Surgery and Breast Reconstruction

Question 1

What surgical factors increase the rate of recurrence of breast cancer?

Answer 1

• no clear margin

Question 2

Different types of cancer require different margins. TRUE/FALSE?

Answer 2

TRUE

e.g. sarcomas require large margin (1cm)

Question 3

What questions should be asked before surgery to remove cancer?

Answer 3

• Is it possible to remove?
• Is patient suitable for surgery?
• Will it impact their quality of life?

Question 4

What does “preserving function” refer to when reconstructing the breast?

Answer 4

• most patients are post-menopausal => breast don’t perform previous function anymore
• any pre-menopausal women are likely to lose function in the affected breast due to radiotherapy anyway

=> preserving function = preserving appearance of breasts for sexual function and psychological reasons

Question 5

Almost all patients with breast cancer have surgery. TRUE/FALSE?

Answer 5

TRUE
- at some point in their journey
=> may not necessarily be first

Question 6

What neoadjuvant treatments are normally used in the UK?

Answer 6

• Chemo +/- Herceptin
• Aromatase inhibitors
• Tamoxifen

(these aim to reduce the size of the cancer for easier surgical excision)

Question 7

What is the difference in mechanism between aromatase inhibitors and oestrogen receptor blockers (tamoxifen)

Answer 7

Aromatase Inhibitors - prevent the aromatase reaction which forms oestrogen

Oestrogen receptor blockers - prevent oestrogen from binding and causing its desired effect

Question 8

Why are aromatase inhibitors only given to post-menopausal women?

Answer 8

Aromatase inhibitors more effective than tamoxifen

=> reserved for postmenopausal women

Question 9

What are the different types of Breast Conservation surgery that are available?

Answer 9

• wide local excision
• wire guided local excision (used for non-palpable lumps picked up on screening)
• Breast conservation and Therapeutic Mammoplasty

Question 10

What are the two types of mastectomy operations that can be performed?

Answer 10

• traditional transverse

- reconstruction at same time

Question 11

What are the 3 main concerns when undertaking oncoplastic surgery?

Answer 11

oncological (is cancer out?)
psychological
cosmetic

Question 12

How are patients allowed to make a decision on which procedure would be the most cosmetically appealing to them?

Answer 12

Shown photographs of the results of surgical procedures performed at that particular hospital

• many patients will have never seen mastectomy results before, therefore these photographs may make them rethink
• allows them to see how these operations scar and where these scars are visible

Question 13

Describe how a wire guided local excision is carried out

Answer 13

• patient is awake (No GA)

- under US or mammogram guidance

Question 14

Name other methods of localisation that can be used to mark a cancer or lesion to be removed?

Answer 14

• magnetic seed

- radiofrequency marker

Question 15

What is a therapeutic mastopexy and when is it normally used?

Answer 15

• Like a breast lift

- usually used if cancer is at bottom of breast (e.g. 6 o’clock position)

Question 16

What are the options after a mastectomy?

Answer 16

• External prosthesis (worn in bra)
• Reconstruction: Immediate or delayed (less skin in this case as it was not spared)
  => Implant
  => Autologous Muscle flap (latissimus dorsi OR from abdomen OR from gluteal region)

Question 17

What are the main problems with immediate reconstruction?

Answer 17

• Loss of implants (infection)
• Capsular contracture
• Implant rippling
• Implant migration
• 40% require revisional surgery

Question 18

If a therapeutic mastopexy is NOT performed after a cancer is removed from the bottom portion of the breast, what can result?

Answer 18

“birds beak” deformity

- nipple forms birds beak shape pointed downwards

Question 19

What reconstruction surgery leaves patients with only a scar under their arm?

Answer 19

Volume replacement using the Lateral Intercostal Artery Perforator Flap

Question 20

What can artificial breast implants be made out of?

Answer 20

silicone (most commonly)

saline (more common in USA)

Question 21

What are the potential benefits of implants as opposed to using tissue from elsewhere in the body?

Answer 21

• No additional scars elsewhere

Question 22

What can occur around the implant after it is inserted?

Answer 22

fibrosis and scarring

- body thinks it is a foreign object

Question 23

What were the potential risks with old implants?

Answer 23

Anaplastic Large Cell Lymphoma (ALCL)

Risk 1:25,000

Question 24

New implants can be used directly on top of the Pec Major muscle. Where were they previously placed?

Answer 24

• behind Pec Major muscle

=> required stretching to allow enough room to place implant in

Question 25

Why is a latissimus dorsi flap less likely to fail than others?

Answer 25

It is flipped around on the same blood supply

=> since this has not been compromised, it is less likely to fail

Question 26

Flaps from the abdomen and gluteal region take longer than a standard implant procedure. TRUE/FALSE?

Answer 26

TRUE

Question 27

Using a Transverse rectus abdominus flap or Deep inferior epigastric artery perforator flap is essentially like performing what procedure?

Answer 27

Abdominoplasty

“Tummy tuck”

Question 28

Liposuction from the abdomen can be used in the breast for what purpose?

Answer 28

To fill any deformed or defective parts of the breast

Question 29

The presence of what on US guided biopsy indicates the need for axillary clearance?

Answer 29

Macrometastases

• if none present, then sentinel node biopsy

Question 30

Why should axillary clearance be avoided if possible?

Answer 30

Arm lymphodema risk

Question 31

When would the lymph nodes under the breast bone (internal mammary) potentially be removed?

Answer 31

• not routinely removed as this would involved removing part of rib
• if already undergoing surgery and access to these nodes is possible, then they may be removed at this point