Oncoplastic and Reconstructive Surgery
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1 Diagnosis and Treatment of Patients with Primary and Metastatic Breast Cancer Oncoplastic and Reconstructive Surgery
2 Oncoplastic and Reconstructive Surgery Versions : Audretsch / Blohmer / Brunnert / Dall / Fersis / Hanf / Kümmel / Nitz / Rezai / Scharl / Thomssen Version 2013: Brunnert / Rody
3 Oncoplastic Surgery Definition and Considerations Oxford LoE: 2b GR: B AGO: ++ Definition: Reconstructive plastic surgical techniques in BCT to enable wider resections with equally aesthetic results Tumor/breast ratio (TBR) Localization of tumor NACT if TBR is unfavourable AGO + Alloplastic volume replacement AGO - - Excision of healthy skin together with lumpectomy as an oncological procedure AGO -
4 Oncoplastic Surgery Common Techniques Oxford LoE: 2b GR: B AGO: + Glandular rotation w/o skin island Mastopexy (periareolar, vertical, inverted T) Tumoradapted reduction mammaplasty Volume replacement techniques Local or distant flaps
5 Definition and Considerations Oxford LoE: 3b GR: B AGO: ++ Type of reconstruction uni-/bilateral: Total breast reconstruction (BR) after MRM Immediate or delayed Total BR after SSM / NSM (nipple sparing mastectomy) Considerations: Individual cancer or patient associated risk factors (LOE 1c A, AGO: ++) Patient s preference Medical and institutional qualifications Concomitant anti-angiogenesis therapy Radiotherapy planned or in medical history BMI, diabetes, smoking
6 Postmastectomy Implant Reconstruction Oxford / AGO LoE / GR Use of silicone filled breast implants (no systemic health hazards documented, no influence on OS and detection of recurrence) 2a B + Implant reconstruction (IR) 2a B + IR without radiotherapy (RT) 2a B ++ IR following MX and RT 2b B +/- IR prior to RT / following PBRT 2a B +/- IR following Mx for local relapse after BCT 2a B +/- Periop. prolonged antibiosis recom. 3b C + (single inst.)
7 Postmastectomy Implant Reconstruction Considerations I Cost effective Bilateral procedure can improve cosmetic result Achievement of shape and symmetry easier with permanent expander implant Independent of age 3b C +/- Mesh- or acellular dermis assisted prosthetic subpectoral BR provides better permanent implant coverage 2b B + Lipofilling can be helpful 3b C +* Delay of expander-implant exchange for at least six months after postmastectomy radiation therapy can significantly Oxford / AGO LoE / GR reduce expander-implant failure** 3b C + *no evidence of higher relapse rate after follow-up of 3-4 years ** single institution experience
8 Improving Implant Coverage after Mastectomy and Reconstruction Oxford / AGO LoE / GR Autologous tissue (e.g. LDF*) 3b C + Acellular dermal matrix 3a B + Synthetic mesh 3b C + Lipofilling 3b C + * LDF = Latissimus dorsi flap
9 Radiotherapy after Implant Breast Reconstruction I McCarthy CM PRS 2008 Author Berry T Ann Surg Oncol 2010 Patient satisfaction Pre-or postop. radiation no significant risk factors 70,1% sucessfull Failure Complications Independent risk factors: smoking, obesity, hypertension, age >65 39% total complication rate Major complic.rate 24,4% +RT 45,4% Observation period prospective Pts. RT/CTR 1170 Exp/impl rec. - Total 1037 Gross E/Cowen D Cancer Radiother 2010 Breast Cancer Res Treat ,4 % pts. satisfied Risk factors for failure: surgeon, tumor size T3 or T4, smoking, pn+,baker ,5 % 37 mths Whitfield GA Radiother Oncol % free of CC after 6 years CC p < (30 % vs. 0 %) 51 mths. 41/110 Christante D Arch Surg 2010 not reported 7 % vs. 44 % p< Cordeiro PG PRS 2004 Mc Carthy PRS 2005 n.s. acceptable 80% satisfied no Baker IV p=0,025 CC (68% vs. 40%) 40% no difference 50% 1 Baker grade up 10% 2 Baker grades up /606 FU 23,5 mths Cordeiro PG PRS % pts. satisfied 49,3% no CC prospective 71/410 Behranwala JPRAS % free of CC after 4 years CC p<0.001 (38,6% vs. 14,1%) 2-5 years 44/92br Benedikktson K JPRAS 2006 Reop. n=16 free of CC after 5 years CC p=0.01 (41,7% vs. 14,5%) 2-5 years 24/83
