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SURGICAL TREATMENT OF CANCER OF MAMMARY GLAND (THE
HISTORY AND CONTEMPORARY)
Akhmedov Dilshod Khabibulloevich
Abdullaeva Parizoda Rustamovna
Ilkhomjonova Sevara Tulkinovna
Department of surgical diseases of pediatric faculty,
Samarkand State Medical Univevrsity, Samarkand, Uzbekistan
Mamarajabov Sobirjon Ergashevich
Scientific advisor – Doctor of medical sciences,
https://doi.org/10.5281/zenodo.14842261
Abstract.
The concern of cancer of mammary gland is problem of today.
The surgical treatment still has a priority. The advances in therapeutic radiation
and chemotherapy improve the surgical treatment to enrich quality of life of the
patients with the introduction of conservative surgery.
Key words:
mammary gland, cancer, surgical treatment.
Over the past decades, breast cancer has rapidly risen to first place in the
overall incidence of malignant tumors in women, both in other CIS countries and
in the Kyrgyz Republic. According to data from the early 1970s to the present,
the average annual growth rate of the number of cases has doubled (I.P.
Napalkov et al., 1982, S.V. Koreneva et al., 1994). The standardized incidence
rate in our region in 2008 was 8.5 per 100,000 population. Mortality from this
disease also continues to grow, although at a lower rate: (4.6 per 100,000)
(Davydov M.I., Aksel E.M., 2008). According to the experts of the World Health
Organization (WHO), in the coming 2010, up to 1.5 million new cases of breast
cancer will be detected in the world (Stoyko Yu. M. et al., 1999). Such
disappointing statistics determine the relevance of improving both the
prevention and diagnosis of breast cancer, and its treatment. According to V. P.
Letyagin (1985), more than 6,000 treatment options for patients with breast
cancer have been proposed at present. All treatment measures are divided into
local-regional (surgery, radiation therapy) and systemic effects (chemotherapy,
hormone therapy, immunotherapy). Certain successes in the treatment of breast
cancer, achieved in recent years, are associated, first of all, with the use of
various new methods of combined and complex treatment of this disease, with
the undoubted successes of drug therapy for breast cancer, the introduction of
highly effective cytostatics, hormonal drugs, bisphosphonates into clinical
practice. Considering that breast cancer at any stage may be a systemic disease
accompanied by latent dissemination of tumor cells throughout the div, the
role of adjuvant systemic chemo- and/or hormone therapy as methods of
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influencing distant metastases is difficult to overestimate. However, the surgical
method of treating this disease remains dominant and basic to this day. The
radicalism of the operation, depending on compliance with ablastics and
antiblastics, is determined mainly by the compliance of the operation with the
individual characteristics of local-regional growth and spread (Bazhenova A.L.,
Ostrovtsev L.D., Khakhanashvili G.N., 1985). Along with this, the surgical method
is also the most ancient method of treating breast cancer, which was used in
Ancient Egypt 3 thousand years BC (Davydov M.I., Aksel E.M., 2008).
The entire history of the development of surgical treatment of breast
cancer reflects the search for optimal volumes of surgical intervention. The
nature of therapy is always determined by the level of knowledge, prevailing
ideas about the disease and the availability of the necessary material and
technical support for treatment programs: from a complete rejection of invasive
interventions during the time of Hippocrates and symbolic herbal treatment
during the Middle Ages to super-extended mutilating operations in the mid-50s
of the 20th century (Semiglazov V.F., Vesnin A.G., Moiseenko V.M., 1989).
An assessment of the results of treatment of this disease based on
available historical documents since the time of Hippocrates shows that it was
actually ineffective and, as a rule, symptomatic, that is, it was aimed at
alleviating suffering (reducing pain, treating tumor ulcers), but did not prolong
the lives of patients. And only at the end of the 19th century was some progress
outlined. A qualitative leap in the effectiveness of breast cancer treatment
occurred more than 100 years ago. In the late 19th and early 20th centuries, W.
