Procedures (axillary clearance, reconstruction, mastectomy, sentinel node biopsy, wide local excision)

Question 1

Define radical vs simple mastectomy.

Answer 1

Radical - removal of the breast tissue, skin, areola, nipple AND most of the axillary lymph nodes
Simple - removal of breast tissue, nipple, areola, skin.

Question 2

What is the position of the breast?

Answer 2

Between 2nd and 6th rib vertically
Projects into the axilla as the axillary tail of Spence

Question 3

What are the indications for mastectomy?

Answer 3

• Conservative Ca treatment CI or unsuccessful
• Inflammatory breast disease
• Multicentric disease
• Diffuse suspicious microcalcifications
• Patient preference
• Patient with malignancy who is pregnant
• Breast cancer risk reduction - BRCA1/2, TP53, PTEN

Question 4

What are the different types of mastectomy?

Which ones are done if choosing delayed or no reconstruction?

Answer 4

Modified radical mastectomy (MRM) - tissue, fascia, axillary nodes
Simple total mastectomy - tissue and fascia
Skin-sparing mastectomy (SSM) - comparable recurrence rates to simple mastectomy, CI for inflammatory breast cancer because it invades dermal lymphatics
Nipple-areolar-sparing mastectomy (NSM)

MRM or simple mastectomy

Question 5

What is another name for radical mastectomy?

Answer 5

Halsted

Question 6

What positioning is used for breast cancer surgery and why?

Answer 6

Supine with arm at <90 degrees as >90 degrees increases potential for stretching brachial plexus

Question 7

At what point of the breast Ca surgery is sentinel node biopsy done?

Answer 7

Before the mastectomy to avoid disupting lymphatics

Question 8

Where are drains inserted after mastectomy?

Answer 8

inferolateral to the main incision

Question 9

What are the complications of mastectomy?

Answer 9

• Seroma/haematoma
• Wound infection
• Nipple necrosis
• Pain
• Phantom breast syndrome
• Arm morbidity - lymphoedema, pain, shoulder stiffness,
• Nerve injury e.g. brachial plexopathy

Question 10

Define axillary clearance.

Answer 10

Surgical procedure to remove lymphatics from the axilla in breast cancer management.

Question 11

What are the levels of axillary nodes?

Answer 11

Level 1 - low axilla
Level 2 - mid axilla
Level 3 - high axilla near breastbone

Question 12

When is axillary clearance indicated?

Answer 12

T3-T4, N0-2 or inflammatory breast cancer

Biopsy proven metastases in axillary nodes

After a positive sentinel node biopsy if:

• 2-3 +ve nods with small tumour (<5cm)
• Any positive nodes with large tumuor (>5cm)
• Any extranodal extension
• Any positive nodes in patients not having whole breast irradiation for any reason

Question 13

What are the borders for axillary node dissection?

Answer 13

• Axillary veins superiorly
• Serratus anterior medially
• Latissimus dorsi laterally

Question 14

What are the complications of axillary node dissection?

Answer 14

• Infection
• Haematoma/seroma
• Arm morbidity - lymphoedema
• Nerve injury (<1% risk)

Question 15

Define sentinel node biopsy.

Answer 15

Removal and examination of the the first lymph node(s) to which cancer cells are likely to spread from a primary tumor.

Sentinel node definition in bold

Question 16

How is a sentinel node biopsy carried out?

Answer 16

Small amount of radioactive material, blue dye, or both are injected near the primary tumour

Then the lymph nodes which are radioactive/blue detected by eye or Geiger counter are removed

The dissected nodes are examined by a pathologist

If no cancer cells are detected then it is unlikely that the cancer has spread

Done under general anaesthetic

Question 17

What are the complications/side effects of sentinel node biopsy?

Answer 17

• Bruising
• Pain
• Swelling
• Bleeding
• Lymphoedema (6% in those with breast cancer and 1% of those with melanoma)

Question 18

What is another name for a wide local excision?

Answer 18

Lumpectomy OR
Breast conserving surgery

Question 19

What are the indications for WLE in breast cancer?

Answer 19

DCIS or breast Ca:

• Tumour <4cm in an average sized breast
• Tumour restricted to one breast quadrant
• Following neo-adjuvant chemo or hormonal therapy to reduce tumour size

Question 20

What are the complications of WLE in breast cancer?

Answer 20

• Pain or bruising
• Risks of general anaesthetic
• Seroma/haematoma
• Re-excision may be needed if clear margin not achieved
• Change in breast shape
• Altered sensation
• Breast lymphoedema - peau d’orange skin which is tight and pink in colour

Question 21

How can the tumour be located in the breast if it is a small tumour?

Answer 21

X marked on skin
Magseed - a magnetic steel marker the size of rice, inserted by radiology team under USS guidance so that the surgeon can locate the tumour using magnetic detector in theatre
Sirius Pintuition - similar to the above

Question 22

When does WLE have poor cosmetic results?

Answer 22

When there is a tumour >4cm in an average sized breast

Question 23

How many nodes should be obtained in sentinel node biopsy?

Answer 23

At least 4

Question 24

What are the indications for breast reconstruction?

Answer 24

Mastectomy - unilateral or bilateral, or WLE with less-than-ideal cosmetic result
Patient choice

Question 24

What are the types of breast reconstruction?

Question 25

What are the benefits of reconstruction after mastectomy?

Answer 25

Psychological, social, emotional, functional improvements, better pscyhological health, self-esteem, sexuality and body image.

Question 26

What are the contraindications to immediate reconstruction?

Answer 26

Advanced disease (stage III or higher)
Need for radiation therapy post-mastectomy
Medical comorbidities such as smoking, obesity, cardiopulmonary disease