CHAPTER 14: BREAST RECONSTRUCTION Flashcards
Describe the anatomy of the breast
Boundaries
- 2nd - 6th rib
- sternal edge
- mid axillary line
- deep superomedial = pec fascia, inferolateral = serratus fascia
- axillary tail of Spence
- 10-100 acini -> lobule -> lobe -> lactiferous duct -> nipple
- lobes separated by fibrous septae, upper breast = suspensory ligaments of Astley Cooper
- Montgomery’s tubercles = sebaceous glands under areolar
NAC
- 4TH ics
- sebaceous glands
- montgomery glands
- tubercles of Morgagni (elevations of gland openings)
- radial smooth muscle fibres (erection)
What is the blood supply to the breast?
Similar to blood supply to pec major
- IMA perforators
- lat thoracic
- pectoral branches of thoracoacromial axis
- anterolateral and medial intercostal perforators
What is the lymphatic drainage of the breast?
lateral -> axilla and infraclavicular
medial -> intercostal spaces to int thoracic parasternal nodes (3-20%)
cxns b/t med & lat
What is the nerve supply to the breast?
2nd - 6th intercostals
Nipple - 4th intercostal med & lat branches
Overlying skin - cutaneous branches T4-6, lat cutaneous
Lactation - hormonal
Describe the stages of breast development
Embryology - breast develops in 4th week as downgrowth from a thickened mammary ridge of ectoderm (milk line) from axilla to inguinal region
Tanner’s stages of pubertal breast dvlpmt
1 - prepubertal
5 - adult
Describe the surface anatomy of the breast
Penn - described the ideal breast measurements
Sternal -> nipple & nipple -> = 21cm
Nipple -> IMF = 6.8cm
NAC = 3.8 - 4.5cm
How is bra cup size measured?
Measure circumference of chest at IMF & maximal projection MP - IMF = INCHES 0 = AA 1" = A 2" = B
Breast cancer epidemiology
30,000 new cases / yr in UK, 50% req mastectomy
~ 7500 breast recons / yr
50% under 65, 50% of these req mastectomy
2nd most common cancer after skin in women
1 in 8 lifetime risk (12%)
1 in 9 women who live to 85
Breast = 25% of general surgery referrals
90% breast clinic referrals are d/c
What is the aetiology of breast cancer?
multifactorial, exo and endogenous factors
- gender (99% women)
- age
- Fhx (no. and proximity), their menstrual status, age of diagnosis, bilat cancer
- linked w early menarche, late menopause, late 1st pregnancy
- premalignant histology
- unilat ca -> inc risk of contralateral ca
How is breast cancer classified histologically?
DUCTAL - derive from ductal element (majority)
NON-DUCTAL - derive from epithelium of breast lobules
Non-invasive and invasive (WHO)
malignant transformation process
NORMAL -> HYPERPLASIA ->ATYPICAL HYPERPLASIA -> DCIS -> INVASIVE CA -> takes 10-20yrs
80% adenocarcinoma (males?)
risk of mets increases with no. of +ve nodes, to lung, liver, bone
What types of ductal ca’s are there?
What types of non-ductal ca’s are there?
DCIS (intraductal ca - still in bm of ducts)
- subtypes - comedo, non-comedo
- 10% bilat, 20% multicentric, 30%->invasive
- mammogram - microcalcification
Invasive ductal
- 75% of all breast ca
- adenoca of ductal elements
- grey gritty spiculated hard
LCIS
- no mammogram changes, marker of invasive disease, not precursor (1% -> invasive)
- usu incidental finding
- 40% bilateral, 60% multifocal
Invasive lobular
- 5-10% invasive ca
- extensively infiltrative /o distinct mass
- no microcalcification
- sim prognosis to inv ductal
What are the special types of breast ca?
Medullary ca
- 6% of invasive ca
- soft fleshy well circumscribed
- good prognosis even w mets
Tubular ca
- 2%, = well diff adenoca
- well diff, good prog
Mucinous / Colloid
- < 5%
- soft gel mass
- well diff, excellent prog
Phyllodes
- mixed CT and epithelial tumour
90% 5yr survival, depends on grade and size of tumour
What are the breast cancer genes?
