Increasing Breast Conservation Using Oncoplastic Techniques Brian - PDF document

3/5/2018 Increasing Breast Conservation Using Oncoplastic Techniques Brian J Czerniecki, MD, PhD Chair Department of Breast Oncology • No pertinent disclosures For Stage I-III Breast Cancer BCT is Equivalent or Superior to Mastectomy Onitillo Clin Med Res. 2015 Jun; 13(2): 65–73. doi: 10.3121/cmr.2014.1245 1

3/5/2018 What is oncoplastic surgery? • In the broadest sense, oncoplastic surgery is the resection of breast cancer with subsequent reconstruction to achieve an oncologically safe resection and a functional and aesthetically pleasing breast reconstruction History of oncoplastic surgery Oncoplastic Surgery: Sub-Group Definitions • Volume Replacement Oncoplastic Surgery – The use of locoregional flaps or implants to replace the large volume removed from a partial mastectomy – Used when greater than 50% of breast volume is removed or the patient has smaller to moderate sized breasts. – Minority of oncoplastic operations 2

3/5/2018 Repairing Cosmetic Defects in Lumpectomy Patients Spear, Surgery of the Breast, 2011 Latissimus dorsi chapter by Hammond Oncoplastic Surgery: Definition (Clough et al.) Oncoplastic Surgery: Definition (Clough et al.) • Volume Displacement Oncoplastic Surgery – OPS Level 1: • Up to 20% removal of breast tissue with local tissue rearrangement – OPS Level 2: • Up to 50% removal of breast tissue with a mastopexy/reduction mammaplasty reconstruction design • Often needs a contralateral symmetry mastopexy/reduction mammaplasty 3

3/5/2018 Oncoplastics and Volume Displacement Spear, Surgery of the Breast, 2011 Oncoplastic surgery chapter by Losken Spear, Surgery of the Breast, 2011 Oncoplastic surgery chapter by Losken Oncoplastic Surgery: The Past “Era of Technique Development ” • The European experience – Oncoplastic surgery first described in Europe – 1998: Audretsch et al. first described the technique of reconstructing a partial mastectomy defect – Clough further described advanced techniques of large volume displacement oncoplastic surgery and defined levels of oncoplastic surgery – Spread throughout Europe • France, Germany, Italy, Britain – Oncoplastic fellowship open to general surgeons and plastic surgeons – Development of the “Oncoplastic Surgeon” • Outcomes similar in cancer surgery and plastic surgery to America 4

3/5/2018 European definition of an oncoplastic service: BASO, BAPRAS EJSO 33 (2007) S1-S23 American definition of oncoplastic surgery  Unclear  In the US, the oncologic resection and subsequent reconstruction is most commonly done by two separate surgical specialties:  Breast surgeons (General Surgeons, OB/Gyn, Breast Surgical Oncologists, Surgical Oncologists)  Plastic Surgeons  Breast oncologic literature and breast surgery meeting topics tend to place oncoplastic surgery more in the realm of volume displacement when it comes to reconstruction American definition (cont.) • Volume displacement – Local tissue rearrangement – Mastopexy (breast lift) – Reduction mammaplasty (breast reduction) • Therefore, presently in the US when one speaks about oncoplastic breast surgery, they most often are referring to a patient being treated for breast cancer receiving a lumpectomy, some kind of volume displacement surgery, and a contralateral breast symmetry operation. 5

3/5/2018 Why do oncoplastic breast surgery? 1. Allows for wide local excision with large negative margins • Leads to fewer re-excisions • May decrease the need for whole breast radiation for DCIS 2. Provides an aesthetically pleasing breast appearance using plastic reconstructive techniques 3. Provides the reconstructive benefits of less neck/upper arm/back pain, rashes, bra strap marks when using a breast reduction (reduction mammoplasty) design for large breasted women 4. Minimizes dead space compared to traditional lumpectomy leading to less nipple inversion especially after combining surgery and radiation Oncoplastic surgery from a radiation oncologist perspective • Perceive it as a very large partial mastectomy • Theoretically should have wide, negative margins • Oncoplastic surgeon should place clips at the margins to help direct your boost dose – Note: incisions most likely are not indicative of where the cancer was present • Otherwise, the general principles for radiation should be the same as for a regular lumpectomy patient coming to your office for a radiation oncology consult A B C D – Markings 1 D – Markings 2 D – Markings 3 D – Markings 4 D – Markings 5 D – Markings 6 D – Markings 7 D – Markings 8 D – Markings 9 6

3/5/2018 Oncoplastic Surgery Level I Doughnut Design • Works well central tumors in women with dense breast tissue or small areola Post Operative Double Doughnut 7

3/5/2018 Oncoplastic Surgery Type II COMPLEX TISSUE REARRANGEMENTS Hemi-batwing Approach • 53 yo female with right upper outer breast cancer approximately 3cm in size • Operation: R sided batwing oncoplastic resection with SLN bx and L sided vertical mastopexy for symmetry 8

3/5/2018 Hemi-batwing Approach Final Result A B – Before B - Markings B - After C – Before C – Markings C - Intraoperative C – Intraoperative C – After D - Before D – Markings tacking D - After E – Before E - Markings E - After 9

3/5/2018 Mastopexy oncoplastic design 2 months post op • T1N0 left breast cancer • Removed with clear margins • Adjuvant radiation • Adjuvant hormonal therapy A B – Before B – After C – Before C – During RT 10

3/5/2018 A B – Before B – After B – After RT Complex Oncoplastic Rescues • 49 yo female with history of L lumpectomy and radiation. Now, has suspicious finding on mammogram with need for L breast excisional biopsy • L sided oncoplastic reduction design and R sided reduction mammoplasty for symmetry 11

3/5/2018 Oncoplastic Balancing Results After Before 12

3/5/2018 Before After Special Situations ONCOPLASTIC SURGICAL PROCEDURES Savi Scout Bracketed Oncoplastic Right Lumpectomy 13

3/5/2018 Oncoplastics Useful in Elderly Patients with Ptotic Breasts Oncoplastics Useful in Patients with Large Regions of DCIS Complications Clough et al. Ann Surg. 2003 Jan; 237(1): 26–34. 14

3/5/2018 Outcomes and patient satisfaction Oncoplastic Surgery: The Present “The Era of Validation ” • Long term outcome studies investigated the long term oncologic safety of (volume displacement) oncoplastic surgery • Meta-analyses investigated the short term oncologic advantages of (volume displacement) oncoplastic surgery • Outcome studies (using validated patient assessment tools) investigated the reconstructive strengths in (large volume) oncoplastic surgery • Cost-utility analyses investigated the value of oncoplastic surgery Oncoplastic surgery: Long term oncoplastic safety • Case matched to compare apples with apples • OS and DFS at 10 years similar for T2 group treated with oncoplastic surgery vs mastectomy • No significant difference in locoregional recurrence 15

3/5/2018 Oncoplastic Surgery: Surgical Oncologic Advantages • 10% positive margin rate for oncoplastic surgery – Compared to 20-40% positive margin rate for standard partial mastectomy Accepted for presentation at the San Antonio Breast Cancer Symposium, December 2017 Oncoplastic Surgery: Outcomes Studies Assessing patient Satisfaction • Case Matched • Validated patient self related assessment scores • Compared oncoplastic surgery vs mastectomy with immediate reconstruction • Clear benefit in psychosocial and self related benefit with oncoplastic surgery compared to mastectomy and immediate reconstruction regardless of radiation effects 16