Atlas of Operative Surgical Oncology Rajendra Badwe, Sabita Jiwnani, Anil D’cruz
INDEX
Page numbers followed by f refer to figure and t refer to table.
A
Abdomen 80, 146
Abdominal defects, lower 203
Abdominal hysterectomy, total 105, 109
Abdominoperineal resection 160, 162
Adductor longus 76
Adhesive obstruction 155
Adrenalectomy, role of 71
Adrenaline infiltration 204
Airway
obstruction 42, 58
transfer 63, 63f
Alpha fetoprotein 80, 87
Alveolar nerve, inferior 32
Alveolus
lower 35f
upper 35f
American Academy of Otolaryngology Head and Neck Surgery 19
American College of Obstetricians and Gynecologists 105
American Head and Neck Society 19
American Society of Clinical Oncology 111
Amputation, levels of 123
Anal sphincter, external 174
Anastomosis 188
safe 159
Anastomotic dehiscence 159
Anastomotic leakage 155, 176
Anesthesia 4, 20, 30, 38, 99, 160, 164, 175, 184, 208, 215
examination under 49, 50, 228
Angioembolization, preoperative 70
Ankle disarticulation 123
Anomalous renal vessels 73
Antibiotic prophylaxis 20, 30, 38, 44
Aorta 154f, 166
invasion of 184
left border of 139f
Arm defects, upper 214
Arteriovenous malformation 73
Aspiration 59
Atelectasis 195
Audio Doppler 203
Autoimmune pancreatitis 138
Axilla
clinically negative 9
coverage of 214
Axillary disease, clinically positive 9
Axillary fold, anterior 208
Axillary incision 11f
Axillary lymph node dissection 9, 12
Axillary sampling 9, 10, 12f
Axillary surgery for breast cancer 9
Azygos vein ligation 185f
B
Back defect, upper 214
Belly of
digastric
anterior 24
muscle, posterior 45, 53
posterior 24
Berry's ligament 41, 42
Beta human chorionic gonadotropin 80
Betadine scrub bath 75
Beta-human chorionic gonadotropin 87
Biopsy 30, 130, 131f, 138, 160, 174
disadvantages with open 133
in sarcoma 130
open 130, 133
types of 130
Bite resection 34, 35
specimen 35f
Bladder dysfunction, chronic 103
Blair's incision 44f, 48
Bleeding 16, 35
from enterostomy 164
reactionary 58
secondary 58
Blood supply 218
Bone 121
marrow examination 228
scan 70, 223
scintigraphy 228
Borderline resectable pancreatic cancer 137
Brachial plexus 25f
Branch of middle colic
left 153f
right 153f
Breast 1
cancer
advanced 12
inflammatory 4, 9
surgery for 3
conserving
surgery 3, 4
therapy 3
lump 3
reconstruction 214
Breastfeeding, loss of 16
Buccal mucosa cancer, surgery for 29
Buck fascia 84
Bulky lymphadenopathy 153
Bulky para-aortic disease 89
Bursectomy 167
C
Calot's triangle 147
Cancer vulva, surgery for 113
Canoe-shaped marginal mandibulectomy 33f
Carbohydrate antigen 199 146
Carbon monoxide 87
Carcinoembryonic antigen 138, 151, 160, 174
Carcinoma gallbladder, surgery for 146
Cardiac arrhythmias 195
Carotid artery
external 24
internal 25, 43
Catheter
blockage 198
fracture 199
Catheter-related bloodstream infection 198
Cattell-Braasch maneuver 139
Celiac artery, branches of 169f
Celiac trunk, encasement of 166
Central nervous system 228
Cervical
esophageal mobilization 187, 187f
hand sewn anastomosis 189
lymphadenectomy 188
root 26f
stapled anastomosis 188
Cervicofacial flap, anteriorly-based 45f
Cervix stages, carcinoma 95
Chest
wall defects
anterior 214
posterior 214
wound, closure of 212f
Chevassu's maneuver 80
Chevron incision 147
Chopart amputation 124
Chyle leak 27
Chylous ascites 97
Clavicular fracture 209
Cloquet's node 75, 78
Coeliac lymph nodes 148
Colectomy 151
preoperative evaluation 151
radical 152
Colic artery
left 154f
middle 153f
Colic pedicle, dissected middle 153f
Colon bed, right 154f
Colonoscopy 160, 174
Colostomy 163
Common bile duct 137, 139
dissection 141
Common carotid artery 21f, 25, 197f
Common hepatic
artery 138, 140, 148, 169, 169f, 170
duct 142
Complete blood count 104
Complete kocherization 148
Conjunctival exposure with mucus accumulation 230
Core needle biopsy 130, 131
