Surgical Management of Surgical Management of Carcinoma BreastCarcinoma Breast

Dr. Sumer yadav

The achievements in the surgical management of breast cancer .The modern era of the management of breast cancer began with the popularization of the Radical Mastectomy (RM) by Halsted W in1894. It was based on the theory of local breast disease, which spread through lymphatics to axilla nodes.The failure of RM to cure many patients was initially thought to be because of failure to remove all of the draining lymphatics.In 1950 it was assessed that a quarter of lymph is drained to internal mammary nodes.Extended Radical Mastectomies were established. But the results of prospective randomized trials showed no benefit of Extended Radical versus Halsted Mastectomy in disease-freeand overall survival.Meir P, Ferguson D, Harrison T. Cancer 1985Urban J. Cancer 1978

Heritage… Heritage…

Types of surgery used now-a-days

Breast conservative surgery

Radical surgery

Reconstructive surgery

Breast conservation Breast conservation surgerysurgery

Includes resection of primary tumor by any mean

+ assessment of axillary L. N. status

+adjuvant radiation therapy for all cases except low grade DCIS <0.5cm in diameter.

Indications of breast Indications of breast conservation surgeryconservation surgery

• Small breast Ca < 4cm

• Breast volume adequate size to allow uniform dosage of irradiation

• Radiation therapist experience to avoid damage of retained breast

Absolute contraindicationsAbsolute contraindications

First or second trimester of pregnancyTwo or more gross tumors in two

different quadrants (multicentricity)Diffuse malignant appearing tumormicrocacification. Prior radiation therapy to breast or

chest wall.Involved surgical margins or unknown

margin status for re-excision.

Relative contraindicationsRelative contraindications

Large tumor / breast ratio.Central tumors.Large pendulous breast.Collagen vascular (connective

tissue) diseases.Age.Extensive In-Situ Carcinoma (EIS).

LumpectomyLumpectomywide excision biopsy,wide excision biopsy,limited breast surgery, limited breast surgery, wide excision of the breast, wide excision of the breast, segmental excision of the breastsegmental excision of the breast

IndicationsDuctal carcinoma in situ (DCIS)Stage IStage II

Lumpectomy cont…Lumpectomy cont…

involves removing the cancerous breast lump and a surrounding margin of normal breast tissue.

A separate incision may be required to include a sampling or removal of the axillary lymph nodes. 

As all breast conservation surgery additional radiotherapy is given.

Adjuvant chemotherapy and hormonal therapy is given.

QUART TherapyQUART Therapy

Quadrant excision (for tumor limited in particular quadrant of breast) quadrant of breast tissue, skin and superficial pectoralis fascia excised

+ Axillary clearance + Radiotherapy Unacceptable cosmetic result

Subcutaneous Subcutaneous MastectomyMastectomy

Indicated in- Premalignant diseases of breast

as lobular CIS Comedo carcinoma Intracystic carcinoma.Nipple is retained.

Stereotactic surgery or Stereotactic surgery or StereotaxyStereotaxy

Recent advances in breast surgery for CIS

Mainly used for biopsy for non palpable suspected lesion

In this radiofrequency wire are attached to the suspected site and digital mammography image is taken.

Dual mode stereotactic localization method and application may be used.

Radical surgeryRadical surgery

Skin sparing mastectomySkin sparing mastectomy

Horizontal elliptical incision given All breast tissue + NAC (nipple

areolar complex) and 1 cm of skin is removed.

Indicated for stage 2 tumors.

Simple or total mastectomy Simple or total mastectomy Same as skin sparing surgery except

clearance of skin is same as tumor.Indicated for 1.low grade carcinoma as stage 2 or 3. 2.large cystosarcoma phyllodes• Types:- Crile – Total mastectomy Mc Whirter – Total mastectomy and radiation

(Axilla, supraclavicular and internal mammary nodes)

Extended simple mastectomy Extended simple mastectomy

Done for low grade tumors. Oblique elliptical incision is

given extending in axilla.Removes all breast tissue + NAC

+skin + level 1 L.N.Axillary L.N. is removed for

sampling.

