Abstract: The historical development of surgical treatment of breast cancer is reviewed, and the theoretical basis, surgical characteristics, clinical benefits and drawbacks of radical, extended radical, modified radical and breast-conserving surgery are analyzed, which are quite clinical references for the clinical treatment of breast cancer.
Subject: Surgical treatment of breast cancer, radical mastectomy, extended radical mastectomy, modified radical mastectomy, breast-conserving surgery
The epidemiology of breast cancer in the United States shows that 12% of American women are likely to have invasive breast cancer in their lifetime; in 2010, there were an estimated 209,060 new cases of invasive breast cancer and 54,010 new cases of non-invasive breast cancer; 28% of female cancer patients are breast cancer patients. There is no national epidemiological report of breast cancer in China for the time being due to various limitations; the epidemiology of breast cancer in Shanghai region in 1996 showed an incidence rate of 44.9 per 100,000. Surgery occupies an extremely important position in the treatment of breast cancer. The surgical treatment of breast cancer has undergone a series of evolutions driven by the technological progress of the society. The historical evolution and progress of surgical treatment of breast cancer are reviewed as follows.
I. The obscure period of surgical treatment of breast cancer
In 400 B.C., Hippocrates, a medical scientist, thought that any surgical treatment would not be effective for breast cancer and described a typical case of advanced breast cancer in his book “Diseases of Women”. In 200 A.D., Leonide (Greece) performed the first mastectomy for breast tumor using cauterization to stop bleeding and burning while cutting; in 1000-1100, Abulcusis (Arabia) proposed total mastectomy for breast cancer; in the mid-16th century, Cabar (France) proposed a method including pectoral muscle mastectomy for breast cancer; in the late 16th century, Hilden ( In the late 16th century, Hilden (Germany) proposed total breast and axillary lymph node excision for breast cancer; in 1693, Houppeville (France) proposed total breast with some surrounding normal tissues excision; in the late 17th century, Jean advocated excision of pectoral fascia and part of pectoral muscle; in the late 18th and early 19th century, most scholars have advocated extensive excision of breast, muscle, lymph node and skin for breast cancer.
The characteristics of surgical treatment of breast cancer mentioned above.
1. There is no systematic theoretical basis for surgical treatment; it is a summary of personal experience not raised to theoretical level; there are no standardized surgical principles.
2. The scope of surgery gradually expanded from local lump excision to the expanded excision including the whole breast and lymph nodes.
3, poor surgical efficacy, recurrence rate of more than 90%, only a very small number of people can benefit from the surgery.
4.Lack of pain relief, hemostasis, incisional infection and surgical instruments, the patient’s surgical mortality rate is extremely high,
5. To provide practical experience for the proposal of classical radical surgery for breast cancer.
II. Radical Breast Cancer Surgery
In 1867, Charles Moore, a British physician, established the principles of breast cancer surgery, and believed that the recurrence of breast cancer was due to the failure to remove the cancer cells, In order to prevent recurrence. In order to prevent recurrence, the entire breast must be removed, including the skin, lymph, fat, chest muscles, and axillary lymph nodes where the cancer has metastasized. Joseph Pancocast (1852) in the United States believed that total mastectomy should be performed, and axillary lymph node dissection should be performed when the axillary lymph nodes are involved. He was the first surgeon to propose the combined excision of the whole breast and axillary tissues using a combined breast and axillary incision, and was the first surgeon to propose total breast and axillary lymph node dissection.
Based on the exploration of surgical treatment of breast cancer mainly by the above three, Halsted and Meyer proposed radical breast cancer surgery, also known as the Halsted procedure, in about 1894, based on the following theories
1. The metastasis of breast cancer is mechanical, with lymphatic metastasis first and then hematologic metastasis.
2.Lymph node metastasis is a sign of tumor dissemination, indicating the possibility of distant metastasis.
3.Regional lymph nodes have certain defense effect on the metastasis of tumor.
4.Bloodway metastasis is not important in tumor metastasis.
5.Operable breast cancer is localized disease and surgical treatment can affect the prognosis.
6.The problems of surgical pain relief, hemostasis and prevention of incisional infection are solved.
The surgical features are.
1.The well established scientific principles of breast cancer surgery and surgical norms.
2.Including the whole breast, pectoralis major muscle, pectoralis minor muscle, axilla and subclavian lymph nodes removal.
3.The scope of surgery: up to the clavicle, down to the upper part of the rectus abdominis muscle, out to the anterior border of the latissimus dorsi muscle, and in to the parasternal or midline of the sternum.
4.Treatment of axillary lymph nodes: removal of three groups of lymph nodes.
5. Choice of surgical incision: transverse or longitudinal shuttle incision, skin excision range is generally about 75px according to the tumor.
