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GP Education Series
Women’s cancers
GP Education Day 11 July 2016
The Royal Marsden
Mr Paul Harris MD FRCS(plast)
Consultant Plastic Surgeon and Medical Director of Private Care,
The Royal Marsden
The changing shape of cancer reconstruction
The Royal Marsden
• more successful curative treatment
with longer life expectancy
• patient (society) driven
• media exposure – patient expectations
• cross-over with cosmetic surgery
enhancing vs preserving body image
Greater demand for reconstructive perfection
The Royal Marsden
Wide variations in national mastectomy and reconstruction rates (cancer less than 15mm)
The Royal Marsden
NHS Breast Screening Programme Audit 93 Units 2004/2005
Evidence of variable access and provision to
reconstruction: UK NHS BSP 2004 -5
The Royal Marsden
National Mastectomy & Breast Reconstruction Audit
improved access to better care & more choice
better reconstructive outcomes
Breast reconstruction nationally
National Mastectomy and Breast Reconstruction Audit: Findings
2008-9
Prospective
195 breast units
18,000 mastectomies
4796 reconstructions
– Immediate
3,216 - 21% (9-43%)
– DCIS 38%,
– Invasive 17%.
– Delayed
1,580
1996-2006
(Retrospective)
Reconstruction rates
increased from 7-11%
Majority were delayed
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• ‘discuss immediate breast reconstruction with all patients having mastectomy’ • ‘offer immediate breast reconstruction except where significant co-morbidity or adjuvant therapy precludes this option’ • ‘all appropriate breast reconstruction options should be offered and discussed, regardless of local availability’
Early and locally advanced breast cancer. Diagnosis and treatment. February 2009.
www.nice.org.uk/CG80
Tackling variable access to reconstruction: NICE guidelines: 2002 /2009
Oncoplastic guidelines: 2008/2012
2008 2012
The Royal Marsden
surgical armamentarium
fixed volume implant
contralateral adjustment
tissue expander implant
pedicled LD flap
extended LD flap
free TRAM flap
free DIEP flap
SGAP / IGAP / TUG
pedicled TRAM flap
The Royal Marsden
envelope (skin)
volume required
immediate or delayed
radiotherapy – environment
available tissue
surgical insult - comorbidities
impact on cancer therapy
Patient’s desires
Surgeon’s preference and training
Factors affecting decision
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RECONSTRUCTIVE SURGERY
Reconstructive toolbox
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multi-disciplinary team:
breast care nurses
oncologists
breast ‘oncoplastic’ surgeons
plastic surgeons
radiologists
Breast reconstruction at The Royal Marsden
The Royal Marsden
Learning points
Familiarity of techniques (concepts) available
Understanding the patient journey & multi-modality
treatments
Hot topics:
timing of radiotherapy
bilateral surgery
ALCL
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-immediate skin preserving (subcutaneous, skin-sparing, skin reducing) main issue is volume -delayed volume and skin needed
Skin preservation, timing and radiotherapy
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Implant based Autologous Additional procedures
Implant-only or implant-assisted Two-stage or one stage Fixed volume, expander or expander implant
Muscle or skin & fat (perforator) Donor site
Reduction & mastopexy Fat transfer
Technique overview
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expanders and implants
Implant reconstruction & ADMs
The Royal Marsden
expanders and implants
Implant reconstruction & ADMs
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PIP issue
Implant reconstruction & ADMs
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traditional two-stage
Implant reconstruction & ADMs
traditional implant-assisted (latissimus dorsi) - one-stage
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current implant-assisted (dermal sling) - one-stage
Implant reconstruction & ADMs
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current implant-assisted (ADM) - one-stage
allow straight to implant
exploded on the scene
greater use of nipple preservation
Implant reconstruction & ADMs
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current implant-assisted (ADM) - one-stage
implant reconstruction & ADMs
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ADMs
hot area for papers
learning curve
products differ
complication rate raised ? how much
possibly reduced capsular contracture
Long term folloe up needed
Implant reconstruction & ADMs
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?role of the LD refinement & enhanced recovery of DIEPs TUG, PAP & GAP flaps
Autologous reconstruction
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latissimus dorsi flap extended latissimus dorsi flap (ELD)
Autologous reconstruction
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?role of the LD
2003 2013
50%
25%
DIEP
ELD
IMPLANT IMPLANT & ADM
LD
TUG
Autologous reconstruction
