Breast Surgery and Reconstruction Flashcards
What sort of things come under the heading of ‘survivorship’ following breast cancer?
- Signs and symptoms of recurrence – many patients live in crippling fear of reoccurrence
- Improving wellbeing
- Relationships and body image
- Finance and work
- Mood changes
- Weight chances
- Hot flushes
What are the 2 main categories for types of breast cancer surgery?
- Conservative
* Mastectomy
What 4 things come under the heading of breast conservative surgery?
- ‘Lumpectomy’ – basically a wide local excision
- Wide local excision
- Wire guided local excision
- Oncoplastic breast conservation including therapeutic mammoplasty
What is a mastectomy?
Removal of the whole breast
What 2 things come under the heading of breast mastectomy?
- Traditional transverse
* Skin sparing with immediate reconstruction
What 2 treatments, when combined, has the same outcome as mastectomy?
Breast conserving surgery + radiotherapy = mastectomy
If breast conservation is done, there is equivalent disease free and overall survival compared to mastectomy as long as?
There are CLEAR MARGINS OF > 1mm PLUS BREAST RADIOTHERAPY
In surgical wide excision aim for _ cm excision at all margins
1cm
What should you do at the anterior and posterior margins of a breast cancer during surgery?
Full thickness excision
Why is neoadjuvant therapy done?
This is done to achieve breast conservation
What are the different options of neoadjuvant therapy?
- Chemotherapy (standard FEC100 and taxane) +/- Herceptin
- Endocrine: aromatase inhibitors more effective than tamoxifen, so reserved for postmenopausal women
- Both methods shown to reduce mastectomy rates
What is chemotherapy used in?
Used in the control of local + systemic disease
Why is chemo good?
Because less surgery is needed so there is more breast conservation
How is response to chemo assessed?
Assessment of response is radiological with mammography, ultrasound and MRI
What is the standard treatment following chemotherapy?
Surgical excision
What does oncoplastic breast surgery mean?
Aafe oncological (cancer) surgery while avoiding tissue deformity
What does oncoplastic breast surgery mean?
Safe oncological (cancer) surgery while avoiding tissue deformity
What is oncoplastic breast surgery?
Uses principles of cancer and plastic surgery to reshape breast contours at time of cancer resection
What type of reconstruction is oncoplastic breast surgery?
Immediate
Outline the different surgical options in oncoplastic breast surgery.
Large breast/large tumour - therapeutic mammoplasty
Small breast - volume replacement techniques
What is a mastectomy?
Removal of all breast tissue
What are the 2 different options for a mastectomy?
- Standard
* Skin sparing, usually if immediate reconstruction
After mastectomy, various things can be done in terms of conserving breast appearance. Outline some of these.
- External prosthesis
- Reconstruction - immediate or delayed:
- Implant only (+/- autologous cellular matrix)
Latissimus dorsi (LD) pedicled flap +/- implant
Deep inferior epigastric artery perforator (DIEP) free flap - Inferior gluteal artery perforator (IGAP) free flap
Outline the 4 different reconstruction options for breasts.
- Implant only (+/- autologous cellular matrix)
- Latissimus dorsi (LD) pedicled flap +/- implant
- Deep inferior epigastric artery perforator (DIEP) free flap
- Inferior gluteal artery perforator (IGAP) free flap
Implant based reconstruction accounts for around 37% of all immediate reconstructions done in the UK
True
What are the main issues with breast implants?
- Loss of implants (infection)
- Capsular contracture
- Implant rippling
- Implant migration
__% of people with breast implants require revisional surgery
40%
How is implant reconstruction carried out?
‘Two stage’ implant reconstruction:
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)
Outline the advantages of ADM (acellular dermal matrix) Implants.
- “One stage” implant reconstruction by providing lower pole coverage
- Better lower pole expansion
- Reduced postoperative pain
- Improved aesthetic outcome
- Permanent implant can be used at 1st operation
- Also useful for revisional surgery
Describe latissimus dorsi reconstruction.
Myocutaneous flap, standard or extended +/- augmentation
Describe TRAM and DIEP flaps.
TRAM – transverse rectus abdominus flap
DIEP – deep inferior epigastric artery perforator flap
Describe IGAP flaps.
Inferior gluteal artery perforatory flap
Note: superior version also available – SGAP
What are some finishing touches of breast reconstruction surgery?
- Nipple reconstruction
- Lipomodelling
- Contralateral symmetrising: reduction or augment
What are the different options for axillary surgery if the cancer has spread?
- Pre-operative axillary staging: USS axilla +/- core biopsy
- Sentinel node biopsy
- Axillary clearance
- Axillary radiotherapy
What is ALWAYS done during breast surgery? Why?
Axillary surgery
ALWAYS done during breast surgery – either for treatment or staging
Why should you not remove ALL lymph nodes?
If you take away all the lymph nodes, you get lymphoedema
Avoid removing all lymph nodes
What is a sentinel node?
The first lymph node which the cancer is likely to have spread to
