Over the past half century, the treatment of breast cancer has undergone epoch-making changes, and the era of mainly surgical treatment has transformed into a new era of comprehensive treatment, however, surgery-based local treatment is still the main treatment for breast cancer. The history of surgical treatment of breast cancer has gone through the process from simple tumor resection → standard radical surgery, expanded radical surgery → modified radical surgery with preservation of pectoral muscle → modified radical surgery with preservation of pectoral muscle and pectoral nerve → breast-conserving surgery and sentinel lymph node biopsy. The evolution of breast cancer surgery originates from the change and update of treatment concept and the in-depth research of basic theory.
1. Early stage of simple tumor resection
This primitive surgical approach is related to the lack of understanding of the biological behavior of malignant tumors at that time. This surgical approach lasted from the 15th century to the middle of the 19th century, including Pare’s mass excision (1510-1590), Vesalius’ extensive local excision (1514-1564), Severinus’ “radical surgery” including pectoral muscle and axillary lymph nodes excision (1580-1645). 1580-1645) and Herster’s so-called “extended radical surgery” including removal of the ribs (1680-1768). At that time, the mortality and complications of the operation were high and the prognosis of patients was very poor.
2.Halsted radical surgery
At the end of the 19th century, Halsted believed that the development of breast cancer was based on local infiltration of tumor cells, followed by metastasis along the lymphatic tracts and finally hematogenous dissemination, so it was believed that breast cancer was a localized disease within a certain time frame and could be cured if the tumor and regional lymph nodes were completely removed. The Halsted procedure involves the removal of the entire breast, including the tumor, the skin and surrounding tissues, as well as the pectoralis major and minor muscles and axillary lymph nodes.
This procedure is a new era in the history of breast cancer surgery and is known as the “classic” radical breast cancer surgery. It has increased the 5-year survival rate of breast cancer from 10%-20% to 40%-50%. However, Halsted radical surgery also has disadvantages that cannot be ignored, such as a high incidence of postoperative upper limb edema, chest deformity and flap necrosis. Radical surgery not only cruelly destroys women’s perfect body shape, but also affects their families, career choices, life attitudes, mental health and other aspects, despite this, Halsted’s surgical method has ruled for most of the century.
3.Extended radical surgery
In the late 1940s, it was recognized that in addition to axillary lymph nodes, internal breast lymph nodes were also the first stop of breast cancer metastasis. Margottini (1949) and Urban (1951) proposed an enlarged radical operation of internal mammary lymph nodes with combined extra- and intrapleural lymph nodes. Since then, a large number of prospective clinical trials and multicenter studies have gradually shown that there is no statistical difference in the efficacy of expanded radical surgery for breast cancer and classical radical surgery for breast cancer or modified radical surgery, and the postoperative complications and sequelae are high, so it is gradually abandoned.
4. Modified radical surgery
Fisher first proposed that breast cancer is a systemic disease from the beginning, and although regional lymph nodes have important biological immune functions, they are not an effective barrier for cancer cell filtration, and blood dissemination is more important. In 1948, Patey reported the Patey procedure and its Scanlon modification, which preserved the pectoralis major muscle and removed its fascia, and in 1963, Auchincloss reported another modified radical operation that preserved the pectoralis major and minor muscles.
Auchincloss did not resect nor cut the pectoralis minor muscle, and this modification limited the clearance of high lymph nodes, but he believed that only 2% of patients might benefit from high lymph node clearance. The Auchincloss procedure has probably been the most commonly performed procedure in the world for some time. A series of prospective randomized studies have shown that the difference in overall and disease-free survival between patients after modified radical surgery and Halsted radical surgery is not significant, but the superiority in terms of functional recovery and its morphology is significant.
5.Breast-conserving surgery
However, with the modernization of radiation therapy equipment and technology, as well as the development of postoperative chemotherapy endocrine therapy and targeted therapy, breast cancer “reduction” surgery does not stop at modified radical surgery, but various breast preservation surgical methods have emerged. In 1981, Veronesi in Italy pioneered the Milan I trial of breast quadrant excision plus whole-breast radiation for early-stage breast cancer; this was followed by the US Surgical Adjuvant Breast and Bowel Cancer Program (NSABP) B-06 trial, led by Fisher et al. The former advocated quadrant or 1 / 4 mastectomy with axillary lymph node dissection, while the latter advocated local excision of the tumor and 1 cm of surrounding normal tissue with axillary lymph node dissection and routine postoperative radiation treatment of the residual breast.
