Chapters Transcript Video Breast Cancer - Changing Surgical Management of Breast Cancer thanks so much for the opportunity to speak with you tonight and uh, we'll be glad to take your questions as they come along. Let's look into the next slide. These are my, uh, uh, in compliance. These are my disclosures and uh, I speak for myriad genetics, merit medical, Cardinal Health and have done a lot of work in the field developing new technologies and new techniques, which you'll hear about later on next life. The objectives of this presentation are to understand current surgical options, trends and controversies in the treatment of breast cancer, including advances in breast cancer care, genetic and genomic testing, emerging roles and technologies as well as the emergence and evolution of uncle plastic surgery. Next slide with this, I'm gonna turn it over to Dr Pernicano and she's going to explain to you some of the multiple things that we've been able to achieve as major advances in breast head cancer care over the past 30 years or so. Both here at Tampa General at Moffitt Cancer Center and USF specifically DR nick on. Thank you very much. Doctor cox. We've enjoyed observing and appreciating and in the case of DR cox pioneering many significant major advances in breast cancer diagnosis assessments and certainly in treatments. The cowboy days of the surgeons solely managing breast lungs and cancers have fallen away as more institutions embrace multidisciplinary breast conferences where breast radiologists, pathologists, surgical, medical and radiation, oncologists, geneticists, plastic surgeons and others come together and present cases and discuss the management options and recommendations. We quite thankfully walked through the evolution from the whole stead radical mastectomies to saving the pectorals muscle in the modified radical mastectomies. We rejoiced and the patients were very happy. Then came even better lump back to me that we could save many breasts and treat breast cancer with conservation and radiation and when mastectomies were necessary. We moved to skin sparing and now skin and nipple sparing mastectomies with or without immediate reconstruction without compromising the cancer outcomes. Inter operative touch preps for psychological margin assessment is possible without excellent is impossible without excellent site a pathological support and without psychopathology. Uh It makes it very difficult. But now we have the advent of the Mozart system that's a three D. Tomoe synthesis for inter operative breast specimen imaging. We can visualize the three D specimen mammogram and better assess the margins of the resection than by the old fax citron. In the 1990s we saw the movement away from the higher morbidity of routine complete X salary look no dissections with every operation for invasive breast cancer. Two sentinel lymph nodes as a standard of care. Again markedly reduced, markedly reducing the morbidity without compromising the oncology standards. Even advancements in the technetium 99 isotope used for sentinel lymph node identification has improved with lymphocytic, a much more comfortable injection for the patient that's for sure rather than open surgical biopsies for diagnosis and then secondary operations for definitive surgical management of breast cancer. The 1990s salt literally an explosion of minimally invasive image guided core biopsy systems using stereotype Actiq guidance, ultrasound guidance and then MRI guidance for core biopsy. Likewise, the core sampling devices used with those systems also steadily improved from the old manual true cut. Remember that the true cut needle biopsy to the bard single push button device to the current vacuum assisted 10 and 13 gauge ma'am atone. Elite biopsies better sampling transition to translate it to two more tissue, not just for diagnosis but to help guide the treatment plans. Besides the typical mammograms, even three D. Tomoe mammograms, breast doctor sounds and breast mris nuclear medicine, breast imaging is also helpful to sort out what and wind biopsy. And it's proving especially helpful in very dense breasts, scarred breasts, busy breasts, post radiation breasts, augmented breasts, even breast where patients poor renal function precludes Enron localization of non palpable lesions moved from the wire localization and wire guided lumpectomies. Two more streamline processes where radioactive seeds could be placed at the non palpable previously biopsied lesion. Well in advance of the day of surgery, the patient with the seed in place has no wire protruding and we avoid potential delays in the flow of cases that day due to a glitch in radiology. But the radioactive seeds placed a bit of a monkey rich into the system in some places because well after all seeds are radioactive. The problem was easily solved though with the same man who invented the seed, He invented the savvy Scout radio frequency localization ship. best cancer risk assessment is also evolving Beyond Risk Assessment calculators. In the early 90s, B. R. C. A. One and two genetic mutations were identified and associated with hereditary cancers. And now genetic profiles have identified more deleterious mutations that contribute to a patient's risk with some mutations called variants of uncertain clinical significance. We're still collecting data so we lack enough data to really impact on the risk assessment or to help guide screening schedules or treatment plans. But that's coming adequate breast