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Objective: To determine if women with subareolar breast carcinoma can be successfully treated by breast-conserving therapy consisting of segmental mastectomy that preserves the nipple-areolar complex, axillary lymph node dissection, and postoperative irradiation. Design: Prospective study. Setting: Tertiary care cancer center. Patients: Twenty-five patients; median age, 56 years; median tumor diameter, 1.4 cm; and median follow-up, 48 months. Intervention: Breast-conserving therapy for subareolar primary breast carcinoma. Results: Two patients had positive surgical margins of resection, and another patient underwent simple mastectomy after developing a local recurrence. Nipple-areolar distortion was the most common cosmetic deformity after breast-conserving therapy, but overall cosmesis was good. At the most recent follow-up, all patients were free of disease. Conclusion: Patients who have small subareolar primary breast carcinomas without evidence of nipple involvement are candidates for breast-conserving therapy with nipple-areolar preservation. (Arch Surg. 1996;131:430-433)

• Angiosarcoma of the breast is an uncommon entity, and the development of cutaneous angiosarcoma of the breast after segmental mastectomy and irradiation therapy is even less common. We report a case of cutaneous angiosarcoma that developed 4½ years after segmental mastectomy (lumpectomy) with axillary dissection and irradiation therapy for infiltrating ductal carcinoma of the breast. ( Arch Surg . 1992;127:1362-1363)

• We describe 111 patients with invasive breast cancer treated by segmental mastectomy at the University of Miami (Fla) since 1975. Postoperative adjuvant radiotherapy was recommended as optional rather than mandatory to 64 of these patients based on small (2.5 cm or less) primary tumor size, adequate resection margins, no lymphatic or vascular invasion within the segmental mastectomy specimen, and minimal associated in situ cancer. Fifty-one of these patients elected to forego postoperative adjuvant radiotherapy. At 72 months median follow-up, relapse occurred in the ipsilateral breast in three patients who elected to forego postoperative adjuvant radiotherapy (6% by Kaplan-Meier analysis). Retrospective pathologic review revealed that tumor grade may also be important in determining whether postoperative adjuvant radiotherapy is necessary following segmental mastectomy. These data suggest that postoperative adjuvant radiotherapy may not be required in every patient treated by segmental mastectomy. Further studies to define which patients can be spared the inconvenience, expense, and potential morbidity of postoperative adjuvant radiotherapy are warranted. ( Arch Surg. 1990;125:364-369)

To the Editor.— Surgical and medical treatment of the patient with breast cancer has changed dramatically in the past two decades. The Halsted radical mastectomy has been replaced by the modified radical mastectomy, and, more recently, evidence has appeared supporting segmental mastectomy as an acceptable alternative when combined with axillary dissection and postoperative radiation therapy. The National Surgical Adjuvant Breast Project has performed numerous studies attempting to resolve the dilemma surrounding the various treatments. One such study, protocol B-04, compared radical mastectomy and total mastectomy with and without radiation therapy. The results showed no significant difference in overall survival when comparing the three treatment arms. 1 Of equal importance, the data indicated that surgical removal of the axillary lymph nodes was useful for staging but did not benefit survival, supporting the theory that breast cancer is a systemic disease and that involved axillary nodes serve only as a marker of

To the Editor. — I am writing in regard to the article by Mann et al 1 that reviews the changing treatment of breast cancer in New Mexico during a 14-year period. In this review, it is stated that "the apparent lack of adjuvant radiotherapy in some women receiving conservative therapy may prove to be a deleterious consequence" of breast-conserving operations for the treatment of breast cancer. When radiation therapy was not routinely given after partial or segmental mastectomy in this survey in New Mexico, it was believed by the authors to be "inadequate treatment." Two articles are quoted by the authors to suggest that decreased survival occurs if radiation therapy is not given after all breast-conserving operations. One article that was referred to, that of Fisher et al, 2 reports "a significantly decreased disease-free survival in patients undergoing segmental mastectomy alone compared with segmental mastectomy plus irradiation." Further reading