BSBR conference Nottingham 10th Nov 2015

BSBR conference Nottingham 10th Nov 2015 Breast imaging after oncoplastic and risk adapted conservation Fiona MacNeill FRCS, MD Breast Surgeon, London With thanks to Miss Katy Green SSM Medical Student Glasgow

Summary Increasing use of complex oncoplastic conservation techniques and risk adapted conservation after primary systemic therapy This may have implications for post surgery surveillance breast imaging recall and biopsy rates. The literature is sparse and limited quality but suggests no increase in recall Need careful dialogue between surgery and radiology to minimise recalls and extended assessments for benign post surgery changes The future: fat transfer on the rise...in the cancer and healthy population 16/11/2015 BSBR Nottingham 2015 2

Breast conservation Benefits On the presumption conservation leaves an acceptable breast aesthetic! Breast conservation (when compared with mastectomy) results in* Lower psychological morbidity Less anxiety and depression Improved body image, sexuality, self esteem *Al-Ghazal et al comparison of psychology and satisfaction after breast conservation, mastectomy and reconstruction EJC 2000 36:1938-43 16/11/2015 BSBR Nottingham 2015 3

Meta-analysis has confirmed the importance of optimal local excision EBCTCG Meta-analysis, Lancet 2005;366:2087 optimal local excision reduces recurrence and will improve survival one breast cancer death avoided for every 4 local recurrences avoided over a 15yr period 16/11/2015 BSBR Nottingham 2015 4

Aesthetic conservation disasters and difficult imaging Poor cosmesis in 5-30% of BCT (Berry/Clough J Plast Reconstr Aesthet Surg 2010) 16/11/2015 BSBR Nottingham 2015 5

Conservation: clashes of interest Risk of residual disease Margins Cosmesis Werner Audretsch (1998) Oncoplastic techniques 16/11/2015 BSBR Nottingham 2015 6

1. Rationale for oncoplastic breast conservation Extend the role of conservation Minimise deformity Numerous publications to demonstrate improved QofL Patel et al PRS 2011 Veiga DF et al PRS 2010 Optimise local excision Excision of larger/locally advanced cancers with maintenance of breast aesthetic reduce mastectomy/reconstruction rates Wider margins Reduce re-excision rates 16/11/2015 BSBR Nottingham 2015 7

Oncology outcomes for sbcs and obcs Losken et al (Emory Atlanta) Annals of Plastic Surgery 2014 72(2): 145-9. Meta analysis Oncoplastic BCS Standard BCS *Tumour size (cm) 2.7 1.2 *Specimen wt (g) 216 64 *Positive margin (%) 12.3 20.2 *Re-excision (%) 4.3 14.6 *Completion Mx (%) 6.2 3.8 Local recurrence rates % 4 37 months 7 64 months *P values oncoplastic Vs standard all <0.0001 8

Oncoplastic Breast conservation techniques Level 1 VOLUME DISPLACEMENT smaller but shapely breast Breast parenchymal flaps breast tissue re-arrangement Re-coning etc Therapeutic mammoplasty: Round block excision (Benelli) Reduction: variety of pedicles Dermoglandular (Grissoti flaps) Contralateral symmetrisation Usually required Poorly vascularised tissue FAT NECROSIS.. Level 2 VOLUME REPLACEMENT volume and shape maintained Imported local vascularised flaps of skin/subcutaneous tissues or muscle and subcutaneous tissue Cresenteric /Rotation Thoraco-epigastric, TDAP, LICAP etc Mini LD Contralateral symmetrisation usually NOT required Well vascularised tissue 16/11/2015 BSBR Nottingham 2015 9

Volume displacement Local Tissue Re-arrangement Drawings with thanks to Mr John Scott, plastic surgeon Cannisburn PARENCHYMAL PILLARS 16/11/2015 BSBR Nottingham 2015 10

Volume displacement - Therapeutic reduction mammoplasty. Poorly vascularized flaps Retro-areolar tumour: 1Kg WLE 16/11/2015 BSBR Nottingham 2015 11

Volume replacement - Vascularised flaps X X LICAP Mini LD flap 16/11/2015 BSBR Nottingham 2015 12

2. Risk adapted breast conservation Primary conservation Risk-adapted conservation Surgery is the first intervention in the multimodality treatment Pathway Current standard Surgery is the adjuvant treatment after primary Systemic (CT) therapy The future..? No survival disadvantage NSABP18 update 16yr follow-up: JCO 2008 16/11/2015 BSBR Nottingham 2015 13

What to remove after primary systemic therapy the surgeons dilemma. Original foot print Residium regardless of response to primary systemic therapy Risk-adapted conservation Easy More complicated 16/11/2015 BSBR Nottingham 2015 14

