the selective treatment. The corrected 5-year survival for the whole material was 80%, for those without axillary metastasis (Stage I) 95% and for those with axillary metastasis (Stage II) 68%. Six women were alive with known distant metastases. Of 63 patients without identified axillary metastases at the time of surgery, axillary recurrences occurred in only 3 (5%). It was concluded that patients without axillary metastases can be reliably selected by the peroperative examination used, and that in this group simple mastectomy results in a high disease-free survival. Early diagnosis and a possible beneficial effect of the actual therapeutic programme might both have contributed to the high overall survival.
... 30,31 Diagnosis and screening of primary breast cancer Before the screening era, the patient herself detected 98% of all breast cancers. 32 The primary tumour initially most often presents as a painless lump, which later can affect the skin or retract the nipple, and in more advanced cases, shows signs of fixation to the chest wall, pain, ulceration and the appearance of enlarged axillary lymph nodes. A proper investigation of a breast tumour should include, besides physical examination, mammography followed by percutaneous fine-needle aspiration for cytology or core-needle biopsy for histopathological examination ("triple diagnosis"). ...
... In 1980 S. Pal and S.K. Sengupta 10 also found that 60% of the patients presented with a lump in breast with significant axillary lymph nodes. Haagensen (1986) 11 reported axillary metastasis in 70% cases. In the present study it was found that as the average size of the tumor increases, so does the average of lymph nodes increases both clinically as well as Histopathologically positive for metastasis. ...
This study includes 392 patients (231 Stage I and 161 Stage II) treated by tumorectomy followed by radiotherapy. The overall actuarial survival for all the patients is 86.5% at 5 years and 78% at 10 years. The 5-year NED survival is 70.2%. The survival rates are depending on the loco-regional extension: Stage I: 92% survival at 5 years and 84% at 10 years; Stage II: 82% survival at 5 years and 75% at 10 years. The percentage of local recurrences were 13% for all stages (10.6% for Stage I, 16% for Stage II), of lymph node recurrences: 1.5% for all stages, 1.3% for Stage I, 2% for Stage II, of distant metastases: 11.2% for all stages, 8% for Stage I and 16% for Stage II. The loco-regional control rates were analyzed according to the TNM classification and discussed and compared to several literature data. The breast preservation rates were at 5 years 85% for Stage I and 80.9% for Stage II. Cosmetic results are judged as good in 80% by doctors and in 90% by patients themselves with very low complication rates.
The treatment of operable breast cancer in eighty-two patients older than seventy years was analyzed. The cancers were treated at an advanced stage and the axilla was involved as frequently as in younger women. The factors influencing survival differ because of competing mortalities from heart disease and stroke. The risks are discussed in relation to life expectancy and treatment method.
After having briefly considered the role of irradiation in the loco-regional therapy of breast cancer, the role of irradiation as a treatment modality aimed at conserving the breast is emphasized. A total of 457 patients were treated either by tumorectomy plus irradiation by 60Co (101 cases) or by primary irradiation (356 cases) with a follow-up of over 5 years. The results are encouraging and similar to those obtained by more standard treatments, particularly by surgery. Among the patients cured, 2 out of 3 have kept their breast with a satisfactory esthetic quality. However, the author insists on the difficulties presented by the irradiation technique, on the necessity of a close cooperation between the surgeon and the radiotherapist, and on the importance of a regular and frequent clinical, mammographic, and thermographic follow-up.
The Cancer Register for the South-West Region of England has been used to examine the survival rate of men with carcinoma of the breast, and a comparison has been made with carcinoma of the breast in women. For all men with carcinoma of the breast the prognosis is worse than for all women, but comparing the prognosis by clinical stage, the difference between men and women is small. However, the survival rate in men under 65 years of age is appreciably better than for men over 65, and for older men the survival rate is considerably less than for women over 65.
The clinical records of 111 young women with breast carcinoma aged thirty years and younger have been analyzed with respect to the clinical stage of disease when first seen, the histologic status of the regional lymph nodes, and ten year survival. Survival in these young women with mammary carcinoma is equivalent to that of older women when the cancer is in its earliest stage, Stage A, but only if the regional lymph nodes are free from metastatic disease. Once the regional lymph nodes are involved by cancer, the prognosis for these young women is indeed dismal, with less than 20 per cent ten year survival regardless of clinical stage.
