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Surgery for Inflammatory Breast Cancer: How and Why

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Part of the 2017 Metastatic Breast Cancer Forum, held by Dana-Farber Cancer Institute.

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Surgery for Inflammatory Breast Cancer: How and Why

  1. 1. Faina Nakhlis Division of Surgical Oncology Dana Farber Cancer Institute 1st Annual IBC Patient Forum May 13, 2017 Surgery for Inflammatory Breast Cancer (IBC): How and Why
  2. 2. Histologic Evaluation Dermal lymphatic invasionGrade 3 invasive ductal carcinoma Image-guided core needle biopsy +/- skin punch biopsy
  3. 3. Initial Evaluation Peau d’orange (dermal lymphatic invasion) Unresectable disease 1. Neoadjuvant systemic therapy for cytoreduction 2. Modified radical mastectomy 3. Chest wall and regional nodal radiotherapy* *Morris, Journal of Surgical Oncology 1983; Dawood et al. Annals of Oncology 2011
  4. 4. What is the Role of Surgery in IBC Survival in 28 patients with IBC (23 patients with stage III disease) with and without surgery, 1969-1980 Hagelberg, Jolly, Anderson, Am Journal of Surgery 1984
  5. 5. What is the Role of Surgery in IBC Recurrence and survival in 107 patients with IBC with and without surgery, 1958-1985 Fields et al, Cancer 1989 Multivariate Analysis
  6. 6. What is the Role of Surgery in IBC Response to chemotherapy, receipt of surgery and outcomes in 178 IBC patients 1974-1993, median follow-up 89 months (22-223 months) Fleming et al, Ann Surg Oncol 1989
  7. 7. What is a Modified Radical Mastectomy Mastectomy (total, simple) + Axillary lymph node dissection
  8. 8. Why Mastectomy The cancer is often present throughout the breast at the time of diagnosis
  9. 9. Why Axillary Lymph Node Dissection? Axillary lymph nodes are almost always involved at diagnosis and it may be unsafe to not to remove them
  10. 10. Drains Round Jackson-PrattRound Blake Flat Jackson-Pratt
  11. 11. Why Should Immediate Reconstruction Not Be Done in IBC? The amount of involved skin can go beyond what is clinically visible
  12. 12. Patterns of Breast Reconstruction in Patients Diagnosed with Inflammatory Breast Cancer: the Dana Farber Cancer Institute’s Inflammatory Breast Cancer Program Experience F. Nakhlis, M.M. Regan, Y.S. Chun, L.S. Dominici, J.R. Bellon, L. Warren, E.D. Yeh, H.A. Jacene, K. Hirko, A. Hazra, J Hirshfield- Bartek, T. A. King, B. Overmoyer SABCS 2015 Poster
  13. 13. Background • Immediate reconstruction is not advised in IBC patients due to lack of safety data for skin-sparing mastectomy • Data on breast reconstruction outcomes in IBC patients are scant • Our experience with breast reconstruction in IBC patients was reviewed
  14. 14. Methods • Retrospective analysis of IRB-approved DFCI IBC database • Patients included in the analysis • Stage III IBC • Sufficient response to preoperative chemotherapy to achieve resectability • No preoperative radiotherapy • No loco-regional progression or distant metastasis during preoperative chemotherapy
  15. 15. Results Stage III IBC patients* (1997-2014), n=167 Immediate reconstruction, n=12 Delayed reconstruction, n=18 No reconstruction, n=135 *In two patients breast reconstruction took place but no information about reconstruction details and follow-up is available
  16. 16. Immediate Reconstruction, n=12* Reconstructive Option Number of Patients Tissue expander 3 Single stage implant 3 DIEP flap 1 TRAM flap 4 Latissimus Dorsi flap 1 *Eleven out of 12 patients with immediate reconstruction underwent surgery outside of DFCI
  17. 17. Delayed Reconstruction, n=18 Reconstructive Option Number of Patients Tissue expander 1 TRAM flap 9 DIEP flap 5 Latissimus Dorsi and tissue expander 1 Latissimus Dorsi flap 2
  18. 18. Complications After Delayed Reconstruction Complication Delayed Reconstruction (N=18) Reoperation for flap donor site wound dehiscence 1 (6%) Reconstruction loss 1 (6%) Total Complications 2 (12%)
  19. 19. Future Direction • Exploration of the role of local therapy (surgery and radiation) in stage IV IBC •Axillary and extra-axillary lymphatic drainage in IBC and the potential for sentinel node mapping

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