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EASO2011 BRS 9 Clough
 

EASO2011 BRS 9 Clough

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    EASO2011 BRS 9 Clough EASO2011 BRS 9 Clough Presentation Transcript

    • ONCOPLASTIC SURGERY FOR BCS WHERE ARE WE GOING ? Krishna B. CLOUGH
    • CONSERVATIVE TREATMENT WHERE WERE WE ?
      • BCS indicated for :
      • Small tumours
      • Unifocal
      • Non central
    • CONSERVATIVE TREATMENT SIZE LIMIT ?
      • 1. Invasive :
      • 2 cm (Veronesi)
      • 4 cm ( NSABP ) OS # mastect.
      • 5 cm ( NCI , EORTC)
      • 2. DCIS :
      • 4 cm ( NSABP)
      • 5 cm ( EORTC)
    • CONSERVATIVE TREATMENT : PUSHING THE LIMITS ?
      • Preop CT :
      • Conservation rate 40 à 60%
      • Preop HT
      • More to come ….
    • Development of new surgical techniques: Oncoplastic surgery CONSERVATIVE TREATMENT : PUSHING THE LIMITS
    • BREAST CANCER SURGERY
      • Small tumors : wide excision
      • Large tumors : mastectomy
      Breast surgery : two bullet rifle 1.Lumpectomy 2.Mastectomy
    • ONCOPLASTIC SURGERY
      • Immediate breast reshaping
      • Wider excisions
      • Better cosmesis
      • Increase breast conservation
      Plastic surgery techniques at the time of tumor excision Audretsch, Clough, Petit, Rainsbury ,...
      • Integrating plastic surgery techniques for BCS
      ONCOPLASTIC SURGERY A new fashion ?
    • ONCOPLASTIC SURGERY
      • Expanding litterature
      • Various techniques
      • ? ? ? ?
      • Lack of classification
    • ONCOPLASTIC SURGERY CLASSIFICATION Ann Surg Oncol 2010
    • CONSERVATIVE TREATMENT LIMITS
      • Oncologic : Tumor volume
      • Multicentricity
      • Margins
      • Anatomic : Breast size
      • Tumor / Breast ratio
      • Location
      • Cosmetic result
    • CONSERVATIVE SURGERY : A CLASH OF INTERESTS
    • CONSERVATIVE TREATMENT Cosmetic results
      • Good : 75 %
      • Poor : 20 %
      • Bad : 5 %
      Volume related
    • POOR RESULTS AFTER BCT : CAUSES ?
      • Obesity, smoking
      • Radiotherapy technique
      • Surgical technique +++
    • RECONTRUCTION AFTER BCT ? No mammoplasty possible !!
    • RECONSTRUCTION POST RT
    • RECONSTRUCTION POST BCT
    • RECONSTRUCTION AFTER CONSERVATIVE TREATMENT ?
      • No mammoplasty possible post RT
      • Sophisticated surgery: flaps
      • Poor results, disappointed patients
      • Prevention +++ :
      Clough KB et al: AnnPlastSurg 1998, PRS 2004 Immediate reshaping PRIOR TO radiotherapy Oncoplastic surgery level 1/2
    • ONCOPLASTIC SURGERY PATIENT SELECTION
      • No guidelines
      • No consensus
      • Extreme variability :
      • level 2 mammoplasties: 0 20%
    • ONCOPLASTIC SURGERY PATIENT SELECTION
      • Large / ill defined tumors :
      • Extensive DCIS
      • Invasive Lobular
      • Partial response Post CT
      • Anatomic problem
      • T vol/Breast vol ratio
      • Tumor location
      • Skin excision
      • 1. Oncologic criteria
      WHO NEEDS OP SURGERY ?
    • WHO NEEDS OP SURGERY ?
      • 2. Anatomic criteria
    • ONCOPLASTIC SURGERY: TOOLS
      • Volume replacement techniques :
      • L atis. Miniflap / Implant / Lipofilling
      • Volume displacement techniques
    • VOLUME REPLACEMENT : LATISSIMUS MINIFLAP
      • Lateral quadrants
      • Fill cavity with miniflap
      • No skin
      Nogushi, Rainsbury, Dixon ...
    • 6 cm DCIS , lower pole
    • ONCOPLASTIC SURGERY: TOOLS
      • Volume replacement techniques :
      • latissimus « miniflaps »
      • Volume displacement techniques :
      • Redistribution of volume loss
      • Mammoplasty techniques
    •  
    • Resection : 350 g
    • Resection : 200 g !
    •  
    • MAMMOPLASTY FOR BREAST CANCER (1)
    • MAMMOPLASTY FOR BREAST CANCER (2)
    • MAMMOPLASTY FOR BREAST CANCER (3)
    • LOWER POLE
    • " SUPERIOR PEDICLE " TECHNIQUE Clough K.B. et al, AnnChirPlastEsth 1990
    •  
    • " LEVEL 2 " MAMMOPLASTY TECHNIQUES
      • Other quadrants ?
      • Same technique ?
      ?
    • DIVERSIFICATION OF OPS TECHNIQUES Berry JPRAS 2009
    • QUADRANT PER QUADRANT LEVEL 2 TECHNIQUES
    • ONCOPLASTIC SURGERY : ONCOLOGIC RESULTS ? Ann. Surg.,2003,237,1,26-34
      • Tumor size : 2 to 10 cm (median 3,5 cm)
      • Resection weight : 150 to 300 g
      • Recurrence rate 5 yrs : 7%
      • OS DFS : no negative impact
      ONCOPLASTIC SURGERY : ONCOLOGIC RESULTS ? Clough 2003, Rietjens 2007, Fitoussi 2010
      • Mastectomy for +ive margins : 8-18%
      • Complications rate : 7-24%
      • Delay in adjuvant treatment ? (PBC: 1.7%)
      ONCOPLASTIC SURGERY : COMPLICATIONS ? Clough 2003, McCulley 2005, Kronowitz 2007
    • ONCOPLASTIC SURGERY COMPLICATIONS
      • Complex procedures
      • Glandular flaps
      • Risk factors : fatty breasts, smokers
      • Surgical Training
      ONCOPLASTIC SURGERY  COMPLICATIONS
    • 3-5 May 2011 29-31 0ctober 2011 [email_address]
    • BREAST CONSERVING SURGERY
      • 90 % of cases :
      • Simple reshaping / level 1 OPS
      • Good local and distant control
      • Good cosmetic results
    • BREAST CANCER SURGERY
      • Small tumors : wide excision
      • Large tumors : mastectomy
      Breast surgery : two bullet rifle 1.Lumpectomy 2.Mastectomy
      • New tools
      • Wider excisions
      • Extension of breast conservation
      • « The third path »
      ONCOPLASTIC SURGERY 2.OPS 1.Lumpectomy 3.Mastectomy
    • ONCOPLASTIC SURGERY IMPACT ON PRACTICE
    • ONCOPLASTIC SURGERY IMPACT ON PRACTICE