Surgery for Breast Cancer Thomas Fisher March 2002

History Hippocrates Galen Systemic disease “best not to excise hidden cancer” Galen Excess of black bile Excision of tumour

History Hunter Virchow Local inflammation arising from systemic injury Defect in lymph Virchow Local disease spread along lymphatic channels Amenable to cure by local therapy

History Halsted Local disease that spread to regional nodes Surgery for cure Radical mastectomy Breast Pectoral muscles Axillary contents

Local vs Systemic Disease Local disease Spread from breast to nodes Nodes as barrier, then metastasis Local intervention affects patient outcome

Local vs Systemic Disease 30% of node negative patients die from metastatic disease Nodal metastasis not indicator of delay in diagnosis but a marker of breast cancer phenotype Positive nodes indicate risk of metastasis rather than instigator

Local vs Systemic Extent of surgery doesn’t dictate overall survival NSABP-04 trial Treatment of axilla at time of primary surgery had no effect on survival Local therapy for local control

Treatment of the Breast Breast Conserving Surgery NSABP-06 trial Now followed 15 years No difference in survival between modified radical mastectomy vs lumpectomy Radiotherapy to remaining breast to decrease local recurrence

Treatment of the Breast Breast Conserving Surgery Margin 5-10mm with good cosmesis All microcalcification removed Normal duct epithelium between DCIS and margin Regular follow-up If DCIS seen without calcification, consider mastectomy

Treatment of the Breast Mastectomy Patient choice Tumour size vs breast size (>4cm) Multi-centric disease (> 1 quadrant) Positive margins after WLE Wider excision first

Mastectomy Position Incision supine,arm extended transverse elliptical to oblique extending to incorporate axillary dissection based over tumour to ensure margins enable primary closure

Skin Incision

Mastectomy Skin flaps elevate skin perpendicular to plane of dissection under tension plane deep to subcutaneous vessels avoid button-holing skin

Mastectomy Skin flaps Margins: medially to midline superiorly to subclavius inferiorly to lower border laterally to lat dorsi

Mastectomy Dissection from medial to lateral Diathermy Deep dissection to include pectoral fascia Perforating vessels may need to be oversewn

Mastectomy Dissection continues into axilla Haemostasis Irrigation with water Drain to axilla and chest wall Closure in two layers

Wide local Excision Position Incision Supine, arm extended Skin crease curvilinear Circumareolar if tumour central Ellipse of skin if tumour close to skin

WLE Skin flaps Incision deepened Deep flaps raised Retraction with cat’s paws retractor Incision deepened Retractors replaced with larger ones Excision of mass with 1cm margin Excise to fascia

WLE Specimen removed and marked Haemostasis Closure without closing cavity No drain

WLE Needle-localized lesion Two wires to localize X-rays for reference in theatre Skin-crease incision over “target” Excision of tissue incorporating wire tips Specimen marked X-ray confirmation

Breast Reconstruction Surgery Preservation of skin flaps Immediate reconstruction Various methods: TRAM flap Lat. dorsi flap Expandable implant Nipple reconstruction

Treatment of the Axilla Staging and prognostic information Local control No effect on survival Level I II or III dissection Related to pect. minor

Treatment of the Axilla Level II dissection Adequate tissue (>10 nodes) Less morbidity Lymphoedema in level III ?overtreating 60% of patients Node negative group

Axillary Dissection Continuation of dissection in mastectomy Separate incision in WLE Inferior axillary skin crease Transverse incision From Pect. Major to Lat. dorsi

Axillary Dissection Medially incise clavipectoral fascia along Pect. major Dissect deep to Pect. Minor and elevate Identify axillary vein at apex Dissect lateral to medial clipping vessels as encountered

Axillary Dissection Identification of thoracodorsal nerve Identification of long thoracic nerve Intercostobrachial nerve Preserve, if possible Dissect tissue from nerve If nodes clinically involved take nerve

Axillary Dissection Continue to sweep tissue inferiorly & laterally Identify anterior border of Lat. dorsi Remove specimen & mark apex Irrigation & haemostasis Closure in 2 layers over drain

Treatment of the Axilla Sentinel lymph node biopsy Sampling of 1-4 nodes Prognostic information Spares morbidity of dissection ? Will replace ALND Trials continue

SLNB Pre-op lymphoscintigraphy Isosulphan blue dye Intra-op gamma camera Detection of draining node(s) and removal

Treatment of Breast Recurrence After BCS g Mastectomy After Mastectomyg If small may be amenable to local excision g Larger areas more difficult to treat

Treatment of Metastatic Disease Liver metastasis Rarely amenable to resection Lung Usually multiple Bone Fixation to prevent fracture