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MASTECTOMY
Presenter:
Dr Janardhan T
Post Graduate

Moderator:
Dr Prakash M
Consultant surgeon
Introduction
• Definition: surgical removal of breast tissue
  partially or completely.

• In a study conducted in 2004,
   – Highest mastectomies were done in Europe 60-70%.

   – USA- 56%.

   – Australia and New Zealand: 34%.
Introduction
• Most common carcinoma in women.
  – 1.3 million women/ yr are diagnosed to have
    carcinoma breast.
  – 77% of incidence seen in women > 50yrs.

• 2nd most common cause of death due to
 carcinoma.
  – 555,000/yr deaths due to carcinoma breast.
History
• 549 A.D: court physician Aetius of Amida
  proposed to Theodora.

• 1882: William Halsted- Radical mastectomy.

• 1943: Patey and Dyson- Modified radical
  mastectomy.

• 1981: Breast conservation surgery.
When is mastectomy indicated
              ?
• Women with carcinoma breast.
• Men with carcinoma breast.
• Extensive benign disease of breast.
• Prophylactic.
• No/ minimal response to systemic therapy to
  CA breast.
Mastectomy
Types of mastectomy
1. Total or simple mastectomy:
   –   Removal of the entire breast
       tissue,

   –   No dissection of lymph
       nodes or removal of muscle.

   –   Sometimes adjacent lymph
       nodes are removed along
       with the breast tissue.
Types of mastectomy
2. Modified Radical
   Mastectomy (MRM):
  –    Removal of breast tissue
       and axillary lymph nodes.
  –    No removal of pectoral
       muscle.
  –    3 modifications:
      a.   Patey’s
      b.   Scanlon’s.
      c.   Auchincloss.
Types of mastectomy
3. Halsted’s Radical Mastectomy:
   –   Most extensive type.
   –   Breast tissue, axillary lymph
       nodes and pectoral muscles are
       removed.
   –   Disadvantages:
       •   Bad scars and unacceptable
           deformity.
       •   Reduced range of mobility of
           shoulder
Types of mastectomy
4. Subcutaneous mastectomy:        5. Skin sparing mastectomy:

  –   Simple mastectomy               – Total/simple mastectomy or
                                        modified radical mastectomy
      sparing nipple.
                                        with preservation of as much
  –   Rarely done, as a large
                                        as breast skin as possible
      amount of breast tissue is        needed for breast
      left in situ.                     reconstruction.

                                      – Local recurrence is
                                        acceptable, 0-3%.
Types of mastectomy
6. Breast conserving
  surgery:
  – Wide local
    excision/Lumpectomy

  – Quadrantectomy.
Types of mastectomy
7. Extended radical                8. Toilet mastectomy:
    mastectomy:
                                   – Done in fungating or
–   Radical mastectomy +
                                      ulcerative growths.
    enbloc resection of internal
    mammary lymph nodes +          – Palliative simple
    supraclavicular lymph             mastectomy.
    nodes.

–   Obsolete.
Which procedure is suitable for the given
                 patient ?
• Age                                • Menstrual status.
• Size of the tumor
                                     • Size of the breast
• Axillary lymph node status.
                                     • Availability of
• Stage of the malignancy
                                       radiotherapy.
• Biologic aggressiveness of the
   tumor                             • Patients choice.

• Receptor status of the tumor.      • Prophylactic/therapeutic/
• Multicentricity or multifocality     palliative.
Which procedure is best ?
• When the tumor size is ≥ 1cm, becomes
  systemic.

• No single method is considered better in terms
  of disease free survival or mortality.

• Suitable local therapy + systemic therapy is the
  most appropriate approach.
Which procedure is best ?
• Loco-Regional therapy include:
  a. Surgery
  b. Radiotherapy

• Systemic therapy:
  a. Chemotherapy
  b. Hormonal therapy
  c. Monoclonal antibodies.

  However surgery is important to get rid of gross cancer
Pre-operative management
• Triple assessment.

• Metastatic workup.

• Routine blood investigations.

• Pre-anesthetic evaluation.

• Control of medical conditions like diabetes and hypertension.

• Counseling and written informed consent.

