surgical anatomy of breast & management of advanced carcinoma breast
Management of carcinoma breast2013
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Transcript of Management of carcinoma breast2013
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