A Combined Practice. Why Its Worked. Barriers to Breast Reconstruction. As a breast oncologist the patient gets seemless care

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1 A Combined Practice A Combined Breast Oncology and Plastic Surgery Practice Why It Works Anne M. Wallace, MD, FACS Director, Comprehensive Breast Health Center Professor of Clinical Surgery, Surgical Oncology and Plastic Surgery UCSD Department of Surgery, Moores Cancer Center Ablative Surgical Oncology Plastic Surgery Focus on breast, melanoma, and oncologic reconstruction while maintaining an aesthetic and general reconstructive practice Have been the Team Leader for the UCSD Breast Program for 20 years Why Its Worked One surgeon, both aspects ablative and reconstruction As a Plastic Surgeon, we know the breast and skin better than any other specialty As a Plastic Surgeon, we follow the patients longer than most As a breast oncologist the patient gets seemless care Barriers to Breast Reconstruction Huge Issue Must understand difficult nature of this field extremely time consuming, very underreimbursed; difficult to achieve patient satisfaction in certain subgroups of body types, etc. Most plastic surgeons are in private practice where reimbursement from insurance does not even begin to pay cost, especially from the BCCTP and medi-cal 1

2 Disparities in Breast Reconstruction Receipt of Breast Reconstruction Data presented at CSPS JCO pts in SEER data, 2260 respondents; 806 patients who received a mastectomy Outcomes receipt of reconstruction 34.6% of 806 patients, 84.5% at time of mastectomy,15.5% later Receipt of Reconstruction by Race: W/AA/Latina-high/Latinalow: 40.9/33.5/41.2/13.5% p < 001 Latina-low tended to be younger, less likely to be high school graduates, and more likely to be without health insurance AA had more comorbidities No difference in stage of disease OSHPD Data Postmastectomy reconstruction rates were determined from the California Office of Statewide Health Planning and Development (OSHPD) inpatient database from 2003 to The proportion of patients undergoing reconstruction rose from 24.8% in 2003 to 29.2% in Do Variations in Provider Discussions Explain Differences in Reconstruction Journal Of American College of Surgeons, April 2008 Data collected from NICCQ, stages I-III 253/626 pts received reconstruction (40.4%) If Discussion of reconstruction not documented, PATIENT LESS LIKELY TO RECEIVE IT 2

3 UCSD Data Of the 1715 operations breast cancer operations 63.6% (N=1091) and 36.4% (N=624) represented breast conservation therapy and mastectomy, respectively. Of the lumpectomy patients, 9.3% (N=168) required reexcision for close or positive margins. (National average by current literature 23%) 78.8% of mastectomy patients underwent breast reconstruction, 4.5% of which were delayed. UCSD same surgeon reconstruction rate 78.8%; Remaining mastectomy patients either did not want reconstruction or had locally advanced disease On multivariate analysis, independent predictors of reconstruction were age, relationship status, and stage of disease, while the effect of race and insurance status were non-significant There was a total recurrence rate of 6.73%. Survival Data from UCSD 615 women treated with mastectomy; 78.8% underwent reconstruction Those pts had higher OS and DFS (8.3% vs 11.3 years, p<0.001 and 6.6 vs 11.5 years, respectively, p<0.001) After controlling for age, race, marital status, payer category, triple negative status, stage of disease and receipt of chemotherapy, radiation therapy and hormone therapy, reconstructed patients still maintained a survival advantage So in an Institution Where A Novel Approach to the Delivery of Breast Care is Made Breast reconstruction rate 78.8% vs national average of 34.6% Positive margin rate 9.8% vs national average of 23% Survival advantage across the board for patients who were reconstructed 3

4 Points to Remember It s the Simple Differences We Make Daily Clear margins is the goal Must accept that taking tissue will leave some change in the effected breast Our goal is to camouflage defect as a much as possible Postoperative correction is very feasible Oncoplastic Techniques For Very Large Defects Central Lumpectomy with inverted T closure A circumareolar, Bennelli-type closure Inferiorly based mammaplasty Other local flaps Basically, volume replacement or volume displacement Any of the above with bracketed localization closure for large periareolar defects 4

5 Inferior Tumor Often Poor Results Preop Radiology localized tumor Mastopexy drawn around Inferior Lower Quadrant tumor Postop 1 year Tumor Involving Nipple Breast Conservation Via Breast Reduction Nipple-Ablation Mastopexy New Nipple Created Later On Patch of Neo-Areolar Skin 5

6 The 12:00 central breast defects are very non-cosmetic when excised primarily BilopedFlap for Central Superior Defect Basic plastic surgery flap-biloped Six days post-op; widely clear margins and NO pulling up of NAC or indentation Asymmetry After Breast Conservation 6

7 Preop Flap procedures for local defect Postop Choosing Mastectomy Tumor too diffuse Tumor in multiple quadrants BRCA family Pt will get better cosmetic result with implants (breast small and ptotic) Recurrence Mastectomies have evolved Traditional Skin sparing Nipple sparing 7

8 Traditional Mastectomy Immediate flap After Skin Sparing Mastectomy Skin Sparing Mastectomy Nipple Sparing/ Minimal Skin/ Implant Removal 8

9 There is No subcutaneous fat between ductal tissue and skin Dissection DIRECTLY under skin, completely skinning the undersurface Invert nipple and cut circular rim of tissue out send separately to path Nipple may DIE Editorial in Annals of Surgical Oncology this month STRESSED importance of adequate mastectomy Nipple Sparing Mastectomy Seemless Cancer Care When the Surgeon Does Both Aspects 9

