Surgical Treatments for Breast Cancer

Question 1

Describe why breast surgery is the best option for breast cancer?

Answer 1

There are very few people who cannot survive breast surgery, and it usually only takes < 2 hours unless you are reconstructing

Question 2

What treatment may be used for individuals who have severe cases of breast cancer where surgery is contra-indicated and have a low life expectancy?

Answer 2

Primary hormone therapy

Question 3

If a person says, “I’ll have a mastectomy to reduce the chances of the cancer coming back” what should you tell them?

Answer 3

You must make sure the patient isn’t making the decision thinking that a mastectomy will stop the cancer from coming back. Systemic treatment is what will stop the person having a recurrence elsewhere.

Question 4

What are the two main types of surgery for breast cancer?

Answer 4

Breast conserving surgery and mastectomy

Question 5

What is the main type of breast conserving surgery?

Answer 5

Wide local excision (lumpectomy)

Question 6

How can breast conserving surgery be done if the cancer is non-palpable?

Answer 6

Wire guided local excision using US preferably and if not mammography (stereotactic)

Question 7

What are the two types of mastectomy?

Answer 7

Traditional transverse and skin sparing with immediate reconstruction

Question 8

If a woman is having a mastectomy, when is the best time to do reconstruction surgery and why?

Answer 8

At the same time, as there is more of the woman’s own breast tissue present

Question 9

What is the preferred surgical management of breast cancer and why?

Answer 9

Breast conserving surgery (with radiotherapy) because it has the same survival benefit as mastectomy and has a better cosmetic outcome

Question 10

Breast conservation surgery has equivalent disease free and overall survival as mastectomy as long as what applies?

Answer 10

There is adjuvant radiotherapy, there are clear margins (must be > 1mm, ideally > 1cm)

Question 11

Following wire guided local excision, what should you always do?

Answer 11

Send a sample to pathology to orientate it and check that the margins are clear

Question 12

Why is skin sparing mastectomy preferred? When is this usually done?

Answer 12

Because it has a better cosmetic outcome, it is usually done when immediate reconstruction is taking place

Question 13

What is the alternative to breast reconstruction?

Answer 13

External prosthesis

Question 14

Modified radical mastectomy removes what?

Answer 14

The entire breast, including the overlying skin and the axillary lymph nodes

Question 15

What is the major modification in modified radical mastectomy? Why?

Answer 15

Preservation of the pectoralis major muscle - facilitates improved wound healing and potentially allows reconstruction

Question 16

Who are candidates for breast reconstruction? When should this be brought up?

Answer 16

Essentially anyone having a mastectomy is a candidate for reconstruction - you should present this option to patients when they are making their choice

Question 17

What are some options for breast reconstruction?

Answer 17

Implant only / latissimus dorsi pedicled flap +/- implant / deep inferior epigastric artery perforator free flap / inferior gluteal artery perforator free flap

Question 18

What are the main issues with breast implants?

Answer 18

Loss of implants due to infection, implant rippling, implant migration

Question 19

What is oncoplastic breast surgery?

Answer 19

Safe oncological surgery while avoiding tissue deformity

Question 20

What oncoplastic option is available for women with large breasts?

Answer 20

Therapeutic mammoplasty (breast reduction)

Question 21

What oncoplastic option is available for women with small breasts?

Answer 21

Volume replacement techniques

Question 22

What are some finishing touches that can be done after oncoplastic surgery?

Answer 22

Nipple reconstruction, lipomodelling, contralateral symmetrising (reduce or augment)

Question 23

What chemotherapy regime is used neo-adjuvantly?

Answer 23

Standard FEC100 and taxane +/- herceptin

Question 24

Assessment of response to neoadjuvant therapy is done radiologically using what modalities?

Answer 24

US, mammography and MRI

Question 25

Should surgical excision still be done even if neoadjuvant treatment has cured the cancer?

Answer 25

Yes

Question 26

When should axillary surgery be done?

Answer 26

Always when doing breast surgery, either as treatment or staging

Question 27

How is pre-operative axillary node staging done?

Answer 27

USS axilla +/- core needle biopsy

Question 28

What is the best method of sampling axillary nodes surgically?

Answer 28

Sentinel node biopsy

Question 29

Why should not all the nodes be taken out during axillary clearance?

Answer 29

Can cause lymphoedema

Question 30

What therapy is done for axillary node involvement after surgery?

Answer 30

Axillary radiotherapy

Question 31

Internal mammary nodes can be removed during which surgery for breast cancer? Why not the other?

Answer 31

Removed if doing mastectomy, not if doing conserving surgery as they are too difficult to get to