Cosmetic deformity 27
C-reactive protein 138
Cricopharyngeal myotomy 63
Cuffed tracheostomy 66
Cystic lymph nodes 148
Cystic neoplasms 138
Cytology 138
Cytoreductive nephrectomy 69
D
Deltopectoral 208
Dense adhesions 95
Dental
prophylaxis 30
rehabilitation 35
Deskeletonization of larynx 62
Devascularization of larynx 62
Disease involving sclera 229
Distant metastases 114, 184
Duct carcinoma 14
Duct ectasia 14
Duct papilloma 14
Ductal carcinoma in situ 9
Duodenal injury 155
Duodenal stump leak 173
Duodenojejunal flexure 155
Duodenum, second part of 154f
Dynamic sentinel lymph node biopsy 74, 75
Dysfunctional larynx 60
Early dumping syndrome 173
Eastern Cooperative Oncology Group 60
Edema 58
Elbow
amputation
above 123, 125f
below 123, 125f
disarticulation 123
Electrolyte imbalance 164
Endoscopic retrograde cholangiopancreatography 137, 149
Endoscopic ultrasonography 137, 182
End-to-end anastomosis 171
Enhanced recovery after surgery 139
Enterostomy 163
herniation 164
prolapse 164
Epiglottis 63
Esophageal cancer 181, 182f, 183t
lymphadenectomy for 181
surgery for 181
Esophagogastric triangulating anastomotic technique 189f
Esophagus, infracarinal part of 184f
Extrahepatic bile duct excision 148
Extraocular disease 228, 229
Eye, enucleation of 229f
F
Facelift incision 44, 44f
Facial
artery 23f
asymmetry 47
nerve 46f
divisions of 46f
injury 47
management of 46
monitoring 44
reconstruction 47
trunk of 45f
vein 45
Familial adenomatous polyposis 152
Fecal soiling of incision 164
Femoral
artery 76, 117f
canal 117f, 118f
nerve 76
vein 76, 117f
Fibrin formation 198
Fine needle aspiration 138
cytology 20, 37, 38, 43, 83, 99, 105, 113, 166
Fistula, late 103
Flank incision, layers of 71f
Fluorodeoxyglucose 87
Foley catheter 75
Forehead flap 218, 219f
Forequarter amputation 123
Frank blood 144
Frey's syndrome 47
G
Gallbladder 89, 141
cancer 146
carcinoma, dissection for 148f
Gastrectomy 165
reconstruction, total 172f
total 166
types of 166
Gastric artery
dissection, right 169f
division of left 170, 170f
left 168, 169f, 170
right 167
Gastric conduit 189f
Gastric dilatation, acute 149
Gastric emptying, delayed 144, 173
Gastric mobilization 186
Gastric pedicle dissection, left 187f
Gastric surgery, radical 166
Gastric transection 140
Gastric tube, formation of 171, 188f
Gastric vessels
division of
right 167
short 170
Gastrocolic omentum, division of 153, 154
Gastrocolic trunk 153f
Gastroduodenal artery 140, 141f, 147, 148
Gastroepiploic
artery
dissection, right 168f
ligated, right 140f
vein 167
dissection, right 168f
Gastrojejunostomy 143, 171
Genetic analysis 38
Germ cell tumors 87
Gerota's fascia 71
Gingivobuccal mucosa complex tumors 49
Gland, dissection of body of 39
Glomerular filtration rate 70
Glossectomy specimen 56f
Gluteal region 203
Gonadal vein 71
right 154f
Greater auricular nerve 23, 24
Groin incision, right 116f
Groin node dissection 74, 116
anatomy for 116f
Gubernaculum, division of 81f
Gustatory sweating 47
Gyne-oncology 93
H
Head and neck
cancers 22
squamous cell carcinoma 19
Head of pancreas 137, 153f, 166
Hematoma 42, 85, 198
Hemicolectomy, left 154f, 155f
right 153f, 154f
Hemiglossectomy defect, left 57f
Hemimandibulectomy 34
Hemorrhage 27, 42, 65
intraoperative 72
postoperative 144
Hemothorax 195, 198
Hepatic artery
left 147, 148
proper 148
right 147, 148
Hepatic flexure mobilization 153
Hepaticojejunostomy 143, 143f
Hepatoduodenal ligament 148
Hereditary nonpolyposis colorectal cancer 152
Hindquarter amputation 123
Hip disarticulation 123
Hyoid bone 62f
Hyperthermic intraperitoneal chemotherapy 106
Hyperthyroid goiter 38
Hypocalcemia 42
Hypoglossal nerve 24f, 53
Hypothyroidism 66
Hysterectomy
radical 99
specimen, radical 103f
I
Ileocecal 88
Ileocolic pedicle, dissected 153f
Ileoinguinal nerve lateralized 81f
