Significance of Location and Number of Axillary Metastases in Carcinoma of the Breast: *

A Justification for a Conservative Operation

HUGH AUCHINCLOSS, M.D.
From the Department of Surgery, Columbia University College of Physicians and Surgeons, and the Surgical Service of the Presbyterian Hospital, New York, N. Y.

THE VALUE of any operative procedure can be measured only in terms of how successful it is in accomplishing its purpose. In recent years the value of radical mastectomy has been challenged by a number of thoughtful workers, and results of treatment of cancer of the breast by other methods, notably radiotherapy and simple mastectomy, have been reported which do not differ greatly from those achieved by conventional radical mastectomy.9' 1' The operation of radical mastectomy, as originally conceived and performed by Halsted,5 had as its aim the complete removal of all breast tissue, much of the overlying skin, the pectoral muscles and especially the axillary lymph nodes. This was and is a very logical approach to the problem of removing as much tissue as possible that might contain cancer cells. Over the ensuing years this classical procedure has probably changed less than any other radical cancer operation. This is understandable because it so well fulfills the criterion of a good cancer operation which is to remove in its entirety not only the cancer, but also the organ in which it grows and the regional lymphatic tissue-all in continuity. However, if it can be shown that this radical procedure produces no better end results than might a more conservative operation, then surely the indications for its use are open to question.
*

Submitted for publication August 8, 1962.

In the early years it seemed logical to hope that by removing involved axillary lymph nodes, patients suffering from breast cancer might be cured. It soon became obvious, however, that in the group of patients in whom the axillary nodes were involved, the salvage rate was low. Nevertheless, some of these patients appeared to be cured after ten or more years had elapsed following the operation. For this reason we have continued to consider radical mastectomy to be the best method of treatment we had to offer, not really knowing preoperatively which patients would profit by the procedure, and which would not. Haagensen and Stout3 described a series of clinical criteria of operability, attempting to exclude certain patients with advanced cancer from being subjected to an operation which could not cure them. More recently Haagensen4 has refined these criteria by performing internal mammary and apical axillary lymph node biopsies in selected cases. He is now convinced that patients with breast cancer in whom these nodes are involved ought not to be subjected to a futile radical mastectomy, and are better treated by radiotherapy. One thing we need to know is the relationship between the number and location of axillary metastases and the patient's chance of cure by radical mastectomy. If early experience had shown that whenever the nodes were involved, cure could not be
37

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AUCHINCLOSS

Annals of Surgery July 1963

FIG. 1. Standard diagram used to plot exact location of each axillary lymph node removed from the cleared axillary tissues.

found, the only survivors after ten years were those in whom the involved nodes were few and confined to the central or lower axillary vein groups, then it might be inferred that the very extensive axillary dissection which can be achieved when the pectoral muscles are removed, is unnecessary because it adds nothing to the salvage rate of patients with breast cancer. A limited axillary dissection, such as can easily be combined with simple mastectomy, could be expected to accomplish the same end. The results of such a study will now be presented. Since the period of the study began in 1951 and ended in 1953, a full ten-year follow up is not yet possible on all cases, but the results fall so clearly into a pattern even now, that the arbitrary tenyear period becomes academic. Material Beginning in 1951, Pickren 12 of the Department of Surgical Pathology undertook the herculean task of clearing the axillary tissues removed in every radical mastectomy performed by the surgeons at the Presbyterian Hospital. He then numbered and plotted the exact location of every lymph node in the axilla on a standard diagram (Fig. 1). Microscopic sections of each node were carefully studied, and those containing metastases indicated in red ink on the diagram. By this method an average of 38 nodes were found per case: the highest number found was 88, the lowest 8. This study, carried out by a single pathologist, achieved a high degree of accuracy and uniformity. A total of 204 cases were thus studied, of which 107 were found to have axillary metastases, and in the remaining 97 all nodes were negative. It is solely with the group of 107 cases that this study is concerned. It must be emphasized that the 204 patients were favorable cases, carefully selected for radical mastectomy by Haagensen's criteria of operability, and do not represent the whole group of pa-

expected, radical mastectomy would long since have been discarded; but this has not been the case. However, all are aware that if there are many lymph node metastases, only an occasional patient will survive ten years following operation. How many are many, and what is the importance of their exact location or level in the axilla? These are questions which have a direct bearing on the value of an extensive axillary dissection such as is done in the classical radical
mastectomy.

