Selective axillary dissection after axillary reverse mapping to prevent breast-cancer-related lymphoedema.

BACKGROUND: It has recently been reported that, using axillary reverse mapping (ARM), the lymphatics from the arm can be spared to reduce the incidence of breast-cancer-related lymphoedema (BCRL). The aim of this study was to assess the feasibility of selective axillary dissection (SAD) after using ARM and partially preserving arm drainage, and to assess the occurrence of BCRL. METHODS: Using a radioisotope and lymphoscintigraphy, ARM was performed in 60 patients scheduled for SAD, who were subsequently divided for the purpose of comparing the BCRL rates into: group A, comprising 45 patients who successfully underwent SAD with a residual lymphatic hot spot; and group B with 15 whose hot nodes were removed as is normally the case during complete axillary lymph node dissection (ALND). RESULTS: SAD was feasible in 75% of the 60 patients. SAD was completed successfully in 19 of the first 30 patients, and in 26 of the second 30 patients (p = 0.072). The median follow-up was 16 months (6-36), during which 9 patients developed a BCRL, 4 in group A (9%) and 5 in group B (33%); p = 0.035. None of the patients had nodal relapses during the follow-up. CONCLUSIONS: Using a radioisotope enables an effective and safe SAD in a large proportion of patients. There was evidence of a trend to suggest a learning curve. The rate of BCRL after SAD was less than one third of the rate recorded after ALND, a result that should encourage the development of the former technique.

Reoperation for locally recurrent breast cancer in patients previously treated with conservative surgery.

BACKGROUND: This study aimed to analyse the possibility of surgical rescue of intrabreast tumour recurrence (IBTR) following conservative operation for breast cancer, i.e. quadrantectomy, axillary dissection and radiotherapy. METHODS: Of 2544 patients treated with this approach, 209 presented with an IBTR as the first and only sign of relapse. Some 197 patients were considered suitable for further surgery; 12 were inoperable. Six patients declined operation. RESULTS: Reoperative surgery was total mastectomy in 134 patients (70 per cent) and further local resection in 57 (30 per cent). Median follow-up after second surgery was 73 (range 1-192) months. The overall survival probability at 60 months was 70 per cent after mastectomy and 85 per cent following further local excision. There was no difference in disease-free survival between the two operative groups. Second IBTR was more common at 5 years in the re-excision group (19 versus 4 per cent). CONCLUSION: Since the type of surgery did not seem to affect survival, breast conservation can be considered in selected patients with IBTR.

Ten year results of a randomised trial comparing two conservative treatment strategies for small size breast cancer.

We report the 10-year results of a randomised clinical trial in which two different breast conservation treatment strategies were compared in women with small, non-metastatic primary breast cancer: quadrantectomy, axillary dissection and radiotherapy (QUART) versus tumorectomy and axillary dissection followed by external radiotherapy and a boost with 192Ir implantation (TART). No second surgery was given to women with affected surgical margins. Axillary node positive women received adjuvant medical therapy. From 1985-1987, this trial accrued 705 patients, 360 in the QUART and 345 in the TART arm. Crude cumulative incidence curves for intrabreast tumour recurrence (IBTR) and metastases as first events and mortality curves in each of the two treatment arms were computed. A crude cumulative incidence curve of IBTR as a second event (in women who had already had a local recurrence) was also computed. The two groups were compared in terms of hazard for IBTR, metastases or death occurrence by using Cox regression models, both with and without adjustment for patient age, tumour size, number of metastatic axillary nodes and histology. Possible interactions between the aforementioned prognostic factors and the type of surgery were also investigated. The two groups were well matched for baseline patient and tumour characteristics, the only exception being resection margins, which were more often positive in the TART group. At the Cox model, a significant difference between groups was detected for IBTR (P < 0.0001), but not for distant metastases and overall survival. In particular, 5- and 10-year estimates of crude cumulative incidence of IBTR were 4.7 and 7.4% in the QUART group and 11.6 and 18.6% in the TART group. The difference was not substantially affected by patient or disease characteristics. Likewise, the status of resection margins in women who underwent TART treatment did not significantly influence the risk of occurrence of IBTRs. Finally, the rate of second IBTR occurrence was relatively high, when compared with the rate of IBTR occurrence as first event. In summary, the results of this trial show that a better local control of the disease can be obtained with the more extensive surgical resection, i.e. QUART.

Argyrophilic carcinoma of the male breast. A neuroendocrine tumor containing predominantly chromogranin B (secretogranin I).

