BCT:Towards Optimal Outcomes

BCT:Towards Optimal Outcomes

Dr VIJAY HARIBHAKTI

Consultant Surgical Oncologist,

Jaslok Hospital and Breach Candy Hospital, Mumbai, India

Dr VIJAY HARIBHAKTI

Consultant Surgical Oncologist,

Jaslok Hospital and Breach Candy Hospital, Mumbai, India

These Power Point presentations are free to download only for academic purposes, with due acknowledgements to authors and this website.

SHIFTING PARADIGMSPast to present

SHIFTING PARADIGMSPast to present

Fundamental understanding of disease

Approach to patient

Stage at presentation

Diagnostic Methods

Surgery

Adjuvant therapy

Reconstruction

Fundamental understanding of disease

Approach to patient

Stage at presentation

Diagnostic Methods

Surgery

Adjuvant therapy

Reconstruction

BCTStage at Presentation

BCTStage at Presentation

Clinically obvious

Clinically occult, demonstrable on mammography / sonography

Mammographically occult,demonstrable by other modalities, i.e.MRI, PET

Clinically obvious

Clinically occult, demonstrable on mammography / sonography

Mammographically occult,demonstrable by other modalities, i.e.MRI, PET

BCT:Is there any debate?

BCT:Is there any debate?

Not if we understand the fundamental biology of disease

Not if we exercise appropriate case selection

Clearly not when we follow the results of RCTs

Not if we understand the fundamental biology of disease

Not if we exercise appropriate case selection

Clearly not when we follow the results of RCTs

BCT: When?BCT:

When?

Patient desire

Single primary tumour

Able to achieve clear margins

Tumour: Breast ratio that permits acceptable cosmetic result

Able to deliver PORT

Able to maintain follow-up

Patient desire

Single primary tumour

Able to achieve clear margins

Tumour: Breast ratio that permits acceptable cosmetic result

Able to deliver PORT

Able to maintain follow-up

BCT: When not?

BCT: When not?

Multiple primary tumours in separate quadrants

Diffuse suspicious microcalcifications on mammography

Inability to achieve negative margins

Inability to deliver PORT (age & fitness, breast configuration, previous RT, pregnancy, collagen disease)

Multiple primary tumours in separate quadrants

Diffuse suspicious microcalcifications on mammography

Inability to achieve negative margins

Inability to deliver PORT (age & fitness, breast configuration, previous RT, pregnancy, collagen disease)

BCT: Essential Goals

BCT: Essential Goals

Excellent Local ControlComparable with mastectomy

Acceptable Aesthetics:Adequate substance, contour, nipple-areola: breast relationship, symmetry

No compromise in survival

Excellent Local ControlComparable with mastectomy

Acceptable Aesthetics:Adequate substance, contour, nipple-areola: breast relationship, symmetry

No compromise in survival

BCT : High risk medial quadrant disease

BCT : High risk medial quadrant disease

BCT:Fundamental Principles

BCT:Fundamental Principles

Appropriate incision plan for primary

Discontinuous axillary incision

Resecting ‘exactly enough’ tissue

Appropriate closure technique

Appropriate post-operative breast support

Appropriate incision plan for primary

Discontinuous axillary incision

Resecting ‘exactly enough’ tissue

Appropriate closure technique

Appropriate post-operative breast support

BCT:Primary Incision Plan

BCT:Primary Incision Plan

Directly over localized mass

Adequate in length to achieve satisfactory lateral margins

Curvilinear and parallel to areola for upper and lateral quadrant masses

Radial incisions for inner central and lower quadrants

Directly over localized mass

Adequate in length to achieve satisfactory lateral margins

Curvilinear and parallel to areola for upper and lateral quadrant masses

Radial incisions for inner central and lower quadrants

BCT: Result at One YearBCT: Result at One Year

BCT : Radial incision for 6 o’clock T2 lesion

BCT : Radial incision for 6 o’clock T2 lesion

BCT:Axillary incision

BCT:Axillary incision

Discontinuous in majority

Preferably in available crease line

Preferably below follicle line

Horizontal, between axillary folds

Invisible in frontal view

Discontinuous in majority

Preferably in available crease line

Preferably below follicle line

Horizontal, between axillary folds

Invisible in frontal view

BCT:Resecting ‘exactly enough’

BCT:Resecting ‘exactly enough’

Key to a good result

Often necessary to employ USG:Disparity in clinical / sonographic sizeSurrounding mastitis / desmoplasia‘Indistict’ palpable margins

