PALLIATIVE I N TERSCAP ULOTH ORACIC AMPUTATION I N T H E MANAGEMENT OF T H E BREAST CANCER PATIENT

ARTHUR I. HOLLEB, M.D., AND JOHN C. LUCAS, JR., M.D.

NTERSCAPULOTHORACIC amputation and hem- I ipelvectomy have become acceptable thera- peutic procedures in selected cases of clini- cally curable melanoma, bone sarcoma, and soft tissue sarcoma of the extremities. Radical amputation has been used therapeutically for lymphangiosarcoma developing in the post- mastectomy lymphedematous arm, but this entity will not be discussed in this report. In the past, an occasional disarticulation through the shoulder joint for a lymphedematous, use- less forequarter has been performed. The pa- tients presented in this study were not suit- able for simple disarticulation.

Prudente3 and da Silva Net0 and Abr504 have done supraradical operative procedures that combined interscapulothoracic amputa- tion with simultaneous radical mastectomy, neck dissection, and resection of the internal mammary lymph node chain. This operative approach was designed to cure the patient with breast cancer fixed to the axillary con- tents and invading the homolateral supra- clavicular lymph nodes.

It is the purpose of this report to show that interscapulothoracic amputation likewise may have a place in the palliation of the patient with breast cancer when there are locally ex- tensive, ulcerated, foul-smelling, recurrent tu- mors requiring frequent dressing changes or producing intractable pain in a useless, lym- phedematous extremity. In certain clinical settings only a radical amputation, used as a last resort, will return the patient with ad- vanced cancer to a state o€ partial activity and ambulation .1

It should be emphasized that cautious se- lection of the setting is necessary to obtain satisfactory palliation for a reasonable period of time. Interscapulothoracic amputation may offer infrequently a remote possibility of cure to an individual with locally recurrent breast cancer.

From the Breast Service, Department of Surgery, Memorial Center for Cancer and Allied Diseases, New York, N.Y.

Received for publication Aug. 25, 1958.

There is a natural and understandable re- luctance on the part of the surgeon to propose amputation to a patient who appears hope- lessly incurable. Nevertheless, interscapulo- thoracic amputation seems to have a definite, though limited, palliative usefulness in the management of some instances of recurrent breast cancer or of complications secondary to the therapy of breast cancer.

INDICATIONS AND CONTRAINDICATIONS

For the patient with breast cancer, the major indications for interscapulothoracic amputa- tion include the presence of immobile recur- rent cancer in the apex of the axilla; radio- necrosis or recurrent cancer with ulceration and direct extension into the major axillary blood vessels and/or brachial plexus: intract- able pain; and a useless, markedly lymphe- dematous arm. When the function of the extremity is unimpaired, the value of amputa- tion must be carefully considered in terms of the loss of function and the expected benefit from palliation. Most patients who become candidates for radical amputation have been treated previously by local surgery, radiation therapy, additive hormone therapy, and abla- tive endocrine surgery. When these measures have failed, amputation has been recom- mended as the final palliative procedure.

Patients with a poor immediate prognosis and those with extensive metastases to vital organs should not be considered as candidates for radical amputation. The patient with a rapidly recurring cancer, i.e., a short interval between initial therapy and the development of recurrence, or the patient with an extremely aggressive neoplasm that disseminates widely, shows no response to the usual modalities of therapy, and progresses unremittingly should also be excluded.

TECHNJQUE

The preoperative and postoperative man- agement and the techniques of interscapulo- thoracic amputation have been described and illustrated by Pack et al.2

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ti 14 CANCER July-A ugust 1959 Val. 12

Fic.. 1 . Patient H.M. (Case I .) A, rccurrcnt adherent breast cancer in left snpraclavicu1;ir and infrac1aviciil;ir spice associaled with a useless. I~nil’heileinatoiis ;irni. 13. Sir months after intcrscapi i lot l ior~~~~i~ ;Iinput;ition. ’l‘herc was pallinlion for 5 years.

