The History of Breast Cancer Surgery - 2

Advances in anesthesia and antisepsis made the 19th century the golden age of surgery. In the 20th century, surgical skills improved further and chemotherapy, radiotherapy, hormonal and targeted treatments were developed. Surgeries achieving cosmetic results also made treatment much more encouraging. These advances translated into lives saved, longer survival and improved quality of life.

The 19th Century: Surgery’s Golden Age

Many discoveries making surgery safer and producing positive outcomes for patients developed rapidly through fundamental principles. Disinfection (removing infectious agents), sterilization (complete removal of all microorganisms) and sterile gloves were the first milestone practices. General anesthesia fundamentally changed surgery, making the work of surgeons—and certainly patients—easier. James Blundell in 1818 attempted, for postpartum hemorrhage, blood transfusion , but safe transfusion succeeded in the early 20th century with Karl Landsteiner’s discovery of blood groups. In addition, in the 17th century in England, Hooke, and in the 19th century in Germany, Müller and Virchow described normal cells and their cancerous relatives using the microscope , making crucial contributions to cancer knowledge. Müller ended humoral theories of cancer’s origin by explaining that cancer consists of living cells and suggesting metastasis results from their spread. Breast cancer spreading through lymphatic vessels to axillary lymph nodes formed the basis of various excision (axillary dissection) techniques.

In the mid-19th century, bold, radical operations were given freedom. Charles Moore in England and Kuster and Volkmann in Germany followed parallel paths. Axillary lymph node dissection was performed by William Banks in Liverpool, England, in 1882. Although destructive by the standards of the time, it provided a major opportunity to examine disease spread. Toward the century’s end, breast cancer surgery became associated with Professor Dr. William S. Halstead, a surgeon at Johns Hopkins Hospital in Baltimore, United States. His approach removed tissues in one piece to prevent spread and removed the pectoralis major chest wall muscle to prevent recurrence, through radical mastectomy surgery (first reported in 1894), which became the undisputed path pursued diligently by subsequent generations of surgeons.

In our country, the first breast cancer surgeries were performed in the late 1890s, a period that can be considered very early, by the physician known as the founder of modern surgery in Türkiye, Dr. Cemil Topuzlu . Having graduated from Mekteb-i Tıbbiye-i Şahane (Mekteb-i Tıbbıye-i Askeriye) in Gülhane in 1886, Dr. Cemil Topuzlu was sent to France (Paris) for surgical specialization in 1887. He worked for three years as a resident at St. Louis Hospital in Paris. In 1890, he returned to Istanbul and was appointed head of the surgery department at Haydarpaşa Military Hospital. While clearing the axilla in a woman undergoing breast cancer surgery, he injured an artery. The severed artery was sutured end-to-end. The same occurred in another patient. He presented these cases and his technique at the Moscow Surgical Congress in 1897. In America, Alexis Carel published the same technique 5 years later in 1902... He served our country for many years as a surgeon and Mayor of Istanbul and trained many valuable surgeons. In 1958, the year he died, Harbiye Open-Air Theater was named after him.

“Tissue suspected of cancer should be removed in one piece. This can prevent wound infection or cancer breaking apart and spreading to other tissues” and similar strict rules introduced in this period prevented preoperative biopsy. Later this view was understood to be wrong, and preoperative diagnostic biopsy became routine. Another discontinued old practice was leaving the surgical wound open to granulate (tissue repair). Use of ligatures (tying thread or wire known as surgical sutures) now improves wound healing and lowers infection rates.

The 20th Century: Surgery Reinvents Itself

Breast cancer’s hormone dependence was initially hypothetical. Observations showed aggressive disease in young women. Beatson stimulated the endocrine surgery era in 1906, long before Jensen’s discovery of estrogen receptors in 1967 and before oophorectomy (ovary removal) and adrenalectomy (adrenal gland removal) became popular. Estrogen receptor modulators, gonadotropin-releasing hormone agonists and aromatase inhibitors later superseded these effective methods.

Halstead’s legacy was maintained for a time by Margottini and Veronesi in Milan, who extended “radicality” to supraclavicular and mediastinal nodes and additionally removed internal mammary lymph nodes. However, in the late 19th and early 20th centuries, this maxim gradually faded: Great surgeons make great incisions (and therefore perform great operations). Patey and Handley in London and Auchincloss Jr. in New York began the movement to “modify” radical mastectomy and preserve the pectoralis major muscle. New forms of chemotherapy and rapid radiotherapy advances to kill cancer cells also emerged during this period, but medical castration or reaching targeted mutated tumor receptors required reconsidering cancer management strategies. This combined with growing knowledge of breast cancer’s biological behavior. Early detection of small cancer lesions through mammography added a new dimension to surgical treatment management.

The call to reorient toward limited surgery came from the surgical community. Professor Dr. Bernard Fisher, a surgeon at the University of Pittsburgh, revived Galen’s idea that breast cancer is a systemic disease. Large studies such as the National Surgical Adjuvant Breast and Bowel Project in 1989 provided scientific support. How ironic that abandoning the radical Halstedian approach and research institutions and accepting neoadjuvant treatment (preoperative shrinking treatment) was a surgeon’s brilliant idea! Veronesi from Italy and many others supported limited surgery complemented by adjuvant methods. Surgery reinvented itself to combine with other methods. As the 20th century ended, breast conservation and reconstruction—with sentinel lymph node dissection when needed—began to take effect. Removing and examining selected “sentinel” nodes (the first nodes to which the tumor spreads) prevented unnecessary removal of all axillary nodes and greatly reduced rates of lymphedematous (swollen) arms due to breast cancer surgery.

Surgeons led the revolution to reduce major tissue loss. This opened the door to various synthetic materials and innovative autologous tissue transfers offering shapes that can even surpass nature’s original creation. Muscle, myocutaneous flaps, lipomas and omentum (the membrane covering the intestines) became natural options. The transverse rectus abdominis myocutaneous flap (TRAM) was introduced by Holmstrom in 1979 and evolved through many modifications to the present. Prosthetic and synthetic options generated industrial and commercial debate: petroleum jelly, ivory, rubber, polyvinyl alcohol sponge and silicone… The list goes on!

Today, surgery remains central in managing various breast cancer treatment approaches. Rather than complete destruction, surgery now comes to breast cancer patients’ aid, balancing cosmetics and treatment.

To read part 1, click here