Ileostomy 163
end 163
Ileus, postoperative 155, 176
Iliac artery, external 77
Iliac gland, dissection of
external 96
internal 96
Iliac spine, anterior superior 73, 76, 81, 81f
Iliac vein, external 77
Iliac vessels, external 96f
Ilio-obturator dissection, completed 97f
Implant migration 230
Inappropriate biopsies 123
Incision 5, 7, 21, 100, 116
Infratemporal fossa 43
Infundibulopelvic 95
Inguinal ligament 76, 77
Inguinal lymphadenectomy
modified 75
radical 76
Inguinal orchiectomy 80
Inguinofemoral lymphadenectomy 116
Inter-aortocaval lymph nodes 148
International Germ Cell Cancer Collaborative Group 88
International neuroblastoma staging system 223
International Study Group of Pancreatic Surgery 144
Interrupted hepaticojejunostomy 149f
Intersphincteric plane 174
Intersphincteric resection 174
Interval cytoreduction 105
Intracapsular dissection 41f, 48
Intracranial
disease 228
extension 43
Intraocular group E disease 228
Intraocular retinoblastoma, staging for 229t
Intraoral defects 214
Intrathoracic stapled anastomosis 189
Intravenous antibiotics 58
Ivor lewis esophagectomy 181
J
Jaundice, obstructive 137
Jaw stretching exercises 35
Jejunojejunal anastomotic leak 173
Jejunum, transection of 141
Jugular vein 20
anterior 23
external 21f, 22
internal 19, 26, 53, 187, 196
right internal 197f
K
Kidney, right 89, 90
Knee disarticulation 123
Kocher's maneuver 139, 139f
Kocher's incision 39
L
Lactate dehydrogenase 80, 87, 223
Laparoscopic gastric mobilization, ports for 189f
Laparoscopic nephrectomy, left 73f
Laparoscopic surgery, role of 149
Laparoscopic technique 73
Laparotomy 100
conventional 100
staging 107
Laryngeal entry 63, 63f
Laryngeal nerve 40
branch of superior 39
dissection 41
left recurrent 187
superior 40f
Laryngeal suspension 58
Laryngectomy 60
Laryngoscopy, direct 60
Latissimus dorsi 214
Ligament of treitz 139
Lingual artery 53
in neck, left 53f
Lisfranc amputation 124
Liver
function test 104, 146
mobilization 110
Loop colostomy 163f
Loop ileostomy 163
Lower limb 123
Low-molecular-weight heparin 75
Lumbar puncture 228
Lumbar vein, left 90
Lumpectomy, incision planning for 5f
Lung
diffusing capacity of 87
metastasis 106
wedge excision 194f
Lymph nodal mass, removal of 96
Lymph node 9, 87, 148, 159
biopsy 12f
dissection of 169f
regional 182f, 183t
supraclavicular 104
Lymphadenectomy 47, 148
abdominal 186
extent of 71, 142
Lymphatic fistula 97
Lymphedema 78, 103
Lymphocele 103
Lymphomas 38
Lymphoscintigraphy 10f
M
Mandibular nerve, marginal 23
Mandibular remnant, deviation of 59
Mandibulectomy
intraoral marginal 33f
marginal 32, 36
types of marginal 32f
Mastectomy 7
McKeown transthoracic esophagectomy 181
Mediastinal route, posterior 189f
Medullary bone invasion 34
Mesenteric artery
inferior 89, 90, 141, 152, 154f, 161, 175
superior 138, 139, 142f, 225f
Mesenteric vein
inferior 154f, 155f
superior 138, 140f, 142, 153, 167
Mesentery, root of 106, 107
Mesorectal excision, total 157
Meta-iodo-benzyl guanidine 223
Metastatic disease 50, 147
Methylene blue injected intradermal 10f
Microdochectomy 14
incision for 15f
Midtarsal joint 124
Minimal access surgery 100
Minimally invasive esophagectomy 181
Motilin agonist 144
Motor innervation 214
Mucosal incision, intraoral
lateral 53f
medial 53f
Multifocal disease 7
Muscle, elevation of 211
Mylohyoid muscle 24f
N
Nasojejunal tube 143
Near-total glossectomy defect 58f
Neck
dissection 19, 20, 57, 62
incision for 22
modified 57
radical 19, 20
types of 19t, 20, 21
flap, closure of 58
left side 187f
nodes 50
inoperable 44
levels of 20f
ultrasonography 37
Neoadjuvant chemoradiotherapy 157
Neoadjuvant chemotherapy 105
Neoplasms of parotid 43
Nephrectomy 69, 72
open partial 72
radical 69
Nephron-sparing surgery 69, 72f
Nerve injury 103
Neuroblastoma, abdominal 223
