Surgical considerations in the management of primary invasive breast cancer

In the nineteenth century, German pathologist Rudolf Virchow (Fig. 13.1.) studied the morbid anatomy of breast cancer. He undertook a series of postmortem dissections and postulated that breast cancer spreads along fascial planes and lymphatic channels [1]. Little importance was given to the hematogenous spread of cancer. Virchow's hypothesis influenced the work of the American surgeon, William Halsted (Fig. 13.2.). In the late nineteenth century, Halsted described radical mastectomy (MT), which is performed for the treatment of breast cancer [2]. This operation removed the breast, the underlying pectoralis muscles, and the ipsilateral axillary lymph nodes. Thus, in keeping with the postulates of Virchow' s hypothesis, the lymphatic channels connecting the breast and axillary lymph nodes were extirpated en bloc. Halsted argued that resection of a node-negative breast cancer was curative, believing that such tumors were extirpated before they spread through the lymphatics. Halsted also maintained that the extent of both the MT and axillary dissection were important determinants of outcome. Therefore, breast cancer recurrence and distant metastases were often attributed to inadequate surgery. Fig. 13.1 Dr. Rudolph Virchow (courtesy of the national library of medicine archives) Fig. 13.2 Dr. William Halsted (courtesy of the national library of medicine archives)