• A standard surgical procedure for breast cancer

• The aims of breast reconstruction after partial mastectomy

are achieving the oncologic safety as well as good cosmetic

outcomes.

]

]

]

]

Partial mastectomy

with reconstruction

Breast conserving

surgery

Mastectomy with

reconstructionMastectomy

OPSOPS

• Local recurrence

- Clear resection margins

- Not to miss separate nodules of breast cancer

• Regional recurrence

- Targeted axillary LNs resection

- Not to miss metastatic LNs

• Distant metastasis

- Distinguish the Subtypes

- Appropriate systemic treatment

• Death

Controllable by Surgery

• Cancer surveillance: 5-10 years

Need to go back to Social daily life

• Higher quality of life

- No recurrence / metastasis

- No pain

- Healthy psychosocial function

Fredholm H, et al. BCRT 2016;160:131-43.

Primary closure

Combination of two flapsLDMCF + Implant insertionTRAM flapImplant insertion technique

Adipo-fascial flapLateral thoracodorsal flapThoracoepigastric flapICAP flapTDAP flap LD flap

VR

Glandular flap

Purse-string suture

Round block technique

Batwing mastopexy

Tennis racket method

Rotation flap

Reduction mammoplasty

VD

Cruz LDL, et al. Ann Surg Oncol 2016;23:3247-58.

Study (year) No. of cases (n)Follow-up(months)

Overall Survival (%)

Disease-free survival (%)

Local recurrence (%)

Distant recurrence (%)

<3 years

Spear (2002) 11 24 90.9 90.9 0 9.1

Newman (2001) 28 23.8 96.4 92.9 0 7.1

Huemer (2006) 32 33.8 100 93.8 0 6.3

Meretoja (2010) 90 26 98.9 96.7 0 3.3

El-Marakby (2011) 50 33.9 0 94 4 2

Kim (2012) 33 24.5 100 100 0 0

Kaviani (2013) 240 26 99.2 93.8 2.9 3.3

Weighted average 98.5 93.4 1.7 3.8

Cruz LDL, et al. Ann Surg Oncol 2016;23:3247-58.

Study (year) No. of cases (n)Follow-up(months)

Overall Survival (%)

Disease-free survival (%)

Local recurrence (%)

Distant recurrence (%)

3-5 years

Clough (2001) 101 46 95.8 75.2 6.9 17.8

Fitoussi (2009) 540 49 92.9 87.9 - -

Hernanz (2011) 41 58 99.9 82.9 2.4 14.6

Grubnik (2012) 251 50 96.4 94.6 3.6 1.2

Aljarrah (2012) 54 45 98.1 96.3 0 3.7

Semprini (2013) 489 40 - - 0.6 -

Mazouni (2013) 45 46 96.2 92.7 4.4 15.6

Weighted average - - 95.3 89 2.5 7.1

Cruz LDL, et al. Ann Surg Oncol 2016;23:3247-58.

Study (year) No. of cases (n)Follow-up(months)

Overall Survival (%)

Disease-free survival (%)

Local recurrence (%)

Distant recurrence (%)

>5 years

Caruso (2008) 63 68 92.1 98.4 1.6 -

Caruso (2011) 52 72.6 98 98 1.9 1.9

Emiroglu (2015) 82 121 82.9 72 6.1 20.7

Lorenzi (2015) 454 86.4 95.9 83.7 7.5 9.9

Rietjens (2007) 148 74 92.6 92.6 3.4 12.8

Weighted average - - 93.4 85.4 6 11.9

Asgeirsson KS, et al. EJSO 2005;31:817-23. Review.

• Different methods of parenchymal redistribution have been

described to fill small or moderate defects in the breast.

• To fill the defect of breast

- advancement

- rotation

- transposition

Lee J, et al. Clin Breast Ca 2017;1:70-5.

Variable Partial mastectomy (n = 158)

Mean Follow-Up Duration (± SD, Months) 60.8 ± 20.02

Mean Disease-Free Interval (± SD, Months) 56.5 ± 19.87

Locoregional Recurrence (n, %) 3 (1.9)

Ipsilateral breast parenchyma 2 (1.3)

Ipsilateral axillary lymph node 1 (0.6)

Distant Metastasis (n, %) 4 (2.5)

Death (n, %) 1 (0.6)

Bramhall RJ, et al. Gland Surg 2017;6:689-97.

Oncologic events (n, %) n=57

Median follow-up duration (years) 5

Local recurrence 2 (3.5)

Distant metastasis 5 (8.8)

Death 1 (1.8)

• Detailed surgical techniques of mammoplasty

- Lateral mammoplasty

- Superior pedicle/Inferior pedicle

- J mammoplasty

- LIQ-V mammoplasty

- Inverted T or vertical scar

- mammoplasty with NAC resection

• 350 cases of reduction mammoplasty

• Local recurrence rate : 2.2 %

Regional recurrence rate : 1.1 %

Distant metastasis rate : 12.4 %

Piper ML, et al. Ann Plast Surg 2016;76:S222-6.