Neuroendocrine tumors 137
Nipple 16
discharge
cytology 14
pathological 14
sensation
loss in 16
Nipple-areola complex 15
Node negative, clinically 74
Node-positive operable breast cancer 12
Nodulectomy 48
Nonregional lymph node 153, 167
disease 166
O
Obesity 203
Obstructive pulmonary disease, chronic 183
Obturator
fossa 96f
gland 96
nerve 77
neurapraxia 103
Oculoplasty 229
for retinoblastoma 228
Omentectomy 109, 110f, 167
Omohyoid muscle 26f
Open biopsy, advantages of 133
Optic nerve 228
Oral
cancer, incision for 21
tongue 55
Orocutaneous fistula 35, 59
Orotracheal intubation 61
Orthopantomogram 50
Osteoradionecrosis 36
Ovarian cancer
advanced 106f, 108
bilateral large 106f
early stage 106f, 107
staging in early 108f
surgery for 104
treatment of
advanced 106
early 105
P
Pain control, postoperative 72
Pancreatic duct
anterior 142f
posterior 142f
Pancreatic ductal adenocarcinoma 137
Pancreatic fistula, postoperative 143, 144
Pancreatic neck dissection 140f
Pancreaticoduodenal arteries, inferior 141, 142f
Pancreaticoduodenectomy 137
Pancreaticojejunostomy 142
Pancreatitis, postoperative 173
Paramandibular disease, extensive 32, 34
Paramedian mandibulotomy 56f
Parametrial tunnel 101
Parathyroid dissection, superior 40
Paratracheal dissection 41
Parenchymal liver 106
Parotid
cysts, multiple 43
fistula 35
neoplasm 45
surgeries 43
classification of 44
tumor 44f
Parotidectomy 48
Parotitis, acute 43
Pectoral branch 208
Pectoralis major 208
flap 208, 209f
muscle 6f
myocutaneous 209, 212
flap 57, 213
myofascial flap 61
Pectoralis muscle with sutures 198f
Pedicle, elevation of 211
Pedicled anterolateral thigh 78f
Pedicled latissimus dorsi flap 214
Pelvic
dissection, complications of 111
lymph node dissection 77, 77f, 95
bilateral 100
complication of 97
lymphadenectomy 100f
bilateral 76
completed 97f
sidewall, entry to 96f, 100f
wall, lateral 160, 174
Pelvis 146
Penectomy, total 85
Penile amputative surgery 86
Penile cancer 83
surgery for 83
Penile stump 85f
Percutaneous biopsy 70, 73
Percutaneous transhepatic biliary drainage 149
Periampullary tumors 138
Pericholedochal lymph nodes 148
Perineal part 161
Perineal region 203
Perineal wound infection 162
Peripheral vascular disease 203
Periportal lymphadenectomy, complete 147f, 148f
Peritoneal disease 167
Peroral wide excision 30
Pharyngeal augmentation 64
Pharyngocutaneous 64
fistula 65
Phrenic nerve 25f
Pirogoff amputation 124
Plaster of Paris slabs 126
Plastic and reconstructive surgery 201
Plastic reconstructive consultation 30
Pneumothorax 198
Polydioxanone 144
Porta hepatis 106, 107
Porta hepatis dissection 140
Portal vein 138, 142, 147, 148, 169
Posterolateral thoracotomy 193
Postoncologic defects 214
Pouch of Douglas 104
Prelaryngeal dissection 41
Pretracheal dissection 41
Prevertebral fascia involvement 44
Proximal
esophagus 189f
femur resection 131f
gastrectomy 166
stomach transection 171f
Psoas muscle, left 90
Pubic tubercle 76, 81
Pulmonary
disease, extensive 183
embolism 78
function test 87, 182
metastasectomy 192
parenchyma 195f
Pylorus, internal dilatation of 188f
Pylorus-preserving pancreaticoduodenectomy 138
R
Radical colectomy, types of 151, 152t
Radical mastectomy, modified 3, 7, 10
Radical neck dissection, modified 20
Radical nephrectomy, open 70
Radical parotidectomy 44
Radiofrequency ablation 70
Ray amputation 124
Reconstruction of vulva 118
Rectal malignancy, low 157
Rectal sphincter dysfunction 103
Rectum 103
mobilization of 158
Rectus femoris 203205, 206
muscle 205
Rectus muscle identified 204f
Red blood cells 14
Renal
artery, left 71, 88, 90
cancer, surgery for 69
cell carcinoma 69
failure
acute 226
chronic 69
function test 104
vein, left 139f
vessels, dissected left 71f
Respiratory distress syndrome, acute 195
Retinoblastoma 228
Retromandibular vein 45