-4 few minor modifications in technique were necessary in our patients. The location of an ulceration or the presence of heavily irradiated skin on the anterior or posterior aspects of the shoulder required changes in the skin incisions so that normal skin could be approximated at the time of closure. In some patients the entire clavicle was resected and in others only the lateral two-thirds of the clavicle was removed. When cancer was ad- herent to the underlying ribs, plans were made to resect the ribs and apply a fascia lata graft.

! CASE REPORTS

Suniniaries of the data for 6 patients treated by the Breast Service of Memorial Center for Cancer and Allied Diseases are presented to demonstrate the varied problems encountered and the palliative results.

Case 1. B.M., a 70-year-old white woman, was first seen at Memorial Center in 1949. A left radical mastectomy had been done elsewhere in January, 1915, followed by post- operative X-ray therapy. When left supra- clavicular metastases appeared in 1948, addi- tional X-ray therapy was given. At her initial visit at Memorial Center, residual cancer was present in the left supraclavicular fossa, and there was a tumor in the opposite breast. T h e left arm was markedly lymphedematous and useless. No distant metastases were demon- strable. Estrogen therapy produced regression

of the tumor i n the right breast, b u t the dis- ease in the left supraclavicular space continued to enlarge and extend inferiorly (Fig. 1A). In November, 1951, when the patient was 72 years of age, a palliative interscapulothoracic amputation was performed to rid her of the bulky mass and the useless arm. In spite of the patient’s advanced age, the postoperative course was uncomplicated. Pathological ex- amination of the operative specimen demon- strated metastatic mammary carcinoma deeply invading the deltoid muscle and the clavicle. T h e patient was immediately pleased with the surgical result and stated that the opera- tion was worthwhile (Fig. 1B).

Three years later recurrent cancer became evident in the left neck and left parasternal region. Additional X-ray therapy was given. Five years after interscapulothoracic amputa- tion, the patient died suddenly of a coronary occlusion at the age of 77. At the time of death induration in the left supraclavicular fossa persisted, but there were no demonstrable distant metastases. However, autopsy was not obtained.

Comment. Palliation was provided for 5 vears by interscapulothoracic amputation in a 72-year-old woman with massive local recur- rence and a useless lymphedematous arm.

Case 2. M.D., a 57-year-old white woman, had a right radical mastectomy for carcinoma of the breast at another hospital in January, 1956. A review of the submitted slides of the original operative specimen revealed “squa- mous carcinoma consistent with origin in the

So. 4 INTERSCAPULOTHORACIC AMPUTATION IN BREAST CANCER * Holleb Q Lucas t i4 5

breast.” Postoperative radiation therapy was given to the right axilla. The patient was first seen at Memorial Center in October, 1956, at which time there was recurrent adherent can- cer in the right axilla and multiple foul- smelling ulcerated metastases extending down the skin of the right arm and forearm (Fig. 2A). The right arm was markedly lymphede- inatous, but function was fairly adequate. There were no distant metastases. Interscapulo- thoracic aniputation was pertorined in No- vember, 1956. Dissection of the operative specimen (Fig. 2B) did not reveal invasion of the brachial plexus or of the major axillary vessels. T h e histological examination showed squamous carcinoma. Wound healing was de- layed because of necrosis of the wound edges (Fig. 2C), and 1 month after amputation re- current cancer appeared at the inferior margin of the wound. Irradiation and hormone ther- apy failed to control the rapid progression of massive local recurrence and distant metasta- ses. T h e patient died 13 months after ampu- tation.

Coiriment. This patient was not helped by radical amputation because the surgical pro- cedure tiid not encompass the tumor locally. Uncontrollable recurrence appeared in 1 nionth. It seeins significant that the time in- terval bctivecn radical mastectomy and the first recurrence was onlv 6 months. In retro- spect, this patient was improperly selected. Perhaps the history should have been inter- preted as precluding radical amputation.

