Breast Cancer Surgery 2004

William A. Barber, M.D.Piedmont Hospital

Breast Cancer Screening

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

CC View of Mammogram April 2002

3.5cm Mass Upper Outer Quadrant

Case Report

US confirmed the existence of 3.5 cm mass

Core biopsy showed a poorly differentiated carcinoma

Diagnosing Breast Cancer: Abnormal Mammograms

Benign AppearingCalcifications

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 MastectomyHow 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 betweenTotal (simple) MastectomyModified 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?

Mammotome Biopsy

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)

Mammosite

Variable 4 to 5 cm balloon

Multilumen, silicone catheter

Radiation source port pathway

Inserted obturator toprevent bending orcoiling of the catheter shaft

Needleless injection site

Mammosite

Mammosite PlacementTime of Lumpectomy Post-lumpectomy

Open Cavity

Scar Entry (SET)

Ultrasound Guided

3-Dimensional rendering of applicator surface

CT Image of Mammosite