Minimally Invasive Breast SurgeryJoint Hospital Grand RoundLuk Wai Yin SallyNDH/AHNH

British Medical Journal EditorialsMinimally invasive surgery for breast cancerMay be trading better cosmetic outcomes for worse rates of cure

Monica Morrow BMJ Feb 2009 338: b557

Minimally invasive surgery for breast cancerWhy ?

What ?

How?

Why minimally invasive?Breast CancerPrevalenceMost common female cancer in HKCumulative life risk 1/22 ScreeningWorldwide, women aged > 40 1Allow detection of small/early breast cancerMedical advancementBetter understanding of the pathophysiology and the necessity of local control of breast CA with its risk of local recurrenceNeoadjuvant/ adjuvant treatmentImprovement in surgical techniques and instrumentsPatient demand

What is it?No definitionBreast conserving surgery, sentinal lymph node bxOncoplastic breast surgeryEndoscopic breast surgery& axillary surgeryGoals:

Oncological clearanceMorbidityAesthetic outcome

How to achieve? Axillary SurgeryLevel II axillary dissectionBreast Conserving Therapy Oncoplastic Breast SurgeryEndoscopic assisted breast surgerySentinel lymph node biopsyEndoscopic SLNB/ ADBreast SurgeryModified Radical Mastectomy

Breast Conserving TherapyWide local excision (WLE) with postoperative adjuvant radiotherapy1Oncological principle for WLE:Relative risk of local recurrence was shown to be directly related to completeness of excisionLocal recurrence direct impact on long-term survivalAim: ideally a clear rim of normal tissue around the carcinoma in all direction at least microscopically disease-free marginIn practice, 1cm macroscopic margin of normal tissue

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

Breast Conversing SurgeryEquivalent outcome to that of mastectomy in early breast cancerEffect 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;333:1444-55Breast 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 -41Twenty-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 womenCosmetic 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 mastectomyComparison 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 BCT23 - 50% dissatified with the appearance after BCTA body image scale for us with cancer patient Hopwood P Eur J Cancer 2001:37:189 -97Cosmetic evaluation of breast conserving treatment for mammary cancer Van limbergen E Radiother Oncol 1989;16:159-67Factors affecting comestic outcomeVolume loss >20%1 Tumor location: central, medial, inferiorNipple areola displacement/ distortion Inappropriate incision/poor surgical techniqueEffect 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 1Thorough tumor resection plus reconstruction of resection defectPrinciple of OBSOncological principle of resection to achieve wide tumor-free marginsPrinciple 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 PrincipleVolume displacementRecruiting and transposing local dermoglandular flaps into the resection site

breast-flap advancementMammaplastySuperior pedicleinferior pedicleCentralization of NAC complex+/- Contralateral surgery (reduction mammoplasty)Volume replacementImporting volume from elsewhere to replace the amount of tissue resected

AutologousLD flapTRAM flapImplants

Reconstruction PrincipleVolume replacementAutologousVolume displacementPicture adopted from Surgical insight: oncoplastic breast-conserving reconstruction; Rainsbury;

Factors influencing technique chosen

FactorsVolume displacementVolume replacementBreast sizeMedium or largeSmall or mediumTumor positionCentral or lower poleAny siteScarsBilateral breastBreast + backTheater time1-2hr2-3 hrComplicationsFlap ischaemiaFat necrosisDonor site morbidityFlap loss

Mastopexy lumpectomy

ProponentPotential oncological benefit to enable very wide excision of breast tissue without risking major local deformity1,2Extend the scope of BCS to include patients with 3-5 cm tumors, without compromising the adequacy of resection or the cosmetic outcomeOverall better cosmetic outcomeOpponentOncological safety of the techniques is not being evaluated properlyPotential cosmetic failure and complication Extra resources and extended operation timeNegative 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 safetycosmetic outcomePotential complications/pitfallExpertises/Guidelines

Review of outcomes of OBSReview: 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

