staging , grading and management of breast carcinoma

1. STAGING, GRADING
AND MANAGEMENT
OF BREAST
CARCINOMA

2. (p)T (Primary Tumor)
Tis Carcinoma in situ (lobular or ductal)
T1 Tumor ≤2 cm
T1a Tumor ≥0.1 cm, ≤0.5 cm
T1b Tumor >0.5 cm, ≤1 cm
T1c Tumor >1 cm, ≤2 cm
T2 Tumor >2 cm, ≤5 cm
T3 Tumor >5 cm
T4 Tumor any size with extension to the chest wall or
skin
T4a Tumor extending to the chest wall (excluding the
pectoralis)
T4b Tumor extending to the skin with ulceration, edema,
satellite nodules
T4c Both T4a andT4b
T4d Inflammatory carcinoma
American Joint Committee on Cancer Staging System for Breast Ca.

3. (p)N (Nodes)
N0 No regional node involvement, no special studies
N0 (i-) No regional node involvement, negative IHC
N0 (i+) Node(s) with isolated tumor cells spanning <0.2 mm
N0 (mol-) Negative node(s) histologically, negative PCR
N0 (mol+) Negative node(s) histologically, positive PCR
N1 Metastasis to 1-3 axillary nodes and/or int. mammary
positive by biopsy
N1(mic) Micrometastasis (>0.2 mm, none >2.0 mm)
N1a Metastasis to 1-3 axillary nodes
N1b Metastasis in int. mammary by sentinel biopsy
N1c Metastasis to 1-3 axillary nodes and int. mammary by
biopsy

4. N2 Metastasis to 4-9 axillary nodes or int. mammaryclinically
positive, without axillary metastasis
N2a Metastasis to 4-9 axillary nodes, at least 1 >2.0mm
N2b Int. mammary clinically apparent, negative axillary nodes
N3 Metastasis to ≥10 axillary nodes or combination of axillaryand
int. mammarymetastasis
N3a ≥10 axillary nodes (>2.0 mm), or infraclavicular nodes
N3b Positive int. mammary clinically with ≥1 axillary nodes or >3
positive axillary nodes with int. mammary positive bybiopsy
N3c Metastasis to ipsilateral supraclavicular nodes

5. M (Metastasis)
M0 No distant metastasis
M1 Distant metastasis

6. STAGE TNM
5-YEAR RELATIVE
SURVIVALRATE (%)[*]
0 Tis, N0, M0 100
I T1, N0, M0 100
IIA T0, N1, M0 92
T1, N1, M0
T2, N0, M0
IIB T2, N1, M0 81
T3, N0, M0
IIIA T0, N2, M0 67
T1, N2, M0
T2, N2, M0
T3, N1, M0
T3, N2, M0
IIIB T4, N0, M0 54
T4, N1, M0
T4, N2, M0
IIIC Any T, N3, M0 [†]
IV Any T, any N, M1 20

7. 7SR_Ca_Breast_Rx
Early Breast Cancer(EBC): Stage I & II, T1N1, T2N1, T3N0
Locally Advanced Breast Cancer(LABC): Stage IIIA & IIIB
Metastatic Breast Cancer: Stage IV

8. Score
1 2 3
A. Tubule formation >75% 10-75% < 10%
B. Mitotic count per high-
power field
< 7 7-12 >12
C. Nuclear size and
pleomorphism
Near normal
Little variation
Slightly enlarged
Moderate variation
Markedly
enlarged
Marked
variation
Grading System in Invasive Breast Cancer
(Modified Bloom and Richardson) )

9. Grade I cancer if the total score (A+ B + C) is 3-5
Grade II cancer if the total score (A+ B + C) is 6 or 7
Grade III cancer if the total score (A+ B + C) is 8 or 9

10. Sentinel Lymph Node Biopsy
• Sentinel lymph node (SLN) biopsy is a minimally
invasive procedure designed to stage the axilla inbreast
cancer patients who have clinically negativenodes.
• Sentinel nodes are the first node or first group of nodes
that drain from the breast to theaxilla.
• SLN biopsy has become the preferred SLN techniquefor
axillary staging, because it offers accuracy equivalent to
that of axillary lymph node dissection with less
morbidity.
• According to the American College of Breast Surgeons
(ACBS), SLN biopsy is suitable for virtually all clinically
node-negative T1-2 invasive breastcancers

11. SLN biopsy technique• The best results with SLN biopsyare
achieved with the combination of
careful intraoperative digital
examination and lymphatic
mapping.
• Technique involves injecting
radioisotope (technetium-99m
sulfur colloid) alone or radioisotope
plus a patent blue dye (Lymphazurin
or methylene blue) into the tissues
of the breast.
• With SLN dissection, typically 1-3
lymph nodes are removed and
tested for nodal metastasis with
hematoxylin and eosin (H&E)stain
and IHC with an anticytokeratin
cocktail.

