Breast Cancer Surgery 2004 William A. Barber, M.D. Piedmont Hospital
Case Report • 45 y.o patient with two children ages 10 and 13 • Mother had breast cancer at age 65 • Gail 5 yr risk score 1.7 • Undergoes yearly mammograms CC View of Mammogram May 2001 3.5cm Mass Upper Outer Quadrant CC View of Mammogram April 2002
Case Report • US confirmed the existence of 3.5 cm mass • Core biopsy showed a poorly differentiated carcinoma
Diagnosing Breast Cancer: Abnormal Mammograms Benign Appearing Calcifications Suspicious Calcification
Breast Cancer Rules Rule #1: • There is no difference in survival between Mastectomy and Lumpectomy
Breast Cancer Rules Rule #2: • If you have a lumpectomy, you also need Radiation Therapy
Breast Cancer Rules Rule #3: • The operation you chose has nothing to do with whether or not you will need chemotherapy.
Breast Cancer Rules Rule #4: • Most Mastectomy patients do not need Radiation Therapy.
Breast Cancer Rules Rule #5: • If you have a lumpectomy and you have positive lymph nodes, you do NOT need to go back and have a Mastectomy.
Breast Cancer Rules Rule #6: • Whether or not you need chemotherapy is determined by • The size of the primary tumor • How aggressive is the primary tumor • Lymph node status • Age of the patient
Partial Mastectomy (Lumpectomy) Versus Mastectomy How do you chose?
Partial Mastectomy (Lumpectomy) • Contraindications • A. Previous history of Radiation Therapy • B. More than one cancer in same breast • C. Large tumor, small breast, cosmetic deformity • D. Nipple involvement
Surgery Terms • Excisional Biopsy vs. Lumpectomy • Partial Mastectomy vs. Lumpectomy • Incisional Biopsy
Mastectomy Difference between Total (simple) Mastectomy Modified Radical Mastectomy
Skin Sparing Mastectomy • Skin sparing mastectomy preserves the majority of the breast skin and the inframammary fold • The entire nipple and areola are removed
Radical Mastectomy Is Radical Mastectomy still in use? What is it?
Subcutaneous Mastectomy Is Subcutaneous Mastectomy a cancer operation? How does it differ from Total Mastectomy?
Sentinel Node Biopsy • Major advance • Almost no risk of lymphedema • Blue dye • Nuclear medicine
Sentinel Lymph Node Biopsy • Quickly becoming the gold standard • May be as accurate or more accurate than ALN dissection while limiting the complications and costs • Involves injection off Technitium-99 sulfur colloid and or 1% isosulfan blue dye • Multiple ongoing trials including B-32 NSABP
Reconstruction Tissue expander Latissimus dorsi TRAM
Reconstruction: Tissue expander Encapsulated silicone implant reconstruction corrected with tissue expansion. The capsule is first excised, and the tissue expander is used to create an oversized pocket for the implant.
Reconstruction: Latissimus Dorsi A, Preop view: 67-YO following MRM. B, Postop view: following left autogenous latissimus reconstruction w/o implant. Opposite breast reduction mammoplasty required for symmetry.
Reconstruction: TRAM A & B, Preop & Postop views following left free TRAM reconstruction. Skin replacement included all skin between scar & inframammary fold. Nipple reconstruction, opposite mastopexy done at separate procedure.
Breast Reconstruction in the Skin Sparing Mastectomy • TRAM flap • Latissimus flap • Implant/Expander • Silicone is preferred and is available on study protocol Tram flap with nipple reconstruction and tatooing
When to Consult? Medical Oncology Radiation Oncology
Chemotherapy What is NeoAdjuvant Chemotherapy? When is it used?
Minimally Invasive Excisional Biopsy: Whats New? • Ultrasound guided directional vacuum assisted breast biopsy with 11g and 8g mammotome • Introduced in 1996 these devices use vacuum to draw the tissue into a chamber and a rotating cutter dissects the specimen (Mammotome)
Inserted obturator to prevent bending or coiling of the catheter shaft Radiation source port pathway Multilumen, silicone catheter Variable 4 to 5 cm balloon Needleless injection site
Mammosite Placement Post-lumpectomy Time of Lumpectomy Open Cavity Ultrasound Guided Scar Entry (SET)
CT Image of Mammosite 3-Dimensional rendering of applicator surface