EASO2011 BRS 9 Clough

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EASO2011 BRS 9 Clough

  1. 1. ONCOPLASTIC SURGERY FOR BCS WHERE ARE WE GOING ? Krishna B. CLOUGH
  2. 2. CONSERVATIVE TREATMENT WHERE WERE WE ? <ul><li>BCS indicated for : </li></ul><ul><li>Small tumours </li></ul><ul><li>Unifocal </li></ul><ul><li>Non central </li></ul>
  3. 3. CONSERVATIVE TREATMENT SIZE LIMIT ? <ul><li>1. Invasive : </li></ul><ul><li>2 cm (Veronesi) </li></ul><ul><li>4 cm ( NSABP ) OS # mastect. </li></ul><ul><li>5 cm ( NCI , EORTC) </li></ul><ul><li>2. DCIS : </li></ul><ul><li>4 cm ( NSABP) </li></ul><ul><li>5 cm ( EORTC) </li></ul>
  4. 4. CONSERVATIVE TREATMENT : PUSHING THE LIMITS ? <ul><li>Preop CT : </li></ul><ul><li>Conservation rate 40 à 60% </li></ul><ul><li>Preop HT </li></ul><ul><li>More to come …. </li></ul>
  5. 5. Development of new surgical techniques: Oncoplastic surgery CONSERVATIVE TREATMENT : PUSHING THE LIMITS
  6. 6. BREAST CANCER SURGERY <ul><li>Small tumors : wide excision </li></ul><ul><li>Large tumors : mastectomy </li></ul>Breast surgery : two bullet rifle 1.Lumpectomy 2.Mastectomy
  7. 7. ONCOPLASTIC SURGERY <ul><li>Immediate breast reshaping </li></ul><ul><li>Wider excisions </li></ul><ul><li>Better cosmesis </li></ul><ul><li>Increase breast conservation </li></ul>Plastic surgery techniques at the time of tumor excision Audretsch, Clough, Petit, Rainsbury ,...
  8. 8. <ul><li>Integrating plastic surgery techniques for BCS </li></ul>ONCOPLASTIC SURGERY A new fashion ?
  9. 9. ONCOPLASTIC SURGERY <ul><li>Expanding litterature </li></ul><ul><li>Various techniques </li></ul><ul><li>? ? ? ? </li></ul><ul><li>Lack of classification </li></ul>
  10. 10. ONCOPLASTIC SURGERY CLASSIFICATION Ann Surg Oncol 2010
  11. 11. CONSERVATIVE TREATMENT LIMITS <ul><li>Oncologic : Tumor volume </li></ul><ul><li>Multicentricity </li></ul><ul><li> Margins </li></ul><ul><li>Anatomic : Breast size </li></ul><ul><li>Tumor / Breast ratio </li></ul><ul><li>Location </li></ul><ul><li>Cosmetic result </li></ul>
  12. 12. CONSERVATIVE SURGERY : A CLASH OF INTERESTS
  13. 13. CONSERVATIVE TREATMENT Cosmetic results <ul><li>Good : 75 % </li></ul><ul><li>Poor : 20 % </li></ul><ul><li>Bad : 5 % </li></ul>Volume related
  14. 14. POOR RESULTS AFTER BCT : CAUSES ? <ul><li>Obesity, smoking </li></ul><ul><li>Radiotherapy technique </li></ul><ul><li>Surgical technique +++ </li></ul>
  15. 15. RECONTRUCTION AFTER BCT ? No mammoplasty possible !!
  16. 16. RECONSTRUCTION POST RT
  17. 17. RECONSTRUCTION POST BCT
  18. 18. RECONSTRUCTION AFTER CONSERVATIVE TREATMENT ? <ul><li>No mammoplasty possible post RT </li></ul><ul><li>Sophisticated surgery: flaps </li></ul><ul><li>Poor results, disappointed patients </li></ul><ul><li>Prevention +++ : </li></ul>Clough KB et al: AnnPlastSurg 1998, PRS 2004 Immediate reshaping PRIOR TO radiotherapy Oncoplastic surgery level 1/2
  19. 19. ONCOPLASTIC SURGERY PATIENT SELECTION <ul><li>No guidelines </li></ul><ul><li>No consensus </li></ul><ul><li>Extreme variability : </li></ul><ul><li>level 2 mammoplasties: 0 20% </li></ul>
