BREAST - A Brief History of Breast Cancer Therapy | SCHWARTZ SURGERY скачать в хорошем качестве

BREAST - A Brief History of Breast Cancer Therapy | SCHWARTZ SURGERY

SCHWARTZ SURGERY BREAST The history of breast cancer therapy spans millennia, marked by shifts in understanding the nature and spread of the disease. The Smith Surgical Papyrus (3000–2500 b.c.) is the earliest known document referencing breast cancer, noting in relation to the disease: “There is no treatment”. In the first century, Celsus commented on the value of operations for early breast cancer (cacoethes), but advised against operating on more advanced tumors. Galen (second century) described the tumor resembling the animal the crab and advocated surgical excision in a circle where it bordered healthy tissue. However, the dominant Galenic system ascribed cancers to an excess of black bile, concluding that local excision could not cure the underlying systemic imbalance. Galenic theories dominated medicine until the Renaissance. The Age of Enlightenment (17th to 19th centuries) led to the abandonment of humoral pathology, notably repudiated by Le Dran. Le Dran introduced the concept that breast cancer was a local disease spreading via lymph vessels to axillary lymph nodes; consequently, he routinely removed enlarged axillary nodes during surgery. In the 19th century, Moore stressed complete resection of the breast for cancer and the removal of palpable axillary lymph nodes. Banks (1877) further advocated the resection of axillary lymph nodes even when palpable disease was not evident, acknowledging the frequent presence of occult involvement. In 1894, Halsted and Meyer established radical mastectomy as the state-of-the-art treatment, demonstrating superior local-regional control rates after comprehensive resection. This procedure included complete dissection of axillary lymph node levels I to III, often involving the routine resection of the long thoracic nerve and the thoracodorsal neurovascular bundle. The radical approach faced challenges. Haagensen and Stout (1943) described "grave signs" (such as skin ulceration or chest wall fixation) that indicated radical surgery was futile for cure. Patey and Dyson (1948) advocated a modified radical mastectomy, removing the breast and axillary nodes while preserving the pectoralis major muscle. By the 1970s, the modified radical mastectomy became the surgical procedure most frequently used by American surgeons, acknowledging that pectoralis major extirpation was not necessary for local-regional control in stages I and II cancer. The focus shifted away from maximizing local extent of surgery: • The NSABP B-04 trial (early 1970s) compared radical mastectomy, total mastectomy plus radiation, and total mastectomy alone (for node-negative women) and found no differences in overall survival equivalence, challenging the Halstedian concept of regional spread. • Breast conserving surgery (BCS) emerged as a major advance, first reported by Keynes in 1937. The NSABP B-06 trial later confirmed that lumpectomy combined with breast irradiation achieved overall survival equivalent to total mastectomy, though omitting radiation significantly increased local recurrence rates. • The findings of B-04 and B-06 supported Bernard Fisher's "alternative hypothesis," proposing that breast cancer is a systemic disease at diagnosis, where regional lymph nodes are a marker of systemic disease rather than a barrier to spread. However, meta-analyses by the EBCTCG later indicated that avoiding local recurrence contributes to survival benefits. Simultaneously, systemic therapy was developed. Adjuvant systemic therapy trials began in the 1970s. The EBCTCG demonstrated that adjuvant chemotherapy regimens (like anthracycline-based ones, often with added taxanes) reduce breast cancer mortality. Importantly, they showed that tamoxifen benefits only estrogen receptor (ER) positive breast cancer patients, potentially reducing mortality by up to 30%. Modern therapy has evolved by integrating surgery, radiation, and systemic treatment. Classification has moved beyond traditional histology, utilizing tools like gene expression arrays to cluster breast cancers into intrinsic molecular subtypes, which are now used for risk stratification and treatment decision-making.