12. Relative contraindications
• any procedure that potentially alterslymphatic
drainage to the axilla.e.g.
 breast augmentation, particularly when the implants
reside in a subglandular position
 reduction mammoplasty
• Allergy to blue dye or radiocolloid
• Pregnancy
Absolute contraindications
• Inflammatory breast cancer
• presence of biopsy proven metastatic axillary
lymphadenopathy

13. Management of Ca Breast
Options available;
I. Surgery
II. Radiotherapy
III. Hormone Therapy
IV. Chemotherapy
Multi-pronged approach adopted
Single approach ineffectual
13

14. I. SURGICAL Approaches
1. Total (Simple) Mastectomy
2. Total Mastectomy with Axillary Clearance
3. Modified Radical Mastectomy [MRM]
1) Patey’s Operation
2) Scanlon’s Operation
3) Auchincloss’ MRM
4. Radical Mastectomy of Halsted
5. Conservative Breast Surgeries
1) Wide Local Excision [WLE]
2) Lumpectomy
3) Quadrantectomy
4) Toilet Mastectomy
5) Skin-Sparing/Keyhole Mastectomy [SSM]
SR_Ca_Breast_Rx 14

15. 1. TOTAL/SIMPLE MASTECTOMY
Tissues removed:
Tumour, entire breast, areola,
nipple, skin over breast,
Axillary tail of Spence, Pectoral
fascia
Tissues retained:
NO Axillary Dissection
Subjected to Radiotherapy
later
SR_Ca_Breast_Rx 15

16. 2. TOTAL MASTECTOMY with AXILLARY
CLEARANCE
Common procedure
Tissues removed:
TM + Axillary fat, Axillary fascia,
Level I and II Axillary LN
SR_Ca_Breast_Rx 16

17. 3. MODIFIED RADICAL MASTECTOMY
1) Patey’s Operation
 Tissues removed:
TM + Clearance of Level I,
II & III Axillary LN +
Pectoralis minor
 Tissues preserved:
Nerve to Serratus
anterior, Nerve to
Latissimus dorsi,
Intercostobrachial nerve,
Axillary Vein, Cephalic
Vein, Pectoralis major
SR_Ca_Breast_Rx 17

18. Procedure:
Elliptical incision made on medial aspect of 2nd and 3rd
ICS enclosing the nipple, areola and tumour which
extends laterally into Axilla along the Anterior Axillary
fold. Upper and lower skin flaps are raised. Breast with
tumour is raised from the medial aspect of Pectoralis
major. Dissection is proceeded laterally while ligating
pectoral vessels. In axilla, lateral border of Pectoralis
minor is divided from Coracoid process to clear Level II
LN. Level III cleared subsequently. Pectoralis minor
removed
2) Scanlon’s Operation: Pectoralis minor incised
Level III LN removed
3) Auchincloss’ MRM: Pectoralis minor left intact
Level III LN not removed
SR_Ca_Breast_Rx 18

19. SR_Ca_Breast_Rx 19

20. SR_Ca_Breast_Rx 20

21. 4. RADICAL MASTECTOMY of HALSTED
Tissues removed:
Tumour, entire breast,
areola, nipple, skin over
tumour, Pectoralis major &
minor muscles, fat, fascia,
Level I,II,III Axillary LN, few
digitations of Serratus
anterior muscle
Tissues retained:
Axillary vein
Bell’s nerve (N.to Serr.ant)
Cephalic vein
SR_Ca_Breast_Rx 21
Complications:
Lymphoedema
Lymphangiosarcoma (>3 years)

22. 5. BREAST CONSERVATIVE SURGERIES
1. Wide Local Excision (WLE)/ Partial
Mastectomy
Removal of unicentric tumour with
1cm clearance margin.
Incision: Over tumour + Axillary
Dissection + RT
2. Quadrantectomy:
Removal of entire quadrant with ductal
system with 2-3cm normal breast tissue
clearance. Part of QUART Therapy
(Quadrantectomy + Axillary dissection + RT)
Not advocated now.
3. Skin Sparing Mastectomy
4. Lumpectomy (=WLE)
Term rarely used
SR_Ca_Breast_Rx 22

