breast surgery, general surgery, cancers

It's about breast cancer

1. Breast Anatomy Dr. SAI DEEPIKA DEPT OF GENERAL SURGERY

2. Introduction Latin word Breast = Mammary gland. Modified sweat gland. Accessory organ of female reproduction system.

3. Situation and extend Lies in superficial fascia of pectoral region. Extended Vertically - from 2 nd to 6 th ribs. Horizontally – lateral border of sternum to maxillary line Lies on deep fascia (pectoral fascia) and separated from fascia by retro mammary space. 2 nd RIB 6 th RIB Pectoral fascia Pectoralis minor Pectoralis Major Retro mammary space

4. Situation and extend

5. Situation and extend Lymphatics are present in retro mammary space. That is why in MRM we dissect the breast tissue with pectoral fascia.

6. Situation and extend Breast is divided in four quadrants Upper inner Upper outer Lower outer Lower inner Nipple areola complex should be mentioned separately while describing breast examination.

7. Situation and extend Upper lateral quadrant has lateral extension – known as axillary tail of Spence. It piers deep pectoral fascia – known as foramen of langer . It has direct communication with anterior group of axillary lymph nodes. That is why we need to remove axillary LN with breast tissue with connecting axillary tail in continuity .

8. Structure of breast It can be divided in 3 components Skin with nipple areola Parenchyma Stroma

9. Structure of breast Nipple A conical projection Present just below the centre of the breast at the level of the fourth intercostal space 10 cm from the midline. The nipple is pierced by 15 to 20 lactiferous ducts. It contains circular and longitudinal smooth muscle fibres which can make the nipple stiff or flatten it, respectively. It has a few modified sweat and sebaceous glands.

10. Structure of breast Areola Pigmented skin surrounding Nipple. Rich in modified sebaceous glands, particularly at its outer margin. These become enlarged during pregnancy and lactation to form raised tubercles of Montgomery. Oily secretions of these glands lubricate the nipple and areola, and prevent them from cracking during lactation.

11. Structure of breast Areola Apart from sebaceous glands, the areola also contains some sweat glands, and accessory mammary glands. The skin of the areola and nipple is devoid of hair, and there is no fat subjacent to it. Below the areola lie lactiferous sinus where stored milk is seen.

12. Structure of breast Langer’ lines Circumareolar incision  Webster’s incision Submammary incision  Galliard Thomas incision In upper quadrants – Incision if away from NAC then it should be along the langer’s line But in lower quadrants – it should be radial to prevent NAC displacement downward.

13. Structure of breast Parenchyma It is a compound tubulo -alveolar gland which secretes milk. The gland consists of 15 to 20 lobes. Each lobe is a cluster of alveoli, and is drained by a lactiferous duct. The lactiferous ducts converge towards the nipple and open on it. Near its termination each duct has a dilatation called a lactiferous sinus

14. Structure of breast Alveolar epithelium cuboidal in the resting phase columnar during lactation. The smaller ducts columnar epithelium The larger ducts two or more layers of cells the terminal parts of the lactiferous ducts by stratified squamous keratinised epithelium.

15. Structure of breast The passage of the milk from the alveoli into and along the ducts is facilitated by contraction of myoepitheliocytes , which are found around the alveoli and around the ducts, lying between the epithelium and the basement membrane.

16. Structure of breast Stroma Stroma forms the supporting framework of the gland. It is partly fibrous and partly fatty. There are fibrous bands that provide structural support and insert perpendicularly into the dermis, termed the suspensory ligaments of Cooper. That is why if involvement of cooper’s ligament  skin retraction

17. Blood supply The mammary gland is extremely vascular. Internal thoracic artery, a branch of the subclavian artery, through its perforating branches. The lateral thoracic, superior thoracic and acromiothoracic ( thoracoacromial ) branches of the axillary artery. Lateral branches of the posterior intercostal arteries.

18. Blood supply The mammary gland is extremely vascular. Internal thoracic artery, a branch of the subclavian artery, through its perforating branches. The lateral thoracic, superior thoracic and acromiothoracic ( thoracoacromial ) branches of the axillary artery. Lateral branches of the posterior intercostal arteries.

19. Lymphatic drainage Specialized lymphatic channels collect under the nipple and areola and form Sappey’s plexus. 75% axillary nodes 20% internal mammary nodes 5% posterior intercostal nodes

20. Lymphatic drainage

21. Lymphatic drainage The lymphatics from the deep surface of the breast pass through the pectoralis major muscle and the clavipectoral fascia to reach the apical nodes, and also to the internal mammary nodes.

22. Lymphatic drainage Lymphatics from the lower and inner quadrants of the breast may communicate with the sub diaphragmatic and sub peritoneal lymph plexuses after crossing the costal margin and then piercing the anterior abdominal wall through the upper part of the linea alba.

