SURGICAL TREATMENT

OPTIONS IN MANAGEMENT
OF BREAST CANCER
CHAIRPERSONS PROF. N. C. NATH
DR. A. MAJI

PRESENTED BY DR. IPSEET MISHRA

HISTORICAL ASPECT
o EGYPTIANS COULD NOT BELIEVE BREAST CANCER COULD BE CURED
o GALEN & ALUBUCASIS STARTED REMOVING BREAST TUMOURS
o AMBROISE PARE FIRST TO RECOGNIZE ROLE OF AXILLARY LYMPH NODES
IN BREAST CANCER
o W H HALSTEAD FIRST TO PERFORM RADICAL MASTECTOMY EN BLOC
REMOVAL OF BREAST WITH LYMPHATICS AND BOTH PECTORALIS MUSCLES
IN 1882
o D H PATEY PECTORALIS MAJOR MUSCLE WAS NOT REMOVED D/T EXCESS
BLOOD LOSS AND COSMETIC DEFORMITY. REMOVAL OF PECTORALIS
MINOR WAS DONE FOR AXILLARY CLEARANCE PATEY MODIFICATION
o R NOER & B FISHER INITIATED NSABP TRIAL AND SUPPORTED USE OF

EXCISIONAL BIOPSY WITH NEEDLE LOCALIZATION

Complete removal of breast lesion with a margin of normal
appearing breast tissue
Reserved for cases where needle core biopsy results are
discordant with imaging findings or needle localization.
Requires a pre-operative visit to mammography suite for
placement of localization wire or radiolabelled seed that can be
detected intra-operatively with handheld probe or can be targeted
by sonography in imaging suite or operating room.

 Impalpable lesions localized prior to surgery using Skin marking,

Injection of Blue dye, Carbon or Radioisotope, insertion of a Hook
wire with postlocalization mammograms , or by intraoperative
ultrasound.
If the lesion localized by ultrasound, the skin directly over the cancer
is marked along with the depth of the cancer below the skin by the
radiologist.
If the lesion is only visible on the mammograms, it is usually possible
for the surgeon to locate the skin directly over the lesion. If dissection
continues toward the wire in place, it can be located above where it
enters the lesion.
Radio-guided occult lesion localization is a newer technique. Under
mammogram or ultrasound control technetium-labelled human
serum albumin or sulfur colloid is injected into the tumor. The

Planned incision over area of microcalcification.

Diagrammatic representation of mammograms illustrating

the position of a hook wire in relation to the area of
micro calcification. A: Lateral view. B: Craniocaudal view.

BREAST CONSERVING SURGERY

- Lumpectomy / Segmentectomy / Partial mastectomy / Wide local excision
- Aim Achieving long term local disease control with minimum local morbidity
- Defined as complete surgical resection of a primary tumour with wide negative
margins ideally 1cm.

- INDICATIONS T1, T2 (<4CM), N0 , N1, M0

- T2 > 4CM
- SINGLE CLINICAL AND MAMMOGRAPHIC LESION
- ADVANTAGES : Survival outcomes are same for BCS or mastectomy whichever
is performed.
Aesthetic outcome more with preservation of Breast shape, skin
or sensation.

- INCISIONS FOR BCS Periareolar incision for centrally placed

lesion ,
- Curvilinear incision for
peripherally located lesion,
- Radial incision
for lower quadrants.
- In general, scars that are parallel both to the lines of maximum
resting skin tension and to the orientation of collagen fibers produce
the best cosmetic incisions with least hypertrophy and keloid
formation.
- The cosmetic result after BCT is influenced by the amount of skin
excised and length of incision.

The direction of Langer's lines (A) and the lines of maximum resting skin tension in
the breast (the so called dynamic lines of Kraissl)

 When elevating skin, it is important not to disrupt the subcutaneous fat

as thin skin flaps has a poor cosmetic result.
The skin flaps should be elevated 1 to 2 cm beyond the edge of the
cancer. The line of incision should be 1 cm beyond the limit of the
palpable mass.
It is usually but not always necessary to remove full thickness of breast
tissue. To ensure that there is an adequate margin deep to the cancer for
the majority of patients, dissection through the breast tissue is
continued down to the pectoral fascia and the breast tissue containing
the cancer is lifted off the pectoral fascia.
It is not necessary to excise pectoral fascia unless it is tethered to the
tumor. A portion of the affected muscle should be removed beneath the
tumor if a carcinoma is infiltrating one of the chest wall muscles.

 The specimen is immediately orientated prior to submission to the

pathologist with sutures, ligacllps, or metal markers. Metal markers or
ligaclips allows anteroposterior orientation for intraoperative specimen
radiography that helps the surgeon to assess the completeness of
excision at all margins. If the specimen radiograph shows that the
cancer or any associated microcalcification is close to a radial margin,
then the surgeon can remove further tissue from the margin.
Having excised the cancer from the breast suturing the defect in the
breast without
mobilization of the breast tissue usually results in distortion of the
breast contour.
Small defects ( <5% breast volume) can be left open and can produce
a good final cosmetic result.
Large defects in the breast should be closed by mobilizing the

 Large defects(> 10% breast volume) can be filled by using a LD muscle,

TRAM flaps, or more major breast reshaping as part of a unilateral or
bilateral therapeutic mammoplasty.
Drains are not necessary following wide local excision and should not be
used routinely. They do not protect against hematoma formation and
increase infection rates.
Breast skin wounds should be closed in layers with absorbable sutures.
finishing with a subcuticular suture.
Staples and interrupted sutures are not an acceptable method of wound
closure in the breast.

