Breast Cancer Surgery 2004 William A Barber M

Breast Cancer Surgery 2004 William A. Barber, M. D. Piedmont Hospital

Breast Cancer Screening

Case Report n n 45 y. o patient with two children ages 10 and 13 Mother had breast cancer at age 65 Gail 5 yr risk score 1. 7 Undergoes yearly mammograms CC View of Mammogram May 2001 3. 5 cm Mass Upper Outer Quadrant CC View of Mammogram April 2002

Case Report n n US confirmed the existence of 3. 5 cm mass Core biopsy showed a poorly differentiated carcinoma

Diagnosing Breast Cancer: Abnormal Mammograms Suspicious Calcification Benign Appearing Calcifications

Breast Cancer Rules Rule #1: n There is no difference in survival between Mastectomy and Lumpectomy

Breast Cancer Rules Rule #2: n If you have a lumpectomy, you also need Radiation Therapy

Breast Cancer Rules Rule #3: n The operation you chose has nothing to do with whether or not you will need chemotherapy.

Breast Cancer Rules Rule #4: n Most Mastectomy patients do not need Radiation Therapy.

Breast Cancer Rules Rule #5: n If you have a lumpectomy and you have positive lymph nodes, you do NOT need to go back and have a Mastectomy.

Breast Cancer Rules Rule #6: n Whether or not you need chemotherapy is determined by n n The size of the primary tumor How aggressive is the primary tumor Lymph node status Age of the patient

Partial Mastectomy (Lumpectomy) Versus Mastectomy How do you chose?

Partial Mastectomy (Lumpectomy) n Contraindications n n A. Previous history of Radiation Therapy B. More than one cancer in same breast C. Large tumor, small breast, cosmetic deformity D. Nipple involvement

Surgery Terms n n n Excisional Biopsy vs. Lumpectomy Partial Mastectomy vs. Lumpectomy Incisional Biopsy

Mastectomy Difference between n. Total (simple) Mastectomy n. Modified Radical Mastectomy

Skin Sparing Mastectomy n n Skin sparing mastectomy preserves the majority of the breast skin and the inframammary fold The entire nipple and areola are removed

Radical Mastectomy Is Radical Mastectomy still in use? n What is it? n

Subcutaneous Mastectomy Is Subcutaneous Mastectomy a cancer operation? n How does it differ from Total Mastectomy? n

Sentinel Node Biopsy n n Major advance Almost no risk of lymphedema Blue dye Nuclear medicine

Sentinel Lymph Node Biopsy n n Quickly becoming the gold standard May be as accurate or more accurate than ALN dissection while limiting the complications and costs Involves injection off Technitium-99 sulfur colloid and or 1% isosulfan blue dye Multiple ongoing trials including B-32 NSABP

Reconstruction Tissue expander n Latissimus dorsi n TRAM n

Reconstruction: Tissue expander Encapsulated silicone implant reconstruction corrected with tissue expansion. The capsule is first excised, and the tissue expander is used to create an oversized pocket for the implant.

Reconstruction: Latissimus Dorsi A, Preop view: 67 -YO following MRM. B, Postop view: following left autogenous latissimus reconstruction w/o implant. Opposite breast reduction mammoplasty required for symmetry.

Reconstruction: TRAM A & B, Preop & Postop views following left free TRAM reconstruction. Skin replacement included all skin between scar & inframammary fold. Nipple reconstruction, opposite mastopexy done at separate procedure.

Breast Reconstruction in the Skin Sparing Mastectomy n n TRAM flap Latissimus flap Implant/Expander Silicone is preferred and is available on study protocol Tram flap with nipple reconstruction and tatooing

When to Consult? Medical Oncology n Radiation Oncology n

Chemotherapy What is Neo. Adjuvant Chemotherapy? n When is it used? n

Mammotome Biopsy

Minimally Invasive Excisional Biopsy: Whats New? n n Ultrasound guided directional vacuum assisted breast biopsy with 11 g and 8 g mammotome Introduced in 1996 these devices use vacuum to draw the tissue into a chamber and a rotating cutter dissects the specimen (Mammotome)

Mammosite

Radiation source port pathway Inserted obturator to prevent bending or coiling of the catheter shaft Multilumen, silicone catheter Variable 4 to 5 cm balloon Needleless injection site

Mammosite

Mammosite Placement Post-lumpectomy Open Cavity Time of Lumpectomy Ultrasound Guided Scar Entry (SET)

CT Image of Mammosite 3 -Dimensional rendering of applicator surface