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
– 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
Spear, Surgery of the Breast, 2011 Latissimus dorsi chapter by Hammond
– OPS Level 1:
rearrangement – OPS Level 2:
mammaplasty reconstruction design
mammaplasty
Spear, Surgery of the Breast, 2011 Oncoplastic surgery chapter by Losken Spear, Surgery of the Breast, 2011 Oncoplastic surgery chapter by Losken
– 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
– Oncoplastic fellowship open to general surgeons and plastic surgeons
– Development of the “Oncoplastic Surgeon”
EJSO 33 (2007) S1-S23
Breast surgeons (General Surgeons, OB/Gyn, Breast Surgical Oncologists, Surgical Oncologists) Plastic Surgeons
– Local tissue rearrangement – Mastopexy (breast lift) – Reduction mammaplasty (breast reduction)
1. Allows for wide local excision with large negative margins
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
– Note: incisions most likely are not indicative of where the cancer was present
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 A B C
with dense breast tissue or small areola
Oncoplastic Surgery Type II
E - Markings E – Before D - After E - After D – Markings C – After C – Intraoperative tacking D - Before C - Intraoperative C – Markings B - After B - Markings C – Before B – Before A
C – Before C – During RT B – Before B – After A
B – Before B – After RT B – After A
lumpectomy and radiation. Now, has suspicious finding on mammogram with need for L breast excisional biopsy
design and R sided reduction mammoplasty for symmetry
Before After
After Before
Special Situations
Clough et al. Ann Surg. 2003 Jan; 237(1): 26–34.
safety of (volume displacement) oncoplastic surgery
(volume displacement) oncoplastic surgery
investigated the reconstructive strengths in (large volume)
treated with oncoplastic surgery vs mastectomy
recurrence
– Compared to 20-40% positive margin rate for standard
Accepted for presentation at the San Antonio Breast Cancer Symposium, December 2017
assessment scores
vs mastectomy with immediate reconstruction
and self related benefit with
to mastectomy and immediate reconstruction regardless of radiation effects
– Consists of General Surgeons and Plastic Surgeons completing an oncoplastic breast fellowship
volume displacement oncoplastic operations – Oncoplastic fellowship and Certificates
– Oncologic Surgery societies: SSO, ASBrS – Plastic Surgery society: ASPS – Goal:
and reconstructive surgical spectrum
perform the reconstruction? (2nd most common question in my breast oncology fellowship interview process)
surgeons in the US
defects
following patient
– Large volume oncoplastic techniques maximize breast conservation options – In the US- breast conservation: mastectomy ratio » 60:40 » This can increase to 80:20 using oncoplastic surgery
compared to standard lumpectomy – Only a 10% positive margin rate
– The oncoplastic breast surgeon, radiologist and radiation oncologist should talk about what is to be and was done in the OR to facilitate planning for radiation – Ideally, clips/makers should be placed intraoperatively by the surgeon in the region where the cancer was present
nipple inversion in a ptotic or large breasted woman after traditional lumpectomy and radiation
– It is a fixable deformity that should be covered by insurance