- CONTRADICTIONS
multicentric

Absolute T4, N2, M1

- clinically evident multifocal or
disease
- h/o previous irradiation or inability to
undergo radiation
- 1st or 2nd trimester of pregnancy
- persistent positive margins after

previous BCS
- patients who prefer mastectomy
- Relative small breast size
- large or central tumours in small
breasts
- collagen vascular diseases
- strong family h/o breast cancer or
BRCA 1/2
mutation carriers

Radiation therapy systemic therapy are must after BCS.

SLN is performed before removal of primary tumour for axillary staging.

FACTORS RESULTING IN POOR SURGICAL

OUTCOME IN BCS
-

Large breast size

Increasing tumour size
Large volume of breast tissue removed
Central tumour size
Re-excision procedure
Increasing scar length
Post-operative complications
Associated axillary dissection
Increasing dose of radiotherapy
Chemotherapy

TOTAL MASTECTOMY
- complete removal of all breast tissue from subclavius superiorly, sternal
border medially, inferiorly 3-4cm down the infra-mammary fold, laterally
anterior margin of latissimus dorsi with en-bloc resection of pectoralis
major fascia
- Indications Risk reducing mastectomy
- Local recurrence in previously treated breast cancer
- Palliative treatment in metastatic breast cancer
- Malignant phylloides tumour
RADICAL MASTECTOMY
- Total mastectomy plus en bloc resection of the pectoralis muscles and
ALND ( complete level I-III axillary LN dissection)
EXTENDED RADICAL MASTECTOMY
- Radical mastectomy with resection of internal mammary lymph nodes

MODIFIED RADICAL MASTECTOMY

- Total mastectomy with axillary lymph node dissection
VARIOUS MODIFICATIONS OF MODIFIED RADICAL MASTECTOMY
- PATEY MODIFICATION : pectoralis minor is divided to allow axillary
clearance
- SCANLON MODIFICATION : pectoralis minor is divided but not
removed that allows level III dissection
- AUCHINCLOSS MODIFICATION : pectoralis minor is retracted that
allows only level I & II dissection

OTHER VARIATIONS OF MASTECTOMY :

- SKIN SPARING TOTAL MASTECTOMY (SSM) AND NIPPLE
SPARING TOTAL MASTECTOMY (NSM)
- Minimally invasive surgical approaches that are technically more
difficult and thus more time consuming than traditional method.
- Gives same extent of resection with preservation of skin envelope
and position of infra-mammary fold.
- Preferred for Early stage breast cancer patients who elect to have
immediate reconstruction.
- Not appropriate for - cancers near skin or nipple
- locally advanced or inflammatory breast
carcinoma.

Classic Stewart elliptical incision for central and

subareolar primary lesions of the breast

Obliquely placed modified Stewart incision for cancer

of the inner quadrant of the breast

Classic Orr oblique incision for carcinoma of the

upper outer quadrants of the breast

Variation of the Orr incision for lower inner and vertically

placed (6 oclock) lesions of the breast

 Flaps are developed at boundaries of dissection for MRM with

electocautery or scalpel
1. anterior margin of LD laterally
2. Midline of sternum medially
3. subclavius superiorly and
4. 3-4 cm inferior to infra-mammary fold inferiorly.
Skin flaps include skin and tela subcutanea and the appropriate
dissection plane is deep to subcutaneous vasculature and superficial to
vessels of breast parenchyma.
Skin flap is raised with consistent thickness to avoid creation of
devascularized subcutaneous tissues that can contribute to wound
seroma, skin necrosis and flap retraction.
Perforators from lateral thoracic arteries or anterior intercostal arteries
supplying pectoralis muscles should be identified and ligated.

COMPLICATIONS OF MASTECTOMY :
Seromas beneath skin flaps or in the axilla Reduced by use of closed system suction drain.
Wound infections infrequent, majority after skin flap necrosis managed with C/S of specimen,
debridement and
effective antibiotic therapy.
Haemorrhage managed with early wound exploration and re-establishment of closed system
suction drain.
Lymphedema incidence 20% but can be 50-60% after post-operative radiation early PMR
referral and use of individually fitted compressive sleeves.
Local regional recurrence of breast cancer
1. Women treated with BCS before should undergo mastectomy and appropriate reconstruction
alongwith chemotherapy
antiestrogen therapy.
2. Women treated with mastectomy previously should undergo resection of recurrence and
appropriate reconstruction alongwith chemotherapy antiestrogen therapy. Radiation therapy to
be given if chest wall has not been previously radiated or by opinion of radiation oncologist.

Thankyou