Oncoplastic breast surgery

Transcription

1 Oncoplastic breast surgery Laszlo Romics New Victoria Hospital Gartnavel General Hospital Queen Elizabeth University Hospital

2 Evolution of breast surgery Partial breast reconstruction Total breast reconstruction

3 Clarify what OBS is Scottish Audit of oncoplastic breast conservations Oncological safety WoS Data Postmastectomy breast reconstructions in Scotland

4 What OBS is Historical definition Oncoplastic breast surgery: all approaches of plastic and reconstructive surgery aimed at achieving tumour resections with satisfactory margins in conservative treatment, thereby attempting to minimise potential deformities and to obtain the best possible cosmetic results. 1 1 Audretsch W, et al. Proceedings of the Second European Congress on Senology. Viena; 1994.

5 Current definition Classification of OBS 2 1. Post mastectomy immediate breast reconstruction 1. Non-skin sparing 2. Skin-sparing 3. Areola- and skin-sparing 4. Nipple-sparing mastectomy (=subcutaneous) 2. Post mastectomy delayed breast reconstruction 3. Conservative post-surgery immediate or delayed reconstruction 4. Chest wall and soft tissue reconstruction 2 John Bostwick III, 1996

6 Current definition Classification of OBS 2 1. Post mastectomy immediate breast reconstruction 1. Non-skin sparing 2. Skin-sparing 3. Areola- and skin-sparing 4. Nipple-sparing mastectomy (=subcutaneous) 2. Post mastectomy delayed breast reconstruction 3. Conservative post-surgery immediate or delayed reconstruction 4. Chest wall and soft tissue reconstruction 2 John Bostwick III, 1996

7 Oncoplastic breast conservation = partial breast reconstruction

8 Algorithm for selection of oncoplastic techniques Small resection: Benelli Body conscious Max. 1 risk factor Large breast Volume displacement Breast conservation feasible Big resection: Wise pattern L/O és L/I: thoraco-epigstr. Not body conscious Many risk factors Small breast Volume replacement U/O: LICAP Complex breast conservation not offered T4 cancers: mátrix rot., tennis racquest exc.

9 Scottish Audit of oncoplastic breast conservations

10 Scottish audit of oncoplastic breast conservations On behalf of Jane Macaskill Tereza Fernandez Elizabeth Morrow Louise Simpson Vassilis Pitsinis Matthew Barber Sian Tovey James Mansell Yasan Massanat Oliver Young Douglas Brown Sheila Stallard Julie Doughty Mike Dixon multicentric retrospective standardised database voluntary contribution most patients / data entered prospectively large volume units

11 498 patients diagnosed mean age: 56 (21 86) presentation: 63.3% sympt. 36.7% NHSBSP

12 Number of cases entered / year Years After an initial steady increase the number of patients treated with OBC plateaued from 2011 (15 (5-35) / year vs. 67 ( / year) p<0.008).

13 Number of cases entered / unit Breast units HIGH VOLUME / LOW VOLUME UNITS

14 Oncoplastic surgical techniques in % Wise: 65.5% (n=302) Round block: 7.4% (n=34) Grisotti: 5.4% (n=25) Vertical mammoplasty: 4.1% (n=19) Tennis racquet: 2.8% (n=13) LICAP / LTAP / TDAP: 2.8% (n=13) Thoracoepigastric flap: 2.6% (n=12) B / S mammoplasty: 2.6% (n=12) Lateral / medial mammoplasty: 2.4% (n=11) Matrix rotation / J mammoplasty: 1.9% (n=9) Batwing / Crescent / Melon slice: < 1%

15 Oncoplastic surgical techniques in units Wise: All units Round block: 5 units Grisotti: 4 units Vertical mammoplasty: 5 units Tennis racquet: 3 units LICAP / LTAP / TDAP: 3 units Thoracoepigastric flap: 1 unit B / S mammoplasty: 2 units Lateral / medial mammoplasty: 2 units Matrix rotation / J mammoplasty: 2 units Batwing / Crescent / Melon slice: 1-3 units

16 Variation in surgical technique / volume Breast units HIGH VOLUME UNITS case #: LOW VOLUME UNITS case #: There is strong positive correlation between number of oncoplastic surgery done in a unit and the variety in the techniques offered (>50 cases: 8-11 techniques vs. <50 cases 2-6 techniques; R=077)

17 Volume replacement rate: 6.3% (29 / 461) Contralateral symmetrisation rate: 62.2% (287 vs 174) Joint operation rate: 64% (319 / 498)

18 Contralateral symmetrisation and joint operation 87% 77% 83% 54% 34% 35% Breast units JOINT OPERATIONS: >82% NOT JOINT OPS: >81 % Units who mostly do oncoplastic surgery as a joint case with plastics have significantly higher simultaneous contralateral symmetrisation rate: 218 / 280 vs 57 / 136; P=0 (Z-test)

19 Incomplete excision rate Incomplete excision rate: 4.1% (50 /484) Mean WTS altogether: 32 mm (180 3)

20 Incomplete excision rate 20.0% 18.7% 3.8% 3.8% 4.5% 8.3% Breast units /30 1/26 3/79 6/133 4/48 27/144 There is no correlation between case load and incomplete excision rate There is no correlation between joint operation rate and incomplete excision rate

21 Neoadjuvant therapy rate Neoadjuvant therapy rate: 32% (131/409 inv. ca) Of these Neoadjuvant hormone: 57% (75 / 131) Neoadjunvant chemo: 43%

22 Neoadjuvant therapy rate / unit 75% 38.90% 31% 12% 13.60% 3.30% Breast units /110 7/18 22/71 3/25 15/110 1/130 There is no (inverse) correlation between neoadjuvant treatment rate and incomplete excision rate

23 Complication rate Complication rate in total: 31.8% (123/386) Complications requiring reoperation: 4.4% (17/386) 8 haematoma 2 infection 2 partial flap loss 2 wound dehiscence 2 fat necrosis washout 1 delayed wound healing

24 Summary Real life data 1177 pts from MD Anderson (Ann Surg Oncol 2016; 23: ) EIO, Marsden, Duesseldorf, Inst Curie TEAM study NEXT: TM audit in Scotland real real-life data MCN data of the whole country all patients dx and tx for br ca

25 Oncological safety Oncological safety of oncoplastic conservations West of Scotland data

26 Oncological safety The Breast, 2017; accepted for publication

27 Oncological safety The Breast, 2015; 24(4)

28 Oncological safety Does not delay adjuvant chemotherapy Does not interfere with mammographic follow-up Low recurrence rates after OPS with reduction techniques and volume replacement techniques EJSO, 2013; 39(8): Breast Care, 2015; 10(5): Int. J. Surg. 2016; 26: Breast Cancer 2016; 10:

29 Trends in reconstructive techniques Post mastectomy breast reconstructions

30 Trends in reconstructive techniques in England Figure 1. Proportional trend over time of type of unilateral immediate post-mastectomy reconstruction procedure performed across the English National Health Service. Each year runs from April to March of the following year. J.C. Mennie, P.-N. Mohanna, J.M. O'Donoghue, R. Rainsbury, D.A. Cromwell National trends in immediate and delayed post-mastectomy reconstruction procedures in England: A seven-year population-based cohort study European Journal of Surgical Oncology (EJSO), Volume 43, Issue 1, 2017, 52 61

31 Trends in reconstructive techniques in Scotland Courtesy of Mr. Andy Malyon Canniesburn Plastic Surgical Unit, Glasgow Royal Infirmary

32 Summary