Drains (high vs. low suction; short vs. long time) – No significant difference
DVT prophylaxis - LMWH 20mg vs. 5000U s/c heparin → ↑ haematoma: 1% vs. 2-5%
Mastectomy versus BCS
Overall survival is equivalent
In a meta-analysis of 30 studies (6 randomized trials and 24 retrospective reviews) including over 1,800,000 patients with follow-up ranging from 4 to 20 years, BCT is associated with improved OS compared with mastectomy (relative risk 0.64, 95% CI 0.55–0.74)
Equivalent local recurrence rates with the addition of radiotherapy
But ipsilateral recurrence with BCS was higher (5-19% versus 4-14%)
Recurrence in WLE reduced (40% ⇒ 15%) with radiotherapy (NSABP-06)
Thus BCS and radiotx equivalent to Mastectomy, but not BCS alone
Breast Conserving Surgery (WLE + Radiotx)
Indications
Contraindications
Surgical contraindications
Small breast vs. tumour ratio
Could consider neoadjuvant treatment or therapeutic mammoplasty and contralateral breast reduction simultaneously
Inflammatory Breast cancer
Diffuse malignant microcalcifications on mammography
Radiotherapy contraindications
Pregnancy
1st/2nd trimester pregnancy – can’t give radiotherapy in timely manner
If 3rd trimester could give soon after delivery
Prev Radiotherapy
Connective tissue disorder
Scleroderma and Sjögren disease are contraindications to radiation because of cutaneous fragility
Patient preference for mastectomy
Carful consideration in patients with strong family of breast Ca / BRCA 1 or BRCA 2 carriers
Although a family history of breast cancer is not a contraindication to BCT, women with hereditary breast cancer (eg, BRCA1 or BRCA2 mutation carrier) should be informed about their increased risk of a second primary cancer, and that bilateral mastectomy may reduce that risk.
Contralateral prophylactic mastectomy (CPM) has not been shown to have a survival benefit
That is because the survival rates tend to be driven by the metastatic potential of the first cancer and mastectomy does not eliminate the risk of either a chest wall recurrence or a new primary.
Technique
Margin
Invasive - “No ink on tumour”
DCIS - 2mm
Orientate specimen ± X-ray
Outcomes
WLE → At least 1:10 chance of need for re-excision
20-25% will need further surgery
In ACT 30% of WLE pts needed ≥ 2 ops
15% unhappy with cosmetic outcome – associated with volume loss
Mastectomy
Indications
See Contraindications to WLE + Radiotx
Extensive calcification on mammography
Can’t obtain clear margins with WLE
+/- Reconstruction
Delayed reconstruction if poor prognosis / high risk of radiotherapy
Don’t delay adjuvant therapy by ↑ risk of wound complications