Post on 21-Jan-2017
Breast Cancer Surgery Options:Oncoplastic SurgeryTam Mai, MDGeneral Surgery
Note: contains explicit images which some may find graphic in nature.*www.freemanhealth.com
Breast Cancer is Common
*www.cancer.org
• Affects 1 in 8 women in the US• In 2015, About 231,840 new cases will be diagnosed–About 60,290 will be in situ cancer–About 40,290 women will die from breast cancer–Currently, there are > 2.8 million breast cancer survivors–Death rates from breast cancer have declined
Early Detection Saves Lives and Breasts!
*American Cancer Society Recommendations for early breast cancer detection
Clinical Breast Exams by a health professional every 3 years starting at age 20-30, then yearly at age 40
More Intense Screening for Increased Risk Patients
• Annual mammogram at diagnosis, but not <30 y.o. May begin 10 years prior to youngest affected family member
• Clinical breast exam every 6-12 months• Consider the addition of annual MRI
Treatment of Breast Cancer• Requires a Team Approach, including collaboration
from:• Radiologist• Pathologist• Surgical Oncologist• Medical Oncologist• Radiation Oncologist• Plastic Reconstructive Surgery
Moving Beyond your DiagnosisEarly Detection and Multimodality Treatment
Improves Survival and Quality of Life
More Breast Cancer Facts- 1960’s1. All Palpable Masses (Average 4.5 cm) 2. No Mammography / No Screening No Image-Detected / Essentially No Nonpalpable3. No Needle Biopsy4. Radical Mastectomy / 1 Stage
5. Complete Axillary Dissection 75% Positive 6. Hospital 7-10 Days for Rad Mastectomy
More Breast Cancer Facts- 1960’s7. No Reconstruction
8. Radiation Therapy - Radical Extended Field 9. No Biologic Markers ER, PR, HER2, Ki6710. No Chemotherapy 5FU and Methotrexate11. No Informed Consent 12. No 2nd Opinion13. No Multidisciplinary Approach
Chance of Living 5 Years ≈ 50%
“The Operation
Women Fear Most”
Radical Mastectomy +
RT = 35% Lymphedema
Tremendous Change
Invasive
DCIS
BC Deaths
1962 2012
56,000
200 (0.35%)
29,000 (1 of 2)
229,000 (4x)
66,300 (23%)
40,000 (1 of 6)
Incidence11/20 1/8
*Courtesy of Dr. Melvin Silverstein
*Courtesy of Dr. Melvin Silverstein
Paradigm ChangesParadigm Changes1. Radical Mastectomy ………. Breast . Radical Mastectomy ………. Breast
ConservationConservation2. One Stage .......... Two Stages (Diagnosis 2. One Stage .......... Two Stages (Diagnosis
First)First)
3. Clinically-Detected ........ Image-Detected 3. Clinically-Detected ........ Image-Detected
4. All Invasive ............ 23% DCIS 4. All Invasive ............ 23% DCIS (Noninvasive)(Noninvasive)
5. Open Surgical Bx .......... Minimally 5. Open Surgical Bx .......... Minimally Invasive Invasive Biopsy (Needle) Biopsy (Needle)
6. Three-Level Axillary Dissection .. Sentinel 6. Three-Level Axillary Dissection .. Sentinel NodeNode
*Courtesy of Dr. Melvin Silverstein
Paradigm ChangesParadigm Changes7. No Reconstruction ....... Immediate 7. No Reconstruction ....... Immediate ReconstReconst
8. Skin Removing / Skin Graft .... Nipple-8. Skin Removing / Skin Graft .... Nipple-AreolaAreola Skin- Skin-SparingSparing
9. Fragmented Care ............ Breast 9. Fragmented Care ............ Breast CentersCenters10. General Surgery Training ...Breast 10. General Surgery Training ...Breast FellowshipFellowship11. No Chemotherapy ........Neoadjuvant 11. No Chemotherapy ........Neoadjuvant ChemoChemo12. 6-7 Weeks RT .............IORT 30 Minutes12. 6-7 Weeks RT .............IORT 30 Minutes
13. Oncologic (Destructive) ......... 13. Oncologic (Destructive) ......... OncoPlastic OncoPlastic (Reconstructive)(Reconstructive)
14. Histology ................Molecular Profiling14. Histology ................Molecular Profiling15. Wide Margins ……… No Ink on Tumor15. Wide Margins ……… No Ink on Tumor
*Courtesy of Dr. Melvin Silverstein
Tremendous ChangeFAR Better 10-Year Survival and Quality of
Life
1962 2012
*Courtesy of Dr. Melvin Silverstein
Can We Do Any Better?
