Breast Cancer Surgery 2004

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Breast Cancer Surgery 2004

• William A. Barber, M.D.
• Piedmont Hospital

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Breast Cancer Screening
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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
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Case Report

• US confirmed the existence of 3.5 cm mass
• Core biopsy showed a poorly differentiated
  carcinoma

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Diagnosing Breast Cancer Abnormal Mammograms
Benign Appearing Calcifications
Suspicious Calcification
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Breast Cancer Rules

• Rule 1
• There is no difference in survival between
  Mastectomy and Lumpectomy

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Breast Cancer Rules

• Rule 2
• If you have a lumpectomy, you also need Radiation
  Therapy

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Breast Cancer Rules

• Rule 3
• The operation you chose has nothing to do with
  whether or not you will need chemotherapy.

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Breast Cancer Rules

• Rule 4
• Most Mastectomy patients do not need Radiation
  Therapy.

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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.

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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

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Partial Mastectomy (Lumpectomy)

• Versus Mastectomy
• How do you chose?

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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

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Surgery Terms

• Excisional Biopsy vs. Lumpectomy
• Partial Mastectomy vs. Lumpectomy
• Incisional Biopsy

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Mastectomy

• Difference between
• Total (simple) Mastectomy
• Modified Radical Mastectomy

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Skin Sparing Mastectomy

• Skin sparing mastectomy preserves the majority of
  the breast skin and the inframammary fold
• The entire nipple and areola are removed

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Radical Mastectomy

• Is Radical Mastectomy still in use?
• What is it?

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Subcutaneous Mastectomy

• Is Subcutaneous Mastectomy a cancer operation?
• How does it differ from Total Mastectomy?

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Sentinel Node Biopsy

• Major advance
• Almost no risk of lymphedema
• Blue dye
• Nuclear medicine

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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

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Reconstruction

• Tissue expander
• Latissimus dorsi
• TRAM

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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.
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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.
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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.
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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
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When to Consult?

• Medical Oncology
• Radiation Oncology

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Chemotherapy

• What is NeoAdjuvant Chemotherapy?
• When is it used?

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Mammotome Biopsy
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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)

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Mammosite
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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
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Mammosite
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Mammosite Placement

• Time of Lumpectomy

Post-lumpectomy
Open Cavity
Ultrasound Guided
Scar Entry (SET)
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CT Image of Mammosite
3-Dimensional rendering of applicator surface