1. “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan

2. Milan Conservation Programme (1970-2010) Phase 1 - Phase 2 - Phase 3 - Phase 4 - Conservation of the breast Conservation of axillary nodes Partial intraoperative radiotherapy (ELIOT) Conservative mastectomy+ELIOT

3. Improvement in diagnosis (ultrasonography, MRI) total mastectomies EIO20002005 23%28% A.Luini

4. Timing of Reconstruction - Always immediate - Delayed only if: - Locally advanced disease - Concomitant diseases A.Luini

5. SSM + immediate reconstruction with prosthesis or expander is nowadays the standard treatment, except for: - Inflammatory cancer - Locally advanced disease - Poor general conditions A.Luini

6. Skin Sparing Mastectomy + immediate reconstruction with prosthesis A. Luini

7. Immediate reconstruction does not affect the prognosis A. Luini

9. 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

10. Multivariate analysis (median f.u. 70 m.) (518 immediate reconstructions vs 159 without reconstruction) Petit JY et al, Breast Cancer Res Treat, 2008 A. Luini

11. Immediate reconstruction: The Nipple Sparing Approach EIO NSM 84% of the mastectomies A. Luini

12. Indications w Multifocal/multicentric cancer w Extensive microcalcifications w Contraindications or refusal to primary medical treatment w Negative retroareolar frozen section A. Luini

13. Contraindications w Involvement of the central quadrant w Paget’s disease w Pathological nipple discharge w Microcalcifications close to the nipple w Previous radiotherapy A. Luini

14. Advantages w Oncologic radicality: skin removal as a quadrantectomy and of the whole glandular tissue (except a thin retroareolar portion) w Intraoperative radiotherapy on the nipple areola complex (16Gy) w Immediate reconstruction with a good cosmetic result (very similar to a “good” quadrantectomy) A. Luini

15. a layer of glandular tissue should be left beneath the NAC a layer of glandular tissue should be left beneath the NAC to avoid NAC necrosis Subcutaneous mastectomy a fifty year old technique ! A. Luini

16. Surgical technique a) Conservation of the retroareolar glandular tissue b) Conservation of the retroareolar subcutaneous vascular plexus

17. Surgical technique a) Sterile LINAC collimator c) Lead and alluminium protective disc d) Pectoralis major muscle

18. ELIOT (16 Gy) ELIOT (16 Gy) Nipple Sparing Mastectomy on the remaining glandular tissue to complete the cancer treatment A. Luini

19. Nipple-sparing mastectomy Irradiated area A. Luini

20. NSM + prosthesis + contralateral breast augmentation 2 weeks 5 months A. Luini

21. Type of reconstruction Anatomic prosthesis 68% Expanders19% Round prosthesis 5% TRAM 8% A. Luini

22. Nipple Sparing Mastectomy Definitive prostheses 73% Immediate left reconstruction with implant A. Luini

23. Nipple Sparing Mastectomy Expanders 19% Two-step implant reconstruction A. Luini

24. Nipple Sparing Mastectomy TRAM 8% Immediate pedicled TRAM reconstruction A. Luini

25. RESULTS

26. A. Luini

27. 1060 NSM in 1023 patients 37 bilateral ( March 2002 - March 2007) infiltrating : 63% in situ : 37% 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

28. Complications (1060 NSM) Immediate NAC necrosis 8.8% Infections2.0% Delayed Capsular contracture15% Radiodystrophy7.5% A. Luini

29. NAC necrosis Partial 58 (5%) Total 26 (3,8%) Secondary reconstruction A.Luini

30. NAC necrosis Spontaneous healing with a TRAM

31. Infections 21 cases 2% 42 prostheses removed 4% A.Luini

32. Capsular contracture 157 capsulotomies 15% A. Luini

33. ELIOT (16 Gy) ELIOT (16 Gy) nipple sparing mastectomy But … 206 cases received a delayed radiotherapy the day after surgery A. Luini

34. Prosthesis removal p = 0.0829 A. Luini

35. Capsular contracture p = 0.3179 A. Luini

36. Cosmetic results minimum follow up 1 year, scale 0 - 10 Good result (score 7-10) Patient evaluation 82.3% Surgeon evaluation 84.8% A. Luini

37. 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

39. Fig.1 Did you find it difficult to look at your self naked? Fig.2 Do 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?

40. 1060 NSM in 1023 patients Invasive carcinoma 63% In situ carcinoma 37% ONCOLOGICAL RESULTS MEDIUM FOLLOW UP 20 MONTHS (RANGE 1-70)

41. EVENTS Local recurrence13 (1.2%) Distant metastases36 (3.5%) Deaths 3 (0.3%) A. Luini

43. Local recurrences 13 cases (1.2 %) All distant from the NAC (10 tumor bed, 3 upper quadrant) A. Luini

44. Nipple sparing mastectomy with intraoperative radiotherapy is a safe procedure to reduce the psychological trauma due to mastectomy in selected cases Conclusion A. Luini