Transcript Oncoplastic Surgery of the Breast and Nipple

So you have Breast Cancer:
NOW WHAT???
Barbara A. Ward, MD
Medical Director
The Breast Center at Greenwich Hospital
DO NOT PANIC!
• Almost everyone survives breast cancer, so
why not you?
• Early detection DOES save lives!
• Why do you think there are so many breast
cancer survivors at those walks?
Educate Yourself
• Buy a book or go to a reliable website:
• WWW.CANCER.ORG
(American Cancer Society)
• WWW.CANCER.GOV
(National Cancer Institute)
Find Out The Facts and Get
Organized
• Request a copy of your reports, especially
your pathology report.
• The American Cancer Society provides a
Patient Organization Tool, as do many
Breast Centers.
• Are you at the right hospital and doctor?
Quality Indicators
National Accreditation Program for Breast
Centers (NAPBC)
Commission on Cancer (CoC)
National Cancer Institute Sponsored Site
Most University Hospitals
Breast or Surgical Oncology FellowshipTrained Surgeon
Multi-disciplinary Care
• Breast Radiologist
• Breast Surgeon
• Reconstructive Surgeon
• Medical Oncologist
• Radiation Oncologist
Other Team Members
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Nurse Navigator or Educator
Pathologist
Tumor Registrar
Cancer Counselor
Nutritionist
Social Worker
Physical Therapist
Keep it Simple
• First decision typically involves surgery:
What type and Where?
• Don’t feel bad about getting a second
opinion, especially if a mastectomy is
recommended
Evolution of Surgical Practice
• Halsted’s Radical Mastectomy
• Modified Radical Mastectomy
• 1985: Lumpectomy plus Radiation= same
survival rates
• 2006: Poor cosmetics so reassess surgical
strategies
Lumpectomy and Radiation
• Patient Selection: Cancer is localized and
can be removed with a margin of normal
tissue…………….. (Clear Margins)
• Surgeon feels that there is good to excellent
cosmetic results.
• Patient willing and able to receive radiation
Radiation Therapy
• Traditional treatment: Whole breast
radiation with boost.
• @ 32 treatments over 6 -7 weeks (minus
weekends)
• Partial breast radiation: possible over 1-2
weeks vs. shortened course of RT to 3 wks
• May include Mammosite catheter
placement…risk of infection and fibrosis.
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• Investigational vs. “Cutting Edge”
• Recommended in the context of a clinical
trial.
Nipple-Sparing Mastectomy
• Progression of Thought: Pre-reconstruction
era (@1960’s) there was no attempt, but
now there is renewed interest.
• Biologic considerations include:
– SAFETY
– COSMESIS
– FUNCTION
Recommendations:
• Garcia-Etienne and Borgen (MSK):
–Negative lymph nodes
–Nipple Sparing Mastectomy for
breast cancers less than 2 cm and
more than 2.5 cm from nipple
–High-risk patients without cancer
Recommendations:
• Ward et al (GH): selective patients with
low risk cancers…small and away from the
nipple, not including extensive DCIS.
• Question including BRCA ½ gene carriers
(no specific data)
• High risk patients due to family history,
anxiety, and LCIS, ADH
Perforator Flap Reconstruction
• New option for reconstructive surgery
• BIG operation, but right for the right person
• Could involve the transfer of tissue from the
abdomen or buttocks
• Seek a specialist in this technique
TRAM
Perforator Flaps
DIEP Flap Technique
Skin and fat from the lower abdomen is surgically transformed to form
a new breast mound. This is the most often performed procedure since
excess fat and skin are usually found in this area - the end result is a
"tummy tuck" - as well as a reconstructed breast.
DIEP Flap Technique
DIEP Flap Technique
Arterial Anastamosis
Double Opposing Clamps and Background are used for
arterial anastamoses
Immediate DIEP Reconstruction
Nipple Sparing Mastectomy
Surgical Decisions
• Identify BRCA1/2 carriers for prophylactic
surgery
• Higher rate of second breast cancer in same
or opposite breast
• Sentinel lymph node surgery: lowers the
chance for lymphedema (arm swelling)
What is my prognosis?
• Prognosis is based upon multiple facts from
the pathology report:
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Tumor Size and Grade
Lymph Node Involvement
Receptor Status
Oncotype DX or Mammoprint Score
Adjuvant Therapy
• Prognostic features from surgery, which
includes removal of the sentinel node, will
determine the need for chemotherapy
• Estrogen and Progesterone Receptors, Her-2
neu status, and size of tumor
• Oncotype DX Test, Mammoprint Test also
factor into decision tree.
Multidisciplinary Team
• Postoperative meeting with a MEDICAL
ONCOLOGIST
• Presentation at Tumor Board
• Second Opinion always an option
• Decisions typically follow NCCN
guidelines
• You are the final decision-maker
New Targeted Therapies
• Herceptin is a new IV treatment targeted at
a marker unique to cancer cells
• It is given over the course of a year…but
has resulted in amazing cures
• Avastin is also targeted at killing the blood
vessels that feed cancer growth
• Results are more preliminary but hopeful
“Survivorship”
• Buzz word for follow-up post treatment
• NEXT Step Program
• Nutrition/EXercise/Therapy
• Counseling and Support Groups
What Can You Do?
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Lead by example regarding screening
Quit smoking
Buy the Breast Cancer Stamp
Contribute to research efforts such as the
American Cancer Society
• Participate in a Clinical Trial as a patient
• VOLUNTEER AT GILDA’S CLUB!
What else can you do?
• Join the “Army of Women”
http://www.armyofwomen.org/
(Remember; why are there so many
people walking? Because so many
are survivors!)
Call for cancer information:
1.800.ACS.2345