Oncoplastic breast surgery for women with breast cancer

Transcription

1 Website Version Oncoplastic breast surgery for women with breast cancer Dr Nicholas Ngui MBBS(Hons) FRACS Breast and General Surgeon Northern Surgical Oncology, The SAN Clinic Sydney Adventist Hospital 0562/SAH/1112/SAH

2 Breast Cancer Breast cancer now affects 1 in 8 Australian women by age 85 1 Goals of breast cancer surgery: 1. Remove cancer with clear margins 2. Whilst aiming to maintain breast shape and appearance Breast cancer surgery- two broad areas 1. Breast conserving surgery + radiotherapy 2. Mastectomy +/- radiotherapy 1 Australian Institute of Health and Welfare, Australian Government.

3 Suboptimal aesthetics Simple wide local excision may not always result in good cosmesis Occurs in up to 30% 2 Mastectomy without reconstruction can potentially be disfiguring 2. Clough KB, Cuminet J, Fitoussi A, et al.: Ann Plast Surg 1998

4 Oncoplastic breast surgery Not a new concept Combines the goals of breast cancer surgery while aiming to achieve the best possible cosmetic outcome Disfigurement after breast cancer surgery should not be accepted as routine Good aesthetic outcomes improve a women s self esteem and quality of life 2 2 Veiga, Veiga-Filho, Ribeiro et al. Plast Reconstr Surg. 2010

5 Spectrum of Oncoplastic breast surgery Breast conservation surgery using oncoplastic techniques Level 1 Level 2 Mastectomy with reconstruction Implant/expander based Autologous flaps Symmetrisation procedures

6 Classification of oncoplastic breast conservative surgery Krishna Clough described two levels Level 1- where <20% breast volume excised Probably includes most simple breast conserving surgeries Level 2- where >20% breast volume excised Breast parenchyma needs to be reshaped Skin need to be excised Requires mammoplasty techniques and training 4. Clough K, et al. Ann Surg Oncol 2010

7 Level 1 Clough K, et al. Ann Surg Oncol 2010

8 Level 2 Vast range of operative techniques! adaptive mammoplasty Clough K, et al. Ann Surg Oncol 2010

9 Clough K, et al. Ann Surg Oncol 2010

10 Clough K, et al. Ann Surg Oncol 2010

11 Benefits of Oncoplastic breast conserving surgery Reduces the need for mastectomy Safe oncological procedure with wider margins- allows larger volumes resected Resect larger tumours Better cosmesis Reduced breast volume allows more targeted radiotherapy treatment Chang, E, Esserman L et al. Annals of Surgery 2012

12 51 yo with left screen detected breast cancer D cup breast Imaging showed 3cm mass at 12oc 2cm from nipple Remainder of breasts and axilla clear BG: Nil Non smoker

13 45yo with right screen detected cancer E cup breasts Imaging: right upper outer quadrant 2cm mass 5cm from nipple BG: diabetes

14 Disadvantages Surgery of longer duration Potentially longer hospital stay Potential for greater wound complications This can delay adjuvant treatment Scars may be larger Some patients/cancers may not be suitable and may need a mastectomy e.g. multifocal

15 Mastectomy with reconstruction Implant/Expander based Autologous flap based Combination of both

16 Implant based reconstruction- Preoperative planning Indications: Patients requiring a mastectomy Risk reducing mastectomy Healthy skin and no skin involvement Clinically node negative Contraindications Diabetic Smokers PMRT Previous radiotherapy

17 Advantages: Types Mastectomy + implant reconstruction Allows for single stage reconstruction No donor site morbidity Fast recovery Good cosmesis Nipple sparing vs nipple sacrificing Skin sparing vs skin reducing

18 Nipple sparing mastectomy Smaller breasts with minimal ptosis

19 Skin reducing mastectomy with implant Larger breasts or ptotic breasts excess skin is used as an extra protective layer over the implant

20 Complications Short term wound infection Wound necrosis/nipple loss Implant loss Implant displacement seroma Long term Capsular contracture Implant loss Implant leak

21 Mastectomy + implants My post operative care at SAN Stay in hospital for 4-5 days Given 48 hours of IV cephazolin, then oral Keflex 500mg tds while drains are still in Physiotherapy from day 1 post op Home with drain in situ (usually 2 weeks) HITH service Drain out when <30ml/day for 2 days after 10 days Avoid exercise Weekly follow up with Dr Nicholas Ngui