Breast Cancer Op Breast Reconstruction Radiation Therapy

Breast Cancer Operations,

Breast Reconstruction,

Radiation Therapy

© Ruthi Peleg

Breast Cancer Treament

Two Options:

Local treatment - treatment of breast area and

lymph nodes near it

Systemic treatment - treatment of the whole

body, or system

© Ruthi Peleg, 2005

If cancer has spread to other places beyond the

breast local treatment to those spots, in

addition to systemic treatment

Type of treatment depends on:


• the characteristics of the cancer( location, size,

multicentricity, microcalcifications…)

• stage of the cancer – how much has spread

• patient’s general health

• patient’s decision


Local Treatment

• Radiation Therapy

Breast removing surgery

(mastectomy)

Breast saving surgery

(lumpectomy)

• Surgery:



Systemic Treatment

• Chemotherapy

• Hormone Therapy



• Radical mastectomy

• Modified radical mastectomy

• Simple or total mastectomy

• Subcutaneous mastectomy


Local Treatment



Radical mastectomy

• whole breast

• pectoralis major& minor

• all axillary lymph nodes

Removal of:


Modified radical mastectomy

Removal of:

• whole breast

• axillary lymph nodes

Adpted from “Dr. Susan Love’s Breast Book” , 1996


Simple or total mastectomy

Removal of:

• all breast tissue, including its extensions to

armpit and sometimes to area of clavicula

• without axillary lymph nodes

Performed when, p.e.:

-prophylactic mastectomy is required

- as palliative procedure (bulky breast tumor,

distant metastasis

• The surgeon removes only the skin of the

nipple, areola, and the original biopsy scar.

• Then the surgeon removes the breast tissue

through the small opening that is created.

• The remaining pouch of skin provides the

best shape and form to accommodate an

implant or a reconstruction using your own

tissue.

• A skin-sparing mastectomy is not safe if

there is a possibility that tumor cells are

close to the skin. If there's any question that

the tumor may involve the skin, such as in

inflammatory breast cancer, then skin-

sparing mastectomy is not an option.

Breast removing surgery Skin-sparing mastectomy


Subcutaneous mastectomy

Removal of:

• breast tissue but saves skin, nipple, areola

Was performed:

• As preventive mastectomy for women with

a cancer in the opposite breast

• Family history of disease

Local Treatment



(mastectomy)


(lumpectomy)

• Surgery:




Lumpectomy, partial mastectomy, wide excision,

segmental mastectomy, quadrectomy

Removal of:

• Lump and part of

surrounding tissue

This operation is combined

in general with postop.

radiation and ALND


Axillary Lymph Node Dissection


Excision of level I, II lymph nodes embedded

in fat tissue ( at least 10 – 15 nodes).

Number of nodes

excised differs in

patients because

of anatomical

variety

Sentinel Lymph Node Biopsy


Based on theory that lymphatic metastases drain from

the primary tumor to a particular lymph node ( SN)

before spreading into other regional ( “non-sentinel”)

lymph nodes.

Injection of dye to tumor area

During operation, excision of

dyed node (SN), 1-4 nodes

If negative no further node

excision

If positive ALND

Local Treatment



(mastectomy)


(lumpectomy)

• Surgery:



Radiation Therapy


• Radiation often used in conjunction with surgery

(lumpectomy, or even mastectomy in patients most

as risk for local recurrence, such as those with more

than 4 positive nodes, large tumor, Dr. Susan Love’s

Breast Book, 1996)

• Radiation works best on few cells, not on large

chunks of cancer therefore after surgery

• In the early days of radiation, machine was aimed

straight-on at the breast radiation of lungs, heart

resulted in complications like heart, lung diseases

Radiation Therapy


•Now much more precise

•Radiation is performed in tangents, as well as

straight on so that the radiation goes through a

particular breast area and out to the air, less into

lungs and heart


Radiation Therapy


• Radiation is administered by a machine, called a

linear accelerator, which accelerates radioactive

particles and shoots them directly at a specific body

part

• Radiation treatment : 1x/ day, several weeks


Radiation Therapy

2. Boost – extra amount of radiation on spot

where the tumor was

Treatment is usually given in two parts:

1. The breast as a whole is radiated, including

lymph nodes if necessary.

