current strategies in breast...
TRANSCRIPT
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Hani Sbitany, MD
Assistant Professor of Surgery University of California, San Francisco
Division of Plastic and Reconstructive Surgery
Current Strategies in Breast
Reconstruction
12th Annual School of Breast Oncology
Atlanta, Georgia
November 7, 2014
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Repair of Partial Mastectomy Defects
with Oncoplastic Surgery
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SOBO 2012 Presentation
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SOBO 2012 Presentation
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Oncoplastic Reconstruction – Effects of
Timing on Complication Rates
All
Reconstruction
following Partial
Mastectomy
Immediate
Reconstruction
Before XRT
Delayed
Reconstruction
after XRT
30%
26%
42%
Kronowitz, SJ, et.al. Determining the optimal approach to breast reconstruction after partial
mastectomy. Plast Reconstr Surg. Jan. 2006.
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Techniques for Oncoplastic Surgery
• Local Tissue Rearrangement • B to C cup breast •Small tumor •Grade 1 ptosis •No skin resection
• Oncoplastic Reduction Mammoplasty •C to D cup breast •Grade 2 to 3 ptosis •Some skin resection
Kronowitz, SJ, et.al. A Management Algorithm and Practical Oncoplastic Surgical Techniques to Repair Partial
Mastectomy Defects. PRS 2008.
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Local Tissue Rearrangement
Kronowitz, SJ, et.al. A Management Algorithm and Practical Oncoplastic Surgical Techniques to Repair Partial
Mastectomy Defects. PRS 2008.
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Local Tissue Rearrangement
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Oncoplastic Reduction Mammoplasty
-Use of neoadjuvant
chemotherapy
-Breast conservation
therapy (BCT)
-Oncoplastic mammoplasty
-Extends BCT option
-Improved cosmetic results
-Minimizes adverse
effects of XRT
Indications
- Minimal Skin Resection or Tumor within Wise
Pattern
- C-Cup Breast Size with ptosis or Small Tumor
- D-Cup Breast size
SOBO 2012 Presentation
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Kronowitz, SJ, et.al. A Management Algorithm and Practical Oncoplastic Surgical Techniques to
Repair Partial Mastectomy Defects. PRS 2008.
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Locally advanced breast cancer
- Neoadjuvant chemotherapy
- Post-operative radiation therapy
Oncoplastic mammoplasty
(N = 37)
Mastectomy with immediate breast
reconstruction
(N = 64)
Two-stage TE
(N = 40)
Autologous (N = 24)
Review of prospectively-maintained surgical
outcomes database
20(3), 2014; 302-307
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Oncoplastic mammoplasty
(N = 37)
Mastectomy/reconstruction
(N = 64)
Mean age 52.3 years 45.5 years
Mean BMI 29.2 kg/m2 25.2 kg/m2
Diabetes 2 (5.4%) 1 (1.6%)
Tobacco use 1 (2.7%) 0
Tumor stage
I 0 0
II 20 (54.1%) 29 (45.3%)
III 14 (37.8%) 33 (51.6%)
IV 3 (8.1%) 2 (3.1%)
Median follow-up 32 months (4 – 116) 30.5 months (8 – 74)
20(3), 2014; 302-307
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Oncologic Outcomes
Recurrence-free survival
Cancer-specific survival
Oncoplastic mammoplasty
Mastectomy/reconstruction
P = 0.29
P = 0.27
Oncoplastic mammoplasty
Mastectomy/reconstruction
Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic
mammoplasty as a strategy for reducing reconstructive
complications associated with post-mastectomy radiation
therapy. Presented at the 2013 American Society of Plastic
Surgery Meeting, San Diego, California. October 12, 2013.
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0
10
20
30
40
50
Oncoplastic mammoplasty
Mastectomy/reconstruction
**
19%
45%
3%
38%
11%
30%
16%
36%
5% 8%
Complications
Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated
with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California.
October 12, 2013.
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•Oncoplastic mammoplasty with equivalent oncologic safety
and fewer complications in setting of neoadjuvant chemo and
PMRT
•Early evaluation by plastic surgeon/multi-disciplinary
approach
•Role in pre-operative patient
counseling/decision-making
Conclusions – Oncoplastic
Reduction
Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated
with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California.
October 12, 2013.
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Treatment Algorithm
Peled AW, Foster R, Sbitany H, Esserman L. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated
with post-mastectomy radiation therapy. Presented at the 2013 American Society of Plastic Surgery Meeting, San Diego, California.
October 12, 2013.
