Breast & Plastic Surgery (R3) - VUMC
Medical Knowledge:
-Basic fundamentals of the pathophysiology, clinical presentation and natural history of breast cancer.
-Basic knowledge of diagnostic tests utilized in the work-up and their indications of patients with common
breast complaints & breast cancer
Imaging: Mammogram, Ultrasound, MRI, galactogram
Biopsy techniques: U/S, stereotactic, & MRI guided biopsies, excisional biopsy
-Basic knowledge of multidisciplinary management (surgery, radiation, and medical) of breast cancer
-Basic knowledge of ancillary services including genetic counseling with testing, physical therapy, and those
addressing psychosocial needs
-Basic knowledge of the anatomy related to breast. (blood supply, innervation, spatial relationship to
surrounding structures)
-Basic knowledge of reconstruction options & techniques for mastectomy patients
-Basic knowledge of benign breast disease (fibrocystic breast changes, atypical hyperplasia, papillomas
fibroadenoma
Patient Care & Systems-based Practice Skills:
-Performs a complete and accurate history and physical examination, including a pertinent review of
systems, with regard to breast disease.
-Appropriate interpretation of mammogram & familiarity with other imaging modalities
-Performs a partial mastectomy, total mastectomy, sentinel lymph node mapping and biopsy and axillary
lymph node dissection
-Can discuss multidisciplinary management of breast cancer
Interpersonal & Communication Skills and Professionalism:
-Knows the importance of communication with patients and families (empathy), staff (teamwork),
attendings, resident team and referring physicians
Practice Based Learning & Improvement and Systems Based Practice:
-Will know the milestones in breast cancer treatment and the importance of lifelong learning in a rapidly
changing field
-Will appreciate the importance of high quality, integrated comprehensive care for cancer patients and
communication with referring physicians
Patient Care & Medical Knowledge Milestones:
-Mammogram Interpretation
-Clear concept of pathophysiology, work-up and appropriate treatment for common breast complaints and
breast cancer
-Performs partial mastectomy& total mastectomy
-Performs sentinel lymph node mapping and biopsy and axillary lymph node dissection.
-Utilization of ultrasound in guiding breast procedures
-Clear understanding of anatomy related to the breast
-Clear understanding of reconstructive options and techniques following mastectomy
PGY-3 Breast & Plastic Surgery
Practice-based Learning & Improvement & Medical Knowledge:
-The third year general surgery resident will acquire knowledge regarding the management of reconstructive
breast surgery including post mastectomy reconstruction and reduction mammoplasty as well as the
correction of developmental deformities of the breast.
-The resident will gain knowledge regarding the pre-operative and post-operative management of patients
undergoing reconstructive procedures of the integument, the extremities, the trunk, as well as the head and
neck.
Patient Care Skills:
-The resident will develop skills in the management of complex reconstructive truncal, integument,
extremity, and head and neck procedures including fundamentals of tissue transfer techniques.
-The resident will develop skills related to selection of appropriate breast reconstructive procedures
individualized to the patient.
-The resident will also learn the fundamentals of the reconstructive ladder in plastic surgery.
Patient Care & Medical Knowledge Milestones:
-Clear concept of the workup and appropriate management of the reconstructive breast patient
-Clearly understands autologous tissue breast reconstruction and complications
-Performs tissue expander reconstruction
-Clear understanding of anatomy related to reconstructive plastic surgery
-Understands the principles of flap surgery and the reconstructive ladder
Schedule (bolded items are primary obligations):
Monday
Meszoely
OR
or
Hooks
morning:
OR
(7:305pm
MCE)
Tuesday Wednesday
Medical
Oncology
clinic
Elective
(Mayer @
9 am
OHO)
Meszoely
Meszoely Plastics
OR
Clinic
clinic,
afternoon:
or
(12:45 - 6, Wendel @
Hooks
OHO)
OHO
OR
Thursday
Friday
Grau OR
or
Hooks OR
(7:30 4S)
or
Wendel
OR
(FLE)
or
or Meszoely
(4s)
Kelley
OR
(MCE)
Grau OR
Wendel
or
OR
or
Meszoely OR
or
Kelley
OR
Hooks OR
Multidisciplinary
Breast
Conference
(5-6, 1st floor
conf. rm OHO)
BREAST REFERENCES:
GENERAL:
The M.D. Anderson Surgical Oncology Handbook; Feig, B.W., et.al.; Lippincott, Williams & Wilkins, 2006;
pg. 1 – 59
AJCC Cancer Staging Handbook, 7th edition; Springer 2010; pg. 419 – 460
NCCN Guidelines for Breast Cancer: http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf
BENIGN BREAST DISEASE:
Santen, RJ & Robert Mansel, NEJM (2005); 353 (3): 275 – 285
Hartmann, L.C.,et.al, NEJM (2005) 353 (3): 229 – 237
BREAST CANCER RISK FACTORS:
Singletary, S.E., Ann.Surg. (2003); 237 (4): 474 - 482
LANDMARK PAPERS: Breast Cancer
Radical mastectomy:
B-04: Radical mastectomy, total mastectomy with or without adjuvant XRT
Fisher,B. et.al., Cancer (1977); 39: 2827 – 2839
Breast Conservation: Invasive cancer
Veronesi quadrantectomy: Radical mastectomy vs. QUART (Quandrantectomy, axillary lymph node
dissection + adjuvant XRT)
Veronesi,U., et.al., NEJM (1981); 305(1): 6 – 11
B-06: Larger tumors & narrower margins
Fisher, B.,et.al., NEJM (1985); 312(11): 665 - 73
Breast Conservation: DCIS
B-17: Lumpectomy +/- XRT
Fisher, B.,et.al.; JEJM (1993); 328 (22): 1581 – 86
Long-term follow up:
Wapnir, I.L.,et.al.; JNCI (2011); 103 (6): 478 - 488
Silverstein: VanNuys Index
Silverstein,M., AJS (2003); 186: 337 – 343
Silverstein, M.J. & Lagios, M.D.; JNCI Monographs (2010), No.41: 193 - 196
Sentinel lymph node biopsy & pathologic assessment:
Giuliano, A.E.,et.al, Ann. Surg. (1994); 220 (3): 391 -401
Giuliano, A.E.,et.al., Ann. Surg. (1995); 222 (3): 394 – 401
Need for completion AND:
ACSOG Z-011: Giuliano, A.E.,et.al., JAMA (2011); 305 (6): 569-575
ADJUVANT TREATMENT:
Chemotherapy:
Up to Date (per Medical Oncologists)
Endocrine:
ATAC
http://www.iss.it/binary/farm2/cont/ATAC.1103702655.pdf
Cuzick,J., et.al., Lancet Oncology (2010); 11: 1135 -41
OncoTypeDX
Paik,S.,et.al., NEJM (2004); 351: 2817 – 26
Paik,S.,et.al, JCO (2006); 24: 3726 – 34
Prat, A. et al. Nat. Rev. Clin. Oncol. 9, 48–57 (2012); published online 6 December 2011;
doi:10.1038/nrclinonc.2011.178
PREVENTION:
P – 1: Tamoxifen
Fisher,B.,et.al.; JNCI (1998); 90 (18): 1371 – 1388
P – 2: Raloxifene (STAR)
Vogel,V.G.,et.al.; JAMA (2006); 295 (23): 2727 - 2741