Surgery plays an important role in the treatment of breast cancer. The main goals of surgical treatment are complete removal of the primary tumor and determination of lymph node involvement. Mastectomy is recommended for large or multicentric tumors while breast-conserving surgery such as lumpectomy is preferred when possible. Sentinel lymph node biopsy is the standard method for staging axillary lymph nodes in clinically node-negative patients. Reconstruction options after mastectomy include implants, TRAM flaps, and latissimus dorsi flaps. Overall, mastectomy and breast-conserving surgery have been shown to have equivalent survival outcomes when combined with radiation or chemotherapy.

1. ROLE OF SURGERY IN
CARCINOMA
BREAST
By-
DR NISHI KUMARI
MS GENERAL SURGERY
NALANDA MEDICAL COLLEGE

2. INTRODUCTION
 BREAST CANCER IS SECOND LEADING
CAUSE OF CANCER RELATED DEATHS IN
THE WORLD
 AS FAR AS ROLE OF SURGERY IS
CONCERNED OUR AIM IS ….
TO CLEAR THE PATIENT OF THE
LOCO REGIONAL DISEASE

3. TREATMENT FOR BREAST
CANCER IS GUIDED BY
Pathology of
the tumor
Staging of
tumor
And more
recent
insights into
breast
cancer
biology

4.  EMPHASIS IS LAID ON :-
DEFINING DISEASE BIOLOGY AND
STATUS IN INDIVIDUAL PATIENTS, WITH
SUBSEQUENT TAILORING OF THERAPIES.

5.  Surgery for carcinoma breast has travelled
from a halstedian era to era of breast
conservative surgery….
but the aim still remains the same…
and that is LOCOREGIONAL CONTROL of
the disease .

6. Surgical principles FOR
MANAGEMENT OF CA BREAST
 Complete eradication of the primary tumor
 Determination of involvement of regional
nodes and metastasis ifany
 Wide excision with radiation therapy for local
tumors
 Mastectomy being recommended for a
multicentric/largertumors.

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

8. Imporatant definitions
• Removal of entire breast tissue,nipple areola
complex,p.major and p.minor muscles and axillary
lymph nodes
Radical
mastectomy(halsted)
• Removal of entire breast tissue,nipple areola
complex
• And axillary lymph node level 1 and 2
Modified radical
mastectomy
• Removal of the totality of the glandular
• breast tissue with overlying skin ellipse
• and nipple-areola complex (no axillary
• surgery)
Simple mastectomy

9. • Removal of the totality of the glandular
breast tissue ,removal of nipple areola
complex with preservation of skin
envelope overlying the breasrt(followed
by immediate reconstruction)
Skin-sparing
mastectomy
(SSM)
• Removal of entire breast tissue with
preservation of nipple areola complex
and skin envelope
Nipple-sparing
mastectomy (NSM)
or total skin-sparing
mastectomy
(TSSM)

10. Radical mastectomy of halsted
 William stewart halsted was the first to
perform and clearly document radical
mastectomy in US at john hopkins hospital
in 1882
 Until mid 1970’s halsted mastectomy was
the standard of care for surgical treatment
of breast cancer

11. 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
Tissues retained:
Axillary vein
Bell’s nerve (N.to Serr.ant)
Cephalic vein

12.  Currently ,early diagnosting imaging and
education with chemo,hormone and
radiotherapy have existentially eliminated the
need for classical halsted radical mastectomy

13. MODIFIED RADICAL
MASTECTOMY
 NSABP B-04 trials in 1971 proved that there
was no survival advantage conferred by
radical mastectomy when compared to MRM
either for clinically node negative or node
positive breast cancer
 Most acceptable and most widely practised
surgery
In present era

14. Modified radical mastectomy
 Advantages over radical mastectomy:
 Good postoperative cosmetic
appearance
 Maintain motor activity in the arm
 Low rate of postoperative arm oedema
 Easy postoperative breast
reconstruction

15. TYPES OF MRM
• P.Major muscle is preserved
• P.Minor muscle along with level 1,2 and 3 of axillary
nodes removed
PATEYS MRM
• P.Minor muscle is divided and not removed
• All three level of lymphnodes are removed
SCANLONS
MRM
• P.Minor is retracted and not divided
• Only level 1 and 2 lymph nodes are removed
• Auchincloss’ Modified Radical Mastectomy is widely
practicednowadays
AUCHINCLOSS’
MRM

16.  Three important structures should be
preserved durin MRM :
1.Axillary vein
2.Bell’s nerve(long thoracic nerve)
3.Cephalic vein

17. MRM
Limits of the modified radical mastectomy are delineated
laterally by the anterior margin of the latissimusdorsi muscle,
medially by the sternal border,
superiorly by thesubclavius muscle, and
inferiorly by the caudal extension of thebreast approximately 3 to 4 cm inferior to the
inframammary fold.
Skin flaps for the modified radical technique are planned with relation to the quadrant in
which the primary neoplasm is located.
Adequate margins are ensured by developing skin edges 3 to 5cm from the tumor
margin. Skin incisions are made perpendicular to the subcutaneous plane. Flap
thickness should vary with patient body habitus but ideally should be 7 to 8 mm thick.
Flap tension should be perpendicular to the chest wall with flap elevation deep to the
cutaneous vasculature, which is accentuated by flap retraction.