23. Indications and Contraindications for Breast-Conserving
Surgery
Indications
•T1, T2 (<4 cm), N0, N1, M0
•T2 >4 cm in large breasts
•Single clinical and mammographic lesion
Contraindications
•T4, N2, or M1 (some localized T4 disease and some patients with limited
metastatic disease may be suitable for breast-conserving surgery)
•Patients who prefer mastectomy
•Clinically evident multifocal/multicentric disease ·
• Prior radiation therapy to the breast or chest wall
• Diffuse suspicious or malignant appearing microcalcifications
• Widespread disease that cannot be incorporated by local excision through a single
incision that achieves negative margins with a
satisfactory cosmetic result.
• Positive pathologic margin

24. Relative contraindications
•Active connective tissue disease involving the skin (especially scleroderma
and lupus)
•Tumors > 5 cm (category 2B)
• Focally positive margin
• Women < 35 y or premenopausal women with a known BRCA 1/2 mutation:
May have an increased risk of ipsilateral breast recurrence or contralateral
breast cancer with breast conserving therapy
 Prophylactic bilateral mastectomy for risk reduction may be considered
•Large or central tumors in small breasts

25. SR_Ca_Breast_Rx 25

26. SR_Ca_Breast_Rx 26

27. Other procedures
Toilet Mastectomy
In locally advanced tumour
(LABC), tumour with breast
tissue removed – prevent
fungation
Post-chemotherapy
Significance: (?)
Extended Radical
Mastectomy
Radical Mastectomy +
Removal of Internal
Mammary Nodes (ipsilateral
+/- contralateral)
Not done at present
SR_Ca_Breast_Rx 27

28. COMPLICATIONS of
M.R.M/MASTECTOMY
• Injury/ Thrombosis of Axillary Vein
• Seroma
• Shoulder Dysfunction
• Pain and Numbness
• Flap Necrosis and infection
• Lymphoedema and its problems
• Axillary hyperaesthesia
• Winged Scapula
SR_Ca_Breast_Rx 28

29. LYMPHANGIOSARCOMA (Stewart-
Treve’s Syndrome)
 In ipsilateral upper limb
 Develops in people with
Lymphoedema after Mastectomy
with Axillary clearance.
 3-5 years after development of
Lymphoedema
 Presentation: Multiple subcutaneous
nodules
 Requires Forequarter Amputation
 Poor prognosis
SR_Ca_Breast_Rx 29

30. II. RADIOTHERAPY Approach
Indications;
1. Conservative Breast Surgery adjuvant [Breast]
2. Total Mastectomy [Axilla]
3. High-risk of relapse patients
1) Invasive Carcinoma
2) Extensive in-situ Carcinoma
3) Age < 35 years
4) Multifocal disease
4. Bone secondaries [Palliative]
5. Atrophic Schirrous Carcinoma [Curative]
6. Pre-Operatively (reduce tumour size and downstage)
7. >4 +’ve Axillary LN, Pectoral fascia involvement, positive
surgical margins, Extra-nodal spread
SR_Ca_Breast_Rx 30

31. Chest Wall Axilla Post-BCS
T3 tumour>5cm
Residual disease
LABC
Positive margin/close
surgical margin <2cm
Conservative surgery
Inflammatory Carcinoma
>4 nodes +’ve
Extra-nodal spread
Axillary status unknown/
not assessed
MANDATORY!
Local + Axilla
Tangential fields: 50 Gy-25
fractions-5 weeks
Another 10 Gy to tumour
bed
Internal Mammary and
Supra-clavicular area may
be included in the
radiation field
SR_Ca_Breast_Rx 31

32. External Radiotherapy
Over Breast area, axilla, Internal mammary and
Supra-clavicular area
Total dosage: 5000 cGy units
200-cGy units daily 5 days a week for 6 weeks
SR_Ca_Breast_Rx 32

33. SR_Ca_Breast_Rx 33

34. III. HORMONE-THERAPY Approach
Principles;
 Used in ER/PR +’ve patients only
 All age groups included now
 Relatively safe
 Easy to administer
 Adequate prophylaxis against Ca of opposite
breast
 Useful in Metastatic Carcinoma
 Reduces recurrence – improves quality of life and
longevity
SR_Ca_Breast_Rx 34