Volume displacementVolume replacementNo of studies117Total no of patient433189Median follow-up (m)21-5424-53Local recurrence(%)0-70-5Cosmetic failure (%)0-180-9

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

Conclusionemerging level II evidence for the short time oncological safety for OBS with good cosmetic outcomesPublished guideline Oncoplastic breast surgery A guide to good practiceAssociation 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 reconstructionEndoscopic assisted techniquesHarvest more bulky myosubcutaneous flapBassLS et al Endoscopic harvest of the rectus abdominus free flap An Plast Surg 1995:34:274-9Endoscopic dissectionEndoscopic techniques in aesthetic breast Surgery Clin Plast Surg 1995:22:683-95Balloon dissection techniqueVan 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 reconstructionNICE guideline support its use under normal clinical arrangementOct 2007

Laparoscopic mobilization of greater omentum for breast reconstruction

Endoscopic Breast SurgeryNICE overview for endoscopic mastectomy and wide local excision for breast cancer NHS April 2009One non randomize trialeight case series (mainly from Japan and Korea)Total no of patients: 809Conclusion:Current evidence on the safety and efficacy of endoscopic mastectomy and wide local excision for breast cancer is inadequate in quantityOnly used in the context of research

SummaryThe goals of minimally invasive surgery for breast cancer is to improve aesthetic outcome without comprising oncological clearanceThe early results suggest Oncoplastic breast surgery has a promising future in management of breast cancerAnticipated maturation of endoscopic technique in assisting breast reconstruction and breast exicion

We should try out BEST to treat our patients BREAST

Thank You

*Good morning ladies and gentlemen. Today, Its my pleasure to present to you the topics of MIBS.MIBS is a very broad and new concept, encompassing the all the new techniques used in current breast surgeryfrom the use of mammotome of breast bx, percutanoeous treatment of benign breast lesion to the management of breast cancer*Early this year, there was a publish in BMJ Online Editorials made by one of the Renowned breast surgeon in the states, Monica morrow She expressed concerns in the editorial online in Feb this year as she worries as these new concepts may jeopardize our patient survival What she said was something is technically possible is it necessarily appropriateThis Stirred up hot disscusion and debate among the breast surgeonAnd therefore, I am going to focus my discussion on this new concept

*Why we need to talk about minimally invasive?What is the definition and what are its goals ?How could we achieve these goals and are there any evidence to support our practice?*Even there is no population wide screening in hk, more people aware of *Nowadays, surgical management of breast cancer would be consisted of two main pillarsNamely breast surgery and axillaryHow could we achieved in a more minimally invasive way?*How wide is wide? This comes to the oncological principle for WLE; most of studies revealed that the RR of LR was directly related to completeness of excisionthere are quite a no of studies addressing this issue; though the extend of local excision remains a controversial issue ; * in the past few decades or so, BCS evolved from a radical idea to well accepted approach in management of early breast cancer*The amount of tissue excised during BCS has a significant impact on LR and Cosmetic outcomeOncologically, the wider the resection, the better the chance of clearanceFrom cosmetic pt of view, the extent of excision would increases the risk local deformitySo, Could we minimize the risk of unacceptable deformity without compromising oncological clearance?*Not well defined term.Common underlying principleSeemingly, its just add on together to gain the synergistic effect*By no means exhaustive*The data for the review was compiled by searching the pubmed and MEDLIND databases for articles published betweenApartment of the length of FU is relatively short ~3yrs, the reported rates of local recurrence and cosmetic failure are within acceptable limits when comparing with conventional BCSemerging level II evidence for the short time oncological safety without comprising cosmetic outcomes.*But this is not the end of story, we surgeons are those people with curiosity. We have extensive use of laparoscopy in MIS of abd, so could we applied it to the breast surgery*Mainly extending the volume replacement techniqueCases series showing the success of mobilization of myosubcutaneous flap via small axillary incisionThe following are some example techniques, to name but a few; With the use of laparoscopy,

*National institute for health and clinical excellence