Reference CasesMean/Median Follow-up

(mo) StagesLocoRegional

Recurrence (%)Distant

Recurrence (%)

Caruso, et al 63 68 I-III 1.6 9.8

Caruso, et al 52 72.6 0-IIIB 1.9 2

Chang, et al 85 39 0-IV 2.3 2.3

Clough, et al 175 49 - 1.7 6.3

Eaton, et al 86 54 0-III 7 1.2

Grubnik, et al 251 50 - 2.4 1.2

Gulcelik, et al 106 33 I-III 0.9 -

Imahiyerobo, et al 64 34.6 0-III 7.8 3.1

Losken, et al 63 40 0-III 3.2 -

Munhoz, et al 106 47 - 6.6 -

• Female, 40

• Lt breast focal microcalcification

• Married, two children

• Family history – mother: breast cancer at her 50’s

• BRCA 1/2 mutation: negative

Stereotactic VABB site

• Breast, left ca +, needle biopsy:

- Ductal carcinoma in situ, Van-Nuys group 3.

- Microcalcification

• Breast, left ca -, needle biopsy:

- Stromal fibrosis, consistent with fibrocystic change.

- No microcalcification.

There was no specific finding in breast ultrasonography.

1) Make a schedule of surgery (without breast MR)

2) Perform breast MR

10cm

1) Breast conserving surgery

2) Reduction mammoplasty

3) Partial mastectomy + LD flap

4) Nipple sparing mastectomy + implant

5) Skin sparing mastectomy + implant

6) Mastectomy

• I will remove or perform…

1) Remove nipple only (without frozen Bx)

2) Remove nipple, when frozen Bx shows positive

3) Remove NAC (without frozen Bx)

4) Remove NAC, when frozen Bx shows positive

5) Radiation only

• Sup / Sup-med margin: No tumor present

• Inf margin: Ductal carcinoma in situ

• Med / Inf-lat margin: Atypical ductal hyperplasia

• Lateral margin: Ductal carcinoma in situ

Sup 2 / Inf 2 / Med 2/ Lat 2 / Sup-Med 2 / Inf-Med 2: No tumor present

• Breast, left, partial mastectomy:

Ductal carcinoma in situ, Van-Nuys group 3,

(size: 5.0x3.5 cm)

with 1) no lymphovascular invasion.

2) no involvement of nipple.

3) clear surgical resection margins.

4) microcalcification in intratumoral stroma.

– Nipple : atypical lesions

Asgeirsson KS, et al. EJSO 2005;31:817-23. Review.Noguchi M, et al. EJSO 2016;42:926-34. Review.

• Volume displacement techniques use breast tissue and

parenchyma to reshape the breast, whereas volume

replacement techniques are external autologous tissue flaps.

• It is most appropriate for patients with small-to-medium sized

breasts, who cannot afford to lose the volume associated with

volume displacement techniques, or who wish to avoid

contralateral surgery.

Asgeirsson KS, et al. EJSO 2005;31:817-23. Review.

• Adjacent tissue flap

- lateral thoracodorsal (LTD) flap

- intercostal artery perforator (ICAP) flap

- thoracodorsal artery perforator (TDAP) flap

- thoraco-epigastric (TE) flap

• Distant tissue flap- deep inferior epigastric perforators (DIEP) flap

- latissimus dorsi (LD) myocutaneous flap

- transversus rectus abdominis myocutaneous (TRAM) flap

Lee J, et al. Surg Oncol 2015;24:35-40.

Variable Partial mastectomy (n = 72)

Mean Follow-Up Duration (± SD, Months) 40.9 ± 18.68

Mean Disease-Free Interval (± SD, Months) 39.7 ± 18.36

Locoregional Recurrence (n, %) 2 (2.8)

Ipsilateral breast parenchyma 1 (1.4)

Ipsilateral axillary lymph node 1 (1.4)

Distant Metastasis (n, %) 4 (5.6)

Death (n, %) 0

Lee J, et al. Surg Oncol 2015;24:35-40.

Reference n Technique Mean duration of FU (months)

Locoregionalrecurrence

(%)

Distantmetastasis

(%)

Ohuchi N et al. (1997)

66 Lateral tissue flapLatissimus dorsi flap

48 4 -

Rainsbury RM et al. (1998)

62 Latissimus dorsi mini flap 43 8 -

Petit JY et al. (2008)

32 Latissimus dorsi flap with implantTransversus rectus abdominis myocutaneous flap

70 3.3 13.9

Min SY et al. (2010) 120 Latissimus dorsi myocutaneous flap 39.2 3.3 4.2

El-Marakby HH et al. (2011)

50 Latissimus dorsi myocutaneous flap 33 4 2

Hamdi M. (2013) 90 Thoracodorsal artery perforator flapLateral/Anterior intercostal artery perforator flapSuperior epigastric artery perforator flap

48 1.7 -

• Simple mastectomy

• Modified radical mastectomy

• Nipple sparing mastectomy

• Skin sparing mastectomy

Oncoplastic surgery

• Preserving of Nipple-areolar complex (NAC) is important in aesthetic

outcomes after breast surgery.