23. Lymphatic drainage Three anatomic levels defined by their relationship to the pectoralis minor muscle. Level I nodes are located lateral to the lateral border of the pectoralis minor muscle. Level II nodes are located posterior to the pectoralis minor muscle. Level III nodes include the sub clavicular nodes medial to the pectoralis minor muscle.

24. Lymphatic drainage The anterior (pectoral) group lie along the lateral thoracic vessels. The posterior (scapular) group lie along the subscapular vessels. The lateral group lie along the upper part of the numerus, medial to the axillary vein. The central group lie in the fat of the upper axilla. The apical ( infraclaaicular ) group lie deep to the clavipectoral fascia, along the axillary vessels.

25. Lymphatic drainage Lymph nodes in the space between the pectoralis major and minor muscles are termed the interpectoral group, or Rotter’s nodes.

26. Anatomy of Axilla A pyramidal component that is tightly invested between upper extremity and thoracic wall. Base – dense axillary fascia Apex – aperture that extends into posterior triangle of neck via cervicoaxillary canal. Anterior wall of axilla – pectoralis muscles and fascia Posteriorly – subscapularis Floor – teres major and latissmus dorsi Lateral wall – bicipital groove Medial wall – serratus anterior

27. Biopsy FNA : performed using a 1.5 inch, 22-G needle attached to a 10ml syringe. - needle is placed in mass, suction is applied while needle is moved back and forth. Cellular material is expressed into slides, air dried and 95% ethanol fixed sections are prepared. Combination of diagnostic mammography, USG or stereotactic localisation with FNA achieves almost 100% accuracy in pre-op diagnosis.

28. 2) Core- Needle biopsy : Performed using 14 G needle such as Tru -cut. - Core needle permits for analysis of breast tissue architecture and allows to determine whether invasive cancer is present or not. - Molecular sub-typing can be done.

29. Vacuum assisted core-biopsy : 8-10 gauge needles are used, where 4-12 samples are acquired from area of mass, architectural distortion, microcalcifications . If the target lesion is microcalcifications , the specimen should be radiographed . A radiopaque marker should be placed at the site of the biopsy to mark the area for future intervention. Therapeutic usage : upto 4-5cm fibroadenoma can be removed.

30. Needle biopsy Tissue for histological examination can be obtained under local anaesthesia using a large-diameter core needle biopsy device (14G for breast tissue and 18G for axillary nodes). The core needle biopsy should always be taken under image guidance. The passage of the biopsy needle can be guided by ultrasonography, mammogram or sometimes MRI; the needle tip should be used to take a sample from only the solid part of the mass, avoiding areas of cystic degeneration and blood vessels in and around the lesion

31. Excision Biopsy

32. SURGICAL TECHNIQUES Skin sparing mastectomy : all breast tissue + NAC + <1cm of skin around excised scars. Simple mastectomy : all breast tissue + NAC + necessary skin without Axillary Lymph Node dissection. Extended simple mastectomy : Simple mastectomy + Level I axillary lymph nodes.

33. 4) Modified Radical Mastectomy : - Elliptical stewart incision is made - All flaps are developed. Breast parenchyma and pectoralis major fascia are elevated from underlying pectoralis major in a plane consistently parallel with muscle. Elevation of breast parenchyma and fascia is continued laterally until the lateral edge of pectoralis major and minor are exposed.

34. An incontinuity axillary LND is performed. The investing fascia of axillary space is sharply divided. The pectoralis minor is defined, and Rotter’s LN between pectoralis muscles are cleared. Loose areolar tissue of lateral axillary space is elevated, the investing layer of axillary vein is dissected sharply. Division and ligation of intervening venous tributaries is done. Dissection continues medially on anteroventral surface of axillary vein and the loose areolar tissue at juncture of axillary vein with anterior margin of latissmus dorsi is swept inferomedially to include lateral group.

35. The lateral axillary LN group is retracted inferomedially and anterior to thoracodorsal neurovascular bundle and dissected en bloc with subscapular group of LN (level I). Dissection of posterior content of axillary space exposes posterior boundary of axilla , then dissection proceeds with removal of central axillary LN (level II). With medial dissection, the chest wall deep and in medial axillary space, we can identify the long thoracic nerve lying anterior to subscapularis muscle and close to serratus fascial compartment of chest wall. Long throacic nerve is then dissected from superior to inferiorly till the point of innervation of serratus anterior muscle. Axillary contents anterior and medial to long throacic nerve are then swept inferomedially with dissection specimen.

