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

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Presentation on theme: "Minimally Invasive Breast Surgery Joint Hospital Grand Round Luk Wai Yin Sally NDH/AHNH."— Presentation transcript:

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 Morrow BMJ Feb : 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 radiotherapy 1 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: –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:

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: 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 :

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 i)Oncological principle of resection to achieve wide tumor-free margins ii)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 :

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

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

13 FactorsVolume displacementVolume replacement Breast sizeMedium or largeSmall or medium Tumor positionCentral or lower poleAny site ScarsBilateral breastBreast + back Theater time1-2hr2-3 hr ComplicationsFlap ischaemia Fat necrosis Donor site morbidity Flap loss Factors influencing technique chosen

14 Mastopexy lumpectomy

15 Proponent –Potential oncological benefit to enable very wide excision of breast tissue without risking major local deformity 1,2 –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) Lumpectomy ws oncoplastic surgery for BCT of cancer. A prospective study of 99 patient Ann Chir 2006 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 studies117 Total no of patient Median follow-up (m) Local recurrence(%) Cosmetic failure (%) 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 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: –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

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 patients BREAST

26 Thank You

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