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Breast Cancer and its Surgical Management Adam Gittins Surgical Oncology Teaching Series Clinical Teaching Fellow SOTS Russells Hall Hospital, DudleyWhat we will be covering • Epidemiology and risk factors • Pathology • Associated genetic mutations • Presentation • Diagnosis and investigations • UK Breast Cancer Screening Programme • Staging including receptorstatus • Non-surgical management • Surgical management • Cancer excision • Breast reconstructionIntroduction • Most common cancer in the UK • Incidence of 55,920 cases per year • 1 in 8 women will develop breast cancer in their lifetime • Peak incidence rate in women >90 • Incidence is rising • Screening programme • Lifestyle factors • Survival rates are improving • 5-year survival 76%Risk Factors Oestrogen exposure Other • Nulliparity • Femalesex • Lack of breastfeeding • Age • Early menarche • Genetic • Late menopause • Familyhistory • Combined oral contraceptive pill • Radiation exposure • Obesity • AlcoholPathology Breast cancers can becategorised by: • Cell of origin • Invasiveness Most breast cancers arise from epithelial cells: • Ductal carcinoma • Ductal carcinoma in situ (non-invasive) • Invasive ductal carcinoma • Paget’s disease of the nipple • Lobular carcinoma • Lobular carcinoma in situ (non-invasive) • Invasive lobular carcinoma A small proportion arise from stromal cells(angiosarcoma, primary stromal sarcoma)BRCA Mutations Mutations of BRCA genes • Prevalence of 1 in 400 • Increased risk of developing breast cancer and ovarian cancer BRCA 1 mutation: • 65-85% lifetime risk of breast cancer BRCA 2 mutation: • 40-85% lifetime risk of breast cancer Women with BRCA mutations may choose to have risk-reducing mastectomiesPresentation Most common symptom is a breast lump • Painless • Hard • Irregular shape • Most commonly in upper outer quadrant of breast Other symptoms: • Axillary lump • Unilateral bloody nipple discharge • Nipple changes (inversion/puckering) • Skin changes (tethering, ulceration, Peaud’orange) • Unexplained weight loss Peaud’orangeDiagnosis 2 week waitreferralto breast cancerclinic Triple assessment: • Breast examinatio n • Imaging to detect masses and microcalcifications • Mammogram • Ultrasound if aged <35 or male • Biopsy of cancer site +/- abnormal lymph nodes • Core biopsy – demonstrates architecture of cells • Can differentiate between invasive and in situ disease • Fine needle aspiration cytology not commonly doneFurther Investigations USS axilla +/- lymph node biopsy • Assess for enlarged lymph nodes MRI breast • Invasive breast cancer • If there is discrepancy in findings between clinical examinationand mammogram/USS OR • If breast density is too high foraccurate mammographic assessment OR • Assess tumour size if breast-conservingsurgery is being considered Genetic testing (BRCA1 and BRCA2) • Women <50 with triple-negative breast cancerBreast Cancer Screening • Women aged 50 70 in the UK • Can still be done after 70 on request • Trials ongoing into expanding age range to 47-73 • Mammogram every 3 years • Craniocaudal view • Mediolateral oblique viewBreast Cancer Screening No further action Signs of breast cancer? Breast examination Further tests Further mammograms needed Breast USS Breast biopsyStaging Most commonlyused staging system in breast cancer is the TNM staging system Clinical stage • Prior to surgery • Based on examination, imaging and biopsy results Pathological stage(surgical stage) • After surgery • Based on histological analysis of surgical specimenStaging TNM staging system Tumour Tis Carcinoma in situ T1 <2cm in size T2 2-5cm in size T3 >5cm in size T4 Invading chest wall and/or skinStaging TNM staging system Node N0 No lymph nodes containing cancer cells N1 Cancer cells in 1-3 axillary lymph nodes OR Cancer cells in internal mammary lymph nodes N2 Cancer cells in 4-9 axillary lymph nodes OR Cancer has enlarged the internal mammary lymph nodes N3 Cancer cells in 10+ axillary lymph nodes OR Cancer cells in infra- /supraclavicular lymph nodesStaging TNM staging system Metastasis M0 No distant metastasis M1 Distant metastasisStaging Numbered staging system: • Simplified • Less descriptive than TNMReceptor Status Breast cancer cells from biopsy / surgery are tested for 3 receptors: • Oestrogen Receptor(ER) status • Progesterone Receptor (PR) status ER • HER2 Receptor status The cancer cells may be positive or negative for each of these receptors PR • Hormone-receptor positive = positive for ER and/or PR • Hormone-receptor negative = negative for ER and PR • Triple positive = positive for ER, PR and HER2 HER2 • Triple negative = negative for ER, PR and HER2 The expression of these receptors predicts response to medical therapies that target these receptorsNon-Surgical Management Chemotherapy: • Taxane(e.g. docetaxel) + Anthracycline (e.g. doxorubicin) Hormone therapy: • ER positive breast cancer • Tamoxifenor men and premenopausal women • Aromatase inhibitor (e.g. anastrozole) for postmenopausal women Biologic therapy: • HER2 positive breast cancer • Trastuzumab Radiotherapy • After breast-conserving surgery • After mastectomy for more advanced cancers (T3+ or node-positive)Surgical Management 1. Removal of cancer • Breast-conserving surgery • Mastectomy • Lymph node removal 2. Breast reconstructionRemoval of Cancer Breast-conserving surgery • Removal ofcanceralong with some surrounding healthy breast tissue • Margin of excision depends on tumour size and type • Typically followed by ~3 weeks of adjuvant radiotherapy • Suitable for early stage breast cancerRemoval of Cancer Mastectomy • Removal of thewhole breast • Often involves subsequent breast reconstruction • Suitable for later stage breast cancers and largertumours (>4cm in average-sized breast) • May spare need for radiotherapy in early stage cancersLymph Node Removal Sentinel lymph node biopsy • If there is no evidence of lymph node spread (N0) • Removal of first lymph nodes (≥4 nodes) in drainage path of cancer • Radioactive substance or blue dye injected to indentify sentinel node(s) • Sent for histological analysis • Usually performed intraoperatively • Can also be done under US guidanceLymph Node Removal Axillary node clearance • If there is evidenceof lymph node spread • Extent of clearance depends on tumour stage • May result inlymphoedema of ipsilateral arm • 3 levels of axillary lymph nodes: 1. Below pectoralis minor 2. Behind pectoralis minor 3. Above pectoralis minorBreast Reconstruction Aims to restore normal appearance of breast following cancer excision Breast reconstruction is a personal choice Often requires more than one procedure Timing of reconstruction: • Immediate reconstruction– started at the same time as cancer excision • Delayed reconstruction– started in a separate operationReconstructive Ladder Reconstructive techniques ordered by increasing complexity Closure should be performed by thesimplest effective technique Breast cancer reconstruction is usually achieved through the use of flapsFlap Reconstruction A flap is a unit of tissue transferred from a donor site to a recipient site with its own intact blood supply Flap location subtypes (increasing complexity): • Local – from adjacent site • Regional (orpedicle) – from same anatomical region but not directly adjacent • Flap remains attached to original blood supply by a pedicle, which is tunnelled under or over the skin • Free – from distant anatomical region • Flap blood supply is anastomosed to blood supply at recipient site (nternal thoracic vessels)Latissimus Dorsi Flap Flap type: • Myocutaneous • Pedicle or free Components: • Part oflatissimus dorsi muscle • Thoracodorsal vessels • Overlying skin and subcutaneous tissue Typically is accompanied by reast implantTransverse Rectus Abdominis Myocutaneous (TRAM) Flap Flap type: • Myocutaneous • Pedicle or free Components: • Part of rectusabdominis muscle • Deep inferior epigastric vessels • Overlying skin and subcutaneous tissue Muscle-sparing free TRAM flap • Takes only a small amount of rectus abdominis muscle • Reduces abdominal wall weaknessDeep Inferior Epigastric Perforator (DIEP) Flap Flap type: • Cutaneous • Free Components: • Deep inferior epigastric vessels • Overlying skin and subcutaneous tissue Similar to TRAM flap, but without muscle Fewer complications (e.g. hernia) than TRAM flap as no abdominal wall muscle is taken Rectus muscle must be split to retrieve the deep inferior epigastric vesselsSuperficial Inferior Epigastric Artery (SIEA) Flap Flap type: • Cutaneous • Free Components: • Superficial inferior epigastric vessels • Overlying skin and subcutaneous tissue Requires no interference with rectus abdominis muscles Higher risk of arterial complications (thrombosis, necrosis, failure) than DIEP flap • Rarely performed • Only in patients with favourablearterial anatomyGluteal Flaps Flap type: • Cutaneous • Free Superior gluteal artery perforator (SGAP) flap Inferior gluteal artery perforator (IGAP) flapPostoperative Complications Seroma: • Accumulation of tissue fluid under wound • Risk can be reduced by drains inserted intraoperatively • May require needle aspiration if does not se-resolve Flap failure: • Risk of ~3% • More common in free flaps than pedicle flaps • Requires return to theatre for flap removal • Flaps should be monitored postoperatively for signs of: • Venous failure congested, reduced capillary refill timetime Sensory loss: • Usually improves over timeChoice of Flap Free flaps often produce the best cosmetic results, but require specialist resources for microvascular anastomosis Pedicle flaps generally have a lower risk of flap failure Flap should ideally be harvested from a part of the patient’s body with excess skin and subcutaneous tissue • Abdomen • GlutealSummary • Breast cancer is the most common cancer in the UK • Incidence ratesare rising but prognosis is improving • Strongly linked with oestrogen exposure • Most commonly presents as a painless breast lump • Diagnosed by “triple assessment” of clinical examination, imaging and biopsy • Non-surgical management options include chemotherapy, radiotherapy, hormone therapy and biologic therapy, depending on expression of particular receptors • Surgical treatment comprises surgery to remove the cancer +/ breast reconstruction • Breast reconstruction is a personal choice and choice of reconstruction depends on patient factors and availability of specialist resourcesReferences and Further Reading 1. Cancer Research UK. Breast cancer statistics [Internet]; [cited 2022 Nov 9]. Available from URL:https://www.cancerresearchuk.org/health- professional/cancer-statistics/statisticsby-cancer-type/breast-cancer 2. National Institute for Health and Care Excellence. (2018) Early and locally advanced breast cancer: diagnosis and management [NICE Guideline 101]. 3. Champaneria, M.C., Wong, W.W., Hill, M.E. et al. The Evolution of Breast Reconstruction: A Historical Perspective. World JSurg 36, 730–742 (2012). 4. Simman R. Wound closure and the reconstructive ladder in plastic surgery. J Am Col Certif Wound Spec. 2009 May 1;1(1)1 6. 5. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with gluteal artery perforator flaps. J Plast ReconstrAesthet Surg. 2006;59(6):614-21.