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“ Conservative mastectomy ” the nipple sparing tecnique. Alberto Luini Senology Division European instiute of Oncology -Milan. Milan Conservation Programme (1970-2010). Conservation of the breast Conservation of axillary nodes Partial intraoperative radiotherapy (ELIOT)
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“Conservative mastectomy”the nipple sparing tecnique Alberto Luini SenologyDivision Europeaninstiute of Oncology-Milan
Milan Conservation Programme (1970-2010) Conservation of the breast Conservation of axillary nodes Partial intraoperative radiotherapy (ELIOT) Conservative mastectomy+ELIOT Phase 1 - Phase 2 - Phase 3 - Phase 4 -
Improvement in diagnosis (ultrasonography, MRI) total mastectomies EIO 2000 2005 23% 28% A.Luini
Timing of Reconstruction - Always immediate - Delayed only if: - Locally advanced disease - Concomitant diseases A.Luini
SSM + immediate reconstruction with prosthesis or expanderisnowadays the standard treatment, except for: • Inflammatorycancer • Locallyadvanceddisease • Poor general conditions A.Luini
Skin Sparing Mastectomy + immediate reconstruction with prosthesis A. Luini
Immediate reconstruction does not affect the prognosis A. Luini
677 Total mastectomies + adjuvant treatment (no RT) 518 immediate rec. 159 no rec. (76.5%) (23.5%) Median follow up 70 months (range 13-144) A. Luini
Multivariate analysis (median f.u. 70 m.) (518 immediate reconstructions vs 159 without reconstruction) A. Luini Petit JY et al, Breast Cancer Res Treat, 2008
Immediate reconstruction: The Nipple Sparing Approach EIO NSM 84% of the mastectomies A. Luini
Multifocal/multicentric cancer • Extensive microcalcifications • Contraindications or refusal to primary medical treatment • Negative retroareolar frozen section Indications A. Luini
Involvement of the central quadrant • Paget’s disease • Pathological nipple discharge • Microcalcifications close to the nipple • Previous radiotherapy Contraindications A. Luini
Oncologic radicality: skin removal as a quadrantectomy and of the whole glandular tissue (except a thin retroareolar portion) • Intraoperative radiotherapy on the nipple areola complex (16Gy) • Immediate reconstruction with a good cosmetic result (very similar to a “good” quadrantectomy) Advantages A. Luini
Subcutaneous mastectomy a fifty year old technique ! a layer of glandular tissue should be left beneath the NAC to avoid NAC necrosis A. Luini
Surgical technique a) Conservation of the retroareolarglandulartissue b) Conservation of the retroareolarsubcutaneousvascularplexus
Surgical technique a) Sterile LINAC collimator c) Lead and alluminium protective disc d) Pectoralis major muscle
Nipple Sparing Mastectomy ELIOT (16 Gy) on the remaining glandular tissue to complete the cancer treatment A. Luini
Nipple-sparing mastectomy Irradiated area A. Luini
NSM + prosthesis + contralateral breast augmentation 2 weeks 5 months A. Luini
Type of reconstruction Anatomic prosthesis 68% Expanders 19% Round prosthesis 5% TRAM 8% A. Luini
Nipple Sparing Mastectomy Definitive prostheses 73% Immediate left reconstruction with implant A. Luini
Nipple Sparing Mastectomy Expanders 19% Two-step implant reconstruction A. Luini
Nipple Sparing Mastectomy TRAM 8% Immediate pedicled TRAM reconstruction A. Luini
1060 NSM in 1023 patients 37 bilateral( March 2002 - March 2007) infiltrating : 63% in situ : 37% despite frozen section negative… 86 final histology positive (8%) (70 in situ, 16 invasive) 43 NAC removed (local anesth.) A. Luini
Complications (1060 NSM) Immediate NAC necrosis 8.8% Infections 2.0% Delayed Capsular contracture 15% Radiodystrophy 7.5% A. Luini
NAC necrosis Partial 58 (5%) Total 26 (3,8%) Secondary reconstruction A.Luini
NAC necrosis Spontaneous healing with a TRAM
Infections • cases 2% • 42 prostheses removed 4% A.Luini
Capsular contracture 157 capsulotomies 15% A. Luini
nipple sparing mastectomy ELIOT (16 Gy) But … 206 cases received a delayed radiotherapy the day after surgery A. Luini
Prosthesis removal p = 0.0829 A. Luini
Capsular contracture p = 0.3179 A. Luini
Cosmetic results minimum follow up 1 year, scale 0 - 10 Good result (score 7-10) Patient evaluation82.3% Surgeon evaluation 84.8% A. Luini
NAC sensibility At one year, scale 0 - 10 score 0-3 48.0% score 4-6 32.8% score 7-10 18.8% A .Luini
Fig.1 Did you find it difficult to look at your self naked?Fig.2Do you find it difficult being seen naked by your partner? Do you feel your body less whole (disabled) as a result of the surgery? Quanto si è sentita mutilata come conseguenza dell’intervento?
ONCOLOGICAL RESULTS MEDIUM FOLLOW UP 20 MONTHS (RANGE 1-70) 1060 NSM in 1023 patients Invasive carcinoma 63% In situ carcinoma 37%
EVENTS Local recurrence 13 (1.2%) Distant metastases 36 (3.5%) Deaths 3 (0.3%) A. Luini
Local recurrences 13 cases (1.2 %) All distant from the NAC (10 tumor bed, 3 upper quadrant) A. Luini
Conclusion Nipple sparing mastectomy with intraoperative radiotherapy is a safe procedure to reduce the psychological trauma due to mastectomy in selected cases A. Luini