18. PRE OP POSITIONING
MRM STEPS

19. MARKING BEFORE SURGERY

20. FIRST INCISION

21. SKIN FLAP ELEVATED WITH HOOKS

22. LIMIT OF DISSECTION IS LATISSIMUS
DORSI

23. MEDIAL SKIN FLAP DEVELOPED

24. DEVELOPMENT OF SKIN FLAPS

25. PECTORAL FASCIA INCISED
INFEROMEDIALLY

26. DISSECTION IN CEPHALAD DIRECTION

27. FULLY MOBILIZED BREAST TISSUE

28. BREAST REMOVED

29. CLAVIPECTORAL FASCIA OPENED

30. AXILLARY FAT PAD EXPOSED

31. AXILLARY VEIN EXPOSED

32. LONG THORACIC NERVE

33. AXILLARY SAMPLING

34. THORACODORSAL NEUROVASCULAR
PEDICLE

35. AXILLARY FAT PAD EXCISED

36. DIVISION OF SUBCAPSULAR VESSELS

37. SUCTION DRAINS PLACED MEDIALLY AND
LITERALLY

38. SKIN CLOSURE

39. BREAST CONSERVATIVE
THERAPY
 SHOULD BE PERFORMED :
IF TECHNICALLY POSSIBLE
 PATIENTS PREFERENCE
 AND NO C/I….TWO ABSOLUTE
CONTRAINDICATIONS FOR BCS BEING-
 FAILURE TO ACHIEVE NEGATIVE MARGINS
WITHOUT CAUSING BREAST DEFORMITY
 AND
 INFLAMMATORY CARCINOMA BREAST

40. BCS
 MOST IMPORTANT RISK FACTORS FOR
LOCAL RECURRENCE AFTER BCS-
 POSITIVE MARGINS AND
 YOUNG PATIENT AGE

41.  THESE DAYS BCS IS ASSOCIATED WITH
DECREASED RISK OF RECURRENCE COZ OF
 IMPROVED PATIENT SELECTION
 BETTER QUALITY SURGERY
 BETTER HISTOPATH EVALUATION OF
RESECTED MARGIN
 USE OF TUMOR BED RADIOTHERAPY
BOOST
 EXTENSIVE USE OF SYSTEMIC
ADJUVANT TREATMENT AND MORE
EFFECTIVE CHEMO REGIME

42. CHECKLIST FOR PLANNING
BCS
 The extent and the location of the primary tumour
 The size of the breast
 The density of the breast parenchyma and the grade of ptosis of
 the breast
 The BMI and the body confrontation of the patient (very skinny,
 slim, normal, obese, very obese)
 Previous breast surgeries
 Tumour biology – especially when considering neoadjuvant
 treatment
 Contraindications to radiotherapy
 The age and comorbidities of the patient
 Family history of the patient
 Patient preference

43. BCS
1.Wide Local Excision (WLE)/ PartialMastectomy
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 ofQUART Therapy (Quadrantectomy +
Axillarydissection + RT) Notadvocated now.
3.Skin Sparing Mastectomy
4.Lumpectomy (=WLE)
Term rarely used
SR_Ca_Breast_

44. AXILLARY SURGERY
 Presence of metastatic disease within axillary
lymph nodes is still the best single marker for
prognosis.
 In early breast carcinoma, if there is no
clinically apparent nodes and the disease is
not multicentric, then sentinel nodebiopsy is
considered.
 Otherwise Complete Axillary Dissection is
done

45. SLNB
 STANDARD METHOD FOR STAGING OF
AXILLA IN CLINICALLY NODE NEGATIVE
PATIENTS OF BREAST CANCER
 IF SLN FRE FROM CANCER, NO AXILLARY
LYMPH NODE DISSECTION NEEDED

46. PROCEDURE FOR SENTINEL
LYMPHNODE BIOPSY
 SLN can be detected either by radioactive Tc-99m
labelled sulphur colloid or Isosulfan blue dye.However
combination of both gives better results.
 Radioactive colloid is injected in subareolar region or
near the primary tumour; 2-24 hours before the
surgery.
 Isosulfan blue dye is injected at the time of surgery in
the same region.
 A hand held gamma camera is used to identify the
location of SLN.

47. 3-4cm transverse incision is given just below the hairline of
axilla.
Blunt dissection is done to visualise the dye containing
lymphatics which are traced to locate the SLN.
The SLN is removed and send for histopathological
examination

48. BREAST RECONSTRUCTION
 Women undergoing mastectomy can be
offered immediate or delayed reconstruction of
breast
 Patient counselling and patient selection are
very important steps in planning breast
reconstruction

49. METHODS OF
RECONSTRUCTION
 Easiest type of reconstruction – a silicone gel
implant under the pectoralis major muscle
 If skin at mastectomy site is poor (following
radiotherapy) or larger volume of tissue is
required
:- a musculocutaneous flap can be
constructed

50.  Types of musculocutaneous flap-
 LD FLAP
 TRAM FLAP (gives excellent
cosmetic result)
 DIEP FLAP (variation of tram
flap requiring less muscle harvesting…based
on deep inferior epigastric vessels) is
increasingly being used

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

53. 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

54. 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

55. Woman with Lattisimus Dorsi muscle in
place.

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

57. conclusion
 According to Two large trials (NSABP) and
MILAN 1 trial
 MASTECTOMY AND BREAST
CONSERVING THERAPY HAVE BEEN
SHOWN TO BE EQUIVALENT IN TERMS OF
PATIENT SURVIVAL , AND THE CHOICE OF
SURGICAL TREATMENT IS INDIVIDUALIZED
.

58.  In the era of minimal access surgery, role of
surgery is still pivotal in management of
carcinoma breast
&
 A complete locoregional control of the disease
should be aimed for in management of
carcinoma breast