34 Breast - Breast Cancer - Medical and Surgical Modalities

  1. Systemic therapies in breast cancer?
    • Chemotherapy 
    • - Anthracyclines - Doxorubicin, Epirubicin 
    • - Taxanes - Pacitaxel, Docetaxel 

    Trastuzumab Based targeted therapy 

    • Endocrine therapy 
    • - SERMS - Tamoxifen, Raloxifen
    • - Aromatase inhibitors – Exemestane (steroidal),  Anastrazole (non-steroidal), Letrozole
    • - Ovarian ablation - Goserelin, in premenopausal women
  2. Tamoxifen therapy duration?
    • For premenopausal or perimenopausal women, tamoxifen for 5 years is recommended.
    • After 5 years, if the patient is still premenopausal, she should be offered an additional 5 years of tamoxifen therapy

    Complications of tamoxifen increases endometrial cancer, pulmonary embolism and DVT.
  3. Aromatase inhibitors duration?
    • Selective AIs  are unable to suppress ovarian function completely in a premenopausal or perimenopausal woman and are restricted for use in postmenopausal women.
    • Postmenopausal women should receive a selective AI at some point during their cancer therapy (ASCO clinical practice guidelines) The 2014 update of the ASCO guidelines recommended that postmenopausal patients with hormone receptor–positive breast cancer be offered one of the following regimens:
    • (1) AI for 5 years
    • (2) Tamoxifen for 10 years
    • (3) Tamoxifen for 5 years followed by an AI for 5 years
  4. Trials in chemoprevention
    • NSABP (National Surgical Adjuvant Breast and Bowel Project) P-1 trial - tamoxifen reduced the risk for invasive breast cancer in high risk cases
    • Italian Tamoxifen Prevention Study, Royal Marsden Hospital Pilot Tamoxifen Chemoprevention Trial- No benefit from Tamoxifen
    • IBIS-I (International Breast Cancer Intervention Study I) – Tamoxifen reduces breast cancer

    The NSABP P-2 trial (STAR trial)- compared tamoxifen with raloxifene in postmenopausal women, both decreased breast cancer, less side effects with raloxifen

    • MORE trial – Raloxifen vs Placebo – Raloxifen decreased breast cancer
    • MAP 3 trial – (Mammary prevention 3) – Exemestane reduces breast cancer
  5. What is medical adrenalectomy?
    • After menopause adrenal gland is the major source of endogenous estrogen.
    • Aminoglutethimide (mitotane) blocks the enzymatic conversion of cholesterol to gamma 5 prednisolone and inhibits the conversion of androstenedione to estrogen in peripheral tissues.
  6. What are gonadotropin-releasing hormone agonist?
    • Interacts with the gonadotropin-releasing hormone receptor to elicit its biologic response, the release of the pituitary hormones FSH and LH. However, after the initial "flare" response, continued stimulation with GnRH agonists desensitizes the pituitary gland (by causing GnRH receptor downregulation) to GnRH. Pituitary desensitization reduces the secretion of LH and FSH and thus induces a state of hypogonadotropic hypogonadal anovulation, sometimes referred to as “pseudomenopause” or “medical oophorectomy.
    • They are also called as LHRH agonists - goserelin, boserelin and leuprolide

    Uses - Treatment of cancers that are hormonal sensitive like breast and prostate cancer.
  7. Types of mastectomy
    1. Skin sparing Mastectomy and Nipple-areola sparing mastectomy

    2. Simple" or "total" mastectomy
    – entire breast removed, no LN removed, no muscle removed. 

    • 3. MRM
    • - Patey: removal of pectoralis minor muscle to allow Level III node dissection
    • - Madden and Auchincloss: preservation of both pectoralis major and minor; only level I-II dissection. Higher chance of medial pectoral nerve preservation and Reduce arm swelling

    4. Radical Mastectomy (Halsted mastectomy) – Level I, II and III, with Pectoralis major and minor,
  8. How will you perform a modified radical mastectomy and axillary node dissection. How will you manage post-operative limb lymphoedema. [TU]
    A modified radical mastectomy preserves the pectoralis major muscle with removal of level I, II, and III (apical) axillary lymph nodes.

    Incision -  most common incision is a transverse or oblique elliptical incision including the tumor mass, with lateral extension towards the axilla

    • Anatomic boundaries of the modified radical mastectomy
    • - Laterally - anterior margin of the latissimus dorsi muscle
    • - Medially - midline of the sternum
    • - Superiorly - subclavius muscle
    • - Inferiorly - caudal extension of the breast 2 to 3 cm inferior to the inframammary fold inferiorly.

    • Skin-flap thickness - 7 to 8 mm inclusive of skin and telasubcutanea
    • Dissection from the chest wall — The breast tissue is dissected off the muscle, using cautery to decrease bleeding from the muscle. The pectoralis fascia is routinely removed with the breast tissue. 
    • Once the skin flaps are fully developed, the fascia of the pectoralis major muscle and the overlying breast tissue are elevated off the underlying musculature, which allows for the complete removal of the breast

