[PPT] - A Combined Practice Ablative Surgical Oncology A Combined Breast PowerPoint Presentation

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3/7/2015 1 A Combined Breast Oncology and Plastic Surgery Practice – Why It Works

Anne M. Wallace, MD, FACS Director, Comprehensive Breast Health Center Professor of Clinical Surgery, Surgical Oncology and Plastic Surgery UCSD Department of Surgery, Moores Cancer Center

A Combined Practice

Ablative Surgical Oncology
Plastic Surgery
Focus on breast, melanoma, and oncologic

reconstruction while maintaining an aesthetic and general reconstructive practice

Have been the Team Leader for the UCSD

Breast Program for 20 years

Why Its Worked

One surgeon, both aspects – ablative and

reconstruction

As a Plastic Surgeon, we know the breast and

skin better than any other specialty

As a Plastic Surgeon, we follow the patients

longer than most

As a breast oncologist the patient gets

seemless care

Barriers to Breast Reconstruction

Huge Issue
Must understand difficult nature of this field –

extremely time consuming, very under- reimbursed; difficult to achieve patient satisfaction in certain subgroups of body types, etc.

Most plastic surgeons are in private practice

where reimbursement from insurance does not even begin to pay cost, especially from the BCCTP and medi-cal

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3/7/2015 2

Disparities in Breast Reconstruction

Data presented at CSPS
JCO 2009 - 3252 pts in SEER data, 2260

respondents; 806 patients who received a mastectomy

Outcomes – receipt of reconstruction
34.6% of 806 patients, 84.5% at time of

mastectomy,15.5% later

Receipt of Breast Reconstruction

Receipt of Reconstruction by

Race: W/AA/Latina-high/Latina- low: 40.9/33.5/41.2/13.5% p < 001

Latina-low tended to be younger,

less likely to be high school graduates, and more likely to be without health insurance

AA had more comorbidities
No difference in stage of disease

OSHPD Data

Postmastectomy reconstruction rates were

determined from the California Office of Statewide Health Planning and Development (OSHPD) inpatient database from 2003 to 2007.

The proportion of patients undergoing

reconstruction rose from 24.8% in 2003 to 29.2% in 2007.

Do Variations in Provider Discussions Explain Differences in Reconstruction

Journal Of American College of

Surgeons, April 2008

Data collected from NICCQ, stages I-III
253/626 pts received reconstruction

(40.4%)

If Discussion of reconstruction not

documented, PATIENT LESS LIKELY TO RECEIVE IT

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3/7/2015 3

UCSD Data 2001-2011

Of the 1715 operations breast cancer operations 63.6% (N=1091) and 36.4% (N=624) represented breast conservation therapy and mastectomy, respectively. Of the lumpectomy patients, 9.3% (N=168) required re- excision for close or positive margins. (National average by current literature 23%)

78.8% of mastectomy patients underwent breast

reconstruction, 4.5% of which were delayed. There was a total recurrence rate of 6.73%.

UCSD “same surgeon” reconstruction rate – 78.8%;
Remaining mastectomy patients either did not want

reconstruction or had locally advanced disease

On multivariate analysis, independent predictors of

reconstruction were age, relationship status, and stage of disease, while the effect of race and insurance status were non-significant

Survival Data from UCSD

615 women treated 2003-2011 with mastectomy;

78.8% underwent reconstruction

Those pts had higher OS and DFS (8.3% vs 11.3 years,

p<0.001 and 6.6 vs 11.5 years, respectively, p<0.001)

After controlling for age, race, marital status, payer

category, triple negative status, stage of disease and receipt of chemotherapy, radiation therapy and hormone therapy, reconstructed patients still maintained a survival advantage

So in an Institution Where A Novel Approach to the Delivery of Breast Care is Made

Breast reconstruction rate 78.8% vs national

average of 34.6%

Positive margin rate 9.8% vs national average
f 23%
Survival advantage across the board for

patients who were reconstructed

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3/7/2015 4

It’s the Simple Differences We Make Daily

Points to Remember

Clear margins is the goal
Must accept that taking tissue will leave some

change in the effected breast

Our goal is to camouflage defect as a much as

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

Any of the above with bracketed localization

closure for large peri- areolar defects

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3/7/2015 5

Inferior Tumor Often Poor Results

Radiology

localized tumor

Mastopexy

drawn around Preop Postop 1 year

Inferior Lower Quadrant tumor

Tumor Involving Nipple

Nipple-Ablation Mastopexy New Nipple Created Later On Patch of Neo-Areolar Skin

Breast Conservation Via Breast Reduction

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3/7/2015 6

The 12:00 central breast defects are very non-cosmetic when excised primarily

Basic plastic surgery flap-biloped Biloped Flap for Central Superior Defect Six days post-op; widely clear margins and NO pulling up of NAC or indentation