All

are

agreed that the majority of

pa-

tients who stay well after either radical mastectomy or simple mastectomy and

radiotherapy do so because the cancer was confined to the breast-so-called Stage I. It is a fair assumption that all of these patients would have done just as well by simple mastectomy alone with neither the added axillary dissection nor the postoperative radiotherapy. The obvious question is, how can one know preoperatively which these patients are? The answer is that one
cannot.

If it could be shown that of the patients subjected to radical mastectomy in whom axillary lymph node involvement was

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tients with breast carcinoma as they were first seen in the hospital. The question that immediately comes to mind is how accurate is even this precise study? Might not an occasional microscopic metastasis in a marginal sinus of a lymph node have been missed? Or might not a section cut at a deeper level in a node have revealed a metastatic deposit not present at the first level? Obviously the answer is yes; this occasionally must have happened. To test the accuracy of the study, Pickren 13 made serial sections of all the lymph nodes removed from 51 cases in which previous routine sections had not shown metastases. By this method he found unsuspected additional metastases in 11 (22%) of his cases. Such tiny foci of cancer, however, were always found in nodes located in the central or lower axillary vein groups-never in the highest group, and the five-year survival rate (91%) for patients with such occult metastases was similar to that for patients with no occult axillary metastases 13 (89% ). The important point to be made, however, is that even though our most careful study of the axillary tissues lacks 100 per cent accuracy, the pattern of the exact location of axillary metastases can be established by the clearing technic. Whether a patient falls into the group in which no axillary metastases are found, or into the group with metastases because a tiny metastatic deposit was detected by serial section of all nodes, the validity of the study is not altered. Returning then to the 107 patients who were found to have axillary metastases: 71
TABLE 1. 107 Cases of Radical Mastectomy uith Metastases to Axillary Lymph Nodes,

TABLE 2. Distribution of 31 Cases Still Apparently Free of Cancer by Number of Nodes Involved, 1951-1953
No. Nodes Involved
1 2 3 4 6

No. Cases 14 4 6 3 1 1 1 1 31

7
13 18

1951-1953
Dead of cancer or have developed recurrence Dead of intercurrent disease without cancer Living and apparently free of cancer 8 to 10 years after operation

have died of cancer or are still alive with recurrence. In other words, none of these patients were cured by radical mastectomy. (It is of passing interest that of the 71, 61 developed recurrence or died within the first five years following operation, and the remaining ten within the next three years. As time goes on, a few others undoubtedly will also develop recurrence.) Five additional patients died of intercurrent disease without demonstrable cancer; 31 patients (29%o) are living and apparently free of cancer from eight to ten years following operation. No patients have been lost to follow up (Table 1). For purposes of this study the axilla has been divided into four groups: 1) The highest nodes include the subclavicular or higher axillary vein group from the apex of the axilla, where the vein passes behind the clavicle, down to the lower border of the pectoralis minor muscle; 2) Rotter's interpectoral nodes or those nodes lying between the pectoralis major and minor muscles; 3) the lower axillary vein group from the border of the pectoralis minor muscle laterally to the subscapular artery, or the lateral limits of the dissection along the vein; and 4) the central group-the largest-which includes the external mammary, paramammary and scapular nodes (Fig. 1). Of the 31 patients now apparently free of cancer, Table 2 shows the distribution

40
TABLE 3.

AUCHINCLOSS
Free of Cancer, 1951-1953 Location
Years Follow uI) 10 10 10 10 9 8 9 8 10 10 8 8 9 8 9 10 10 10 10 10 10 10 9 9 10 9 9 10 9 8 9

Annals of Surgery July 1963

Niiumlber and Location of Involved Nodes in Each of 31 Cases Still A pparentlv

andl Number Positive Nodes

Lower

Patient G. G. E. W. M. T. K. B. -M. L. C. W. J. B. E. M. A. B. M. R. J. M. T. R. MI. K. G.B. B. MI. M. R. R. F. E. K. M. R. N. O. G. W. J. C. D. P. H. R. J. B. H. G. J. C. P. W. E. C. M. R. M. M.

