3/7/2015 A Combined Practice • Ablative Surgical Oncology A Combined Breast Oncology and Plastic Surgery • Plastic Surgery Practice – Why It Works • Focus on breast, melanoma, and oncologic reconstruction while maintaining an aesthetic Anne M. Wallace, MD, FACS and general reconstructive practice Director, Comprehensive Breast Health Center • Have been the Team Leader for the UCSD Professor of Clinical Surgery, Surgical Oncology and Plastic Surgery Breast Program for 20 years UCSD Department of Surgery, Moores Cancer Center Barriers to Breast Reconstruction Why Its Worked • Huge Issue • One surgeon, both aspects – ablative and • Must understand difficult nature of this field – reconstruction • As a Plastic Surgeon, we know the breast and extremely time consuming, very under- reimbursed; difficult to achieve patient skin better than any other specialty satisfaction in certain subgroups of body • As a Plastic Surgeon, we follow the patients types, etc. longer than most • Most plastic surgeons are in private practice • As a breast oncologist the patient gets where reimbursement from insurance does not even begin to pay cost, especially from the seemless care BCCTP and medi-cal 1
3/7/2015 Disparities in Breast Reconstruction Receipt of Breast Reconstruction • Data presented at CSPS • Receipt of Reconstruction by • JCO 2009 - 3252 pts in SEER data, 2260 Race: W/AA/Latina-high/Latina- low: 40.9/33.5/41.2/13.5% p < respondents; 806 patients who received a 001 mastectomy • Latina-low tended to be younger, • Outcomes – receipt of reconstruction less likely to be high school graduates, and more likely to be • 34.6% of 806 patients, 84.5% at time of without health insurance mastectomy,15.5% later • AA had more comorbidities • No difference in stage of disease OSHPD Data Do Variations in Provider Discussions Explain Differences • Postmastectomy reconstruction rates were in Reconstruction determined from the California Office of Statewide Health Planning and Development • Journal Of American College of (OSHPD) inpatient database from 2003 to Surgeons, April 2008 • Data collected from NICCQ, stages I-III 2007. • 253/626 pts received reconstruction • The proportion of patients undergoing (40.4%) reconstruction rose from 24.8% in 2003 to • If Discussion of reconstruction not 29.2% in 2007. documented, PATIENT LESS LIKELY TO RECEIVE IT 2
3/7/2015 UCSD Data 2001-2011 • UCSD “same surgeon” reconstruction rate – 78.8%; Of the 1715 operations breast cancer operations 63.6% (N=1091) and 36.4% (N=624) represented breast conservation therapy • Remaining mastectomy patients either did not want and mastectomy, respectively. reconstruction or had locally advanced disease • On multivariate analysis, independent predictors of Of the lumpectomy patients, 9.3% (N=168) required re- excision for close or positive margins . (National average by reconstruction were age, relationship status, and current literature 23%) stage of disease, while the effect of race and insurance status were non-significant 78.8% of mastectomy patients underwent breast reconstruction, 4.5% of which were delayed. There was a total recurrence rate of 6.73%. So in an Institution Where A Novel Survival Data from UCSD Approach to the Delivery of Breast Care is Made • 615 women treated 2003-2011 with mastectomy; 78.8% underwent reconstruction • Breast reconstruction rate 78.8% vs national • Those pts had higher OS and DFS (8.3% vs 11.3 years, average of 34.6% p<0.001 and 6.6 vs 11.5 years, respectively, p<0.001) • Positive margin rate 9.8% vs national average • After controlling for age, race, marital status, payer category, triple negative status, stage of disease and of 23% receipt of chemotherapy, radiation therapy and • Survival advantage across the board for hormone therapy, reconstructed patients still patients who were reconstructed maintained a survival advantage 3
3/7/2015 Points to Remember • Clear margins is the goal • Must accept that taking tissue will leave some change in the effected breast It’s the Simple Differences We Make • Our goal is to camouflage defect as a much as Daily possible • Postoperative correction is very feasible Oncoplastic Techniques – For Very Large Defects • Central Lumpectomy with inverted T closure • A circumareolar, Bennelli-type closure • Inferiorly based mammaplasty • Other local flaps • Basically, volume replacement or volume displacement closure for large peri- areolar defects • Any of the above with bracketed localization 4
3/7/2015 Inferior Tumor Often Poor Results Preop Inferior Lower Quadrant tumor • Radiology localized tumor • Mastopexy drawn around Postop 1 year Tumor Involving Nipple Breast Conservation Via Breast Reduction Nipple-Ablation Mastopexy New Nipple Created Later On Patch of Neo-Areolar Skin 5