36. Breast conservation surgery Currently the standard of treatment for stage 0, I or II invasive breast cancer. Women with DCIS only require resection of the primary cancer and adjuvant radiation therapy without assessment of regional lymph nodes. Involves resection of primary breast cancer with a margin of normal appearing breast tissue, adjuvant radiation therapy and assessment of regional lymph node status. Adjuvant RT reduces recurrence incidence by half. Advantages : Preservation of breast shape skin, sensation and psychological advantage of not having a body part amputated.

37. FACTORS AFFECTING ELIGIBLITY FOR BREAST CONSERVATION INCLUDE: TUMOR SIZE lumpectomy is considered when the tumor, regardless of size, can be excised with clear margins and an acceptable cosmetic result and depends on the tumor to breast ratio II) MARGIN “no ink on tumor” should be used as the standard for an adequate margin in invasive breast cancer or DCIS III) HISTOLOGY: Invasive lobular cancers and cancers with an extensive intraductal component can be treated with lumpectomy if clear margins can be achieved.

38. INDICATIONS T1/T2 (<5cm) , No, N1 Mo T2 (>4cm) in large breasts Mammographically detected lesion Clinically negative axillary nodes Adequate sized breast and volume to allow proper RT Well differentiated tumor with low S phase

39. CONTRAINDICATIONS I) RELATIVE: Prior radiation therapy to chest wall or breast Active connective tissue disease involving the skin ( e.g scleroderma) Extensive positive pathological margins Tumors > 5 cm Large tumor size relative to breast Known or suspected Li-Fraumeni syndrome ( p53 mutation) Patients with BRCA1 or BRCA2 mutation.

40. II) ABSOLUTE: First trimester of pregnancy (as radiation therapy is contraindicated) Multicentric disease Extensive DCIS Tumors for which clear margins are unobtainable with lumpectomy with favourable cosmetic results Homozygous for ATM mutations

41. Incision is made directly over tumor or around the areola. Skin and subcutaneous fat are dissected off breast tissue. Skin flaps should be elevated 1 to 2 cm beyond the edge of cancer. Finger of non dominant hand to be placed over palpable cancer and breast tissue , can be divided 1cm beyond the limit of palpable mass, 1cm deep to deepest aspect of tumor and then breast tissue under cancer is divided.

42. Oriented with sutures, ligaclips , or metal markers. Using metal markers and ligaclips or attaching the specimen to an orientated grid has the advantage of allowing orientated anteroposterior-intraoperative specimen radiography to be performed. This helps the surgeon to determine first that the target lesion has been excised and second allows assessment of completeness of excision at the radial margins. If inspection of the specimen radiograph shows that the cancer or any associated microcalcification is close to a radial margin, then the surgeon should remove further tissue from the margin of concern.

43. After excision, a small defect (<5% breast volume) can be left and usually produces good cosmetic result. Larger defects should be closed by moblising surrounding breast tissue from overlying skin and subcutaneous tissue. Defect is closed with a series of interrupted absorable sutures. Larger defects can be filled by local flaps, or more major breast reshaping as part of U/L or B/L therapeutic mammoplasty .

44. Margin Probe Intra-operative assessment tool based on near-field radio frequency (RF) spectroscopy designed to detect differences between dielectric properties of malignant and normal breast tissue adjacent to the probe’s sensor. The MarginProbe System was approved by the U.S. Food and Drug Administration in January 2013.

45. Sentinel Lymph Node Biopsy Principle : - Sentinel node is the first LN that drains the area under consideration ( tumor ). - When mapping agents are injected subareola / subdermally in site of primary tumor ( peritumorally ), the material passes through lymphatics to sentinel node, which is then identified and biopsied. Indications : - Early breast cancer with clinico-radiologically node negative axilla . Contraindications : - Inflammatory breast cancer - Biopsy proven metastasis - DCIS without mastectomy

46. Procedure : - Pre-operative lymphoscintigraphy – A dose of 2.5mCi of Tc99m labelled sulfur colloid is injected on the day prior to surgery and films are obtained. - On day of surgery – 0.5mCi of Tc99m sulfur colloid injected peritumorally or in subareolar location or at the prior biopsy site. - On operating table – 3-5ml of blue dye ( isosulfan / methylene blue) is injected into breast parenchyma near the tumor / subareolar . - Using a hand held gamma camera, the area of increased radioactivity in axilla is identified transcutaneously : Incision is made over it, blue lymphatic channels are visualised leading upto sentinel node. - Best result is obtained when we remove all the blue LN alongwith >10% of radioactivity of the 10sec ex-vivo count of SN harvested.

