History of irradiation in the primary management of apparently regionally confined breast cancer.

After the discovery of X rays by Roentgen in 1895, Emil Grubbe, a medical student in Chicago, testing Crookes’ tubes with his hand, developed a severe dermatitis of the skin of that hand. A physician who had seen Grubbe’s lesion referred a patient with breast cancer to him for irradiation, because of the apparent biologic damaging effect of the recently discovered X rays.28 From 1900 until the 192Os, the practice was to give one treatment, which produced a brisk skin erythema. The dose was called HED, that is, Haut (skin) Erythema Dosis. Later, the HED was measured to be approximately 1000 R. The concept was that the dose killing the epithelium of the skin would kill cancer. In the 192Os, after the Coolidge tube was invented, somewhat more systematic treatments of breast cancer were done with external irradiation. Technical advances were made in external irradiation treatment planning, and in 1928 in a textbook of roentgentherapy, tangential fields were described for irradiating the breast. 37 Inoperable lesions were irradiated, producing some regression that was noticed with interest. Also, irradiation was used preor postoperatively. The rationale of using irradiation before surgery was the same as today, that is, shrinking the tumor cell population, thus making the spread of cancer cells less likely during the surgical procedure. The invasion of the internal mammary chain of nodes had been known and recorded for the first time in an autopsy report from Middlesex Hospital Cancer Ward on October 22, 1806. Halsted was probably the first to attempt to excise the internal mammary nodes as part of the surgical attack on breast cancer. In 1922 Sampson Handley, a surgeon at Middlesex Hospital, explored the mediastinum in six patients. He found involvement of the chain in two of the six patients. In 1927, Handley again documented his belief in the importance of the internal mammary chain route of metastases. “It is the fact that in more than half of my recurrent cases, before I began the prophylactic use of radium, the return of the disease manifested itself either by an enlargement of the gland at the lower and inner angle of the posterior triangle, or by the appearance of nodules, later merging in sternal recurrence, upon the deep fascia at the inner end of the first? second, or third intercostal spaces. The position of these recurrences accurately along the line of the internal mammary artery shows, I think, beyond doubt that they are due to invasion of the lymphatic glands which lie along its c’ourse” (p. 722).35 In the early 192Os, radium needles were made available in the Surgical Department of St. Bartholomew’s Hospital. Geoffrey Keynes, a surgeon, began to treat patients with recurrent disease in 1922. He found that the growth in nearly every instance was found to disappear. The method was extended for primary disease in 1924, initially for every advanced or inoperable tumor and later for operable lesions.41 Figure 1 shows the implant of the breast, axillary, supraclavicular, and internal mammary chain lymphatics. In 1’937, Keynes reported that long-term, disease-free survival rates were of the same order as those obtained with radi’cal mastectomy; he stated that this method was an alternative to radical mastectomy.42 He also carefully mentioned the disadvantages, specifically the development of fibrosis and neuropathies.