Axillary surgery for breast cancer: past, present, and future.

In breast cancer surgery, there has been a major shift toward less invasive local treatment. Although axillary lymph node dissection (ALND) was an integral part of surgical treatment for breast cancer, sentinel lymph node (SLN) biopsy was developed as an accurate method for axillary staging. ALND can be avoided not only in patients with negative SLNs but also in those with one or two positive SLNs receiving breast and/or axillary radiation. On the other hand, ALND has remained the standard treatment for patients with clinically positive nodes. However, axillary reverse mapping (ARM) was developed to map and preserve arm lymphatic drainage during ALND and/or SLN biopsy. This procedure allowed reduction of the rate of arm lymphedema without increasing axillary recurrence, although patients receive postoperative chemotherapy and high-risk patients undergo axillary radiation. Standard ALND may not be necessary even for patients with clinically positive nodes who receive axillary radiation and systemic therapy. Thus, the extent of axillary surgery in breast cancer has been decreased with increased use of systemic and radiation therapy.

I Thought I Must Have Expired - Experiences of Surgery Before Anaesthesia.

In 1812, Frances (Fanny) Burney (born in 1752 and died in 1840) underwent a mastectomy performed by Larry without anaesthesia. In the days after surgery, Burney wrote a letter to her sister, Esther Burney, describing her experience. In total, the letter is four pages long including information on before, during and after the surgery. Although this letter has been cited in numerous texts, it has yet to be analysed from multiple perspectives, shedding new light on the history of anaesthesia.

Management of breast cancer 50 years ago.

In 1970, 50 years ago, I had headed the newly established Academic Unit of Surgery at the Westminster Medical School for 10 years. Since my appointment there in 1960, and for the next 30 years, one of my main interests as a general surgeon was the management of diseases of the breast - breast cancer in particular.

Invasion and metastasis: a historical perspective.

The idea that neoplasms grow, becoming unresectable through dissemination, which is initially loco-regional, and systemic only in a later stage, is historically at the basis of the radical surgery - where, by 'radical', the old surgery meant the complete removal of the tumor and, in practice, aggressive surgery. Halsted's "radical mastectomy", as well as many principles of surgical anatomy of the first decades of the twentieth century, obey to an idea of tumor progression as a linear process taking place in continuity and contiguity, where the various anatomical layers and the peritumoral desmoplastic reaction are mistaken for a wall of defense against the neoplasm's dissemination, capable of containing and orienting it. However, the investigations of the processes of invasion and metastasis by Rudolf Virchow and Stephel Paget helped to reorient surgical approaches.

The changing surgical treatment of breast cancer in the United States: The tipping point.

The surgical management of breast cancer began to change in the middle of the last decade. The use of unilateral mastectomy decreased while the rate of contralateral prophylactic mastectomy for unilateral cancer increased sixfold from 1998 to 2011. The use of immediate breast reconstruction increased from 30% in 2005 to 45% in 2012. Four changes came together in the middle of the last decade to cause this paradigm shift in the surgical management of early breast cancer. (a) Breast MRI would be available in nearly 75% of breast imaging centers. (b) Genetic counseling would become a standard of care for patients with potential hereditary breast cancer. (c) In 2006, the FDA would approve the use of silicone-gel implants. (d) Nipple-sparing mastectomy would become a standard of care in the treatment of early breast cancer.

Evolution of Operative Technique for Mastectomy.

The radical mastectomy was the mainstay of breast cancer treatment through the majority of the twentieth century. However, as the understanding of breast cancer increased, the indications for more extensive surgical intervention decreased. The mastectomy has evolved so that skin-sparing or nipple-sparing mastectomy can be performed in the majority of women who undergo mastectomy currently. Today, nearly 40% of all women undergo mastectomy for breast cancer. The improved cosmetic appearance associated with skin- or nipple-sparing mastectomies does not compromise oncologic outcomes.

Breast Reconstruction: A Century of Controversies and Progress.

