Transcript RADICAL MASTECTOMY - SGPGI

Patey’s Mastectomy
Patey’s (Radical) Mastectomy
Sandeep Kumar
MS FRCS (Edinburgh) PhD (Wales) MMSc (Newcastle)
Professor of Surgery
Department of Surgery
King George’s Medical University
Lucknow, Uttar Pradesh, India
Patey’s Mastectomy
Breast Cancer
A relaxed approach to local treatment in the
last 20 years
Loco Regional Recurrence (LRR) represents a
biologic disease rather than a treatment failure
NEW – Not so New
Recognition of the importance of extent and
quality of primary surgery in determining
outcomes
‘R’ = Residual
Local treatment
Improved loco regional control
Improved survival
Improved local treatment – not been a subject of
intensive, high profile randomised clinical trials
Breast cancer : the survival
Local treatment
+
Systemic treatment
Survival
Adjuvant radiotherapy
Survival
Overgaard et al, NEJM 1997; 337:949
Ragaz et al,
NEJM 1997; 337:956
Hellman S,
NEJM 1997; 337:996
Radical surgical treatment Survival
Quality of life
Conservation Technique
Seek
LRR
Require intensive radiotherapy
Chemotherapy
Long term follow-up monitoring
Psychological Benefits of
Conservation
Radiotherapy
Outcome
Chemotherapy
Is this really good s
or
as hoped ss
An Alternative is
More radical surgery to maximize local control
± Immediate breast reconstruction as cherished
Good loco-regional control related to improved
survival rates
Avoid adjuvant therapies
The Benefits
Breast conservation treatment unsuitable for
50% patients
Oldhoff 1992
Surgery remains necessary to treat large tumors
Surgery for unresponsive to chemotherapy
Long term adverse effects of high dose radiotherapy
Breast Can Res Treat 1998; 47:101
Lower treatment and monitoring cost
Breast Conservation – a Commodity
Early stage disease – a reference bias
Epidemiologically downstage – screen achieved
Large breasts – well nourished population
Radiotherapy support – overburdened
Meticulous surgical technique – sentinel node training
Chemotherapy mandate – ensured compliance, subsidy
Intensive follow up – education / means
LRR / Survival
Conservatively treated
n=241
Radically treated
n=210
LRR
97 (40.2%)
29 (13.8%)*
Total alive
102
123
Percentage
Alive
42.3 %
58.5 %**
Median
survival
time (mo)
100
>132
*p < .001, ** p < .01
Annals Surg Oncol 1999; 6 (5) : 455 - 60
Survival Related to Tumor Size
Tumor Conservatively treated
size
Radically treated
No Alive Percent Median
survival
(mo)
No Alive Percent Median
survival
(mo)
P value
T1
49 / 81
55 / 73
75.3 % >132
<.05
T2
43 / 119 36.1 %
89
49 / 97
50.5 %
115
NS
T3
9 / 30
30.0 %
49
10 / 21
47.6 %
73
NS
T4
1/9
11.1 %
39
09 / 19
47.3 %
83
<.05
60.4 % >132
NS = Not Significant
Annals Surg Oncol 1999; 6 (5) : 455 - 60
Who developed systemic recurrence ?
The survival
disadvantage in
conservatively
treated group
=
Excess of patients
in the group with
LRR who
subsequently
developed SR
An outcome at variance
Clear survival advantage for those who
achieved good loco-regional control
A hypothesis which has not been a subject of
high profile prospective RCT
Overtaken by “new biology”
“Breast cancer is systemic from its onset and
lymphnode involvement has significance
only as an indicator of systemic spread”
Fisher
Halstedian paradigm
Radicality of treatment - panacea for cure
Paradigm shift
Breast cancer - a systemic disease
Fisher’s rhetoric
New millenium paradigm
Loco-regional recurrence - harbinger of
systemic recurrence
Equivalence of Radical vs Conservative
Equivalent LRR between conservative and radical because of
multicentric trials - ? quality control in surgery
Euphemism in Group allocation (Milan - Veronesi) :
Quadrantectomy, meticulous axillary dissection and high
dose post-op radiotherapy = radical mastectomy
Powerful, high profile, randomised, multicentric and
controlled clinical trials neglect assessment of surgical
technique
In Summary
Radical local treatment contributes significantly to
survival
Reduced loco-regional recurrence influences
survival
High quality loco-regional control should be
emphasized as is systemic therapy
Assessment of surgical techniques should be included
in studies in which surgery is a component of therapy
David Patey