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Minimally Invasive Breast Surgery

Minimally Invasive Breast Surgery. Joint Hospital Grand Round Luk Wai Yin Sally NDH/AHNH. British Medical Journal Editorials Minimally invasive surgery for breast cancer May be trading better cosmetic outcomes for worse rates of cure Monica Morrow BMJ Feb 2009 338: b557.

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Minimally Invasive Breast Surgery

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  1. Minimally Invasive Breast Surgery Joint Hospital Grand Round Luk Wai Yin Sally NDH/AHNH

  2. British Medical Journal Editorials • Minimally invasive surgery for breast cancer • May be trading better cosmetic outcomes for worse rates of cure • Monica MorrowBMJ Feb 2009 338: b557

  3. Minimally invasive surgery for breast cancer • Why ? • What ? • How?

  4. Why minimally invasive? • Breast Cancer • Prevalence • Most common female cancer in HK • Cumulative life risk 1/22 • Screening • Worldwide, women aged > 40 1 • Allow detection of small/early breast cancer • Medical advancement • Better understanding of the pathophysiology and the necessity of local control of breast CA with its risk of local recurrence • Neoadjuvant/ adjuvant treatment • Improvement in surgical techniques and instruments • Patient demand

  5. What is it? • No definition • Breast conserving surgery, sentinal lymph node bx • Oncoplastic breast surgery • Endoscopic breast surgery& axillary surgery • Goals: Oncological clearance Morbidity Aesthetic outcome

  6. How to achieve? Axillary Surgery Level II axillary dissection Breast Conserving Therapy Oncoplastic Breast Surgery Endoscopic assisted breast surgery Sentinel lymph node biopsy Endoscopic SLNB/ AD Breast Surgery Modified Radical Mastectomy

  7. Breast Conserving Therapy • Wide local excision (WLE) with postoperative adjuvant radiotherapy1 • Oncological principle for WLE: • Relative risk of local recurrence was shown to be directly related to completeness of excision • Local recurrence direct impact on long-term survival • Aim: ideally a clear rim of normal tissue around the carcinoma in all direction • at least microscopically disease-free margin • In practice, 1cm macroscopic margin of normal tissue 1 NIH Consensus Conference Treatment of early stage breast cancerJAMA 1991:265:391-5

  8. Breast Conversing Surgery • Equivalent outcome to that of mastectomy in early breast cancer • Effect of radiotherapy and surgery in early bresat cancer: an overview of the randomize trial; Early Breast Cancer Trialists’ Collaborative Group N Engl J Med 1995;333:1444-55 • Breast conserving therapy versus mastectomy in early stage breast cancer: a metaanalysis of 10 year survival; Morris etal Cancer J sci Am 1997;3:6-12 • Long term Oncological safety • Twenty-year follow-up of a randomized trial comparing total mastectomy,lumpectomy and lumpectomy plus irradiation of the treatment of invasive breast cancer Fisher B et al N Eng J med 2002;347:1233 -41 • Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer Veronesi U et al N Eng J med 2002; 347:1227 • Better cosmetic appearance in majority of women • Cosmetic assessment of breast-conserving surgery for primary breast cancer. Sharif K et al Breast 1999;8:162-8 review of level II evidence • Lower levels of psychological morbidity with improved body image, sexuality and self-esteem, compare to mastectomy • Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction Al-Ghazal SK et al. Eur J Cancer 2000;36:1938-43

  9. Comestic failure after BCT • 23 - 50% dissatified with the appearance after BCT • A body image scale for us with cancer patient Hopwood P Eur J Cancer 2001:37:189 -97 • Cosmetic evaluation of breast conserving treatment for mammary cancer Van limbergen E Radiother Oncol 1989;16:159-67 • Factors affecting comestic outcome • Volume loss >20%1 • Tumor location: central, medial, inferior • Nipple areola displacement/ distortion • Inappropriate incision/poor surgical technique • Effect of Radiotherapy 1 Cosmesis and satisfaction after BCS correlates to the precentage of breast volume excised Cochrane R et al. Br J Surg 2003 90:1505-1509

  10. Oncoplastic Breast Surgery (OBS) • Definition? • Seamless joining of extirpative and reconstructive breast surgery performed by a single surgeon 1 • Thorough tumor resection plus reconstruction of resection defect • Principle of OBS • Oncological principle of resection to achieve wide tumor-free margins • Principle of plastic reconstruction to optimize cosmetic outcomes and minimize complication 1 Oncoplastic breast surgery: A Global Perspective on Practice, Availability, and training Peter L Malycha et al; World J Surg 2008 32:2570 -2577