Nodes Removed
34 18 29 25 27 21 58 25 27 24 24 77 28 8 23 35 28 57 49 57 38 49 70 23 23 39 33 43 32 42 60

Axillary
Central Rotter's
1 1 1 1 1 1
1 Vein

Highest

1 1 1 1 1 1 1 1 2 2 2 1 1 1 3 3 1 3 3 4 3 3 3 8

1 2 1
1

1
1

2 3

1 1 4 4

6 6

of cases by number of nodes involved, and Table 3 the number and location of involved nodes in each case. Slightly more than half (18) had only one or two nodes involved; if more than three were involved the chances of a cure apparently are small indeed, and it is likely that some of the seven in this group will be lost in the next five years. The location of the involved nodes (Table 3) is of next or of equal importance to the number involved. Of the 14 cases in which only one node was involved, it lay in the central group in 13 and in Rotter's group in one. Of the four cases with two nodes involved, 3 had them both in

the central group and one in Rotter's and the central groups. In the remaining 13 cases the nodes were in various groups, mostly in the central group, but in only four were the highest nodes involved: two of these had a total of three nodes involved and the other two are extraordinary cases one of whom had 13, including six highest, of 42 nodes involved, and the other 18, including six highest, of 60. In summary it may be said that only those patients with axillary metastases who have three or fewer nodes involved stand much of a chance of being cured of their cancer by radical mastectomy, and that in
every

instance except four these nodes all

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T s., OF CARCINOMA
I. .
.

v---

BREAST
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lay in what might be described as the lower two-thirds of the axilla-that is, the nodes lying lateral to the pectoralis minor muscle or occasionally in Rotter's group. The significance of this statement lies in the fact that it is perfectly possible and convenient to accomplish the removal of these nodes by simple mastectomy with sub-total axillary dissection, to be described below. Such a modified radical mastectomy does not attempt to remove the highest apical group of nodes, since if these nodes are involved, the chance of permanent eradication of the cancer is minimal if not zero. Thirty-four of 38 cases in this series in which they were involved have already developed recurrence of cancer. Indeed, had these so-called apical axillary nodes been biopsied prior to operation and been found to contain metastases, these patients would not even have been subjected to radical mastectomy according to Haagensen's present criteria of opera-

well for 22 years, until eight months prior to her death in 1960 from recurrent breast carcinoma involving liver and peritoneal cavity (autopsy). H. M. A 44-year-old woman underwent radical mastectomy in 1947 for a small carcinoma of the breast with metastases to ten axillary lymph nodes including the highest. She eventually developed skeletal and pleural metastases and died 12 years later. F. H. A 47-year-old single woman underwent radical mastectomy in 1937. Seven axillary nodes were involved. She died of metastases in 1960, 23 years later (autopsy).
J. B. A 48-year-old woman underwent radical mastectomy in 1942 for a large, undifferentiated carcinoma with extensive involvement of axillary nodes, two of which measured 3.0 cm. in diameter. Tumor had invaded the capsule of the nodes and surrounding axillary tissue, and was found in large clumps in blood vessels. She is alive and clinically free of cancer today, 19 years later.
D. C. A radical mastectomy was performed on this patient in 1931 at age 53. She died 28 years later of cardiac failure with known local recurrence on the chest wall for the last 10 years of her life.
F. S. This patient was 48 years old at the time of radical mastectomy in 1945. Two axillary nodes were involved. In 1956 a local recurrence on the lateral chest wall was resected. She has remained well until the recent appearance of pulmonary metastases 15 years postoperatively. M. D. A 29-year-old woman underwent radical mastectomy in 1946 for an undifferentiated carcinoma with metastases to 14 of 21 axillary lymph nodes, including the highest. Two years postoperatively she developed local recurrence treated with radiotherapy, but did not succumb to mediastinal and liver metastases until 1960, 14 years later (autopsy).

bility.4 What about the four patients in whom the highest nodes were involved and who are still apparently free of disease eight to 10 years later? Has the conventional radical mastectomy, by removing these nodes, cured them of their cancer? It is doubtful and cannot be proved yet. A longer period of follow up is necessary, for it is well known that a few unpredictable patients do not behave in the expected way and, with almost hopeless prognosis, live for many years before succumbing to their disease. The cancer and its host seem, indeed, to have achieved a happy form of peaceful coexistence. To illustrate this point, several cases are briefly cited. Case Reports
R. C. A 63-year-old woman underwent right radical mastectomy in 1938. Pathological study showed what was thought to be an extremely malignant form of carcinoma represented by at least three different and separate tumors in the breast which had metastasized to four axillary nodes, one from the highest point in the axilla. She remained

