BCT: Towards Optimal Outcomes Dr VIJAY HARIBHAKTI Consultant Surgical Oncologist, Jaslok Hospital and Breach Candy Hospital, Mumbai, India These Power Point presentations are free to download only for academic purposes, with due acknowledgements to authors and this website.

SHIFTING PARADIGMS Past to present Fundamental understanding of disease Approach to patient Stage at presentation Diagnostic Methods Surgery Adjuvant therapy Reconstruction

BCT Stage at Presentation Clinically obvious Clinically occult, demonstrable on mammography / sonography Mammographically occult, demonstrable by other modalities, i.e. MRI, PET

BCT: Is there any debate? Not if we understand the fundamental biology of disease Not if we exercise appropriate case selection Clearly not when we follow the results of RCTs

BCT: When? Patient desire Single primary tumour Able to achieve clear margins Tumour: Breast ratio that permits acceptable cosmetic result Able to deliver PORT Able to maintain follow-up

BCT: When not? Multiple primary tumours in separate quadrants Diffuse suspicious microcalcifications on mammography Inability to achieve negative margins Inability to deliver PORT (age & fitness, breast configuration, previous RT, pregnancy, collagen disease)

BCT: Essential Goals Excellent Local Control Comparable with mastectomy Acceptable Aesthetics: Adequate substance, contour, nipple-areola: breast relationship, symmetry No compromise in survival

BCT : High risk medial quadrant disease

BCT: Fundamental Principles Appropriate incision plan for primary Discontinuous axillary incision Resecting ‘exactly enough’ tissue Appropriate closure technique Appropriate post-operative breast support

BCT: Primary Incision Plan Directly over localized mass Adequate in length to achieve satisfactory lateral margins Curvilinear and parallel to areola for upper and lateral quadrant masses Radial incisions for inner central and lower quadrants

BCT: Result at One Year

BCT : Radial incision for 6 o’clock T2 lesion

BCT: Axillary incision Discontinuous in majority Preferably in available crease line Preferably below follicle line Horizontal, between axillary folds Invisible in frontal view

BCT: Resecting ‘exactly enough’ Key to a good result Often necessary to employ USG: Disparity in clinical / sonographic size Surrounding mastitis / desmoplasia ‘Indistict’ palpable margins Achieve accurate ‘three-dimensionality’ of margins Avoid ‘excess’ tissue removal in any plane

BCT: Technique – Palpable lesions Accurately marked incision Preserve subcutaneous fat to maintain contour Maintain ‘digital vigilance’ for margins Progress along all lateral margins one by one Maintain lesion at the centre of the specimen Tag base of axcision with radio-opaque clips

BCT: Technique: Wire-localized lesions Adequate understanding with radiologist Gain accurate 3-D idea about hook position Place incision over hook, NOT through wire entry point Resect all around hook Remove specimen with hook in its centre

BCT: Specimen Management Must remove as a single piece Accurate orientation for pathologist: Place marking sutures at 12 and 3 o’clock positions and ink deep margin Ensure inking of entire specimen by pathologist Gain information on 6 margins Adequate fixation technique for evaluation of receptors

TECHNIQUE : Sonographic Localization

BCT : Operative Technique Specimen

BCT: Extended Indications Large lateralised lesions Overlying skin resection needed Quadrantectomy able to achieve satisfactory margins Reconstruction optimal: Commonly with pedicled L.dorsi flap

BCT : Quadrantectomy & L.Dorsi flap

BCT: Re-excision Indications: Margins with gross microscopic tumour Margin status unknown Questionable, for focally positive margin Method: Incision reopened, fluid evacuated Systematic palpation of cavity walls Appropriate cavity walls excised to 1 cm thickness using knife New margin surface marked with sutures

BCT: Closure and post-op care No drains No deep sutures Accurate approximation of sub-cutaneous fat Subcuticular closure Steri-strip support to wound Supportive garment post-operatively

BCT : Closure Technique

BCT: Results Over 10-year experience: 200 cases 2 local failures (both advised mastectomy after BCT but refused) No significant complications Uniform patient satisfaction

BCT : Young patient with T1 N2 disease

BCT : Long-term result – T3N2 disease

BCT: Conclusions BCT is here to stay Must be offered in all indicated cases Careful attention to technique Vigilant systemic management Careful long-term follow-up