In The Name of God

Asieh S. Fattahi M.D. Surgical Oncologist Assistant Professor of Surgery Department of Surgery,Ghaem Hospital Mashhad University of Medical Sciences Jan 2011

Breast cancer treatment needs multidisciplinary approach and team Good relation between radiologists,Pathologists, Surgeons, Medical oncologists and radiotherapist is needed to choose the best treatment options for every patients Trained nurses needed to help patient and physician in diagnosis and treatment Supportive group and programs are needed to increase information of patient and her quality of life

With progress in screening modality breast cancer will detected in earlier stage and it can be treated more than before so: New techniques and modalities are used in diagnosis and treatment of breast cancer

Before 1990 Frequency of DCIS : unusual Biopsy: Surgical Molecular biology :minimal understanding Treatment: Mastectomy Reconstruction: None/Delayed After Common -needle - Rapid knowledge growth - Breast conservations -immediate

Ductography -Nipple Discharge specially bloody N.D of contrast media is injected and Mamo are obtained -Irregular mass or filling defects maybe be signs of cancer -most of the time Intra ductal Papilloma Ductoscopy for Nipple Discharge -New technical improvement allow intraductal biopsy -in Bloody Nipple increase risk of cancer detections -can used specially in high risk patients -helps having better clean margin with lumpectomy

Sonographic guided biopsy mass is present Mammography guided biopsy and Streotactic biopsy micro calcifications are presents MRI guided biopsy when MRI indicated

wire localized Needle Biopsies Non palpable mass, Micro calcifications With mass wire insert via ultrasound guidance,and with calcifications via mammography guidance

With increase of screening mamo,the number of non palpable lesions increase Localization of lesion with wire guided surgeon to excise the exact lesion and helps to less aggressive resection with good results It can be used for helping in lumpectomies for better cosmetic and trapuetic results If one or two margins will be positive after lumpectomy reexcision will be done

Breast Conservation surgeries (lumpectomy or partial Mastectomy) Mastectomy Radical Modified Radical Mastectomy (MRM) Extended simple mastectomy Simple mastectomy Skin sparing mastectomy Nipple areola sparing mastectomy

breast conservation surgeries # oncoplastic breast surgeries long term follow up has confirmed that lumpectomy with radiations provides survival equivalent to mastectomy Technical improvement in lumpectomy and radiation techniques have reduced local recurrence rate (2-5 % at 10 years) radiotherapy has no added morbidity for patient

Lumpectomy with assessment of axillary lymph node status and Radiotherapy: In early breast cancer,stage I & II In selected locally advanced patients can be used after neoadjuvant chemotherapy and downsize of tumor ¾ of breast cancer patients are eligible for BCT in USA At least 2mm free margin needed

From 87 articles review: In larger lesions or smaller breast the removal of adequate volumes of breast tissue to achieve better tomour free margins and reduce risk of local recurrence may compromise cosmetic outcome. New surgical techniques so called oncoplastic surgery have been introduced Neoadjuvant chemo and oncoplastic surgery have reduced the indications of mastectomy

Reconstructions for partial mastectomies ONCOPLASTIC SURGERIES Different methods of mamoplasty used to fill defects after wide lumpectomies,and re-excision and makes better cosmetic resuls they extended indications for more conservstive resection instead of mastectomy

Simple reshaping Breast reduction techniques Local tissue arrengements Pedicled flaps …. Negative margins with frozen section Marking the tumor place with clips for radiotherapy

Patients who desire this kind of surgery Multifocal lesions Diffuse ductal carcinoma insitu Recurrence after BCT Mutations of BRCA1& 2 Involved surgical margins after re-excision Sclrederma or other connective tissue disorder Prior radiation to breast and chest wall

Skin Sparing Mastectomy mastectomy with resection of nipple and areola and preservation of skin for immediate reconstruction biopsy site will be excised 1cm around scar T1-T3 cancers Good cosmetic results,less than 2% recurrence No more increase in recurrence There is no local,regional,or systemic risk with this technique

Nipple Areola Sparing Mastectomy subcutaneos mastectomy with preservation of NAC (nipple areola complex) in selected patients there are some risks of recurrence in NAC one choice: in prophylactic mastectomy Or in T1 & periferal tumors _ In some trials they use this technique with intra operative radiotherapy for reduction in risk of recurrence

Meta-analysis: Comparison : 1104 skin sparing mastectomy + immediate reconstruction 2653 MRM without reconstruction In stage I & II No significant different in local recurrence with a better cosmetic results ANN SURG 2010;251:632

Prophylactic mastectomies simple bilateral mastectomy and immediate reconstruction is used in some patients with strong family history and BRCA1 or BRCA2 mutations if patient selects prophylactic mastectomy because of higher risk of breast cancer in this group --Prophylactic Oophorectomy and hormone replacement therapy must consider after child bearing ages

Radio Frequency Ablation of a breast lesion Cry ablation Focused ultrasound

RFA is accomplished by heat generated from high frequency alternating the friction generated heat from ion movement in the tissue causes increasing levels of cell damage A single prong or an array prongs deployed from a probe

Small studies Complete ablation 80 – 100 % With ultrasound guidance Focus on T1 dis. Ablation fallowed with immediate or late resections Imaging expertise required Disadvantage:extent and completeness of ablation can not be evaluated by RFA without resection RFA with resection improves more negative margins after lumpectomy and decreases need for re-excision

Created an elliptical ice ball as argon gas flows through the needle percutaneousely placed into the lesion Uses US guidance FDA approved this for core biopsy-proven fibroadenomas Effective and safe,can be used with local anesthesia

Some studies used this for small invasive ductal carsinoma (T=1-1.5) the presence of DCIS limits the success of US-guided cryoablations

FUS is a thermal ablation technique that uses focused US beams to penetrate through soft tissues to targeted the lesions Some studies used it in fibroadenoma and invasive breast cancers less than 3.5 cm with 78-96% success rate

Sentinel Lymph node Biopsy (SLNB) Axillary Lymph Node Dissection (ALND) Axillary radiation

Axillary dissection - in clinically node + patient and after SLN+ will be done - the number of involved node is the most important factor in survival -There are some morbidity with that Pain,Arm edema, risk of nerve injury,sarcoma (rare), …..

SLN Mapping is standard method for staging axilla in patients with clinically node negative breast cancer,T1,T2 early breast cancer. Mapping has allowed us to be selective about which patients have completion axillary dissection

Time :The day before or in the morning of surgery place:Intradermal, or sub dermal, peritumoral or periareolar injection of radicolloid (Tc – SC 99) 1 ml will be done In OR injection of blue dye (Lymphazurine,patent blue,Methilene blue) can be used for increase the rate of finding SLN

Mapping lable: Radioisotope or blue dye alone or combonation can be used Combination improves SLN detection rate Blue dye:disadvantage is 1-3 %allergic reactions Methylene Blue has been used similar to blue dye :lower cost,lower allergic rate Radioisotope dose mCi : -Technetium-99m sulfur colloid is used in US - Tc 99 m-colloidal albumin is used in Europe

Recently several studies have shown that axillary radiation is an effective treatment in clinically node negative patients with less morbidity Local recurrence 3-7%(with ALND 2-5%)

Ether Dome in MGH the 3th oldest hospital in USA The place for first surgery with general anesthesia in the world