Discussion Consideration of the foregoing facts seems to suggest the following conclusion: that the operation of radical mastectomy is unnecessarily radical. The more thorough axillary dissection which it affords accomplishes nothing for the survival rate of patients with breast cancer and axillary metastases that a more limited operation would not do equally well. No one would

42
V-l---l/
......

AUCHINCLOSS
.i

Annals of Surgery July 1963

FIG. 2. Modified radical mastectomy: (A) Transverse elliptical skin incisions. (B) Upper, thin, skin and subcutaneous tissue flap already elevated using "handle-bar" retractor hofding rubber band skin hooks for even traction. Breast with underlying pectoral fascia is dissected from the muscle.

dispute that the chief advantage of the conventional radical mastectomy over a modified operation in which the pectoral muscles are preserved is that by removing the latter the axilla can easily be dissected in its entirety. Another advantage is the wide skin removal which is possible and is advocated by many surgeons, but without proof that by so doing the cure rate is improved or even that the local recurrence rate is reduced. A study which bears on this subject involving cases with wide skin removal and skin flaps cut within the dermis was reported in 1958.1 A third possible advantage is that by removing the muscles themselves, the tumor in the breast is given a wider berth, and the lymphatic vessels traversing the muscles are also removed. Even though this be true, it would be a rare case that even radical mastectomy might cure if cancer had already invaded these structures. Furthermore, Handley states that in his first 100 cases of a modified radical mastectomy with preservation of the pectoralis major muscle, he has never seen a recurrence in that muscle.7

It is suggested that conventional radical mastectomy be modified as follows. A transverse, elliptical skin incision is made surrounding the nipple and tumor in such a way as to leave a 4.0 or 5.0 cm. margin beyond the palpable limits of the tumor (Fig. 2A) followed by elevation of thin skin flaps just as one would do in the standard radical procedure (Fig. 2B). Then, commencing medially, the entire breast with the underlying pectoral fascia is dissected off the muscle. If one chooses, in some cases, a portion of the pectoral muscle directly beneath the tumor can also be removed. The fascial investment of the pectoralis major muscle is stripped from the muscle around its lateral edge and, staying in this same plane, with the muscle retracted medially, the fascia covering the pectoralis minor muscle is similarly stripped in order to remove Rotter's interpectoral nodes (Fig. 3). The dissection is then carried upward along the edge of the minor muscle and somewhat posterior to it until the axillary vein is encountered (Fig. 4). This is the high point of the axillary dissection and is suitably tagged for later pathological identification. It usually lies approximately 3.0 cm. below the clavicle.

P.ctorwitis Maior
Peotoralis minor

*Rotters ftoso

FIG. 3. Modified radical mastectom The pectoralis major muscle is retracted medily exposing Rotter's fascia covering the pectoralis minor muscle. The fascia is being removed from the underlying muscle.

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From this point on, the dissectioin is performed exactly as would be do ne in a standard radical mastectomy: the 1-vein is cleared of all its branches from the high point, laterally; the serratus fascia is removed from its underlying muscle; the long thoracic nerve of Bell is preser ved; the thoracodorsal nerve is sacrificed a nd, as a final step, the fasciae overlying the subscapularis and latissimus dorsi muiscles are removed, and the operation is c )mpleted (Fig. 5). Skin is nearly always cl(osed primarily, sometimes undermining tlh,- 1nwu?r flap to facilitate this, and the su ture line is always supported with elastic adhesive strips to avoid fatal tension on the thin skin flaps. The axilla and lateral chest wall are drained using small, plastic, si liconized drainage catheters with multiple ti: ny fenestrations (Hemovac*), placed on 1Light suction for several days postoperat ively, or until drainage stops. All forms of pressure dressings are avoided. The advantages of this operattion are many. An unnecessarily radical p,rocedure has been avoided. The disabilityr from a carefully performed radical maste -ctomy is
*

1P

osioolis

FIG. 5. Modified radical mastectomy: Completed operation.

not

the cosmetic result bears no comparison with the appearance following the simpler operation (Fig. 6). This of course would not be a consideration if the radical operation accomplished a higher cure rate, but the evidence already cited seems to indicate that it would not. The axillary tissues that are removed are subjected to precise pathological study. If more than one axillary node (or perhaps two) is found to be involved, the patient is then given postoperative radiation. Patients in whom the cancer is limited to the breast, Stage I, are spared the unnecessary and often disabling
effects of extensive radiation which they

great from a functional standpoint, but

Supplied by Zimmer Manufacturiing Co.

