Breast Cancer Surgery Options and Oncoplastic Surgery

Breast Cancer Surgery Options:Oncoplastic SurgeryTam Mai, MDGeneral Surgery

Note: contains explicit images which some may find graphic in nature.*www.freemanhealth.com

http://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

http://www.cancer.org/

Breast Cancer Survival Rates by Stage

*www.cancer.org

http://www.cancer.org/

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

Patients with Increased Lifetime Risk Includes:

*www.nccn.org

http://www.nccn.org/

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


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


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


Tremendous ChangeFAR Better 10-Year Survival and Quality of

Life

1962 2012


Can We Do Any Better?

1962 2012


First Excision Best Opportunity

to Do it Right

But if You Take Too Much…. Or Do it Wrong…….


May end up with poor cosmetic results and/or necessitates:

Re-Excisions Mastectomies


First ExcisionDone Poorly


These Results Could Have Been

Avoided with OncoPlastic

Breast Surgery


OncoPlastic Breast Surgery

Requires a Philosophy that Appearance of the Breast

afterBreast Conservation

is Important


OncoPlastic Breast Surgery:

Combination of Oncologic Principles with Plastic Surgical

Techniques


OncoPlastic Breast Surgery

Often Utilizes Chemotherapy

Mammography, US, MRI to Increase

Breast Conservation Rate


Crescent Mastopexy

Preop


Crescent Mastopexy

Preop 6 Weeks PO

Batwing/Hemibatwing


Preop 1 Week PO

J Mammaplasty

PostOp

Triangle Excision

PostOp


Circumareola, Round Block

Preop 1 Week PO

Circumareola, Round Block


Preop 6 month PO


Reduction Mammaplasty

Preop PO Day 6


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

https://www.rockisrocknbeads.blogspot.com/

Mastectomy with Delayed Reconstruction

TRAM/DIEP Flap Reconstruction

*lindase65.wordpress.com

http://lindase65.wordpress.com/

Latissimus Dorsi Flap Reconstruction

*www.newmamma.edu

http://www.newmamma.edu/

SGAP Flap Reconstruction

*www.davidgreenspunmd.com

http://www.davidgreenspunmd.com/

Implant Reconstruction

*www.brighamandwomens.org

http://www.brighamandwomens.org/

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?

Breast Cancer Surgery Options and Oncoplastic Surgery

Health & Medicine

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