Patey s Mastectomy Patey s (Radical) Mastectomy Patey

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Pateys Mastectomy
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Pateys (Radical) Mastectomy
Sandeep Kumar MS FRCS (Edinburgh) PhD (Wales)
MMSc (Newcastle) Professor of Surgery Department
of Surgery King Georges Medical
University Lucknow, Uttar Pradesh, India
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Pateys Mastectomy
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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

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NEW Not so New

• Recognition of the importance of extent and
• quality of primary surgery in determining
• outcomes
• R Residual

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Local treatment

• Improved loco regional control
• Improved survival

Improved local treatment not been a subject of
intensive, high profile randomised clinical trials
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Breast cancer the survival
Local treatment Systemic treatment
Survival

• Adjuvant radiotherapy
• Overgaard et al, NEJM 1997 337949
• Ragaz et al, NEJM 1997 337956
• Hellman S, NEJM 1997 337996
• Radical surgical treatment
• Quality of life

Survival
Survival
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Conservation Technique

• Seek LRR
• Require intensive radiotherapy
• Chemotherapy
• Long term follow-up monitoring

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Psychological Benefits of

• Conservation
• Radiotherapy Outcome
• Chemotherapy
• Is this really good s
• or
• as hoped ss

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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

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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
  47101
• Lower treatment and monitoring cost

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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

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LRR / Survival
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Survival Related to Tumor Size
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Who developed systemic recurrence ?
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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

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Overtaken by new biology

• Breast cancer is systemic from its onset and
  lymphnode involvement has significance only as an
  indicator of systemic spread
• Fisher

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Halstedian paradigm Radicality of
treatment - panacea for cureParadigm shift
Breast cancer - a systemic disease
Fishers rhetoric New millenium paradigm
Loco-regional recurrence - harbinger of
systemic recurrence
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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

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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

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David Patey