45 year old female presented with a breast lump on Lt side Upper quadrant 12-0-clock position. It was Hard in consistency, Mobile, Non tender. Trucut biopsy of the same was s/o Infiltrating Duct Carcinoma Grade II. Mammography performed was suggestive of a BIRADS IV lesion in Lt breast and ipsilateral axillary nodes. Rest of the breast and opposite breast was normal ( no evidence of any malignant or premalignant lesions)PET scan was s/o no distant metastases.
Pt was counselled for Primary surgery. Surgical options were offered in form of Modified Radical Mastectomy (MRM) and Breast Conserving Surgery (BCS).Pros and cons of both the surgeries were explained. (Fig 1 – Preoperative photograph)
Patient opted for BCS. Frozen section was appointed for intraoperative margin evaluation.
In view of upper quadrant lump , post lumpectomy a volume displacement procedure was planned for cosmetic outcomes. A Batwing incision was planned. (Fig 1-Planned Incision)
Wide local excision of the lump performed. Radioopaque markers were placed to mark margins. Breast tissue adjacent to the scar was mobilized in both the planes i.e. subcutaneously and above the pectoral fascia and primary closure of the wound done as depicted in photograph.(Fig 3)
Final Histopathology was s/o pT2N1. Patient is at present receiving adjuvant chemotherapy. She is then planned for Radiation therapy.
Review of literature:
When a woman is diagnosed with breast cancer many aspects of her physical, emotional, and sexual wholeness are threatened.
The quickly expanding field of oncoplastic breast surgery aims to enhance the physician commitment to restore the patient's image and self-assurance. By combining a multidisciplinary approach to diagnosis and treatment with oncoplastic surgery, successful results in the eyes of the patient and physician are significantly more likely to occur.
Since the Early Breast Cancer Trialists’ Collaborative Group established the equivalency of mastectomy and breast conserving therapy in 1985, breast conserving surgery has remained the optimal surgical treatment for the breast cancer patient . The goals of breast conserving surgery are the removal of breast cancer with an adequate surgical margin and maintenance of a breast that is cosmetically acceptable to the patient. Mastectomy with or without breast reconstruction is the treatment of choice when tumor resection and cosmesis is unattainable. Given the understandable desire to preserve a sense of wholeness, it is not surprising that many women consider mastectomy to be an unacceptable cosmetic alternative to breast conserving surgery.
Increasing use of mammographic screening and neoadjuvant chemotherapy has rendered 70–80% of breast cancer patients as potential candidates for breast conserving surgery (BCS). Nonetheless, BCS remains highly underutilized, with nearly 50% (Western Literature) of women either selecting or being advised to undergo mastectomy .
Oncoplasty was originally defined as an assortment of volume replacement techniques performed by plastic surgeons to replace all or part of the resected breast volume with myocutaneous tissue flaps. It has recently been expanded to include a wide range of volume displacement or volume redistribution procedures performed by breast surgeons optimize breast shape and breast volume following breast cancer surgery (3-7).
The cornerstone of oncoplastic breast conserving surgery is the mobilization and redistribution of the breast gland to reconstruct the breast mound. Since nearly all patients are expected to undergo adjuvant radiotherapy, placement of multiple radiopaque tissue markers (e.g., Hemoclips) along the surgical margins should be performed to facilitate radiation planning, margin re-excision, and subsequent mammographic surveillance. (9).
For tumors in Upper central portion ,within a few centimeters of but not directly involving, the nipple there are two incision which can be planned. (8,10)
- The Batwing Incsion
- Crescent Mastopexy
The batwing resection consists of a crescent-shaped central area of skin and gland adjoining 2 triangle-shape or wing-like areas of skin and gland extending from both sides of the areola. This permits correction of breast ptosis by elevating the lower half of the breast and nipple-areolar complex. However, since the skin and glandular incision extends both medially and laterally to the nipple-areolar complex, the batwing incision also permits resection of a larger lesion that extends a few centimeters medial and/or lateral to the nipple-areolar complex. In addition, the large area of skin and glandular tissue that may be resected with the batwing resection allows for greater correction of ptosis than is possible with the crescent mastopexy resection. The cosmetic result is a smaller, less ptotic breast possessing two horizontal scars (at the 9-10 o’clock and 2-3 o’clock positions) connected by a less visible circumareolar incision at the upper half of the areola. (Fig 4)
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