Rosebank Oncoplastic and Cosmetic Surgery Institute
1) BREAST CANCER SCREENING

ROCSI provides mammogram screening services for the early detection of breast cancer and other breast abnormalities. We use digital mammography, which provides a clearer and more accurate image of the breast and aids in the accurate diagnosis of early stage breast cancers. After your screening a radiologist will read your mammogram and prepare a report.

There are two types of breast evaluation: the screening evaluation and the diagnostic evaluation.

Screening is for women who have no breast problems to check for cancer. Ultrasound and occasionally MRI is added to the screening mammogram in women who are at increased risk based on their family history, presence of the breast cancer gene, or a previous high-risk biopsy.

The diagnostic evaluation is for women (and men) who have a breast problem, usually a lump or abnormal nipple discharge. An ultrasound is often used in conjunction to mammography to further evaluate the problem. A radiologist will be there to discuss the findings directly with you. If the findings warrant further investigation, your radiologist may recommend a breast biopsy.

2) DIAGNOSIS

BIOPSY
Every breast biopsy is precisely targeted to sample only the suspicious breast tissue, leaving the rest of the breast intact. In fact, all breast biopsies performed by radiologists use image guidance and are obtained in a minimally-invasive manner without an incision or general anesthesia.

Your physician will recommend the most minimally-invasive procedure possible depending on the size and location of your mass. Having an expert opinion about the type and grade of cancer will affect your treatment from the very beginning.

We offer the following biopsies:

This kind of biopsy is performed when the abnormality is so small that it cannot be felt during an exam or if suspicious microcalcifications were seen on a mammogram. You will lie on a table on your stomach, with your breast placed through an opening in the table to allow for the breast to be biopsied. While the breast is compressed by mammography paddles, the image is projected on a computer screen. A special needle designed to obtain tissue samples is guided to the suspicious mass. Several samples will be taken and images will confirm that an adequate amount was removed for examination under the microscope. This procedure is performed by a radiologist.

This kind of breast biopsy is performed when the lump is easily seen on an ultrasound. Using ultrasound to locate the mass, a needle withdraws tissue samples for examination under the microscope.

During this kind of biopsy, the radiologist uses MRI guidance to sample an abnormality not seen on an ultrasound or mammography.. By doing so, your radiologist can make sure that he or she is pinpointing the tumor accurately, so that the samples can be interpreted by the pathologist under the microscope.

(Open) Excisional biopsy – This biopsy is done making an incision in the breast and removing tissue from the suspicious area. Excisional biopsy and lumpectomy should not be confused with one another. Lumpectomy is performed when there is a known diagnosis of breast cancer and the mission is to remove all of the cancer with a health margin of tissue around the tumor. An excisional biopsy is not a surgical treatment, it is diagnostic procedure. Excision biopsy may need to be done if the results of a needle biopsy are inconclusive.

Sentinel lymph node biopsy – The sentinel lymph node is the lymph node in the arm pit that is the first place breast tumors may spread. It is identified during surgery using a special blue dye and radioactive isotope that is injected before the surgery. Following the path of the dye or isotope, your surgeon will identify the sentinel node, remove it, and send it to pathology for review. Knowing if the cancer has spread to the nearby lymph nodes is a critical part of staging and treatment of breast cancer. This procedure is performed when there are known invasive breast cancer cells in the breast, or when mastectomy is being done for the treatment of DCIS. If the sentinel lymph node is positive for cancer, additional lymph nodes may be removed to determine the extent of disease.

Skin punch biopsy – This kind of biopsy is performed when inflammatory breast cancer or Paget’s disease is suspected. A tiny device that looks like a miniature cookie cutter is used to core out a piece of the skin of the breast (in the case of inflammatory breast cancer) or a piece of the nipple-areola complex (in the case of Paget’s disease). Usually, one to two stitches are needed to close the puncture site. This procedure is typically performed by a surgeon.

PATHOLOGY

Ensuring the accuracy of your pathology results is of utmost importance. Knowing the exact type of breast cancer and the specifics of its prognostic factors is critical to creating a specific treatment plan that will provide you with the best opportunity for defeating this disease. Our team of breast specialists includes pathologists who specialize in breast cancer and have extensive experience evaluating and accurately classifying breast tissue specimens.

