“conservative mastectomy” the nipple sparing tecnique alberto luini senology division european...
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“Conservative mastectomy”the nipple sparing tecnique
Alberto LuiniSenology Division
European instiute of Oncology-Milan
Milan Conservation Programme (1970-
2010)
Phase 1 -
Phase 2 -
Phase 3 -
Phase 4 -
Conservation of the breast
Conservation of axillary nodes
Partial intraoperative radiotherapy (ELIOT)
Conservative mastectomy+ELIOT
Improvement in diagnosis (ultrasonography, MRI)
total mastectomies
EIO 2000 200523% 28%
A.Luini
Timing of Reconstruction
- Always immediate
- Delayed only if:
- Locally advanced disease
- Concomitant diseasesA.Luini
SSM + immediate reconstruction with prosthesis or expander is nowadays the standard treatment, except for:- Inflammatory cancer- Locally advanced disease- Poor general conditions
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Skin Sparing Mastectomy + immediate reconstruction with prosthesis
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Immediate reconstruction does not affect the prognosis
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677 Total mastectomies + adjuvant treatment (no RT)
518 immediate rec. 159 no rec.
(76.5%) (23.5%)
Median follow up 70 months
(range 13-144) A. Luini
Multivariate analysis (median f.u. 70 m.)
(518 immediate reconstructions vs 159 without reconstruction)
Petit JY et al, Breast Cancer Res Treat, 2008 A. Luini
Immediate reconstruction:Immediate reconstruction:
The Nipple Sparing The Nipple Sparing ApproachApproach
EIO NSM 84%
of the mastectomies
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IndicationsIndications
Multifocal/multicentric cancer Multifocal/multicentric cancer
Extensive microcalcifications Extensive microcalcifications
Contraindications or refusal to Contraindications or refusal to primary medical treatmentprimary medical treatment
Negative retroareolar frozen Negative retroareolar frozen sectionsection
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ContraindicationsContraindications
Involvement of the central Involvement of the central quadrantquadrant
Paget’s disease Paget’s disease
Pathological nipple dischargePathological nipple discharge
Microcalcifications close to the Microcalcifications close to the nipplenipple
Previous radiotherapy Previous radiotherapy A. Luini
AdvantagesAdvantages Oncologic radicality: skin removal Oncologic radicality: skin removal
as a quadrantectomy and of the as a quadrantectomy and of the whole glandular tissue (except a whole glandular tissue (except a thin retroareolar portion)thin retroareolar portion)
Intraoperative radiotherapy on Intraoperative radiotherapy on the nipple areola complex (16Gy)the nipple areola complex (16Gy)
Immediate reconstruction with a Immediate reconstruction with a good cosmetic result (very good cosmetic result (very similar to a “good” similar to a “good” quadrantectomy)quadrantectomy) A. Luini
a layer of glandular a layer of glandular tissue should be tissue should be left beneath the left beneath the NAC NAC to avoid NAC necrosis
Subcutaneous mastectomy
a fifty year old technique !
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Surgical technique
a) Conservation of the retroareolar glandular tissue
b) Conservation of the retroareolar subcutaneous vascular plexus
Surgical technique
a) Sterile LINAC collimator
c) Lead and alluminium protective disc
d) Pectoralis major muscle
ELIOT ELIOT (16 Gy)(16 Gy)
Nipple Sparing Mastectomy
on the remaining glandular tissue to complete the cancer treatment
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Nipple-sparing mastectomy
Irradiated area
Irradiated area A. Luini
NSM + prosthesis + contralateral breast
augmentation
2 weeks 5 monthsA. Luini
Type of reconstruction
Anatomic prosthesis 68%
Expanders 19%
Round prosthesis 5%
TRAM 8%A. Luini
Nipple Sparing Mastectomy
Definitive prostheses 73%
Immediate left reconstruction with implant
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Nipple Sparing Mastectomy
Expanders 19%
Two-step implant reconstruction A. Luini
Nipple Sparing Mastectomy
TRAM 8%
Immediate pedicled TRAM reconstruction
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RESULTS
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1060 NSM in 1023 patients
37 bilateral ( March 2002 - March 2007) infiltrating : 63% in situ : 37% infiltrating : 63% in situ : 37%
despite frozen section negative…
86 final histology positive (8%)
(70 in situ, 16 invasive)43 NAC removed (local anesth.)
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Complications (1060 NSM)
Immediate
NAC necrosis 8.8%
Infections 2.0%
Delayed
Capsular contracture15%
Radiodystrophy 7.5%A. Luini
NAC necrosis
Partial 58 (5%) Total 26 (3,8%)
Secondary reconstructio
n A.Luini
NAC necrosis
Spontaneous healing with a TRAM
Infections
21 cases 2%
42 prostheses removed 4%
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Capsular contracture
157 capsulotomies 15%
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ELIOT ELIOT (16 Gy)(16 Gy)
nipple sparing mastectomy
But … 206 cases received a delayed radiotherapy the day after surgery
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Prosthesis removal
2,815,56
0
1
2
3
4
5
6
Eliot Del. Radiotherapy
p = 0.0829 A. Luini
Capsular contracture
5,22 7,78
0
1
2
3
4
5
6
7
8
Eliot Del. Radiotherapy
p = 0.3179 A. Luini
Cosmetic results
minimum follow up 1 year, scale 0 - 10
Good result (score 7-10)
Patient evaluation
82.3%
Surgeon evaluation 84.8%A. Luini
NAC sensibility
At one year, scale 0 - 10
score 0-3 48.0%
score 4-6 32.8%
score 7-10 18.8%
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Fig.1 Did you find it difficult to look at your self naked? Fig.2 Do you find it difficult being seen naked by your partner?
Do you feel your body less whole (disabled) as a result of the surgery? Quanto si è sentita mutilata come conseguenza dell’intervento?
1060 NSM in 1023 patientsInvasive carcinoma 63%In situ carcinoma 37%
ONCOLOGICAL RESULTS MEDIUM FOLLOW UP 20 MONTHS (RANGE 1-
70)
EVENTS
Local recurrenceLocal recurrence 13 (1.2%)13 (1.2%)
Distant metastasesDistant metastases 36 36 (3.5%) (3.5%)
DeathsDeaths 3 (0.3%) 3 (0.3%)
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Local recurrences
13 cases (1.2 %)
All distant from the NAC
(10 tumor bed, 3 upper quadrant)
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Nipple sparing mastectomy with intraoperative
radiotherapy is a safe procedure to reduce the
psychological trauma due to mastectomy in selected
cases
Conclusion
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