Clinical benefits: Halsted radical surgery improves the 5-year survival rate of breast cancer from 10% – 20% to 40-50%. Disadvantages.
1. The surgery is extensive, which is physiologically and psychologically devastating to the patient;
2.The control of distant metastasis and overall survival rate of breast cancer is far from what is expected.
3. Expanding the scope of surgery based on radical breast cancer surgery
Around 1950s, on the basis of radical surgery Margottni and Urban proposed expanded radical surgery Dahl a Iverson proposed the surgical approach of super radical surgery or even Wangensteen proposed expanded super radical surgery. Theoretical basis and conditions: the discovery of internal mammary lymph nodes. in 1949 Handley and Thackrdy found the presence of internal mammary lymph nodes during intraoperative exploration. in 1959 Turner confirmed by isotope measurements that both internal mammary and axillary lymph nodes receive lymphatic return from the axilla. New pathological perspectives were driven by the use of electron microscopy in the 1940s, which allowed for more precise observation of cellular structures and pathological patterns. The development of pathology led to the demand for treatment and the formation of the pathological view that “the treatment of the disease is the elimination of its pathological state, the complete removal of the lesion, and the prophylactic elimination of the pathways and sites of possible metastases”.
Surgical features
1.Enlarged radical surgery is based on Halsted radical surgery to clear three groups of lymph nodes, while removing the arteries, veins and surrounding lymph nodes in the thorax (i.e. parasternal lymph nodes)
2.Super radical surgery expands the lymph node clearance to the second station of lymphatic drainage in the breast, i.e. supraclavicular lymph node.
3.Extended super radical surgery to expand the lymph node dissection to the mediastinal lymph nodes.
4. Other similar to radical breast cancer surgery.
Clinical benefits: reduced local recurrence rate of breast cancer. Disadvantages: The efficacy of expanded radical surgery and super radical surgery is not significantly improved, and even due to the large scope of surgery, the surgery is more devastating to the patient’s organism, with more postoperative complications, reduced quality of survival and high mortality rate. There was no significant difference. Therefore, many scholars questioned the idea of reducing the scope of surgery.
IV. Modified radical mastectomy and total mastectomy for breast cancer
While some scholars expanded the scope of radical surgery for breast cancer, on the basis of standard radical surgery, Patey in 1948 and Auchincloss in 1950 proposed modified radical surgery for breast cancer to narrow the surgical scope of radical surgery for breast cancer, respectively. Rationale and conditions.
1, radical surgery with expanded surgical scope did not significantly improve patient survival.
2.The pectoralis major muscle and its fascia have no lymphatic vessels, and tumors rarely metastasize through them.
3.Physiological point of view, the first consideration is how to preserve the normal tissue.
4.The development of integrated treatment techniques such as chemotherapy radiotherapy for breast cancer.
5.People pay more attention to breast cancer and the progress of examination means, breast cancer is detected at earlier stage. 1975-1978 Alabama trial: patients underwent radical or modified radical surgery for breast cancer, and there was no significant difference in survival rate between the two groups after 10 years of follow-up (71% in the radical surgery group and 64% in the modified radical surgery group).
The surgical characteristics were.
1. There are two types of modified radical surgery for breast cancer, one is Patey’s surgery: preservation of the pectoralis major muscle to remove the pectoralis minor muscle; the other is Auchincloss’s surgery: preservation of the pectoralis major and minor muscle.
2.Surgical scope: similar to Halsted radical surgery.
3. Treatment of axillary lymph nodes: the former is similar to expanded radical surgery, and the latter does not remove the third group of lymph nodes.
4.Surgical incision: similar to radical surgery.
5.Simple mastectomy only performs mastectomy and pectoralis major myofascial resection, and does not mainly involve lymph node clearance compared to modified radical surgery.
Clinical benefits.
1. Compared with radical mastectomy, the survival rate and local recurrence rate of modified radical mastectomy are not significantly different, but the scope of surgery is relatively smaller.
2. Good motor function of the upper extremity is preserved.
3. The incidence of upper limb edema is lower.
4.It can improve the cosmetic effect and it is easy to breast reconstruction. Disadvantages: Modified radical surgery is also costly to remove the breast, which causes greater psychological and physiological trauma to women, and the patient’s postoperative survival quality decreases.
V. Period of breast-conserving surgery for breast cancer
In 1972, Veronesi et al. performed 1/4 mastectomy, axillary lymph node dissection and local radiotherapy for stage I breast cancer; in 1981, Greening et al. performed partial mastectomy with axillary lymph node dissection and radiotherapy; in 1983, Fisher et al. performed only breast lump excision, axillary lymph node dissection and local radiotherapy; Fisher et al. Fisher et al. proposed a partial mastectomy approach, i.e. breast-conserving surgery. The rationale and conditions are as follows
1. Breast cancer can spread through the bloodstream even in the early stage, so it is a systemic disease at the beginning.