Retroperitoneal
hematoma 82
lymph node dissection 87
complications of 111
Rhytidectomy 44
Robotic technique 73
Ryle's tube color 144
S
Salivary
fistula 47
leak 59
leakage 47
extensive 47
Salpingo-oophorectomy, bilateral 105, 109
Saphenofemoral junction 77, 117f
Saphenous vein 117f
Sartorius muscle exposed 116f
Scapular defect 214
Scarpa's fascia 76
Sciatic nerve 160, 174
Segmental mandibulectomy 34, 36, 56f
Semen analysis 80
Sensation over chin, loss of 35
Sentinel lymph node 11f
bilateral 76f
biopsy 9, 10
dissection 10
Seroma formation 42
Serum
calcitonin 138
carcinoembryonic antigen 157
tumor markers 87, 104
Sexual dysfunction 103, 159, 162, 176
Shock, circulatory 226
Shoulder
dysfunction 27
joint disarticulation 123
Skin
closure 8
erythema 11
incision 75, 224f
transverse 187f
island dimensions 209
necrosis 35
paddle 211
design 209
territory 218
Small bowel 89f
Society of Gynecologic Oncology 105
Soft tissue 121
margin by palpation 52f
sarcomas 127
Speech and swallowing dysfunction 35, 59
Sperm banking 80
Spermatic cord 76
Spinal accessory nerve 19, 20, 23, 24, 27f
Splenic artery 169, 169f, 170
Splenic flexure mobilization 154
Split skin graft 219f
Split-thickness skin graft 211
Sternocleidomastoid muscle 19, 20, 46, 187
Stoma 61
Stomach with gastroepiploic arcade 186f
Stomal complications 162
Stomal stenosis 66
Stylomastoid foramen 45
Subcutaneous emphysema 195
Submandibular gland 45, 46, 53
Subplatysmal flaps 39
Subtotal gastrectomy 165, 166, 171f
Suprahilar dissection 90
Suprahyoid muscle 54, 54f, 62f
Suprasternal incision 39f
Syme's amputation 124
Systemic inflammatory response syndrome 143
T
Tarsometatarsal amputation 124
Temporal area, defects of 214
Tenon's capsule 230f
Testis, normal 80
Thigh
anterolateral 118, 203
flap, anterolateral 58f
Thoracic duct ligation 185f
Thoracoabdominal incision 224
Thoracoscopic esophageal mobilization, ports for 189f
Thoracotomy
anterior 193
anterolateral 193
Thorax 69, 80, 146
lymphadenectomy in 185
Throat pack 51
Thromboprophylaxis 75
Thyroid
artery, superior 24f, 62f
cancer 38
function tests 38
gland 40f, 62
mobilization of 40f
neoplasms 38
vein, inferior 40f
Thyroidectomy 39f
total 37
Thyroiditis 38
Toe with metatarsal head 124
Tongue cancer 50
surgery for 49
Tracheoesophageal
fistula 184
groove 40
prosthesis 65
failure of 66
puncture 63
Tracheostomy 58
Transection of parotid duct 46f
Transhiatal esophagectomy 181, 190
Transthoracic esophagectomy, incision 184
Transverse cutaneous nerve 23
Tumor 35
abutting mandible 32
early superficial 30
infiltrating root of mesentery 224
lysis syndrome 70
markers 38, 137
primary 74
requiring bite resection 35f
resectability 153, 167
U
Uncinate dissection, initial 139
Unresectable nodal disease 50
Unresectable primary disease 50, 184
Upper limb 123
Upper vagina, clamping 102
Ureter 103
dissection of 100
right 154f
Ureteral injury 97, 155
Ureteric stricture 103
Ureterovesical fistula 103
Urethra, isolated 84f
Urinary
tract infections 103
vanillylmandelic acid 223
Urology 67
Uterine artery 101f
Uterosacral ligaments, division of 102
Uterovesical pouch 101
Uterus from rectum, mobilization of 101
V
Vascular anatomy 208
Vascular pedicles, division of 153, 154
Vastus lateralis 203205
Vein thromboembolism, early deep 103
Vein thrombosis, deep 78, 110, 119, 158, 162, 176
Vena cava
inferior 69, 88, 90, 139, 154f, 224
superior 196
Venous thrombi 71
Vesicovaginal fistula 103
Vessels, encasement of major 224
Vicryl suture 65
Vigorous palpation 195
Visceral injury 103
Vulva, anatomy of 114f
Vulvectomy
closure of 115
radical 115
W
Wedge resection of liver 147f
Whipple surgery, classical 140
Wire localization, preoperative 193
Wound
dehiscence 155
infection 65, 78, 85, 103
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Chapter Notes