Breast cancer treatment has dramatically changed over the past century. Since Halsted's first description of radical mastectomy in 1882, breast reconstruction has evolved slowly from being considered as a useless or even dangerous procedure by surgeons to the possibility nowadays of reconstructing almost any kind of defect. In this review on the development of breast reconstruction, we outline the historical milestone innovations that led to the current management of the mastectomy defect in an attempt to understand the economic, social and psychological factors, which contributed to slow down its acceptance for several decades.

Los ojos de Renata. Anécdota de una paciente superviviente / Os olhos de Renata. Anedota duma paciente sobrevivente / Renata's eyes. A survival patient anecdote

Renata había sido doblemente mastectomizada. Las heridas quirúrgicas habían cicatrizado, ya no tenía los puntos de sutura, sin embargo, las cicatrices aún tenían ese color rosáceo típico de las heridas que llevan poco tiempo cerradas. Ese color "rosa vulnerable". Tres veces fueron los intentos de querer marcharse, tres los amagos de partida y en las tres ocasiones le salvaron la vida aquella misma tarde, en un intervalo de dos o tres horas. La ausencia de pechos en Renata, así como su alopecia secundaria a la quimioterapia y los recientes tatuajes por causa de las quemaduras de las palas del desfibrilador, justo en el lugar donde se encontraban aquellas heridas rosas, daban a Renata un aspecto andrógino desconcertante, grotesco. ¿Podríamos contarle alguna vez que había estado a punto de irse…, tres…, veces? ¿Podríamos decirle alguna vez con algunas risas que era una mujer muy terca y obstinada? (AU)

Renata had been doubly mastectomized. Surgical wounds had scarred, no longer had the stitches, however, the scars still had that typical pink color of the wounds that have only recently closed. That color "vulnerable-pink". Three were her attempts wto leave, three the feints of leaving and on all three occasions they saved her life that afternoon, in an interval of two or three hours. The absence of breasts in Renata, and her alopecia secondary to chemotherapy and her recent tattoos caused by burns of the defibrillator paddles, right there, in the place where those roses wounds were, gave Renata a bewildering androgynous look, grotesque. Could we ever tell her that she had been about to leave... three ... times? Could we ever tell her with some laughs how headstrong she was, how stubborn? (AU)

Renata tinha sido mastectomizada duplamente. As feridas cirúrgicas tinhan curado, já não tinha os pontos de sutura, no entanto, as cicatrizes ainda tinhan aquela cor-de-rosa típico das feridas que só recentemente fechadas. Que a cor "rosa vulnerável". Três foram as tentantivas dela querendo deixar, três as fintas de sair embora e em todas as três ocasiões salvaram a sua vida, essa mesma tarde, em um intervalo de duas ou três horas. A ausência de seios en Renata, e sua alopecia secundária à quimioterapia, e tatuagens recentes causado por queimaduras as pás do desfibrilador, bem no lugar onde essas feridas rosas eram, deu Renata uma aparência andrógina grotescamente desconcertante. Poderíamos alguma vez dizer que ela estava prestes a sair ... três ... vezes? Poderíamos alguma vez dizer com algumas risadas que era uma mulher muito teimosa? (AU)

Frances Burney's Mastectomy Narrative and Discourses of Breast Cancer in the Long Eighteenth Century.

This paper examines Frances Burney's 1812 mastectomy letter alongside contemporaneous medical treatises on the subject of breast cancer. Burney's letter offers a critique of a medical community that misconstrues her experience and can be viewed as pathography, or disability memoir. Examining the letter and the treatises in this way illuminates the brutality of some medical practices and the frequent incongruity between the patients' and the physicians' understandings of pain. However, the letter and the treatises also share much in common; both at times emphasize the patient's words and experiences, and both reveal the impressive and contradictory range of ideas surrounding breast cancer in the long eighteenth century. The paper ends by suggesting that the complex rapport between the letter and the treatises holds particular interest for the field of disability studies in its confrontations with socio-medical tendencies to normalize the body and downplay the harsh realities of breast cancer.

A Consideration on the Origin of Seishu Hanaoka's Nyugan-jun and Nyugan-jun Furoku.