4-5% of all breast ca’s are inherited
AD with high penetrance
>25% of cases under 30y.o. = genetic
> 4 cases under 60 in family = likely genetic
BRCA1 lifetime risk of breast ca = 85%
50% BRCA1 carriers with ca treated by lumpectomy and DXT will develop recurrence / 2nd ca
BRCA 65% risk of ovarian ca by 70
Histo - usu grade 3, ER-ve, medullary type, early onset, bilat
TP53 assoc w sarcoma
BRCA 2 less
Ashkenazi Jews - 2% have BRCA 1/2 mutn
Carriers offered
(a) SSM and recon (risk reducing mastectomy)
- only 90% effective in reducing risk of ca
(b) annual screening
(c) prophylactic tamoxifen - usu not helpful as most are ER-ve
How is a breast lump assessed?
Risk assessment - age, FHx, endogenous oestrogen
Triple assessment - clinical exam, radiology, pathology
MDT discussion
UK Breast screening
- women b/t 50-70, gradually 47-73 (2016)
- identifies 6/1000 screened
- MRI better for premenopausal women, BRCA pts
USS (for solid vs cystic) - High res USS can identify some cancers and for DXT chemo response
- MRI for implant imaging
- linguine sign (implant pulled away from capsule, leaving multiple parallel lines = stepladder sign)
- snowstorm appearance
- Eklund mammogram views for breast implants
What is the role of mammograms?
- part of NHSBSP
- women every 2-3yrs
- US every yr above 40
- signs - microcalcifcation, density changes, asymmetry , architectural distortion
- Swedish trials - decreased 44% mortality w reg mammogram
- BC f/u - annual mammogram
Staging of breast cancer
TNM Staging & 5yr survival (%) I : <2cm T1 (85%) II : mobile axillary nodes N1 (65%) IIIa : fixed axillary nodes N2 (40%) IIIb : chest wall / skin involvement T4 or int mammary nodes N3 (25%) IV : distant mets M1 (10%)
Stage I Early good prog II good prog III locally advanced, poor inflammatory BC (III)
TNM staging, Nottingham Prognostic Index
What are the goals of treatment?
- optiimise local control
- accurate staging
- longterm survival
- preserve / restore body form
When is breast conservation surgery considered?
Name a trial supporting this.
stage 1-2 disease
contraindicated - multiple lesions, diffuse microcalcification
relative contra - small breast + large ca, radiation induced, ongoing pregnancy
NSABP B06 trial
no diff in survival b/t total mastectomy vs lumpectomy vs lumpectomy and DXT
Current Rx - lumpectomy with -ve margins, DXT, ANS / clearance
BCS - quadrantectomy. How do you reconstruct?
usu for T2 tumours
circumareolar orientated mobilisation of breast mound and direct closure of overlying skin
thoraco-epigastic flaps for skin following lower quadrant resection
axillary tail transposition flap for upper outer quadrant
wise pattern reduction
symmetrisizing contralateral breast
What is the follow-up for breast ca?
Postop 3mths (check arm mobility)
6mthly 2yrs
annual 4yrs +/- d/c 6yrs
Classify the different types of mastectomy
- subcutaneous (NAC preserved)
- skin sparing (NAC excised)
- preserves native breast skin & IMF
- indications: prophylaxis, DCIS,stage 1-2 invasive ca, phyllodes, immediate recon - simple (total)
- stage 3-4
- remove entire breast, NAC and skin overlying tumour - modified radical
- simple mast + ax level 1&2 clearance - risk reducing
What are the indications of risk reducing mastectomy?
Hi risk women (>25% lifetime risk) BRCA 1,2 gene mutation carriers - contralateral RRM (depends on histo) - 2 relatives, 1 <60 - 90% risk reduction - upper outer quadrant - highest risk of recurrence
What is management of the axilla in breast ca?
ax LN clearance / sampling
DXT if +ve nodes
prognosis= 90% 5yr with -ve nodes, 60% 1 +ve LN
sentinel LNB
25% clinically normal LN have micromets
Level of dissection - I,II,III (pec minor)
What is the treatment for DCIS?
local recurrence - after surgical excision only ~ 30% (50% will become invasive) NHSBP B17 (Fisher 1993) - lump only 16% local recurrence - lump + DXT 7% extensive DCIS => SSM
What systemic therapies are there for breast ca?
increase disease free survival in premeno
CMF C, methotrexate, 5FU
FAC - 5FU, A, C
AC - doxorubicin, cyclophosphamide
Receptors
ER/PR TAMOXIFEN / LETROZOLE (postmeno)
HER2 (Human epidermal growth factor 2) HERCEPTIN
triple -ve
