Surgery and Reconstruction for Breast Cancer Flashcards
What are the different types of breast surgery?
Conservation; lumpectomy, wide local excision, wire guided local excision, oncoplastic breast conservation
Mastectomy; transverse or skin sparing with immediate reconstruction
What needs to be ensured with breast conservation surgery?
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
Why is neoadjuvant treatment given in breast cancer?
To allow for breast conservation surgery
What are the different types of neoadjuvant therapy in breast conservation?
Chemo +/- herceptin
Endocrine; aromatase inhibitors, tamoxifen
How is response of neoadjuvant therapy assessed?
Mammography
USS
MRI
What is oncoplastic surgery?
Safe oncological surgery while avoiding tissue deformity
Uses principles of cancer and plastic surgery to reshape breast contours at time of resection
What is the oncoplastic method of breast conservation surgery for women with large breasts with a large tumour?
Therapeutic mammoplasty
What is the oncoplastic method of breast conservation surgery in women with small breasts?
Volume replacement techniques
What are mastectomy reconstruction options?
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
What are the main problems with implant reconstructions?
Loss of implants Capsular contracture Implant rippling Implant migration 40% require revisional surgery; fat filling, nipple reconstruction
What are the current methods for breast implant insertion?
Mastectomy and creation of submuscular pocket with expander insertion
Clinic visits for expansion 2 weekly
Exchange of expander for permanent implant
What are the “finishing touches” in terms of breast reconstruction?
Nipple reconstruction
Lipomodelling
Contralateral symmetrising; reduction or augmentation
How is the axillary nodes stages pre-op?
USS axilla +/- core biopsy
What is the management for normal axillary nodes?
Sentinel node biopsy in surgery
What is the management for macromets in the axillary nodes?
Axillary node clearance
Where does 95% of the lymph from the breast drain to?
Axillary nodes
How are axillary nodes classified?
In relation to the pectoralis minor muscle:
Level 1 = lateral to muscle
Level 2 = central, lie behind muscle
Level 3 = apical nodes
What are factors of breast cancer associated with lymph node involvement?
Large tumour Poorly differentiated tumour (grade 3) Symptomatic tumour Presence of lymphatic or vascular invasion HER2 +ve ER neg
What is the current practice surrounding sentinel node biopsy?
Subaeolar injection gives highest rate of sentinel node detection
Need to use both radioisotope and blue dye
What is the major morbidity of axillary surgery?
Arm swelling and lymphoedema
What are the physical management options for lymphoedema?
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
What is paget’s disease of the nipple?
Eczematoid change of nipple asoc with underlying malignancy
Describe tamoxifen
Partial oestrogen antagonist
Reduces risk of contralateral breast can by 40-50%
More effective given after chemo
What is the mode of action of aromatase inhibitors?
Inhibit oestrogen synthesis
In what subgroup of women is chemo therapy in breast ca most effective?
Greatest in women with ER negative and/or HER2 positive cancers
Least benefit for post menopausal women with ER positive and HER2 neg cancers
Side effects of tamoxifen?
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
Side effects of aromatase inhibitors?
Hot flushes Joint and muscle pain Osteoporosis Fatigue Vaginal dryness
What are clinical features of locally advanced breast cancer?
Ulceration, dermal infiltration, erythema over tumour, satellite nodules, peau d’orange
Tumour fixation to ribs, serratus anterior or intercostal muscles
Axillary nodes fixed
What is the significance of a radial scar?
Assoc with malignancy; in 10% assoc with DCIS or low grade invasive cancers