This will last ca. 5 weeks, often using about

4700 rads ( chest X ray is a fraction of a rad)


Radiation Therapy


Skin care guide lines during treatment:

• Avoid all soaps that use fragrance, deodorants, or

any kind of metal can interact with radiation

• Don’t use deodorant on the treated side,

deodorants have lots of aluminium! Instead use

natural deodorants

• Use cornstarch on radiated area, not talcum

powder

Radiation Therapy


Side effects of radiation depend on the treated

body part.

Tumor cells are particularly sensitive to

radiation as all cells that divide frequently

- cells of hair roots loss of hair

- Skin radiation dermatitis

- Mucus of bowl radiation colitis

- If radiation gets to the lungs cough

Radiation Therapy and side effects


Fatigue

• Radiation in the body inself creates tiredness:

the body uses up all its resources to cope with

the radiation

• The fatigue usually gets worse toward end of

treatment

• The fatigue may last several months after

treatment has finished



Acute radiation erytema •Hyperemic erytema can develop as a result of

inflammatory process

Breast may swell and get more sensitive

•Tip: Hold a pillow between breasts and sleep on

the untreated side

•These early changes are reversible to a large extent

•Irradiated area has normal appearance LM: yes

•Irradiated area is reddened or irritated LM: no



Chronic effects are caused by pathological

changes to connective tissues, vessel system

(appear gradually or only after several years):

•Sclerosis of skin and subcutis: hardening of skin,

limited mobility

•Secondary atrophic changes to dermis: brown

hyperpigmentation, telangiectase, damaged

sebaceous glands ( still perspiring in irradiated

area?), radiogenic ulcerations



• Injury to Brachial Plexus, can lead to intense pain,

paresis/paralysis, impaired sensation (attention with

bandages!)

The injury can show up many years after radiation

therapy – important to rule out tumor recidivism.

• Costochondritis, kind of arthritis that causes

inflammation of sternocostal joints – can lead to

intense pain, can be treated with aspirin, anti-

arthritis medicine

• Very rarely, radiation can cause second cancers, p.e.

sarcoma

Treatment of radiation- induced fibrosis


•Regular careful skin care with oil-based moisturizing

creams – keep skin smooth, elastic

•Pretreatment of central areas before treatment of

radiation- induced fibrosis

•Two different massage techniques for loosening the

tissue: small, stationary circles usind fingertips

moving towards pretreated healthy area

Stationary circles using both hands, one

hand takes over from the other hand

Breast Reconstruction

• The woman who has undergone a B.C.O., has to deal

not only with the threatening illness, but also with the

damage to her femininity and body image

• The physical defect is a permanent

reminder of the existence of the

illness

Breast reconstruction is not a

cosmetic surgery it intends to

restore the physical & mental

balanceenables improvement in

quality of life

Breast Reconstruction

Tissue Expander + Implant

Body-own tissue, TRAM, DIEP, Gluteus

flap

Combination of body-own tissue + implant

© Ruthi Peleg, 2005 © Ruthi Peleg, 2005

Breast reconstruction with tissue expander,

silicon implant

• Insertion of implant/tissue exp. beneath pect. major

• Injection of saline solution

expansion of muscle

and skin ( months)

•Exchange tissue expander with implant

•Areola, nipple

•Adjustment of healthy breast to

reconstructed breast

Breast reconstruction with tissue expander,

silicon implant

Breast reconstruction with body own tissue

Use of muscle , skin , fat from abdomen

Use of skin, fat from

abdomen

Transverse Rectus Abdominis Myocutaneous Flap

1. TRAM

Deep Inferior Epigastric

Perforator Flap

2. DIEP

Latissimus Dorsi Myocutaneous Flap

Breast reconstruction: combination with

body own tissue + implant

Use of muscle and skin

combined with silicon

implant

Breast reconstruction with body own tissue

Documents

Breast Cancer Op Breast Reconstruction Radiation Therapy