    • Closed suction drains are placed through separate stab wounds inferior to the main incision and sewn in place. The drains are left in place until the drainage of serous fluid has decreased to approximately 25 to 30 mL per 24-hour period.
    • The incisions are usually closed in two layers, using absorbable sutures.
  9. Steps of Axillary lymph node dissection?
    • The most lateral extent of the axillary vein is identified and the areolar tissue of the lateral axillary space is elevated as the vein is cleared on its anterior and inferior surfaces.
    • The areolar tissues at the junction of the axillary vein and the anterior edge of the latissimus dorsi muscle, which include the lateral and subscapular lymph node groups (level I), are cleared.
    • Care is taken to preserve the thoracodorsal neurovascular bundle.
    • The dissection then continues medially with clearance of the central axillary lymph node group (level II).
    • The long thoracic nerve of Bell is identified and preserved as it travels in the investing fascia of the serratus anterior muscle.
  10. Differential diagnosis of breast lump?
    • „ Breast cancer
    • „ Fibroadenoma of breast
    • „ Antibioma
    • „ Chronic abscess
    • „ Tuberculosis of breast
    • „ Traumatic fat necrosis
    • „ Fibroadenosis of breast with nodularity.
  11. Management of breast cyst?
    • Breast cyst are rarely malignant
    • Aspiration of content – if mass resolves after aspiration and cyst content is not grossly bloody – fluid does not need to be sent for cytological examination
    • If cyst recurs two times – core needle biopsy to evaluate any solid components
    • Surgical removal if cyst recurs multiple times or biopsy reveals atypia
  12. What is QUART?
    QUART is quadrantectomy, axillary dissection (level I-III) and postoperative radiotherapy. 

    Quadrantectomy is a form of breast conserving surgery for early breast carcinoma. The entire segment of the breast containing the tumor is excised. The resultant defect should be reconstructed by oncoplastic technique.
  13. What is Oncoplastic technique in BCS?
    Oncoplastic surgery merges the principles of oncology and plastic surgery, utilizing full-thickness breast-flap advancement to address tissue defects and improve cosmesis from breast conserving surgery (BCS).

    The goal of oncoplastic procedures is to resect the breast cancer with negative histologic margins while preserving the contour of the breast

    Oncoplastic techniques are generally not required for excision of smaller cancers in adequately sized breasts. The conventional lumpectomy generally removes 20 to 40 grams of breast tissue, with adverse cosmetic outcomes only typically seen when 80 grams or more of breast tissue are removed.
  14. Indications of oncoplastic technique in BCS?
    1. When the cancer resection is large in relation to the size of the breast.

    • •The conventional approach to obliterating the postexcision cavity risks significant long-term cosmetic deformities once 20 percent or more of the breast volume has been excised. These deformities include dimpling of the skin and displacement of the nipple-areolar complex.
    • •Oncoplastic techniques allow for removal of between 200 and 1000 grams of breast tissue without causing significant breast deformity by advancing breast tissue to obliterate the postexcision cavity. The use of oncoplastic techniques, therefore, broadens the application of BCS to patients with larger tumors who would otherwise have to undergo mastectomy.

    2. When the cancer location requires repositioning of the nipple-areolar complex (NAC). Oncoplastic techniques can maintain a natural breast appearance and reduce breast ptosis.
  15. Technique of oncoplastic surgery?
    • It is also called as Bilateral Breast Reduction or Lift Combined with Lumpectomy. 
    • When a large lumpectomy is required (which will leave the breast distorted), the remaining tissue can be sculpted to restore natural appearance to the breast. The opposing breast will also be reduced to create symmetry.

    Image Upload 1
  16. Selection of Oncoplastic Breast Surgery technique according to tumour location?
    • Image Upload 2
    • Image Upload 3
  17. Benefits of Oncoplastic surgery?
    • • Allows for a larger amount of tissue to be removed, which is helpful is cases where the tumor is larger or when there is a concern about the ability to get negative margins.
    • • When a larger amount of tissue has to be removed, performing a matching procedure on the other breast provides better symmetry.
    • • Involves only one surgery.
    • • Surgery is completed prior to radiation, so you avoid the risks of wound-healing problems that can occur with a post-radiation surgery.
    • • Relief of symptoms of large breasts, if this was a problem before surgery.
    • These surgeries generally do not involve drains. They may be outpatient or possibly require one night in the hospital. Recovery time is six weeks, but most people usually feel better and are able to return to work in three to four weeks.
  18. Breast reconstruction?
    • May be performed as immediate reconstruction—that is, the same day as mastectomy—or as delayed reconstruction, months or years later.
    • Immediate reconstruction has the advantages of preserving the maximum amount of breast skin for use in reconstruction, combining the recovery period for both procedures, and avoiding a period of time without a breast mound.
    • Immediate reconstruction does not have a detrimental effect on long-term survival, local recurrence rates, or detection of local recurrence.
    • Reconstruction may be delayed in patients who might require postmastectomy radiation therapy and is usually delayed in patients with locally advanced cancer.
    • Reconstruction options include tissue expander and implant and autologous tissue reconstructions, most often with transverse rectus abdominis muscle (TRAM) flaps, latissimus dorsi myocutaneous flap (LDMF) and, more recently, muscle-preserving perforator abdominal flaps.
  19. Short note on Microdochectomy. [TU 2068/2]
    • Microdochectomy is the surgical removal (excision) of a lactiferous duct. A mere incision of a mammary duct (without excision) is called microdochotomy. 
    • Galactography may be used to investigate the condition of the mammary duct system before the intervention.  
    • Pre-operatively, also breast ultrasound and mammogram are performed to rule out other abnormalities of the breast.
    • If the condition involves from several ducts or if no specific duct could be determined, then a subareolar resection of the ducts (central duct excision, also called Hadfield's procedure) may be indicated instead

    • Indications
    • Nipple discharge from a single duct.
    • Ductal papilloma 
    • Recurrent breast abscess and mastitis; in this case however the total removal of all ducts from behind the nipple has been recommended to avoid further recurrence.

    Procedure - A radial cut or preferably a circumareolar cut (following the circular line of the areola) is made and a milk duct is removed. The removed duct is normally sent for histologic examination. The excision can be directed by ductoscopy.

    • Complications - 
    • Alteration of shape of breast, alteration of nipple areola complex.  
    • Hematoma
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34 Breast - Breast Cancer - Medical and Surgical Modalities