3/7/2015 Biloped Flap for Central Superior Defect The 12:00 central breast defects are very non-cosmetic when excised primarily Basic plastic surgery flap-biloped Asymmetry After Breast Conservation Six days post-op; widely clear margins and NO pulling up of NAC or indentation 6
3/7/2015 Flap procedures for local defect Preop Postop Choosing Mastectomy Mastectomies have evolved • Tumor too diffuse • Tumor in multiple quadrants • Traditional • BRCA family • Skin sparing • Pt will get better cosmetic result with implants • Nipple sparing (breast small and ptotic) • Recurrence 7
3/7/2015 Immediate flap After Skin Sparing Traditional Mastectomy Mastectomy Nipple Sparing/ Minimal Skin/ Implant Skin Sparing Mastectomy Removal 8
3/7/2015 • There is No subcutaneous fat between ductal tissue and skin • Dissection DIRECTLY under skin, completely “skinning” the undersurface • Invert nipple and cut circular rim of tissue out – send separately to path • Nipple may DIE • Editorial in Annals of Surgical Oncology this month STRESSED importance of adequate mastectomy Nipple Sparing Mastectomy Seemless Cancer Care When the Surgeon Does Both Aspects 9
3/7/2015 1. Example RM, Continued RM, 65 year old female, s/p masto/aug Unhappy with right side – nipple too • Right side corrected with pocket adjustment, re-do mastopexy high, bottomed out to lower NAC, new implant Now scheduled with me for right side • So decision to open left side to place same implant correction and if necessary in OR • Once implant out on left, palpation of the inside pocket adjustment of left side revealed a hard mass on far lateral breast, just anterior to Mammogram, PE normal capsule • Immediate removal and frozen section – Invasive ductal CA; took a wider margin on the spot; scheduled for sentinel lymph node several days later after MRI; • Tumor small enough and node negative; thus an intermediate ONCOTYPE score allowed her NO chemotherpy • Radiation than proceeded and she is doing very well • She later became the donor for my $2 million endowment to establish an integrated fellowship 2. Example Continued… Triple Negative Breast Cancer; BRCA+ Had neoadjuvant chemo, • Was scheduled for fat grafting, upper poles Mastectomties, • During marking in preop area, pt says “Dr. Wallace, I expanders; Post op day 3 implants have a lump under my arm”. • I had not seen her for a month. I examined and there was a 2cm mass in the right axilla • Immediate CHANGE in OR plan – excisional biopsy, frozen section, followed by ALND when it returned metastatic CA to axilla. Fat grafting aborted as she would now need radiation and would return later for more reconstruction 10
3/7/2015 3. Example Clear Margins Large cancer forming a “U” up and across breast Took 5 needles to localize and a breast reduction to close it correctly. 7 cm cancer with clear margins 4. Example ML 68 Year Old Female • 2003 had bilateral mastectomies by me for DCIS and a low grade early stage 1 disease • Had expander/implant reconstruction, but on the left side had several implant infections. • After several implant surgeries, in 2006 we converted her left side to a TRAM flap. • She did well until 2012 February 2012, she Noticed one small bruise • No history of chemotherapy or radiation Like area on left side. Progressed over 2 months To this . 11
3/7/2015 ML, Continued Went on to complete resection of the TRAM, • She lives in Reno, NV. Biopsy done by my Chemotherapy and radiation recommendation and it was inconclusive Came back a year later for a latissimus • MRI just showed skin thickening Flap/ revisions pending • All blood work normal; no new meds that cause bruising • Clinical picture was still concerning • The Answer: Angiosarcoma; Was embedded in the TRAM; no Ductal tissue seen; • ????? Related to history of implant infection??? .5 Example JC 65 Year Old Female JC, Continued • MRI of breast shows a mass again beneath • History of nearly 40 year old silicone implants implant and enlarged IMA nodes • Pelvic pain – Primary Care Doc works up with • Not amenable to core biopsy due to location scans; PET/CT eventually done that shows • Implant rupture suspected as well mass under left implant, and PET+ nodes in • I’m referred pt – level of expertise that internal mammary chain, left side incorporates both aspects - discussed implant • Some indistinct nodes in pelvis removal, identifying and removing mass and removal of internal mammary nodes at that level 12
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