The Veronesi quadrantectomy: an historical overview

Giovanni Corso1, Paolo Veronesi1,2, Virgilio Sacchini1,2, Viviana Galimberti3 and Alberto Luini1

1European Institute of , Division of Senology, Via G Ripamonti 435, 20141, Italy 2Università degli Studi di Milano, Via Festa del Perdono 7, Milan 20100, Italy 3European Institute of Oncology, Unit of Molecular Senology, Via G Ripamonti 435, Milan 20141, Italy

Correspondence to: Giovanni Corso. Email: [email protected]

Abstract

Following a clinical trial in which the Halsted mastectomy was compared to the less invasive quadrantectomy, no differences were reported in terms of local recurrence, disease-free or overall survival between the two. As a result, Umberto Veronesi was the first in the world to state that the appeared to involve unnecessary mutilation in patients with breast of less than 2 cm and no pal- pable axillary nodes. To date, the Veronesi quadrantectomy is routinely considered for treatment. This brief review, which highlights the main advances over the last 50 years, is dedicated to Professor Umberto Veronesi.

Keywords: breast cancer, conservative treatment, mastectomy, axillary dissection, radiotherapy Short Communication

Published: 08/06/2017 Received: 16/12/2016 ecancer 2017, 11:743 https://doi.org/10.3332/ecancer.2017.743

Copyright: © the authors; licensee ecancermedicalscience. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1 advances overthelast50years,isdedicatedtoProfessorUmbertoVeronesi. To date,theVeronesifor breastcancertreatment. considered isroutinely quadrantectomy This briefreview,the main highlights which mutilation inpatientswithbreastcanceroflessthan2cmandnopalpableaxillarynodes surgeries.Veronesiand thequadrantectomy unnecessary to involve mastectomy appeared to statethattheradical was thefirstinworld No differencesthe Halstedmastectomy survival (OS)between survival oroverall werereportedintermsoflocalrecurrence,disease-free QUART). Eligiblepatientshadinfiltratingcarcinoma upto2cm(cT1N0). (so-called sted mastectomy)and352wereassignedtothequadrantectomy plusaxillarydissectionpost-operativebreastradiotherapy The trial was calledMilanI: A total of 701 patientswithbreastcancerwererecruited,349randomisedto the standardtreatment (Hal- results. Randomisationstartedin1973andtheaccrualofpatients continueduntilDecember1980. with itscosmeticandpsychological of thetreatment,along tests toverifythefeasibility in1971withanumberofclinical The studybegan 1973–1980: MilanItrial radiotherapy. The proposalstimulatedintense discussionwhichintheendwasunexpectlyaccepted. the traditionalmastectomywithanewconservativeapproach consistingof wide resection (so-calledlaterquadrantectomy),followedby ment ofbreastcancer. Umberto Veronesitrial tocompare wasamongthe15invitedexperts.Hepresentedaproposalforrandomised In 1969,theWorldand treat- of diagnosis the methods to evaluate of investigators a meeting convened Geneva in Organisation Health cer treatment,inwhichtheHalstedmastectomywas,certaincases,anexcessiveapproach(so-calledovertreatment). a newconceptofbreastcan- opened and carcinogenesis, about tumourbiology knowledge stage. Increasing at amuchearlier diagnosed was beingintroducedandthis mammography During thisperiod, was ableto detect muchsmalltumours,sothat breast cancercouldbe therapy, whichleavesthebreastintact,cansubstitutemutilatingmastectomyandyetobtain the samecurerates. studyconceivedandconductedbyVeronesiThe randomised wasthefirst to demonstratethatconservativebreastsurgeryplusradio breast cancer, amuchcommonercancerthanmelanomaandthemaincauseofdeathinwomenworldwide. The modernprospectivestudyofUmbertoVeronesi nowfocusedon 1969: thenewdiscovery treatment ofearlymelanoma,andinfact,survivalwasidenticalpatientsreceivingalimitedresection(1cm) lymph nodedissectionshouldnotbeperformed[2], and subsequently, he demonstratedthatwideexcision(3cm)isnotnecessaryinthe The firststudiesofUmbertoVeronesi werefocusedonthetreatmentofcutaneousmelanoma. uninvolved The authorverifiedthatclinically that anewapproachwasnecessaryanddevelopedtheconceptofminimumeffective treatment’. treatment’tolerated However,disease. of curing inthehope Veronesiwere improving, techniques astreatmentsanddiagnostic realised At the endof1950s,UmbertoVeronesito thetreatmentofcancer. conceivedanewapproach At the time,aimwastogive‘maximum 1950: thebeginning Some yearslater, followingaclinicaltrial,thisevidencewaspublishedwithgreatsuccessinthe not wellreceivedbytheaudienceandtheythoughtIwasacrazyphysician quadrantectomy). (the so-called approach necessary.mastectomy wasnotalways Halsted that theradical At thistime,Isensed Thiswas ‘Some yearsago, I purposed, duringascientificmeeting,to surgical compare thetraditionalmutilatingmastectomywithanewconservative Introduction 2 www.ecancer.org .’ [1]. New EnglandJournalofMedicine [3]. ecancer 2017,11 . :743 -