The historic development of breast cancer staging began early in the 20th century with the simple concept of early localized disease, spread to regional nodes, and the presence of distant metastases. This last group often was divided into patients with advanced but perhaps still curable locoregional disease and incurable patients with distant metastases. As increasing numbers of prognostic factors were recognized, efforts were made to incorporate them into the staging systems to combine patients with similar prognosis into the same stages. These attempts resulted in the development of four classifications, namely, the Columbia, Manchester, International, and American tumor-node-metastasis (TNM) staging systems. Although many benefits of staging were reported, the most important was that of permitting valid comparisons between different treatments and different institutions. Many success-limiting factors were noticed during the developmental years, and even though the TNM system has been accepted, numerous speakers and authors present their staged data in a confusing and ambiguous manner. Recommendations are made that would permit clarification of presentations to general medical audiences along with recognizable statistical validity.
The literature on the role of irradiation in breast carcinoma was reviewed in detail. Routine postoperative irradiation of breast cancer has not altered the prognosis of carcinoma of the breast. Various classifications of breast cancer, including AJC, UICC, Haagensen, and M. D. Anderson, are discussed in detail and differences outlined in Table II. The clinical stages of cancer of the breast are outlined in Table III. Stage I is essentially operable; Stage III is essentially inoperable. It is in Stage II that preoperative irradiation should be considered, although at present untested. The future role of irradiation in cancer of the breast is in the preoperative treatment of operable Stage II lesions, and in the early lesion which, perhaps, can be treated with preservation of the breast. Small doses of irradiation for breast cancer are not recommended.
Histological sections of the primary tumour and of homolateral axillary lymph nodes from 500 women with operable invasive breast cancer have been examined. The tumours have been graded and the degree of round cell infiltration assessed. These features, together with clinical palpability and pathological involvement of axillary nodes, have been related to survival.
It was found that prognosis was worse in patients with a high grade tumour and in those with histological evidence of axillary node spread. Round cell infiltration of the primary tumour did not confer improved survival.
The clinical state of the axillary nodes was associated with prognosis in so far that palpable nodes were twice as commonly the seat of metastatic spread as were impalpable nodes.
The four most popular systems of anatomic staging for breast cancer have been analyzed for details of construction and results of application. The constituents of all four systems are described imprecisely. Important elements are either omitted entirely or cited without criteria to designate the prerequisite observational evidence. Elements combined in the same stage are often heterogeneous biologically and have not been tested for similarity of associated survival rates. When the reported survival results were evaluated for quantitative distinctions, the International TNM system appeared superior in range of survival gradient, score for linear trend, chi-square test of "significance," and proportional distribution of population. The reported populations, however, contained mixtures of patients chosen in diverse manners and showed significant disparities among different institutions for the distribution of patients among stages and for survival rates within the same stage. Although all these defects can be remedied with careful attention to methodology, a purely anatomic system of staging will remain unsatisfactory for the needs of clinical science. To improve the identification of patients and the analysis of data, the anatomic stages must be augmented with classifications for such clinically important (but currently omitted) prognostic factors as neoplastic rate of growth, symptomatic effects, and associated co-morbidity.
The ubiquitous problem of mammary carcinoma has been publicized increasingly in both scientific and lay publications in the past decade, both because of an apparent increase in incidence and because of raging controversies regarding optimal therapy. No new curative methods of treatment for breast cancer have been found during the present century. Surgery and irradiation remain the only curative weapons, with irradiation being, at best, a poor second choice. If patient survival is to be improved, increased efficiency at earlier detection must be realized, in addition to the continued search for new avenues of therapy. Planned educational programs for prospective patients are essential, as well as improvements in the clinical teaching of physicians. Until the nemesis of breast cancer has been eradicated, it behooves all physicians who care for patients with breast disease to continue to collect detailed and accurate clinical data regarding their patients, to classify each patient encountered according to the clinical stage of disease when therapy is begun, and finally to accumulate survival data for all patients treated by whatever methods are chosen. Screening programs employing combinations of techniques, such as thermography, xerography, and clinical examination should be encouraged and supported to determine if they will not only detect carcinoma in its earliest stages, but also identify the women in whom it may already exist in a preclinical state. When devoted teams of physicians encompassing all disciplines of modern medicine - surgery, medicine, and radiation therapy - will cooperate with one another, using all the techniques which twentieth century science can provide, the final conquest of this formidable threat will be that much closer at hand.
