roleofsurgeryincarcinomabreastn-191017170949.pptx

Gygggh

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

4. 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 .

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

6. 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]

7. Imporatant definitions

8. 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

9. 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

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

11. 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

12. 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

13. TYPES OF MRM

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

15. 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 perpendicula r 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 .

16. PRE OP POSITIONING MRM STEPS

17. MARKING BEFORE SURGERY

18. FIRST INCISION

19. SKIN FLAP ELEVATED WITH HOOKS

20. LIMIT OF DISSECTION IS LATISSIMUS DORSI

21. MEDIAL SKIN FLAP DEVELOPED

22. DEVELOPMENT OF SKIN FLAPS

23. PECTORAL FASCIA INCISED INFEROMEDIALLY

24. DISSECTION IN CEPHALAD DIRECTION

25. FULLY MOBILIZED BREAST TISSUE

26. BREAST REMOVED

27. CLAVIPECTORAL FASCIA OPENED

28. AXILLARY FAT PAD EXPOSED

29. AXILLARY VEIN EXPOSED

30. LONG THORACIC NERVE

31. AXILLARY SAMPLING

32. THORACODORSAL NEUROVASCULAR PEDICLE

33. AXILLARY FAT PAD EXCISED

34. DIVISION OF SUBCAPSULAR VESSELS

35. SUCTION DRAINS PLACED MEDIALLY AND LITERALLY

36. SKIN CLOSURE

37. 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

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

39. 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

40. 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

41. 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 _

42. 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

43. 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

44. 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.

45. 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

46. 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

47. 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

48. 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

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

50. 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

51. 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

52. Woman with Lattisimus Dorsi muscle in place.

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

54. 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 .

55. 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