Achieve accurate ‘three-dimensionality’ of margins

Avoid ‘excess’ tissue removal in any plane

Key to a good result

Often necessary to employ USG:Disparity in clinical / sonographic sizeSurrounding mastitis / desmoplasia‘Indistict’ palpable margins

Achieve accurate ‘three-dimensionality’ of margins

Avoid ‘excess’ tissue removal in any plane

BCT:Technique – Palpable lesions

BCT:Technique – Palpable lesions

Accurately marked incision

Preserve subcutaneous fat to maintain contour

Maintain ‘digital vigilance’ for margins

Progress along all lateral margins one by one

Maintain lesion at the centre of the specimen

Tag base of axcision with radio-opaque clips

Accurately marked incision

Preserve subcutaneous fat to maintain contour

Maintain ‘digital vigilance’ for margins

Progress along all lateral margins one by one

Maintain lesion at the centre of the specimen

Tag base of axcision with radio-opaque clips

BCT:Technique: Wire-localized lesions

BCT:Technique: Wire-localized lesions

Adequate understanding with radiologist

Gain accurate 3-D idea about hook position

Place incision over hook, NOT through wire entry point

Resect all around hook

Remove specimen with hook in its centre

Adequate understanding with radiologist

Gain accurate 3-D idea about hook position

Place incision over hook, NOT through wire entry point

Resect all around hook

Remove specimen with hook in its centre

BCT:Specimen Management

BCT:Specimen Management

Must remove as a single piece

Accurate orientation for pathologist:Place marking sutures at 12 and 3 o’clock positions and ink deep marginEnsure inking of entire specimen by pathologistGain information on 6 margins

Adequate fixation technique for evaluation of receptors

Must remove as a single piece

Accurate orientation for pathologist:Place marking sutures at 12 and 3 o’clock positions and ink deep marginEnsure inking of entire specimen by pathologistGain information on 6 margins

Adequate fixation technique for evaluation of receptors

TECHNIQUE : Sonographic Localization

TECHNIQUE : Sonographic Localization

BCT : Operative Technique

BCT : Operative Technique

SpecimenSpecimen

BCT:Extended Indications

BCT:Extended Indications

Large lateralised lesions

Overlying skin resection needed

Quadrantectomy able to achieve satisfactory margins

Reconstruction optimal:Commonly with pedicled L.dorsi flap

Large lateralised lesions

Overlying skin resection needed

Quadrantectomy able to achieve satisfactory margins

Reconstruction optimal:Commonly with pedicled L.dorsi flap

BCT : Quadrantectomy & L.Dorsi flap

BCT : Quadrantectomy & L.Dorsi flap

BCT:Re-excision

BCT:Re-excision

Indications:Margins with gross microscopic tumourMargin status unknownQuestionable, for focally positive margin

Method:Incision reopened, fluid evacuatedSystematic palpation of cavity wallsAppropriate cavity walls excised to 1 cm thickness using knifeNew margin surface marked with sutures

Indications:Margins with gross microscopic tumourMargin status unknownQuestionable, for focally positive margin

Method:Incision reopened, fluid evacuatedSystematic palpation of cavity wallsAppropriate cavity walls excised to 1 cm thickness using knifeNew margin surface marked with sutures

BCT:Closure and post-op care

BCT:Closure and post-op care

No drains

No deep sutures

Accurate approximation of sub-cutaneous fat

Subcuticular closure

Steri-strip support to wound

Supportive garment post-operatively

No drains

No deep sutures

Accurate approximation of sub-cutaneous fat

Subcuticular closure

Steri-strip support to wound

Supportive garment post-operatively

BCT : Closure Technique

BCT : Closure Technique

BCT:Results

BCT:Results

Over 10-year experience:200 cases2 local failures (both advised mastectomy after BCT but refused)

No significant complications

Uniform patient satisfaction

Over 10-year experience:200 cases2 local failures (both advised mastectomy after BCT but refused)

No significant complications

Uniform patient satisfaction

BCT : Young patient with T1 N2 disease

BCT : Young patient with T1 N2 disease

BCT : Long-term result – T3N2 disease

BCT : Long-term result – T3N2 disease

BCT:Conclusions

BCT:Conclusions

BCT is here to stay

Must be offered in all indicated cases

Careful attention to technique

Vigilant systemic management

Careful long-term follow-up

BCT is here to stay

Must be offered in all indicated cases

Careful attention to technique

Vigilant systemic management

Careful long-term follow-up