Surgery and Breast Reconstruction Flashcards
What surgical factors increase the rate of recurrence of breast cancer?
- no clear margin
Different types of cancer require different margins. TRUE/FALSE?
TRUE
e.g. sarcomas require large margin (1cm)
What questions should be asked before surgery to remove cancer?
- Is it possible to remove?
- Is patient suitable for surgery?
- Will it impact their quality of life?
What does “preserving function” refer to when reconstructing the breast?
- most patients are post-menopausal => breast don’t perform previous function anymore
- any pre-menopausal women are likely to lose function in the affected breast due to radiotherapy anyway
=> preserving function = preserving appearance of breasts for sexual function and psychological reasons
Almost all patients with breast cancer have surgery. TRUE/FALSE?
TRUE
- at some point in their journey
=> may not necessarily be first
What neoadjuvant treatments are normally used in the UK?
- Chemo +/- Herceptin
- Aromatase inhibitors
- Tamoxifen
(these aim to reduce the size of the cancer for easier surgical excision)
What is the difference in mechanism between aromatase inhibitors and oestrogen receptor blockers (tamoxifen)
Aromatase Inhibitors - prevent the aromatase reaction which forms oestrogen
Oestrogen receptor blockers - prevent oestrogen from binding and causing its desired effect
Why are aromatase inhibitors only given to post-menopausal women?
Aromatase inhibitors more effective than tamoxifen
=> reserved for postmenopausal women
What are the different types of Breast Conservation surgery that are available?
- wide local excision
- wire guided local excision (used for non-palpable lumps picked up on screening)
- Breast conservation and Therapeutic Mammoplasty
What are the two types of mastectomy operations that can be performed?
- traditional transverse
- reconstruction at same time
What are the 3 main concerns when undertaking oncoplastic surgery?
oncological (is cancer out?)
psychological
cosmetic
How are patients allowed to make a decision on which procedure would be the most cosmetically appealing to them?
Shown photographs of the results of surgical procedures performed at that particular hospital
- many patients will have never seen mastectomy results before, therefore these photographs may make them rethink
- allows them to see how these operations scar and where these scars are visible
Describe how a wire guided local excision is carried out
- patient is awake (No GA)
- under US or mammogram guidance
Name other methods of localisation that can be used to mark a cancer or lesion to be removed?
- magnetic seed
- radiofrequency marker
What is a therapeutic mastopexy and when is it normally used?
- Like a breast lift
- usually used if cancer is at bottom of breast (e.g. 6 o’clock position)
What are the options after a mastectomy?
- External prosthesis (worn in bra)
- Reconstruction: Immediate or delayed (less skin in this case as it was not spared)
=> Implant
=> Autologous Muscle flap (latissimus dorsi OR from abdomen OR from gluteal region)
What are the main problems with immediate reconstruction?
- Loss of implants (infection)
- Capsular contracture
- Implant rippling
- Implant migration
- 40% require revisional surgery
If a therapeutic mastopexy is NOT performed after a cancer is removed from the bottom portion of the breast, what can result?
“birds beak” deformity
- nipple forms birds beak shape pointed downwards
What reconstruction surgery leaves patients with only a scar under their arm?
Volume replacement using the Lateral Intercostal Artery Perforator Flap
What can artificial breast implants be made out of?
silicone (most commonly)
saline (more common in USA)
What are the potential benefits of implants as opposed to using tissue from elsewhere in the body?
- No additional scars elsewhere
What can occur around the implant after it is inserted?
fibrosis and scarring
- body thinks it is a foreign object
What were the potential risks with old implants?
Anaplastic Large Cell Lymphoma (ALCL)
Risk 1:25,000
New implants can be used directly on top of the Pec Major muscle. Where were they previously placed?
- behind Pec Major muscle
=> required stretching to allow enough room to place implant in
Why is a latissimus dorsi flap less likely to fail than others?
It is flipped around on the same blood supply
=> since this has not been compromised, it is less likely to fail
Flaps from the abdomen and gluteal region take longer than a standard implant procedure. TRUE/FALSE?
TRUE
Using a Transverse rectus abdominus flap or Deep inferior epigastric artery perforator flap is essentially like performing what procedure?
Abdominoplasty
“Tummy tuck”
Liposuction from the abdomen can be used in the breast for what purpose?
To fill any deformed or defective parts of the breast
The presence of what on US guided biopsy indicates the need for axillary clearance?
Macrometastases
- if none present, then sentinel node biopsy
Why should axillary clearance be avoided if possible?
Arm lymphodema risk
When would the lymph nodes under the breast bone (internal mammary) potentially be removed?
- not routinely removed as this would involved removing part of rib
- if already undergoing surgery and access to these nodes is possible, then they may be removed at this point
