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“Conservative mastectomy” the nipple sparing tecnique Alberto Luini Senology Division European instiute of Oncology-Milan
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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
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Improvement in diagnosis (ultrasonography, MRI) total mastectomies EIO20002005 23%28% A.Luini
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Timing of Reconstruction - Always immediate - Delayed only if: - Locally advanced disease - Concomitant diseases A.Luini
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SSM + immediate reconstruction with prosthesis or expander is nowadays the standard treatment, except for: - Inflammatory cancer - Locally advanced disease - Poor general conditions A.Luini
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Skin Sparing Mastectomy + immediate reconstruction with prosthesis A. Luini
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Immediate reconstruction does not affect the prognosis A. Luini
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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
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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
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Immediate reconstruction: The Nipple Sparing Approach EIO NSM 84% of the mastectomies A. Luini
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Indications w Multifocal/multicentric cancer w Extensive microcalcifications w Contraindications or refusal to primary medical treatment w Negative retroareolar frozen section A. Luini
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Contraindications w Involvement of the central quadrant w Paget’s disease w Pathological nipple discharge w Microcalcifications close to the nipple w Previous radiotherapy A. Luini
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Advantages w Oncologic radicality: skin removal as a quadrantectomy and of the whole glandular tissue (except a thin retroareolar portion) w Intraoperative radiotherapy on the nipple areola complex (16Gy) w Immediate reconstruction with a good cosmetic result (very similar to a “good” quadrantectomy) A. Luini
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a layer of glandular tissue should be left beneath the NAC a layer of glandular tissue should be left beneath the NAC to avoid NAC necrosis Subcutaneous mastectomy a fifty year old technique ! A. Luini
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Surgical technique a) Conservation of the retroareolar glandular tissue b) Conservation of the retroareolar subcutaneous vascular plexus
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Surgical technique a) Sterile LINAC collimator c) Lead and alluminium protective disc d) Pectoralis major muscle
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ELIOT (16 Gy) ELIOT (16 Gy) Nipple Sparing Mastectomy on the remaining glandular tissue to complete the cancer treatment A. Luini
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Nipple-sparing mastectomy Irradiated area A. Luini
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NSM + prosthesis + contralateral breast augmentation 2 weeks 5 months A. Luini
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Type of reconstruction Anatomic prosthesis 68% Expanders19% Round prosthesis 5% TRAM 8% A. Luini
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Nipple Sparing Mastectomy Definitive prostheses 73% Immediate left reconstruction with implant A. Luini
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Nipple Sparing Mastectomy Expanders 19% Two-step implant reconstruction A. Luini
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Nipple Sparing Mastectomy TRAM 8% Immediate pedicled TRAM reconstruction A. Luini
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RESULTS
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A. Luini
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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.) A. Luini
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Complications (1060 NSM) Immediate NAC necrosis 8.8% Infections2.0% Delayed Capsular contracture15% Radiodystrophy7.5% A. Luini
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NAC necrosis Partial 58 (5%) Total 26 (3,8%) Secondary reconstruction A.Luini
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NAC necrosis Spontaneous healing with a TRAM
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Infections 21 cases 2% 42 prostheses removed 4% A.Luini
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Capsular contracture 157 capsulotomies 15% A. Luini
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ELIOT (16 Gy) ELIOT (16 Gy) nipple sparing mastectomy But … 206 cases received a delayed radiotherapy the day after surgery A. Luini
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Prosthesis removal p = 0.0829 A. Luini
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Capsular contracture p = 0.3179 A. Luini
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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
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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
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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?
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1060 NSM in 1023 patients Invasive carcinoma 63% In situ carcinoma 37% ONCOLOGICAL RESULTS MEDIUM FOLLOW UP 20 MONTHS (RANGE 1-70)
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EVENTS Local recurrence13 (1.2%) Distant metastases36 (3.5%) Deaths 3 (0.3%) A. Luini
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Local recurrences 13 cases (1.2 %) All distant from the NAC (10 tumor bed, 3 upper quadrant) A. Luini
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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 A. Luini
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