1. Surgery for Breast Cancer
Thomas Fisher
March 2002

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

3. 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

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

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

6. 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

7. 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

8. 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

9. 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

10. 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

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

12. Skin Incision

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

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

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

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

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

18. 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

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

20. 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

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

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

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

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

25. 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

26. 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

27. 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

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

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

30. 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

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