B

Breast cancer: see invasive ductal cancer and invasive lobular cancer entries.

Breast conservation surgery: removal of a breast cancer without having to remove the breast. Various terms are used to describe the procedure, usually related to the extent of excision. Several terms are used to describe breast conservation surgery: wide local excision refers to a cuff of nomal tissue radially around the cancer; a segmental resection refers to removal of the tumour with a segment orientated towards the nipple; a quadrantectomy refers to removing the quadrant containing the cancer. Clearly the larger the tumour and the greater the resection margin, the more extensive the defect in the conserved breast. Larger defects can be repaired by primary reconstruction using tissue recruited from an adjacent area or from the back (see breast reconstruction entry). Breast conservation aims for clear radial margins (clear tissue adjacent to the edges of the tumour). Larger tumour may be treated by primary chemotherapy (see entry) that could reduce the size in order for breast conservation to be successful. Central tumours sometimes may require excision of the nipple and areolar complex with the breast cancer. Breast conservation surgery can be combined with plastic surgery techniques to obtain the optimum aesthetic outcome after surgery. This is an evolving field of oncoplastic surgery. In its simplest form, local breast parenchymal flaps are raised to fill the defect by displacement. A number of techniques can be used to combine breast reduction techniques in women with larger breasts to resect the tumour and to achieve good subsequent symmetry with the opposite breast. Other methods to resect central tumours are described, such as the Grisotti flap. Some contraindications for breast conservation include extensive multifocal breast cancer or extensive DCIS (see entries). Breast conservation surgery for cancer requires to be consolidated with adjuvant radiotherapy to the remaining breast (see also DCIS entry). Good breast conservation surgery with radiotherapy aims to lower the risk of recurrent breast cancer to less that 5-10% at ten years. Adjuvant chemotherapy (see entry) and adjuvant endocrine therapy (see entry) may also be necessary.

Breast reconstruction: rebuilding a breast removed at mastectomy, either at the time of the mastectomy - immediate reconstruction, or at a later operation - delayed reconstruction. The advantages of immediate reconstruction are to avoid awakening from the anaesthetic without a breast, and enabling maximum preservation of native skin from around the original breast envelope (skin-sparing mastectomy). Possible disadvantages are information overload at a time when women are faced with a diagnosis of breast cancer and a range of treatment options, and converting the relatively straightforward operation of mastectomy to one that might be complicated and prolonged. In general terms, there are several methods of breast reconstruction. (i) Implant alone - the use of an implant placed behind the chest wall muscles and their covering fascia. The degree of ptosis (or droop) that can be achieved by this method may be limited. The implant may be silicone or gel filled, or a combination of both. Implants can be round or breast shaped. (ii) Latissimus dorsi (LD) (back muscle) flap, with or without an implant. The latissimus muscle is a flat muscle from the back that can be mobilised and transposed to the front of the chest to reconstruct the breast. An implant is usually used in conjunction with this technique, but in selected cases, an implant can be avoided. (iii) A pedicled transverse rectus abdominus flap (TRAM) involves moving the tissue from the lower abdomen to reconstruct the breast, usually without the need to use an implant. The TRAM is mobilised connected to its blood supply within the muscle - hence the term pedicled. Taking the muscle with the fat and skin leaves a potential source of weakness at the muscle bed that may need to be repaired at the time of surgery. (iv) A free transverse rectus abdominus flap is similar to the pedicled TRAM but only a small section of the muscle is resected. The blood supply is disconnected from the lower abdomen and reconnected using a specialised microvascular surgical technique to a set of small vessels under the arm. There are many variations of this TRAM technique. (v) the lower abdominal skin and fat can also be mobilized with the deep inferior epigastric vessels (DIEP) or the superficial inferior epigastric artery (SIEA) – these flaps have the advantage of muscle sparing. (vi) Other free flaps can be created using similar microvascular anastomotic techniques without an implant:, buttock (based on the superior or inferior gluteal artery, the S-GAP or I-GAP, or lateral thigh (tensor fascia lata). Breast reconstrustion may be accompanied by adjustment of the opposite breast to achieve symmetry.