Radical mastectomyRadical mastectomyFirst done by Willi Meyer Halsted.Oblique elliptical incision is given

extending in axillaRemoval of all breast tissue + NAC +

skin +level 1,2 and 3 lymph nodes + pectoralis major + P. minor muscles.

Rarely done now-a-days due to more morbidity & mortality.

Indicated for muscle and chest wall involvement. (stage 4 cancer)

Extended Radical Extended Radical MastectomyMastectomy

Indicated in tumors with positive lymph nodes other than axilla.

Hardly 21% of outer quadrant and 44% inner quadrant tumor has (+) internal mammary nodal involvement.

1. Wangesteen (Classical RM + Internal mammary mediastinal and supraclavicular LN)

2. Urban (CRM + ipsilateral half of sternum, part of 2nd to 5th rib and pleura and internal mammary LN)

Modified Radical Modified Radical MastectomyMastectomy

1.Patey modification:-

• most common mastectomy procedure for invasive breast cancer

• Oblique elliptical incision is given extending in axilla

• include removal of

Entire breast, NAC, skin, level 1 2 & 3 L.N.

Pectoralis minor muscle is removed or divided at it’s insertion on coracoid process.

2.Madden / Auchincloss modification–

preserved both the pectoralis major and minor

Modified radical mastectomy Modified radical mastectomy stepssteps

Preop positioning.

marking

Marked

First incision

Skin flap elevated with hooks

Palpation of skin flap

Limit of dissection is Lattisimus Dorsi.

Medial skin flap developed.

Development of skin flaps.

Pectoral fascia incised inferomedially.

Dissection in cephalad direction.

Dissection encounters biopsy cavity.

Rim of pectoralis major removed.

Base of excised muscle.

Fully mobilized breast tissue.

Breast removed.

Clavipectoral fascia opened.

Axillary fat pad exposed.

Axillary vein exposed.

Long thoracic nerve.

Axillary nerves.

Axillary sampling.

Thoracodorsal neurovascular pedicle.

Axillary fat pad excised.

Division of the subscapular vessels.

Closed suction drains placed medially and

laterally.

Skin closure.

Criteria of Criteria of Inoperability/IncurabilityInoperability/Incurability (Haangensen)(Haangensen)

a) Extensive edema of the skin over the breastb) Satellite nodule in the skin over the breastc) Inflammatory carcinoma of the breastd) Parasternal tumor nodulee) Supraclavicular metastasis f) Edema of the armg) Distant metastasish) Any 2 or more of the following locally advances cancer

i. Ulceration of skinii. Edema of skin less 1/3iii. Solid fixation of tumor to the chest walliv. Axillary LN 2 cm or morev. Fixation of axillary LN to skin and deep structure

Therapeutic Approach for Therapeutic Approach for Breast CancerBreast Cancer

1. Carcinoma in Situ:DCIS:-Breast conserving surgery

Lobular Carcinoma in Situ:a. Observation after diagnostic biopsyb. Bilateral prophylactic total mastectomy w/o axillary

dissection

2. Stage I & II :- Modified radical mastectomy

3. Advance Stage 3 & 4:- MRM or Extended Radical Mastectomy

Therapeutic Approach for Breast Therapeutic Approach for Breast CancerCancer4. Inflammatory Breast Carcinoma:

◦ 3 – 5% 5 year survival◦ Main role of surgery is in the diagnosis◦ Primary therapy is chemotherapy and radiotherapy and if

possible surgery (mastectomy).CAF ----- regression ------> extended mastectomy (level I) ----------> irradiation of axillary and skin flap (30% - 5 yr survival)

5. Breast Cancer and Pregnancy/Lactation:◦ The risk of aggressive and distant metastasis is profound

due to high level of estrogen and progesterone secreted from the placenta and corpus luteum.

