Breast Surgery and Reconstruction

Question 1

describe concept of survivorship?

Answer 1

community of people who are living after breast cancer

should consider signs/symptoms of recurrence, wellbeing, relationships and body image, finance and work etc

Question 2

what is used for neoadjuvant therapy

Answer 2

chemotherapy +/- herceptin
endocrine therapy (aromatase inhibitors more effective than tamoxifen)

Question 3

aromatase inhibitors vs tamoxifen?

Answer 3

aromatase inhibitor = inhibits oestrogen production

tamoxifen = blocks oestrogen receptors

Question 4

2 types of breast surgery?

Answer 4

breast conservation (wide local excision, wire guided local excision, oncoplastic breast conservation including therapeutic mammoplasty)
mastectomy (traditional transverse or skin sparing with immediate reconstruction)

Question 5

methods to localisation of tumour before surgery?

Answer 5

wires

magnetic seed??

Question 6

effectiveness of breast conservation?

Answer 6

equivalent recurrence rate and survival as mastectomy as long as:
- clear margins >1mm
- breast radiotherapy
(should have 1cm excision at all margins and full thickness excision at anterior and posterior margins)

Question 7

what is oncoplastic surgery?

Answer 7

safe oncological surgery without tissue deformity

Question 8

how does size affect surgical options?

Answer 8

smaller = volume replacement 
medium = therapeutic mamoplexy
larger = basically a breast reduction (therapeutic mammoplasty)

Question 9

mastectomy options?

Answer 9

external prosthesis
reconstruction (immediate or delayed)
implant only (+/- autologous cellular matrix)
latissimus dorsi pedicled flap +/- implant
deep inferior epigastric artery perforator (DIEP) free flap
inferior gluteal artery perforator (IGAP) free flap

Question 10

immediate reconstruction options?

Answer 10

tissue expansion/breast implant

abdominal
- DIEP (deep inferior epigastric perforators)
- SIEA (superficial inferior epigastric artery)
free TRAM/pedicled TRAM (transverse rectus abdominus muscle)

buttocks
- IGAP (inferior gluteal artery peforator)

upper buttocks/hips

• LSGAP (lateral superior gluteal artery perforator)
• SGAP (superior gluteal artery perforator)

upper inner thigh:
- TUG (transverse upper gracilis muscle)

T-Dap
latissimus dorsi muscle

Question 11

complications of implant reconstruction?

Answer 11

loss of implant (infection)
capsular contracture
implant rippling
implant migration
older implants have a 1 in 25,000 risk of ALC lymphoma

Question 12

current 2 stage method of implant reconstruction?

Answer 12

1 = mastectomy and creation of submuscular pocket with expander insertion
(clinic visits for expansion 2 weekly)
2 = swap expander for permanent implant

Question 13

benefits of using latissimus dorsi?

Answer 13

can keep own blood supply and just swing it round to the breast so less likely to die

Question 14

axilla management if nodes are normal on US?

Answer 14

sentinel node biopsy

Question 15

if nodes are suspicious?

Answer 15

US guided biopsy

etc

Question 16

options for axillary node treatment?

Answer 16

sentinel node biopsy
axillary clearance
axillary radiotherapy