2.Surgical excision of lesions and metastatic lymph nodes can reduce the load of tumor, improve the body’s response to tumor, and enhance the body’s defense ability, but unlimited expansion of surgery will not only increase complications but also affect the patient’s immune function.
3.The local treatment of the primary tumor does not affect the survival rate.
4.The regional lymph nodes have no defense function in the process of tumor development, and cancer cells can bypass the lymph nodes or enter the blood channel directly.
5.In the 1970s, various combination treatments gradually entered the first line of treatment for breast cancer.
The NSABP B-06 trial, the INT Mllan 1 trial, the NCI trial, the EORTC trial, the DBCG-82TM trial and other prospective trials have proven the feasibility of breast-conserving surgery for breast cancer.
7. The standardized line of surgery has been further improved, emphasizing the principle of intraoperative tumor-free and reducing intraoperative implantation and metastasis.
Surgical features.
1.The surgery is not the removal of the whole breast, which can ensure the integrity of the patient’s breast appearance.
2. Local lesion excision during surgery should be performed with intraoperative rapid pathology to ensure negative margins, i.e. no cancer cells remain at the margins.
3.Lymph node dissection in the axilla, mainly group I and group II, and generally group III lymph node dissection cannot be performed.
4.The surgical incision is divided into two incisions: breast incision and axillary incision.
5.The purpose of axillary lymph node dissection is to understand whether the axillary lymph nodes are involved, to clarify the stage of breast cancer, to decide whether to apply adjuvant chemotherapy and to assess the prognosis, and to control the regional disease at the same time.
Clinical benefits.
1. It is possible to achieve the same long-term survival rate as radical breast cancer surgery with reduced surgical excision and less surgical damage,
2. Preserve the perfect breast appearance to meet the patient’s spiritual needs.
Disadvantages.
1.Breast-conserving surgery should be combined with chemotherapy, radiotherapy, endocrine therapy and other comprehensive treatments, which requires patients to have high financial ability.
2. Contraindications to breast-conserving surgery: previous chest wall or breast radiotherapy; radiotherapy during pregnancy; mammogram showing diffuse suspicious or cancerous calcified foci; extensive lesions that cannot be achieved through a single incision with negative cut margins and without affecting cosmetic results; positive pathological cut margins.
3.Breast-conserving surgery is mainly suitable for stage I and II breast cancer with small lumps of 75px in diameter. It is not suitable for patients with large cancer but relatively small breast.
VI. New Advances
Changes in the understanding of breast cancer itself and the concept of treatment.
1. Breast cancer is a systemic disease, while breast lump is only a local manifestation of the systemic disease.
Breast cancer can have cancer cell dissemination from very early stage, but cancer cell dissemination is not equal to metastasis, and no metastasis is not equal to no cancer cell dissemination.
A significant proportion of T0 breast cancer has metastasis to liver and lung.
4. Drainage of lymph nodes in the cancer area is not an effective “filter” to stop the spread of cancer cells. Lymph nodes may have an anti-cancer immune effect in the early stage of cancer development, but local lymph node dissection does not reduce the host immunity.
5. A certain volume of cancerous tissue is a burden on the immune function of the body, and the removal of a large cancerous tissue can reduce this burden;,
The treatment of breast cancer not only requires to cure the disease, but also to improve the quality of life, not only to restore the body function, but also to maintain the beauty of body shape.
The use of neoadjuvant chemotherapy or endocrine therapy or a combination of both before surgery reduces the clinical stage and expands the scope of breast-conserving surgery for breast cancer. The application of sentinel lymph node biopsy technique has reduced the unnecessary axillary lymph node dissection in breast cancer patients and further reduced the surgical trauma. The development of breast lumpectomy technology has provided a realistic and feasible opportunity for the development of minimally invasive breast cancer surgery. For mastectomy surgery, breast reconstruction techniques are used to improve patients’ postoperative survival quality.
VII. Summary
Today’s breast cancer treatment is no longer purely surgical, but a comprehensive treatment model centered on surgical treatment, radiotherapy, chemotherapy, endocrine and targeted therapy. The treatment of breast cancer is no longer a simple local treatment, but a combination of systemic treatment. The requirements of surgical treatment mode are neither to blindly expand the scope of surgery, nor to reduce the scope of surgery against the principle, nor to give up the opportunity of surgery easily; meanwhile, we should avoid over-expanding the incision, and make the wound heal in one stage as soon as possible to facilitate with the postoperative comprehensive treatment.