The document summarizes the history and current practices of surgical management of breast cancer. It discusses: 1) The evolution from radical mastectomy to more conservative breast-conserving surgery and modified radical mastectomy based on evidence that removal of all breast tissue did not improve survival outcomes. 2) The types of breast surgery now commonly used including lumpectomy, quadrantectomy, mastectomy, and reconstructive surgeries using tissue expanders, implants, or flaps. 3) The indications and contraindications for different surgical procedures based on tumor size and location.

1. Surgical Management of
Carcinoma Breast
Dr. Sumer yadav

2. The achievements in the surgical management of
breast cancer .
The modern era of the management of breast
cancer began with the popularization of the Radical
Mastectomy (RM) by Halsted W in1894. It was based
on the theory of local breast disease, which spread
through lymphatics to axilla nodes.
The failure of RM to cure many patients was initially
thought to be because of failure to remove all of the
draining lymphatics.
In 1950 it was assessed that a quarter of lymph is
drained to internal mammary nodes.
Extended Radical Mastectomies were established.
But the results of prospective randomized trials
showed no benefit of Extended Radical versus
Halsted Mastectomy in disease-free
and overall survival.
Meir P, Ferguson D, Harrison T. Cancer 1985
Urban J. Cancer 1978
Heritage…

3. Types of surgery used now-a-days
 Breast conservative surgery
 Radical surgery
 Reconstructive surgery

4. Breast conservation surgery
 Includes resection of primary tumor by
any mean
+ assessment of axillary L. N. status
+adjuvant radiation therapy for all cases
except low grade DCIS <0.5cm in
diameter.

5. Indications of breast
conservation surgery
• Small breast Ca < 4cm
• Breast volume adequate size to
allow uniform dosage of
irradiation
• Radiation therapist experience
to avoid damage of retained
breast

6. Absolute contraindications
 First or second trimester of pregnancy
 Two or more gross tumors in two different
quadrants (multicentricity)
 Diffuse malignant appearing tumor
 microcacification.
 Prior radiation therapy to breast or chest
wall.
 Involved surgical margins or unknown
margin status for re-excision.

7. Relative contraindications
 Large tumor / breast ratio.
 Central tumors.
 Large pendulous breast.
 Collagen vascular (connective tissue)
diseases.
 Age.
 Extensive In-Situ Carcinoma (EIS).

8. Lumpectomy
wide excision biopsy,
limited breast surgery,
wide excision of the breast,
segmental excision of the breast
Indications
 Ductal carcinoma in situ (DCIS)
 Stage I
 Stage II

9. Lumpectomy cont…
 involves removing the cancerous breast lump
and a surrounding margin of normal breast
tissue.
 A separate incision may be required to include
a sampling or removal of the axillary lymph
nodes.
 As all breast conservation surgery additional
radiotherapy is given.
 Adjuvant chemotherapy and hormonal therapy
is given.

10. QUART Therapy
 Quadrant excision (for tumor limited in
particular quadrant of breast) quadrant
of breast tissue, skin and superficial
pectoralis fascia excised
 + Axillary clearance
 + Radiotherapy
 Unacceptable cosmetic result

11. Subcutaneous
Mastectomy
 Indicated in-
Premalignant diseases of breast as
lobular CIS
Comedo carcinoma
Intracystic carcinoma.
 Nipple is retained.

12. Stereotactic surgery or Stereotaxy
 Recent advances in breast surgery for
CIS
 Mainly used for biopsy for non palpable
suspected lesion
 In this radiofrequency wire are attached
to the suspected site and digital
mammography image is taken.
 Dual mode stereotactic localization
method and application may be used.

13. Radical surgery

14. Skin sparing mastectomy
 Horizontal elliptical incision given
 All breast tissue + NAC (nipple areolar
complex) and 1 cm of skin is removed.
 Indicated for stage 2 tumors.

15. Simple or total mastectomy
 Same as skin sparing surgery except
clearance of skin is same as tumor.
 Indicated for
1.low grade carcinoma as stage 2 or 3.
2.large cystosarcoma phyllodes
• Types:-
Crile – Total mastectomy
Mc Whirter – Total mastectomy and radiation (Axilla,
supraclavicular and internal
mammary nodes)

16. Extended simple mastectomy
 Done for low grade tumors.
 Oblique elliptical incision is given
extending in axilla.
 Removes all breast tissue + NAC
+skin + level 1 L.N.
 Axillary L.N. is removed for sampling.