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1Breast
Rajendra A Badwe
  1. Surgery for Breast Cancer
  2. Axillary Surgery for Breast Cancer
  3. Microdochectomy2

Surgery for Breast CancerCHAPTER 1

Nita S Nair,
Vani Parmar,
Rajendra A Badwe
 
INTRODUCTION
Over the years, the original Halstedian theory has given way to Fisher's theory that breast cancer is a systemic disease at inception. With the advances in systemic therapy, there has been a paradigm shift toward conservation in locoregional treatment. However, the foundation of locoregional therapy still stands on complete eradication of all malignant cells from the breast and the draining nodal basin. This can be achieved by either a modified radical mastectomy (MRM) or breast conserving surgery (BCS).
Patey, in 1932, performed the first documented modified radical mastectomy, and the landmark National Surgical Adjuvant Breast and Bowel Project B-04 trial by Bernard Fisher demonstrated equivalence between radical mastectomy and MRM with or without radiation.1 This was followed by studies evaluating the safety of breast conserving therapy (BCT) against the then gold standard MRM. BCT has been assessed prospectively in numerous randomized trials initiated in the 1970s.2 However, the data clearly indicated that BCS was safe only when accompanied by adjuvant breast radiotherapy.
Breast conserving surgery aims to provide wide excision of the primary tumor with negative margins, but at the same time provides a good cosmetic outcome with minimal postoperative deformity. Breast conserving surgery encompasses a wide range of procedures from simple wide excision to more complex oncoplastic surgeries. Adequate surgical excision and obtaining clear margins are the main prognostic factors for local recurrence after conservative surgery. Repeated revision of margins may result in poor cosmetic outcome, adverse psychological reactions and delay in starting oncological treatments, and higher cost. Thereby stressing on the need for proper selection of patients for breast conservation surgery, adequate surgical excision, and obtaining clear margins at the time of the primary surgery.2
 
APPROACH TO A BREAST LUMP
Approach to a breast lump is mentioned in Flowchart 1.
 