• Parts preparation- neck to mid thigh including pelvic
  region, axilla and arm.
Anatomy of breast
Anatomy of axilla
TNM staging
Stage        Tumor        Node     Metastasis
Stage 0      Tis          N0       M0
Stage I      T1           N0       M0
Stage IIA    T0           N1       M0
             T1           N1       M0
             T2           N0       M0
Stage IIB    T2           N1       M0
             T3           N0       M0
Stage IIIA   T0           N2       M0
             T1           N2       M0
             T2           N2       M0
             T3           N1       M0
             T3           N2       M0
Stage IIIB   T4           N0       M0
             T4           N1       M0
             T4           N2       M0
Stage IIIC   Any T        N3       M0
Stage IV     Any T        Any N    M1
Operative procedures-Mastectomy

1. Simple mastectomy.

2. Modified radical mastectomy.

3. Breast conserving surgery.
Operative procedure
• Anesthesia
  – General anesthesia.

• Position
  – The patient is placed in supine position with the
    arm abducted < 90 degree.
  – Sandbag or folded sheet is placed under the thorax
    and shoulder of affected side.
Operative procedures- Simple
                Mastectomy
•   Indications:
    –   Stage I and stage IIa carcinoma
    –   Large cancers that persist after adjuvant therapy
    –   Multifocal or multicentric CIS.
•   Incision:
    –   Horizontal elliptical incision is marked so as to include the entire
        areolar complex.
    –   Should be 1-2cm away from the tumor margins.
    –   Skin sparing incision- if breast reconstruction is planned
    –   Two skin edges should be of equivalent length
Mastectomy
Simple Mastectomy-procedure
• Skin incision is deepened with
  electro-cautery.
• A plane between breast fat and the
  subcutaneous fat, seen as white
  fibrous plane.
• Dissection is carried in this plane and
  flaps are raised inferiorly and
  superiorly.
• Ideally thickness of the flap should
  be 7-10mm.
Simple Mastectomy-procedure
• Extent of dissection:
   – Superiorly till clavicle,
   – Laterally till P.major lateral border
   – Medially to the sternal border, and
   – Inferiorly till infra-mammary fold

• Breast tissue along with the pectoral fascia
  (controversial) is dissected from the P.major.
Simple Mastectomy-procedure
• Usually started superiorly and the proceeded clock-wise ending
  in the axillary region.
• Care must be taken to ligate perforating branches of lateral
  thoracic and anterior intercostal vessels.
• Lateral branches of the medial pectoral neurovascular bundle is
  carefully dissected while removing axillary tail.
• Wound irrigated with sterile water to crenate (shrivel or shrink)
  cancerous cells.
• Subcutaneous tissue is closed using 00 absorbable interrupted
  sutures.
• Skin closed using 00 non-absorbable mattress sutures or using
  staples.
Operative procedures- Modified radical
                 Mastectomy
•   Indications:
    –   LABC
    –   Residual large cancers that persist after adjuvant therapy
    –   Multifocal or multicentric disease.
•   Incision:
    –   Oblique elliptical incision angled towards axilla.
    –   Should include the entire areolar complex and previous scars, if
        present.
    –   Should be 1-2cm away from the tumor margins.
    –   Two skin edges should be of equivalent length
Modified radical Mastectomy-procedure
• Procedure till approaching axilla is
  same as simple mastectomy.

• Extent of dissection:
   – Superiorly till clavicle,

   – Laterally till anterior margin of
      latissimus dorsi.

   – Medially to the sternal border, and

   – Inferiorly till the costal margin near the
      insertion of the rectus sheath.
Modified radical Mastectomy-procedure
• The specimen is retracted upwards and laterally to
  expose P.minor.
• The dissection is continued to axillary lymph node
  clearance.
• Care must be taken not to injure medial pectoral nerve
  and vessels.
• The axillary investing fascia is incised to expose the
  axillary group of lymph nodes.
Modified radical Mastectomy-procedure
1. Patey’s procedure:
  –   The P.minor is removed for better visualization and easy
      dissection of level III lymph nodes.
2. Scanlon’s procedure:
  –   P.minor is retracted to expose level III nodes and
      dissected out.
3. Auchincloss procedure:
  –   Level I and II lymph nodes are cleared, level III nodes are
      left behind.
Modified radical Mastectomy-procedure
•   The inter-pectoral (Rotter) group of lymph nodes are removed.

