1. Minimally Invasive Breast Surgery
Joint Hospital Grand Round
Luk Wai Yin Sally
NDH/AHNH
Good morning ladies and gentlemen. Today, It’s my pleasure to present to you the topics of MIBS.
MIBS is a very broad and new concept, encompassing the all the new techniques used in current breast surgery
from the use of mammotome of breast bx, percutanoeous treatment of benign breast lesion to the management of breast cancer

2. 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 : b557
Early this year, there was a publish in BMJ Online Editorials made by one of the Renowned breast surgeon in the states, Monica morrow
She expressed concerns in the editorial online in Feb this year as she worries as these new concepts may jeopardize our patient survival What she said was “ something is technically possible is it necessarily appropriate
This Stirred up hot disscusion and debate among the breast surgeon
And therefore, I am going to focus my discussion on this new concept

3. Minimally invasive surgery for breast cancer
Why ?
What ?
How?
Why we need to talk about minimally invasive?
What is the definition and what are its goals ?
How could we achieve these goals and are there any evidence to support our practice?

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
Even there is no population wide screening in hk, more people aware of

5. Oncological clearance
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? Breast Surgery Axillary Surgery
Modified Radical Mastectomy
Axillary Surgery
Level II axillary dissection
Breast Conserving Therapy Oncoplastic Breast Surgery Endoscopic assisted breast surgery
Sentinel lymph node biopsy Endoscopic SLNB/ AD
Nowadays, surgical management of breast cancer would be consisted of two main pillars
Namely breast surgery and axillary
How could we achieved in a more minimally invasive way?

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
How wide is wide? This comes to the oncological principle for WLE; most of studies revealed that the RR of LR was directly related to completeness of excision
there are quite a no of studies addressing this issue; though the extend of local excision remains a controversial issue ;

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:
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:
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:
in the past few decades or so, BCS evolved from a radical idea to well accepted approach in management of early breast cancer

9. Comestic failure after BCT
% dissatified with the appearance after BCT
A body image scale for us with cancer patient Hopwood P Eur J Cancer 2001:37:
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 :
The amount of tissue excised during BCS has a significant impact on LR and Cosmetic outcome
Oncologically, the wider the resection, the better the chance of clearance
From cosmetic pt of view, the extent of excision would increases the risk local deformity
So, Could we minimize the risk of unacceptable deformity without compromising oncological clearance?

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 :
Not well defined term.
Common underlying principle
Seemingly, its just add on together to gain the synergistic effect

11. Reconstruction Principle
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
By no means exhaustive

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

13. Factors influencing technique chosen
Volume displacement
Volume replacement
Breast size
Medium or large
Small or medium
Tumor position
Central or lower pole
Any site
Scars
Bilateral breast
Breast + back
Theater time
1-2hr
2-3 hr
Complications
Flap ischaemia
Fat necrosis
Donor site morbidity
Flap loss

14. Mastopexy lumpectomy

15. 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
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
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 Apr:131(4):

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

17. Review of outcomes of OBS
Volume displacement
Volume replacement
No of studies 11 7
Total no of patient
433
189
Median follow-up (m)
21-54
24-53
Local recurrence(%)
0-7
0-5
Cosmetic failure (%)
0-18
0-9
The data for the review was compiled by searching the pubmed and MEDLIND databases for articles published between
Apartment of the length of FU is relatively short ~3yrs, the reported rates of local recurrence and cosmetic failure are within acceptable limits when comparing with conventional BCS
emerging level II evidence for the short time oncological safety without comprising cosmetic outcomes.
Review: Oncoplastic breast-conserving reconstruction – indication,benefits,choices and outcomes
(from 1 Jan 1980 to 31Jan 2007) Rainsbury Nat clinical pract onoclogy Nov :

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?
But this is not the end of story, we surgeons are those people with curiosity. We have extensive use of laparoscopy in MIS of abd, so could we applied it to the 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:
Laparoscopic mobilization of greater omentum for breast reconstruction
NICE guideline support its use under normal clinical arrangement
Oct 2007
Mainly extending the volume replacement technique
Cases series showing the success of mobilization of myosubcutaneous flap via small axillary incision
The following are some example techniques, to name but a few;
With the use of laparoscopy,

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
National institute for health and clinical excellence

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