Surgery

• The Smith Surgical Papyrus (3000–2500 b.c.) is the earliest known document to refer to breast cancer

  
• The cancer was in a man, but the description encompassed most of the common clinical features
• The author concluded, "There is no treatment."
• In De Medicina, Celsus commented on the value of operations for early breast cancer
• Galen inscribed his classical clinical observation about a tumor resembling a crab in the breast

  
• Galen's system of medicine ascribed cancers to an excess of black bile and concluded that excision of a local bodily outbreak could not cure the systemic imbalance
• In 1652, Tulp introduced the idea that cancer was contagious when he reported an elderly woman and her housemaid who both developed breast cancer
• Le Dran stated that breast cancer was a local disease that spread by way of lymph vessels to axillary lymph nodes

  
• Moore emphasized complete resection of the breast for cancer and stated that palpable axillary lymph nodes also should be removed

  
• Banks advocated the resection of axillary lymph nodes even when palpable lymphadenopathy was not evident, recognizing that occult involvement of axillary lymph nodes was frequently present
• Halsted and Meyer established radical mastectomy as state-of-the-art treatment for that era
• Haagensen and Stout described the grave signs of breast cancer and declared that women with grave signs were beyond cure by radical surgery

  
• Patey and Dyson advocated a modified radical mastectomy for the management of advanced operable breast cancer

  
• During the 1970s, there was a transition from the Halsted radical mastectomy to the modified radical mastectomy as the surgical procedure most frequently used by American surgeons to treat breast cancer
• The National Surgical Adjuvant Breast and Bowel Project (NSABP) conducted a randomized trial in the early 1970s to determine the impact of local and regional treatments on survival in operable breast cancer

  
• The NSABP B-06 trial showed no difference in disease-free, distant disease-free, and overall survival among the three groups of total mastectomy, lumpectomy alone, or lumpectomy with breast irradiation
• Bernard Fisher proposed the "alternative hypothesis" that breast cancer was a systemic disease at diagnosis and that tumor cells had access to both the blood and lymphatic systems

  
• The Early Breast Cancer Trialists' Collaborative Group (EBCTCG) overview analysis reported that the avoidance of recurrence in a conserved breast avoids about one breast cancer death over the next 15 years for every four such recurrences avoided

  
• The EBCTCG overview has demonstrated that anthracycline containing regimens are superior to cyclophosphamide, methotrexate, and 5-fluorouracil (CMF), and more recently, that the addition of a taxane to an anthracycline-based regimen reduces breast cancer mortality by one-third
• The EBCTCG data have shown that proportional reduction in risk was not significantly affected by standard clinical and pathologic factors such as tumor size, ER status, and nodal status
• Clinical trials to examine the impact of adjuvant treatments for breast cancer

  Examine impact on recurrence and mortality

  
• The EBCTCG overview has demonstrated that anthracycline containing regimens are superior to cyclophosphamide, methotrexate, and 5-fluorouracil (CMF)
• The EBCTCG overview has demonstrated that the addition of a taxane to an anthracycline-based regimen reduces breast cancer mortality by one-third
• The EBCTCG overview has demonstrated that tamoxifen is of benefit only in patients with estrogen receptor (ER) positive breast cancer and that tamoxifen may decrease mortality from breast cancer by as much as 30%
• This underscores the importance of stratification of risk in determining adjuvant therapy decisions in order to minimize the toxicities of therapies in those unlikely to benefit, yet realize the substantial benefits gained in local-regional control and survival in those at higher risk
• Many early randomized clinical trials considered all patients similarly in terms of treatment viewing breast cancer as more of a homogeneous disease

  
• Breast cancer has traditionally been defined by pathologic determinants using conventional light microscopy and basic histologic techniques

  
• In the 1980s, immunohistochemistry allowed assessment of the expression of individual tumor markers (most commonly proteins) while DNA was initially assessed in terms of its ploidy status
• Subsequently, breast cancer specimens have been interrogated at the level of the DNA by labeling genes of interest and allowing fluorescent dyes to quantify the abundance of a particular gene and comparing a large number of genes simultaneously in a single breast cancer specimen

  
• Gene expression arrays have shown that breast cancers cluster according to their intrinsic gene expression patterns into at least five intrinsic subtypes and these intrinsic subtypes correlate with breast cancer outcomes

  
• Breast cancers are now classified by molecular subtypes and these are being used for risk stratification and decision making in terms of local-regional and systemic therapies

  
• Currently, 50% of American women will consult a surgeon regarding breast disease, 25% will undergo breast biopsy for diagnosis of an abnormality, and 12% will develop some variant of breast cancer

  
• Considerable progress has been made in the integration of surgery, radiation therapy, and systemic therapy to control local-regional disease, enhance survival, and improve the quality of life of breast cancer survivors
• Surgeons are traditionally the first physician consulted for breast care, and it is critical for them to be well trained in all aspects of the breast from embryologic development, to growth and development, to benign and malignant disease processes
• This will allow the greatest opportunity to achieve optimal outcomes for patients and their families
• Mammary ridges (milk lines)


  Ventral bands of thickened ectoderm evident in the embryo at the fifth or sixth week of fetal development
• Mammary ridges


  • Extend from the base of the forelimb (future axilla) to the region of the hind limb (inguinal area)
  • Not prominent in the human embryo and disappear after a short time, except for small portions that may persist in the pectoral region
• Accessory breasts (polymastia)


  Breasts that develop along the milk line
• Accessory nipples (polythelia)


  Nipples that develop along the milk line
• Breast development


  • Ingrowth of ectoderm forms a primary tissue bud in the mesenchyme
  • Primary bud initiates the development of 15 to 20 secondary buds
  • Epithelial cords develop from the secondary buds and extend into the surrounding mesenchyme
  • Major (lactiferous) ducts develop, which open into a shallow mammary pit
  • During infancy, a proliferation of mesenchyme transforms the mammary pit into a nipple