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TRAM - pedicled
Autologous reconstruction
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free tissue transfer
Autologous reconstruction
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introduction 1989 & popularised 1994 increasing drive to use DIEP rather than TRAM preservation of rectus muscle and sheath: - reduced abdominal bulge, hernia and weakness - reduced postoperative pain - improved recovery - reduced overall cost flap loss rates <0.5% pre-operative CT planning
DIEP flap
Autologous reconstruction
The Royal Marsden
DIEP flap
Autologous reconstruction
The Royal Marsden
Enhanced Recovery is the use of novel surgical pathways aiming to optimise the patient outcome through pre-operative preparation, intra-operative care, and post-
operative rehabilitation. The result is that patients get better quicker, have a better experience and reduced length of stay
NHS London
Enhanced recovery –A National Perspective, Monty Mythen, Smiths Medical Professor of
Anaesthesia and Critical Care University College London National Clinical Lead Enhanced
Recovery Partnership Programme –Department of Health UK)
DIEP flap – enhanced recovery
Autologous reconstruction
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PROTOCOLS education – two consultations, CNS, pre-assessment planning – CT angio anaesthetic protocols, positioning, minimise dissection alleviate pain – blocks early mobilisation & drain removal wound care
DIEP flap – enhanced recovery
Autologous reconstruction
The Royal Marsden
At The Royal Marsden: Last 10 years >1000 DIEPS – 3 failed flaps 2010 – unilateral cases mean LOS 6.2 days median LOS 5 days 2015 – mean LOS 4.7 days median LOS 4 days
Autologous reconstruction
DIEP flap – enhanced recovery
The Royal Marsden
TUG/TMG Thomas Schoeller - Austria selected patients simple technique
secondary flaps
autologous reconstruction
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contralateral breast reduction / mastopexy / augmentation
nipple reconstruction
nipple-areolar tattooing
donor site adjustment
liposuction
fat transfer
ADMs
Additional procedures
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increasing demand and increasing drive for perfection implants are not life long “process of care” ‘Autologous reconstruction’ is cheaper funding of adjustment procedures: - ? NHS - PMIs
Financial issues
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Learning points
Familiarity of techniques (concepts) available
Understanding the patient journey & multi-modality
treatments
Hot topics:
timing of radiotherapy
bilateral surgery
ALCL
The Royal Marsden
radiotherapy is detrimental to all types of breast reconstruction increases capsular contracture rate (~50% in 5 years) flap fibrosis and volume loss progressive (increased survival) options to mitigate effects: refine fields – IMRT temporising implants to preserve skin (delayed-immediate)
skin preservation, timing & radiotherapy Timing of radiotherapy
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PRADA trial Primary Radiotherapy And DIEP flAp reconstruction Standard – Surgery / CT / RT or NeoCT / Surgery / RT Proposed – NeoCT / RT/ Surgery Mitigate radiation damage to DIEP flap reconstruction and improve long term reconstructive outcome Outcome - oncological & reconstructive - PROMS - 3D photography - Translational study
Timing of radiotherapy
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greater awareness of genetic mutation - BRCA 1, 2 and others Angelina Jolie effect increasing requests for contralateral risk-reduction surgery complex decision making process - genetics - actuarial risk - aesthetic outcome (implants) ?? long term implications
Bilateral surgery
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Recently recognised condition - Breast Implant related - Anaplastic Large Cell Lymphoma (BI-ALCL) Presents as an acute swelling several years after implant insertion Very rare – probably 250 – 300 cases worldwide so far but under reported and recognised, 8 deaths. 1 in 400,000 breast implants 13 cases in UK 29 in France – ANSM (French Regulator) – statement last week
ALCL
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Linked to textured implants - ? Allergan (salt-loss) - biofilm Treated with removal and excision of capsule, some cases require chemotherapy BAPRAS, BAAPS, ABS & MHRA joint statement RMH – collating UK data Mail on Sunday 24th July running as a feature article
ALCL
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multi-disciplinary approach is essential wide surgical armamentarium (craft specialty) ‘breast reconstructive process’ – not operation critical to have awareness of the (developing) techniques increasing autologous (higher quality) reconstruction financial issues
Summary
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Post-mastectomy breast reconstruction – Clinical Review
BMJ 2013 Oct 15:347:f5903
Email: [email protected]
Summary