radiation therapy also has made tremendous strides from six weeks of whole breast external beam radiation therapy to five days of mammoth site balloon catheter delivery systems to the Savvy Breaky breaky therapy catheters and now even inter operative delivery systems. Inter operative radiation and even stereotype tactic radiation therapy all are streamlining both the length of treatment and reducing the potential side effects and complications of radiation therapy. Besides our mainstay tumor characterizations of hormone receptor status, which were developed in the 70s. That's the 1970s. Uh sorry, genomic testing of tumors now contributes greatly and allows risk stratification with mammoth, mammoth print, aqua type Dx and others. Next slide, please thank you. The family history of breast cancer has been known for decades to be a risk factor. But now we have genetic testing to better understand that risk But who to test and when currently genetic mutations are determined to be a major factor in the development of only 5-10% of all breath of all cancers. Next slide, please, mm quantifying a patient's hereditary cancer risk is invaluable in guiding screening and treatment plans as well as a patient's own life decisions. Myriad labs has online videos for patients and even live portal for genetic counseling to help patients virtually so that they can better understand the testing process, informed consent and many other aspects of genetic testing. Next slide, please having multiple cancer types in one patient cancers at a younger age or rare cancers at any age are all red flags for hereditary cancer and help us to identify who should undergo genetic testing. Having multiple cancer types on one side of the family that is having two or more relatives with breast ovarian prostate, pancreatic cancer or colorectal gynecologic gastric. You're a federal or real pelvic cancers, biliary or small bowel cancers or two or more family members on one side with melanoma or pancreatic cancers. All are red flags for hereditary cancer in the patient should be tested, Having a single family member at age 50 or less with breast colorectal or endometrial cancer should prompt consideration of hereditary cancer and having even a single family member with ovarian cancer. Male breast cancer, triple negative breast cancer, colorectal cancer and immaterial cancer with the with the micro satellite instability pathway confirmed on immune, artistic chemistry Or more than 10 gastrointestinal polyps should also prompt testing. Additionally certain ancestries, for example the Ashkenazi jewish ancestry carry a much higher risk of hereditary cancer syndromes. For example, a patient of Ashkenazi heritage has a one in 40 chance of carrying a BRC A mutation which is 10 times the risk of carrying one of the BRC A mutations compared to the general population. Next slide please. No your patients and know their risks. We must look at history, family history and genetics to help at a minimum implement a proper screening schedule. Next slide please. We can use developing technology to ensure as early a diagnosis as possible and also help formulate and execute management plans. Next slide please. Over the past 5 to 10 years, breast breast rest timo synthesis or three D mammography has provided an avenue for readily imaging masses and distortion, especially in the dense fiber cystic breasts. Next slide please, here's another example of how in a sea of nodule or fiber glandular tissues and otherwise non specific modular area is clarified by tomoe synthesis to bear irregular margins and subtle surrounding distortion. Next slide please from the high resolution spiral MRI. Called the rodeo breast MRI got FDA approval in 2000 and six and tremendously improved the acquisition time and sensitivity of breast MRI. But breast MRI in general is an important tool in preoperative assessment and clinical staging of breast cancer, helping to identify occult disease in either breast and to assess the lymph node basin. It also has become a key tool in screening the high breast cancer risk patients who for example Carry a 20% or higher lifetime breast cancer risk to the age of 80 by the tire acoustic risk assessment score. Next slide please. Another relatively new kid on the block is molecular breast imaging MB. That developed out of the positron emission tomography. The pen studies Where a radioactive isotope on a sugar molecule is injected intravenously and even small tumors able to be identified. I mean small five millim tumors or less have been able to be identified regardless of density of the breast or the presence of implants where the pam nuclear medical nuclear med study has a high dose of the radioactive tracer. The male clinic decided to investigate the utility of using to imaging plates like a gentleman um a graphic compression and found lower doses obsessed maybe were required and the images were better and the baby was born next slide, please. Sure. This is a 58 year old lady with a history of left breast lumpectomy in her 12 o'clock left breast in 2010 for 1.3 centimeter intermediate grade two E. Er positive Pr positive, her two neu negative and negative disease. She was followed carefully after treatment and was stable by her exam and mammogram until 2018. Then following a mild trauma to that breast, she developed a little fat necrosis, drainage but all that easily resolved with antibiotics. However, an NBC study saw through these issues and identified new progression of uptake at