•   Then dissection can be done either from medial to lateral or vise-
    versa.

•   The loose lateral areolar tissue in axillary space is dissected to
    expose the axillary vein.

•   The investing layer of axillary vessels is cut, the tributaries are
    transfixed and cut.

•   Dissection is carried out laterally including lateral grp (level I) of
    lymph nodes.
Modified radical Mastectomy-procedure
•   Thoracodorsal neurovascular bundle lies over the lat.dorsi, with nerve
    more laterally placed, subscapular (level I) nodes are removed.

•   The level II lymph nodes between superior trunk of
    intercostobranchial bundle and axillary vein are removed.

•   The central grp of lymph nodes are removed carefully separating from
    axillary vein and its tributaries.

•   While dissecting medially, long thoracic nerve is encountered, which
    lies anterior to the subscapular muscle. The dissection carried out
    anterior and medial to long thoracic nerve and the specimen
    delivered.
Modified radical Mastectomy-procedure
• Care must be taken while dissecting in axillary area to
  preserve,
   –   Medial and lateral pectoral nerve.
   –   Long thoracic vessels and nerve
   –   Nerve to latissimus dorsi.
   –   Axillary vein.
• Wound irrigated with sterile water to shrink/crenate
  cancerous cells.
• 2 drains, 1 below and other above P.major are secured.
• Subcutaneous tissue is closed using 00 absorbable
  interrupted sutures.
• Skin closed using 00 non-absorbable mattress sutures or
  using staples.
Mastectomy
Post-operative care
• Wound examined on post-op day 3.
• Drain can be removed when it is < 30ml.
• Any collection is to be aspirated under aseptic
  precautions.
• Staples can be removed after 10days.
• Arm movements started in the 1st week..
• Active shoulder and upper limb exercises are started
  from 2 weeks
Breast conserving surgery

• Method:                 • Indications:
  – Wide local               – Stage 0 (CIS), Stage I,
    excision/Lumpectomy        Stage IIa breast
    or Quadrantectomy +
                               carcinoma.
    axillary lymph node
                             – Single lesion.
    clearance +
    radiotherapy.            – Clinically downstaged

                               LABC (controversial)
Breast conserving surgery
• Contraindications:                     • Advantages:
– Multicentric tumor.
                                            – Maintenance of appearance
– Positive margins after excision.
                                              and function of breast.
– Size > 4cm (relative).
                                            – Disease free interval is same as
– Advanced stages.
                                              MRM.
– No assess to radiation/ poor patient
   compliance.                              – Better quality of life and
– C/I for radiation: SLE/ Rheumatoid          psychological advantage.
   arthritis/ Scleroderma/ pregnancy/
   prior chest radiation.
Breast conserving surgery-Procedure
• Incision-circular/ radial/ subareolar incision near to the tumor,
  about 3-4cm.

• Excision of the carcinoma tissue with a margin of atlaeast 1cm
  of normal breast tissue to get a 2-mm cancer-free margin.
   – If tumor is situated superficially then excision of that part of skin.

   – If tumor is deep then tumor is excised till pectoralis major.

• Depending on post-surgical defect
   – Primary closure or

   – Reshaping of breast tissue is done.
Breast conserving surgery-
                     Lumpectomy
• After skin incision, subcutaneous tissue is deepened using electric
   cautery.

• While dissecting the breast tissue, better to use scalpel.

• Care must be taken while dissecting to palpate the tumor, so that
   entire lesion is excised. Specimen radiography can be done to check
   for clear margins.

• Hemoclips are applied along the margins of the cavity.

• Wound closed in 2 layers:
    – Subcutaneous tissue with interrupted inverted 3-0 absorbable suture.

    – Skin with subcuticular 3-0 absorbable sutures.
Breast conserving surgery-Procedure
Quadrantectomy:

• Usually done for lesion in the upper outer and inner lower
   quadrants.

• Radial incision is taken.

• Entire breast tissue in that quadrant is excised till pectoral fascia.

