conservative surgery for early breast cancer

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. Breast Cancer Lines of
Surgical Treatment
Hamed Rashad
Professor of surgery Banha faculty of
medicine - Egypt

3. Management of Ca Breast
Options available;
I. Surgery
II. Radiotherapy
III. Hormone Therapy
IV. Chemotherapy
Multi-pronged approach adopted
Single approach ineffectual

4. I. SURGICAL Approaches
1. Total (Simple) Mastectomy
2. Total Mastectomy with Axillary Clearance
3. Modified Radical Mastectomy [MRM]
1) Patey’s Operation
2) Scanlon’s Operation
3) Auchincloss’ MRM
4. Radical Mastectomy of Halsted
5. Conservative Breast Surgeries
1) Wide Local Excision [WLE]
2) Lumpectomy
3) Quadrantectomy
4) Toilet Mastectomy
5) Skin-Sparing/Keyhole Mastectomy [SSM]

5. 1. TOTAL/SIMPLE MASTECTOMY
Tissues removed:
Tumour, entire breast,
areola, nipple, skin over
breast, Axillary tail of
Spence, Pectoral fascia
Tissues retained:
NO Axillary Dissection
Subjected to Radiotherapy
later

6. 2. TOTAL MASTECTOMY
with
AXILLARY CLEARANCE
Common procedure
Tissues removed:
TM + Axillary fat,
Axillary fascia, Level
I and II Axillary LN

7. 3. MODIFIED RADICAL MASTECTOMY
1) Patey’s Operation
Tissues removed:
TM + Clearance of Level I, II
& III Axillary LN +
Pectoralis minor
Tissues preserved:
 Nerve to Serratus anterior,
Nerve to Latissimus dorsi,
Intercostobrachial nerve,
Axillary Vein, Cephalic
Vein, Pectoralis major

8. Procedure:
Elliptical incision made on medial aspect of 2nd and
3rd ICS enclosing the nipple, areola and tumour
which extends laterally into Axilla along the Anterior
Axillary fold. Upper and lower skin flaps are raised.
Breast with tumour is raised from the medial aspect
of Pectoralis major. Dissection is proceeded laterally
while ligating pectoral vessels.
In axilla, lateral border of Pectoralis minor is divided
from Coracoid process to clear Level II LN. Level III
cleared subsequently. Pectoralis minor removed

9. 3. MODIFIED RADICAL
MASTECTOMY
2) Scanlon’s Operation: Pectoralis
minor incised Level III LN removed
3) Auchincloss’ MRM: Pectoralis minor
left intact Level III LN not removed

12. 4. Radical Mastectomy of Halsted
Tissues removed:
Tumour, entire breast, areola, nipple, skin over
tumour, Pectoralis major & minor muscles, fat,
fascia, Level I,II,III Axillary LN, few digitations of
Serratus anterior muscle
Tissues retained:
Axillary vein Bell’s nerve (N.to Serr.ant) Cephalic vein
SR_Ca_Breast_Rx 13
Complications:
 Lymphoedema
 Lymphangiosarcoma (>3 years)

13. 5. Breast Conservative Surgeries
1. Wide Local Excision (WLE)/ 1Partial
Mastectomy Removal of unicentric tumour with 1cm
clearance margin. Incision: Over tumour + Axillary
Dissection + RT
2. Quadrantectomy: Removal of entire quadrant
with ductal system with 2-3cm normal breast tissue
clearance. Part of QUART Therapy
(Quadrantectomy + Axillary dissection + RT) Not
advocated now.
3. Skin Sparing Mastectomy
4. Lumpectomy (=WLE) Term rarely used

15. Other procedures
Toilet Mastectomy
In locally advanced tumour (LABC), tumour with
breast tissue removed – prevent fungation
 Post-chemotherapy
 Significance: (?)
Extended Radical Mastectomy
Radical Mastectomy + Removal of Internal Mammary
Nodes (ipsilateral +/- contralateral)
Not done at present

