Procedures (axillary clearance, reconstruction, mastectomy, sentinel node biopsy, wide local excision) Flashcards
Define radical vs simple mastectomy.
Radical - removal of the breast tissue, skin, areola, nipple AND most of the axillary lymph nodes
Simple - removal of breast tissue, nipple, areola, skin.
What is the position of the breast?
Between 2nd and 6th rib vertically
Projects into the axilla as the axillary tail of Spence
What are the indications for mastectomy?
- 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
What are the different types of mastectomy?
Which ones are done if choosing delayed or no reconstruction?
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
What is another name for radical mastectomy?
Halsted
What positioning is used for breast cancer surgery and why?
Supine with arm at <90 degrees as >90 degrees increases potential for stretching brachial plexus
At what point of the breast Ca surgery is sentinel node biopsy done?
Before the mastectomy to avoid disupting lymphatics
Where are drains inserted after mastectomy?
inferolateral to the main incision
What are the complications of mastectomy?
- Seroma/haematoma
- Wound infection
- Nipple necrosis
- Pain
- Phantom breast syndrome
- Arm morbidity - lymphoedema, pain, shoulder stiffness,
- Nerve injury e.g. brachial plexopathy
Define axillary clearance.
Surgical procedure to remove lymphatics from the axilla in breast cancer management.
What are the levels of axillary nodes?
Level 1 - low axilla
Level 2 - mid axilla
Level 3 - high axilla near breastbone
When is axillary clearance indicated?
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
What are the borders for axillary node dissection?
- Axillary veins superiorly
- Serratus anterior medially
- Latissimus dorsi laterally
What are the complications of axillary node dissection?
- Infection
- Haematoma/seroma
- Arm morbidity - lymphoedema
- Nerve injury (<1% risk)
Define sentinel node biopsy.
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
How is a sentinel node biopsy carried out?
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
What are the complications/side effects of sentinel node biopsy?
- Bruising
- Pain
- Swelling
- Bleeding
- Lymphoedema (6% in those with breast cancer and 1% of those with melanoma)
What is another name for a wide local excision?
Lumpectomy OR
Breast conserving surgery
What are the indications for WLE in breast cancer?
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
What are the complications of WLE in breast cancer?
- 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
How can the tumour be located in the breast if it is a small tumour?
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
When does WLE have poor cosmetic results?
When there is a tumour >4cm in an average sized breast
How many nodes should be obtained in sentinel node biopsy?
At least 4
What are the indications for breast reconstruction?
Mastectomy - unilateral or bilateral, or WLE with less-than-ideal cosmetic result
Patient choice
