oncological outcome & patient satisfaction with skin-sparing mastectomy & immediate breast...
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Oncological Outcome & Patient Satisfaction with Skin-Sparing Mastectomy & Immediate Breast
Reconstruction at The LBI: A Prospective Observational Study
Prof. Kefah Mokbel MS, FRCS
The London Breast Institute
Introduction
• Most women with early breast cancer (BC) are managed with breast-conserving therapy (BCT)
• Approximately one-third undergo mastectomy– patient preference – BCT not oncologically adequate or aesthetically acceptable
• Lack of level-1 evidence regarding– optimal type of mastectomy – subsequent technique and timing of reconstruction– skin-sparing mastectomy (SSM) and immediate breast
reconstruction (IBR)
Current trends in IBR rates
IBR in the USA (1999-2003)
• Immediate breast reconstruction rate = 23.6% (range of 22.2% to 25.3%). IBR rate in the UK = 21%
• Independent predictors of immediate breast reconstruction after mastectomy include:
private insurance hospital in an urban location teaching hospital white race hospital region in the south age between the 3rd and 6th decades low number of comorbidities
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10
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IBR rate
USA 2003UK 2009LBI 2009/10
Skin-Sparing Mastectomy• En-bloc removal of all glandular tissue, nipple–areola complex
(NAC) and in some cases adjacent biopsy scars and skin overlying superficial tumours with maximal preservation of breast skin envelope and infra-mammary fold [1]
• Facilitates immediate breast reconstruction (IBR) with autologous tissue and/or prosthetic implants by utilising the native skin envelope to optimise contour, texture, colour and scarring of the reconstructed breast [1]
• Single-stage procedure– hospital admissions, return to employment and elimination of
post-mastectomy pre-reconstruction period
1. Cunnick GH, Mokbel K. Skin-sparing mastectomy. Am J Surg. 2004;188(1):78–84
Skin-Sparing Mastectomy• Aesthetic advantages tempered by concerns about oncological safety
• Complete excision of glandular tissue can be more demanding
• Perceived increase in risk of local recurrence (LR) attributed to preservation of skin envelope.
• Post-mastectomy radiotherapy (PMR) is recommended for those at high-risk.
• One-third of breast surgeons avoid SSM and IBR – concerns over oncological safety or uncertainty of the benefits or
indications [2]
2. Singletary SE, Robb GL. Oncologic safety of skin-sparing mastectomy. Ann Surg Oncol. 2003;10:95–97
Breast Reconstruction Following Mastectomy
• Implant only
• Conventional flap +/- implantLD flap
• Free flaps: DIEPGAP
Breast Reconstruction:Recent Advances
• Biological ImplantsStrattice: acellular dermal matrix
• Autologous Adipose-derived Stem Cells: formation of new subcutaneous tissue
Coleman fat transfer Cytorie technology• Stem cell reconstruction
Aims of Study
• Recently, several studies have supported the oncological adequacy of SSM in selected early-stage BC, excluding inflammatory BC and tumours with extensive skin involvement of the skin [1]
• In this study, the oncological outcome, post-operative morbidity and patients’ satisfaction with SSM and IBR using the latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis is evaluated
1. Cunnick GH, Mokbel K. Skin-sparing mastectomy. Am J Surg. 2004;188(1):78–84
Patients & Methods
• Prospective cohort of 127 consecutive women with early-stage BC
• Selection criteria – pre-operative diagnosis (clinical examination, imaging and
needle biopsy) of Tis, T1 and T2 tumours without extensive skin involvement.
