“Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European...
-
Upload
eunice-sanders -
Category
Documents
-
view
217 -
download
0
Transcript of “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European...
![Page 1: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/1.jpg)
“Conservative mastectomy”the nipple sparing tecnique
Alberto LuiniSenology Division
European instiute of Oncology-Milan
![Page 2: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/2.jpg)
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
![Page 3: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/3.jpg)
Improvement in diagnosis (ultrasonography, MRI)
total mastectomies
EIO 2000 200523% 28%
A.Luini
![Page 4: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/4.jpg)
Timing of Reconstruction
- Always immediate
- Delayed only if:
- Locally advanced disease
- Concomitant diseasesA.Luini
![Page 5: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/5.jpg)
SSM + immediate reconstruction with prosthesis or expander is nowadays the standard treatment, except for:- Inflammatory cancer- Locally advanced disease- Poor general conditions
A.Luini
![Page 6: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/6.jpg)
Skin Sparing Mastectomy + immediate reconstruction with prosthesis
A. Luini
![Page 7: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/7.jpg)
Immediate reconstruction does not affect the prognosis
A. Luini
![Page 8: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/8.jpg)
![Page 9: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/9.jpg)
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
![Page 10: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/10.jpg)
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
![Page 11: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/11.jpg)
Immediate reconstruction:Immediate reconstruction:
The Nipple Sparing The Nipple Sparing ApproachApproach
EIO NSM 84%
of the mastectomies
A. Luini
![Page 12: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/12.jpg)
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
A. Luini
![Page 13: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/13.jpg)
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
![Page 14: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/14.jpg)
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
![Page 15: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/15.jpg)
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 !
A. Luini
![Page 16: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/16.jpg)
Surgical technique
a) Conservation of the retroareolar glandular tissue
b) Conservation of the retroareolar subcutaneous vascular plexus
![Page 17: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/17.jpg)
Surgical technique
a) Sterile LINAC collimator
c) Lead and alluminium protective disc
d) Pectoralis major muscle
![Page 18: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/18.jpg)
ELIOT ELIOT (16 Gy)(16 Gy)
Nipple Sparing Mastectomy
on the remaining glandular tissue to complete the cancer treatment
A. Luini
![Page 19: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/19.jpg)
Nipple-sparing mastectomy
Irradiated area
Irradiated area A. Luini
![Page 20: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/20.jpg)
NSM + prosthesis + contralateral breast
augmentation
2 weeks 5 monthsA. Luini
![Page 21: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/21.jpg)
Type of reconstruction
Anatomic prosthesis 68%
Expanders 19%
Round prosthesis 5%
TRAM 8%A. Luini
![Page 22: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/22.jpg)
Nipple Sparing Mastectomy
Definitive prostheses 73%
Immediate left reconstruction with implant
A. Luini
![Page 23: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/23.jpg)
Nipple Sparing Mastectomy
Expanders 19%
Two-step implant reconstruction A. Luini
![Page 24: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/24.jpg)
Nipple Sparing Mastectomy
TRAM 8%
Immediate pedicled TRAM reconstruction
A. Luini
![Page 25: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/25.jpg)
RESULTS
![Page 26: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/26.jpg)
A. Luini
![Page 27: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/27.jpg)
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.)
A. Luini
![Page 28: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/28.jpg)
Complications (1060 NSM)
Immediate
NAC necrosis 8.8%
Infections 2.0%
Delayed
Capsular contracture15%
Radiodystrophy 7.5%A. Luini
![Page 29: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/29.jpg)
NAC necrosis
Partial 58 (5%) Total 26 (3,8%)
Secondary reconstructio
n A.Luini
![Page 30: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/30.jpg)
NAC necrosis
Spontaneous healing with a TRAM
![Page 31: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/31.jpg)
Infections
21 cases 2%
42 prostheses removed 4%
A.Luini
![Page 32: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/32.jpg)
Capsular contracture
157 capsulotomies 15%
A. Luini
![Page 33: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/33.jpg)
ELIOT ELIOT (16 Gy)(16 Gy)
nipple sparing mastectomy
But … 206 cases received a delayed radiotherapy the day after surgery
A. Luini
![Page 34: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/34.jpg)
Prosthesis removal
2,815,56
0
1
2
3
4
5
6
Eliot Del. Radiotherapy
p = 0.0829 A. Luini
![Page 35: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/35.jpg)
Capsular contracture
5,22 7,78
0
1
2
3
4
5
6
7
8
Eliot Del. Radiotherapy
p = 0.3179 A. Luini
![Page 36: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/36.jpg)
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
![Page 37: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/37.jpg)
NAC sensibility
At one year, scale 0 - 10
score 0-3 48.0%
score 4-6 32.8%
score 7-10 18.8%
A .Luini
![Page 38: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/38.jpg)
![Page 39: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/39.jpg)
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?
![Page 40: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/40.jpg)
1060 NSM in 1023 patientsInvasive carcinoma 63%In situ carcinoma 37%
ONCOLOGICAL RESULTS MEDIUM FOLLOW UP 20 MONTHS (RANGE 1-
70)
![Page 41: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/41.jpg)
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%)
A. Luini
![Page 42: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/42.jpg)
![Page 43: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/43.jpg)
Local recurrences
13 cases (1.2 %)
All distant from the NAC
(10 tumor bed, 3 upper quadrant)
A. Luini
![Page 44: “Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan.](https://reader031.fdocuments.us/reader031/viewer/2022012916/56649daa5503460f94a97d40/html5/thumbnails/44.jpg)
Nipple sparing mastectomy with intraoperative
radiotherapy is a safe procedure to reduce the
psychological trauma due to mastectomy in selected
cases
Conclusion
A. Luini