Handley (1922) put forward a hypothesis according to which it was believed
that breast cancer spreads primarily through the lymphatic pathways and that
regional lymph nodes are an ideal barrier to the spread of cancer cells. At the
same time, the spread of tumor cells through the bloodstream was clearly
underestimated. Based on this theory, Halsted (1889) developed his own
mastectomy technique, which involved the removal of the mammary gland with
the pectoral muscles, subclavian, axillary and subscapular lymph nodes in one
block. This operation was considered the main method of treatment for a long
time and was recognized as a standard radical mastectomy. Immediately after
the widespread introduction of the Halsted operation into clinical practice, very
encouraging results were obtained: the frequency of local and regional relapses
decreased from 80 to 26% (Semiglazov V.F., Vesnin A.G., Moiseenko V.M., 1989).
It should be noted that before W.S. Halsted, in 1888, N.I. Studensky proposed a
radical operation for the treatment of breast cancer, but this intervention
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remained little known in Russia and abroad (Bazhenova A.L., Ostrovtsev L.D.,
Khakhanashvili G.N., 1985).
By the 1950s, the scope of the operation had increased, as it became
possible to detect metastatically affected retrosternal, parasternal and
mediastinal lymph nodes. M. Margotti was the first to remove this group of
lymph nodes in 1951 (1952), and J. Urban (1952) developed the operation of
extended radical mastectomy in 1951 based on oncological grounds. An
unsuccessful race for lymphogenous metastases began, which from the point of
view of the modern understanding of breast cancer is not entirely correct and to
a large extent one-sided, since the main threat of this disease lies in the possible
development of so-called hematogenous distant metastases, that is, the spread
of tumor cells through the blood vessels, which can occur simultaneously with,
and even much earlier than, lymphogenous metastasis. However, during all this
time, two directions of surgical treatment of this disease were simultaneously
developing in oncology - methods of both superradical, extended, and
functional-saving and organ-preserving operations appeared. J. Urban (1953)
proposed to remove not only the mammary gland in a single block with the
pectoral muscles, subclavian, axillary and subscapular lymph nodes, but also the
lymph nodes located along the intrathoracic vessels. E. Dahl-Iversen, along with
the above-mentioned anatomical structures, also removed the supraclavicular
lymph nodes. However, in 1969, in his retrospective works, the author himself
reported that his results were no better than with the classic Halsted operation.
O. Wagensteen (1956) proposed removing the mediastinal lymph nodes
together with the mammary gland and the subclavian, axillary, subscapular,
supraclavicular and parasternal lymph nodes. Despite the superradical nature of
the operation, the long-term results were also no better than with Halsted's
operation. It is important to emphasize that tumors that were considered early
(operable) in Halsted's time, for which radical and later superradical
interventions were performed, are now considered by most oncologists to be
advanced, inoperable, widespread diseases that require the use of a full range of
therapeutic measures, including radiation, chemotherapy and hormone therapy.
The advent of radiation therapy at the end of the 19th century helped to reduce
the scope of surgical intervention [Garin A.A. et al., 1991].
Numerous clinical trials conducted in various centers and countries
have shown that removal or, conversely, preservation of regional lymph nodes
of any group (axillary, subclavian, supraclavicular, parasternal) can affect the
frequency of regional relapses, but does not actually affect survival rates
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(neither 5- nor 10-year) [Semiglazov V.F., Vesnin A.G., Moiseenko V.M., 1989].
The results of the study according to the B-01 NSABP (National Surgical
Adjuvant Breast Project) protocol, covering 820 observations, showed the
following 10-year survival rates [Fisher B., Wolmark N., 1975]: 1) in the absence
of metastases in the axillary lymph nodes - 65%; 2) in the presence of
metastases in the axillary lymph nodes - 25%, including: a) 1-3 lymph nodes
with metastases - 38%, b) 4 or more lymph nodes with metastases - 13%.
Analyzing these results, A.A. Garin et al. (1991) came to the conclusion that
surgical treatment alone is insufficient regardless of the scope of the operation.