After years of prospective, multicenter randomized clinical trials, a number of internationally renowned breast cancer collaborative groups such as NSABP, NCI Milan, and Gustave-Poussy have confirmed that local excision of early breast cancer plus radiotherapy has the same results as radical surgery plus radiotherapy. The combination of breast conservation and postoperative radiotherapy plus chemotherapy is now the conventional treatment for early-stage breast cancer in Europe and the United States. Currently, breast-conserving surgery accounts for more than 50% of all breast cancer surgeries in the United States, 70% to 80% in Singapore, more than 40% in Japan, 30% in Hong Kong, and the number is increasing in mainland China. In the early stage of breast-conserving surgery, there are strict restrictions on tumor size, generally within 3 cm, mainly for early stage tumors (T1 to T2).
Its absolute contraindications are.
(1) More than 2 foci visible to the naked eye in different quadrants or diffuse microcalcifications found on mammogram;
(2) Adequate radiation therapy to the affected breast;
(3) Breast cancer during pregnancy;
(4) Persistent positive cut margins. Relative contraindications.
(1) Large tumor/breast ratio;
(2) Connective tissue disease;
(3) Tumor located under the nipple;
(4) Very large breasts. With the continuous development and proficiency of this technique, as well as the maturation of neoadjuvant chemotherapy and the refinement and improvement of radiological equipment, the indications for breast-conserving treatment are being explored and some patients previously considered contraindicated for breast-conserving surgery have been successfully treated with breast-conserving treatment, even for locally advanced breast cancer (LABC According to Peoples et al, the indications for breast-conserving surgery after neoadjuvant chemotherapy for LABC are: no skin edema, residual tumor diameter less than 5 cm, no evidence of multicentric tumor lesions, no tumor metastasis in the internal breast lymph nodes or no significant intra-breast
6.Sentinel lymph node biopsy (SLNB)
In 1997, Cobanas first discovered and named the sentinel lymph node, which is defined as the lymph node that receives the first lymphatic drainage and has the earliest lymph node metastasis among the lymph nodes in the drainage area of the primary tumor. 1993, Alex first reported the animal experiment of using radioactive tracer to label the sentinel lymph node. In the same year, Krag reported a clinical study of intraoperative identification and biopsy of sentinel lymph nodes with a probe using 99m TC-labeled sulfur colloid in breast cancer patients. In the second year, Ciuliano reported the results of a study on the identification of sentinel lymph nodes using a blue dye (1% isothiolan) to label the lymphatic system. Sentinel lymph node biopsy in breast cancer has become a hot topic of research in oncology, and as Beechey-Xew-man described, sentinel lymph node biopsy (SLNB) is another major breakthrough in breast cancer surgery and has been considered the second revolution in breast surgery. Several clinical study interviews on SLNB as an alternative to axillary lymph node dissection have shown that if there are no metastases in the anterior lymph nodes, axillary lymph node dissection can be considered as an option.
The accuracy of SLNB in predicting positive axillary lymph nodes can reach 90%-98%, while the false-negative rate can be controlled at 5%-10%, and the only lymph node with metastasis is the sentinel lymph node in about 38%-76% of patients. SLNB can not only clarify the presence or absence of metastasis in axillary lymph nodes, but also eliminate unnecessary axillary lymph node dissection in patients with negative sentinel lymph nodes, reduce the blindness of surgery, and improve the quality of life of patients. Successful sentinel lymph node biopsy is defined as biopsy of more than 1 sentinel lymph node, so how to accurately locate the sentinel lymph node is crucial. The main techniques currently available are enhanced CT, MR I, SPECT, and γ2 counter. Among them, γ2 counter can accurately quantify the scanning hot spots, so biopsy can be performed on very small lesions.
7.Breast reconstruction
Breast reconstruction includes phase I reconstruction and phase II reconstruction, which can be performed using either self-flap or breast prosthesis, or a combination of both. Studies have shown that breast reconstruction does not have a negative impact on local recurrence and overall survival, so every post-mastectomy patient is a potential candidate for reconstruction without interfering with disease diagnosis and follow-up. Overall, first-stage reconstruction is superior to second-stage reconstruction.
First-stage reconstruction saves time, improves safety, reduces costs, and alleviates psychological barriers; skin-sparing mastectomy (SSM) improves the naturalness of the reconstructed breast, preserves skin nerve endings, and does not affect local recurrence rates. Autologous tissue is the tissue of choice for reconstruction. The transverse rectus abdominis muscle (TRAM) flap, free TRAM flap, inferior epigastric artery perforator (DIEP) flap, and latissimus dorsi muscle flap are the more common choices. Other reconstructive approaches such as super-charged TRAM flap, gluteus maximus flap, and superior gluteal artery perforator flap have also been performed.