The Case FOR Oncoplastic Surgery in Small Breasts Barbara L. Smith, MD, PhD Massachusetts General Hospital Harvard Medical School Boston, MA USA
Changing issues in breast cancer management Early detection and improved treatment lead to many healthy, long term survivors Side effects of cancer treatment, quality-of-life issues more important than in past Increasing respect for cosmetic outcomes
Mastectomy vs. Lumpectomy: 20-year Data No Difference in Survival NSABP B-06 Milan I Trial
Breast Conservation vs. Mastectomy 20 year follow-up: lumpectomy and mastectomy provide equivalent survival Technical improvements in lumpectomy and radiation 10-year local recurrence rates now 2-5% further reduces relative benefit of mastectomy
Local recurrence reduces survival Oxford Overview Lancet 2005;366:2087 42,000 patients in 78 trials Increased local recurrence at 5 years = decreased survival at 15 years 4:1 ratio - 1 extra death for each 4 local failures Critical to get clean margins to prevent local recurrence
The challenge of small breasts Successful lumpectomy requires clean margins Goal of good cosmetic result Lumpectomy volume may be large relative to breast size in slim women Can a small breast be saved while achieving oncologic goals?
Can oncoplastic techniques help small breasted women safely keep their breasts? YES! Careful incision placement Avoid unnecessary excision Oriented shaved margins Oncoplastic closure of cavity?fat grafting and implant augmentation later
Lumpectomy and oncoplastic closure for 12:00 cancer 5.2.x.3.6.x.1.8 cm specimen
A great oncoplastic surgeon starts by being a great oncologic surgeon
Reasons for mastectomy instead of oncoplastic breast conserving surgery No radiation therapy available Contraindications to radiation therapy Medial or lower inner breast lesions best cosmetic results for lateral, central and upper Access to immediate reconstruction If reconstruction not available, lumpectomy may be preferable even if poorer cosmetic result
Incision placement Good cosmetic location Would not prevent nipple sparing or skin sparing mastectomy approach Allows good view for oncoplastic advancement flaps
Periareolar incision for approach to cancer upper mid breast, oncoplastic closure
Avoid unnecessary excision Center margins around mass Non-palpable: Multiple localizing wires to outline area to be excised
Avoid unnecessary excision Center margins around mass Non-palpable: Multiple localizing wires to outline area to be excised
Careful technique can reduce volume of excision Careful specimen margin orientation to allow targeted and limited re-excision of positive margins rather than global re-excision Small lumpectomy with shaved margins better than very large single lumpectomy specimen
Simple oncoplastic closure of lumpectomy defects Local advancement flaps to close / hide defect Extend deep margin to fascia Lift 2-3 cm of breast off pectoralis major around entire lumpectomy cavity Lift skin off breast at incision edges if needed Local anesthesia for comfort Oncoplastic closure Protect nipple projection first Advance remaining tissue flaps to restore shape
Complex oncoplastic closure of lumpectomy defects Can achieve an excellent cosmetic result for larger lumpectomies or when skin excision required Extensive mobilization of skin and re-arrangement of tissue for larger defects Partial breast reconstruction with latissimus dorsi or omentum
Cosmetic revisions after treatment Fat grafting of localized defects Caution to avoid fat necrosis and mammogram changes at lumpectomy site Implant placement to replace lost volume Option to augment opposite breast Wait minimum 1-2 years after radiation to improve outcome
Immediate reconstruction for small breasts Nipple sparing mastectomy possible Single stage implant reconstruction for many Option to increase size with tissue expander reconstruction
Breast enlargement with bilateral mastectomies and reconstruction for breast cancer treatment
Nipple sparing increases options for single stage implant reconstruction for smaller breasts Acelular dermal matrix Single stage approach reduces morbidity and cost Acellular dermal matrix, Vicryl mesh Tessler et al Beyond biologics: absorbable mesh as a low cost, low complication sling for implant-based breast reconstruction. J Plastic and Reconstr Surg 133: 90e-99e, 2014
Nipple sparing in small to moderate size breasts: MGH 1/2007-2/2013 293 breasts <400 ml volume in 187 patients Mean patient age 45.9 years (range 25-71) mean BMI 22.1 kg/m2 (range 16.9-31.6) Mean mastectomy volume 246 ml (range 46-396ml) Mastectomies for cancer, DCIS, and risk reduction High nipple retention rates, few major complications
NSM with reconstruction in smaller breasts: procedures and outcomes # % Risk reduction 150 51% Invasive cancer 94 32% Intraductal cancer (DCIS) 49 17% Lymph node positive 21/94 22% Direct to implant 182 62% Tissue expander 106 36% Tissue flap 5 2% Any complication 33 11% Nipple loss 3 1% Implant loss 1 0.3%
Bilateral prophylactic nipple sparing mastectomies BRCA mutation carrier - Pre-op Single stage implant reconstruction 6 weeks post op
Oncoplastic surgery can save small breasts
Conclusions Oncoplastic surgery is an option for most women with small breasts Smart lumpectomy with oncoplastic closure and radiation excellent for many Mastectomy with immediate reconstruction also an option Increasing options for nipple sparing and single stage implant reconstruction