TNM staging halstead radical mastectomy modified radical mastectomy breast conservation surgeries skin sparing mastectomy nipple sparing mastectomy oncoplastic surgery

1. SURGERIES FOR
BREAST CARCINOMA
By
Dr .P.Monikha

4. Distant metastasis:
•MX-cannot be assessed
•M0-no distant metastasis
•M1-distant metastasis
(including mets to I/L
supraclavicular lymph
nodes )

5. • Early Breast Cancer(EBC): Stage I & II –BCS + RT + Sentinel
lymph node biopsy or simple / total mastectomy with axillary
clearance
• Locally Advanced Breast Cancer(LABC): Stage IIIA & IIIB
–NACT + MRM + RT
• Metastatic Breast Cancer: Stage IV –Hormonal >
chemotherapy
• Hormonal –ER / PR +ve
asymptomatic visceral metastasis
bone /soft tissue metastasis
• Chemo –ER /PR –ve
symptomatic visceral metastasis
hormonal therapy refractory

6. Adjuvant Chemo –
maximize distant
disease-free survival
radio-maximize
locoregional disease
free survival
neoadjuvant-
chemo- decrease
the locoregional
cancer burden

8. • Halsted radical mastectomy – first procedure
INDICATIONS:
•Advanced stage refractory to CT and RT (IIIa , IIIb, IIIc)
•Fixation to muscle,skin changes
•Advanced locoregional disease
•Large, bulky recurrences, especially for posterior lesions that recur with
fascial or muscle fixation
•Prior therapy with total breast irradiation and / or multimodality cytotoxic
therapy

9. Procedure :
•Incision –classical orr and stewart
•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

10. Technique :
•Along with tumor specimen
•Pectoralis major is transected at its insertion over humeral end and
rotated medially
•Pectoralis minor exposed –digital elevation –avoid injury to axillary
vein and transected
•Anterior thoracic (pectoral) nerve penetrates p.minor before giving
brances to major –ligated posteriorly
•Both major and minor elevated
•Lateral thoracic nerve ligated as move medially
•Superiomedial dissection continues and medial attachment of major
has to be removed
•Multiple perforator vessels identified and ligated
•Inferomedial traction –axilla is fully exposed

11. • Pectoralis minor is divided at its origin in the sternocostal joint
• Rotters nodes swept enbloc and visualisation of axillary vein till
clavipectoral fascia
• Level III LN (subclavicular, apical ) dissected
• Tendinous insertion of latissimus dorsi–dissection of axillary vein
starts
• Level I(lateral) cleared
• Thoracodorsal vessels ,nerve has to be secured
• Level I (subscapular) cleared
• Subscapularis muscle exposed –medial to teres minor
• Central nodes dissected
• External mammary nodes dissection –medial and contiguous with
axillary tail of spence

12. • Long thoracic nerve
–preserved
• Dissection from superior
to inferior –specimen is
removed

13. • Tissues retained: Axillary vein
Bell’s nerve (N.to Serr.ant)
Cephalic vein
• Complications: Lymphoedema ; Lymphangiosarcoma (>3 years)
• Procedure abandoned – patients died of metastatic breast cancer even after
more extensive surgical procedure
• This led to multimodality Treatment ( chemotherapy
hormonal therapy
adjuvant radiotherapy)
• Radical mastectomy vs total mastectomy,with or without RT :
• Clinically negative nodes pts were taken –mode and timing of axillary nodes
does not alter the DFS or OS
• Clinically positive nodes –DFS or OS is equivalent to node –ve pts

14. Indications of mastectomy :
•Multifocal DCIS
• Stage I,IIa, IIb, IIIa ,IIIb
• Tumors that are large relative to breast size
• Tumors with extensive calcifications on mammography / multicentricity
• Tumors for which clear margins cannot be obtained on wide local excision
• Collagen vascular diseases
• Prior radiation
• Bulky axillary LN involvement
• Pregnancy ( first or second trimester )
• Prophylactic mastectomy for familial or high risk women (reduce risk >90%)

15. Contraindications:
•Non palpable or small tumors
•Advanced disease with distant metastasis
•Who wants reconstructive surgeries
•Need of improved cosmetic result
•Co existing severe systemic diseases like CHF , CRF

16. MODIFIED RADICAL MASTECTOMY :
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

17. • Scanlon’s Operation: Pectoralis minor divided instead of removing
Level III LN removed
• Auschincloss’ MRM: Pectoralis minor left intact
Level III LN not removed
 Higher chance of medial pectoral nerve preservation
 Reduce arm swelling