47. Breast Reconstruction After lumpectomy or a BCS with adjuvant radiotherapy, post-radiation contracture can cause contour deformities of the breast and nipple areolar deviation toward the location of the lumpectomy. Oncoplastic breast reconstruction, prevents these deformities, lower morbidity, improves quality of life, and gives a more natural aesthetic outcome. Goals of oncoplastic breast reconstruction are – obliteration of dead space, vascular support of the nipple, and tailoring the local tissues to place the NAC and the remaining skin and parenchyma in an aesthetically acceptable shape. It encompasses three main techniques : reduction/ mastopexy , intrinsic tissue rearrangement, and adjacent tissue transfer/ locoregional flaps.

48. Indications and Contraindications Breast cancer for which a standard BCS is seemingly impossible – larger tumors (>10-20% breast volume), multifocal disease. C/I : Large tumors requiring mastectomy for clear margins. Insufficient residual breast tissue after excision Multicentric disease Inflammatory carcinoma Previous irradation Multiple co-morbidities Chronic smoker

49. Types of Oncoplastic Surgeries Volume displacement – Resected defect is reconstructed by moving local glandular/ dermoglandular tissue into the defect. Volume replacement – Extensive resections in breast should be replaced with a similar volume of autologous tissue from an extramammary site.

50. Grisotti advancement rotational flap

51. Round Block – Doughnut mastopexy

52. Radiation therapy has a role to decide which type of reconstruction is to be performed. As the pre-operative radiation damages the recipient field and intra-mammary vessels increasing the risk of intra-operative vascular complications, minor complications, skin loss, and infection in autologous reconstruction. The higher risk of reconstructive failure (reported to be as high 50%), capsular contracture, infection, mastectomy flap necrosis, and seroma have led implant-based reconstruction to fall out of favor in the setting of prior radiation. Autologous reconstruction is the ideal method of reconstruction in a patient with prior chest wall irradiation.

53. Local flaps include intrinsic parenchymal flaps to support nipple areolar complex vascularity or to fill in dead space. Regional flaps include lateral, medial, and anterior intercostal artery perforator flaps (LICAP, MICAP, and AICAP) , as well as the lateral thoracic artery perforator (LTAP), thoracodorsal artery perforator (TDAP), and internal mammary artery perforator (IMAP) flaps. These flaps can be chosen and tailored based on patient breast size, location of the tumor , planned size of resection/anticipated defect, and understanding of radiation effects on this local flap. Final choice must take into account the extent of skin resection, need for neoadjuvant or adjuvant radiation and chemotherapy, patient body habitus , aesthetic desires, and activity level.

54. Timing of Reconstruction Delayed reconstruction in the setting of implant-based reconstruction is classically accomplished with two stages using a tissue expander to gradually expand the mastectomy flaps and breast pocket followed by exchange for permanent implant. Immediate breast reconstruction , a newer concept, means that the final reconstructive modality is done at the time of the mastectomy. - It may be the choice of reconstruction for a young, thin, healthy, non-smoker with small breasts, who has thick and well- perfused mastectomy skin flaps. Delayed-immediate reconstruction - immediate placement of tissue expanders at the time of skin-sparing mastectomies followed by delayed reconstruction in the case of radiation and immediate reconstruction (implants or autologous ) in the case of no radiation.

55. Implant Reconstruction Breast reconstruction should not be limited to focusing on the affected breast and attaining symmetry to the native breast but must consider patient goals and satisfaction for both breasts. There are two most widely used plane of Implant placement – Pre-pectoral and Sub-pectoral. Pre-pectoral reconstruction is performed by creating a new pocket anterior to the pectoralis muscle and can be done immediately or delayed, in one or two stages, with saline or air in the tissue expander, and with or without acellular dermal matrix.

56. Plane of Implant

57. Complications Hematoma Wound dehiscence Malposition Deflation adverse scarring capsular contracture mastectomy skin flap necrosis Infection Seroma extrusion reconstructive failure Venous thromboembolic events

58. Autologous Breast reconstruction Provides a more natural shape, texture, proportional changes in size and contour of the breast with the rest of the body following weight changes, as well as potential improvement in the contour of other parts of the body that serve as donor sites. Divided broadly into – Pedicled flaps and Free flaps.

59. Nipple Areola Reconstruction The goal is to create symmetric nipples and areolas on both breasts. Technique depends on the size and position of the contralateral breast. Commonly, a nipple-areola reduction technique enhances the aesthetics of the contralateral breast, offering tissue that can be utilized for reconstruction of the affected breast. The nipple can be reconstructed with multiple techniques, including local flaps, grafts, injectable fillers, engineered tissue substitutes, or combinations of the these. Postoperative contraction is to be anticipated so the reconstructed nipple is designed 25% to 50% larger than the desired final size. Areola can be reconstructed either by using skin grafts or medical tattoo. Skin grafts can be harvested from the groin area, which is naturally more hyperpigmented , or from the contra-lateral areola combined with mastopexy

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