Aspects of breast cancer control: is prophylactic mastectomy a feasible modality?

Even though mammographic techniques have improved and small tumors of 0.5 cm in diameter can be detected, decreased breast cancer mortality has not yet resulted. Because small tumors may cause systemic spread, in many patients breast cancer at the time of diagnosis is a systemic disease which is incurable. A reduction in breast cancer mortality seems possible by prophylactic bilateral mastectomy in women at extraordinary high risk of breast cancer. These are patients with (a) breast cancer in mother and sister, (b) breast cancer in mother or sister and a combination of various risk factors (early menarche - late menopause, nulliparity, late first pregnancy), (c) noninvasive malignant breast disease (carcinoma in situ), (d) therapy-resistant fibrocystic disease with intolerable pain and/or extreme anxiety (carcinophobia, and (e) benign breast neoplasia with malignant potentials (cellular atypia = precancerosis). Also, in breast cancer patients without regional and systemic spread and who are at high risk for developing cancer in the other breast, prophylactic contralateral mastectomy may be indicated. These are patients with (a) unilateral invasive breast cancer in the premenopause and a family history (mother or sister) of breast cancer, (b) unilateral invasive lobular carcinoma or tubular (ductal) carcinoma, and (c) unilateral invasive breast cancer and precancerous lesions in the other breast.

Subcutaneous mastectomy: indications, histological results.

This operation is made for therapeutic as well as diagnostic reasons. It is an enucleation of the mammary gland tissue under a saving of the skin and the areola. The operation is also made on women having one breast ablated: on account of the bilaterality of the carcinoma, because the symmetry of the reconstructed breast has to be realized.

Reconstruction of an ablated breast.

It is the aim of the reconstruction of an ablated breast to repair the woman's integrity. The technique of this operation, according to Bomert, is the sliding of a flap of skin in the case of a horizontal breast scar. For the reconstruction, a silicone prosthesis is implanted which in most cases is prepectoral.

[Bilateral radical mastectomy for carcinoma of the breast of the stages T0 and T1 (N0, M0) and mammoplasty of both breasts, areola and nipples in a single operation (author's transl)]. / Die beidseitige Radikaloperation der Mammakarzinomstadien T0 und T1 (N0, M0) und die Rekonstruktion beider Brüste, Warzenhöfe und Mamillen in einer Sitzung bei der Frau (Bilateral radikale und simultan rekonstruktive Mastektomie)

Bilateral radical mastectomy and concomitant mammoplasty is a new operative procedure for the treatment of carcinoma of the breast in the stages T0 and the small T1, N0, M0. The advantage of the procedure is the increased extent of the operation, the improved cosmetic result and the single stage of the procedure. Consequently the cure rate is improved and the psychic trauma to the patient is decreased. The operation is more radical since the so-called healthy breast is operated first, including axillary lymphadenectomy and subsequent mammoplasty followed by the same procedure on the so-called diseased breast. If the pectoral muscles are involved, a conventional radical mastectomy has to be done. The diagnosis is made by excisional biopsy and frozen section microscopy. The cosmetic result is improved because both breasts are subjected to the same operation, and lateral differences in shape, volume and consistency of the breasts are eliminated. Cylastic prostheses are inserted as new breasts usually sub-pectorally and rarely subcutaneously. The nipples are surgically reconstructed and pigmented by tattooing. The advantage of this single stage procedure is a single general anaesthesia and less psychic trauma since the patient goes to sleep with the knowledge of waking up with two breasts even though endoprothetic breasts. Post-operative radiotherapy can be applied with the prostheses in place. The principle of cure before cosmetics is preserved. Radical operation of the so-called healthy side is justified because of the above mentioned cosmetic advantages and the 25% incidence of primary or metastatic cancer of the so-called healthy side. The post-operative care of women with a bilateral operation is not a problem since no more breast tissue is left behind. Orthopedic complaints which can occur because of macromastia of the remaining breast are also eliminated.