the lumpectomy site and subsequently excision revealed a 2.1 centimeter recurrent too invasive ductal carcinoma. With negative margins. Next slide, please. This demons Yes. This demonstrates the clarity of imaging with a pim but also the dose of the pim is higher than on the FBI. So although those images might be brighter, we can detect easily. Well with the FBI at the lower dose. Next slide please. Wire localizations of non palpable lesions or even bracketing wire placement to ensure that a more extensive area of diseases excised have been very helpful and breast surgery. But coordinating wire placements on the day of surgery is challenging. And one time glitch in radiology can throw off an entire already tight or schedule. Next slide please. Next one. Yeah. Advanced. One more. I think they missed one. There you go. Okay. See I'm not seeing that image. All I'm saying is you Abby spring. Something weird going to go check. Okay. So yeah, I think she needs to pin her. I can't see the Yeah. Yeah. Help us on the way. It sounds like oh, that's kind of neat. Hope that there. Okay, thank you. Oh it's all fixed. Okay. Here you go. Thank you so much. Well dr cox developed the radioactive seed used for seed localization of non palpable breast leisure like for wire localizations. The seed placement technique may be done by mammogram or ultrasound guidance Placement begins with loading of the seed into an 18 gauge needle with bone wax to keep it in the needle. When the needle tip is in a good position, the seat is deployed by inserting a style it down the needle and then as in the wire looks, a mammogram is taken to confirm proper placement. Next one please. Okay in the interest of time. Next slide please. This demonstrates the post seed placement procedure mammogram. Next side slide please. In the operating room. The maximum signal is located with the gamma probe. Next slide please. The game of probe maintains the orientation of the lesion in the dissection area and helps to judge the depth of excision. Using both numerical counts and an auditory signal. Excision of the lesion is confirmed when the counts are only in the specimen. Next slide please. The pathology technicians, pa's residents. Whoever's grossing in the specimen can then use the game of probe to identify and remove the localization seed from the specimen. Next life please, compared to wire guided lumpectomy, video active. See local. Don't you want to please? Here we go. One more Lord guided lumpectomy radioactive see localized lumpectomy specimens have about half as many patients with positive margins and the volumes of the lumpectomy are substantially smaller. Using seed localization techniques compared to wire localized lumpectomy. Ex slide please. Using the radioactive seed localization technique. No lesions were missed, no seed migration occurred, no seed fragments were retained and few margins required. Re accession radioactive seed localization can easily be combined with lymphatic mapping. Next slide please. Now another FDA approved localization system, again developed by DR cox. one without radioactive parts is the Savvy Scout surgical guidance system. The SGS, like the see. The savvy scalp may be placed well ahead of the day of surgery using ultrasound or mammogram guidance replacement and during the excision breast excision of breast biopsy, the SGS provides real time guidance. Next slide, please. There are several advantages to using the Scout, including the fact that it uses radar wave technology and not gamma wave and therefore the Scout does not have to have the stringent regulatory guidelines that the radioactive materials do. The surgical case need not be delayed because of the difficult localization procedure and this proves to be a huge advantage. Next slide, please. The Scout reflector measures 12 centimeters and consists of two tiny antony, one at each in and the infrared light receptor and the transistor switch. The reflector is smaller than Roosevelt's head on a dime. Next slide please. The localization needle is placed in this case under ultrasound guidance such that the tip of the needle is john it just passes the center of the target. This drops the reflector right in the center of the target. A post placement mammogram is obtained. And then following the excision, the specimen mammogram shows confirmation that the reflector is intact and within the specimen. Next like please. Yeah, here's another image example of this Scout. Next slide please. The Scout is easy to use. But as with everything there's a learning curve with the technique, the Scout uses electromagnetic waves designed specifically to work in breast tissue. The hand piece must be placed on the breast surface to transmit the signal to the reflector through the tissue. Next slide please. Here we see the Scout specimen and the specimen radiograph. Next slide please. And the data shows. Next slide please. The savvy Scout localization reflector has demonstrated several essential advantages over the both the wire and the sea. Using the savvy reflector. No lesions were missed. No migration occurred. No reflector fragments were retained. The use of this savvy Scout reflector for localization of non palpable breast lesions has improved operative logistics. Fewer of the patients had to return for margin re excision using the SGS and the FDA. Now has approved that no limits should be placed on the implant. Time for the Scout. Thank you very much. Doctor cox. I'll turn it over to you. Yeah. Thank