• Wound closed in multiple layers:
    – Breast tissue with interrupted 3-0 absorbable suture.

    – Subcutaneous tissue with interrupted inverted 3-0 absorbable suture.

    – Skin with subcuticular 3-0 absorbable suture.
Breast conserving surgery
• Quadrantectomy v/s Lumpectomy.
  – Lumpectomy has more local recurrence risk.

  – Lumpectomy has better cosmetic outcome.
Breast conserving surgery
• After BCS, radiotherapy is essential, otherwise
  the local recurrence rate is unacceptably high

• Without radiotherapy, the local recurrence can
  be as high as 40%
Survival after BCS and
                       Mastectomy
    Trial         Endpoint    Overall Survival   Disease-free Survival
                             CS&RT Mastect       CS&RT       Mastect


NCI Milan          18 yrs     65%        65%           N/A


Institut Gustav                73%       65%           N/A
                   15 yrs
Roussy
NSABP B-06         12 yrs      63%       59%       50%         49%


NCI USA            10 yrs      77%       75%       72%         69%


EORTC               8 yrs      54%       61%
                                                         N/A

Danish Breast                 79%        82%         70%        66%
                   6 yrs
Cancer Group
Follow-up after breast conservation
              surgery

• Mammogram at 6 months after radiotherapy

• Clinical evaluation and mammogram every
  yearly then after.

• If local recurrence detected, mastectomy must
  be done.
Complications
• Most Common,
  – Reduced ROM of the shoulder

  – Numbness

  – Lymphoedema

  – Pain
Complications
• Less common,
  – Hematoma
  – Skin flap necrosis
  – Fibrosis
  – Winging of scapula
  – Postural changes
  – Psychological implications
  – Chronic/phantom pain
Breast reconstruction surgery
• The most common reason of breast reconstruction surgery, is for
  psychological well being.

• Reconstructive surgery post mastectomy can be either immediate
  or delayed.
   – Immediate
       • Skin sparing

       • Better outcomes

   – Delayed
       • When immediate reconstruction is contraindicated.

       • Other reconstructive options
Breast reconstruction surgery
• Types:
  – Latissimus dorsi myocutaneous flap.

  – Transverse rectus abdominus myocutaneous
    (TRAM) flap.
References
• F. Charles Brunicardi, editor. Schwartz’s Principles of
  surgery. 9th ed. McGraw Hill; 2010. chapter 17.
• Fischer, Josef E, editors. Mastery of Surgery. 5th ed.
  Lippincott Williams & Wilkins; 2007. chapter 41-46A.
• DeVita, Vincent T, editors. DeVita, Hellman &
  Rosenberg's Cancer: Principles & Practice of Oncology.
  9th ed. Lippincott Williams & Wilkins; 2008. chapter 43
• Zollingers atlas of surgical operations. 8th ed.

