BCT: Towards Optimal Outcomes Dr VIJAY HARIBHAKTI Consultant Surgical Oncologist, Jaslok Hospital and Breach Candy Hospital, Mumbai, India These Power Point presentations are free to download only for academic purposes, with due acknowledgements to authors and this website.
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BCT: Towards Optimal Outcomes Dr VIJAY HARIBHAKTI Consultant Surgical Oncologist, Jaslok Hospital and Breach Candy Hospital, Mumbai, India Dr VIJAY HARIBHAKTI.
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BCT:Towards Optimal Outcomes
BCT:Towards Optimal Outcomes
Dr VIJAY HARIBHAKTI
Consultant Surgical Oncologist,
Jaslok Hospital and Breach Candy Hospital, Mumbai, India
Dr VIJAY HARIBHAKTI
Consultant Surgical Oncologist,
Jaslok Hospital and Breach Candy Hospital, Mumbai, India
These Power Point presentations are free to download only for academic purposes, with due acknowledgements to authors and this website.
SHIFTING PARADIGMSPast to present
SHIFTING PARADIGMSPast to present
Fundamental understanding of disease
Approach to patient
Stage at presentation
Diagnostic Methods
Surgery
Adjuvant therapy
Reconstruction
Fundamental understanding of disease
Approach to patient
Stage at presentation
Diagnostic Methods
Surgery
Adjuvant therapy
Reconstruction
BCTStage at Presentation
BCTStage at Presentation
Clinically obvious
Clinically occult, demonstrable on mammography / sonography
Mammographically occult,demonstrable by other modalities, i.e.MRI, PET
Clinically obvious
Clinically occult, demonstrable on mammography / sonography
Mammographically occult,demonstrable by other modalities, i.e.MRI, PET
BCT:Is there any debate?
BCT:Is there any debate?
Not if we understand the fundamental biology of disease
Not if we exercise appropriate case selection
Clearly not when we follow the results of RCTs
Not if we understand the fundamental biology of disease
Not if we exercise appropriate case selection
Clearly not when we follow the results of RCTs
BCT: When?BCT:
When?
Patient desire
Single primary tumour
Able to achieve clear margins
Tumour: Breast ratio that permits acceptable cosmetic result
Able to deliver PORT
Able to maintain follow-up
Patient desire
Single primary tumour
Able to achieve clear margins
Tumour: Breast ratio that permits acceptable cosmetic result
Able to deliver PORT
Able to maintain follow-up
BCT: When not?
BCT: When not?
Multiple primary tumours in separate quadrants
Diffuse suspicious microcalcifications on mammography
Inability to achieve negative margins
Inability to deliver PORT (age & fitness, breast configuration, previous RT, pregnancy, collagen disease)
Multiple primary tumours in separate quadrants
Diffuse suspicious microcalcifications on mammography
Inability to achieve negative margins
Inability to deliver PORT (age & fitness, breast configuration, previous RT, pregnancy, collagen disease)
BCT: Essential Goals
BCT: Essential Goals
Excellent Local ControlComparable with mastectomy
Acceptable Aesthetics:Adequate substance, contour, nipple-areola: breast relationship, symmetry
No compromise in survival
Excellent Local ControlComparable with mastectomy
Acceptable Aesthetics:Adequate substance, contour, nipple-areola: breast relationship, symmetry
No compromise in survival
BCT : High risk medial quadrant disease
BCT : High risk medial quadrant disease
BCT:Fundamental Principles
BCT:Fundamental Principles
Appropriate incision plan for primary
Discontinuous axillary incision
Resecting ‘exactly enough’ tissue
Appropriate closure technique
Appropriate post-operative breast support
Appropriate incision plan for primary
Discontinuous axillary incision
Resecting ‘exactly enough’ tissue
Appropriate closure technique
Appropriate post-operative breast support
BCT:Primary Incision Plan
BCT:Primary Incision Plan
Directly over localized mass
Adequate in length to achieve satisfactory lateral margins
Curvilinear and parallel to areola for upper and lateral quadrant masses
Radial incisions for inner central and lower quadrants
Directly over localized mass
Adequate in length to achieve satisfactory lateral margins
Curvilinear and parallel to areola for upper and lateral quadrant masses
Radial incisions for inner central and lower quadrants
BCT: Result at One YearBCT: Result at One Year
BCT : Radial incision for 6 o’clock T2 lesion
BCT : Radial incision for 6 o’clock T2 lesion
BCT:Axillary incision
BCT:Axillary incision