1962 2012
*Courtesy of Dr. Melvin Silverstein
First Excision Best Opportunity
to Do it Right
But if You Take Too Much…. Or Do it Wrong…….
*Courtesy of Dr. Melvin Silverstein
May end up with poor cosmetic results and/or necessitates:
Re-Excisions Mastectomies
*Courtesy of Dr. Melvin Silverstein
First ExcisionDone Poorly
*Courtesy of Dr. Melvin Silverstein
First ExcisionDone Poorly
*Courtesy of Dr. Melvin Silverstein
First ExcisionDone Poorly
*Courtesy of Dr. Melvin Silverstein
These Results Could Have Been
Avoided with OncoPlastic
Breast Surgery
*Courtesy of Dr. Melvin Silverstein
OncoPlastic Breast Surgery
Requires a Philosophy that Appearance of the Breast
afterBreast Conservation
is Important
*Courtesy of Dr. Melvin Silverstein
OncoPlastic Breast Surgery:
Combination of Oncologic Principles with Plastic Surgical
Techniques
*Courtesy of Dr. Melvin Silverstein
OncoPlastic Breast Surgery
Often Utilizes Chemotherapy
Mammography, US, MRI to Increase
Breast Conservation Rate
*Courtesy of Dr. Melvin Silverstein
Crescent Mastopexy
Preop
*Courtesy of Dr. Melvin Silverstein
Crescent Mastopexy
Preop 6 Weeks PO
Batwing/Hemibatwing
*Courtesy of Dr. Melvin Silverstein
Preop 1 Week PO
J Mammaplasty
PostOp
Triangle Excision
PostOp
*Courtesy of Dr. Melvin Silverstein
Circumareola, Round Block
Preop 1 Week PO
Circumareola, Round Block
*Courtesy of Dr. Melvin Silverstein
Preop 6 month PO
*Courtesy of Dr. Melvin Silverstein
Reduction Mammaplasty
Preop PO Day 6
Reduction Mammaplasty
Preop PO Day 6
*Courtesy of Dr. Melvin Silverstein
*Courtesy of Dr. Melvin Silverstein
If Mastectomy Had To Be Done….
•Unilateral vs Bilateral Mastectomy•Mastectomy With no Reconstruction•Mastectomy With Delayed Reconstruction•Mastectomy With Immediate Reconstruction
•Skin Sparing Mastectomy•Nipple Sparing Mastectomy•Goldilocks Mastectomy
Reconstruction Could be done with Autologous Flap vs. Implant
•Implant•Autologous
•TRAM•DIEP•Latissimus Flap•SGAP•Etc
Mastectomy With No Reconstruction
*https://www.rockisrocknbeads.blogspot.com
Mastectomy With No Reconstruction
*https://www.rockisrocknbeads.blogspot.com
Mastectomy with Delayed Reconstruction
Skin Sparing Mastectomy w/ Immediate Implant Reconstruction
Preop Postop
Nipple Sparing Mastectomy w/ Immediate Implant Reconstruction
1 Week Postop 8 Months Postop
Skin Sparing Mastectomy w/ No Reconstruction: “Goldilocks Mastectomy”
Thank You for Your Attendance• Questions?