17. Radical mastectomy
 First done by Willi Meyer Halsted.
 Oblique elliptical incision is given
extending in axilla
 Removal of all breast tissue + NAC + skin
+level 1,2 and 3 lymph nodes + pectoralis
major + P. minor muscles.
 Rarely done now-a-days due to more
morbidity & mortality.
 Indicated for muscle and chest wall
involvement. (stage 4 cancer)

18. Extended Radical Mastectomy
Indicated in tumors with positive lymph
nodes other than axilla.
Hardly 21% of outer quadrant and 44%
inner quadrant tumor has (+) internal
mammary nodal involvement.
1. Wangesteen (Classical RM + Internal
mammary mediastinal and
supraclavicular LN)
2. Urban (CRM + ipsilateral half of sternum,
part of 2nd to 5th rib and pleura and
internal mammary LN)

19. Modified Radical Mastectomy
1.Patey modification:-
• most common mastectomy procedure for
invasive breast cancer
• Oblique elliptical incision is given extending in
axilla
• include removal of
 Entire breast, NAC, skin, level 1 2 & 3 L.N.
 Pectoralis minor muscle is removed or divided
at it’s insertion on coracoid process.

20. 2.Madden / Auchincloss
modification–
preserved both the pectoralis
major and minor

21. Modified radical mastectomy
steps

22. Preop positioning.

23. marking

24. Marked

25. First incision

26. Skin flap elevated with
hooks

27. Palpation of skin flap

28. Limit of dissection is Lattisimus
Dorsi.

29. Medial skin flap developed.

30. Development of skin flaps.

31. Pectoral fascia incised
inferomedially.

32. Dissection in cephalad
direction.

33. Dissection encounters biopsy
cavity.

34. Rim of pectoralis major
removed.

35. Base of excised muscle.

36. Fully mobilized breast
tissue.

37. Breast removed.

38. Clavipectoral fascia
opened.

39. Axillary fat pad exposed.

40. Axillary vein exposed.

41. Long thoracic nerve.

42. Axillary nerves.

43. Axillary sampling.

44. Thoracodorsal neurovascular
pedicle.

45. Axillary fat padexcised.

46. Division of the subscapular
vessels.

47. Closed suction drains placed
medially and laterally.

48. Skin closure.

49. Criteria of Inoperability/Incurability
(Haangensen)
a) Extensive edema of the skin over the breast
b) Satellite nodule in the skin over the breast
c) Inflammatory carcinoma of the breast
d) Parasternal tumor nodule
e) Supraclavicular metastasis
f) Edema of the arm
g) Distant metastasis
h) Any 2 or more of the following locally advances cancer
i. Ulceration of skin
ii. Edema of skin less 1/3
iii. Solid fixation of tumor to the chest wall
iv. Axillary LN 2 cm or more
v. Fixation of axillary LN to skin and deep structure

50. Therapeutic Approach for Breast
Cancer
1. Carcinoma in Situ:
DCIS:-Breast conserving surgery
Lobular Carcinoma in Situ:
a. Observation after diagnostic biopsy
b. Bilateral prophylactic total mastectomy w/o axillary
dissection
2. Stage I & II :- Modified radical mastectomy
3. Advance Stage 3 & 4:- MRM or Extended
Radical Mastectomy

51. Therapeutic Approach for Breast Cancer
4. Inflammatory Breast Carcinoma:
◦ 3 – 5% 5 year survival
◦ Main role of surgery is in the diagnosis
◦ Primary therapy is chemotherapy and radiotherapy and if possible
surgery (mastectomy).
CAF ----- regression ------> extended mastectomy (level I) ---------->
irradiation of axillary and skin flap (30% - 5 yr survival)
5. Breast Cancer and Pregnancy/Lactation:
◦ The risk of aggressive and distant metastasis is profound due to high
level of estrogen and progesterone secreted from the placenta and
corpus luteum.
◦ Lactation should be suppressed promptly, even if biopsy was benign
because milk from transected lactiferous will drain via the biopsy site
◦ If patient is undergoing radiotherapy and chemotherapy for breast
CA, advice patient not to get pregnant. ( advice not to use
contraceptive pills).
Treatment:
 MRM / Segmental resection + radiation (after delivery)
 (+) axillary ---> chemotherapy is delayed on the 2nd trimester (single
agent) 11 – 12% teratogenicity on 1st trimester.