35. Includes;
 Medical
i. Oestrogen Receptor Antagonists – Tamoxifen 20 mg
ii. Progesterone receptor Antagonist
iii. Oral Aromatase Inhibitors – Letrozole 2.5 mg OD, Anastrozole, Exemestane;
Aminoglutethimide [Medical Adrenalectomy]
iv. Androgens – inj.Testosterone propionate 100mg IM three times a week,
Fluoxymestrone 30 mg daily
v. LHRH Agonists – Goserelin (Zoladex) [Medical Oophorectomy]
vi. Progestogens – Medroxypregesterone acetate 400 mg
 Surgical
i. Ovarian Ablation by
a. Surgery (Bilateral Oophorectomy)
b. Radiation
ii. Adrenalectomy
iii. Pituitary ablation
SR_Ca_Breast_Rx 35

36. Tamoxifen
 SERM (Selective Estrogen Receptor Modulator)
 Blocks cytosolic ER in breast tissue
 Dose: 10 mg BD or 20 mg OD for 5 days
 T1/2: 7 days. Shows effects after 4 weeks
 Cheap, easily available, effective
 Indications:
 Carcinoma Breast
 Fibroadenosis
 Male infertility
 Desmoid tumours
 Side-effects:
 ‘Tamoxifen Flare’: Flushing, tachycardia, sweating, pruritis vulva,
vaginal atrophy and dryness (pre-menopausal), vaginal discharge
(post-menopausal), fluid retention, weight gain
 Agonistic action: Endometrium (Ca), Bone (Osteoporosis, pathological
#), Coagulation system (DVT, TIA, CVA, MI)
SR_Ca_Breast_Rx 36

37. Letrozole
 Non-steroidal competitive inhibitor of Aromatase
Reduces Oestrogen levels by 98%
 More expensive, more effective, fewer side-effects
Indications:
1. Adjuvant Endocrine therapy in Post-menopausal women
with hormone sensitive breast cancer
2. Metastatic disease
3. Recurrent disease
 Dosage: 2.5 mg OD for 5 years or for 3 years after
Tamoxifen
 Side-effects: Vaginal atrophy, bleeding p.v, CVS
problems and osteoporosis.
SR_Ca_Breast_Rx 37

38. Novel drugs - Biologicals
1. TRANSTUZUMAB (Herceptin)
 Monoclonal Ab. Blocks Her-2/Neu receptors
(Tyrosine kinase receptor)
 Useful only in Her-2/Neu +’ve cases Metastatic
d/s
 Intravenous infusion 4mg/kg loading, 2mg/kg
maintenance dose for 1 year
2. BEVACIZUMAB
Vascular Growth Factor receptor inhibitor
3. LAPITINAB
Combined Growth Factor receptor inhibitor
SR_Ca_Breast_Rx 38

39. IV. CHEMOTHERAPY Approach
Types;
A. Adjuvant Chemotherapy
 Administration of Cytotoxics after surgery
 Eliminate clinically undetectable distant spread
B. Neoadjuvant Chemotherapy
 Administration of Cytotoxics in large operable tumours
before surgery
 Reduce loco-regional tumour burden – downstage
 Amenable to surgical resection after 3 doses
C. Palliative Chemotherapy
 Advanced Ca Breast
 Metastatic Ca Breast
SR_Ca_Breast_Rx 39

40.  Indications;
• All node +’ve patients
• Primary tumour >1cm in size
• Poor prognostic factors
• Advanced Ca Breast
• Inflammatory Ca Breast
• Metastatic Ca Breast
 Drugs;
SR_Ca_Breast_Rx 40
CMF Regime CAF Regime MMM Regime
Cyclophosphamide Cyclophosphamide Methotrexate
Methotrexate Adriamycin Mitomycin-C
5-Fluorouracil 5-Fluorouracil Mitozantrone

41. Chemotherapy Regimes
 CAF and CMF – commonly used, monthly/3
weeks cycles for 6 months
 Taxanes
 Eg: PACLITAXEL and DOCETAXEL
 G2/M phase arrestors
 Use: Metastatic Ca Breast
 1st line: CMF > CAF > MMM
 2nd line: Taxanes
 3rd line: Gemcitabine
SR_Ca_Breast_Rx 41