you. Next slide please. Abby. I'm sorry. This is my time. I think critical things that that you need to understand. That as a as a surgical educator, as a surgeon uh Now of breast cancer care for the last 37 years. Uh the surgeon's role is twofold local control and accurate staging. And honestly, that hasn't changed in the 30 years that I've been in practice or for the former Probably 50 years since hostages time back in the 1880s. But critically, these pieces are important to understand what they mean in today's realm and in today's use of the technologies that we have available. Next slide. So in in looking at the local control and accurate staging, Obviously local control means getting all of the cancer out. Which we've just seen some demonstrations of technologies that have been developed to help with that first step. But the significant thing is is that history, pathology, tumor type size grade central nodes, number and involved nodes, all of which are based on uh physical measurement in microscopic evaluation are the main ST tools that have been available for us for many, many years. Uh The molecular staging including estrogen receptor progesterone receptor history, chemistry KI 67 um or am I standing in her two status with a C. Or fish are also very important are very important molecular image tests that help us to determine the aggressiveness of the cancer and sometimes the treatment modalities that need to be used. We also need to consider now genomic evaluation with the advent of the whole genome being evaluated and delineated. Genomic testing has now come to the fore and may replace in many cases the pathology of the of the lesion. Next line. So again, molecular staging includes all of these things that we've just described. The gene expression or molecular biology Has been delineated in several new tests, Ma'am a print being one of those which is a 70 gene risk assessment. And really and really these are designed to answer the question which patients really need chemotherapy, uncle uncle type DX, which was sort of the leader in the field at least. The first test that came out is a 21 gene recurrent score, pam 50 50 pro cigna is a 50 jean risk stratification test. And mando Strat is really more based in pathology. Looking at I. H. D. And you know, it's the chemical standing markers in the tumors. Uh using that this technology which stains for markers which are genomic markers. Next slide uh The contrast of the of the appearance of versus expression of Vienna typing is interesting. So we look here at a low grade tumor versus high grade tumor and you look at the genomic expression in the lower panel and you can kind of see a by measuring those genomic tests, you can assess whether the patient has a low risk tumor or a high risk tumor. Next line. So the president future trends in genomic testing for breast cancer or kind of as follows. Next line Initially in nature, in 2000 to the beginning of this stratification was published. And Ma'am, a print was born from this publication. And it demonstrates those patients clearly, which were low risk signatures versus high risk signatures. Next line, what gene profiling interrogates are these are these multiple fosse of cancer growth from from growth and proliferation to angiogenesis, local invasion, uh survival in the circulation of cells in Travis, ation, extra visitation, growth and proliferation. All of things these particular genes were elucidated through this analysis of genomic testing interestingly enough, when the way this test was derived, as they had about 380 patients who were ah Followed after they had had genomic testing done. Of all 23 genes. What's interesting is is they then followed them and they found out which patients with breast cancer had recurrences and or died versus those who had no recurrences and we're still surviving 10 years later. And basically uh applied all this information back to the interrogation of those genes to figure out which genes were most important. Indeed, what they did is they rank ordered all 23 genes based on probability of prediction and the patients who had a 10 to the -6 or higher uh P value, which means they were a million times more important than all of their genes fell into this 70 gene category, Interestingly, 30 of the genes, they didn't even know what they did. So this is pure science that's dictating this. This is not uh anybody deciding what needs to be done based on what the outcome was. It's just based on what they saw in the jeans and which genes predicted the final outcomes next life. So again, you they can now go back and look in these 70 genes. All of the genes are delineated here of those 70 genes that measure all of these very important functionalities of tumor growth and spread. And so that's why these genes are so important to the growth and spread of cancer and would dictate which patients should or should not benefit from chemotherapy. Next live. So again, we know that breast cancer consists of several subtypes like uh and this was all the linea delineated by a physician named Peru who demonstrated that there were basil like tumors, her to type tumors. Normal breast tissues, Luminal A. And B. Tumors which were hormone sensitive but had different risk assessments associated with them. And this is how this was delineated through this heat. Heat map of all of the genes of breast in a breast cancer cell line next line. So again, knowing if you can if you can place these uh tumors into specific types or