Transcript Breast Cancer Surgery 2004

Breast Cancer Surgery 2004
William A. Barber, M.D.
Piedmont Hospital
Breast Cancer Screening
Case Report
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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
Case Report
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US confirmed the
existence of 3.5 cm
mass
Core biopsy showed a
poorly differentiated
carcinoma
Diagnosing Breast Cancer:
Abnormal Mammograms
Suspicious
Calcification
Benign Appearing
Calcifications
Breast Cancer Rules
Rule #1:
 There is no difference in survival between
Mastectomy and Lumpectomy
Breast Cancer Rules
Rule #2:
 If you have a lumpectomy, you also need
Radiation Therapy
Breast Cancer Rules
Rule #3:
 The operation you chose has nothing to
do with whether or not you will need
chemotherapy.
Breast Cancer Rules
Rule #4:
 Most Mastectomy patients do not need
Radiation Therapy.
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.
Breast Cancer Rules
Rule #6:
 Whether or not you need chemotherapy
is determined by
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The size of the primary tumor
How aggressive is the primary tumor
Lymph node status
Age of the patient
Partial Mastectomy
(Lumpectomy)
Versus Mastectomy
How do you chose?
Partial Mastectomy
(Lumpectomy)
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Contraindications
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A. Previous history of Radiation Therapy
B. More than one cancer in same breast
C. Large tumor, small breast, cosmetic
deformity
D. Nipple involvement
Surgery Terms
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Excisional Biopsy vs. Lumpectomy
Partial Mastectomy vs. Lumpectomy
Incisional Biopsy
Mastectomy
Difference between
Total (simple) Mastectomy
Modified Radical Mastectomy
Skin Sparing Mastectomy
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Skin sparing
mastectomy
preserves the
majority of the breast
skin and the
inframammary fold
The entire nipple and
areola are removed
Radical Mastectomy
Is Radical Mastectomy still in
use?
 What is it?
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Subcutaneous Mastectomy
Is Subcutaneous Mastectomy a
cancer operation?
 How does it differ from Total
Mastectomy?
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Sentinel Node Biopsy
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Major advance
Almost no risk of lymphedema
Blue dye
Nuclear medicine
Sentinel Lymph Node Biopsy
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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
Reconstruction
Tissue expander
 Latissimus dorsi
 TRAM
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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.
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.
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.
Breast Reconstruction in the
Skin Sparing Mastectomy
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TRAM flap
Latissimus flap
Implant/Expander
Silicone is preferred
and is available on
study protocol
Tram flap with nipple reconstruction and tatooing
When to Consult?
Medical Oncology
 Radiation Oncology
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Chemotherapy
What is NeoAdjuvant
Chemotherapy?
 When is it used?
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Mammotome Biopsy
Minimally Invasive Excisional
Biopsy: Whats New?
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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)
Mammosite
Radiation source
port pathway
Inserted obturator to
prevent bending or
coiling of the catheter shaft
Multilumen, silicone catheter
Variable 4 to 5 cm balloon
Needleless injection site
Mammosite
Mammosite Placement
Time of Lumpectomy
Post-lumpectomy
Open Cavity
Ultrasound Guided
Scar Entry (SET)
CT Image of Mammosite
3-Dimensional rendering of applicator surface