42. Lobular Carcinoma in Situ
Lobular carcinoma in situ (LCIS) identified on breast biopsy
Stage 0 Tis, N0, M0
surgical biopsy
LCIS withoutother
cancer
Counseling regarding risk reduction
And
observation
6-12 monthly CBE and annual mammogram
pleomorphic LCIS may have a similar biological behavior to that of DCIS.
• may consider complete excision with negative margins

43. Ductal carcinoma in situ (DCIS)
Stage 0 Tis, N0, M0
Lumpectomy without lymph node surgery + whole breast radiationtherapy
or
Total mastectomy with or without sentinel node biopsy ±reconstruction
or
Lumpectomy without lymph node surgery without radiation therapy
Consider tamoxifen for 5 years for:
 Patients treated with breast-conserving therapy (lumpectomy) andradiation
therapy especially for those with ER-positive DCIS. The benefit oftamoxifen
for ER-negative DCIS is uncertain
 Patients treated with excision alone
 Interval history and physical exam every 6-12 mo for 5 y, thenannually
 Mammogram every 12 mo
 If treated with tamoxifen, monitor

44. INDICATIONS FOR SENTINEL LYMPH NODE BIOPSY IN DCIS
• Patients with microinvasion
• Patients undergoing mastectomy for diffuse disease
• Patients with a high suspicion of harboring invasive disease
• Extensive high-grade disease or necrosis on core biopsy
• Imaging studies suggesting invasion
INDICATIONS FOR MASTECTOMY IN DUCTAL CARCINOMA IN SITU
1. Multicentric disease
2. Diffuse microcalcifications on mammography
3. Large tumor size with predictably bad cosmetic outcome
4. Contraindication to radiation
 Pregnancy
 Connective tissue disorder(scleroderma)
 Previous radiation therapy
 Patient preference

45. RADIATION THERAPY AFTER LUMPECTOMY FOR DUCTAL CARCINOMA IN SITU
• Radiation therapy (XRT) reduces ipsilateral breast tumor recurrence by 50% to 60%.
• After XRT, the annual rate of an invasive recurrence is 0.5% to 1% per year.
• XRT does not improve necessarily survival.
PEARLS IN M/M OF DCIS
•Complete axillary lymph node dissection should not be performed in the
absence of evidence of invasive cancer or proven metastatic disease
•Patients found to have invasive disease at total mastectomy or re-excision
should be managed as stage l or stage ll disease, including lymph node staging
•Margins greater than 10 mm are widely accepted as negative
•Margins less than 1 mm are considered inadequate.
•There is no evidence that survival differs between the three treatment Options

46. EARLY CARCINOMA BREAST [ECB] -
Management
 Breast Conservation Surgery – Wide Local Excision/ QUART/
SSM; RT locally
 Patey’s Operation [MRM]
 Tamoxifen 10mg BD
 Sentinel Lymph Node Biopsy [SNLB]
 Regular follow-up with
 Radioisotope Bone scan
 CEA tumour marker
 Indications for Total Mastectomy in EBC;
 Tumour size >5cm
 Multicentric tumour
 High-grade (poorly-differentiated) tumour
 Tumour margin not clear after BCS
SR_Ca_Breast_Rx 46

47. Stage I
T1, N0, M0
or
Stage IIA
T0, N1, M0
T1, N1, M0
T2, N0, M0
or
Stage IIB
T2, N1, M0
T3, N0, M0
or
Stage IIIA
T3, N1, M0
General workup
If clinical stage
lllA (T3, N1,M0)
consider:
Bone scan
(category 2B)
 Abdominal ±
pelvis CT or US or
MRI
 Chest imaging
Lumpectomy withsurgical
axillary staging (category1)
(Preferred)
OR
Total mastectomy with
surgical axillary
staging(category 1) ±
reconstruction
Or
Preoperative Chemotherapy
If T2 or T3 and fulfills criteria
for breast conserving therapy
except for size
TREATMENT OF CLINICAL STAGE I, IIA, OR IIB DISEASE OR T3, N1, M0

48. MANAGEMENT OF LOCALLY ADVANCED BREAST CA.
•LABC is defined as either large,bulky
primary tumors or extensive adenopathy.
•Patients with AJCCT3 or T4 tumors
(associated with chest wall fixation, skin
ulceration, or both) are classified asLABC.
•Patients with AJCC N2 or N3 disease
(matted axillary nodes, supraclavicular or
internal mammary metastases)

