Minimally Invasive Breast Surgery

Joint Hospital Grand Round

Luk Wai Yin Sally

NDH/AHNH

British Medical Journal

Editorials

• Minimally invasive surgery for breast cancer– May be trading better cosmetic outcomes for worse

rates of cure

– Monica MorrowBMJ Feb 2009 338: b557

Minimally invasive surgery for breast cancer

• Why ?

• What ?

• How?

Why minimally invasive?• Breast Cancer

– Prevalence• Most common female cancer in HK• Cumulative life risk 1/22

– Screening• Worldwide, women aged > 40 1

• Allow detection of small/early breast cancer

• Medical advancement– Better understanding of the pathophysiology and the necessity

of local control of breast CA with its risk of local recurrence– Neoadjuvant/ adjuvant treatment– Improvement in surgical techniques and instruments

• Patient demand

What is it?• No definition

– Breast conserving surgery, sentinal lymph node bx– Oncoplastic breast surgery– Endoscopic breast surgery& axillary surgery

• Goals:Oncological clearance

Morbidity Aesthetic outcome

How to achieve?

Axillary SurgeryLevel II axillary dissection

Breast Conserving Therapy

Oncoplastic Breast Surgery

Endoscopic assisted breast surgery

Sentinel lymph node biopsy

Endoscopic SLNB/ AD

Breast SurgeryModified Radical Mastectomy

Breast Conserving Therapy

• Wide local excision (WLE) with postoperative adjuvant radiotherapy1

• Oncological principle for WLE:– Relative risk of local recurrence was shown to be directly

related to completeness of excision

– Local recurrence direct impact on long-term survival

– Aim: ideally a clear rim of normal tissue around the carcinoma in all direction

– at least microscopically disease-free margin

• In practice, 1cm macroscopic margin of normal tissue

1 NIH Consensus Conference Treatment of early stage breast cancerJAMA 1991:265:391-5

Breast Conversing Surgery• Equivalent outcome to that of mastectomy in early breast cancer

– Effect of radiotherapy and surgery in early bresat cancer: an overview of the randomize trial; Early Breast Cancer Trialists’ Collaborative Group N Engl J Med 1995;333:1444-55

– Breast conserving therapy versus mastectomy in early stage breast cancer: a metaanalysis of 10 year survival; Morris etal Cancer J sci Am 1997;3:6-12

• Long term Oncological safety – Twenty-year follow-up of a randomized trial comparing total mastectomy,lumpectomy and

lumpectomy plus irradiation of the treatment of invasive breast cancer Fisher B et al N Eng J med 2002;347:1233 -41

– Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer Veronesi U et al N Eng J med 2002; 347:1227

• Better cosmetic appearance in majority of women– Cosmetic assessment of breast-conserving surgery for primary breast cancer.

Sharif K et al Breast 1999;8:162-8 review of level II evidence

• Lower levels of psychological morbidity with improved body image, sexuality and self-esteem, compare to mastectomy

– Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction Al-Ghazal SK et al. Eur J Cancer 2000;36:1938-43

Comestic failure after BCT

• 23 - 50% dissatified with the appearance after BCT• A body image scale for us with cancer patient Hopwood P Eur J

Cancer 2001:37:189 -97

• Cosmetic evaluation of breast conserving treatment for mammary cancer Van limbergen E Radiother Oncol 1989;16:159-67

• Factors affecting comestic outcome– Volume loss >20%1

– Tumor location: central, medial, inferior

– Nipple areola displacement/ distortion

– Inappropriate incision/poor surgical technique

– Effect of Radiotherapy 1 Cosmesis and satisfaction after BCS correlates to the precentage of breast

volume excised Cochrane R et al. Br J Surg 2003 90:1505-1509

Oncoplastic Breast Surgery (OBS)• Definition?

– Seamless joining of extirpative and reconstructive breast surgery performed by a single surgeon 1

– Thorough tumor resection plus reconstruction of resection defect

• Principle of OBSi) Oncological principle of resection to achieve wide tumor-free

marginsii) Principle of plastic reconstruction to optimize cosmetic

outcomes and minimize complication

1 Oncoplastic breast surgery: A Global Perspective on Practice, Availability, and training Peter L Malycha et al; World J Surg 2008 32:2570 -2577

Reconstruction Principle

• Volume displacement

Recruiting and transposing local dermoglandular flaps into the resection site

– breast-flap advancement

– Mammaplasty• Superior pedicle

• inferior pedicle

– Centralization of NAC complex

– +/- Contralateral surgery (reduction mammoplasty)

