Breast Surgery and Reconstruction

Question 1

What sort of things come under the heading of ‘survivorship’ following breast cancer?

Answer 1

• Signs and symptoms of recurrence – many patients live in crippling fear of reoccurrence
• Improving wellbeing
• Relationships and body image
• Finance and work
• Mood changes
• Weight chances
• Hot flushes

Question 2

What are the 2 main categories for types of breast cancer surgery?

Answer 2

• Conservative

* Mastectomy

Question 3

What 4 things come under the heading of breast conservative surgery?

Answer 3

• ‘Lumpectomy’ – basically a wide local excision
• Wide local excision
• Wire guided local excision
• Oncoplastic breast conservation including therapeutic mammoplasty

Question 4

What is a mastectomy?

Answer 4

Removal of the whole breast

Question 5

What 2 things come under the heading of breast mastectomy?

Answer 5

• Traditional transverse

* Skin sparing with immediate reconstruction

Question 6

What 2 treatments, when combined, has the same outcome as mastectomy?

Answer 6

Breast conserving surgery + radiotherapy = mastectomy

Question 7

If breast conservation is done, there is equivalent disease free and overall survival compared to mastectomy as long as?

Answer 7

There are CLEAR MARGINS OF > 1mm PLUS BREAST RADIOTHERAPY

Question 8

In surgical wide excision aim for _ cm excision at all margins

Answer 8

1cm

Question 9

What should you do at the anterior and posterior margins of a breast cancer during surgery?

Answer 9

Full thickness excision

Question 10

Why is neoadjuvant therapy done?

Answer 10

This is done to achieve breast conservation

Question 11

What are the different options of neoadjuvant therapy?

Answer 11

• Chemotherapy (standard FEC100 and taxane) +/- Herceptin
• Endocrine: aromatase inhibitors more effective than tamoxifen, so reserved for postmenopausal women
• Both methods shown to reduce mastectomy rates

Question 12

What is chemotherapy used in?

Answer 12

Used in the control of local + systemic disease

Question 13

Why is chemo good?

Answer 13

Because less surgery is needed so there is more breast conservation

Question 14

How is response to chemo assessed?

Answer 14

Assessment of response is radiological with mammography, ultrasound and MRI

Question 15

What is the standard treatment following chemotherapy?

Answer 15

Surgical excision

Question 16

What does oncoplastic breast surgery mean?

Answer 16

Aafe oncological (cancer) surgery while avoiding tissue deformity

Question 17

What does oncoplastic breast surgery mean?

Answer 17

Safe oncological (cancer) surgery while avoiding tissue deformity

Question 18

What is oncoplastic breast surgery?

Answer 18

Uses principles of cancer and plastic surgery to reshape breast contours at time of cancer resection

Question 19

What type of reconstruction is oncoplastic breast surgery?

Answer 19

Immediate

Question 20

Outline the different surgical options in oncoplastic breast surgery.

Answer 20

Large breast/large tumour - therapeutic mammoplasty

Small breast - volume replacement techniques

Question 21

What is a mastectomy?

Answer 21

Removal of all breast tissue

Question 22

What are the 2 different options for a mastectomy?

Answer 22

• Standard

* Skin sparing, usually if immediate reconstruction

Question 23

After mastectomy, various things can be done in terms of conserving breast appearance. Outline some of these.

Answer 23

• External prosthesis
• Reconstruction - immediate or delayed:
• Implant only (+/- autologous cellular matrix)
  Latissimus dorsi (LD) pedicled flap +/- implant
  Deep inferior epigastric artery perforator (DIEP) free flap
• Inferior gluteal artery perforator (IGAP) free flap

Question 24

Outline the 4 different reconstruction options for breasts.

Answer 24

• Implant only (+/- autologous cellular matrix)
• Latissimus dorsi (LD) pedicled flap +/- implant
• Deep inferior epigastric artery perforator (DIEP) free flap
• Inferior gluteal artery perforator (IGAP) free flap

Question 25

Implant based reconstruction accounts for around 37% of all immediate reconstructions done in the UK

Answer 25

True

Question 26

What are the main issues with breast implants?

Answer 26

* Loss of implants (infection) * Capsular contracture * Implant rippling * Implant migration

Question 27

__% of people with breast implants require revisional surgery

Answer 27

40%

Question 28

How is implant reconstruction carried out?

Answer 28

‘Two stage’ implant reconstruction: 1st – mastectomy and creation of submuscular pocket with expander insertion. - clinic visits for expansion 2 weekly 2nd – exchange of expander for permanent implant (although can leave some expanders and remove ports only)

Question 29

Outline the advantages of ADM (acellular dermal matrix) Implants.

Answer 29

* “One stage” implant reconstruction by providing lower pole coverage * Better lower pole expansion * Reduced postoperative pain * Improved aesthetic outcome * Permanent implant can be used at 1st operation * Also useful for revisional surgery

Question 30

Describe latissimus dorsi reconstruction.

Answer 30

Myocutaneous flap, standard or extended +/- augmentation

Question 31

Describe TRAM and DIEP flaps.

Answer 31

TRAM – transverse rectus abdominus flap | DIEP – deep inferior epigastric artery perforator flap

Question 32

Describe IGAP flaps.

Answer 32

Inferior gluteal artery perforatory flap | Note: superior version also available – SGAP

Question 33

What are some finishing touches of breast reconstruction surgery?

Answer 33

* Nipple reconstruction * Lipomodelling * Contralateral symmetrising: reduction or augment

Question 34

What are the different options for axillary surgery if the cancer has spread?

Answer 34

* Pre-operative axillary staging: USS axilla +/- core biopsy * Sentinel node biopsy * Axillary clearance * Axillary radiotherapy

Question 35

What is ALWAYS done during breast surgery? Why?

Answer 35

Axillary surgery ALWAYS done during breast surgery – either for treatment or staging

Question 36

Why should you not remove ALL lymph nodes?

Answer 36

If you take away all the lymph nodes, you get lymphoedema Avoid removing all lymph nodes

Question 37

What is a sentinel node?

Answer 37

The first lymph node which the cancer is likely to have spread to