TRIPLE TEST
 
Clinical Examination
  • Site, size, and number of lesions
  • Multifocal or multicentric lesions
  • Duct discharge
  • Skin involvement in the form of peau d'orange, satellite lesions, and ulceration.
 
Imaging
  • Bilateral mammogram is advised to evaluate the ipsilateral breast for other nonpalpable lesions/microcalcification and for screening of the opposite breast4
zoom view
Flowchart 1: Approach to a breast lump3Note: If carcinoma treat as per stage.
  • Ultrasound of the breast can be used in cases of dense breast
  • There is no role of routine breast magnetic resonance imaging (MRI) for planning BCS.4
 
Histology
  • Diagnosis of breast cancer is confirmed by fine needle aspiration or core biopsy.
 
STAGING INVESTIGATIONS
  • Only stage IIb–III cases undergo additional staging investigations to rule out distant metastasis (contrast-enhanced computed tomography chest and abdomen, bone scan)
  • Blood investigations: Complete blood count, liver function tests, renal function tests, electrocardiogram, 2D echocardiography (depending on the patient's electrocardiogram).
 
BREAST CONSERVING SURGERY
 
Indications of Breast Conserving Surgery
  • Single tumor
  • Women keen on conservation.
 
Contraindications of Breast Conserving Surgery
 
Absolute Contraindications
  • Inflammatory breast cancer
  • Inability to deliver radiation therapy (during pregnancy, prior radiation therapy received)
  • Diffused suspicious or malignant-appearing microcalcifications
  • Multicentric disease involving more than one quadrant or widespread disease that cannot be incorporated by local excision through a single incision that achieves negative margins with satisfactory cosmetic results
  • Persistently positive pathologic resection margin.
 
Relative Contraindications
  • Active connective tissue disease involving the skin (especially scleroderma and lupus)
  • Tumors more than 5 cm or with a poor tumor: Normal breast tissue ratio (can be given neoadjuvant therapy to downsize the tumor)
  • Focally positive margins.
 
Procedure
Anesthesia: General.
Position: Supine with the ipsilateral arm abducted.5
 
Incision
  • The incision is placed over the tumor (Figs 1 and 2)
  • In well-selected cases with no skin involvement, the incision may be placed periareolar and oncoplastic procedures may be considered
  • Radial incisions are avoided except in the inferior quadrants
  • Incision is placed within the area of skin that could be included within a mastectomy if it is deemed necessary subsequently.
 
Steps of the Procedure
  • Wide excision of the tumor with negative margins right down to the pectoral fascia is ensured
  • A cylinder of tissue is excised from the skin to the pectoral fascia. A thin sliver of skin is excised in cases where the skin is close
  • The pectoral fascia is excised in all cases except those with small superficial tumors in large breasts (e.g. in the central region)
  • First one margin is excised either superior or inferior followed by the base and then delineation of lateral and medial pillars (Figs 3 to 5)
  • Once that is done the tumor is held by a tissue holding forceps or a towel clip and after confirming a wide margin the remaining parenchyma is excised (Fig. 6)
  • After excision of the tumor, the cavity margins are evaluated and adequate hemostasis is achieved
zoom view
Fig. 1: Incision planning for lumpectomy
zoom view
Fig. 2: Lump in lower inner quadrant radial incision marked. Axillary incision is shown
zoom view
Fig. 3: Lump retracted by left hand while skin is elevated and one margin excised
  • 6Clips are placed one layer on the muscle and a second on the parenchyma to mark the cavity for postoperative radiotherapy (Fig. 7)
  • The cavity can be left to fill with seroma and skin is closed in a single layer (Fig. 8)
  • However, if the defect is large glandular mobilization or use of pedicled flaps may be required for a good cosmetic outcome
  • No drain is placed in the primary cavity
  • The excised specimen is marked by sutures to orient the pathologist for the relevant margins. Skin depicts the anterior margin (if no skin excised a black silk suture is placed anteriorly), a short linen stitch is placed superior and a long linen stitch is placed laterally (Fig. 9).
zoom view
Fig. 4: After raising one margin, the base (pectoralis major muscle) is exposed
zoom view
Fig. 5: Incision of medial/lateral pillar
zoom view
Fig. 6: Lump held in the left hand/tissue forcep and the final margin is excised
zoom view
Figs 7A and B: Lumpectomy done, clips placed to mark the base
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Fig. 8: Single layer closure over axillary drain
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Fig. 9: Specimen labeling: A short linen stitch is placed superiorly and a long linen stitch is placed laterally
 
