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

2. Breast Cancer Screening

3. Case Report 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
3.5cm Mass Upper
Outer Quadrant
CC View of Mammogram April 2002

4. Case Report US confirmed the existence of 3.5 cm mass
Core biopsy showed a poorly differentiated carcinoma

5. Diagnosing Breast Cancer: Abnormal Mammograms
Benign Appearing
Calcifications
Suspicious
Calcification

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

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

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

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

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

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

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

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

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

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

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

17. Is Radical Mastectomy still in use? What is it?

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

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

20. Sentinel Lymph Node Biopsy
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

21. Tissue expander Latissimus dorsi TRAM
Reconstruction
Tissue expander
Latissimus dorsi
TRAM

22. 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.

23. 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.

24. 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.

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

26. Medical Oncology Radiation Oncology
When to Consult?
Medical Oncology
Radiation Oncology

27. What is NeoAdjuvant Chemotherapy? When is it used?

28. Mammotome Biopsy

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

30. Mammosite

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

32. Mammosite

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

34. CT Image of Mammosite 3-Dimensional rendering of applicator surface
Refer to text on slide
3-Dimensional rendering of applicator surface