Nyugan-jun is a manual that was used at Hanaoka's school, Shunrinken, describing two oral medicines and three ointments routinely administered after breast cancer surgery. Nyugan-jun Furoku is also a manual that was used at the school, depicting a variety of diseases of the breast, and oral concoctions to be administered. The earliest manuscript of both manuals was transcribed in February 1812. A manuscript of Ben-nyugansho narabini Chiho Soko, written by Ryozo Chiba in 1811, includes descriptions of an oral medicine and four ointments routinely given after breast cancer surgery. Although Choeito was only a common oral concoction in Nyugan-jun and Chiba's manuscript, the latter bears an original trace of Nyugan-jun. This indicates that Nyugan-jun and Nyugan-jun Furoku were completed by the end of February 1812, and their completion dates were not before August 1811.

[Victory over surgical pain : 170 years ago the era of modern anesthesia began - but what happened in the operating theater in the time before?] / Sieg über den Operationsschmerz : Vor 170 Jahren begann die Ära der modernen Anästhesie ­ aber was geschah in der Zeit davor im Operationssaal?

170 years ago, on 6 October 1846, the dentist William Thomas Green Morton, sucessfully demonstrated ether anesthesia in a patient undergoing surgery in the operating theater of the Massachusetts General Hospital in Boston. He thereby put an end to the unthinkable suffering of patients who had to undergo surgery when fully conscious. Before this "discovery" surgical procedures resembled a battle for life and death. Only a few documents exist illustrating the attitude of surgeons concerning their actions and which tortures patients had to tolerate. One of the first German standard operating procedures for the perioperative period was formulated in 1812 by Christian Bonifacius Zang. In her diaries and letters, the english novelist Frances Burney described her mastectomy without anesthesia on 30 September 1811. The Scottish physician and novelist John Brown, in his story of "Rab and his friends", painted a picture of the mastectomy of Ailie Noble by the famous Scottish surgeon James Syme in 1833, also without anesthesia. Finally, in his letters the Scottish scientist George Wilson described the amputation of his left foot at the ankle in January 1843, again by James Syme and again without the use of anesthesia.

Mastectomy with tears: breast cancer surgery in the early nineteenth century.

BACKGROUND: By the early nineteenth century, breast cancer was better understood and surgical treatment was emerging as a more favoured option although anaesthesia had yet to be discovered. Many questions would have arisen for a woman advised to have surgery, including possible alternatives, what the operation would entail, pain and risks involved and the competence, ethical and professional behaviour of the surgeon. This paper addresses these questions in the context of the contemporary environment, focusing in particular on the personal experiences of the women involved. METHODS: A review of the surviving personal letters and information regarding three women who had breast surgery, and of the contemporary surgical writings on breast cancer, training of surgeons, ethical and professional expectations and the concurrent status of women in society. RESULTS: Surgical training was in its infancy and the first pronouncements on medical ethics had just been published. Pain, bleeding and infection presented formidable challenges and carried significant risks. Women were frequently devoid of information, suffered a loss of their dignity and were progressively stripped of their authority. CONCLUSIONS: Breast cancer surgery was accompanied by enormous emotional and physical distress and significant risks from bleeding and infection. Although efforts were being made to give women a greater voice and autonomy in society, their position when receiving health care remained largely a submissive one. Lack of information, feelings of vulnerability, helplessness and loss of control occurred. The public perception of detachment most likely accounted for the occasional negative stigma then associated with the surgical profession.

Development of Mafutsusan by Seishu Hanaoka and General Anesthetics in the Very Early Part of the 19th Century in Japan.

Seishu Hanaoka's medicine is famed for its breast cancer surgery. Hanaoka, who,was motivated by Dokushoan Nagatomi's Man-yu zakki, published in 1771, had the idea to excise a breast cancer tumor and not to perform a breast amputation. Because he recognized that general anesthesia was indispensable for performing a surgical operation of the breast, he developed a general anesthetic and surmounted various difficulties: selection of an anesthetic method, anesthetic ingredients, determination of the opti- mal dosage, administration methods, indications and contra-indications, evaluation of the depth of anesthesia, facilitation of the smooth emergence from anesthesia, and postoperative care. I reviewed previous articles on these subjects and, using several unpublished manuscripts, provided new information on disseminated general anesthetics in Japan during the decade after the first general anesthesia for Kan Aiya in 1804.