52. Therapeutic Approach for Breast Cancer
6. Breast Cancer in Men:
◦ Factors:
a. Klinefelter syndrome
b. Estrogen therapy
c. Testicular feminizing syndromes
d. Irradiation
e. Trauma
◦ Age: 60-70y/o
◦ s/sx: breast mass, nipple retraction and/or discharge,
ulceration and pain.
◦ Commonly ER positive and well differentiated
◦ Prognosis is similar w/ female
◦ Treatment:
 MRM + radiation if with ulceration and high grade
 Orchiectomy / chemotherapy

53. Reconstruction surgery
1. Breast reconstruction
2. Maintenance of breast shape
3. Reconstruction of nipple
4. Fulfillment of bony defect

54. 1.Breast reconstruction :-
To fill the wound after surgery by
 Abdominal flaps
TRAM flap:-single pedicle, double
pedicle, free flap, deep inferior epigastric
artery perforator flap
Upper abdominal horizontal flap
Vertical abdominal flap
Tubed abdominal flap

55.  Lattisimus Dorsi myocutaneous flap
 Gluteal flap superior or inferior
based
 Rubens flap
 Thoracoepigastric flap
 Lateral thigh flap
 Breast splitting procedures

56. TRAM Transverse Rectus Abdominis
myocutaneous flap
 Based on thoracodorsal artery primilarily accompanying
with posterior intercostal artery.
 Indications
1.Breasts of all sizes
2.Breast ptosis
 Contraindications
 Smoking
 Abdominal liposuction
 Previous abdominal surgery
 Pulmonary disease
 Obesity
 Unable to tolerate long procedure or stay

57. Woman with lines of trans–rectus abdominis muscle (TRAM)
reconstruction incisions.
A lines of reconstructed breast incisions
C line of abdominal surgery incision

58. A mastectomy site
B right trans rectus abdominis muscle
C left trans rectus abdominal muscle
D segment of abdominal tissues: skin and fat, to be transferred along
with muscle to create the new breast

59. A lines of reconstructed breast incisions
B right trans rectus abdominis muscle
C left TRAM muscle is swung over to re–create the new breast
D incision circle
E line of abdominal surgery

60. Lattisimus Dorsi myocutaneous
flapBased on deep inferior epigastric artery.
 Indications
 Small breasts
 Minor breast ptosis
 Abdominal donor site unavailable
 Salvage of previous breast reconstruction
 Contraindications
 Previous lateral thoracotomy
 Planned postop radiotherapy
 Bilateral reconstruction
 Significant breast ptosis
 Very large breast.

61. Woman with Lattisimus Dorsi muscle in place.

62. Woman with Lattisimus Dorsi muscle swung forward to
re–create the new breast.
A Lattisimus Dorsi muscle in new location to re–create
breast.

63. Maintenance of breast shape
 Use of expandable tissue expanders.
 Alloplastic
Silicone gel implant
Silicone implant with saline fill
Silicon injections
 Combined procedures
Lattisimus Dorsi flap with implant
TRAM flap with implant

64. Side view of breast area with unfilled tissue expander in place.
A tissue expander–unfilled B port C catheter D syringe E ribs
F pectoralis major muscle
G Other muscles of the chest wall

65. Side view of breast area with filled tissue expander in place labels.
A tissue expander–filled B port C catheter D syringe
E ribs F pectoralis major muscle
G Other muscles of the chest wall

66. 3.Reconstruction of nipple:-primilarily or
using prosthetic nipple.
4.To fulfill the bony defect of chest wall :-
• If 2 or <2 ribs excised fulfill by soft
tissue flap.
• If >2 ribs excised fulfill the gap with
Marlex mesh than cover with soft tissue
flap.

67. Thank you