Case 3. R.T., a :44-year-old white woman, had a right radical mastectomy and X-ray t h e r a p a t another hosnital in September, 19.51. 111 May, 1933, axillary recurrence ap-

peared at the operative site. Additional radia- tion therapy was given. Testosterone was pre- scribed, and in November, 1955, radiation to the pelvis, to diminish ovarian function, was begun. There was a temporary regression of the axillary mass followed shortly by an in- crease in size and ulceration. T h e patient was first seen at Memorial Center in May, 1956, with a massively lymphedematous, virtu- ally useless, right upper extremity and a foul- smelling IO-cm. adherent axillary ulceration. A right interscapulothoracic amputation was done in June, 1956. T h e operative specimen demonstrated necrotic metastatic mammary carcinoma extensively invading the deltoid niuscle and the skin of the arm. A tumor thrombus was found in the axillary vein, and inetastatic tumor was present in a lymph node at the apex of the axilla. Healing was com- plete within 1 month. T h e patient was com- fortable and pleased with the surgical result. One year later pultnonary and cerebral me- tastases appeared. T h e patient died in Novem- ber, 1957; 17 months alter interscapulotho- racic amputation.

Comment. Satisfactory palliation of 17 months was provided for a patient with ul- cerated recurrent cancer in the axilla and a massively lymphedematous, virtually useless arm.

Case 4. M.C., a 27-year-old white woman, was first seen at Memorial Center in April, 1939, with cancer of the left breast and con- current pregnancy of 3 months’ duration, Be- cause the patient refused mastectomy, she was treated with radiation therapy to 2 chest wall ports and 3 axillary ports. .4lthough the dose was moderate, a severe skin reaction occurred.

FIG. 2. Patient M.D. (Case 2.) A, Recurrent squamous carcinoma of the breast. B, Inta- scapulothoradc operative specimen. C, One inonth after interscapulothoracic amputation, showing inadequate healing and cutaneous recurrence at inferior margins of wound.

646 CANCER Ju ly-Augzist 1959 VOl. 12

FIG. 3. Patient M.C. (Case 4.) A, Preoperative photo, showing extensive radiation ulcerations that required daily dressings for 3 years. The arm was useless, and edematous. R, One year after interscapulothoracic amputation.

In October, ICISY, because of persistent breast cancer, the patient consented to radical nias- tectoiny. The pathology report was medullary carcinoma, Grade 11, with no demonstrable lymph node metastases. A few weeks later the pregnancy terminated spontaneously with the birth of a stillborn child.

Delayed healing necessitated skin grafting. Atrophy of the inusculature of the left arm and almost complete paralysis ensued. These findings were attributed to radiation fibrosis involving the brachial plexus. During the next 10 years many radiation ulcerations ap- peared o n the left anterior chest wall and in the lett axilla. Repeated operative attempts

to repair the defects failed, and the left arm gradually became lymphedeinatous (Fig. 3A). In 1947 she had a normal spontaneous de- livery. Interscapulothoracic amputation was repeatedly recommended, but the patient de- clined the operation until the onset ol profuse hemorrhage from a radiation ulceration in January, 1953. Healing was complete in 2 months, and this was the first time in 3 years that the patient did not require a daily change of dressings (Fig. 3H). In December, 1957, examination revealed no evidence of recurrent cancer. Psychic and physical adjustment to the amputation have been very satisfactory.

Cornment. This patient had excellent pal-

FIG. 4. Patient AS. (Case 5.) Necrotic, fixed, recurrent breast cancer in the axilla with massive lymphedema of the am]. B, Fifteen months after interscapulothoraac amputation.

No. 4 INTERSCAPULOTHORACIC AMPUTATION IN BREAST CANCER Holleb 6 Lucas 647

liation after radical amputation. T h e pro- cedure was performed for an extensive, chronic, bleeding radiation ulceration and a useless, swollen arm. T h e need for daily dressings prior to the operation and the long term post- operative survival adequately justify the am- puta tion.