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Oncoplastic Reduction Mammoplasty
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Breast Reconstruction
After Mastectomy
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Immediate Reconstruction
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Immediate Reconstruction
Bilateral DIEP free flaps
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Delayed Reconstruction
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Delayed Reconstruction
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Implant-Based Breast
Reconstruction
• Two-Stage Implant
• One-Stage Implant
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Two-Stage Breast Reconstruction
Tissue Expander Followed By Permanent Implant
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Two-Stage Breast Reconstruction
Tissue Expander Followed By Permanent Implant
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Two-Stage Implant Example of Outcome
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Two-Stage Implant: 2nd Stage
Additional Enhancements
ADM: Acellular Dermal Matrices
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Acellular Dermal Matrix
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Plast Reconstr Surg. 134: 396, 2014
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Autologous Fat Grafting
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Microsurgical Breast
Reconstruction
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TRAM/DIEP Flap Breast
Reconstruction
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Pedicled TRAM Flap
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Free (Microvascular)
TRAM Flap
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Free & Pedicled TRAM Flap
ABDOMINAL DONOR SITE
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DIEP: Deep Inferior Epigastric
Perforator Flap
GAP: Gluteal Artery Perforator
Perforator Flaps
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Abdominal Wall Perforators
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Abdominal Wall Perforators
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Deep Inferior Epigastric Perforator
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Deep Inferior Epigastric Perforator
(DIEP) Flaps
SOBO 2012 Presentation
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SOBO 2012 Presentation
Case example: DIEP
flap
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Autologous Tissue +
PMRT
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Redesigned GAP Flap
Kronowitz, SJ. The Gluteal Artery Perforator Flap Re-designed for Breast Reconstruction. PRS,
March 2008.
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Case Example: Redesigned GAP flap
SOBO 2012 Presentation
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Case Example: Redesigned GAP flap
SOBO 2012 Presentation
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Total Skin
Sparing
Mastectomy
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Annals of Plastic Surgery. Accepted for Publication - In Press. Epub ahead of print, 2014 Jul 23.
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Total skin-sparing
mastectomy Preservation of entire breast
skin envelope with excision
of nipple-areolar complex
(NAC) tissue
Benefits
Aesthetic
Psychological
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Purpose
Review 12-year experience with nipple-sparing mastectomy
(NSM) and immediate reconstruction
-Oncologic outcomes
-Surgical complications
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Methods
Prospectively-maintained database of TSSM and
immediate reconstruction (2001-2012)
Outcomes
Tumor recurrence
-Local-regional
-NAC
Post-operative complications
-NAC necrosis
-Mastectomy skin flap necrosis
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Tumor characteristics Total patients 599
Total cases 924
Indication for mastectomy
Therapeutic 604 (65.4%)
Prophylactic 320 (34.6%)
Contralateral 60%
Bilateral 40%
Tumor stage
In situ 148 (16%)
Stage I 204 (22.2%)
Stage II 162 (17.5%)
Stage III 84 (9.1%)
Stage IV 6 (0.6%)
Prophylactic 320 (34.6%)
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Treatment characteristics
Chemotherapy
Any 294 (49%)
Neoadjuvant 195 (66%)
Adjuvant 99 (34%)
Radiation therapy
Any 181 (20%)
Prior history 67 (37%)
Post-mastectomy 114 (63%)
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TSSM incisions
0%
20%
40%
60%
80%
100%
1st 100 cases Next 557 cases
IMF
Radial
Lateral
Mastopexy (< 30% of NAC)