18. Classic stewart incision –central and
subareolar primary lesions
Modified stewart –inner quadrant lesions

19. Classic orr incision –upper outer
quadrant
Variant of orr incision –lower inner and
vertically placed lesions

20. Upper inner quadrant primary lesions
Lower outer quadrants

21. Lesions that are high
lying, infraclavicular or
fixed to pectoralis major
muscle

22. • Incision for MRM
• Acheive 3 to 5 cm free margin
• Boundaries of MRM:
laterally-anterior margin of latissmus
dorsi
medially-midline of sternum
superiorly-subclavius
inferiorly-3 to 4 cm below inframammary
fold

23. Technique of MRM:
• Supine
• Rolled towels-nonrestrictive elevation of I/L hemithorax and
shoulder – shoulder movement not compromised
• Boundaries of MRM
• Breast parenchyma and Pectoralis major fascia elevated-till
lateral edge of p.major
• Lateral thoracic or anterior intercostal arteries-ligated
• Medial pectoral nerve-preserve (if possible)
• Axillary lymph node dissection
• Pectoralis minor muscle is defined and interpectoral nodes are
removed

25. • Lateral axillary space is eleveted-lateral extent of axillary vein
• Ligation and division of the tributaries of axillary vein
• Lateral pectoral nerve –preserve
• Anteroventral surface of axillary vein –dissection of loose areolar tissue at the
junction of axillary vein and anterior margin of latissimus dorsi –lateral LN
(I Level)
• Thoracodorsal artery,vein and nerve –preserved
• Lateral and subscapular axillary lymph nodes(level I) removed –anterior to
thoracodorsal neurovascular bundle
• Posterior contents of axillary space exposed
• Laterally-head of teres major
Medially –subscapularis
• Medial dissection; anterior to subscapularis –long thoracic nerve –preserve
• Level II(central) lymph nodes below the axillary vein –removed

26. • If level III lymphadenopathy is present –patey modification is done
• Pectoralis minor is divided or removal of muscle is done –coarcoid process
• Apical axillary lymph nodes (level III) –removed
• Axillary vein full extent can be visualized–drains into subclavian vein beneath
the costoclavicular ligament
• Specimen –HPE and immunohistochemistry
• Surgical bed irrigated with saline or sterile water
• Fresh surgical gloves and clean instruments –avoids implantation of cancer
cells
• Closed suction drains –lateral in axillary space -2cm inferior to axillary vein
on the ventral surface of latissimus dorsi
-medial under skin flaps
• Shoulder exercises –after 24hrs of surgery

27. ADVANTAGES OVER RADICAL MASTECTOMY:
•Good postoperative cosmetic appearance
•Maintain motor activity in the arm
•Decreased postoperative arm edema
•Early postoperative breast reconstruction

28. COMPLICATIONS of M.R.M/MASTECTOMY:
• Injury/ Thrombosis of Axillary Vein –if ligated chronic edema
• Seroma
• Shoulder Dysfunction
• Pain and Numbness
• Flap Necrosis and infection
• Lymphoedema (<10%) and its problems
• Axillary hyperaesthesia
• Winged Scapula ( long thoracic nerve damage)
• Medial and lateral thoracic nerves –pectoralis muscle atrophy
• Thoracodorsal nerve-internal rotation and abduction of shoulder weakened
• Intercostobrachial nerve –circumscribed numbness of medial aspect of the
ipsilateral upper arm

29. • Lumpectomy with postop irradiation shows better results than
lumpectomy alone and MRM incase of loco-regional recurrence
• OS and DFS is equal in MRM , lumpectomy and lumpectomy
with postop irradiation
Mastectomy vs BCS:

30. TOTAL/SIMPLE MASTECTOMY :
INDICATIONS:
•Local recurrence in a previously treated breast cancer
•Malignant phyllodes tumor
•Risk reducing mastectomy
CONTRAINDICATIONS:
•LABC (locally advanced breast cancer)
Tissues removed:
•Tumour, entire breast, nipple areola complex, skin over breast, Axillary
tail of Spence, Pectoral fascia
Tissues retained:
•NO Axillary Dissection
•Subjected to Radiotherapy later

31. • Boundaries of total mastectomy –superiorly -2nd rib
inferiorly–inframammary fold
medial –sternum
lateral –latissimus dorsi
EXTENDED SIMPLE MASTECTOMY :
INDICATIONS:
• Multifocal breast cancer
• Large tumor relative to breast size
• Extensive DCIS
• Patient preference for mastectomy
Tissues removed:
• Total Mastectomy + Axillary fat, Axillary fascia, Level I Axillary Lymph
nodes

