Management of carcinoma breast2013


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Management of carcinoma breast2013

  1. 1. Surgical Management of Carcinoma Breast Dr. Sumer yadav
  2. 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. 3. Types of surgery used now-a-days  Breast conservative surgery  Radical surgery  Reconstructive surgery
  4. 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. 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. 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. 7. Relative contraindications  Large tumor / breast ratio.  Central tumors.  Large pendulous breast.  Collagen vascular (connective tissue) diseases.  Age.  Extensive In-Situ Carcinoma (EIS).
  8. 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. 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. 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. 11. Subcutaneous Mastectomy  Indicated in- Premalignant diseases of breast as lobular CIS Comedo carcinoma Intracystic carcinoma.  Nipple is retained.
  12. 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. 13. Radical surgery
  14. 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. 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. 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. 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. 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. 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. 20. 2.Madden / Auchincloss modification– preserved both the pectoralis major and minor
  21. 21. Modified radical mastectomy steps
  22. 22. Preop positioning.
  23. 23. marking
  24. 24. Marked
  25. 25. First incision
  26. 26. Skin flap elevated with hooks
  27. 27. Palpation of skin flap
  28. 28. Limit of dissection is Lattisimus Dorsi.
  29. 29. Medial skin flap developed.
  30. 30. Development of skin flaps.
  31. 31. Pectoral fascia incised inferomedially.
  32. 32. Dissection in cephalad direction.
  33. 33. Dissection encounters biopsy cavity.
  34. 34. Rim of pectoralis major removed.
  35. 35. Base of excised muscle.
  36. 36. Fully mobilized breast tissue.
  37. 37. Breast removed.
  38. 38. Clavipectoral fascia opened.
  39. 39. Axillary fat pad exposed.
  40. 40. Axillary vein exposed.
  41. 41. Long thoracic nerve.
  42. 42. Axillary nerves.
  43. 43. Axillary sampling.
  44. 44. Thoracodorsal neurovascular pedicle.
  45. 45. Axillary fat padexcised.
  46. 46. Division of the subscapular vessels.
  47. 47. Closed suction drains placed medially and laterally.
  48. 48. Skin closure.
  49. 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. 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. 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. 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. 53. Reconstruction surgery 1. Breast reconstruction 2. Maintenance of breast shape 3. Reconstruction of nipple 4. Fulfillment of bony defect
  54. 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. 55.  Lattisimus Dorsi myocutaneous flap  Gluteal flap superior or inferior based  Rubens flap  Thoracoepigastric flap  Lateral thigh flap  Breast splitting procedures
  56. 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. 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. 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. 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. 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. 61. Woman with Lattisimus Dorsi muscle in place.
  62. 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. 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. 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. 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. 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. 67. Thank you