Surgery and Reconstruction for Breast Cancer

Question 1

What are the different types of breast surgery?

Answer 1

Conservation; lumpectomy, wide local excision, wire guided local excision, oncoplastic breast conservation
Mastectomy; transverse or skin sparing with immediate reconstruction

Question 2

What needs to be ensured with breast conservation surgery?

Answer 2

Clear margins >1mm
Breast radiotherapy adjuvant
Surgical wide excision aims for 1cm excision at all margins
Perform full thickness excision at anterior and posterior margins

Question 3

Why is neoadjuvant treatment given in breast cancer?

Answer 3

To allow for breast conservation surgery

Question 4

What are the different types of neoadjuvant therapy in breast conservation?

Answer 4

Chemo +/- herceptin

Endocrine; aromatase inhibitors, tamoxifen

Question 5

How is response of neoadjuvant therapy assessed?

Answer 5

Mammography
USS
MRI

Question 6

What is oncoplastic surgery?

Answer 6

Safe oncological surgery while avoiding tissue deformity

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

Question 7

What is the oncoplastic method of breast conservation surgery for women with large breasts with a large tumour?

Answer 7

Therapeutic mammoplasty

Question 8

What is the oncoplastic method of breast conservation surgery in women with small breasts?

Answer 8

Volume replacement techniques

Question 9

What are mastectomy reconstruction options?

Answer 9

External prosthesis
Reconstruction; immediate or delayed 
Implant +/- autologous cellular matrix 
Latissimus dorsi pedicled flap 
Deep inferior epigastric artery perforator free flap 
Inferior and superior gluteal artery perforator free flap 
Transverse upper gracilis free flap
Profunda artery perforator free flap

Question 10

What are the main problems with implant reconstructions?

Answer 10

Loss of implants
Capsular contracture
Implant rippling
Implant migration 
40% require revisional surgery; fat filling, nipple reconstruction

Question 11

What are the current methods for breast implant insertion?

Answer 11

Mastectomy and creation of submuscular pocket with expander insertion
Clinic visits for expansion 2 weekly
Exchange of expander for permanent implant

Question 12

What are the “finishing touches” in terms of breast reconstruction?

Answer 12

Nipple reconstruction
Lipomodelling
Contralateral symmetrising; reduction or augmentation

Question 13

How is the axillary nodes stages pre-op?

Answer 13

USS axilla +/- core biopsy

Question 14

What is the management for normal axillary nodes?

Answer 14

Sentinel node biopsy in surgery

Question 15

What is the management for macromets in the axillary nodes?

Answer 15

Axillary node clearance

Question 16

Where does 95% of the lymph from the breast drain to?

Answer 16

Axillary nodes

Question 17

How are axillary nodes classified?

Answer 17

In relation to the pectoralis minor muscle:
Level 1 = lateral to muscle
Level 2 = central, lie behind muscle
Level 3 = apical nodes

Question 18

What are factors of breast cancer associated with lymph node involvement?

Answer 18

Large tumour
Poorly differentiated tumour (grade 3) 
Symptomatic tumour
Presence of lymphatic or vascular invasion 
HER2 +ve 
ER neg

Question 19

What is the current practice surrounding sentinel node biopsy?

Answer 19

Subaeolar injection gives highest rate of sentinel node detection
Need to use both radioisotope and blue dye

Question 20

What is the major morbidity of axillary surgery?

Answer 20

Arm swelling and lymphoedema

Question 21

What are the physical management options for lymphoedema?

Answer 21

Defined as arm swelling greater than 10% increase in volume from basleing 
Skin care; reduce risk of infection 
Exercise; promotes lymph flow
Manual lymph drainage 
Support/ compression

Question 22

What is paget’s disease of the nipple?

Answer 22

Eczematoid change of nipple asoc with underlying malignancy

Question 23

Describe tamoxifen

Answer 23

Partial oestrogen antagonist
Reduces risk of contralateral breast can by 40-50%
More effective given after chemo

Question 24

What is the mode of action of aromatase inhibitors?

Answer 24

Inhibit oestrogen synthesis

Question 25

In what subgroup of women is chemo therapy in breast ca most effective?

Answer 25

Greatest in women with ER negative and/or HER2 positive cancers
Least benefit for post menopausal women with ER positive and HER2 neg cancers

Question 26

Side effects of tamoxifen?

Answer 26

Venous thromboembolism 
Hot flush
Altered libido 
GI upset
Vaginal discharge or dryness
Menstrual disturbance
Wt gain 
Endometrial cancer; has an agonist effect in the endometrium

Question 27

Side effects of aromatase inhibitors?

Answer 27

Hot flushes 
Joint and muscle pain 
Osteoporosis
Fatigue
Vaginal dryness

Question 28

What are clinical features of locally advanced breast cancer?

Answer 28

Ulceration, dermal infiltration, erythema over tumour, satellite nodules, peau d’orange
Tumour fixation to ribs, serratus anterior or intercostal muscles
Axillary nodes fixed

Question 29

What is the significance of a radial scar?

Answer 29

Assoc with malignancy; in 10% assoc with DCIS or low grade invasive cancers