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Mastectomy

  • 1. MASTECTOMY Presenter: Dr Janardhan T Post Graduate Moderator: Dr Prakash M Consultant surgeon
  • 2. Introduction • Definition: surgical removal of breast tissue partially or completely. • In a study conducted in 2004, – Highest mastectomies were done in Europe 60-70%. – USA- 56%. – Australia and New Zealand: 34%.
  • 3. Introduction • Most common carcinoma in women. – 1.3 million women/ yr are diagnosed to have carcinoma breast. – 77% of incidence seen in women > 50yrs. • 2nd most common cause of death due to carcinoma. – 555,000/yr deaths due to carcinoma breast.
  • 4. History • 549 A.D: court physician Aetius of Amida proposed to Theodora. • 1882: William Halsted- Radical mastectomy. • 1943: Patey and Dyson- Modified radical mastectomy. • 1981: Breast conservation surgery.
  • 5. When is mastectomy indicated ? • Women with carcinoma breast. • Men with carcinoma breast. • Extensive benign disease of breast. • Prophylactic. • No/ minimal response to systemic therapy to CA breast.
  • 7. Types of mastectomy 1. Total or simple mastectomy: – Removal of the entire breast tissue, – No dissection of lymph nodes or removal of muscle. – Sometimes adjacent lymph nodes are removed along with the breast tissue.
  • 8. Types of mastectomy 2. Modified Radical Mastectomy (MRM): – Removal of breast tissue and axillary lymph nodes. – No removal of pectoral muscle. – 3 modifications: a. Patey’s b. Scanlon’s. c. Auchincloss.
  • 9. Types of mastectomy 3. Halsted’s Radical Mastectomy: – Most extensive type. – Breast tissue, axillary lymph nodes and pectoral muscles are removed. – Disadvantages: • Bad scars and unacceptable deformity. • Reduced range of mobility of shoulder
  • 10. Types of mastectomy 4. Subcutaneous mastectomy: 5. Skin sparing mastectomy: – Simple mastectomy – Total/simple mastectomy or modified radical mastectomy sparing nipple. with preservation of as much – Rarely done, as a large as breast skin as possible amount of breast tissue is needed for breast left in situ. reconstruction. – Local recurrence is acceptable, 0-3%.
  • 11. Types of mastectomy 6. Breast conserving surgery: – Wide local excision/Lumpectomy – Quadrantectomy.
  • 12. Types of mastectomy 7. Extended radical 8. Toilet mastectomy: mastectomy: – Done in fungating or – Radical mastectomy + ulcerative growths. enbloc resection of internal mammary lymph nodes + – Palliative simple supraclavicular lymph mastectomy. nodes. – Obsolete.
  • 13. Which procedure is suitable for the given patient ? • Age • Menstrual status. • Size of the tumor • Size of the breast • Axillary lymph node status. • Availability of • Stage of the malignancy radiotherapy. • Biologic aggressiveness of the tumor • Patients choice. • Receptor status of the tumor. • Prophylactic/therapeutic/ • Multicentricity or multifocality palliative.
  • 14. Which procedure is best ? • When the tumor size is ≥ 1cm, becomes systemic. • No single method is considered better in terms of disease free survival or mortality. • Suitable local therapy + systemic therapy is the most appropriate approach.
  • 15. Which procedure is best ? • Loco-Regional therapy include: a. Surgery b. Radiotherapy • Systemic therapy: a. Chemotherapy b. Hormonal therapy c. Monoclonal antibodies. However surgery is important to get rid of gross cancer
  • 16. Pre-operative management • Triple assessment. • Metastatic workup. • Routine blood investigations. • Pre-anesthetic evaluation. • Control of medical conditions like diabetes and hypertension. • Counseling and written informed consent. • Parts preparation- neck to mid thigh including pelvic region, axilla and arm.
  • 19. TNM staging Stage Tumor Node Metastasis Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage IIA T0 N1 M0 T1 N1 M0 T2 N0 M0 Stage IIB T2 N1 M0 T3 N0 M0 Stage IIIA T0 N2 M0 T1 N2 M0 T2 N2 M0 T3 N1 M0 T3 N2 M0 Stage IIIB T4 N0 M0 T4 N1 M0 T4 N2 M0 Stage IIIC Any T N3 M0 Stage IV Any T Any N M1
  • 20. Operative procedures-Mastectomy 1. Simple mastectomy. 2. Modified radical mastectomy. 3. Breast conserving surgery.
  • 21. Operative procedure • Anesthesia – General anesthesia. • Position – The patient is placed in supine position with the arm abducted < 90 degree. – Sandbag or folded sheet is placed under the thorax and shoulder of affected side.