• Volume replacement

Importing volume from elsewhere to replace the amount of tissue resected

– Autologous• LD flap

• TRAM flap

– Implants

Reconstruction Principle

• Volume replacement– Autologous

• Volume displacement

Picture adopted from Surgical insight: oncoplastic breast-conserving reconstruction; Rainsbury;

Factors Volume displacement Volume replacement

Breast size Medium or large Small or medium

Tumor position Central or lower pole Any site

Scars Bilateral breast Breast + back

Theater time 1-2hr 2-3 hr

Complications Flap ischaemia

Fat necrosis

Donor site morbidity

Flap loss

Factors influencing technique chosen

Mastopexy lumpectomy

• Proponent– Potential oncological benefit to

enable very wide excision of breast tissue without risking major local deformity1,2

– Extend the scope of BCS to include patients with 3-5 cm tumors, without compromising the adequacy of resection or the cosmetic outcome

– Overall better cosmetic outcome

• Opponent– Oncological safety of the

techniques is not being evaluated properly

– Potential cosmetic failure and complication

– Extra resources and extended operation time

– Negative impact on the adjuvant treatment

1 Oncoplastic techniques allow extensive resections for BCT of Breast cancinoma Krishna B Clough at el. Ann Surg 2003 Jan;237(1)26-342 Lumpectomy ws oncoplastic surgery for BCT of cancer. A prospective study of 99 patient Ann Chir 2006 Apr:131(4):256-61.

Any clinical evidence ?

• Evaluation of oncological safety

• cosmetic outcome

• Potential complications/pitfall

• Expertises/Guidelines

Review of outcomes of OBSVolume displacement

Volume replacement

No of studies 11 7

Total no of patient 433 189

Median follow-up (m) 21-54 24-53

Local recurrence(%) 0-7 0-5

Cosmetic failure (%) 0-18 0-9

Review: Oncoplastic breast-conserving reconstruction – indication,benefits,choices and outcomes(from 1 Jan 1980 to 31Jan 2007) Rainsbury Nat clinical pract onoclogy Nov 2007 4:11657-664

Study design: case-control cohort studies from Sept 1994- December 1999No of subject: 148 (10-108)Median follow up: 74 monthsOncoplastic procedure:volume displacement for small defect and volume replacement for large defectConcomitant contralateral breast mammaplastyResults:Local recurrence: 3%; distant metastasis 13%; Mortality 7.53%Conclusions: Long term oncological outcomes are comparable with result of BCT in RCT

Conclusion• emerging level II evidence for the short

time oncological safety for OBS with good cosmetic outcomes

• Published guideline Oncoplastic breast surgery – A guide to good practice

Association of breast surgery at BASO; Association of breast surgery at BQPRAS and the training Interface group in Breast Surgery

Royal college of Surgeons EJSO 33(2007) S1-S23

Endoscopic Breast Reconstruction?

Endoscopic Breast Surgery?

Endoscopic breast reconstruction

• Endoscopic assisted techniques– Harvest more bulky myosubcutaneous flap

• BassLS et al Endoscopic harvest of the rectus abdominus free flap An Plast Surg 1995:34:274-9

– Endoscopic dissection• Endoscopic techniques in aesthetic breast Surgery Clin Plast Surg

1995:22:683-95

– Balloon dissection technique• Van Buskark Er et al. Endoscopic harvest of the lastissimus doris muscle

using balloon dissection technique Plast Reconstr Surg 1997:99:899-903

• Laparoscopic mobilization of greater omentum for breast reconstruction– NICE guideline support its use under normal clinical arrangement

Oct 2007

Laparoscopic mobilization of greater omentum for breast reconstruction

Endoscopic Breast Surgery

• NICE overview for endoscopic mastectomy and wide local excision for breast cancer NHS April 2009

– One non randomize trial

– eight case series (mainly from Japan and Korea)

– Total no of patients: 809

• Conclusion:– Current evidence on the safety and efficacy of endoscopic

mastectomy and wide local excision for breast cancer is inadequate in quantity

– Only used in the context of research

Summary

• The goals of minimally invasive surgery for breast cancer is to improve aesthetic outcome without comprising oncological clearance

• The early results suggest Oncoplastic breast surgery has a promising future in management of breast cancer

• Anticipated maturation of endoscopic technique in assisting breast reconstruction and breast exicion

• We should try out BEST to treat our patient’s BREAST

Thank You