16. Complications Of M.R.M/Mastectomy
 Injury/ Thrombosis of
Axillary Vein
 Seroma
 Shoulder Dysfunction
 Pain and Numbness
 Flap Necrosis and
infection
 Lymphoedema and its
problems
 Axillary hyperaesthesia
 Winged Scapula

17. Lymphangiosarcoma (Stewart-
Treve’s Syndrome)
 In ipsilateral upper limb
 Develops in people with
Lymphoedema after
Mastectomy with Axillary
clearance.
 3-5 years after development
of Lymphoedema
 Presentation: Multiple
subcutaneous nodules
 Requires Forequarter
Amputation
 Poor prognosis

18. Early Carcinoma Breast [ECB] -
Management
 Breast Conservation Surgery – Wide Local
Excision/ QUART/SSM; RT locally
 Patey’s Operation [MRM]
 Tamoxifen 10mg BD
 Sentinel Lymph Node Biopsy [SNLB]
 Regular follow-up with
Radioisotope Bone scan
CEA tumour marker

19. Early Carcinoma Breast [ECB] -
Management
Indications for Total Mastectomy in EBC;
 Tumour size >5cm
 Multicentric tumour
 High-grade (poorly-differentiated) tumour
 Tumour margin not clear after BCS

20. Advanced carcinoma breast
Refers to;
 Locally Advanced
Carcinoma Breast [LACB]
 Inflammatory Ca Breast
 Bilateral Ca Breast
 Metastatic Ca Breast
 Fixed axillary/supra-
clavicular LN

21. Advanced carcinoma breast
LACB
 Neoadjuvant Chemotherapy
 Response assessment
 Non-responders: RT + Surgery
 Responders: Surgery (Toilet Mastectomy/MRM)
Inflammatory Ca Breast
 ‘Mastitis carcinomatosis’/ ‘Lactating Ca of Breast’ T4d
LACB (Stage IIIB)
 Neoadjuvant ChemoT and RT
 Surgery (if downstaged) + Axillary clearance

22. Metastatic Ca Breast
Hematogenous spread to;
 Bone: most common. Vertebra – Batson’s
(valveless) venous plexus and posterior intercostal
veins, Ribs, Humerus, Femur
 Lungs – ‘Cannon-ball’ 20 in parenchyma, Pleural
effusion, Chest wall 20
 Liver
 Brain

23. Metastatic Ca Breast
Treatment strategies;
 Chemotherapy: CMF/CAF
 Radiotherapy
 Tamoxifen, Oophorectomy
 Transtuzumab, Bevacizumab
 Hypercalcemia – Hydration, steroids,
Palmidronate 90mg i.v once a month
 Internal fixation of pathological #

24. Carcinoma Breast in
Pregnancy - Management
1st Trimester
 MRM
 Axillary node +’ve:
Termination of pregnancy +
Chemotherapy
2nd trimester
MRM
Chemotherapy carefully
3rd trimister
 MRM
 After delivery –
Chemotherapy with
suppression of lactation

25. Carcinoma Breast in
Pregnancy - Management
Note the following;
 Hormone treatment contra-indicated:
Teratogenic
 Radiotherapy: No role
 MRI is the investigation of choice
 Can become pregnant 2 years after
completion of therapy as recurrence rates
are highest in 2 years

26. Follow-up
 Clinical examination in detail @ regular
intervals
 Yearly/2-yearly Mammography of the
treated and contralateral breast is a must
 Bone-scan, CT Chest/abdomen, tumour
markers are done only if there is clinical
suspicion. Not a regular routine follow-up at
present

27. FOLLOW-UP
 Regular follow-up examinations are needed
– Early detection of recurrent or new cancer,
allowing timely intervention.
– Identification of any complications and
appropriate interventions where indicated
 Examinations and Mammography are the
standard follow up methods.

28. Frequency of examination
 Every 3 to 6 months, for first 3 years
 Every 6 months, from 3 to 5 years
 Yearly after 5 years.

29. THAK YOU