Evolution of breast surgery- from butchery to finesse

Highlight on key aspects of development of breast surgery

1. The Evolution of Breast Cancer Surgery “from mutilation to minimalization” Dr.Bharath S PDCC- Breast surgery,SGPGIMS Mentored by- Dr.Vikram S Prof. Anjali Mishra

2. Evolution …..!!! 01 02 04 Medieval times Greek Romans Japaneese Ancient Civilisations The Egyptians Indians Babylonians The Golden ERA Halstedian Era Fischers Era * 03 The Modern ERA Evolution of chemoradiation BCS - SLNB Endoscopic and robotic surgeries

3. Pre historic and ancient world The earliest known medical record-the dwin Smith Surgical Papyrus, Thebes,Egypt .(3000-2500BC) “When thou findest a purulent swelling with the apex elevated, sharply defined and of a rounded form, then sayest thou, it is a purulent tumor which is growing in the flesh – I must treat the disease with the knife ” Use of cautery for tumour removal- Indians,Egyptians and Babylonians

4. Hippocrates,Greece (460-377 BC) “. . . It is better not to excise hidden cancer, for those who are excised quickly perish; while they who are not excised live longer “

5. Galen, Greek physician 131-203 AD “We have often seen in the breast a tumor exactly resembling the animal called the crab. Just as a crab has legs on both sides of his body, so in this disease the veins extending out from the unnatural growth take the shape of crab’s legs. We have often cured this disease in the early stages , but after it has grown to a noticeable size no one has cured it with surgery. In all surgery we attempt to excise a pathologic tumor in a circle in the region where it borders on the healthy tissue” Leonides , Alexandrian school,Egypt - 1 st to coin nipple retraction-manifestation of breast cancer.

6. The Renaissance period-Medieval era Ambroise Pare (1510-1590 )-Army surgeon,France Conservative management rather than mutilation Small tumours -excision Large tumours with ulceration-sweet milk,vinegar,ointments Pain relief-poppy juice.

7. Joyannes Scultetus (1595–1645) A leading German surgeon of the 17th century, was a famous illustrator of surgery and surgical instruments. He wrote the famous book Armamentarium Chirurgicum ( Scultetus 1653), where he gave a very vivid portrayal of the operative procedure for cancer of the breast

8. The 19th century dramatically changed the field of surgery. In 1804, Japanese surgeon Seishu Hanaoka performed the world’s first procedure under general anesthesia—a mastectomy. He had worked tirelessly to concoct an anesthetic potion (named Tsusensan ) after learning of ancient Chinese physician Hua  Tuo’s  success

9. Joseph Pancoast (1805–1882), Professor of General Descriptive and Surgical Anatomy at Jefferson Medical College in Philadelphia, was one of the earliest American surgeons who emphasised the need to remove the entire breast and the axillary nodes if they were involved Most importantly, he suggested that any node should be removed in continuity and not through a separate incision. This was the first description of an en bloc removal of the breast with its axillary lymphatic drainage

10. Compared with current standards, the situation was totally different in the past regarding breast cancer. In the past the combination of modesty of the women and ignorance of the profession usually caused the cancers to become rather large and widespread before attempt at their eradication were made. Early diagnosis was an unknown concept. Therefore, amputation was usually preferred over wide local excision, despite that some surgeons (i.e. Guy de Chaulaac , Ambroise Pare, Vesalius, Velpeau , etc.) had advocated local resection in selected cases (‘small’ cancers).

11. Sir James Paget (1814), who described Paget’s disease of the breast, published statistics showing a 10% mortality rate of 235 patients undergoing mastectomy, with the remainder having cancer recurrence within 8 years of follow-up . Charles Moore (1821) published the widely-accepted paper, “On the Influence of Inadequate Operation on the Theory of Cancer” in 1867, which stated that wide resection of cancer is necessary because more advanced stages were caused by dispersion from a primary tumor

12. The Dawn- Halstedian Era In 1894 William S. Halsted published the landmark paper, ‘ The results of operations for the cure of cancer of the breast’ performed at the Johns Hopkins Hospital from June 1889, to January 1894. He recommended en bloc resection of all suspected tissues including the pectoralis major muscle, which became known as the “Halsted radical mastectomy” 

13. Halsted a local recurrence rate – 7% only , unmatched by his peers. He worked tirelessly to spread his procedure among breast surgeons of the time, including the trainees in his residency program, the first surgical residency in the United States. After the widespread acceptance of Halsted’s radical mastectomy, some notable surgeons such as Jerome Urban and Owen Wangensteen advocated even further resections that included the internal mammary lymph nodes and supraclavicular lymph nodes—a “ supraradical  mastectomy” Halsted’s radical mastectomy remained a standard procedure for more than 70 years.

14. The discovery of X-rays by William Roentgen in 1895 changed the landscape of medicine and led to the shift of breast cancer treatment during the 20th century from purely surgical to the multiple modalities employed today. 1902 Russian physicist S. Goldberg successfully used radiation for cancer treatment, and the following year the first department for radiotherapy was established at the Cancer Hospital in London

15. The new challenge 1948 the modified radical mastectomy, which spared the pectoralis muscles, was introduced by Patey and Dyson from Middlesex Hospital in London . In the same year, simple mastectomy combined with radiotherapy was introduced by McWhirter in Edinburgh. EF Scanlon(1975) and Auchincloss (1963) proposed their modifications to MRM preserving the pectoral muscles.

16. Fischers theory – Breast conservation Surgery The Milan trials demonstrated no difference in 5-year survival rates between quadrantectomy plus radiotherapy plus axillary dissection versus radical mastectomy The National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04 trial by Fisher et al. successively proved equivalent 5-year survival when comparing lumpectomy versus removal of all breast tissue, pectoral fascia, and axillary contents. These studies heralded the paradigm shift away from the mutilation previously believed to be necessary for disease control

17. A timeline illustrating the evolution of breast management

18. Management of Axilla SLNB- AE Guilliano – 1994 Dyes- Methylene / isosulphan blue , flurescein dye Radioactive- Tc99m along with gamma probe

19. NEWER MODALITIES….! BCS-

20. Robotic surgeries

21. Conclusion The cancer which was thought to be uncurable has developed to a present stage where the tumour removal is done through small incisions or minimally invasive techniques, improving the better patient acceptability. Overall, the history of breast surgery is a testament to the continued advancement and refinement of surgical techniques, as well as the ongoing challenges and controversies that must be addressed in order to ensure patient safety and satisfaction.

22. Thank you ….!!!