  • 22. Operative procedures- Simple Mastectomy • Indications: – Stage I and stage IIa carcinoma – Large cancers that persist after adjuvant therapy – Multifocal or multicentric CIS. • Incision: – Horizontal elliptical incision is marked so as to include the entire areolar complex. – Should be 1-2cm away from the tumor margins. – Skin sparing incision- if breast reconstruction is planned – Two skin edges should be of equivalent length
  • 24. Simple Mastectomy-procedure • Skin incision is deepened with electro-cautery. • A plane between breast fat and the subcutaneous fat, seen as white fibrous plane. • Dissection is carried in this plane and flaps are raised inferiorly and superiorly. • Ideally thickness of the flap should be 7-10mm.
  • 25. Simple Mastectomy-procedure • Extent of dissection: – Superiorly till clavicle, – Laterally till P.major lateral border – Medially to the sternal border, and – Inferiorly till infra-mammary fold • Breast tissue along with the pectoral fascia (controversial) is dissected from the P.major.
  • 26. Simple Mastectomy-procedure • Usually started superiorly and the proceeded clock-wise ending in the axillary region. • Care must be taken to ligate perforating branches of lateral thoracic and anterior intercostal vessels. • Lateral branches of the medial pectoral neurovascular bundle is carefully dissected while removing axillary tail. • Wound irrigated with sterile water to crenate (shrivel or shrink) cancerous cells. • Subcutaneous tissue is closed using 00 absorbable interrupted sutures. • Skin closed using 00 non-absorbable mattress sutures or using staples.
  • 27. Operative procedures- Modified radical Mastectomy • Indications: – LABC – Residual large cancers that persist after adjuvant therapy – Multifocal or multicentric disease. • Incision: – Oblique elliptical incision angled towards axilla. – Should include the entire areolar complex and previous scars, if present. – Should be 1-2cm away from the tumor margins. – Two skin edges should be of equivalent length
  • 28. Modified radical Mastectomy-procedure • Procedure till approaching axilla is same as simple mastectomy. • Extent of dissection: – Superiorly till clavicle, – Laterally till anterior margin of latissimus dorsi. – Medially to the sternal border, and – Inferiorly till the costal margin near the insertion of the rectus sheath.
  • 29. Modified radical Mastectomy-procedure • The specimen is retracted upwards and laterally to expose P.minor. • The dissection is continued to axillary lymph node clearance. • Care must be taken not to injure medial pectoral nerve and vessels. • The axillary investing fascia is incised to expose the axillary group of lymph nodes.
  • 30. Modified radical Mastectomy-procedure 1. Patey’s procedure: – The P.minor is removed for better visualization and easy dissection of level III lymph nodes. 2. Scanlon’s procedure: – P.minor is retracted to expose level III nodes and dissected out. 3. Auchincloss procedure: – Level I and II lymph nodes are cleared, level III nodes are left behind.
  • 31. Modified radical Mastectomy-procedure • The inter-pectoral (Rotter) group of lymph nodes are removed. • Then dissection can be done either from medial to lateral or vise- versa. • The loose lateral areolar tissue in axillary space is dissected to expose the axillary vein. • The investing layer of axillary vessels is cut, the tributaries are transfixed and cut. • Dissection is carried out laterally including lateral grp (level I) of lymph nodes.
  • 32. Modified radical Mastectomy-procedure • Thoracodorsal neurovascular bundle lies over the lat.dorsi, with nerve more laterally placed, subscapular (level I) nodes are removed. • The level II lymph nodes between superior trunk of intercostobranchial bundle and axillary vein are removed. • The central grp of lymph nodes are removed carefully separating from axillary vein and its tributaries. • While dissecting medially, long thoracic nerve is encountered, which lies anterior to the subscapular muscle. The dissection carried out anterior and medial to long thoracic nerve and the specimen delivered.
  • 33. Modified radical Mastectomy-procedure • Care must be taken while dissecting in axillary area to preserve, – Medial and lateral pectoral nerve. – Long thoracic vessels and nerve – Nerve to latissimus dorsi. – Axillary vein. • Wound irrigated with sterile water to shrink/crenate cancerous cells. • 2 drains, 1 below and other above P.major are secured. • Subcutaneous tissue is closed using 00 absorbable interrupted sutures. • Skin closed using 00 non-absorbable mattress sutures or using staples.