Case 5. AS., a 66-year-old white woman, had a left radical mastectomy performed at another hospital in 1948; this was followed by radiation therapy. I n 1953, excision of a local recurrence in the axilla was done. Marked lymphedema of the extremity appeared im- mediately. In 1955, the axillary mass recurred and ulcerated, and the lymphedema pro- gressed. T h e patient was first seen at Memorial Center in November, 1956, with a 5 ~ 8 x 4 cm. necrotic ulceration in the left axilla (Fig. 4A). Complete study revealed no evidence of dis- tant metastases. A left interscapulothoracic amputation combined with a low neck dis- section was performed. T h e neck dissection was done because of a palpably enlarged supraclavicular node detected dur ing the course of the amputation. T h e operative speci- men revealed metastatic mammary carcinoma extensively involving the shoulder joint, the brachial plexus, and the axillary vein. One lymph node in the posterior triangle of the neck contained metastatic cancer. Healing was complete in 3 weeks. Figure 4B shows the patient 15 months after the operation. She is now 18 months postoperative and remains free of local recurrence or distant metastases.

Comment. Satisfactory palliation for 18 months has been provided, to date, for a pa- tient with an extensive, ulcerated axillary recurrence and a nonfunctioning arm. The possibility of cure is present, though remote.

Case 6. C.B. had a right radical mastectomy at Memorial Center in January, 1946, at the age of 37. Pathological examination revealed a primary infiltrating duct carcinoma without axillary lymph node involvement. Radiation therapy was given to the right axilla post- operatively. In 1957 ( 1 1 years after radical mastectomy), the patient developed a firm 3-cm. elevated mass, which was fixed to the chest wall, in the apex of the right axilla. A small wedge biopsy was reported as “fibro- sarcoma-unrelated to breast carcinoma but possiblv induced by previous radiation ther- aov.” There was no limitation of arm func- tion, but there was local pain. There were no distant metastases. Owing to the location of the mass and its fixation to the chest waII, in- terscapulothoracic amputation was selected as

the surgical procedure of choice. T h e ampu- tation was done in December, 1957. Dissec- tion of the operative specimen revealed the tumor to be 9 x 6 ~ 6 cm., involving the bra- chial plexus and the subscapularis and pecto- ralis major muscles. T h e final histological report suggested synovioma rather than radia- tion-induced sarcoma. The wound was com- pletely healed in 11 days. Examination 7 months later revealed no evidence of local recurrence or distant metastases. T h e patient is pleased with the operative result.

Comment. Interscapulothoracic amputation was performed for a suspected radiation- induced sarcoma in a patient who had had a radical mastectomy and postoperative X-ray therapy for breast cancer. The final patho- logical diagnosis was synovioma. The opera- tion was performed too recently for evalua- tion.

SUMMARY

Six patients who have had palliative inter- scapulothoracic amputations are presented. In each there was a history of breast cancer. Five patients had satisfactory palliation lasting from 8 months (recently operated upon) to 5 years. One patient was improperly selected, and although she survived for 13 months after amputation, no palliation was achieved.

T h e indications and contraindications for radical amputation are discussed. One must exclude those patients whose progress of dis- ease or extent of metastases suggest an im- mediate poor prognosis. Proper selection of patients for interscapulothoracic amputation, when there is associated breast cancer, will usually provide worthwhile palliation and rarely a “cure.”

REFERENCES

1. PACK, G. T.; EHRLICH, H. E., and GENTIL, F.: Radical amputation of extremities in treatment of cancer. Surg. Cynec. 6. Obst. 84: 1105-1116, 1947.

2. PACK, G. T.; MCNEER, G., and COLEY, B. L.: In- terscapulothoracic amputation for malignant tumors of upper extremity; report of 31 consecutive cases. Surg. Cynec. dr Obst. 74: 161-175, 1942.

8. PRUDENTE, A.: L’Amputation inter-scapulo-mammo- thoracique (technique et rhultats). J . chir. 65: 729-746, 1949.

4. DA SILVA NETO, J. B., and ABRXO. A.: Amputa@o inter-esciipulo-mamo-toriaca ampliada corn esvazia- mento suDra-clavicular e resseccPo da cadeia eanelionar mamaria ‘intma. por cfincer da mama. Rev. =br&l. cis. 35: 205-208, 1958.