◦ Lactation should be suppressed promptly, even if biopsy was benign because milk from transected lactiferous will drain via the biopsy site

◦ If patient is undergoing radiotherapy and chemotherapy for breast CA, advice patient not to get pregnant. ( advice not to use contraceptive pills).

Treatment: MRM / Segmental resection + radiation (after delivery) (+) axillary ---> chemotherapy is delayed on the 2nd trimester

(single agent) 11 – 12% teratogenicity on 1st trimester.

Therapeutic Approach for Breast Therapeutic Approach for Breast CancerCancer6. Breast Cancer in Men:

◦ Factors: a. Klinefelter syndromeb. Estrogen therapyc. Testicular feminizing syndromesd. Irradiatione. Trauma

◦ Age: 60-70y/o◦ s/sx: breast mass, nipple retraction and/or discharge,

ulceration and pain.◦ Commonly ER positive and well differentiated◦ Prognosis is similar w/ female◦ Treatment:

MRM + radiation if with ulceration and high grade Orchiectomy / chemotherapy

Reconstruction surgeryReconstruction surgery

1. Breast reconstruction

2. Maintenance of breast shape

3. Reconstruction of nipple

4. Fulfillment of bony defect

1.Breast reconstruction :- 1.Breast reconstruction :-

To fill the wound after surgery byAbdominal flaps TRAM flap:-single pedicle, double

pedicle, free flap, deep inferior epigastric artery perforator flap

Upper abdominal horizontal flap Vertical abdominal flap Tubed abdominal flap

Lattisimus Dorsi myocutaneous flap

Gluteal flap superior or inferior based

Rubens flapThoracoepigastric flapLateral thigh flapBreast splitting procedures

TRAM Transverse Rectus TRAM Transverse Rectus Abdominis myocutaneous flapAbdominis myocutaneous flap

Based on thoracodorsal artery primilarily accompanying with posterior intercostal artery.

Indications1.Breasts of all sizes2.Breast ptosis

Contraindications Smoking Abdominal liposuction Previous abdominal surgery Pulmonary disease Obesity Unable to tolerate long procedure or stay

Woman with lines of trans–rectus abdominis muscle (TRAM) reconstruction incisions.A lines of reconstructed breast incisions

C line of abdominal surgery incision

A mastectomy siteB right trans rectus abdominis muscleC left trans rectus abdominal muscleD segment of abdominal tissues: skin and fat, to be transferred along with muscle to create the new breast

A lines of reconstructed breast incisionsB right trans rectus abdominis muscleC left TRAM muscle is swung over to re–create the new breastD incision circleE line of abdominal surgery

Lattisimus Dorsi Lattisimus Dorsi myocutaneous flapmyocutaneous flap

Based on deep inferior epigastric artery. Indications Small breasts Minor breast ptosis Abdominal donor site unavailable Salvage of previous breast reconstruction

Contraindications Previous lateral thoracotomy Planned postop radiotherapy Bilateral reconstruction Significant breast ptosis Very large breast.

Woman with Lattisimus Dorsi muscle in place.

Woman with Lattisimus Dorsi muscle swung forward to re–create the new breast.A Lattisimus Dorsi muscle in new location to re–create breast.

Maintenance of breast shapeMaintenance of breast shapeUse of expandable tissue

expanders.Alloplastic Silicone gel implant Silicone implant with saline fill Silicon injectionsCombined procedures Lattisimus Dorsi flap with implant TRAM flap with implant

Side view of breast area with unfilled tissue expander in place.

A tissue expander–unfilled B port C catheter D syringe E ribs F pectoralis major muscle

G Other muscles of the chest wall

Side view of breast area with filled tissue expander in place labels.

A tissue expander–filled B port C catheter D syringeE ribs F pectoralis major muscle

G Other muscles of the chest wall

3.Reconstruction of nipple:-primilarily or using prosthetic nipple.

4.To fulfill the bony defect of chest wall :-

• If 2 or <2 ribs excised fulfill by soft tissue flap.

• If >2 ribs excised fulfill the gap with Marlex mesh than cover with soft tissue flap.

Thank youThank you