MODIFIED RADICAL MASTECTOMY
The footprint of the breast and its boundaries include the clavicle superiorly, the sternum medially, the inframammary fold inferiorly, and the latissimus dorsi along with the pectoralis major fascia laterally. A mastectomy involves removal of the entire mammary gland including the nipple-areolar complex and pectoralis fascia.
 
Indications for Mastectomy
  • Patient's choice
  • Multifocal disease
  • Recurrence after BCT when radiotherapy has already been given
  • Pregnant women who would require radiotherapy while still pregnant (risking harm to the child).
 
Incision
  • A transverse ellipse (Stewart's) or an oblique incision (Orr's) is made (depending on the site of the primary tumor) including the nipple-areolar complex. This is done after ensuring that the skin edges will approximate and no redundant skin will remain (Fig. 10)
  • The incision is placed within the field of adjuvant radiation (medially 2 cm from the midline, laterally the anterior axillary fold).
 
Steps of the Procedure
  • The skin flaps are elevated between the subcutaneous fat and mammary fat. This is usually identified by giving traction to the breast tissue and retracting the skin with skin hooks. A loose areolar tissue plane is seen which demarcates the plane of dissection which will be bloodless
  • It is a useful habit to constantly check the flap thickness, to ensure that the flap is neither too thin nor so thick that you leave breast tissue in the flaps
  • Also, the flap with skin hooks should be retracted by the assistant carefully without resulting in a “button hole”
  • The upper flap is raised to the upper limit of the breast. This is usually 2–3 cm below the clavicle, but varies from patient to patient. A good guide is the second intercostal space. Raise the lower flap in a similar manner, to the inframammary fold
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Fig. 10: Modified radical mastectomy incision planning
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Fig. 11: Superior skin flap is raised and breast is lifted off the pectoralis major muscle
  • The breast is raised off the pectoralis major muscle. If the tumor appears to infiltrate into the pectoralis muscle, then excise a portion of this muscle with the specimen (Fig. 11)
  • Skin closure: After confirming adequate hemostasis, one suction drain is placed below the flap and another in the axilla. The skin is closed in a single layer avoiding a dog ear.
 
SUMMARY
  • Appropriate choice of incision in breast conservation surgery (radial from 3-6-9 o'clock and circumareolar in upper half breast)
  • Correct extent of incision in mastectomy not crossing anterior axillary line laterally and medially 2 cm from midline
  • Adequate flap thickness not making it too thin and maintaining uniform thickness
  • Raise pectoral fascia off the muscle when raising breast parenchyma
  • Tumor bed is clipped after primary excision in BCS
  • Careful and gentle handling of wound edges and flaps
  • Drain care and postoperative exercises are essential.
REFERENCES
  1. Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002;347:567–75.
  1. Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347:1233–41.
  1. Tata Memorial Hospital. Evidence Based Management Handbook, 2015. Online: https://tmc.gov.in/tmh/PDF/Treatment%20of%20Algorithms.pdf.
  1. Turnbull L, Brown S, Harvey I, Olivier C, Drew P, Napp V, et al. Comparative effectiveness of MRI in breast cancer (COMICE) trial: A randomised controlled trial. Lancet. 2010;375(9714):563–71.