.... \....

..

-Pecto
...

iRw*or
rtus m

.I

PectordLAis

do not need. The postoperative radiation, when given, should not be directed to the lower axilla, but only to the upper portion, internal mammary, subclavicular and supraclavicular nodes. If the lower axilla were to be subjected to both the effects of
radical

and radiation, the incidence of edema of the arm might be expected to

surgery

FIG. 4. Modified radical mastecton ralis major and minor muscles, both s tripped of their fascial investments, are now retra(cted medially, and the axillary vein exposed I:)ehind the pectoralis minor muscle. This is the "I iigh point" of the dissection. The serratus fascia iis removed from its underlying muscle.

be high. Thus, it might be said, one achieves by this method the best that radical surgery and radiation have to offer: the operation is modified in a less radical direction, and the patients who are to receive radiation can be selected, it being given only to those in whom more than minimal axillary metastases are demonstrated.
Such
a

modified radical

mastectomy

de-

no

scribed above is not a new operation, and claim is made that it is. Patey'" de-

44

AUCHINCLOSS

Annals of Surgery July 1963

following standard radical left and, several months later, a modified radical mastectomy on the right. Cosmetic difference is obvious. (b & c) Result following modified radical mastectomy. Note normal axillary fold and absence of visible scar with low neck line.
FIG. 6a. Result
on

mastectomy

scribed an operation in which the pectoralis major muscle is preserved, but the minor muscle is removed-together with a dissection of the axilla. This procedure was further extended by Handley and Patey6 to include a resection of the internal mammary lymph node chain (not en bloc) in selected cases. However, Handley has now abandoned internal mammary node resection, "because the early results did not hold out much hope of good five-year survival figures" 7 and has now returned to the original orperation described by Patey. Holman8 similarly advised preservation of the pectoral muscles, and presented a 42 per cent five- to ten-

year survival rate in 106 cases with proven axillary metastases. Crile 2 states that in favorable, clinical Stage II cancers, modified radical mastectomy, with preservation of the muscles and without radiation therapy, seemed to be as effective as any other treatment or combination of treatments. He further believes that the success of simple treatments is well enough established so that controlled clinical studies can now be done without fear of doing an injustice to the patients receiving the simpler treatments. Since 1956 this modified radical mastectomy has been performed by the author on 16 carefully selected patients at the Presbyterian Hospital. The group includes cases of lobular carcinoma, intraductal carcinoma without demonstrable invasion, papillary carcinoma and several older patients with small tumors. In only two were the nodes involved. The survival rate (100%o so far) has no significance, because the group was a selected, highly favorable one. The cases are mentioned merely to show how complete an axillary dissection can be accomplished by this operation. The average number of lymph nodes recovered from the axilla on pathologic study using the clearing technic was 32, only six less than in the standard radical procedure. The highest number was 56, and the lowest 11. It should be stressed that this operation must be done with care, and fascial planes closely followed. If the initial diagnostic biopsy incision were to penetrate the pectoral fascia, then, obviously, a portion of the underlying pectoral muscle should be removed with the breast. The same would hold if the tumor appeared to extend to the fascia or involve the muscle beneath it. Reasonably wide skin removal is advocated, even though grafting be necessary, and thin skin flaps are essential to insure removal of all breast tissue. Particularly is this true as the axilla and the apocrine

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sweat glands are approached. Here the dissection should be within the dermis, since in this area the axillary prolongation of the breast and the lower axillary nodes also lie extremely close to the skin.

Throughout this discussion no attempt has been made to indicate how patients should be selected for this operation. Each surgeon has his own criteria and methods of determining operability. As a generality, any patient who is deemed suitable for radical mastectomy in the conventional manner would be a candidate for the modified operation. The more selective one is, the better will be the operative results, of course. Those not deemed suitable for operation should receive radiation alone or in combination with simple mastectomy, again depending on individual circumstances or preferences. Conclusion Tradition, experience, training, and personal prejudice tinged with emotion, have established radical mastectomy as the treatment of choice in primary operable breast carcinoma throughout most parts of the world. Nowhere is this more true than at the Presbyterian Hospital, nor are these traits more deeply ingrained in any surgeon than in the author. Thus it is with considerable trepidation and much hesitance that a more conservative operation is suggested. However, it is difficult to deny the implications of this study, namely, that of 204 radical mastectomies performed, 97 were unnecessarily radical because none of the axillary nodes studied were involved, and a simple mastectomy with sub-total axillary dissection would almost surely have produced the same results, even assuming that a few patients actually did have node involvement which was missed on pathological study. The operation failed to arrest the disease in 71, and so was futile. Excluding the five who died of intercurrent disease without cancer, we are left with 31 patients in whom an axillary dis-