The current status of clinical classification of breast cancer is characterized by increasing emphasis on detailed examination records. A checklist for the examining physician is presented as one way of achieving such records. Detailed records are more valuable than summary stage classifications for most of the purposes of clinical classification, but summary classification systems are useful for certain types of end-results reporting. The present coexistence of several systems impedes communication, and efforts to reach agreement upon a single scheme should be continued. To be widely accepted, such a scheme needs to be based upon a convincingly large and representative sample of clinical data, analyzed in sufficient detail to assure recognition of the most appropriate category boundaries.
514 patients were treated for a surgically operable (T1, T2, T3, N0, N1a, N1b) infiltrating breast carcinoma at the Foundation Curie, Paris, France, from 1960 to 1970 inclusive. Patients with tumors 3 cm or less and without axillary adenopathy had lumpectomy followed by radiotherapy. Patients with larger tumors and all patients with clinically significant lymph nodes (N1b) had exclusive radiotherapy (without lumpectomy). 120 had lumpectomy and 394 had exclusive radiotherapy. The five and ten years absolute survivals, free of disease (N.E.D.), for the lumpectomy are 85% and 75%, respectively. 12% had secondary surgery for local recurrence. The cosmetic results were satisfactory in 98%, with no severe radiation sequelae. The five and ten years, N.E.D., of the exclusive radiotherapy group are 68% and 43%. 55% had secondary surgery for persistent or recurrent disease. The cosmetic results were satisfactory in 85%. There were only three patients with severe radiation sequelae. The overall survival for 514 patients at five and ten years are 72% and 51%. Two-thirds of patients, alive at five years, had a preserved breast. Our conservative treatment resulted in survival at five and ten years comparable to those of radical surgery.
Combinations of carcinoembryonic antigen (CEA), gamma glutamyl transpeptidase (GGT), pregnancy-associated macroglobulin (PAM) and placenta-like alkaline phosphatase (PLAP) were studied in groups of patients with ovarian and cervical cancer. In ovarian cancer, only CEA and PLAP levels appeared to reflect tumor burden and were complementary in detecting active disease. In cervical cancer, CEA and GGT reflected tumor burden, while PLAP showed just the reverse—the highest degree of positivity being present in minimal disease. PLAP positivity was even more pronounced in patients with cervical dysplasia and carcinoma in situ while CEA and GGT were negative. The data indicate that the use of marker combinations can improve our capacity to detect minimal disease and provide information regarding tumor biology that may not be available by studying individual markers or by other means. It remains to be determined whether the use of tumor markers can influence existing therapy sufficiently to alter the outcome in cancers which are notoriously difficult to treat.
756 ♀ mit Mammacarcinom wurden in den Jahren 1946 bis 1958 verschiedenartig behandelt. Die Resultate wurden mittels der statistischen
Methode vonBoag analysiert. Als Ergebnis: Der ausschlaggebende Faktor für die Heilung des Mammacarcinoms ist der vorliegende Tumorbefund,
hierin zusammengefaßt die Wachstumsgeschwindigkeit (oder die Tumorverdopplungszeit) und die Neigung zur Metastasierung. Die
Behandlungsresultate können daher nicht durch Kombination gleichwertiger Behandlungsverfahren gesteigert werden. Bei radikaler
Tumorentfernung garantiert die Nachbestrahlung das volle Ausnutzen der Heilchance, der “Wert” der zusätzlichen Strahlenanwendung
läßt sich dabei nicht in Zahlen fassen. Die prä-und/oder postoperative Bestrahlung hat dagegen ihren Wert bei fraglicher oder
nichtradikaler chirurgischer Behandlung. Die Nachbestrahlung der Brustwand mit Tumordosen vermindert die Häufigkeit des Lokalrezidivs.
Dagegen vermag die Nachbestrahlung der Axillar- und der Supraclavicularregion den Ablauf der Brustkrebskrankheit nicht entscheidend
zu beeinflussen. Mit der Konzeption einer determinierten Heilungsaussicht sollten Operation und Bestrahlung sinnvoll und logisch
zur Behandlung des Mammacarcinoms eingesetzt werden.