– 1 patient had T3 BC
• The principal indication for surgery was BC– 7 procedures were undertaken as risk-reducing prophylactic
mastectomies – 1 BRCA-1 gene carrier, 5 contra-lateral BC
Patients & Methods
• Pre-operatively counselling regarding ablative and reconstructive options available
• Surgical recommendations made case-by-case following discussion of tumour and patient factors within multidisciplinary team
• Surgical procedures were performed by the same surgeon, 2001 - 2008
• All 127 women underwent SSM and IBR – 117 unilateral and 10 bilateral procedures, total of 137 cases
• Nipple-preserving SSM (NP-SSM) & IBR undertaken in 10 cases (6 patients)
Patients & Methods
• IBR employed– LD pedicle-flap and implant (n = 86, including 1 bilateral case)– implant only (n = 51, including 9 bilateral cases)
• Initial implant was tissue expander, subsequently replaced with an anatomically profiled bio-dimensional cohesive silicon implant at the same time as nipple reconstruction or contra-lateral adjustment
• Nipple reconstruction was performed in 69 (54%) patients – trefoil local flap technique (n = 61), nipple sharing (n = 6), skin graft (n
= 1) and Monocryl mesh (n = 1)
Patients & Methods
• 30 (23.6%) patients underwent contra-lateral surgery for symmetry/cosmesis– 19 augmentations & 11 mastopexy/reduction mammoplasties
• Patients at high risk of requiring PMR – encouraged to opt for SSM and IBR using tissue expander alone– ‘immediate-delayed’ strategy in 11 cases.
• All patients underwent clinical examination on a 6 monthly basis and annual surveillance mammography.
• Satisfaction assessed using a linear visual analogue scale, 0 - 10– postal questionnaire or interview
Surgical Considerations
• SSM performed through peri-areolar incision – occasionally short horizontal incisions at the 3 and 9 o’clock positions
added– infra-mammary fold was preserved in all cases
• Intra-operative frozen section analysis of sub-areola tissue for NP-SSM
• Patients with clinically negative axillae underwent sentinel lymph node biopsy (SLNB)– axillary node clearance if intra-operative frozen section showed
malignancy
• Subsequent replacement of tissue expander with definitive implant prosthesis performed through short infra-mammary incisions– prosthesis placed in sub-muscular pocket
Results
• Median patients' age = 47 years (range = 27-72)
• Histopathological analysis of resection specimens – invasive carcinoma (+/- DCIS) in 105 cases– pure DCIS in 25 cases– BRCA-1 mutation - bilateral prophylactic mastectomies -
normal histology
• Median tumour size = 28mm (range 1mm - 100mm) – all superficial surgical margins were clear– 2 patients with extensive multi-centric disease, tumour focally
extended to the medial surgical margin, one received PMR
Results
• Lymph nodes involved in 45 patients– 41 macro-metastasis, 4 micro-metastatic spread
• Adjuvant chemotherapy required by 38 patients
• Prior RT had been received by 6 patients and 21 women underwent PMR – LD flap and implant reconstruction = 10, implant
only reconstruction = 11
Results
• No LR after median follow-up of 36 months (range = 6-101 months)
• Overall survival = 99.2%– 8 patients developed distant disease– 1 patient died of metastatic breast cancer, another died of lung cancer
• No cases of partial or total LD flap loss
• Morbidities– Infection - requiring implant removal in 2 (1.5%) cases – 1 patient (smoker) developed marginal ischemia of the skin envelope– Chemotherapy delayed by 2 weeks in 1 patient due to infection– Blood transfusion was required by 2 patients
Results
• All patients undergoing LD reconstruction developed donor site seromas– requiring percutaneous drainage as outpatient, median inpatient stay =
5 days
• Significant capsule formation in 87% of patients who had either prior RT or PMR vs. 13% without RT. – Capsulotomy performed when exchanging tissue expander for definitive
prosthesis– 1 patient required further capsulotomy several months after definitive
prosthesis
• 82/127 (64.6%) completed satisfaction survey – median score of 9 (range = 5-10)– IBR using LD + implant (mean = 9.3, median = 10)– implant only (mean = 9, median = 10)
SSM
SSM plus IBR
The LD Flap
SSM and LD Flap Recon.
SSM plus IBR
SSM plus IBR
Nipple Reconstruction
Nipple Reconstruction
NS-SSM plus IBR
Conclusions
• SSM and IBR is oncologically adequate in selected patients with Tis, T1 and T2 tumours in the absence of extensive skin involvement
• NAC preservation is possible, provided the tumour is not close to the nipple and a frozen section protocol is followed
• Radiotherapy is not a contra-indication for SSM & IBR
• SSM and IBR is associated with high levels of satisfaction and low morbidity
Thank You