Extending breast conservation and other new oncoplastic techniques
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1 Extending breast conservation and other new oncoplastic techniques Dick Rainsbury BSBR November 2013 Liverpool
2 What s the maximum volume of the breast which can be resected during lumpectomy without causing major local deformity? 1. 10% 2. 20% 3. 30% 4. 40% 5. 50%
3 In which of the following situations is oncoplastic breast conserving surgery contraindicated? 1. when treating multifocal tumours 2. when treating tumours >50mm 3. following NAC 4. in patients with very small breasts 5. when treating multicentric tumours
4 Which of the following statements is correct about intra-operative specimen radiology? 1. images take 30 seconds to generate 2. it can t be used for big specimens (~15cm) 3. it increases delayed re-excision rates 4. it is unhelpful after NAC 5. it reduces specimen weights
5 The expanding role of oncoplastic breast conservation... the clinical problem role of radiology and pathology new oncoplastic techniques current solutions to the problem clinical and radiological outcomes
6 The clinical problem: major deformity which follows WLE for bulky cancers breast volume resected % mastectomy indicated risk of major local deformity increases conservation indicated Bulstrode et al, Breast 2001; 10:117 Cochrane et al, BJS 2003; 90:1505
7 The clinical problem: patients still present with bulky cancers cancers screen-detected cases : 27% mastectomy rate symptomatic cases: 52% mastectomy rate patients per year risk deformity after WLE or face a mastectomy <15mm 15-20mm 21-35mm 36-50mm >50mm All Breast Cancer Report NCIN: 2009
8 current solutions which avoid mastectomy
9 Current solutions: oncoplastic breast conserving techniques volume displacement volume replacement breast volume reduced breast volume unchanged
10 Volume displacement techniques: two groups Level 1 procedures dense breasts skin and nipple undermined full thickness glandular excision glandular mobilization and approximation nipple-areola repositioned resection volume <20% Clough K et al Ann Surg Oncol 2010;17:
11 Level 1 procedures: example
12 Volume displacement techniques: two groups Level 2 procedures dense or fatty breasts major glandular excision range of mammoplasty techniques used resection volume 20-70% specific training required Clough K et al Ann Surg Oncol 2010;17:
13 Superior pedicle mammoplasty for lower pole tumour
14 V- mammoplasty for lower inner quadrant tumour
15 inferior pedicle mammoplasty for upper pole tumour
16 J-mammoplasty for lower outer tumour
17 Volume replacement techniques* flap free techniques implants saline injection lipofilling pedicle flaps lateral adipofascial flap inferior adipofascial LD miniflap pectoralis major omentum thoracoepigastric perforator flaps thoracodorsal artery lateral intercostal artery anterior intercostal artery superior epigastric artery free flaps omentum DIEP SIEP TRAM TUG * Rusby J, Rainsbury R Recon Breast Cancer Surg 2013; Eds: Reitjens M, Urban C
18 pedicled flaps latissimus dorsi miniflap
19 Operative details: LD miniflaps
20 LD miniflap reconstruction of 250gm defect: on table appearance
21 LD miniflap reconstruction: appearance 5yr post-operatively
22 perforator flaps thoracodorsal artery TDAP perforator flaps
23 TDAP Images provided by Douglas Macmillan, Nottingham Breast Institute
24 Images provided by Douglas Macmillan, Nottingham Breast Institute
25 role of radiology in oncoplastic resections?
26 Pre-operative localisation and rapid intra-operative large-specimen imaging <15 seconds post-resection 15 cm
27 Rapid intra-operative specimen radiology (IOSR) BioVision FaxitronBioptics mobile easy to use in the theatre images 10-15sec clear display image manipulation re-excision images 10x15cm capacity 52UK 2/3 theatre 1/3 shared
28 IOSR generated during volume replacement for 58mm tumour <15 seconds post-resection 15 cm
29 IOSR generated during volume displacement for 65mm tumour post-neoadjuvant Rx 12 cm <15 seconds post-resection
30 IOSR during volume replacement enabling immediate re-excision for 80mm tumour post-neoadjuvant Rx <15 seconds post-reexcision <15 seconds post-resection 11 cm
31 Impact of IOSR on specimen weights and re-excision rates? pre-iosr post-iosr p-value specimen weight (g) re-excision (%) Layfield DM et al Breast 2012; 21: Naeem H et al EJSO submitted abstract 2013
32 role of pathology in oncoplastic resections?
33 Pathology support: frozen section margin analysis primary tumour bed biopsies inked re-excision bed biopsies
34 Operative details: frozen section margin analysis technique
35 Pathology support for therapeutic mammoplasty
36 Impact of frozen section on further surgery? 100 therapeutic mammoplasty patients FS status of BB negative number 44 further surgery 1 (2%) equivocal or not done 56 7 (14%) Winchester Oncoplastic Database: 2013
37 outcomes of oncoplastic BCS?
