Surgery & reconstruction for breast cancer

Question 1

What are the 2 main types of breast surgery for cancer ?

Answer 1

1. Breast conserving surgery (BCS) - Wide local excision (WLE)
2. Masectomy - skin sparing or non-skin sparing

Question 2

Is there any difference in the 10 year survival following BCS vs masectomy ?

Answer 2

No - BSC has the same disease free & overall survival as masecomy provided there is clear margins ≥ 1mm & it is followed with radiotherapy

Question 3

What margins should you aim for when doing WLE ?

Answer 3

Aim for 1cm excision at all margins

Question 4

If BCS is to be done but the disease is not palpable eg breast screening detected, what method of surgery can be done ?

Answer 4

Wire guided local excision

Question 5

What is meant by neoadjuvant treatment ?

Answer 5

This is the administration of theraputic agents before the main treatment (surgery in this case)

Question 6

Neoadjuvant chemo should be considered for all patients with breast cancer whose disease is what?

Answer 6

Either:

1. Inoperable (locally advanced or inflammatory) but localised to the breast/locoregional lymph node groups
2. Only surgical option is masectomy & down staging via neoadjuvant therapy might offer the patient the opportunity for BCS

Question 7

What is the standard chemo regime used for breast cancer?

Answer 7

FEC100 and taxane +/- Herceptin (TZ) if HER2 +ve

Question 8

Define what onocplastic sugrery is

Answer 8

• “oncoplastic”: safe oncological (cancer) surgery while avoiding tissue deformity
• uses principles of cancer and plastic surgery to reshape breast contours at time of cancer resection

Question 9

Following BCS what may be done for large breasts ?

Answer 9

Theraputic mammoplasty - operation to remove breast cancer whilst also significantly reducing the size of the breast

Question 10

Following BCS what may be done for small breasts ?

Answer 10

Volume replacement techniques

Question 11

Following masectomy what breast reconstruction options are there?

Answer 11

They may opt for external prosthesis or reconstruction may be Immediate or delayed, options of internal reconstruction include:

• Implant only
• Latissimus dorsi (LD) pedicled flap +/- implant
• Deep inferior epigastric artery perforator (DIEP) free flap
• Inferior gluteal artery perforator (IGAP) free flap
• Superior gluteal artery perforator (SGAP) free flap
• Transverse upper gracilis (TUG) free flap
• Profunda artery perforator (PAP) free flap

Question 12

What are the benefits of implant only reconstructions ?

Answer 12

• Simpler
• Less scarring
• Doesnt change size if you lose or gain weight

Question 13

What are the disadvantages with implant only breast reconstruction ?

Answer 13

• Loss of implants (infection)
• Capsular contracture
• Implant rippling
• Implant migration
• 40% require revision surgery
• Cant have radiotherapy as it affects the implant

Question 14

What are the pros of latissimus dorsi (LD) pediculed flap +/- implant reconstructions ?

Answer 14

• SImpler op tha (TRAM or DIEP flaps) abdominal flaps
• More likely to be successful as flap use retains its original blood supply

Question 15

What are the disadvantages of LD pediculed flap reconstructions?

Answer 15

• Needs to be done alongise an implant if they have larger breasts
• Uses thicker & paler skin from the back, which might result in an obvious patch on the new breast
• Might need surgery on opposite breast for a good match

Question 16

What are the pros of using an abdominal wall tissue reconstruction (TRAM or DIEP flap) ?

Answer 16

• Gives you a flatter tummy
• Reconstructed breast will loose or gain weight as you do

Question 17

What are the cons with abdominal wall tissue reconstructions (TRAM or DIEP flaps)?

Answer 17

• Original blood supply not used like in LD
• Might not be possible if you already have abdominal surgical scars
• Might need surgery to the opposite breast for good match
• Can increase the risk of hernias (due to weaking abdo wall)

Question 18

What are the pros of using an inferior (or superior) gluteal artery perforator free flap (IGAP/SGAP) ?

Answer 18

Tend to be used for women having both breasts reconstructed but they cant have tissue taken from abdo (e.g. due to surgical damage or thin abdomen)

Question 19

What are the cons of using an inferior (or superior) gluteal artery perforator free flap (IGAP/SGAP) ?

Answer 19

• More complicated than abdo flaps & not many surgeons do it
• Original blood supply not used

Question 20

What is the main benefit of body tissue breast reconstruction over implants/prostheses ?

Answer 20

It gives you a breast that is warm, soft & feels more natural

Question 21

When cant body tissue breast reconstructions be used ?

Answer 21

Those with diabetes, heavy smokers, or very overweight as the flap needs a good blood supply or it will die

Question 22

All breast reconstruction methods create a smooth breast shape without a nipple, what are the options for nipple reconstruction ?

Answer 22

1. Nipple tattoo
2. Nipple made from your own body tissue
3. A stick on nipple

Question 23

Alongside nipple reconstruction what 2 other procedures may be done following breast reconstruction ?

Answer 23

1. Lipomodelling = taking away or injection fat in some areas of the breast. This technique can fill in dents following WLE
2. Contralateral symmetrising: reduction or augment = reduction or increase in the opposite breast size to match the breast that underwent the surgery to match them more closely