MASTECTOMY THROUGH THE AGES - Advocate …...“Liberty Leading the People”, Delacroix 1830 The...
Transcript of MASTECTOMY THROUGH THE AGES - Advocate …...“Liberty Leading the People”, Delacroix 1830 The...
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MASTECTOMY THROUGH
THE AGES
Barry Rosen, MD, FACS
Medical Director
Advocate Good Shepherd Hospital
Breast Care Center
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TRUE CONFESSIONS
I
AM
A
BREAST
MAN
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History of the Breast as a Symbol
• Art
• Sculpture
• Literature
• Advertising
• Politics
Reflecting spiritual, familial, social, and contemporary perspectives of the breast
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Breasts Revered….
“Artemis of Ephesus”
800 B.C.“Venus”, Fertility Goddess
25,000 B.C. (Stone Age)
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The Sacred Breast
“Madonna del Latte”
Italian 14th Century
Among first nursing
Madonna portraits
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The Erotic Breast
Transition from sacred breast
of the Middle Ages
to the erotic breast of the
Renaissance
Charles VII’s mistress, Agnes Sorel
~ Madonna
(15th Century)
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The Domestic Breast
Sophie Hedwig, Countess of Nassau. 1621
Symbolizing charity
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The Political Breast
“Liberty Leading the People”, Delacroix 1830
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The Commercialized Breast
Princess Bust Developer Sears, Roebuck and Co. 1897
Promised to make the breast “round, firm and beautiful”
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The Commercialized Breast
Fruit crate label 1950
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The Liberated Breast
Demonstrator displaying her post-mastectomy chest - 1994
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The Augmented Breast
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The Augmented Breast: a US "Epidemic"
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The Surgical Breast
Thomas Eakins “The Agnew Clinic”
Philadelphia - 1889
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History of Breast Cancer Surgery
• Second half 19th century: anesthesia (Morton) &
antiseptic principles (Lister) facilitated surgery
• 1867: Moore “radical mastectomy”
• 1882: Halsted “radical mastectomy” Johns Hopkins,
standard for 60 years in USA
• 1905: Ombredanne—1st pectoral muscle flap for
breast reconstruction France
• 1906: Tansini latissimus dorsi mastectomy repair in
Italy
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MODERN ERA:
Evolution of Mastectomy
• Radical Mastectomy (Skin, Breast, Chest Wall Muscles, Many Lymph Nodes)
• Modified Radical Mastectomy ([less] Skin, Breast, Lymph Nodes)
• Skin-Sparing Mastectomy (NAC, breast, SLN)
• Nipple Sparing Mastectomy (no skin, breast, +/-LN)
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MODERN ERA:
Timing of Reconstruction
• 1960s: rare reconstruction, always
delayed (recurrence rates, survival)
• 1980s: immediate vs. delayed (lower
recurrence rates, psychological benefit)
• 1990s: tissue expanders, microsurgery
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MODERN ERA:
Evolution of Reconstruction
Autologous vs. Implants
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Post-Mastectomy Reconstruction
20%
25%
35%
19%
21%
28%
32%
27%
14%
20%
16%
11%
10%
35%
1999-2004 2005-2009 2010-2014
U/L Implant
B/L Implant
U/L Autologous
B/L Autologous
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MODERN ERA:
Mastectomy vs. Lumpectomy
-Since the 1970s, it has been well-established
that survival rates are comparable*
-Why would a woman ever have a mastectomy?
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INDICATIONS FOR MASTECTOMY
• Multi-centric cancer
• Hereditary predisposition
• Large tumor*
• Patient preference
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MASTECTOMY RATES
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2013 BILATERAL MASTECTOMY
RATES BY AGE
NCDB
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CONTRALATERAL PROPHYLACTIC MASTECTOMY
(CPM)
Oncology vs.
Quality of Life
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EVOLUTION OF
RECONSTRUCTION OVER
THE PAST 50 YEARS
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Transposition of Flaps (1960s)
Labial nipple / areola graft
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Simple Augmentation (1970s)
Modified radical mastectomy
Implant alone
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1980s-1990s: Pedicled TRAM Flap
Pre Op TRAM
Post Op TRAM
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1990s-2000s: Latissimus Reconstruction
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1990s: DIEP Flap
Microsurgery Advantage• Better overall outcomes
• Less donor site morbidity
• Improved patient
satisfaction
• 1991: DIEP perforator flap,
Japan
• 1994: Allen for breast
reconstruction
Wilkins, Prospective Outcomes in Breast
Reconstruction
Plast Reconstr Surg 106: 2000
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Implant Reconstruction
Whole muscle coverage
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3-D Tattoo Now Popular
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NIPPLE SPARING MASTECTOMY
Pre-Operative Post-Operative
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NSM v. MRM/SSM
• Patient satisfaction
• Patient selection
• Recurrence rates
• Complications
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NSM: Patient Satisfaction
• Higher sexual/psychosocial well-
being
• Higher satisfaction with cosmetic
outcome
• Greater sensation over breast mound
(~50% at NAC)
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NSM: Patient Selection
• Prevention
• Treatment
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NSM For Prophylaxis
• 3 studies published encompassing
over 200 pts with BRCA mutations
• 7% rate of incidental cancers
• Follow-up ranged from 10-60 months
• 1 new cancer observed (0.7%)
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Patient Selection for NSM
• Tumor size less than 5cm
• Distance from nipple >2cm
• HER2/Neu nonamplified
• No prior radiation, smoking*
• Breast Size/Degree of Ptosis*
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Oncologic Safety of NSM
(Headon, et al,2016)
• Retrospective review of 12,358 NSM
from 73 studies published up till 2015
• Local recurrence rate of 2.4% (mean
follow-up of 38 months)
• Nipple necrosis rate 5.9% (8.7% v.
3.4% comparing before/after 2013)
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OPTIMAL INCISION FOR NSM
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NSM: Reconstructive Options
• Autologous vs. Implants
• Direct-to-implant vs. Staged (tissue expander)
• Sub-pectoral vs. Pre-pectoral (ADM)
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Preoperative Postoperative
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Direct to Implant (1-Stage)
Preoperative Postoperative
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Case Study 3-stage NSM
Preop
mastopexy/reduction
s/p bilateral tissue
expansions/p bilateral
subpectoral implants
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NSM CONCLUSIONS
• Cosmetic outcome superior
• Greater sensation/pt preference
• Risk of local recurrence similar to MRM
• Pt selection is critical (>2cm from
nipple, <5cm tumor, neg. PATH at
nipple)
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We have a long way to go...
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