Argyrophilic tumors were diagnosed in 28 of 134 (20.8%) consecutive male patients who had a carcinoma of the breast removed between 1961 and 1990. Histologically, most argyrophilic tumors showed uniform cellularity and prevalent expansive growth. Ultrastructural observation disclosed the presence of electron-dense cored granules in the cytoplasm of the tumor cells. By immunocytochemistry, 17 of 28 argyrophilic tumors (60.7%) contained chromogranin B (secretogranin I)-immunoreactive cells, whereas chromogranin A was present in four of these 17 tumors only (14.2%). Immunoblotting studies showed chromogranin B immunoreactivity similar to that found in normal neuroendocrine cells. Despite these findings, which would argue for a distinct morphologic and immunochemical entity, no statistically significant differences between argyrophilic and common male breast carcinomas were found when a number of clinicopathologic features and relapse-free survival were considered.

The use of lympho-venous anastomoses to prevent complications from ilio-inguinal dissection.

Lympho-venous anastomoses (LVA) were performed in 30 patients, immediately after the completion of ilio-inguinal dissection for metastatic nodal involvement. This surgical procedure, originally devised to treat post-mastectomy lymphedema from radical mastectomy, was intended in this series of cases to prevent complications from ilio-inguinal nodal dissection. Actually, when compared to another group of 84 patients previously operated on by ilio-inguinal nodal dissection without lympho-venous anastomoses, the series showed a lower rate of local-regional complications (38% vs 65.9%). The mean duration of hospital stay was also reduced (18.5 vs 34.7 days). Distant lymphedema of the lower limb was observed in 7 of 23 patients who had received LVA, whereas in the control group, lymphedema was recorded in 39 of 52 patients who were regularly followed-up (30% vs 75%). LVA should be routinely used, as a useful surgical procedure, to prevent or reduce the occurrence of local-regional complications following ilio-inguinal nodal dissections.

Clinical considerations on 8 cases of abdominal carcinoids.

Eight cases of abdominal carcinoids are reported, 5 males and 3 females, whose age ranged from 21 to 66 years. The site of the carcinoids was appendix in 3 cases, ileum in 3, cecum in 1 and the ovary in 1. Synchronous metastases were present at regional lymph nodes and liver in 5 of the 8 cases. Radical surgery was performed in 3 patients, whereas in 3 cases nonradical surgery, due to the presence of nodal or hepatic metastases, was followed by chemotherapy (2 cases) and radiotherapy (1 case). The patients radically operated on are alive and free of disease at 22, 27 and 27 months. Surgery should be resorted to, when possible, even in the presence of liver metastases, since the life expectancy for these patients is longer than that of patients with liver secondaries from tumors other than carcinoids. Chemotherapy and radiotherapy seem to play a complementary role, if any.

Malignant pheochromocytomas: report of 4 cases.

Four cases of pheochromocytomas are reported: 3 cases of malignant pheochromocytomas of the adrenal glands and 1 case of pheochromocytoma, diagnosed on the basis of clinical and biologic signs, whose site and malignant character were not demonstrated. A rare association of pheochromocytoma and stenosis of the renal artery, recorded for one of the cases, is discussed.

[Surgical treatment of minimal breast carcinoma]. / Terapia chirurgica del carcinoma minimo della mammella.

The surgical approach to minimal breast cancer is still under discussion. In fact by the term "minimal" three lesions are meant, namely "lobular carcinoma in situ", "intraductal carcinoma" and invasive "microcarcinoma". It is really difficult to indicate appropriate treatment for these tumors, also because the series reported in the literature are few and represented by a small number of cases. The present paper is a critical review of the literature on the subject. According to the most recent view lobular carcinoma in situ and intraductal carcinoma demand for radical surgery (total mastectomy) due to the high percentage of multicentricity and bilaterality of these lesions. More particularly with regard to lobular carcinoma in situ recent reports claim for a "wait and see" policy which is gaining favour, on the ground that the risk of developing invasive cancer in women with lobular carcinoma in situ is not so high and that the period of time between diagnosis of the lobular carcinoma and the development of the invasive cancer is usually very long. On the other side, for intraductal carcinoma, axillary dissection seems to be pleonastic due to the low percentage of secondary deposits in axillary lymph-nodes (1-3%) in women operated on for intraductal carcinoma. Invasive microcardinomas, less than 5 mm in diameter, should be considered as T1N0 tumors; actually there is no reason to treat them by a more conservative surgery than is done for T1N0 cancers, as they present the same involvement of the axillary lymph nodes. In a small series of 38 microcarcinoma observed at the Milan Cancer Institut N+ cases were 27%.