1. BCT: Towards Optimal Outcomes
Dr VIJAY HARIBHAKTI
Consultant Surgical Oncologist,
Jaslok Hospital and Breach Candy Hospital, Mumbai, India
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2. SHIFTING PARADIGMS Past to present
Fundamental understanding of disease
Approach to patient
Stage at presentation
Diagnostic Methods
Surgery
Adjuvant therapy
Reconstruction

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

4. 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

5. 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

6. 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)

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

8. BCT : High risk medial quadrant disease

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

10. 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

11. BCT: Result at One Year

12. BCT : Radial incision for 6 o’clock T2 lesion

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

14. 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

15. 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

16. 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

17. 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

18. TECHNIQUE : Sonographic Localization

19. BCT : Operative Technique
Specimen

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

21. BCT : Quadrantectomy & L.Dorsi flap

22. 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

23. 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

24. BCT : Closure Technique

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

26. BCT : Young patient with T1 N2 disease

27. BCT : Long-term result – T3N2 disease

28. 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