Therefore, the so-called superradical operations, in which not only the axillary,
subclavian, but also the parasternal, supraclavicular and even mediastinal lymph
nodes are removed, are now considered unjustified - due not only to their
complexity and severity for patients, but also to the impossibility of combating
the dissemination of the tumor process.
As noted in the materials of "Controlled therapeutic trials in cancer"
(UIСС; Geneva, 1978), the revision of the scope of surgical intervention is the
main unresolved issue. By this time, a return to the position of standard radical
mastectomy after superradical interventions could no longer satisfy surgeons.
The fact is that strict adherence to the principle of surgical radicalism, which is
the basis of the generally accepted classical Halsted-Mayer operation, creates
real prerequisites for various kinds of disorders, primarily in the upper limb.
This was already shown by Halsted's initial experience. Thus, swelling of the
upper limb was noted in 81-87.5% of cases, limited mobility in the shoulder
joint - in 40%, pain - in 76%, decreased muscle strength with the loss of fine
manual skills - in 39%, which leads to serious damage to professional activity in
every second case [Pronin V.I. et al., 1985; Beltran M.A., 1989].
Along with the loss of physical health, severe mental trauma is also
inflicted. For female patients who have undergone surgery - radical mastectomy,
the problem of psychological adaptation and optimal life arrangement in general
arises. Awareness of the disease, surgery and other types of treatment are for
them the most severe stress and (without exaggeration) a personal tragedy, the
constant experience of which leads to a depressive state of varying severity and
serves as an independent factor influencing the further development of the
disease, i.e., the possibility of its relapse. This relationship is very characteristic
of breast cancer and has a convincing explanation. Oncological disease poses a
problem for a woman that she has not encountered before. In fact, life begins
anew with the awareness of a sudden danger and the need to build a new world
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in order to adequately respond to the challenge. In the conditions of a serious
illness, a woman suffers such a noticeable loss of physical and mental energy
that it is very difficult to restore it. After all, it is necessary not only to cope with
the loss of the past and the familiar world, what is commonly understood as
“female completeness”, but also to determine how to live on, build a new world
to replace the one that has passed and establish oneself in it, despite the
challenge thrown down by the disease [S. Karpilovskaya, 2006]. the loss of
physical activity, the presence of a cosmetic defect and, as a consequence, the
depressed psycho-emotional state of patients led to the fact that it became
necessary to perform surgical treatment without causing severe trauma to the
mental and physical health of patients with breast cancer.
In those same years, experience in performing functional-saving and
organ-preserving operations was gradually accumulating. G. Crile (1963) at the
first stage of the disease limited himself to only removing the mammary gland
with the fascia of the pectoralis major muscle. D. Patey and W. Dyson (1948)
published a technique for mastectomy they developed, in which, unlike Halsted's
technique, the pectoralis major muscle was preserved. H. Auchincloss (1963)
developed a technique of modified radical mastectomy, in which both pectoral
muscles were preserved, lymphatic dissection was performed up to the inner
edge of the pectoralis minor muscle, while the subclavian lymph nodes located
medially were not removed. Much later, a similar radical mastectomy was
described by Madden (1965), which differed from the technique of H.
Auchincloss in that the author preserved not only the subclavian, but also the
apical lymph nodes located behind the pectoralis minor muscle, starting
lymphatic dissection from the outer edge of the pectoralis minor muscle.
Although radical and modified mastectomies remain the standard
method of treating operable breast cancer, over the past decade there has been
an increasing interest in organ-preserving treatment (including sectoral
resection or quadrantectomy with axillary lymph node dissection) [1,10,8,4]. In
many foreign clinics, this direction was called conservative treatment, which at
first had the correct meaning, since the main emphasis was on radiation therapy
after local economical excision of the primary tumor (tumorectomy,
lampectomy) by the type of limited excisional biopsy. G. Crile (1964) performed
simple sectoral resection without lymph node dissection in 53 patients with
stage I breast cancer, and did not note any reliable differences in survival
compared to mastectomy. Recently, U. Veronesi (1977) introduced the concept
of quadrantectomy into surgery (in Russian literature, such an operation is
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called radical resection). The operation involves removing only part of the
mammary gland together with the tumor and regional lymphatic dissection.
