Breast Cancer Surgery and Reconstruction

Question 1

what is happening to the rates of breast cancer

Answer 1

incidence, prevalence and survival increasing

Question 2

what are the functions of the breast that may need to be preserved after surgery

Answer 2

breast feeding

sexual and aesthetic

Question 3

what distance of margin is aimed for in breast cancer surgery

Answer 3

1cm clear

Question 4

what influences survivorship after breast cancer surgery

Answer 4

signs and symptoms of recurrence
improving and wellbeing
relationships and body image
finance and work

Question 5

what neoadjuvant therapies are available

Answer 5

radio
chemo +/- herceptin
endocrine (aromatase inhibitors more effective than tamoxifen)

Question 6

what are the types of breast cancer surgeries

Answer 6

breast conservation

• wide local excision
• wire guided local excision
• oncoplastic breast conservation

mastectomy

• traditional transverse
• skin sparing with immediate reconstruction

Question 7

what is oncoplastic surgery

Answer 7

safe surgery that aims to avoid deformity

reshapes breast via plastic surgery principles- theraputic mastoplexy or volume replacement

Question 8

does a mastectomy have lower risk of recurrence than brest conserving surgery

Answer 8

no

breast conserving surgery with radiotherapy and >-=1cm margins has slight lower risk of recurrence

Question 9

is body image reported to be better after breast conserving surgery or mastectomy

Answer 9

BCT

Question 10

what are the methods of tumour localisation

Answer 10

wires
magnetic clips
radio frequency localisation

Question 11

what do neoadjuvant therapies reduce the rate of

Answer 11

mastectomy

Question 12

how does tamoxifen work

Answer 12

oestrogen receptor blocker

Question 13

how do aromatase inhibitors work

Answer 13

prevent the production of oestrogen

Question 14

how is the response to neoadjuvant chemo assessed

Answer 14

radiological with mgm, USS and MRI

Question 15

what oncoplastic techniques for large breasts or large tumour and reshaping

Answer 15

theraputic mammoplasty (reduction in breast size)

Question 16

what oncoplastic breast techniques for smaller breasts

Answer 16

volume replacement

Question 17

what delayed oncoplastic techniques exist

Answer 17

delays symmetrising augmentation or lipomodelling

Question 18

what are the types of mastectomy

Answer 18

(both removal all breast tissue)
standard
skin sparing (usually with immediate reconstruction)

Question 19

what are the reconstruction options for a mastectomy

Answer 19

external prothesis
reconstruction (immediate or delayed)
-implant
-autologous based:
-latissiumus dorsi pedicled flap +/- implant
-artery free flap (deep inferior epigastric, inferior gluteal, superior gluteal, transverse upper gracilis, profunda)

(free flap= skin and fat, not muscle. only use muscle for transverse upper gracilis and profuna artery perforator)

Question 20

what are the pros and cons of implant reconstruction

Answer 20

pros- short initial op, no other scars

cons- loss of implants (infection), capsular contracture, implant rippling/ migration)
40% need revisional surgery
small risk of ALC lymphoma (1:25000)

Question 21

what is the current method for implant reconstruction

Answer 21

two stage:
1st: mastectomy and creation of submuscular pocket with expander insertion
Clinic visits for expansion 2 weekly
2nd: exchange of expander for permanent implant (although can leave some expanders and remove ports only)

Question 22

what are the ‘finishing touches’ for breast reconstruction

Answer 22

nipple reconstruction
lipomodelling
contralateral symmetrising - reduction or augmentation

Question 23

what is the pre-op axillary staging

Answer 23

USS axilla +/- core biopsy

Question 24

what are the axillary treatment options

Answer 24

Sentinel node biopsy- tracer injected into breast , nodes that take up tracer are the ones draining the breast so need to be taken out
Axillary clearance
Axillary radiotherapy

Question 25

what is the management pathway for axilla disease

Answer 25

USS if suspicious of breast cancer:
if suspicious nodes -> USS guided biopsy:
-if macrometastasis axially lymph node clearance
-if no macrometastases sentinal node biopsy

(if normal nodes on first USS then do sentinal node biopsy)