52. •Interval history and physical exam every 4-6 mo for 5 y, then every 12 mo
Annual mammography
Women on tamoxifen: annual gynecologic assessment every 12 mo if
uterus present
Women on an aromatase inhibitor or who experience ovarian failure
secondary to treatment should have monitoring of bone health with a
bone mineral density determination at baseline and periodically thereafter
Assess and encourage adherence to adjuvant endocrine therapy.
Evidence suggests that active lifestyle, achieving and maintaining an
ideal body weight (20-25 BMI) may lead to optimal breast cancer
outcomes.
SURVEILLANCE/FOLLOW-UP

53. Intervention Year1 Year2 Year3-5 Year6+
History &
physical
examination
q3-4mo q4mo q6mo Annually
Mammography Annually(or 6
mo after post –
BCS*
irradiation)
Annually Annually Annually
CXR Not
recommended
Not
recommended
Not
recommended
Not
recommended
Pelvic
examination
Annually Annually Annually Annually
Bone density q1-2y

54. Metastatic Ca Breast
– Hematogenous spread to;
• Bone: most common. Vertebra – Batson’s (valveless) venous
plexus and posterior intercostal veins, Ribs, Humerus, Femur
• Lungs – ‘Cannon-ball’ 20 in parenchyma, Pleural effusion,
Chest wall 20
• Liver
• Brain
– Treatment strategies;
• Chemotherapy: CMF/CAF
• Radiotherapy
• Tamoxifen, Oophorectomy
• Transtuzumab, Bevacizumab
• Hypercalcemia – Hydration, steroids, Palmidronate 90mg i.v
once a month
• Internal fixation of pathological #
SR_Ca_Breast_Rx 54

55. 55SR_Ca_Breast_Rx

56. 56SR_Ca_Breast_Rx

57. CARCINOMA BREAST in PREGNANCY -
Management
1st Trimester 2nd Trimester 3rd Trimester
MRM MRM MRM
Axillary node +’ve:
Termination of pregnancy +
Chemotherapy
Chemotherapy carefully After delivery –
Chemotherapy with
suppression of lactation
SR_Ca_Breast_Rx 57
Note the following;
Hormone treatment contra-indicated: Teratogenic
Radiotherapy: No role
MRI is the investigation of choice
Can become pregnant 2 years after completion of therapy as recurrence rates
are highest in 2 years

58. Follow-up
• Clinical examination in detail @ regular
intervals
• Yearly/2-yearly Mammography of the treated
and contralateral breast is a must
• Bone-scan, CT Chest/abdomen, tumour
markers are done only if there is clinical
suspicion. Not a regular routine follow-up at
present
SR_Ca_Breast_Rx 58

59. BREAST RECONSTRUCTION
 Done in young patients with early stage of disease
 Symmetry is the most important factor
 Factors deciding reconstruction;
 Amount of skin retained – SSM best
 Stage of Carcinoma
 Earlier Radiotherapy
 Type of flap used
 Timing
 Immediate Reconstruction: in Early stages with good response to
neoadjuvants. CI in LABC
 Delayed Reconstruction: 3-9 months after surgery. Done in LABC.
Allows post-op RT without prosthesis exposure, avoids fibrosis and
fat necrosis where TRAM flap in used
SR_Ca_Breast_Rx 59

60. Methods of Reconstruction
1. Breast Implants – Silicone gel
2. Expandable Saline prosthesis
3. Flap with implant/expanders
4. External breast prosthesis
5. Flap reconstruction
1. Latissimus dorsi (LD) flap
2. Contralateral Tranversus Abdominis (TRAM) flap
3. Superior Gluteal flap
4. Ruben’s flap: soft tissue over Iliac crest
SR_Ca_Breast_Rx 60

61. SR_Ca_Breast_Rx 61

62. SR_Ca_Breast_Rx 62

63. 63SR_Ca_Breast_Rx

64.  Complications of Implants;
 Pain, exposure of implant and rupture
 Displacement, extrusion
 Infection
 Capsular contraction
SR_Ca_Breast_Rx 64
LD Flap TRAM flap
Myocutaneous flap Myocutaneous flap
Subscapular artery Superior Epigastric artery
Easy Ipsilateral or contralateral flap
Can be placed over prosthesis Gives bulk. No need of prosthesis
Reliable, well-vascularised Free TRAM flap into IMA
Low complication rate Mesh placement in abdomen required
Unsightly donor area on back Donor site morbidity & fat necrosis

65. 65SR_Ca_Breast_Rx

66. Thank you
SR_Ca_Breast_Rx 66