Surgery and Reconstruction

Question 1

what are the main principles of surgical oncology

Answer 1

surgical excision with a clear margin

preserve function

multidisciplinary team working

Question 2

what are the types of breast conservation surgery

Answer 2

‘lumpectomy’ - wide local excision

wire guided local excision

oncoplastic breast conservation with therapeutic mammoplasty (eg. to increase size after radio)

Question 3

what are the types of mastectomy

Answer 3

traditional transverse

skin sparking with immediate reconstruction

Question 4

what factors are considered when deciding between breast conserving surgery or mastectomy

Answer 4

oncological
psychological
cosmetic

Question 5

is breast conservation as effective at getting rid of the cancer as mastectomy

Answer 5

yes - equivalent disease free and overall survival as long as:

clear margins (>1mm) 
Breast radiotherapy

Question 6

what is an impalpable breast cancer

Answer 6

can’t feel the lump

detected at breast screening

Question 7

how do you manage impalpable disease

Answer 7

specimen x-ray

wire guided local excision

Question 8

what is neoadjuvant treatment

Answer 8

treatment given before the surgery

Question 9

what neoadjuvant treatment is used to achieve breast conservation

Answer 9

chemotherapy (FEC100 and taxmen) +/- Herceptin

Endocrine (aromatase inhibitors - reserved for post menopausal women (letrozole) )

both methods reduce mastectomy rates

theres an overall survival advantage for younger women if chemo is done pre-surgery

Question 10

how do you asses response to neoadjucant therapy

Answer 10

mammography
ultrasound
MRI

Question 11

what is oncoplastic surgery

Answer 11

safe cancer surgery while avoiding tissue deformity

uses principles of cancer and plastic surgery to reshape the breast contours at the time of cancer resection

Question 12

what oncoplastic breast conservation techniques is used for large breasts/large tumour and reshaping

Answer 12

theraputic mammoplasty

Question 13

what oncoplastic breast conservation techniques are used for small breasts

Answer 13

volume replacement techniques

Question 14

what is a mastectomy

Answer 14

removal of all breast tissue

can be standard or skin sparing - usually if immediate reconstruction

Question 15

what are the breast reconstruction options after mastectomy (and where they come from)

Answer 15

external prosthesis (chicken fillets)

Reconstruction (Immediate or delayed)

• implant only (+ autologous cellular matrix)
• latissmus dorsi pedicle flap + implant
• depp inferior epigastric arterator perforator free flap
• inferior plural artery perforator free flap

Question 16

what is the difference between a pedicled flap and a free flap

Answer 16

pedicled flap stays attached to its blood supply and just swung around to a new position

free flap is detached from its blood supply and reattached to a new one

Question 17

what are the main complications of reconstruction using prosthetic breast implants

Answer 17

loss of implants (infection)
capsular contracture
implant rippling
implant migration

40% require revision surgery

Question 18

what are the two stages of implant reconstruction

Answer 18

1- mastectomy and creation of a sub muscular pocked with an expander inserted

(clinic visits for expansion 2 weekly)

2- exchange the expander for permanent implant

Question 19

what are the advantaged of acellular dermal matrix with the implant

Answer 19

pig skin or cow tissue which holds the implant in place

means theres just one stage implant reconstruction by lowering pole coverage

better pole expansion

reduced post op pain

improved aesthetic outcome

permanent implant can be used at 1st operation

also useful for revision surgery

Question 20

what finishing touches are done after breast reconstruction

Answer 20

nipple reconstruction 
lipomodelling 
contralateral symmetrising (reduction or augmentation)

Question 21

what treatment options are there for spread to the axillary nodes

Answer 21

pre-op axillary staging
sentinel node biopsy
axillary clearance
axillary radiotherapy