Finally, in recent years, publications have appeared on lambectomies - removal
of only the tumor of the mammary gland with biopsy of the "sentinel lymph
node", which is the first on the path of lymph flow from the mammary gland
[Moiseenko V.M., Semiglazov V.F., Tyulyandin S.A., 1997].
The "sentinel" lymph node is detected using radioisotope research. In
case of metastatic lesion of the "sentinel" lymph node, lymphatic dissection is
performed in full, if there are no cancer cells in it, lymphatic dissection is not
performed at all [Zurida S., 1997]. All organ-preserving operations are
supplemented by radiation therapy to the remaining part of the mammary
gland. Remote results after organ-preserving operations turned out to be the
same as after Halsted operations [Trapeznikov N.N., Letyagin V.P., Aliev D.A.,
1989]. It should be noted that the prerequisites for the development of limited-
volume surgical methods for the treatment of breast cancer were: 1) improved
diagnostics of early forms of breast cancer (for example, mammography allows
you to identify non-palpable tumors in the mammary glands, as well as a tumor
less than 0.5 cm in diameter); 2) preventive examinations of women at risk of
developing breast cancer; 3) popularization of knowledge about breast cancer
and surgical treatment methods; 4) development of radiation and later drug
antitumor therapy methods in addition to surgical intervention [Garin A.A. et al.,
1991]. Gradually, the volume of organ-preserving operations increased to
classical sectoral resection, segmental resection with axillary subclavian
dissection, and even quadrantectomy in combination (or without) with
postoperative radiation therapy. The "retrospective" (exploratory) stage of
clinical studies of this problem has been completed. Currently, a stage of more
reliable, randomized clinical trials is underway [Stoyko Yu.M., Skryabin O.N.,
Karachun A.M., 1999].
As an example, it seems appropriate to cite the results of a study
[Dorofeev A.V., An integrated approach to selection for organ-preserving
treatment of breast cancer stages I-II a-b// Abstract of Cand. Sci. (Medicine)
Dissertation. – St. Petersburg, 1996. – 20 p.], using randomization of breast
cancer patients. According to the author, the functional effect of the operations
was as follows: after organ-preserving operations, swelling of the upper limb
and impaired mobility in the shoulder joint area were observed in 6.0 and 7.9%
of cases; after mastectomy – 21.6 and 14.4%, respectively. The cosmetic effect
was assessed as good and excellent in 50.5% of patients. Unsatisfactory cosmetic
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results were obtained in 6.5%. Three-year survival rates after mastectomy and
organ-preserving surgeries were virtually identical, amounting to 94.25% and
92.20%, respectively (P> 0.05). In an analysis of five-year survival rates in
breast cancer patients who underwent organ-preserving treatment (sectoral
resection with axillary-subclavian lymphadenectomy), local recurrences of
cancer were detected in 4.5%, and after Patey mastectomy – in 2.3%. Distant
metastases in patients of the first group were detected in 6.25% of cases, and in
the second – in 6.3%. Five-year survival was 89.35%, and after organ-preserving
surgeries – 89.86% (P> 0.05). Thus, the author comes to the conclusion that with
careful selection of patients with breast cancer, when performing organ-
preserving intervention, the long-term results are no worse than after
mastectomy according to Patey, and the "functional" and "cosmetic" ones allow
patients to go through the rehabilitation stage much easier and faster.
As U. Veronesi (1988) rightly believes, the coming years should be
fundamentally important for understanding the significance of organ-preserving
techniques in the treatment of minimal breast cancers, and in case of success, a
great psychological effect can be expected in women who will be interested in
regular visits to the doctor, having a firm hope that the mammary gland will be
preserved.
In conclusion, it should be especially emphasized that the organ-preserving
and functionally sparing focus of treatment is a priority in modern clinical
oncology. This encourages the development of all components of this treatment:
organizational, diagnostic, therapeutic, rehabilitation, etc. In terms of treatment,
the further development of organ-preserving treatment is undoubtedly
associated with the use of high-precision medical technologies [Issov V.I. et al.,
1995].
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