  20. 20. ONCOPLASTIC SURGERY PATIENT SELECTION <ul><li>Large / ill defined tumors : </li></ul><ul><li>Extensive DCIS </li></ul><ul><li>Invasive Lobular </li></ul><ul><li>Partial response Post CT </li></ul><ul><li>Anatomic problem </li></ul><ul><li>T vol/Breast vol ratio </li></ul><ul><li>Tumor location </li></ul><ul><li>Skin excision </li></ul>
  21. 21. <ul><li>1. Oncologic criteria </li></ul>WHO NEEDS OP SURGERY ?
  22. 22. WHO NEEDS OP SURGERY ? <ul><li>2. Anatomic criteria </li></ul>
  23. 23. ONCOPLASTIC SURGERY: TOOLS <ul><li>Volume replacement techniques : </li></ul><ul><li>L atis. Miniflap / Implant / Lipofilling </li></ul><ul><li>Volume displacement techniques </li></ul>
  24. 24. VOLUME REPLACEMENT : LATISSIMUS MINIFLAP <ul><li>Lateral quadrants </li></ul><ul><li>Fill cavity with miniflap </li></ul><ul><li>No skin </li></ul>Nogushi, Rainsbury, Dixon ...
  25. 25. 6 cm DCIS , lower pole
  26. 26. ONCOPLASTIC SURGERY: TOOLS <ul><li>Volume replacement techniques : </li></ul><ul><li>latissimus « miniflaps » </li></ul><ul><li>Volume displacement techniques : </li></ul><ul><li>Redistribution of volume loss </li></ul><ul><li>Mammoplasty techniques </li></ul>
  27. 28. Resection : 350 g
  28. 29. Resection : 200 g !
  29. 31. MAMMOPLASTY FOR BREAST CANCER (1)
  30. 32. MAMMOPLASTY FOR BREAST CANCER (2)
  31. 33. MAMMOPLASTY FOR BREAST CANCER (3)
  32. 34. LOWER POLE
  33. 35. &quot; SUPERIOR PEDICLE &quot; TECHNIQUE Clough K.B. et al, AnnChirPlastEsth 1990
  34. 37. &quot; LEVEL 2 &quot; MAMMOPLASTY TECHNIQUES <ul><li>Other quadrants ? </li></ul><ul><li>Same technique ? </li></ul>?
  35. 38. DIVERSIFICATION OF OPS TECHNIQUES Berry JPRAS 2009
  36. 39. QUADRANT PER QUADRANT LEVEL 2 TECHNIQUES
  37. 40. ONCOPLASTIC SURGERY : ONCOLOGIC RESULTS ? Ann. Surg.,2003,237,1,26-34
  38. 41. <ul><li>Tumor size : 2 to 10 cm (median 3,5 cm) </li></ul><ul><li>Resection weight : 150 to 300 g </li></ul><ul><li>Recurrence rate 5 yrs : 7% </li></ul><ul><li>OS DFS : no negative impact </li></ul>ONCOPLASTIC SURGERY : ONCOLOGIC RESULTS ? Clough 2003, Rietjens 2007, Fitoussi 2010
  39. 42. <ul><li>Mastectomy for +ive margins : 8-18% </li></ul><ul><li>Complications rate : 7-24% </li></ul><ul><li>Delay in adjuvant treatment ? (PBC: 1.7%) </li></ul>ONCOPLASTIC SURGERY : COMPLICATIONS ? Clough 2003, McCulley 2005, Kronowitz 2007
  40. 43. ONCOPLASTIC SURGERY COMPLICATIONS
  41. 44. <ul><li>Complex procedures </li></ul><ul><li>Glandular flaps </li></ul><ul><li>Risk factors : fatty breasts, smokers </li></ul><ul><li>Surgical Training </li></ul>ONCOPLASTIC SURGERY  COMPLICATIONS
  42. 45. 3-5 May 2011 29-31 0ctober 2011 [email_address]
  43. 46. BREAST CONSERVING SURGERY <ul><li>90 % of cases : </li></ul><ul><li>Simple reshaping / level 1 OPS </li></ul><ul><li>Good local and distant control </li></ul><ul><li>Good cosmetic results </li></ul>
  44. 47. BREAST CANCER SURGERY <ul><li>Small tumors : wide excision </li></ul><ul><li>Large tumors : mastectomy </li></ul>Breast surgery : two bullet rifle 1.Lumpectomy 2.Mastectomy
  45. 48. <ul><li>New tools </li></ul><ul><li>Wider excisions </li></ul><ul><li>Extension of breast conservation </li></ul><ul><li>« The third path » </li></ul>ONCOPLASTIC SURGERY 2.OPS 1.Lumpectomy 3.Mastectomy
  46. 49. ONCOPLASTIC SURGERY IMPACT ON PRACTICE
  47. 50. ONCOPLASTIC SURGERY IMPACT ON PRACTICE

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