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EASO2011 BRS 9 Clough
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EASO2011 BRS 9 Clough Presentation Transcript

  • 1. ONCOPLASTIC SURGERY FOR BCS WHERE ARE WE GOING ? Krishna B. CLOUGH
  • 2. CONSERVATIVE TREATMENT WHERE WERE WE ?
    • BCS indicated for :
    • Small tumours
    • Unifocal
    • Non central
  • 3. 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)
  • 4. CONSERVATIVE TREATMENT : PUSHING THE LIMITS ?
    • Preop CT :
    • Conservation rate 40 à 60%
    • Preop HT
    • More to come ….
  • 5. Development of new surgical techniques: Oncoplastic surgery CONSERVATIVE TREATMENT : PUSHING THE LIMITS
  • 6. BREAST CANCER SURGERY
    • Small tumors : wide excision
    • Large tumors : mastectomy
    Breast surgery : two bullet rifle 1.Lumpectomy 2.Mastectomy
  • 7. 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 ,...
  • 8.
    • Integrating plastic surgery techniques for BCS
    ONCOPLASTIC SURGERY A new fashion ?
  • 9. ONCOPLASTIC SURGERY
    • Expanding litterature
    • Various techniques
    • ? ? ? ?
    • Lack of classification
  • 10. ONCOPLASTIC SURGERY CLASSIFICATION Ann Surg Oncol 2010
  • 11. CONSERVATIVE TREATMENT LIMITS
    • Oncologic : Tumor volume
    • Multicentricity
    • Margins
    • Anatomic : Breast size
    • Tumor / Breast ratio
    • Location
    • Cosmetic result
  • 12. CONSERVATIVE SURGERY : A CLASH OF INTERESTS
  • 13. CONSERVATIVE TREATMENT Cosmetic results
    • Good : 75 %
    • Poor : 20 %
    • Bad : 5 %
    Volume related
  • 14. POOR RESULTS AFTER BCT : CAUSES ?
    • Obesity, smoking
    • Radiotherapy technique
    • Surgical technique +++
  • 15. RECONTRUCTION AFTER BCT ? No mammoplasty possible !!
  • 16. RECONSTRUCTION POST RT
  • 17. RECONSTRUCTION POST BCT
  • 18. 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
  • 19. ONCOPLASTIC SURGERY PATIENT SELECTION
    • No guidelines
    • No consensus
    • Extreme variability :
    • level 2 mammoplasties: 0 20%
  • 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
  • 21.
    • 1. Oncologic criteria
    WHO NEEDS OP SURGERY ?
  • 22. WHO NEEDS OP SURGERY ?
    • 2. Anatomic criteria
  • 23. ONCOPLASTIC SURGERY: TOOLS
    • Volume replacement techniques :
    • L atis. Miniflap / Implant / Lipofilling
    • Volume displacement techniques
  • 24. VOLUME REPLACEMENT : LATISSIMUS MINIFLAP
    • Lateral quadrants
    • Fill cavity with miniflap
    • No skin
    Nogushi, Rainsbury, Dixon ...
  • 25. 6 cm DCIS , lower pole
  • 26. ONCOPLASTIC SURGERY: TOOLS
    • Volume replacement techniques :
    • latissimus « miniflaps »
    • Volume displacement techniques :
    • Redistribution of volume loss
    • Mammoplasty techniques
  • 27.  
  • 28. Resection : 350 g
  • 29. Resection : 200 g !
  • 30.  
  • 31. MAMMOPLASTY FOR BREAST CANCER (1)
  • 32. MAMMOPLASTY FOR BREAST CANCER (2)
  • 33. MAMMOPLASTY FOR BREAST CANCER (3)
  • 34. LOWER POLE
  • 35. " SUPERIOR PEDICLE " TECHNIQUE Clough K.B. et al, AnnChirPlastEsth 1990
  • 36.  
  • 37. " LEVEL 2 " MAMMOPLASTY TECHNIQUES
    • Other quadrants ?
    • Same technique ?
    ?
  • 38. DIVERSIFICATION OF OPS TECHNIQUES Berry JPRAS 2009
  • 39. QUADRANT PER QUADRANT LEVEL 2 TECHNIQUES
  • 40. ONCOPLASTIC SURGERY : ONCOLOGIC RESULTS ? Ann. Surg.,2003,237,1,26-34
  • 41.
    • 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
  • 42.
    • 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
  • 43. ONCOPLASTIC SURGERY COMPLICATIONS
  • 44.
    • Complex procedures
    • Glandular flaps
    • Risk factors : fatty breasts, smokers
    • Surgical Training
    ONCOPLASTIC SURGERY  COMPLICATIONS
  • 45. 3-5 May 2011 29-31 0ctober 2011 [email_address]
  • 46. BREAST CONSERVING SURGERY
    • 90 % of cases :
    • Simple reshaping / level 1 OPS
    • Good local and distant control
    • Good cosmetic results
  • 47. BREAST CANCER SURGERY
    • Small tumors : wide excision
    • Large tumors : mastectomy
    Breast surgery : two bullet rifle 1.Lumpectomy 2.Mastectomy
  • 48.
    • New tools
    • Wider excisions
    • Extension of breast conservation
    • « The third path »
    ONCOPLASTIC SURGERY 2.OPS 1.Lumpectomy 3.Mastectomy
  • 49. ONCOPLASTIC SURGERY IMPACT ON PRACTICE
  • 50. ONCOPLASTIC SURGERY IMPACT ON PRACTICE