Staging of breast cancer is critical for making treatment decisions as well as for prognosis. Staging systems have evolved over time, and most providers caring for patients with breast cancer use American Joint Commission on Cancer staging. This chapter also provides a review of multicentric and multifocal characteristics of breast cancer.
The disconcerting realization that carcinoma of the breast usually is disseminated when called to the attention of the clinician not only lends a sense of urgency to the solution of a major problem in oncology but also causes the physician to weigh the probable stage of the disease against the best odds offered by a variety of therapeutic regimens. Radical mastectomy has maintained a place in the forefront of best choices for therapy of localized and regional disease for over three-quarters of a century and is responsible for the first really successful management of mammary carcinoma. The remarkable advances in palliative therapy consisting of administration of hormones and ablation of endocrine glands marked a surge of hope in mid-century which so far has not been reflected in dramatically increasing the number of cures. On the other hand, the results of radiotherapy have improved with the use of megavoltage and gamma irradiation and possibly may be made even more effective by future developments of alternate choices.
The most common method of treating operable breast cancer is still the classic Halsted operation (radical mastectomy; see Greiner and Widow, 1977) or minor modifications thereof. Frequently, this operation is supplemented by radiotherapy. Preoperative irradiation has been widely used and still is (Baclesse, 1962; Fletcher, 1967), but now mainly in locally or regionally more advanced cases. More often, postoperative irradiation is administered, in some clinics only to the supraclavicular region, axilla, and internal mammary chain.
Breast cancer is the most frequently diagnosed type of cancer and the second leading cause of cancer death in women after lung cancer. It is estimated that breast cancer affects more than 1,000,000 women worldwide each year, and about 450,000 die from the disease. During the last decades, breast cancer has received considerable attention, yet it is a very old disease that was described years and years ago. This book provides a summary of breast cancer history. It covers the ages from the ancient times to the early 2000's, but mainly focuses on the 20th century and its numerous discoveries and inventions in the field of breast cancer detection, analysis and treatment.
Plasma CEA levels have been determined in 92 normal women and 768 women with benign or malignant breast diseases. Only one of 92 normal women had a CEA level above 5 ng/ml. Of 253 women with benign breast diseases (gross cystic disease, adenofibroma, fibrosis, etc.) only one had a CEA level above 5 ng/ml. Ninety-four percent of the above two groups of women had CEA levels below 3 ng/ml. Of 164 women operated upon for Columbia Clinical Classification Stage A or B breast carcinoma, preoperative CEA levels were above 5 ng/ ml in seven (4%). Patients with a preoperative CEA level above 3 ng/ml seemed to have an increased incidence of tumor recurrence. Elevated CEA levels (>10 ng/ml) in our postmastectomy population of 288 patients have correlated with development of metastases in 14 of 46 subjects. Of 216 patients under treatment for metastatic breast carcinoma, CEA levels above 10 ng/ml have been detected in 15 percent of patients with soft tissue metastases, 38% of patients with visceral metastases and 50% of patients with osseous metastases. Of metastatic breast carcinoma patients with CEA levels above 10 ng/ml serial measurements have correlated with the patients response to therapy, progressively increasing in treatment failures and decreasing in treatment responders.
In der Mammaklinik in Columbia erreichen wir mit der radikalen Mastektomie nach Haagensen für alle Mammacarcinome im Stadium A und B eine 10-Jahres-Überlebensrate von 70% und 43%. Fast alle Patientinnen erhalten prophylaktische Bestrahlung der inneren Mammaregion, diejenigen Patientinnen mit 8 oder mehr befallenen Lymphknoten erhalten Vollbestrahlung. Patientinnen der Stadien C und D werden nur bestrahlt. Bei Vergleich der verschiedenen Behandlungsmethoden ergibt die radikale Mastektomie nach Haagensen die besten Resultate in operablen Fällen.
L~/St man die wichtigsten Gesichtspunkte zur Betrachtung des Mammacarcinoms Revue passieren, dann kSnnen gesicherte von umstrittenen Aussagen sowie weitgehend ungekl~irte Fragen unterschieden werden. Ich ordne hier nur die allerwichtigsten Angaben nach ihrer Bedeutung. Dabei stfitze ich reich im wesentlichen auf die Sorgf~iltigkeit einer Darstellung oder auf eigene Beobachtungen in den Kliniken und Laboratorien der zitierten Autoren.
