oncologic and cosmetic challenges do not routinely … · 2012-10-15 · oncologic and cosmetic...
TRANSCRIPT
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ONCOLOGIC AND COSMETIC CHALLENGES DO
NOT ROUTINELY OPPOSE BREAST CONSERVING
SURGERY IN RETRO-AREOLA PRIMARY LESIONS
16TH UP CONTROVERSIES AND PROBLEMS IN SURGERY
SYMPOSIUM
Ines Buccimazza
Breast Unit
Department of Surgery
Nelson R. Mandela School of Medicine
University of KwaZulu-Natal
Durban
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16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
All truth passes through
three phases.
First, it is ridiculed.
Second it is violently
opposed.
Third, it is accepted as
being self-evident (Arthur Schopenhauer)
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INTRODUCTION
Goal of BCT
Oncological Good cosmetic
treatment outcome
Challenging Excision with clear margins
Preserve aesthetic appearance
Single, definitive surgical procedure
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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INTRODUCTION
Contraindications to BCT
Multicentricity
Extensive DCIS
Radiotherapy matters
Central tumours
Mastectomy conventional treatment
What is the evidence?
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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CENTRAL QUADRANT LESIONS
5% - 20% breast cancers
2 scenarios
Entirely subareola
1.5 – 2cm beyond
areola edge
BCT contraindicated
Oncological perspective Higher incidence multicentricity/ multifocality and NAC infiltration
Cosmetic perspective Resection NAC + central portion loss of a defining feature and
central projection
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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CENTRAL QUADRANT LESIONS
Incidence NAC infiltration
Breast cancer at any site
11% - 58% 58% - 82% neoplastic involvement occult
Higher
NAC involvement
1° lesion superficial retroareola 54% NAC involvement
Lesion within 2.5cm from nipple edge 95% involved nipples
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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CENTRAL QUADRANT LESIONS
Predictors NAC involvement
Tumour location: tumour-areola (<2cm)/ tumour-nipple (<4cm)
Tumour size: ≥T2
Clinical involvement: NAC or adjacent skin
Minimal requirement
En bloc NAC, tumour excision + adequate margin
Limitations sBCS
Particular challenge
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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ONCOPLASTIC SURGERY
Definition Oncological principles + best principles PRS techniques =
↑ cosmetic outcome
↓ complications
Indications Medium to large breasts
Volume excisions 20% - 50%
Small lesions (<3.5cm) in unfavourable location
Considerations Specific training
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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OPS: CENTRAL QUADRANT LESIONS
Central quadrant lesions BCT
Alternatives to mastectomy Therapeutic mammoplasty
Myocutaneous (LD) or fasciocutaneous (ICAP) flaps
Steps NAC and skin over tumour excised
Full-thickness glandular excision to pectoralis fascia
Re-shaping without extensive glandular mobilization
Tumour bed clips
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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TH. MAMMOPLASTY: TECHNIQUE 1
Modified inverted-T mammoplasty
Superior pedicle mammoplasty
NAC resection
NAC reconstruction
immediate or delayed
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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TH. MAMMOPLASTY: TECHNIQUE 2
Modified vertical scar mammoplasty Modification by Lejour
Site, volume excision identical
Avoids submammary scar
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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TH. MAMMOPLASTY: TECHNIQUE 3
Grisotti technique
2 reduction mammoplasty techniques
Strombeck
Regnault B-flap mammoplasty
Reconstruct central quadrantectomy defect
Immediate NAC reconstruction
Skin island on advancement flap
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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MARKINGS DEFECT AND FLAP
ADVANCED FLAP CLOSURE
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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TH. MAMMOPLASTY: TECHNIQUE 3
Grisotti technique
NAC reconstruction
Areola: dermal tatooing
Nipple: flaps
Few patients complete 3 months post-surgery
Across spectrum
Breast mound preservation > nipple reconstruction
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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FASCIOCUTANEOUS (ICAP) FLAP
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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FASCIOCUTANEOUS (ICAP) FLAP
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
1 YEAR POST-RADIOTHERAPY
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COMPLICATIONS OPS
Common types Necrosis: skin, flap, glandular
Hematoma, seroma
Glandular necrosis: 26% Risk factors
Sequelae
SSI, abscess, wound dehiscence
Flap necrosis: 13% Superficial epidermolysis > full thickness
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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SAFETY OPS
LRR and OS 1996: Cothier-Savey
5 years: LRR 9.4% and OS 86%
2003: Clough
5 years: LRR 8.5% and OS 95.7%
2007: Rietjens
>6 years: LRR 3% and OS 92%
Central quadrant OPS: LRR 4.3% and OS 95.7% at 18 months
Adjuvant therapy Onset not delayed
Radiographic surveillance
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM
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CONCLUSION
Retroareola lesions particular challenge
Concerns excluded BCT
OPS most BCT
Volume displacement techniques
Volume replacement techniques Safe
Satisfactory outcomes
Mastectomy select cases
16TH UP CONTROVERSIES AND PROBLEMS IN
SURGERY SYMPOSIUM