10 Radiotherapy after Implant Breast Reconstruction II Author Tran Tet al Patient satisfaction no significant differences between irradiated and nonirradiated patients Failure Complications more frequently lymphedema in radiated patients Observation period retrospective Pts. RT/CTR 175 (25.7% with radiotherapy), 54,8% implant based reconstruction Brooks S et al ,1% successfull expander/implant reconstruction 28,4% (<50y.), 37% (>50y.) 27,5 (BMI<30), 49% (BMI>30) retrospective 560 Nava MB, Plast Reconstr Surg 2011 not reported Implant + RT 6.4% Expander + RT 40% exp vs. implant rec
11 Postmastectomy Pedicled Flap Reconstruction Reconstruction (BR) with autologous living tissue ( natural breast) TRAM, latissimus-dorsi-flap (both can be performed as a muscle-sparing technique) 3b C + Delayed TRAM in risk patients 3a B + Ipsilateral pedicled TRAM 3b A + Radiotherapy: Oxford / AGO LoE / GR BR following RT 4 C + BR prior to RT 3b C +/- (dependent on quality of blood supply)
12 Free Tissue Transfer Free tissue transfer 3b B +/- Free TRAM-flap DIEP-flap SIEA-flap 4 C +/- SGAP- / IGAP-flap Free gracilis flap (TMG) 4 C +/- Latissimus dorsi free flap Advantage: Free TRAM and DIEP are potentially muscle-sparing procedures Disadvantages: Oxford / AGO LoE / GR Time- and personnel-consuming microsurgical procedure Intensified postoperative monitoring Higher rate of re-operations Higher total failure rate Pre-reconstruction RT increases rate of vascular complications No higher patient satisfaction than with pedicled TRAM in multivariate analysis
13 Pedicled vs. Free Tissue Transfer Muscle-sparing techniques and accuracy of abdominal wall closure will lead to low rates of late donor site complications whatever method used 3a A ++ Autologous abdominal-based reconstructions have the highest satisfaction in all patient groups without any difference Perforator flaps appear to have a higher risk for fat necrosis than free or pedicle TRAM Donor site morbidity (e.g. impaired muscle function) has to be taken into consideration in all flap techniques Oxford / AGO LoE / GR
14 Flap-Implant Combination Flap-implant combination 4 C + TRAM, LDF* + implant IR following RT 3b C + IR prior to RT 5 D - Advantages: TRAM: staged procedure preferable Improved implant coverage Suitable for radiated tissue Disadvantage: Muscle contraction (LDF) Oxford / AGO LoE / GR
15 Timing of Breast Reconstruction Delayed BR 3b B ++ No interference with adjuvant procedures (CHT, RT) Disadvantage: loss of skin envelope Oxford / AGO LoE / GR Immediate BR 3b B ++ Preferential in combination with partial Mx (BCT) Mandatory: SSM / NSM Avoidance of a postmastectomy syndrome Delayed-immediate BR 3b B +/-
16 Skin/Nipple Sparing Mastectomy (SSM/NSM) and Reconstruction Skin sparing mastectomy (SSM/NSM) Oxford / AGO LoE / GR Safe (same recurrence rate as MX) 2b B ++ Higher QoL for patients 2b B ++ NAC can be preserved under special conditions 2b B ++ Skin incisions different options possible: Periareolar ( purse-string ) (higher risk of necrosis) Reduction pattern: inverted-t or vertical Inferior lateral approach Inframammary fold lowest incidence of complications
17 SSM / Nipple SM Author Cases reported Partial skin necrosis Local recurrence Time period Lanitis S et al Ann Surg Jensen JA Ann Surg Oncol 2010 Yi M, Kronowitz SJ 2010 Cancer 1104 SSM 2635 NSSM -- 6,2% SSM 4,2% NSSM n.s Metaanalyse 99 6 % 2,7 % Median FU 60,2 mths 799 SSM 1011 CM - n.s. (local+syst. 6.6%) KIM HJ Ann Surg SSM 152 NSSM 9.6% NAC 0.8% SSM 2.0% NSSM (1.3%NAC) Paepke S Ann Surg SSM (96 NSM) 1,0 % of nipple necrosis no rec. in the nipple Chen CM 2009 PRS 115 (62 benign) Loss of NAC: 5.2% Occ.ca. 3.5% Necrosis Garwood ER 2009 Ann Surg 170 Cohort 1: 16% Cohort 2: 11% 0,6% Yano K et al Breast Cancer 128 3,1% 2,3% Petit JY et al Breast Cancer Res Treat 106 NSM 4,7% Loss of NAC 0,9% Far from NAC Gerber B et al Ann Surg 112 (Incl.61 NSM) 0% 5,4%
