Presentation on theme: "Minimally Invasive Breast Surgery"— Presentation transcript:
1 Minimally Invasive Breast Surgery Joint Hospital Grand RoundLuk Wai Yin SallyNDH/AHNHGood 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 surgeryfrom 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 cancerMay be trading better cosmetic outcomes for worse rates of cureMonica Morrow BMJ Feb : b557Early this year, there was a publish in BMJ Online Editorials made by one of the Renowned breast surgeon in the states, Monica morrowShe 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 appropriateThis Stirred up hot disscusion and debate among the breast surgeonAnd 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 CancerPrevalenceMost common female cancer in HKCumulative life risk 1/22ScreeningWorldwide, women aged > 40 1Allow detection of small/early breast cancerMedical advancementBetter understanding of the pathophysiology and the necessity of local control of breast CA with its risk of local recurrenceNeoadjuvant/ adjuvant treatmentImprovement in surgical techniques and instrumentsPatient demandEven there is no population wide screening in hk, more people aware of
5 Oncological clearance What is it?No definitionBreast conserving surgery, sentinal lymph node bxOncoplastic breast surgeryEndoscopic breast surgery& axillary surgeryGoals:Oncological clearanceMorbidityAesthetic outcome
6 How to achieve? Breast Surgery Axillary Surgery Modified Radical MastectomyAxillary SurgeryLevel II axillary dissectionBreast Conserving Therapy Oncoplastic Breast Surgery Endoscopic assisted breast surgerySentinel lymph node biopsy Endoscopic SLNB/ ADNowadays, surgical management of breast cancer would be consisted of two main pillarsNamely breast surgery and axillaryHow could we achieved in a more minimally invasive way?
7 Breast Conserving Therapy Wide local excision (WLE) with postoperative adjuvant radiotherapy1Oncological principle for WLE:Relative risk of local recurrence was shown to be directly related to completeness of excisionLocal recurrence direct impact on long-term survivalAim: ideally a clear rim of normal tissue around the carcinoma in all directionat least microscopically disease-free marginIn practice, 1cm macroscopic margin of normal tissue1 NIH Consensus Conference Treatment of early stage breast cancerJAMA 1991:265:391-5How 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 excisionthere 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 cancerEffect 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;3:6-12Long term Oncological safetyTwenty-year follow-up of a randomized trial comparing total mastectomy,lumpectomy and lumpectomy plus irradiation of the treatment of invasive breast cancerFisher 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; 347:1227Better cosmetic appearance in majority of womenCosmetic assessment of breast-conserving surgery for primary breast cancer.Sharif K et al Breast 1999;8:162-8 review of level II evidenceLower levels of psychological morbidity with improved body image, sexuality and self-esteem, compare to mastectomyComparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstructionAl-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 BCTA 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;16:159-67Factors affecting comestic outcomeVolume loss >20%1Tumor location: central, medial, inferiorNipple areola displacement/ distortionInappropriate incision/poor surgical techniqueEffect of Radiotherapy1 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 outcomeOncologically, the wider the resection, the better the chance of clearanceFrom cosmetic pt of view, the extent of excision would increases the risk local deformitySo, 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 1Thorough tumor resection plus reconstruction of resection defectPrinciple of OBSOncological principle of resection to achieve wide tumor-free marginsPrinciple of plastic reconstruction to optimize cosmetic outcomes and minimize complication1 Oncoplastic breast surgery: A Global Perspective on Practice, Availability, and trainingPeter L Malycha et al; World J Surg :Not well defined term.Common underlying principleSeemingly, its just add on together to gain the synergistic effect
11 Reconstruction Principle Volume displacementRecruiting and transposing local dermoglandular flaps into the resection sitebreast-flap advancementMammaplastySuperior pedicleinferior pedicleCentralization of NAC complex+/- Contralateral surgery (reduction mammoplasty)Volume replacementImporting volume from elsewhere to replace the amount of tissue resectedAutologousLD flapTRAM flapImplantsBy no means exhaustive
15 OpponentOncological safety of the techniques is not being evaluated properlyPotential cosmetic failure and complicationExtra resources and extended operation timeNegative impact on the adjuvant treatmentProponentPotential oncological benefit to enable very wide excision of breast tissue without risking major local deformity1,2Extend the scope of BCS to include patients with 3-5 cm tumors, without compromising the adequacy of resection or the cosmetic outcomeOverall better cosmetic outcome1 Oncoplastic techniques allow extensive resections forBCT of Breast cancinomaKrishna B Clough at el. Ann Surg 2003 Jan;237(1)26-342 Lumpectomy ws oncoplastic surgery for BCT of cancer.A prospective study of 99 patientAnn Chir Apr:131(4):
16 Any clinical evidence ? Evaluation of oncological safety cosmetic outcomePotential complications/pitfallExpertises/Guidelines
17 Review of outcomes of OBS Volume displacementVolume replacementNo of studies117Total no of patient433189Median follow-up (m)21-5424-53Local recurrence(%)0-70-5Cosmetic failure (%)0-180-9The data for the review was compiled by searching the pubmed and MEDLIND databases for articles published betweenApartment 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 BCSemerging 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 monthsOncoplastic procedure:volume displacement for small defect and volume replacement for large defectConcomitant contralateral breast mammaplastyResults:Local recurrence: 3%; distant metastasis 13%; Mortality 7.53%Conclusions: Long term oncological outcomes are comparable with result of BCT in RCT
19 Conclusionemerging level II evidence for the short time oncological safety for OBS with good cosmetic outcomesPublished guidelineOncoplastic breast surgery – A guide to good practiceAssociation of breast surgery at BASO;Association of breast surgery at BQPRAS and the training Interface group in Breast SurgeryRoyal 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 techniquesHarvest more bulky myosubcutaneous flapBassLS et al Endoscopic harvest of the rectus abdominus free flap An Plast Surg 1995:34:274-9Endoscopic dissectionEndoscopic techniques in aesthetic breast Surgery Clin Plast Surg 1995:22:683-95Balloon dissection techniqueVan 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 reconstructionNICE guideline support its use under normal clinical arrangementOct 2007Mainly extending the volume replacement techniqueCases series showing the success of mobilization of myosubcutaneous flap via small axillary incisionThe 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 2009One non randomize trialeight case series (mainly from Japan and Korea)Total no of patients: 809Conclusion:Current evidence on the safety and efficacy of endoscopic mastectomy and wide local excision for breast cancer is inadequate in quantityOnly used in the context of researchNational institute for health and clinical excellence
24 SummaryThe goals of minimally invasive surgery for breast cancer is to improve aesthetic outcome without comprising oncological clearanceThe early results suggest Oncoplastic breast surgery has a promising future in management of breast cancerAnticipated maturation of endoscopic technique in assisting breast reconstruction and breast exicion
25 We should try out BEST to treat our patient’s BREAST