NIPPLE SPARING MASTECTOMY

Transcription

1 NIPPLE SPARING MASTECTOMY 29th Annual Montefiore-Einstein Controversies in Surgery Symposium Virgilio Sacchini, MD Memorial Sloan-Kettering Cancer Center Professor of Clinical Surgery Weill Cornell Medical College

2 Institutional trend in NSM 300 # of NSM performed by year # OF NSM TOTAL 542 NSM (354-65%) PROPHYLACTIC

3 Therapeutic NSM (188) 35% Indications for Surgery Prophylactic Cancer 65% TOTAL 542 NSM

4 Therapeutic NSM 900 Number of Therapeutic NSM per Year Number of Procedures NSM All Other Mx Procedure Type 5.2% of all the therapeutic mastectomies

5 QUALITY OF LIFE: NSM Vs SKIN SPARING MATECTOMY WITH NIPPLE RECONSTRUCTION N Psychosocial well-being Sexual well-being MEAN MEAN NSM p < R-square=0.14 SSM Data corrected for BMI, Age, Original Cup Size, Marital Status, Type of implant Alison Price: Abstract accepted for oral presentation ISOQOL October 2012

6 NIPPLE SPARING MASTECTOMY Priority: no breast tissue left 3 mm N.A. flap

7 NIPPLE-AREOLA NECROSIS Author Year Number of Pts NA complex loss Gerber % total, 9.8% partial Crowe % total, 6% partial Caruso % total Crowe % total, 1.3% partial Regolo % NAC complication Stolier % Sookhan % total, 10% partial Petit % total, 5.5% partial Paepke % De Alcantara % total

8 CORONAL SECTION OF THE NIPPLE Vessels stained with anti-factor VIII antibody to vascular endothelium Peripheral 3 mm (66% of the vessels ) Peripheral 2 mm (50% of the vessels ) Duct bundle 87% Duct bundle 96% Rusby J. et Al, AJS, 2007

9 SCISSORS INSTEAD OF CAUTERY FOR DUCTAL DISSECTION TO AVOID THERMAL DAMAGE

10 0THER POSSIBLE CAUSES OF NECROSIS OF THE NIPPLE-AREOLA Excessive retraction of the skin injuring the subcutaneous vessels Excessive inflation of the tissue expander compressing the subcutaneous vessels Surgical bra may compress the nipple and areola

11 NIPPLE/AREOLA/FLAPS NECROSIS COMPLICATIONS 3.2% Partial Necrosis (2/3 rd involvement) 10/542 (1.9%) Total Necrosis requiring excision 7/542 (1.3%)

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13 MINIMISING POSSIBLE POSITIVE ANTERIOR/POSTERIOR MARGINS

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16 INFERIOR INVERTED T Sacchini Nava 2011

17 Nipple sparing mastectomy: radial external incision Good exposure to the breast parenchyma in all the quadrants, possibility to do axillary dissection and preservation of the blood supply from the skin of all the quadrants

18 INCISION: MAMMARY FOLD 4%

19 DO WE HAVE CHOICE FOR THE INCISION IN NEPPLE SPARING MASTECTOMY? Testut Jacob: Trattato di Anatomia Topografica - UTET

20 INTRAOPERATIVE PERFUSION ASSESSMENT SYSTEM Tricarbocyanine Dye injection and scan with fluorescence detecting device

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22 INTRAOPERATIVE PERFUSION ASSESSMENT SYSTEM (TRICARBOCYANINE DYE)

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27 HOW SAFE IS NSM IN CANCER? Risk of local relapses (nipple and areola + flaps) Selection of Patients Management of positive margins (retro-areolar )

28 Nipple sparing mastectomy for cancer (188 Pts ) Stage O (DCIS) 79 (42%) 1A 1B 2A 2B 3A % of Patients were candidate to conservation surgery MSKCC 2012

29 Nipple sparing mastectomy for cancer(136 Pt > 18 Ms FU) Mean Median Range Age f/u cancer months NONE LOCAL RELAPSES, 3 DISTANT METASTASIS Included the 5% incidental cancers in the prophylactic setting MSKCC 2012

30 Local and nipple areolar complex recurrence after nipplesparing mastectomy. Author Study design Number of Pts LR NAC recurrence Median followup (months) Gerber Prospective % 0.9% 59 Caruso Prospective 50 2% 2% 66 Sacchini Retrospective 192 3% Regolo Retrospective Crowe Prospective % 0 41 Sookhan Retrospective Voltura Retrospective Garwood e Prospective % 0 13 Garcia-Etienne Retrospective Paepke Retrospective 96 2% 0 34 De Alcantara Filho Prospective Modified from Tokin C. et Al, International Journal of Surgical Oncology, 2012

31 MSKCC : ELEGIBLE CRITERIA Female age 18 years or older Breast ptosis less than 4th grade No clinical involvement of the nipple or areola Any site and any size DCIS or invasive carcinoma < 3 cm at least 1 cm from the nipple at MX, US or MRI with biopsy of retro-areolar tissue proven to be negative. Frozen section 4% of false negative results

32 MAY MRI BETTER PREDICT THE N.A. INVOLVEMENT? No. of total mastectomies with preop MRI = 125 ( ) de Alcantara et Al, SSO 2011

33 NIPPLE AND AREOLAR TUMESCENCE Better Surgical Plane improving the retro-areolar dissection

34 NIPPLE AND AREOLAR TUMESCENCE: ONCOLOGIC IMPLICATION BETTER DELIMITATION DERMA/BREAST PARENCHIMA/DUCTS Folli et Al, Breast 2012

35 NIPPLE AND AREOLAR TUMESCENCE: ONCOLOGIC IMPLICATION RESIDUAL BREAST PARENCHYMA PRESENT ABSENT TUMESCENCE 1.4% (1) 86% (6) NO TUMESCENCE 92% (12) 8% (1) Residual breast tissue after removal of the nipple-areola for positive pathology Folli et Al, Breast 2012

36 NIPPLE AND AREOLAR TUMESCENCE RESIDUAL CANCER PRESENT 3/11 (23%) ABSENT 8/11 (77%) TUMESCENCE (115/7) 0% (0) 100% (7) NO TUMESCENCE (84/4) 75% (3) 25% (1) 199 Patients: 11 (5.5%) positive retro-areolar or anterior margins MSKCC 2012

37 RISK REDUCING NSM (197) Mean Median Range (months) Age 43.83= Follow-up months % Pts positive for BRCA 1-2, other with risk > 30% No Breast Cancers in the all Patients de Alcantara et Al, SSO 2011

38 Mayo Clinic Experience: Hartmann et al. NEJM, 1999

39 Mayo Clinic Experience: Hartmann et al. NEJM, 1999

40 NIPPLE SPARING MASTECTOMY: FINAL CONSIDERATION Reasonable approach in selected patients with IC and DCIS and for Risk Reducing Surgery Better cosmesis. Better quality of life Technically more difficult than a conventional mastectomy Possible increase risk of post op complications Any size IC or DCIS with negative margins?