Short Communication his career.during to thebreastquadrantectomy coveries inaddition biopsy,lymph-node Sentinel radiotherapy, intraoperative mastectomy radicality, of oncological offeringterm survival.Veronesiof life(QoL)withthebestlong quality ahigh many otherimportantdis- contributed The rationaleof Umberto Veronesi duringhislongcareerwastheminimumeffectivethe maximum of treatmentobtainingresultsinterms tocol scientificallyvalidated. The Veronesi quadrantectomyrepresentsagreatmilestoneinthe treatment of breast cancer, and currently, it is thefirst pro- conservative Conclusions Conclusive datawerepublishedin2002andtheresultsclearly demonstratedthatsurvivalratesinthetwogroupswereabsolutelyidentical[11]. Veronesi, werepublished by Umberto both conducted radiotherapy’, and of‘postoperative resection’- of both‘extentsurgical the role studies clarifying randomised In subsequent years,theresultsof the trialwereupdatedandpresentedto the scientificpress.In addition to the first main trial,twonovel the study. particularly.sub-group failure wasverifiedinthepre-menopausal Importantly, overallsurvivaldidnotdifferthe twomainarmsof between differencea notable The resultsdemonstrated oflocal frequency in the QUADgroup,ahigher In particular intherateoflocalrelapse. 294 wererandomisedtoQUART and263toQUADrespectively in thistrialbetween1987and1989, (QUAD); 567 patientswereenrolled with quadrantectomyplusaxillarydissectionwithoutradiotherapy the QUARTwithin clarify theimpactofradiotherapy III trialwould The Milan QUARTstudy thatcompared protocol.Itwasarandomised 1987–1989: MilanIIItrial tumour relapse. the riskoflocal to reduce was necessary such asquadrantectomy resection II trialwasthatawide of Milan The conclusion failure doesnotimpactonsurvival. differedThe twogroups that local demonstrating the OSwasidentical, although intermsoffrequencytumourrelapses, significantly criteria weresimilartothefirststudy‘MilanI’ exceptthatthetumourvolumecouldbeupto2.5cm.insteadof2cm. entrusted mainlytotheradiotherapy. in December1989recruited705patientsfrom1985to1987.Inclusion This secondtrialconcluded Tumourectomycontrol was local tissue, sothatthetaskofensuring of surrounding margin the tumourmasswithonlyalimited removed randomised trialin1985tocomparequadrantectomywithtumourectomycombinedcompleteaxillarydissectionandradiotherapy[7]. However, itwasnotclearwhethertheresultswereduetosurgeryorradiotherapy. To clarifythispoint,Veronesi proposedasecond 1985–1987: MilanIItrial The New York Times, The Washington Post, The Los Angeles Times arejustsomeofthecitednewspapers. space tothefindings; devoted considerable and magazines surgical approach.Severalmajornewspapers women, asamoreacceptable especially by thepublic, and hailed worldwide profession with greatinterestbythemedical was greeted in thisjournal The publication was thatradiotherapyhadnocarcinogeniceffect. difference betweenthe two groups of patients as regards localrecurrences andsurvival[1]. Another importantfindingof the Milan I study of Journal England On July11981,theNew To informthescientificcommunityaboutpurposeoftrialaninterimreportwaspublishedinjournal characterised amastectomy(removalofskin,subcutaneoustissue,gland,andfasciathepectoralmuscle) Initially, theterm‘quadrantectomy’ that the radicality maintained as theoperation procedure for thissurgical more appropriate seemed [10]. published the firstresultsoftrial. published that therewasno very clearly These showed [8] [9]. 3 www.ecancer.org [4, 5]. Cancer ecancer in1977[6]. 2017,11 :743

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References ment toadvancingclinicalcancerdiagnosis,treatment,research,andQoL forthepatient. Wethe Veronesi areproudtorecognise to thescientificcommunity,contribution our commit- strengthen andwetrustthattheseresultswill Umberto Veronesi diedinMilanon8November2016. to eachoncologicpatient.Hesaidinoneofhisinterviews:‘ Alongside theseimportantscientific innovations, the best contribution of Umberto Veronesi interms of patient carewasthe attention given on thisconcept,includingminimallyinvasivesurgeryandmorerecentlyroboticsurgery. treatments arejustafewexamples. with skinandnippleareolasparing,neo-adjuvant Toare based date,severaltherapeuticapproaches 10.

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