• Local recurrence after NSM

1) breast ductal tissue could be remained behind the NAC

2) breast tissue could be remained on skin flaps

3) periphery of the breast is poorly exposed.

Smith BL, et al. J Am Coll Surg 2017;225:361-5.

In 575 therapeutic NSM with negative nipple margins (including those nipple

margins with atypia or LCIS), there were no recurrences at the nipple/NAC

site, but there were 6 (1%) chest wall recurrences separate from the NAC.

Median follow-up of 2,182 NSM 51 mo [range 4 - 101]

Location of recurrence, n (%)

Nipple areola complex 0 (0)

Chest wall only 4 (1.3)

Chest wall + axilla 2 (0.6)

Chest wall + distant 1 (0.3)

Axilla only 3 (1.0)

Axilla + distant 1 (0.3)

Distant only 6 (2.0)

Total locoregional recurrence, n (%) 11 (3.7)

Total distant recurrence, n (%) 8 (2.7)

N (%)

Locoregional breast recurrence 8 (2.2)

Breast

Axilla

Isolated distant metastases 9 (2.4)

Concurrent local and distant recurrence 6 (1.6)

Breast and distant recurrence 2

Axillary and distant recurrence 4

Overall 23 (6.3)

• Skin-sparing mastectomy (SSM) the surgeon removes the gland but leaves

most of the breast skin to create a pocket that is filled with a breast

implant or the patient's own tissue.

• Nipple sparing mastectomy (NSM) is the real conservative innovation in

that the nipple-areola complex is preserved as well as the skin.

• NSM was significantly better than SSM for body image, satisfaction with

nipple appearance, satisfaction with nipple sensitivity, and feeling of

mutilation.

Galimberti V, et al. Breast 2017;34 Suppl1:S82-4.

• May be really nipple or may be subareolar remained tissues

• Female, 38

• Rt breast microcalcification

breast nodule : Bx – Invasive ductal carcinoma

• Unmarried

• BRCA 1/2 - wild type

2.7cm

• Breast, right, mastectomy:

Invasive ductal carcinoma, grade2, (x2), (size: #1: 0.8cm, #2: 0.6cm)

with 1) extended background ductal carcinoma in situ, Van-Nuys group 3 .

(total extension size: 2.7x1.6 cm)

2) no lymphovascular invasion.

3) no involvement of skin.

4) clear surgical resection margins.

(0.2 cm from closest posterior and anterior resection margin)

5) extensive intraductal component (60 %).

6) microcalcification in ductal carcinoma in situ.

• Lymph node, axilla, right, sentinel lymph node biopsy:

No tumor. (0/11)

[ sentinel, frozen (0/3), non-sentinel, frozen (0/1), axilla (0/7) ]

Breast, right, excisional biopsy:

- Ductal carcinoma in situ, Van-Nuys group 2, multifocal. (up to 0.1 cm)

- Microcalcification.

Refer to multidisciplinary clinic

- Remove NAC

- No radiation

Breast, nipple-areolar complex, excision:

- No residual ductal carcinoma in situ,

(Status post excisional biopsy for ductal carcinoma in situ of breast)

- Chronic inflammation with foreign body reaction, procedure-related.

- Microcalcification

Breast, right, areolar skin, biopsy:

Chronic inflammation

with 1) focal active inflammation.

2) eosinophils.

3) perivascular lymphocytic infiltration.

No tumor present.

• Female, 61

• Rt LOQ microcalcification

MMG-guided excision Bx – Ductal carcinoma in situ

Wide excision [2019-1-28]: DCIS, lateral margin (+)

• Married

• Postmenopause

Wide excision [2019-1-28]

- DCIS, lateral margin (+)

• Sup / Med /Lat / Sup-Lat / Inf-Med: No tumor present

• Inf-Lat margin (1) (2) (3) (4) : Ductal carcinoma in situ

1) Frozen biopsy once again

2) Finish the surgery ( RT)

3) Mastectomy

4) Partial mastectomy + other flap

5) Nipple sparing mastectomy + implant

• Breast, right, wide excision:

- Ductal carcinoma in situ, Van-Nuys group 3, residual (size: 0.5x0.4 cm)

with 1) no lymphovascular invasion.

2) no involvement of skin.

- Fat necrosis with foreign body reaction, procedure-related.

• Infero-lateral margin 2": DCIS, 0.2cm

• Infero-lateral margin 3": DCIS, 0.2cm

• Iinfero-lateral margin 4": DCIS, multifocal, upto 0.5cm

• Breast, right, Nipple sparing mastectomy:

- Ductal carcinoma in situ, Van-Nuys group 2, residual (size: 0.3x0.2 cm)

• To improve the Oncologic safety of OPS

- Discuss with other physicians to predict the accurate ranges

- Obtain negative margin from breast cancer

- Appropriate local/systemic treatment should be supported.