  • 35. Post-operative care • Wound examined on post-op day 3. • Drain can be removed when it is < 30ml. • Any collection is to be aspirated under aseptic precautions. • Staples can be removed after 10days. • Arm movements started in the 1st week.. • Active shoulder and upper limb exercises are started from 2 weeks
  • 36. Breast conserving surgery • Method: • Indications: – Wide local – Stage 0 (CIS), Stage I, excision/Lumpectomy Stage IIa breast or Quadrantectomy + carcinoma. axillary lymph node – Single lesion. clearance + radiotherapy. – Clinically downstaged LABC (controversial)
  • 37. Breast conserving surgery • Contraindications: • Advantages: – Multicentric tumor. – Maintenance of appearance – Positive margins after excision. and function of breast. – Size > 4cm (relative). – Disease free interval is same as – Advanced stages. MRM. – No assess to radiation/ poor patient compliance. – Better quality of life and – C/I for radiation: SLE/ Rheumatoid psychological advantage. arthritis/ Scleroderma/ pregnancy/ prior chest radiation.
  • 38. Breast conserving surgery-Procedure • Incision-circular/ radial/ subareolar incision near to the tumor, about 3-4cm. • Excision of the carcinoma tissue with a margin of atlaeast 1cm of normal breast tissue to get a 2-mm cancer-free margin. – If tumor is situated superficially then excision of that part of skin. – If tumor is deep then tumor is excised till pectoralis major. • Depending on post-surgical defect – Primary closure or – Reshaping of breast tissue is done.
  • 39. Breast conserving surgery- Lumpectomy • After skin incision, subcutaneous tissue is deepened using electric cautery. • While dissecting the breast tissue, better to use scalpel. • Care must be taken while dissecting to palpate the tumor, so that entire lesion is excised. Specimen radiography can be done to check for clear margins. • Hemoclips are applied along the margins of the cavity. • Wound closed in 2 layers: – Subcutaneous tissue with interrupted inverted 3-0 absorbable suture. – Skin with subcuticular 3-0 absorbable sutures.
  • 40. Breast conserving surgery-Procedure Quadrantectomy: • Usually done for lesion in the upper outer and inner lower quadrants. • Radial incision is taken. • Entire breast tissue in that quadrant is excised till pectoral fascia. • Wound closed in multiple layers: – Breast tissue with interrupted 3-0 absorbable suture. – Subcutaneous tissue with interrupted inverted 3-0 absorbable suture. – Skin with subcuticular 3-0 absorbable suture.
  • 41. Breast conserving surgery • Quadrantectomy v/s Lumpectomy. – Lumpectomy has more local recurrence risk. – Lumpectomy has better cosmetic outcome.
  • 42. Breast conserving surgery • After BCS, radiotherapy is essential, otherwise the local recurrence rate is unacceptably high • Without radiotherapy, the local recurrence can be as high as 40%
  • 43. Survival after BCS and Mastectomy Trial Endpoint Overall Survival Disease-free Survival CS&RT Mastect CS&RT Mastect NCI Milan 18 yrs 65% 65% N/A Institut Gustav 73% 65% N/A 15 yrs Roussy NSABP B-06 12 yrs 63% 59% 50% 49% NCI USA 10 yrs 77% 75% 72% 69% EORTC 8 yrs 54% 61% N/A Danish Breast 79% 82% 70% 66% 6 yrs Cancer Group
  • 44. Follow-up after breast conservation surgery • Mammogram at 6 months after radiotherapy • Clinical evaluation and mammogram every yearly then after. • If local recurrence detected, mastectomy must be done.
  • 45. Complications • Most Common, – Reduced ROM of the shoulder – Numbness – Lymphoedema – Pain
  • 46. Complications • Less common, – Hematoma – Skin flap necrosis – Fibrosis – Winging of scapula – Postural changes – Psychological implications – Chronic/phantom pain
  • 47. Breast reconstruction surgery • The most common reason of breast reconstruction surgery, is for psychological well being. • Reconstructive surgery post mastectomy can be either immediate or delayed. – Immediate • Skin sparing • Better outcomes – Delayed • When immediate reconstruction is contraindicated. • Other reconstructive options
  • 48. Breast reconstruction surgery • Types: – Latissimus dorsi myocutaneous flap. – Transverse rectus abdominus myocutaneous (TRAM) flap.
  • 49. References • F. Charles Brunicardi, editor. Schwartz’s Principles of surgery. 9th ed. McGraw Hill; 2010. chapter 17. • Fischer, Josef E, editors. Mastery of Surgery. 5th ed. Lippincott Williams & Wilkins; 2007. chapter 41-46A. • DeVita, Vincent T, editors. DeVita, Hellman & Rosenberg's Cancer: Principles & Practice of Oncology. 9th ed. Lippincott Williams & Wilkins; 2008. chapter 43 • Zollingers atlas of surgical operations. 8th ed.