Recently, there has been considerablediscussion about simple mastectomyversus radical mastectomy in the treatment of breast cancer. This report willnot attempt to compare the merits ofeach technique.

Simple mastectomy is being used as atreatment for benign lesions such aschronic cystic mastitis, persistent sanguineous nipple discharge, benign cystosarcoma phyllodes and mammary hypertrophy. Although “¿�simplemastectomy―suggests total removal of breasttissue, the appearance of the operativesite indicates that, at times, only a widelocal excision has been done or protuberant breast tissue has been removed.(Figs. 1 and 2.)

Breast cancer is often multifocal andmay involve separate areas of the samebreast. Inadequate mastectomy mayleave foci of residual carcinoma. Equally disturbing is the situation in whicha patient has had a so-called “¿�simplemastectomy― for a benign conditionyears earlier and later develops cancerin remaining breast tissue.

The anatomic extent of breast tissuevaries with the age of the patient andthe size of the breast. At its borders,breast tissue becomes a thin layerwhich may extend to the clavicle, themidline of the sternum, the border ofthe latissimus dorsi muscle and the

Dr. Holleb is Associate Chief Medical Officerand Associate Attending Surgeomi, Breast Service,Department of Surgery, Memnorial Hospital forCancer and Allied Diseases, New York, N.Y.

Dr. Farrow is .4ttemidimig Surgeomi (imid Chief,Bm'east Service, Departniemit of Surgery, MemnorialHospital for Cancer amid .4llied Diseases.

*.4@japted froni an article titled “¿�St.Agathaamid inadequate Simple Mastertomy.― Reprintedfrom the American Journni of Roentgenoiogy,Radium Therapy and Nuclear Medicine 99: 962-964, 1967.

costal margin. There is also an axillarytail of Spence (Fig. 3), which extendsupward into the axilla through Langer's foramen. At times, breast tissue islocated in the fascia of the pectoralismajor muscle.

A proper simple mastectomy can beperformed through an elliptical ortransverse incision. The skin flapsshould be thin so that all the superficialfascia is included in the operativespecimen. The surgeon must excisebreast tissue which reaches the midlineof the sternum, the inferior border ofthe clavicle, the costal margin and themedial border of the latissimus dorsi.The axillary prolongation should also beincluded in the resection.

The most recent report of incompletesimple mastectomy was made in 1940by Hicken, in which he proved that thebreast tissue had not been removed in17 patients who had simple mastectomy,by injecting dye and demonstratingthat the duct systems had beensevered.' He also reported a case of cancer appearing in the axillary tail aftera simple mastectomy had beefi done 15years earlier.

Recently, we have seen two examplesof similar situations which are representative.2 The first, Case 1, was a 73-year-old woman who had had a simplemastectomy done elsewhere in 1951 fora bleeding nipple. Ten years later shewas seen at Memorial Hospital with alarge mass in the lateral portion of thesimple mastectomy scar. (Fig. 4.) Aradical mastectomy was performed andthe specimen showed cancer arising inresidual breast tissue. The second, Case2, was a 62-year-old woman who hadhad a right simple mastectomy in 1951for an intraductal papilloma and a left

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Inadequate Simple Mastectomy*

Arthur I. Holleb, M.D., and Joseph H. Farrow, M.D.

.—.

simple mastectomy for cancer in 1955.She was seen in Memorial Hospital in1963 and examination revealed residualbreast tissue bilaterally. In addition,there was a mass in the scar of the rightsimple mastectomy, which had beenperformed for a benign condition.Right radical mastectomy was done andthe specimen showed papillary carcinoma arising in residual breast tissue.(Fig. 5.)—¿�S.

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Legends

Fig. 1. Inadequate “¿�simplemastectomy.― Onlyprotuberant breast has been excised.

Fig. 2. Considerable breast tissue remains after“¿�simplemastectomy.―

Fig. 3. The axillary tail of Spence has not beenremoved at time of “¿�simplemastectomy.―

Fig. 4. Case 1. Cancer arising in lateral breasttissue after “¿�simplemastectomy.―

Fig. 5. Case 2. Cancer originating in residualbreast tissue after right “¿�simplemastectomy―for benign disease. Note also residual breasttissue on left side after “¿�simplemastectomy.―

Conclusion menclature and be replaced by “¿�totalThe cited cases prove that breast can- mastectomy― to emphasize that all

cer may develop in remaining breasttissue when an incomplete simple mastectomy has been done. We would liketo urge that the term simple mastectomy be deleted from the medical no

References

breast tissue should be removedwhether the operation is being performed for benign or malignant disease.

Photographs are reproduced by permmmissiiimifroimiSurgery, Gynecology & Obstetrics.5

1. Hicken, N. F.: Mastectomy: clinical pathologicstudy demonstrating why most snastectomies result in incomplete remmmot'al of mamnmmumrygland.Arch. Surg. 40: 6-14, 1940.

2. Holleb, A. I.; Montgonmere, R., amid Farrow,J. H.: The hazard of incomnplete simple mmm(Istectoimmy. Surg., Gynec.@ Obst. 121: 819@822, 1965.

GASTRIC ANALYSIS FOR DETECTION OF CURABLECANCER UNSATISFACTORY

Gastric analysis is done at each annual [Minnesota] Cancer Detection Center visit.Patients found to have achlorhydria or hypochlorhydria, plus those with symptoms suggestive of stomach cancer or with strong family histories of cancer, undergo an uppergastrointestinal X-ray examination. During the 11-year period from January 1, 1953, toJanuary 1, 1964, 42,953 annual examinations were done; 18,873 upper gastrointestinal X-ray studies were performed. Ten adenocarcinomas of the stomach werefound, or one cancer was detected per 1,887 X-ray examinations;nine of these tenpatients died as a result of their cancer. The tenth patient is alive and well, more thanseven years after her cancer was detected. One of the nine dead patients, althoughtechnically a five-year survivor, developed a recurrence and expired three monthsafter the five-year period. Therefore the absolute rate for five-year cancer-free survival was 10% for the ten patients with stomach cancer detected 1954-1964 at theCenter.

In the final analysis, the delineation of those patients achlorhydric or hypochlorhydric by means of routine gastric analysis is not a satisfactory screening method forthe detection of early, potentially curable stomach cancer. In fact, most achlorhydricstomach cancer patientswere elderlywith advanced cancer which could not be curedwith available therapeutic technics, and those younger patients seen relatively earlywith potentially curable stomach cancers were achlorhydric in about the same proportion as seen in the general “¿�healthy―population.

—¿�VictorA. Gilbertsen, M.D., “¿�ThePotentiality for SurvivalEnhancement by Expeditious Detection of Neoplastic Diseases: Experience of the Cancer Detection Center at theUniversity of Minnesota.―In I. M. Arid, ed., Progress in ClinicalCancer. New York: Grune & Stratton,1966; pages 48-67;page 58.

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