SPECIAL ISSUES IN BREAST CANCER HISTORY OF MASTECTOMY BEFORE AND AFTER HALSTED

The operation described by Halsted, in 1894 and called radical mastectomy, represents a milestone in the treatment of breast cancer. It con- sisted of removal of the breast, muscles and axillary lymph nodes. The pre-Halsted era saw attitudes ranging from the willful abstention to brutal treatments by cauteriza- tion or amputation. The introduction of anesthesia and asepsis enabled more advanced surgical attempts. The stratification of patients into operable and non- operable categories has improved surgical outcome. After attempts to extend Halsted procedure (by ex- tended or super-radical mastectomies) proved to be of little benefit, a minimally-invasive trend emerged gradually. It started with modified radical mastectomy that spares the muscles and was then followed by breast conservative surgery that leaves breast tissue behind. Then sentinel lymph node mapping was introduced with the hope of reducing the extent of axillary dis- section. Finally, skin sparing mastectomy appeared in order to conserve skin and facilitate breast recon- struction. RESUME • L'operation decrite par Halsted en 1894 et appelee mastectomie radicale, represente un jalon important dans le traitement du cancer du sein. Elle consistait en l'ablation du sein, des muscles et des ganglions lymphatiques axillaires. L'epoque prehalstedienne a vu des attitudes allant de l'abstention volontaire aux traitements brutaux par cauterisation ou amputation. L'introduction de l'anes- thesie et de l'asepsie a permis plus d'avancees chirur- gicales. La stratification des patients en operables et non operables a permis d'ameliorer les resultats. Les tentatives d'elargir l'operation en pratiquant la mastectomie radicale etendue ou la mastectomie super- radicale, se sont revelees peu avantageuses. Une ten- dance mini-invasive est progressivement apparue avec la mastectomie radicale modifiee respectant les muscles puis la chirurgie conservatrice gardant le sein apres mastectomie partielle, suivie de curage axillaire et de radiotherapie. Recemment le mapping du ganglion sen- tinelle a permis d'eviter les curages surtout dans les cas precoces. Enfin, l'excision de la peau est de plus en plus limitee (skin sparing mastectomy) pour faciliter les reconstructions du sein.