32. EXTENDED RADICAL MASTECTOMY:
•Radical mastectomy + removal of internal mammary LN
SUPER RADICAL MASTECTOMY :
•Radical mastectomy + removal of internal mammary LN +
mediastinal LN + supraclavicular LN

33. BREAST CONSERVATIVE SURGERIES :
Indications :
•DCIS ;Stage I and II Breast carcinoma
•Single factor for BCS- relationship b/w tumor size and breast size (tumor
must be small)
Contraindications:
•Multicentric tumor
•Positive margins after excision
•Advanced stages
•Collagen vascular diseases (SLE/ RA/ SCLERODERMA )
•Pregnancy
•Prior radiation therapy to breast or chest wall

34. • Non palpable lesions–lateral-orthogonal mammography films
should be available
• Localization of the lesion –intraop ultrasound
Central lesions and more peripheral
-curvilinear
Upper outer and lower inner –radial

35. Wide Local Excision(WLE)/ Partial Mastectomy :
•Removal of unicentric tumour with 1cm clearance margin.
•Incision: Over tumour + Axillary Dissection + RT
Quadrantectomy:
•Removal of entire quadrant with ductal system
with 2-3cm normal breast tissue clearance.
•Part of QUART Therapy
(Quadrantectomy + Axillary dissection + RT)
Lumpectomy (=WLE): benign tumors
•Term rarely used

37. Skin Sparing Mastectomy:
Indication :
•If immediate reconstruction is planned in DCIS (preferable)
Procedure:
•removal of Breast tissue+nipple areola complex + 1cm of skin around scars
from previous biopsy procedures
periareolar
Tennis racquet
Reduction mammoplasty
Modified elliptical

38. • Boundaries of total mastectomy –superiorly -2nd
rib
inferiorly–inframammary
fold
medial –sternum
lateral –latissimus dorsi

39. Nipple areola sparing mastectomy:
•Patients undergoing prophylactic mastectomy for risk reduction, including
BRCA 1 and BRCA2 gene mutation carriers
Eligibility criteria:
•tumor located more than 2-3 cm from the border of areola
•smaller breast size
•minimal ptosis
•no prior breast surgeries with periareolar
incisions
•BMI < 40kg/m2
•no prior breast irradiation
•no active tobacco use
•no evidence of collagen vascular disease

40. ADVANTAGES OF BCS:
•Maintenance of appearance and function of breast
•Disease free interval is same as that of MRM
•Better quality of life and psychological advantage
DISADVANTAGES OF BCS:
•Radiotherapy is essential
•Local recurrence is high (40%)

41. Toilet Mastectomy:
INDICATIONS:
•In locally advanced tumour (LABC), tumour with breast tissue removed –
prevent fungation
•Palliative procedure in metastatic and LABC
•Post-chemotherapy
PROCEDURE:
•Reaching upto the muscle and in some cases removing a part of adherent
muscle fibres
•Avoid going into axilla in view of adherent lymph node masses engulfing
the axillary vessels

42. ONCOPLASTIC SURGERY:
• Range from simple re-shaping of breast tissue to local tissue rearrangement
to the use of pedicled flaps or breast reduction techniques
• Goal – achieve the best possible aesthetic result
• Criteria : significant area of skin will need to be resected with the specimen
to achieve negative margins
large volume of breast parenchyma will be resected resulting in
significant defect( >20% to 30%)
tumor is located between the nipple and the inframammary fold
excision of the tumor and closure of the breast –malpositioning of
nipple may result
• Timing :immediate repair of a partial mastectomy defect is almost always
preferred to delayed approach

43. procedure Structures removed
Simple or total mastectomy Removal of breast tissue, nipple -areola complex, skin
Extended simple
mastectomy
Simple mastectomy + removal of level I LN
Modified radical
mastectomy
Removal of breast tissue , nipple – areola complex , skin ,
level I and II axillary LN
Halstead’s radical
mastectomy
Removal of breast tissue and skin,nipple –areola complex
Pectoralis major and minor, level I, II and III LN
Extended radical
mastectomy
Radical mastectomy + removal of internal mammary LN
Super radical mastectomy Radical mastectomy + removal of internal mammary LN+
mediastinal and supraclavicular LN

44. VARIANTS OF MRM STRUCTURES REMOVED
Auschincloss procedure Removal of breast tissue , nipple areola complex , skin,
level I and II axillary LN
Patey’s procedure Pectoralis minor removed to allow dissection of level III LN
Scanlon’s modification of
patey’s procedure
Pectoralis minor is divided instead of removing
Division of pectoralis minor allows complete removal of
level III LN

45. Thank you