10 1. Example RM, 65 year old female, s/p masto/aug Unhappy with right side nipple too high, bottomed out Now scheduled with me for right side correction and if necessary in OR adjustment of left side Mammogram, PE normal RM, Continued Right side corrected with pocket adjustment, re-do mastopexy to lower NAC, new implant So decision to open left side to place same implant Once implant out on left, palpation of the inside pocket revealed a hard mass on far lateral breast, just anterior to capsule Immediate removal and frozen section Invasive ductal CA; took a wider margin on the spot; scheduled for sentinel lymph node several days later after MRI; Tumor small enough and node negative; thus an intermediate ONCOTYPE score allowed her NO chemotherpy Radiation than proceeded and she is doing very well She later became the donor for my $2 million endowment to establish an integrated fellowship 2. Example Triple Negative Breast Cancer; BRCA+ Had neoadjuvant chemo, Mastectomties, expanders; Post op day 3 implants Continued Was scheduled for fat grafting, upper poles During marking in preop area, pt says Dr. Wallace, I have a lump under my arm. I had not seen her for a month. I examined and there was a 2cm mass in the right axilla Immediate CHANGE in OR plan excisional biopsy, frozen section, followed by ALND when it returned metastatic CA to axilla. Fat grafting aborted as she would now need radiation and would return later for more reconstruction 10

11 3. Example Clear Margins Large cancer forming a U up and across breast Took 5 needles to localize and a breast reduction to close it correctly. 7 cm cancer with clear margins 4. Example ML 68 Year Old Female 2003 had bilateral mastectomies by me for DCIS and a low grade early stage 1 disease Had expander/implant reconstruction, but on the left side had several implant infections. After several implant surgeries, in 2006 we converted her left side to a TRAM flap. She did well until 2012 No history of chemotherapy or radiation February 2012, she Noticed one small bruise Like area on left side. Progressed over 2 months To this. 11

12 ML, Continued She lives in Reno, NV. Biopsy done by my recommendation and it was inconclusive MRI just showed skin thickening All blood work normal; no new meds that cause bruising Clinical picture was still concerning The Answer: Angiosarcoma; Was embedded in the TRAM; no Ductal tissue seen;????? Related to history of implant infection??? Went on to complete resection of the TRAM, Chemotherapy and radiation Came back a year later for a latissimus Flap/ revisions pending.5 Example JC 65 Year Old Female History of nearly 40 year old silicone implants Pelvic pain Primary Care Doc works up with scans; PET/CT eventually done that shows mass under left implant, and PET+ nodes in internal mammary chain, left side Some indistinct nodes in pelvis JC, Continued MRI of breast shows a mass again beneath implant and enlarged IMA nodes Not amenable to core biopsy due to location Implant rupture suspected as well I m referred pt level of expertise that incorporates both aspects - discussed implant removal, identifying and removing mass and removal of internal mammary nodes at that level 12

13 Bilateral capsulectomies done Internal mammary node removal Mass taken with rib fascia Right implant GROSSLY ruptured Left intact, but being pushed and elevated by this mass Ambiguous pathology for 2 weeks; thought to be angiosarcoma; but finally determined to be atypical vascular lesion consistent with an old organized hematoma Care of this pt was facilitated by me knowing both the plastic surgery and the surgical oncology 6. Example BRCA Patients All referred to me Discuss better screening and observation - MRI Discuss chemoprevention tamoxifen, raloxifene, oophrectomy Discuss bilateral mastectomies/reconstruction Follow for years Then DO the mastectomies when the time is right for the patient MASTECTOMIES ARE NOT ALWAYS THE IMMEDIATE ANSWER FOR THESE PATIENTS BRCA +; bilateral preventative Mastectomies, expanders, Implants and fat grating 13

14 Pt BRCA positive 29, BRCA+, Advanced breast cancer treated with chemo first Followed by mastectomies and reconstruction; Despite positive Lymph nodes, etc., she had a great result Triple negative breast cancer Treated first with clinical trial Bilateral mastectomies and Implant reconstruction, nipple sparing PT with bilateral breast cancer; hx Radiation Did Hyperbaric Oxygen First to Help Nipple Survival 14

15 One Pt is a breast augmentation; another is bilateral mastectomies for cancer; Is getting very close to minimal differences in cosmetic outcome Right sided reconstruction ONLY with Mentor MM shaped gel. Nothing done on left; This Implant is fantastic for unilateral reconstruction Because Mentor makes a broader lower profile Shaped implant and it is somewhat softer. Bilateral Tram Flaps after prophylactic mastectomies for family history A Few Additional Comments I do LESS mastectomies than my colleague at UCSD; rvu incentive for general surgeons to do more Efficiency of practice in both the clinic and OR Having a dual practice is obviously better for the patient, but also increases job satisfaction for the surgeon 15

16 Axillary Tumor Recurrence Locally advanced and infiltrating Breast cancer; failed all other modalities Latissimus flap reconstruction Failed TRAM; there is no Implant in this TRAM; Its all Fat necrosis, etc. Contracated implant Since 1995; salvage latissimus Salvage Latissimus Flap 16

17 Chronic 10 month old wound; radiated, necrotic Rib; debridement, rib resection, flap for closure; 6 months later expander placed and fully expanded And Sometimes I Have to Know When NOT to Operate And Manage with my Radiation and Medical Oncology Colleagues PLAN: begin a fellowship for dual trained surgeons with emphasis on both the oncology and the reconstruction Perfect opportunity after an Integrated Plastic Surgery Residency 17