3) ONCOPLASTIC BREAST SURGERY

Once you have been told that you have breast cancer or might have breast cancer, you will be referred to a surgeon. At -ROCSI our surgeons are experts in Oncoplastic Surgery. They all work collaboratively to give women the best cosmetic results and options all in one operation. Oncoplastic surgery is most often performed after a lumpectomy and is often done via a breast lift type operation. This is termed a therapeutic mammaplasty. [Link to Therapeutic mammaplasty PDF] We also offer nipple sparing and skin sparing mastectomy for patients who meet specific pathology criteria.

4) RECONSTRUCTIVE BREAST SURGERY

This reconstruction involves placing a temporary tissue expander either under or over the muscle at the time of your mastectomy. The expander gradually stretches the muscle and skin in preparation for either an implant or flap reconstruction. The overall result is more symmetric, natural and aesthetically pleasing. It allows a woman to complete radiation treatment while having a “placeholder” implanted. It allows enough time to make sure all the cancer has been treated.

  • While a tissue expander remains the most common first step in breast reconstruction with implants, some patients may be candidates for a direct to implant breast reconstruction. This means that patients can bypass a preliminary surgery where temporary breast tissue expander implants are inflated over time to stretch the overlying skin and muscle. Rather, the fully filled breast implant is placed in the beginning while the patient is still under general anaesthesia to have their breast removed during mastectomy. The obvious advantage is that patients can reduce the number of surgeries and office visits required with other forms of breast reconstruction. However, several factors determine whether a patient is a good candidate, or even eligible for a direct-to-implant breast reconstruction:
  • Patient must be willing to have reconstructed breasts be the same size, or often smaller than the original breast size
  • There must be enough remaining breast skin following mastectomy relative to the desired volume of the breast reconstruction. Often, this limits eligible patients to those able to undergo a nipple-areola sparing-, nipple sparing-, or skin-sparing mastectomy
  • The remaining breast skin must be healthy. Patients with underlying medical conditions like lupus or diabetes or who smoke cigarettes or use other recreational drugs are more predisposed to wound healing problems and are rarely candidates for direct-to-implant breast reconstruction.
  • Absence of previous radiation. Previous radiation, for example in patients who had a lumpectomy and radiation, developed a recurrent breast cancer and now require mastectomy are not usually good candidates for a direct-to-implant breast reconstruction due to concerns over tissue quality and wound healing problems.

The Goldilocks procedure begins with a traditional skin-sparing mastectomy incision: a circular or elliptical mastectomy incision is made around the nipple and areola, through which all visible breast tissue is removed. A Wise-pattern incision, which is often used in breast reduction, is then made, and the skin inside the outline is removed. The layer of fat just beneath the breast skin that is normally removed and discarded during mastectomy is then rearranged into a small breast mound. The incision edges are then pulled together and sutured in place. Goldilocks works best for women who have large, pendulous breasts because they have more fat to sculpt into a breast mound once breast tissue is removed. The nipple and areola are removed or treated as a free nipple graft (the nipple is removed from the breast and then relocated on the remaining post-mastectomy breast mound. If a unilateral Goldilocks mastectomy is performed, the opposite breast can be reduced for better symmetry.

The DIEP flap represents further evolution of the free TRAM flap procedure. Both the DIEP flap and the free TRAM use the same abdominal skin and fat to reconstruct the breast, and the same blood supply – the deep inferior epigastric artery – to provide blood supply. The difference is that in the DIEP flap, the rectus abdominis muscle is completely spared whereas in the free TRAM a variable amount ranging from a sliver to a substantial patch of it is taken with the flap.

In some studies, the DIEP flap is associated with less pain, quicker recovery and less abdominal wall weakness than the free TRAM flap although other studies show very little difference between these procedures. The free TRAM, because of the inclusion of muscle, can support a larger flap in heavier patients or when the goal is to reconstruct a larger breast.

Depending on the pattern of circulation from the deep inferior epigastric artery, the DIEP flap may take longer to perform than the free TRAM while in other cases the operative time is very similar. Hospitalization tends to be 1 to 2 days faster with the DIEP flap and recovery 1 or 2 weeks faster but this is certainly variable between patients.