Asymmetry After Breast Conservation

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3/7/2015 7

Preop Postop

Flap procedures for local defect

Choosing Mastectomy

Tumor too diffuse
Tumor in multiple quadrants
BRCA family
Pt will get better cosmetic result with implants

(breast small and ptotic)

Recurrence

Mastectomies have evolved

Traditional
Skin sparing
Nipple sparing

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3/7/2015 8

Traditional Mastectomy

Immediate flap After Skin Sparing Mastectomy

Skin Sparing Mastectomy

Nipple Sparing/ Minimal Skin/ Implant Removal

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3/7/2015 9

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

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3/7/2015 10

RM, 65 year old female, s/p masto/aug Unhappy with right side – nipple too high, bottomed out Now scheduled with me for right side correction and if necessary in OR adjustment of left side

Mammogram, PE normal

1. Example

RM, Continued

Right side corrected with pocket adjustment, re-do mastopexy

to lower NAC, new implant

So decision to open left side to place same implant
Once implant out on left, palpation of the inside pocket

revealed a hard mass on far lateral breast, just anterior to 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

Triple Negative Breast Cancer; BRCA+ Had neoadjuvant chemo, Mastectomties, expanders; Post op day 3 implants

2. Example

Continued…

Was scheduled for fat grafting, upper poles
During marking in preop area, pt says “Dr. Wallace, I

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

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3/7/2015 11

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

3. Example

Clear Margins

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
No history of chemotherapy or radiation
4. Example

February 2012, she Noticed one small bruise Like area on left side. Progressed over 2 months To this.

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3/7/2015 12

ML, Continued

She lives in Reno, NV. Biopsy done by my

recommendation and it was inconclusive

MRI just showed skin thickening
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???

Went on to complete resection of the TRAM, Chemotherapy and radiation Came back a year later for a latissimus Flap/ revisions pending

JC 65 Year Old Female

History of nearly 40 year old silicone implants
Pelvic pain – Primary Care Doc works up with

scans; PET/CT eventually done that shows mass under left implant, and PET+ nodes in internal mammary chain, left side

Some indistinct nodes in pelvis

.5 Example

JC, Continued

MRI of breast shows a mass again beneath

implant and enlarged IMA nodes

Not amenable to core biopsy due to location
Implant rupture suspected as well
I’m referred pt – level of expertise that

incorporates both aspects - discussed implant removal, identifying and removing mass and removal of internal mammary nodes at that level

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3/7/2015 13

Right implant GROSSLY ruptured Left intact, but being pushed and elevated by this mass Bilateral capsulectomies done Internal mammary node removal Mass taken with rib fascia

Ambiguous pathology for 2 weeks; thought to be angiosarcoma; but finally determined to be atypical vascular lesion consistent with an old organized hematoma Care of this pt was facilitated by me knowing both the plastic surgery and the surgical oncology

BRCA Patients

All referred to me
Discuss better screening and observation - MRI
Discuss chemoprevention – tamoxifen, raloxifene,
ophrectomy
Discuss bilateral mastectomies/reconstruction
Follow for years
Then DO the mastectomies when the time is right for

the patient

MASTECTOMIES ARE NOT ALWAYS THE IMMEDIATE

ANSWER FOR THESE PATIENTS

6. Example

BRCA +; bilateral preventative Mastectomies, expanders, Implants and fat grating

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3/7/2015 14

Pt BRCA positive

29, BRCA+, Advanced breast cancer treated with chemo first Followed by mastectomies and reconstruction; Despite positive Lymph nodes, etc., she had a great result

Triple negative breast cancer Treated first with clinical trial Bilateral mastectomies and Implant reconstruction, nipple sparing

PT with bilateral breast cancer; hx Radiation Did Hyperbaric Oxygen First to Help Nipple Survival

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3/7/2015 15

One Pt is a breast augmentation; another is bilateral mastectomies for cancer; Is getting very close to minimal differences in cosmetic

utcome

Right sided reconstruction ONLY with Mentor MM shaped gel. Nothing done on left; This Implant is fantastic for unilateral reconstruction Because Mentor makes a broader lower profile Shaped implant and it is somewhat softer.

Bilateral Tram Flaps after prophylactic mastectomies for family history

A Few Additional Comments

I do LESS mastectomies than my colleague at

UCSD; rvu incentive for general surgeons to do more

Efficiency of practice in both the clinic and OR
Having a dual practice is obviously better for

the patient, but also increases job satisfaction for the surgeon

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3/7/2015 16

Locally advanced and infiltrating Breast cancer; failed all other modalities

Axillary Tumor Recurrence

Latissimus flap reconstruction Failed TRAM; there is no Implant in this TRAM; Its all Fat necrosis, etc. Salvage Latissimus Flap Contracated implant Since 1995; salvage latissimus

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3/7/2015 17

Chronic 10 month old wound; radiated, necrotic Rib; debridement, rib resection, flap for closure; 6 months later expander placed and fully expanded