patey’s mastectomy. patey’s (radical) mastectomy sandeep kumar ms frcs (edinburgh) phd (wales)...
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Patey’s Mastectomy
Patey’s (Radical) Mastectomy
Sandeep Kumar MS FRCS (Edinburgh) PhD (Wales) MMSc (Newcastle)
Professor of SurgeryDepartment of SurgeryKing George’s Medical UniversityLucknow, 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
Adjuvant radiotherapyOvergaard et al, NEJM 1997; 337:949Ragaz et al, NEJM 1997; 337:956Hellman S, NEJM 1997; 337:996
Radical surgical treatment
Quality of life
Local treatment+
Systemic treatment
Survival
Survival
Survival
Breast cancer : the survival
Conservation Technique
Seek LRR
Require intensive radiotherapy
Chemotherapy
Long term follow-up monitoring
Psychological Benefits of
Conservation Radiotherapy Outcome
Chemotherapy
Is this really good or
as hoped
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 SizeTumor size
Conservatively treated Radically treated
No Alive Percent Median survival (mo)
No Alive Percent Median survival (mo)
P value
T1 49 / 81 60.4 % >132 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
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 SummaryRadical 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 includedin studies in which surgery is a component of therapy
David Patey