[Tumor-adapted oncoplastic mastopexy and reduction-plasty]. / Die tumoradaptierte onkoplastische Mastopexie und Reduktionsplastik.

Reduction mammaplasties can be performed--if contraindications are respected--as oncoplastic operations. They have the advantage that the lump has clear margins and is surrounded by a thick layer of healthy tissue. This works only under the condition that the right type of the different mammaplasties is chosen as to cancer site, which guarantees that the cancer part of the breast will be removed ("landmap of removed breast tissue"). The axillary cavity must be cleared and the oncoplastic (reconstructed) breast be irradiated with 50 Gy. The mastopexia (breastlifting) is less apt to be used as an oncoplastic operation, as the removed tissue is rather skin and subcutaneous fatty tissue than the breast gland itself.

[Acute preoperative normovolemic hemodilution in gynecologic operations. A retrospective analysis]. / Die akute präoperative normovolämische Hämodilution bei gynäkologischen Operationen. Eine retrospektive Analyse.

In a retrospective analysis, a comparison of two groups of 100 patients each showed that in major breast surgery the need for heterogeneous banked blood can be considerably reduced by means of acute preoperative normovolemic hemodilution. The method involves replacing the blood withdrawn directly before or after anesthetization with a colloidal substitute solution, subsequently reinfusing it either intraoperatively, following hemostasis, or in the postoperative phase. Hemodilution could not be shown to influence the postoperative courses of HB, hexokinase or thrombocyte values. In contrast to major breast surgery, hemodilution was not found to have any advantages as regards reducing the requirement for heterogeneous blood in major abdominal wall grafting procedures.

[Growth velocity of breast carcinoma and radiographic "early diagnoses"]. / Wachstumsgeschwindigkeit des Mammakarzinoma und röntgenologische "Frühdiagnosen"

Between 1960 and 1975, 53 mammary carcinomas have been observed in a collective of 15000 women a part of whom, comprising finally 80 per cent, was free from troubles (annual prophylactic examination for breast cancer). Of these 53 cases were available two up to eleven preceding mammographic series made within an observation period of 0.2 to eleven years. A "mean growth curve" was obtained empirically, based on 163 mammographic tumor measurements with tumor sizes between 2 mm and 60 mm. In the course of a development period between two and eleven years, 33 per cent of the carcinomas were seen to accelerate their further growth in comparison with the initial value; 66 per cent revealed an increasing slow-down of growth, and all tumors showed considerable changes in their growth rates. Mammary carcinomas altogether continually decelerated their growth as measured by the duplication time of the tumor volume from Tv = 309 days on the average up to an average of Tv = 381 days after two through eleven years. The mean growth curve exhibited an exponential shape which was completed by biomathematical methods and can be described by means of a Power function. It corresponds well to the rate of incidence of the mammary carcinoma which shows an identical rise in relation to increased old age. The medium growth time from a primary cancerous cell with ten micron in size up to the tumor 2 mm in diameter may be estimated biomathematically only and amounts to ten or twenty years with 23 duplication periods. The further average growth rate between the tumor sizes of two and ten millimeter, stages which can be diagnosed roentgenologically, was empirically six years; the most quickly growing tumor needed almost two years. For the purpose of early cancer detection (tumor size below 10 mm, lymph nodes histologically free from metastases), the serial mammography to be performed every 18 months or two years is the only technique which provides utilizable early recognition marks and besides does allow a simple judgement. Solely the symptoms "suspect desification, partly spiculated" in sixty per cent and "typical cancerous microcalcification" in forty per cent have been observed as the earliest signs. The reliability ("certainty") of mammography is frequently overestimated (false negative rate: 7 to 18%) and should be quoted only for collectives where control mammographies have been made over a period of five or ten years. Roentgenological controls of alterations below three millimeter in size and without an indication for biopsy ought to be performed within six months, and still sooner in case of larger alterations. It is not possible earlier than after five or ten years to judge of the radicality of a therapy, as spread cancerous cells, on he average, reveal similar growth rates as does the primary tumor.