Risk- adapted conservation Principle: Must achieve clear margins to minimise local recurrence So need to define residual disease extent and type of response for surgical planning difficult to define on clinical/imaging assessment especially for ILC and DCIS Need careful dialogue between surgery and radiology. Usually best defined on post surgery pathology! 16/11/2015 BSBR Nottingham 2015 15

Patterns of disease responses after NACT vary None/minimal Type II Patchy ILC? Group A Same foot print (+/-volume reduction) Original plan Type I Implosion IDC? Complete Group B Smaller foot print and volume Original plan or Conservation 16/11/2015 BSBR Nottingham 2015 16

But what about M/C s? M/C s are not always a barrier to post NACT conservation Not all M/C s in a diseased breast are malignant must biopsy to facilitate accurate surgical planning M/C s assoc with DCIS or invasion Generally do not disappear Therefore not reliable indicator of disease response Post NACT biopsy of malignant M/C to assess response Whole extent of M/C s may not require removal However residual M/C s complicate mammographic follow up 16/11/2015 BSBR Nottingham 2015 17

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Coil fell from specimen 16/11/2015 BSBR Nottingham 2015 20

What are the imaging issues after oncoplastic and risk-adapted conservation? Complex oncoplastic Risk adapted Fat necrosis mimics cancer Dystrophic M/C Oil cysts/inclusion cysts, Managing residual M/C Dense scarring, asymmetric densities Issues are slightly different Increased recall and biopsy rates? Impact on detection of recurrent cancer? 16/11/2015 BSBR Nottingham 2015 21

What is the evidence? Imaging changes post reduction mammoplasty wellcharacterized. Kim H et al Breast cancer 2013 skin thickening stromal oedema, architectural distortion, nipple elevation, calcifications and oil cysts. Does not increase additional imaging, recall or biopsy rates Roberts et al Journal Am Surg 2011, Muir et al Clin Radiol 2010 Very few papers on imaging post oncoplastic surgery 16/11/2015 BSBR Nottingham 2015 22

Post obcs imaging- whose learning curve? Impact of partial breast reconstruction using reduction techniques on surveillance. Losken A Plast Reconstr Surg. 2009 Jul;124(1):9-17 N=17 obcs (mammoplasty) N=17 sbcs (control group) FU 6 years, schedule not specified Breast density scores, architectural distortion, cysts, calcifications and time to mammographic stabilisation (21-24mnths) similar for both groups. obcs group had significantly higher biopsy rate (53%) than sbcs (18%). Incidence of abnormal mammograms after reduction mammoplasty Roberts JM Am J Surg. 2011 May;201(5):611-4. 2001-5 N=87 obcs mammoplasty N=30 control group no surgery 52 weeks: obcs had 25% further imaging 16/11/2015 BSBR Nottingham 2015 23

Impact of contra-lateral breast reshaping on mammographic surveillance in women undergoing breast reconstruction following mastectomy for breast cancer. Nava et al Breast. 2015 Aug;24(4):434-9. N=103. 2002-7. All had unilateral Mx and recon Contralateral symmetry surgery A/B: reduction C. no contralateral surgery Group A and B had more stromal distortions, skin oedema, No increase in MRI use or biopsies Mammographic sensitivity, specificity same between groups 16/11/2015 BSBR Nottingham 2015 24

N=98 Matched cohorts Mammoplasty more advanced disease Standard WLE N=49 4 (8%) had in-breast recurrence 6/12,1yr,2yr, 5yrs: total biopsies P = 0.46 9 (18%) 4 palpable mass Oncoplastic WLE Bilateral Mammoplasty N=49 6 (12%) had in-breast recurrence 12 (24%) 5 for M/C 1yr more abnormal findings no action 1,2,5yrs more benign M/C 16/11/2015 BSBR Nottingham 2015 25

Incidence of fat necrosis between the 2 groups was comparable 16/11/2015 BSBR Nottingham 2015 26

cancer to biopsy ratio: WLE 33 % Mammoplasty: 42 % Conclusion: Significant tissue rearrangement does not lead to unwarranted biopsies Radiologists were able to distinguish cancer recurrence from other abnormal mammographic findings successfully, as evidenced by relatively low biopsy rate and high cancer to biopsy ratio 16/11/2015 BSBR Nottingham 2015 27

Summary Increasing use of complex oncoplastic conservation techniques and risk adapted conservation after primary systemic therapy This may have implications for post surgery surveillance breast imaging recall and biopsy rates. The literature is sparse and limited quality but suggests no increase in recall Need careful dialogue between surgery and radiology to minimise recalls and extended assessments for benign post surgery changes The future: fat transfer on the rise...in the cancer and healthy population 16/11/2015 BSBR Nottingham 2015 28

The future Fat transfer on the rise...in the cancer and normal population 16/11/2015 BSBR Nottingham 2015 29