Ryozo Chiba's Ben-nyugansho narabini Chiho Soko and Nyuganbensho or Nyuganben: The Practice of Hanaoka's Breast Cancer Surgery in 1811.

In 1811, Ryozo Chiba (1789-1861) from Sendai Province enrolled in a private school of Shunrinken, presided by Seishu Hanaoka and wrote up a manuscript titled Nanki Seishu Sensei Nyugan Chyutu Koju (the title on the first page is Ben-nyugansho narabini Chiho Soko) in August 1811, only 6 months after enrollment. The manuscript describes Hanaoka's teachings about breast cancer surgery; signs and symptoms of breast cancer, differential diagnosis, preoperative care, administration of Mafutsusan, operative procedures, hemostatic techniques, wound suture; wound dressing, recovery from anesthesia with Mafutsusan, postoperative care, and prescriptions of drugs for internal and external use. After repeated transcriptions and the addition of various papers on other subjects, the title of the manuscript changed to Nyuganbenshio or Nyuganben. Chiba's original manuscript is considered important because the transcriber and the year of transcription of the manuscript are identified, and it unfolds the practice of Hanaoka's breast canicer surgery as of 1811.

Iginio Tansini revisited.

The origin of the muscolocutaneous latissimus dorsi flap dates back to 1906 when Igino Tansini, an Italian surgeon, described a procedure to reconstruct the mastectomy defect. After a detailed study of Tansini's original description and drawings, new insights about the pedicle of its compound flap have been found, showing that it has the same pedicle of the scapular flap. In the end, Tansini's flap should be more correctly considered as a compound musculocutaneous scapular flap.

Amputation of the breast.

Today we take for granted the blessing of anaesthesia and it is almost impossible for us to imagine the agonies that surgical patients underwent in the past. This description of a mastectomy, performed in 1720 by Lorenz Heister, Professor of Surgery and Anatomy in Altdorf in the republic of Nurnberg, (now part of Germany), gives a vivid idea of major surgery in those days. In this much shortened abstract from his lengthy report, which appears in the 1775 English edition of his textbook entitled 'Medical, Chirurgical and Anatomical cases and Observations' he discusses the preoperative preparation, the mastectomy itself, performed as quickly as possible and the tedious postoperative dressings of the inevitably suppurating wound.

"Entrenched practices and other biases": unpacking the historical, economic, professional, and social resistance to de-implementation.

BACKGROUND: In their article on "Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices," Prasad and Ioannidis (IS 9:1, 2014) referred to extra-scientific "entrenched practices and other biases" that hinder evidence-based de-implementation. DISCUSSION: Using the case example of the de-implementation of radical mastectomy, we disaggregated "entrenched practices and other biases" and analyzed the historical, economic, professional, and social forces that presented resistance to de-implementation. We found that these extra-scientific factors operated to sustain a commitment to radical mastectomy, even after the evidence slated the procedure for de-implementation, because the factors holding radical mastectomy in place were beyond the control of individual clinicians. We propose to expand de-implementation theory through the inclusion of extra-scientific factors. If the outcome to which we aim is appropriate and timely de-implementation, social scientific analysis will illuminate the context within which the healthcare practitioner practices and, in doing so, facilitate de-implementation by pointing to avenues that lead to systems change. The implications of our analysis lead us to contend that intervening in the broader context in which clinicians work--the social, political, and economic realms--rather than focusing on healthcare professionals' behavior, may indeed be a fruitful approach to effect change.

Pain and Surgery in England, circa 1620-circa 1740.

The scholarship on the discussion and role of pain in early modern English surgery is limited. Scholars have given little consideration to how surgeons described and comprehended pain in their patients' bodies in early modern England, including how these understandings connected to notions of the humours, nerves and sex difference. This article focuses on the attention that surgeons paid to pain in their published and manuscript casebooks and manuals available in English, circa 1620-circa 1740. Pain was an important component of surgery in early modern England, influencing diagnosis, treatment and technique. Surgeons portrayed a complex and multi-dimensional understanding of their patients' bodies in pain, which was further connected to their portrayals of their professional ability.