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Halstedian model of cancer progression

Posted in Cancer and Current Therapeutics, tagged breast cancer, Halsted, Johns Hopkins School of Medicine, lymph node spread, radical mastectomy, reconstructive surgery, sentinal node, tamoxifin chemotherapy on April 30, 2015| Leave a Comment »

Halstedian model of cancer progression [4.1]

Writer and Curator: Larry H. Bernstein, MD, FCAP

The Halstedian model of cancer progression is attributed to the meticulous care that William Halsted, Chairman of Surgery at the founding of the Johns Hopkins Medical School who in 1894 introduced “radical mastectomy” (1-3). This would be the standard of care until the 1970s, and was made possible by his exquisite knowledge of anatomy, his sparing of tissue including debridement in all surgical procedures, his introduction of the use of cocaine into neural tissue after the introduction of antiseptic by Lister. The radical mastectomy was an extensive debilitating procedure that included the removal of the breast with all axillary lymph nodes and removal of pectoral muscles for lifesaving surgery of breast cancer. (1-6) The changes that followed were modified radical mastectomy that spares the muscles and that was followed by breast conservation surgery that leaves breast tissue behind. Then sentinel lymph node mapping was introduced with the hope of reducing the extent of axillary dissection. Finally, skin sparing mastectomy appeared in order to conserve skin and facilitate breast reconstruction. In addition, surgery was followed by radiation. (4-6)

His work was based in part on that of W. Sampson Handley, the London surgeon who believed that cancer spread outward by invasion from the original growth. (The general concept of the radical mastectomy can be traced all the way back to Lorenz Heister, a German who wrote about his ideas for mastectomy and lumpectomy in his book, Chirurgie, published in 1719.)(5)
Halsted did not believe that cancers usually spread through the bloodstream: “Although it undoubtedly occurs, I am not sure that I have observed from breast cancer, metastasis which seemed definitely to have been conveyed by way of the blood vessels.”(4)

Halsted proposed that although breast cancer begins as a local disease, it spreads in a contiguous manner away from the primary site through the lymphatic system. This proposal led to his emphasis on aggressive locoregional treatment to prevent further spread. Halsted himself suggested, “disability, ever so great, is a matter of very little importance as compared with the life of the patient.” (4) The view that surgeons at the time believed was that mastectomy was crucial to life saving treatment and it was this belief that prevented progress to other initial surgical approaches. It must be acknowledged that in Halsted’s time there was no method of grading or staging cancers, which he acknowledged. This principle, however (known as the ‘Halsted Theory’), was also critical in introducing the concept of a sentinel node in relation to breast cancer. This led to Guiliano et al. introducing lymphatic mapping for breast cancer in 1994. (5)

At the same time Halsted and Handley were developing their radical operations, another surgeon was asking, “What is it that decides which organs shall suffer in a case of disseminated cancer?” Stephen Paget, an English surgeon, concluded that cancer cells spread by way of the bloodstream to all organs in the body but were able to grow only in a few organs.(5) He drew an analogy between cancer metastasis and seeds that “are carried in all directions, but they can only live and grow if they fall on congenial soil.” This highly sophisticated hypothesis was adopted almost a hundred years later after an understanding of metastasis became a basis for recognizing the limitations of cancer surgery, and chemotherapy was introduced for treating a systemic disease (6).

In 1971 Fisher et al. (7) commenced a randomized trial comparing the radical mastectomy with total mastectomy with or without radiotherapy. Studies such as these heralded the advent of breast conserving surgery and the acknowledgement that routine radical mastectomy may not always be the most appropriate surgical management. Today, a radical mastectomy is almost never done and the “modified radical mastectomy” is performed less frequently than before. Most women with breast cancer now have the primary tumor removed (lumpectomy), and then have radiation therapy.(4-6)

The Four Founding Physicians

http://www.hopkinsmedicine.org/about/history/history5.html

Biographical Memoir of William Stewart Halsted 1852-1922
G. MacCallum
Presented to the NAS at the Autumn Meeting, 1935 http://nasonline.org/publications/biographical-memoirs/memoir-pdfs/halsted-w-s.pdf
William Stewart Halsted – A Lecture by Dr. Peter D. OlchJ Scott Rankin, MD
Ann Surg. 2006 Mar; 243(3): 418–425. http://dx.doi.org:/1097/01.sla.0000201546.94163.00