FIGURE 6C.

section appears to have been important in their treatment since they now remain well having had involved nodes removed. However, in all but four of these, a type of modified radical mastectomy, as described, would in all probability have accomplished what the classical radical mastectomy did. These facts notwithstanding, this more conservative approach could not justifiably be recommended if there were not available an increasing volume of evidence to support the belief that radiotherapy and simple mastectomy afford nearly as good results as does radical mastectomy.9' 10 Accordingly, a patient found to have extensive axillary node involvement following modified radical mastectomy may be given supplementary radiotherapy. No longer need one have the belief that this is a distinctly less good way of treating such patients, but rather that it is truly an alternative to conventional radical mastectomy. Indeed, it becomes possible to offer the

46

AUCHINCLOSS Annals of Surgery of the Breast; Criteria of Operability. Ann. patient-strictly on the basis of pathologiSurg., 118:1032, 1943. cal (not clinical) selection-the best that 4. : Diseases of the Breast. Saunders, 1956, both surgery and radiotherapy have to 559-574. pp. offer. 5. Halsted, W. S.: The Treatment of Wounds
with Especial Reference to the Value of the Blood Clot in the Management of Dead Spaces. Johns Hopkins Hosp. Rep., 2:255, 1890-91. Handley, R. S., D. H. Patey and B. H. Hand: Excision of Intemal Mammary Chain in Radical Mastectomy. Results in 57 Cases. Lancet, 1:457, 1956. : Observations and Reflections on Breast Cancer. J. Royal Coll. Surg., Edinburgh, 6: 1, 1960. Holman, C. C.: Cancer of the Breast; The Principles of Surgical Treatment. Lancet, 1: 174, 1954. Kaae, S. and H. Johansen: Breast Cancer, a Comparison of the Results of Simple Mastectomy with Postoperative Roentgen Irradiation by the McWhirter Method with Those of Extended Radical Mastectomy. Acta Radio. Suppl., 188:155, 1959. McWhirter, R.: Simple Mastectomy and Radiotherapy in Treatment of Breast Cancer. Brit. J. Radiol., 28:128, 1955. Patey, D. H. and W. H. Dyson: Prognosis of Carcinoma of the Breast in Relation to Type of Operation Performed. Brit. J. Cancer, 2: 7, 1948. Pickren, J. W.: Lymph Node Metastases in Carcinoma of Female Mammary Gland. Roswell Park Memorial Inst. Bull., 1:79, 1956. : Significance of Occult Metastases-A Study of Breast Cancer. Cancer, 14:1266, 1961. Williams, I. G., R. S. Murley and M. P. Curwen: Carcinoma of the Female Breast: Conservative and Radical Surgery. Brit. M. J., 2:787, 1953.

Summary Eight- to ten-year results in 107 cases of carcinoma of the breast with axillary metastases treated by conventional radical mastectomy are presented. The exact number and location of each axillary lymph node metastasis were recorded by clearing technic and correlated with those patients clinically cured eight to ten years following operation. Of 31 patients clinically free of cancer eight to ten years postoperatively, 27 had four or fewer nodes involved by cancer, and these invariably were located in the lower two thirds of the axilla. Four cases were exceptions. The rationale, based on these facts, for advocating simple mastectomy with subtotal axillary dissection and preservation of the pectoralis muscles, as the treatment of choice for primary operable breast carcinoma, is discussed. References
1. Auchincloss, H.: The Nature of Local Recurrence Following Radical Mastectomy. Cancer, 11:611, 1958. 2. Crile, G., Jr.: Simplified Treatment of Cancer of the Breast: Early Results of a Clinical Study. Ann. Surg., 153:745, 1961. 3. Haagensen, C. D. and A. P. Stout: Carcinoma

6.

7.
8.
9.

10. 11.

12. 13.

14.