18 Bilateral Prophylactic Mastectomy (BPM) Oxford / AGO LoE / GR BPM reduces breast cancer incidence 1b A ++ BPM in deleterious BRCA1/2 mutation 2a B +* BPM in high risk (i.e. lifetime risk >=30% or heterozygote risk >=20%) but index case negative for BRCA1/2 mutations 3a C +/-* High risk and no BRCA counselling in specialized centre* (list in chapter Early detection and diagnosis) 5 D - - Non-directive counselling prior to BPM 2b B ++* BPM should be considered with other prophylactic surgical options incl. salpingoophorectomy (BSO) 2a A ++* *Counselling, risk prediction and follow-up in Familial Breast * Study and Ovarian participation Cancer Centres recommended
19 Types of Prophylactic Mastectomy Prophylactic bilateral mastectomy reduces breast cancer incidence; bc-spec mortality reduction likely Oxford / AGO LoE / GR Simple mastectomy 2b B + Prophylactic SSM 2b C + Prophylactic NSM (NAC sparing) 2b C + Contralateral prophylactic MX 4 C +/- * Study participation recommended
20 DIEP-Flap I Xu H 2009 PRS Wan DC 2010 PRS 113 3,5 % 17,7% 0 % hernia 0,9 % bulges (med. FU only 12,3 months!) 275 1) ftram 2) MS ftram 3) DIEP 1+2)BMI<30: 0 % 1)BMI>30: 0 % 2)BMI>30: 2,8 % 3)BMI<30: 6,1 % 4)BMI>30:14,3%
21 DIEP-Flap II Author Cases reported Complete loss of flap Liponecrosis partial flap loss Hernias/ Bulges in donor region Munhoz AM et al 2007 Breast J (on DIEP and SSM) 30 3,7% 7,4% 3,7% Lindsey JT PRS Hofer SO et al Ann Plast Surg 140 6,4% ,6% 8,6% -- Peeters WJ 2009 PRS 202 n.a. 49% Clinical 14% n.a. US 35% Selber JC 2010 PRS ftram 569 DIEP 97 0,2% 1,0% n.s. 4,1% 2,1% n.s. 1,9% 0 n.s.
22 DIEP-Flap III Author Cases reported Complete loss of flap Liponecrosis partial flap loss Hernias/ Bulges in donor region Garvey BP et al. PRS n.a. 8,3/3,3% n.a. Conroy K et al. PRAS 2011 Momoh AO et al. Ann PS 2011 Andree C. et al. Med Sci Monit epigastric hernia 217 n.a. n.a. 2,3%/ 0% ,8% n.a. n.a. Gart, M et al. J Am Coll Surg Free Flaps 5,7% n.a. n.a.
23 Pedicled / Free TRAM I Author Watterson PA, Bostwick J PRS Kroll SS (f-tram) 2000 PRS Lacotte B, Lejour M 1994 Ann Chir Plast Esthet Clugston PA, Maxwell GP 2000 PRS Petit JY, Rietjens M 1997 Ann Chir Plast Esthet Rezai M IGCS 2010 Reported cases Complete loss of flap Liponecrosis Hernias in donor region ,6% 8,8% 279 0,4%(1,1%) 15,1% % ,1% 5,8% ,2% 7% ,2% 0,6% Brunnert 2001 unpublished ,4% 0,4% Kim EK 2009 Ann Plast Surg 500 major fl. 0,2 % 14,2% 3% (bulges) Chun YS 2010 PRS 105 biped, 0 11,4% 2,9%
24 Pedicled / Free TRAM II Author Momoh AO et al. Ann PS 2011 Garvey BP et al. PRS 2011 Reported cases Complete loss of flap Liponecrosis Hernias in donor region 197 n.a. n.a. 2,3%/ 0% 228 n.a. 11,3/2,8% n.a.
25 Radiotherapy after Autologous Reconstruction I Author Patient satisfaction Failure complications Observation period Pts. RT/CTR Williams JK 1997 PRS unchanged nature of complications changes from fat necrosis to fibrosis /680 Soong IS 2004 Clin Oncol (Radiol) cosmesis 85% good to excellent no difference /-- Mehta VK no problems 10% skin desquam / Breast 30% grade 2 erythema Huang CJ fat fibrosis / PRS 8% n.s. Kronowitz SJ 2009 PRS Radiation Therapy and BR: A critical review of the literature > articles reviewed
26 Radiotherapy after Autologous Reconstruction II Author Patient satisfaction Failure Complications Observation period Pts. RT/CTR Barry M, Breast Cancer Res Treat Metaanalysis not reported OR = 0.21; 95% CI, [autologous vs. implantbased Implant vs. Autologous Recon.
27 Algorithm of Breast Reconstruction I 1st choice: Implant-Reconstruction Implant alone not suitable hostile environment TRAM-Flap or Consider implant + additional acellular matrix and/or fat grafting LADO+Implant if both not suitable if not suitable Microsurgery/free flaps
28 Algorithm of Breast Reconstruction II *Brunnert, K. Gyn. Prax., Band 31, 2007
29 Algorithm of Autologous Breast Reconstruction (1)
30 Algorithm of Autologous Breast Reconstruction (2) (MS-2) Double MS-2 ptram or Free TRAM (MS-2) Bip TRAM (MS-2) ftram DIEP
31 Algorithm of Implant Breast Reconstruction SSM/NSM Expander/Implant Reduction pattern + perm. Exp./ Implantat
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