Discontinuous in majority
Preferably in available crease line
Preferably below follicle line
Horizontal, between axillary folds
Invisible in frontal view
Discontinuous in majority
Preferably in available crease line
Preferably below follicle line
Horizontal, between axillary folds
Invisible in frontal view
BCT:Resecting ‘exactly enough’
BCT:Resecting ‘exactly enough’
Key to a good result
Often necessary to employ USG:Disparity in clinical / sonographic sizeSurrounding mastitis / desmoplasia‘Indistict’ palpable margins
Achieve accurate ‘three-dimensionality’ of margins
Avoid ‘excess’ tissue removal in any plane
Key to a good result
Often necessary to employ USG:Disparity in clinical / sonographic sizeSurrounding mastitis / desmoplasia‘Indistict’ palpable margins
Achieve accurate ‘three-dimensionality’ of margins
Avoid ‘excess’ tissue removal in any plane
BCT:Technique – Palpable lesions
BCT:Technique – Palpable lesions
Accurately marked incision
Preserve subcutaneous fat to maintain contour
Maintain ‘digital vigilance’ for margins
Progress along all lateral margins one by one
Maintain lesion at the centre of the specimen
Tag base of axcision with radio-opaque clips
Accurately marked incision
Preserve subcutaneous fat to maintain contour
Maintain ‘digital vigilance’ for margins
Progress along all lateral margins one by one
Maintain lesion at the centre of the specimen
Tag base of axcision with radio-opaque clips
BCT:Technique: Wire-localized lesions
BCT:Technique: Wire-localized lesions
Adequate understanding with radiologist
Gain accurate 3-D idea about hook position
Place incision over hook, NOT through wire entry point
Resect all around hook
Remove specimen with hook in its centre
Adequate understanding with radiologist
Gain accurate 3-D idea about hook position
Place incision over hook, NOT through wire entry point
Resect all around hook
Remove specimen with hook in its centre
BCT:Specimen Management
BCT:Specimen Management
Must remove as a single piece
Accurate orientation for pathologist:Place marking sutures at 12 and 3 o’clock positions and ink deep marginEnsure inking of entire specimen by pathologistGain information on 6 margins
Adequate fixation technique for evaluation of receptors
Must remove as a single piece
Accurate orientation for pathologist:Place marking sutures at 12 and 3 o’clock positions and ink deep marginEnsure inking of entire specimen by pathologistGain information on 6 margins
Adequate fixation technique for evaluation of receptors
TECHNIQUE : Sonographic Localization
TECHNIQUE : Sonographic Localization
BCT : Operative Technique
BCT : Operative Technique
SpecimenSpecimen
BCT:Extended Indications
BCT:Extended Indications
Large lateralised lesions
Overlying skin resection needed
Quadrantectomy able to achieve satisfactory margins
Reconstruction optimal:Commonly with pedicled L.dorsi flap
Large lateralised lesions
Overlying skin resection needed
Quadrantectomy able to achieve satisfactory margins
Reconstruction optimal:Commonly with pedicled L.dorsi flap
BCT : Quadrantectomy & L.Dorsi flap
BCT : Quadrantectomy & L.Dorsi flap
BCT:Re-excision
BCT:Re-excision
Indications:Margins with gross microscopic tumourMargin status unknownQuestionable, for focally positive margin
Method:Incision reopened, fluid evacuatedSystematic palpation of cavity wallsAppropriate cavity walls excised to 1 cm thickness using knifeNew margin surface marked with sutures
Indications:Margins with gross microscopic tumourMargin status unknownQuestionable, for focally positive margin
Method:Incision reopened, fluid evacuatedSystematic palpation of cavity wallsAppropriate cavity walls excised to 1 cm thickness using knifeNew margin surface marked with sutures
BCT:Closure and post-op care
BCT:Closure and post-op care
No drains
No deep sutures
Accurate approximation of sub-cutaneous fat
Subcuticular closure
Steri-strip support to wound
Supportive garment post-operatively
No drains
No deep sutures
Accurate approximation of sub-cutaneous fat
Subcuticular closure
Steri-strip support to wound
Supportive garment post-operatively
BCT : Closure Technique
BCT : Closure Technique
BCT:Results
BCT:Results
Over 10-year experience:200 cases2 local failures (both advised mastectomy after BCT but refused)
No significant complications
Uniform patient satisfaction
Over 10-year experience:200 cases2 local failures (both advised mastectomy after BCT but refused)