Breast

Question 1

Axillary clearance

Answer 1

Axillary dissection is a surgical procedure that incises the axilla to identify, examine, or remove lymph nodes

Indications:
● Locally advanced (T4a, b, c) or inflammatory breast cancer.
● Needle-biopsy-proven metastatic disease in axillary lymph nodes, which are either clinically palpable or nonpalpable but abnormal by imaging (mostly ultrasound)

COMPLICATIONS

The anatomic disruption caused by ALND may result in lymphedema, nerve injury, and shoulder dysfunction, which compromise functionality and quality of life.

● Infection
● Hematoma
● Seroma – The normal lymphatic drainage of the breast to the axilla can lead to seroma formation after axillary
● Arm morbidity – Lymphedema of the arm is a potential and serious complication of ALND.

Question 2

Fibrocystic breasts

Answer 2

It is a condition characterised by ‘lumpy’ breasts, associated with pain and tenderness that fluctuate with the menstrual cycle.

These changes do not correlate with an increased risk of breast cancer;

Supportive treatment if symptomatic:

analgesia
evening primrose oil (EPO)
hormonal therapy
cyst aspiration

Question 3

Breast reconstruction

Answer 3

Breast reconstruction is an option for patients following a unilateral or bilateral mastectomy, or after breast conservation therapy that has had a less than ideal cosmetic result. Breast reconstruction provides psychological, social, emotional, and functional improvements, including improved psychological health, self-esteem, sexuality, and body image . Patients who choose breast reconstruction are presented with complex decisions, including the type and timing of reconstruction.

Options for breast reconstruction following total mastectomy include prosthetic devices and autologous tissue.

Question 4

Breast reconstruction Complications

Answer 4

The risk for some complications is increased for certain patient factors (eg, smoking obesity) and others associated with treatment of breast cancer (radiation therapy).

Complications associated with flap-based or implant-based breast reconstruction that may or may not lead to reoperation can be classified as:

• Complications inherent to surgery, and common to all, including seroma, bleeding, and hematoma; skin necrosis; and infection, among others.
• Complications specifically related to the reconstruction, such as flap ischemia/necrosis/loss, fat necrosis, implant capsular contracture, implant failure, exposure, or malposition, and suboptimal aesthetic appearance.
• Complications related to donor tissue sites.

● Failure in silicone gel implants is difficult to detect since the gel typically remains confined within the breast capsule (intracapsular rupture), it may extrude into the breast tissue and beyond (extracapsular rupture). Ruptured silicone gel implants should be removed due to the possibility of the gel material causing inflammation and other tissue reactions, particularly when rupture is extracapsular.

● A very rare type of cancer called anaplastic large cell lymphoma has been associated with breast implants, located within the scar capsule adjacent to a silicone or saline-filled breast implant. The overall risk is extremely low.

Question 5

Ductal disease

Answer 5

Breast cancer in situ is cancer that is confined to the duct or lobule in which it originated and does not extend beyond the basement membrane.

incidentally found LCIS and low risk and a low level of anxiety: observation and counselling

Women are treated based on their calculated University of Southern California (USC)/Van Nuys score.

Low score (4-6) excision followed by observation (without radiation) + clear margin, preferably >1 cm, in all directions. > 6 is treated with excision plus radiotherapy, which allows breast conservation.

Question 6

Van Nuys score.

Answer 6

The index uses patient age, tumour size, tumour growth patterns (histological grade) and the amount of healthy tissue surrounding the tumour after removal (resection margin width) to predict the risk of cancer returning.

Question 7

Ductal disease: Complications and prognosis

Answer 7

invasive breast cancer

Ductal carcinoma in situ (DCIS) can recur if inadequately treated or if unknown disease is present in the area treated or in other areas of the breast. Mastectomy carries the lowest risk of disease recurrence, approximately 2%.

Question 8

Mastectomy

Answer 8

the complete removal of the breast tissue, is a surgical option for patients diagnosed with breast cancer as well as a prophylaxis to reduce the risk of breast cancer in high-risk women.

Mastectomy is indicated for patients who are not candidates for breast conserving therapy, patients who prefer mastectomy, and for prophylactic purposes to reduce the risk of breast cancer.

Radical mastectomy — A radical mastectomy consists of en bloc removal of the breast, the overlying skin, the pectoralis major and minor muscles, and the entire axillary contents.

Modified radical mastectomy — A modified radical mastectomy (MRM) is complete removal of the breast and the underlying fascia of the pectoralis major muscle along with the removal of the level I and II axillary lymph nodes.

Simple mastectomy — A total or simple mastectomy is removal of the entire breast, with preservation of the pectoral muscles and the axillary contents.

Skin-sparing mastectomy — The “skin-sparing” mastectomy is a surgical technique in which the majority of the natural breast skin envelope is not resected.

Complications:
Seroma, wound infection, skin flap necrosis, chest wall pain, phantom breast syndrome, and arm morbidity.

Question 9

Sentinel lymph node biopsy

Answer 9

The status of the axillary lymph nodes is one of the most important prognostic factors in patients with breast cancer. Sentinel lymph node biopsy has replaced axillary lymph node dissection in many patients with early breast cancer.

●For patients with early-stage breast cancer who are clinically node-negative, we recommend an initial axillary evaluation with sentinel lymph node biopsy (SLNB)

●For patients with ductal carcinoma in situ (DCIS)

●Inflammatory breast cancer is an absolute contraindication to SLNB

Question 10

Wide local incision

Answer 10

Breast-conserving therapy — BCT for DCIS refers to lumpectomy to remove the tumor with negative surgical margins, generally followed by RT to eradicate any residual disease

Surgical resection — The goal of BCT for DCIS is complete resection with negative margins in a cosmetically acceptable manner. When DCIS is present on a core biopsy, needle or wire localization under mammographic guidance prior to BCT may ensure complete resection.

For larger areas of suspicious microcalcifications, bracketing of the area maximizes the likelihood of a complete excision with adequate margins on the first attempt, thereby diminishing the need for re-excision

Same risk as for any surgery already detailed