  11. Volume displacement Recruiting and transposing local dermoglandular flaps into the resection site breast-flap advancement Mammaplasty Superior pedicle inferior pedicle Centralization of NAC complex +/- Contralateral surgery (reduction mammoplasty) Volume replacement Importing volume from elsewhere to replace the amount of tissue resected Autologous LD flap TRAM flap Implants Reconstruction Principle

  12. Volume replacement Autologous Volume displacement Reconstruction Principle Picture adopted from Surgical insight: oncoplastic breast-conserving reconstruction; Rainsbury;

  13. Factors influencing technique chosen

  14. Mastopexy lumpectomy

  15. Proponent Potential oncological benefit to enable very wide excision of breast tissue without risking major local deformity1,2 Extend the scope of BCS to include patients with 3-5 cm tumors, without compromising the adequacy of resection or the cosmetic outcome Overall better cosmetic outcome Opponent Oncological safety of the techniques is not being evaluated properly Potential cosmetic failure and complication Extra resources and extended operation time Negative impact on the adjuvant treatment 1 Oncoplastic techniques allow extensive resections for BCT of Breast cancinoma Krishna B Clough at el. Ann Surg 2003 Jan;237(1)26-34 2 Lumpectomy ws oncoplastic surgery for BCT of cancer. A prospective study of 99 patient Ann Chir 2006 Apr:131(4):256-61.

  16. Any clinical evidence ? • Evaluation of oncological safety • cosmetic outcome • Potential complications/pitfall • Expertises/Guidelines

  17. Review of outcomes of OBS Review: Oncoplastic breast-conserving reconstruction – indication,benefits,choices and outcomes (from 1 Jan 1980 to 31Jan 2007) Rainsbury Nat clinical pract onoclogy Nov 2007 4:11657-664

  18. Study design: case-control cohort studies from Sept 1994- December 1999 No of subject: 148 (10-108) Median follow up: 74 months Oncoplastic procedure: volume displacement for small defect and volume replacement for large defect Concomitant contralateral breast mammaplasty Results: Local recurrence: 3%; distant metastasis 13%; Mortality 7.53% Conclusions: Long term oncological outcomes are comparable with result of BCT in RCT

  19. Conclusion • emerging level II evidence for the short time oncological safety for OBS with good cosmetic outcomes • Published guideline Oncoplastic breast surgery – A guide to good practice Association of breast surgery at BASO; Association of breast surgery at BQPRAS and the training Interface group in Breast Surgery Royal college of Surgeons EJSO 33(2007) S1-S23

  20. Endoscopic Breast Reconstruction? Endoscopic Breast Surgery?

  21. Endoscopic breast reconstruction • Endoscopic assisted techniques • Harvest more bulky myosubcutaneous flap • BassLS et al Endoscopic harvest of the rectus abdominus free flap An Plast Surg 1995:34:274-9 • Endoscopic dissection • Endoscopic techniques in aesthetic breast Surgery Clin Plast Surg 1995:22:683-95 • Balloon dissection technique • Van Buskark Er et al. Endoscopic harvest of the lastissimus doris muscle using balloon dissection technique Plast Reconstr Surg 1997:99:899-903 • Laparoscopic mobilization of greater omentum for breast reconstruction • NICE guideline support its use under normal clinical arrangement Oct 2007

  22. Laparoscopic mobilization of greater omentum for breast reconstruction

  23. Endoscopic Breast Surgery • NICE overview for endoscopic mastectomy and wide local excision for breast cancer NHS April 2009 • One non randomize trial • eight case series (mainly from Japan and Korea) • Total no of patients: 809 • Conclusion: • Current evidence on the safety and efficacy of endoscopic mastectomy and wide local excision for breast cancer is inadequate in quantity • Only used in the context of research

  24. Summary • The goals of minimally invasive surgery for breast cancer is to improve aesthetic outcome without comprising oncological clearance • The early results suggest Oncoplastic breast surgery has a promising future in management of breast cancer • Anticipated maturation of endoscopic technique in assisting breast reconstruction and breast exicion

  25. We should try out BEST to treat our patient’s BREAST

  26. Thank You

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