The survival of a uniform series of 318 cases of Columbia Clinical Classification stage A breast carcinoma for 10 or more years postmastectomy was analyzed, with particular reference to influence of the nuclear grade of the cancer and sinus histiocytosis of the axillary lymph nodes. No statistically significant effect of these two factors on survival was found in this stage of the disease.
“And strangely visited people—all swollen and ulcerous, the very despair of surgery, he cures.” So said Shakespeare of Lady Macbeth's doctor. But in Hamlet he also uttered a prayer which we as radiotherapists must have prayed many a time—“Oh that this too solid flesh would melt”. When I see in my mind' eye and remember that tragic procession of women, young, middle aged and elderly, whom I have seen during the past 20 years— they are indeed the very despair of surgery. But I preferred not to use this for a title for this address, for it might have implied more than I have in mind. Shakespeare has some other words, words which Sir Ernest Kennaway called to my attention and which, he points out, the poet with a subtle purpose, perhaps, puts into the mouth of a clown. They are in Twelfth Night; the clown looking up at the darkened house mutters under his breath that it is dark—all dark—but “the only darkness is ignorance”. I am conscious that this is an address and not reading a paper or a lecture. I have ch...
An account has been presented of the method of treatment at present in use in Edinburgh. It must be accepted as representing but one direction in which the survival rates of breast cancer may be improved. There may be other better methods.
Considerable emphasis has been placed on the importance of assessing the true value of a method of treatment so that better methods may be recognised without undue delay. The view has been expressed that the publication of results of selected cases has greatly confused the issue and has tended to convey the impression that radical mastectomy is a highly successful method of treatment of breast cancer.
When radical mastectomy is the only method of treatment available, and when all cases coming to a large general hospital are taken into account, the five year survival rate is unlikely to exceed 25 per cent.
A brief account of the method of treatment by simple mastectomy and radiotherapy has been presented. The five year survival rate of all cases coming to the Royal Infirmary in the period 1941–45 is 43·7 per cent.
The most important feature of this method is the substitution of radiotherapy for surgery in the treatment of the axilla. The decision to do so was taken because when the axilla is not involved by malignant cells it appears unnecessary to carry out an axillary dissection, and when the axilla is involved the results of surgical dissection are poor.
The fact that a five year survival rate of 29 per cent. was obtained in the advanced cases without distant metastases indicates that radiotherapy, even in such adverse circumstances, is an effective method of treating the axilla. It is therefore not surprising that this same method of treatment in operable cases should be associated with a survival rate much higher than that obtained by radical mastectomy.
A high standard of radiotherapy is essential and adequate dosage must be given. It is most important to appreciate that simple mastectomy and a low standard of radiotherapy will be associated with results poorer than those obtained by radical mastectomy without any radiotherapy.
Les Metastases Parasternales du Carcinome Mammaire
Tobiassen, T.: Les Metastases Parasternales du Carcinome Mammaire. Med. et Hyg., 18:644, 1960
Curwen: Carcinoma of the Female Breast: Conserva-tive and Radical Surgery Unilateral Carcinoma of the Breast in Irradiation at the Radiumhemmet
I G Williams
R S Murley
Williams, I. G., R. S. Murley and M. P. Curwen: Carcinoma of the Female Breast: Conserva-tive and Radical Surgery. Brit. Med. J., 2: 787, 1953. Unilateral Carcinoma of the Breast in Irradiation at the Radiumhemmet, 1921-1957. I. G.: The Role of Radiotherapy and
The Treatment of Carcinoma of the Breast
The Treatment of Carcinoma of the Breast.
Irish J. Med. Sci., 6:475, 1956.
League of Nations Health Organization, Cancer Commission: Report Submitted by the Biological Sub-Commission
League of Nations Health Organization, Cancer
Commission: Report Submitted by the Biological Sub-Commission. Geneva, 1929, p. 14.
The Results of Radium and X-ray Therapy in Malignant Disease
Paterson, R., M. Tod and M. Russell: The Results of Radium and X-ray Therapy in Malignant Disease. Edinburgh, E. & S. Livingstone
Lt., 1946, p. 88.