Oncoplastic Breast Surgery

Transcription

1 Disclosures Oncoplastic Breast Surgery Newfoundlander OAGS 2016 Dr Renee Hanrahan General Surgeon Oncologic and Reconstructive Breast Surgeon Objectives What is Oncoplastic Surgery Define Oncoplastic Surgery Describe the underlying principles of Oncoplastic surgery Discuss an approach to appropriate patient and procedure selection Oncoplastic Tool Box Discuss aesthetic mastectomies 1. Flowers, rainbows and pink stuff. 2. Never heard of it. 3. Not safe. 4. Combination of ablative and plastic surgery techniques in breast cancer treatment. Definition and Principles First described by Audretsch in Originating out of Europe. The technical convergence of oncologic (ablative) surgery and aesthetic breast surgery. Consideration of aesthetic outcomes and survivorship. Main principles; Complete excision of tumor with clear margins Immediate reshaping/remodeling of breast tissue Consideration of contralateral symmetry Aesthetic Outcomes The single most important determinant of aesthetic outcome in breast surgery is the percentage of tissue removed from the breast. Studies have shown that if anything greater than 20% of the breast volume is being excised, it will result in a deformity. Some areas of the breast are easier to reconstruct than others. lower pole upper inner/cleavage Oncoplastic surgery provides options for closure. 22nd OAGS Annual Meeting Nov

2 One of the most dangerous phrases in medicine.. This is the way we have always done it. Principles Cancer comes first Multidisciplinary approach Patient Involvement Patient selection Incision selection Good technique Oncologic Principles Multidisciplinary Approach Oncologic safety Milan 2007 London 2012 UK 2013 no long term follow up Larger specimens and increased exposure. Re excision vs completion mastectomy for positive margin. Location of scar and radiation planning. Patient Plastic surgeon Radiology Pathology Radiation Oncology Medical Oncology Patient Centered Care Patient Selection Do they want it? Do they need it? Is it safe for them? Anxiety vs Pleased Level of expectation They are sisters, not twins. All patients even if a radial incision utilize the multilayer closure, parenchymal mobilization, good hemostasis.. No significant risk for surgical complications eg. DM, smoker, GA risks. Contralateral breast immediate or delayed and normal imaging. Appropriateness for breast conserving therapy when to consider a mastectomy +/- reconstruction. Pre op imaging try to avoid the need for re-excision. 22nd OAGS Annual Meeting Nov

3 Algorithm Incision Selection Four factors 1. breast size/density 2. nipple location/ptosis 3. Tumor size 4. Tumor location Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated with postmastectomy radiation therapy. Peled AW, Sbitany H, Foster RD, Esserman LJ Breast J May-Jun; 20(3): Anatomic Considerations Benelli / Donut / circumareolar My Personal Favorites Inframammary / Horizontal / Smile Racket / Lateral or medial mammoplasty 22nd OAGS Annual Meeting Nov

4 Case Presentation Very young 72 yo with palpable left breast cancer, clinically node negative. Previous reduction On exam tumor at 3 o clock position skin dimpling moderate breast size, described as a C cup grade 2 ptosis Partial mastectomy with Racket closure, SLN Bx and balancing mastopexy Post op 2 weeks 55 yo female with Locally Advanced Breast Cancer Presented with large central mass, nipple involvement. 1 node positive Triple negative receptor status Genetically negative Treated with Neoadjuvant chemotherapy Central Lumpectomy 22nd OAGS Annual Meeting Nov

5 Paget s Disease Nipple Reconstruction Provides symmetry Hide scars Appear more natural 3-D tattooing Benefits Decreased breast volume, better tolerated adjuvant radiation Decreased re-excision rates 2-3% vs. 5-15% Improvement in patient reported outcomes Improved self esteem Decreased mental health issues post treatment >80% would do it again 40% of sbct patients seek reparative surgery Surgical Complications 15 30% Hematoma, fat necrosis, skin flap necrosis/wound issues, nipple areola loss/sensation Delay to adjuvant therapies Surveillance mammo and scarring Oncologic Positive margin Recurrence Treatment is same as sbct, completion mastectomy Local Experience 239 case over re-excision 2 completion mastectomy 1 local recurrence 0 deaths 3 evacuation of hematoma 28 wound infections, 1 nipple areola loss 22nd OAGS Annual Meeting Nov

6 Tips of the Trade Tools Markings do them standing before you go into the room. Orientation place stitches prior to removal of the specimen. Clips Radiation Oncologist love them. Close the defect avoid dimpling/delayed contracting. Use drains. Considerations for the contralateral breast Weight specimen Radiation effects Make the cut a smaller scar is not always better, but double layer closure. Closure 3 Layered Closure 3 layered Defect raise parenchymal flaps in the subcutaneous spaces. 2-0 vicryl Deep Dermal spreads tension, 3-0 monocryl Sub Q will use staples in the inframammary fold. Nipple folds will flatten, make up of difference, 4-0 PDS suture Rescue stitch 4-0 plain RH1 Nipple Areolar Closure Billing Tips Do the work History and Physical Operative Header Dictation Balancing procedures 22nd OAGS Annual Meeting Nov

7 Slide 36 RH1 Renee Hanrahan, 07/06/2015

8 Training Aesthetic Mastectomy Amount of training depends on what you want to incorporate into your practice. Local plastic surgeon Provincial training programs International courses/electives Residents and Fellows Skin sparing, nipple sparing are felt to be oncological safe as long as margin is clear. Only appropriate in the case of immediate reconstruction or within a vey short time period to delayed reconstruction (weeks). Considerations for mastectomy; Keep incision low, inframammary to areola, low lying ellipse V-Y advancement flap, for lateral dog ear Inverted T Summary These techniques leave patients with minimal deformities without compromising oncologic safety. ASBS consensus conference July 2015 recommended that the utilization of oncoplastic surgery should be considered, (along with other factors) in optimization of lumpectomy surgery. Simple techniques can be employed in any general surgeons OR but more complex approaches require specific training. 45 yo female with LABC (6 cm) triple negative breast cancer. Genetic testing negative, Node negative. Which of the following would be your option for treatment? 1. Modified Radical Mastectomy 2. Neoadjuvant chemotherapy followed by obct and SLN Bx 3. sbct and SLN Bx 4. Mastectomy and SLN Bx +/- reconstruction Questions 22nd OAGS Annual Meeting Nov