Mastopexy (>30% of NAC)
Free graft
NAC crossing
Inframammary Radial Lateral/
Inferolateral
Mastopexy Type
Involving < 30% of the NAC
Preferred
Involving > 30% of the NAC
Circumareolar/ Free
Graft NAC
Crossing
No longer
recommended
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Reconstructions performed
Two-stage
expander-implant Microvascular
(abdominal, gracilis)
Transverse rectus
abdominis myocutaneous
(TRAM) flap
Immediate
permanent implant
0%
20%
40%
60%
80%
100%
1st 100 cases Next 557 cases
Immediate implant
TRAM flap
Microvascular
2-stage expander-implant
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Ischemic complications
(n=6) (n=5) (n=17) (n=24) (n=15) (n=46) (n=117) (n=143) (n=159) (n=125) (n=6) (n=5) (n=17) (n=24) (n=15) (n=46) (n=117) (n=143) (n=159) (n=125)
(n=6) (n=5) (n=17) (n=24) (n=15) (n=46) (n=117) (n=143) (n=159) (n=125) (n=6) (n=5) (n=17) (n=24) (n=15) (n=46) (n=117) (n=143) (n=159) (n=125)
0%
5%
10%
15%
20%
Nipple necrosis (partial or complete) Skin flap necrosis
1st 100 cases
Next 557 cases
Latest cohort
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Local-regional recurrence N Local recurrence, n
(%)
All patients
(median follow-
up: 28 months)
Total
Invasive cancer
In situ cancer
412
301
111
8 (1.9)
5 (1.7)
3 (2.7)
Patients with
minimum 36
months follow-up
(median: 45
months)
Total
Invasive cancer
In situ cancer
126
95
31
3 (2.4)
2 (2.2)
1 (3.2)
No recurrences in the NAC
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Distant recurrence
N Distant recurrence,
n (%)
All patients
(median follow-
up: 28 months)
Total
Invasive cancer
In situ cancer
412
301
111
12 (2.9)
11 (3.7)
1 (0.9)
Patients with
minimum 36
months follow-up
(median: 45
months)
Total
Invasive cancer
In situ cancer
126
95
31
2 (1.6)
2 (2.2)
0 (0)
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Conclusions
Low rates of local-regional recurrence
No recurrences in the NAC
Low rates of ischemic complications
Targeted technical improvements
-Incisions avoiding NAC
-Minimal pressure on NSM skin flaps
--2-stage tissue expander reconstruction
--Delayed autologous reconstruction
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Expanded Experience
Plast Reconstr Surg. 134: 396, 2014
Plast Reconstr Surg. 134: 169, 2014
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Plast Reconstr Surg. 134: 169, 2014
FIGURE 1. Complication rates for inframammary fold incisions (IMF) compared to all other types of incisions *
* Other incision types includes sub-areolar, radial, lateral, circumareolar incisions
!!!!!!!!!!!!!! !
21.0% 21.0%
11.3%
29.0%
11.3%
0.0%
10.3% 10.3%
0.0%
17.2%
6.9%
0.0% 0% 5%
10% 15% 20% 25% 30% 35%
Incisional
breakdown
p=0.2
Unplanned OR for
incisional
breakdown
p=0.2
Implant loss
due to incisional
breakdown
p=0.06
Significant
infection
p=0.2
Implant loss from
infection
p=0.5
NAC necrosis
p=1.0
Inframammary Fold Incision (IMF) All Other Incision Types *
• Review of prospectively-collected complications database of TSSM/expander-
implant reconstruction from 2005-2012
• Compared IMF incision to all incisions in non-dependent areas of breast
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No Hormonal
(n=342)
Hormonal
(n=425)
P-value
Chi-Square
Wound
Breakdown
26 (8%) 42 (10%) .3
Infections
PO Antibiotics 35 (10%) 78 (18%) .002
IV Antibiotics 33 (10%) 52 (12%) .3
Procedure 18 (5%) 35 (8%) .1
Implant Exposure 14 (4%) 21 (5%) .6
Implant Loss 24 (7%) 31 (7%) .9
Expanded Experience
Effects of Hormonal and Anti-HER Therapy
Wang F, Peled A, Alvarado M, Ewing C, Fowble B, Esserman L, Foster R, Sbitany H. The Impact of Hormonal and Anti-HER Therapy
on Outcomes of Total Skin-Sparing Mastectomy and Immediate Tissue Expander-Based Reconstruction. Plast Reconstr Surg. Submitted
for Publication
Overall Complications by hormonal therapy (n=767)
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No Anti-HER
(n=675)
Anti-HER (n=92) P-value
Chi-Square
Wound
Breakdown
63 (9%) 5 (5%) .2
Infections
PO Antibiotics 102 (15%) 11 (12%) .4
IV Antibiotics 78 (12%) 7 (8%) .3
Procedure 48 (7%) 5 (5%) .6
Implant Exposure 31 (5%) 4 (4%) .9
Implant Loss 48 (7%) 7 (8%) .9
Expanded Experience
Effects of Hormonal and Anti-HER Therapy
Wang F, Peled A, Alvarado M, Ewing C, Fowble B, Esserman L, Foster R, Sbitany H. The Impact of Hormonal and Anti-HER Therapy
on Outcomes of Total Skin-Sparing Mastectomy and Immediate Tissue Expander-Based Reconstruction. Plast Reconstr Surg. Submitted
for Publication
Overall Complications by anti-HER therapy (n=767)
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Thank You