The TRAM (transverse rectus abdominis myocutaneous) flap is a common method of reconstructing the breasts with a patient’s own tissues. Abdominal skin, fat and a varying degree of muscle tissue are taken from between the belly button and pubic area and used to reconstruct one or both breasts following mastectomy. The skin, fat, and a small amount of muscle along with the deep inferior epigastric artery are detached from the body and then repositioned in the breast. The blood supply is restored by reconnecting the deep inferior epigastric artery and vein to blood vessels around the breast. The most common options are the internal mammary blood vessels underneath the 3rd or 4th ribs, or the thoracodorsal artery in the armpit region.

DIEP, SIEA, SGAP Flaps – The DIEP flap is the technique where skin and tissue (no muscle) is taken from the abdomen in order to recreate the breast. Other flap techniques, called the SIEA flap, the LSGAP flap and the SGAP flap, take tissue from the lower abdomen or lateral buttock regions. Since the reconstruction involves using the patient’s own tissues, the risks of implant reconstruction are avoided, particularly in the case of radiation.

5) MEDICAL ONCOLOGY

Most, but not all, patients diagnosed with breast cancer need some form of systemic therapy as part of their treatment. At ROCSI, our medical oncologists are specialists in the treatment of breast cancer.
We have a thorough knowledge of the complications, side effects and psychological needs that patients with breast cancer experience. Our medical teams work closely together every day and can coordinate treatment efforts across different disciplines.

Types of systemic therapies that may be recommended as part of your breast cancer treatment:

What is neoadjuvant chemotherapy?
Neoadjuvant chemotherapy refers to medicines that are administered before surgery for the treatment of breast cancer. Your doctors may recommend neoadjuvant chemotherapy due to the size of the tumor, since the drugs may shrink the tumor and give you more surgical options. In some cases, a woman who would have needed a mastectomy due to the large size of her tumor can become a candidate for lumpectomy by shrinking the invasive tumor prior to surgery. Neoadjuvant chemotherapy is also performed for certain types of breast cancer, such as inflammatory breast cancer.
What is adjuvant chemotherapy?
Adjuvant (meaning “in addition to”) chemotherapy refers to medicines administered after surgery for the treatment of breast cancer. Adjuvant chemotherapy is designed to prevent recurrence of the disease, particularly distant recurrence. Your doctors may recommend chemotherapy if your breast cancer is invasive, has unfavorable prognostic factors, is a certain size, or has spread to nearby lymph nodes. It also may be recommended if you are relatively young at the time of diagnosis.

Hormonal therapy (not to be confused with hormone replacement therapy that some women take to ease menopausal symptoms) is classified as selective estrogen receptor modulator (SERM) or an aromatase inhibitor (AI). Both of these types of treatments help block estrogen’s ability to reach a breast cancer cell. If your hormone receptor (HR) test was positive, that tells the doctors that estrogen and/or progesterone may promote the growth of breast cancer cells in your body. By taking a drug that works on breast cancer cells, like an estrogen blocker, the risk of breast cancer recurring or possibly continuing to grow is reduced.

In recent years clinical trials have been conducted to evaluate the effectiveness of new drugs that alter the behavior of the breast cancer cell. These drugs are referred to as targeted therapy or biologic targeted therapy.

6) RADIATION ONCOLOGY

Patients who undergo lumpectomy breast cancer surgery for treatment of their breast cancer almost always receive radiation therapy afterward. This form of adjuvant (supplemental) therapy uses high-energy rays (such as X-rays) to kill cancer cells or shrink tumors. Most commonly, radiation therapy is used to kill any cancer cells that may remain in the breast, chest wall or underarm area after surgery. It is also used to treat the healthy breast tissue that remains after a lumpectomy—not to kill cancer cells that may have remained, but to radiate the tissue to prevent cancer cells coming back.

7) PATIENT NAVIGATION & SURVIVORSHIP

Having ready access to professionals who can guide, support, and help you and your family develop coping skills will make your breast cancer treatment go more smoothly for everyone. At ROCSI, our professionals have extensive experience with breast cancer patients and their families and are familiar with the treatment you will be receiving. They also know the doctors and nurses involved in your care. This provides for an integrated approach to getting you well again physically and emotionally.