Breast Anatomy and Cancer Overview

Breast Anatomy and Pathology

• Breast tissue is composed of fatty tissue, lobes (containing lobules/glandular tissue), ducts, and a nipple surrounded by the areola.
• Lobules produce milk, and ducts carry milk to the nipple.
• Ductal carcinoma is the most common breast cancer type, starting in the ducts. Invasive ductal carcinoma spreads, while ductal carcinoma in situ (DCIS) remains contained within the ducts.
• Lobular breast cancer is the second most common type, originating in the milk-producing glands.
• The areola secretes oil to protect the nipple during breastfeeding.
• Lymph nodes in the axilla drain lymph from the breast.

Breast Cancer Diagnosis and Treatment

• Mammography and ultrasound are used for initial breast cancer screening by radiologists.
• If abnormalities are detected, a needle biopsy is performed.
• The American Cancer Society recommends mammograms starting at age 40.
• Breast conserving surgery (lumpectomy, quadrantectomy, etc.) and mastectomy are used to remove breast lesions.
• Localization devices (like the MOLLI) are used for non-palpable lesions to guide surgical removal.
• Wire-guided localization is an older method, while MOLLI is a newer, more advanced technology.

MOLLI Localization System

• MOLLI is a 3.2 mm, gold-coated, biocompatible marker, placed by a radiologist, using imaging (mammography or ultrasound).
• MOLLI is placed to mark the target lesion and can be detected with imaging in the presence of hematomas and dense breasts.
• It has a vented introducer needle to prevent displacement and bone wax is deployed to increase stability.
• MOLLI has an end-deploy design for precise targeting, and a 14 gauge introducer.
• It uses neodymium magnets, which are the strongest permanent rare earth magnets, and is not deactivated.
• MOLLI introducers come in 8cm and 12cm lengths, with 10 in a box.
• Surgeons receive feedback on distance, directionality, visual cues and auditory confirmation when using MOLLI.
• The MOLLI tablet can be mounted on IV poles, and the wand tip is 10mm long with a 10° curve.
• The MOLLI wand and introducer are sterilized separately.
• MOLLI is MRI-conditional, but may create image artifacts.
• MOLLI should be placed after neoadjuvant chemotherapy.

Sentinel Lymph Node Biopsy (SLNB)

• SLNB is a procedure to determine if breast cancer has spread to the axillary lymph nodes.
• SPY (Surgical Photon Imaging) and a special dye (agent green) are used to identify and mark the sentinel lymph node for removal.
• Targeted axillary dissection (TAD) is sometimes used in conjunction with SLNB.
• MOLLI is not limited to SLNB or TAD but is also used in general breast procedures where localization is needed.

SPY-PHI Surgical Photon Imaging

• SPY-PHI is a fluorescence imaging device used during surgery to identify lymphatic channels.
• The device has different modes for viewing information (overlay, contrast, CSF), each providing different levels of detail.
• SPY-PHI includes a light cord and a data cable to interact with the light source/camera control unit (VPI).
• SPY-PHI is a Class II medical device, and sterile methodology must be followed when using the device.
• SPY-PHI is not a radiation source.

Breast Reconstruction

• Autologous flap reconstruction uses tissue from the patient's own body.
• DermACELL is a processed acellular dermal matrix, a common source of allograft tissue, stored at room temperature.
• Different styles of breast implants, like sub-pectoral and pre-pectoral, are used with DermACELL.
• DermACELL is sterile and is low in donor DNA, doesn't need to be rehydrated.

Comparison of Localization Technologies

• Competitors to MOLLI (wire, radioactive seeds, Savi Scout, Magseed, Elucence, Pintuition) have varying strengths and weaknesses.

Surgical Considerations

• Surgeons of various specialities (breast surgical oncologist, general surgeon, plastic surgeon) may be involved in breast procedures.
• Understanding arterial, venous, and lymphatic structures, and potential complications are essential to a surgeon's skillset.
• Careful attention to patient safety and procedure optimization improves surgical outcomes.

Other Surgical Instruments and Techniques

• The Invuity illuminated retractors use xenon light sources, provide excellent visualization with volumetric lighting, are non-conductive for use with electrocautery. Various styles are available, including Heaney and Tebbetts, some offering smoke evacuation.
• The PhotonSaber Y is a lighted aspirator with suction tip options. Different retractor and light source and suction device types are used during various surgical procedures.