38 Outcomes of OPBCS summarised for 23 studies involving 1,447 patients studies (no) patients (no) T-size (mm) follow up (mo) local recurrence (%) good cosmesis (%) volume displacement volume replacement* Franceschini G et al Eur Rev Med Pharm Sci 2012; 16: * Rusby J, Rainsbury R Recon Breast Cancer Surg 2013; Eds: Reitjens M, Urban C
39 Clinical outcomes: tumour details in 100 VDs and 246 VRs volume displacement position of tumours volume replacement position of tumours mean tumour size: 32mm mean specimen weight: 409g multifocal tumours: 22% mean tumour size: 33mm mean specimen weight: 193g multifocal tumours: 15%
40 Clinical outcomes of OPBCS: complications requiring intervention volume replacements (12%) 100 volume displacements (23%) NMBRA full breast reconstruction (28%) (%) infection haematoma delayed healing NAC necrosis other infection Data on file: Winchester Oncoplastic Database
41 Long-term oncological outcomes: local recurrence 371 cases oncoplastic BCS and DXT 121 volume replacements 100 volume displacements 150 volume displacements follow up 95 mo follow up 45 mo follow up 60 mo 3LR 0.3% pa 1 LR 0.3% pa 3 LR 0.6% pa personal communication D Macmillan, S McCulley, Nottingham Breast Institute, 2013
42 Long-term radiological outcomes: typical mammographic appearances MLO CC MLO isodense flap radiolucent rim minimal scar WLE Monticciolo D et al. AJR 1996;130:385
43 Trends in oncoplastic BCS: Mx +BR versus OPBCS 62 versus 21 cases PA 25 volume replacement volume displacement all cases Data on file: Winchester Oncoplastic Database
44 new oncoplastic techniques
45 New techniques: lipomodelling for correction of deformity Courtesy of Eva Weiler-Mithoff
46 New techniques: lipomodelling for correction of deformity
47 Lipomodelling: for total breast reconstruction Ueberreiter K et al. Handchir Mikrochir Plast Chir 2010; 42:
48 Radiological changes following lipomodelling? cysts increased density microcalcification macrocalcifications calcification without mass calcification with mass incidence of radiological changes in 2560 patients = 13.0% Claro F et al Br J Surgery 2012; 99:
49 Lipomodelling and risk of local recurrence: the skeleton in the cupboard lipomodelling (37 patients) no lipomodelling (74 patients) cumulative incidence of recurrence (%) 10 5 p-value< months from baseline Petit JY et al Ann Oncol 2012; 23:
50 New techniques: the rising popularity of the acellular dermal matrix
51 Placement of an acellular dermal matrix
52 US trends in reconstruction : the ADM effect number of cases PA US Plastic Surgery Statistics Report
53 Complications following ADM-assisted versus implant only reconstruction? complication seroma infection cellulitis haematoma skin necrosis implant loss OR (95% CI) 3.89 ( ) 3.52 ( ) 2.00 ( ) 1.99 ( ) 1.85 ( ) 2.96 ( ) NS NS NS trend towards less capsular contracture meta-analysis of 4,800 patients in 16 studies Ho G et al Annals Plast Surg 2012; 68:
54
55
56 New best practice guidelines for oncoplastic breast reconstruction key recommendations better patient information improved patient access informed patient choice rigorous infection control multimodal analgesia standardised monitoring service redesign oncoplastic units oncoplastic centres ISBN
57
58 What s the maximum volume of the breast which can be resected during lumpectomy without causing major local deformity? 1. 10% 2. 20% 3. 30% 4. 40% 5. 50%
59 In which of the following situations is oncoplastic breast conserving surgery contraindicated? 1. when treating multifocal tumours 2. when treating tumours >50mm 3. following NAC 4. in patients with very small breasts 5. when treating multicentric tumours
60 Which of the following statements is correct about intra-operative specimen radiology? 1. images can be viewed in 30 seconds 2. it can t be used for big specimens (~15cm) 3. it increases delayed re-excision rates 4. it is unhelpful after NAC 5. it reduces specimen weights
61 1 st ABS Multidisciplinary Meeting Neoadjuvant chemotherapy: an MDT approach 20 January 2014 Royal College of Surgeons of England The ABS is hosting its first MDT meeting on neoadjuvant chemotherapy. Topics will include: patient selection pre-nac imaging & pathology timing of sentinel node biopsy non responders imaging residual disease future developments
62 Radiological outcomes of OPBCS: which bit of the breast should be boosted...?
63 IOSRs during oncoplastic procedures confirming clearance of multifocal disease
64 Round block technique for upper pole tumour
65 Racquet technique for upper outer tumour
66 Lipomodelling: for total breast reconstruction Courtesy of Susanna Kauhanen, Helsinki
67 Pathology support for therapeutic mammoplasty typical request form, specimens and report
68 Clinical outcomes of OPBCS: complications requiring intervention
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