The earliest written records of breast cancer date back to ancient Egyptian works from 3000-2500 BCE. In this book, found in 1862 and now known as the Eden Smith Surgical Manuscripts, the ancient Egyptian physician’s description of a breast tumor is recorded, yet the answer to its management is simple and honest – no treatment. Since then, the controversy surrounding whether breast cancer is a systemic disease or a localized problem at the time of diagnosis, whether the tumor needs to be removed and what the scope of surgery is has continued to this day. Hippocrates, the “father of Western medicine,” proposed the doctrine of humors that breast cancer is a systemic disease caused by an excess of “black bile” and that removing the primary tumor would worsen the disease. Around 400 B.C., he warned, “It is better not to remove a hidden tumor. Those who have tumors removed die quickly, while those who do not live longer.” Later, Galen, who was also a leading Greek physician, developed the theory of humors, which also considered breast cancer to be a systemic disease. He believed that the earliest description of the growth of the cancer was “crab foot-like” and actively advocated surgical treatment of breast cancer and that the tumor should be removed in the surrounding normal tissue. However, Galen’s disciples believed that breast cancer could not be cured by surgery and preferred non-surgical treatments including dietary therapy, laxatives, bloodletting and blister therapy to treat breast cancer by draining excess black bile. As history entered the 18th and 19th centuries, the significance of lymph nodes began to be discovered. During this time, Petit (1674-1750), director of the French College of Surgeons, was the first to propose a unified concept of surgery for breast cancer. He pointed out that the enlarged lymph node gland was the source of the tumor and that it should be identified and removed during surgery. The pectoralis fascia and even some of the muscle fibers of the pectoralis muscle should be removed in order to avoid tumor remnants. In 1757, the French surgeon Ledran suggested that breast cancer was a localized lesion disseminated through the lymphatic vessels and that lymph node dissection should be an integral part of the surgical treatment of breast cancer. However, the French view and these more invasive surgical approaches were not universally accepted at the time due to the prevalence of the Galen doctrine of humoral fluids. In the mid-19th century, Virchow, a German pathologist, suggested by autopsy that breast cancer originated from the ductal epithelium of the breast and spread along the fascia and lymphatic tracts. In the 1880s, Halsted, an American surgeon, was influenced by Virchow’s theory and proposed radical mastectomy, which is a complete excision of the entire breast, pectoralis major and minor muscles and fatty lymphatic tissue of the axilla. The theoretical basis of the Halsted procedure is the theory of progressive breast cancer metastasis, which suggests that breast tumor cells first spread to regional lymph nodes via lymphatic vessels before systemic metastasis occurs. The introduction of radical breast cancer surgery led to a reduction in the rate of local regional recurrence of breast cancer from 51% to 82% reported in Europe during the same period to 6% and a 5-year disease-free survival rate of 31%, which was a remarkable achievement at the time. Since then, Halsted radical surgery has been the standard procedure for breast cancer for more than 70 years. After half a century of radical surgery as the standard of care, a new exploration in the surgical treatment of breast cancer began. Considering that the lymphatic metastasis of breast cancer with masses located in the medial aspect of the breast may reach the internal breast lymph nodes next to the sternum, the resection of the internal breast lymph nodes in the first to fifth rib planes was added to Halsted radical surgery, i.e., extended radical surgery, including Margottni’s extrapleural approach (1949) and Urban’s intrapleural approach (1951). Later, Lewis et al. suggested that the surgical resection should also include supraclavicular and mediastinal lymph nodes, also known as super radical surgery, because of the observation that breast cancer is often associated with supraclavicular lymph node metastases. These more extensive procedures did not further improve the outcome of breast cancer and were abandoned due to the high number of complications and mortality. During the same period, in 1948, Patey discovered that the pectoralis major fascia was relatively free of lymphatic vessels, which led to the proposal of removing only the pectoralis minor muscle while preserving the pectoralis major; subsequently, Auchincloss further created the surgical approach of preserving the pectoralis major and minor muscles in 1951. In contrast to Halsted radical surgery, these two procedures are collectively referred to as modified radical surgery. Because of the preservation of the pectoralis muscle, the postoperative deformity of the chest wall is less and the function of the upper extremity is less affected, and the efficacy of early breast cancer is not affected. At the same time, Halsted’s theory of progressive breast cancer metastasis was challenged by Fisher and other scholars. Fisher et al. demonstrated that the vascular system of the breast, similar to the lymphatic system, was a potential pathway for tumor spread and that survival of breast cancer patients was mainly related to the biological characteristics of the tumor rather than the surgical approach. 04 trial that was validated. This trial compared the difference in efficacy between total mastectomy with or without radiotherapy and radical mastectomy for breast cancer in a randomized controlled manner. Patients with positive clinical lymph nodes were randomized to the radical surgery and total mastectomy plus radiotherapy groups, while patients with negative clinical lymph nodes were randomized to the radical surgery, total mastectomy plus radiotherapy or mastectomy alone groups. After 25 years of follow-up, the results showed no statistical differences in overall survival, disease-free survival, or survival without distant metastases between either the two lymph node-positive groups or the three lymph node-negative groups. Six subsequent prospective randomized controlled clinical trials directly compared the efficacy of breast-conserving surgery plus radiotherapy with mastectomy. The overall results showed that although the risk of local recurrence after surgery was increased in the breast-conserving treatment group, the modality of surgical treatment itself did not affect patient survival. A meta-analysis of the EBCTCG series showed that local recurrence was associated with survival and that adjuvant systemic therapy significantly improved patient survival while reducing the chance of local recurrence of breast cancer. However, radical surgery with removal of the pectoralis muscle did not result in more survival benefit than modified radical surgery, and total mastectomy versus breast-preserving surgery did not show a difference in patient survival. Breast-preserving surgery thus became the preferred treatment for patients with early-stage breast cancer. In the early 1990s, Krag and Giuliano et al. reported the successful use of anterior lymph node biopsy in breast cancer, respectively. The results of four randomized controlled clinical trials also suggest that in patients with negative clinical axillary lymph nodes, sentinel lymph node biopsy accurately determines axillary status, allowing 60-75% of patients to be spared axillary lymph node dissection and reducing the number of resulting lymph node dissections. This reduces complications such as upper limb lymphedema, pain, shoulder mobility and sensory abnormalities, and further improves the quality of life of breast cancer patients. Currently, almost all patients with confirmed negative axillary lymph nodes can undergo only sentinel lymph node biopsy; the goal of axillary lymph node dissection is to achieve optimal local control in those patients with positive sentinel lymph nodes. Thus, the understanding of the characteristics of breast cancer over the past 2500 years has come full circle and returned to the starting point of breast cancer being a systemic disease at the time of diagnosis. In this circle, the concept of surgical treatment of breast cancer has changed from inoperable to operable, from the “maximum tolerated treatment” to the “minimum effective treatment”.