subtypes like Luminal A. Then endocrine therapy is all it really would benefit that patient chemotherapy hardly even works on those patients. Aluminium B. And her two negative would certainly benefit from both side of toxic therapy as well as in different therapy. Uh And clearly Luminal bees with her two positive would certainly benefit from her two treatments and Herceptin projet to and other drugs that are now available for the treatment of those patients as well. And clearly there are positive tumors that basically over expressed to her two gene in our clinically very significantly treated and can have as high as a 70 plus percent uh complete response rate to Cida toxic and anti her two drugs. And then there's the triple negative patients which are obviously a very resistant to most treatment inside a toxic drugs are really the key drugs in question for that group of patients. Uh next slide. Mm. Yeah. So what every patient asks when they come to see me for the first time without even just having a diagnosis of breast cancer? Do I need chemotherapy? Will it help me? And do I have? Do I have to have my no dreaming and well, I get a swollen arm of lymphedema. So these are critical questions that are on the minds of patients as they understand their diagnosis and as they bert begin their treatment of breast cancer. Next line. So this 70 gene signature trial, the mind back trial uh looked at this very issue in terms of which patients benefit from chemotherapy and which don't. And this has always been a considerable concern for for the regulators of medicine in the upper levels, as well as for physicians on the ground level and face to face trenches. So, this article next slide demonstrated out of 6,693 patients enrolled. That, and this was over nine countries in 112 centers uh, in the European area. This uh looked at the entire genomic array of these of each of these patients. And then was they were stratified, stratified by the mammoth print diagnostic tool, as well as their pathology. Next line, I might parenthetically say, this trial that was published in the New England Journal with 6000 patients as a randomized controlled Trial is probably the most significant piece of literature on breast cancer management and care published in the last 40 years. So to me it's worth, you read it's a very complicated paper, but a synthesis of the information can kind of help you understand and understand what patients benefit most from chemo and came out there next line. So again, one critical pieces as we discussed discussed before, pathology or tumor anatomy has been important in clinical pathologic factors relative to uh patient's tumor and how it responds and how it looks under the microscope versus tumor biology. I think many of us have seen patients who come in with a Small, very small cancer, maybe less than one cm and two years later the patient's dead. How do we describe that? We'll see another patient show up and they have a 10 centimeter tumor that's fun gating and bleeding in a mess. And 10 years later they're still alive. How do we justify that when we actually have to look at those parameters that make that um are aggressive or non aggressive. Indeed, this solves that issue for us. It's not all about just looking at the um are under the microscope but it's also looking at how it genetically and genomic lee fares in the care of the patient. Next line. I won't go through all of these things. I think the underscored piece of information is that 46% of the clinically high risk patients for recurrence would be usual. Candidates for adjuvant chemotherapy were classified as low risk by ma'am a print and basically did not benefit or showed no significant benefit from chemotherapy. So in the past basically a lot of patients were getting more chemotherapy than they needed. And this study clearly defined which patients do not need chemotherapy next line. So why do we need to remove my why they needed to remove my lymph nodes? The Z 10 trial in S. A. B. P 32 micro mitts were supposedly not important to to do a complete total dissection. The Z 11 showed no advantage in the removal of no positive patients. So when can I avoid complete no dissection? If my note is positive. Next slide? Well, the Z- 10 data having participated in both of these studies and entered many patients onto these studies, I would hasten to point out that there were some flaws in the study. Uh The Z 10 trial was very skewed. Most patients 87% were T. One A. Or B. That means they were five mm to one cm And 88% where er positive with no grading ever described. So these were all very small low grade lesions. From my perspective. Just looking at that data, uh the Z 11 underpowered and overstated current omission for complete axillary node dissection and was biased because older patients in property pathology is negative, it comes back positive post operatively. And so people just avoid doing an axillary dissection because they don't want to do more surgery Or hurt the patient and they can kind of use the Z-11 under power data to say, well I don't really need to do an axillary node dissection Again. Remember 60 of the patients are central now positive and it's the only positive note max line. So the limits of microscopy and descriptive pathology have been reached and the prognostic assessment requires molecular tumor biology for therapeutic decisions. I think that's the take home lesson for all of you next lot. Next line. So genomic tumor biology of subtyping and risk assessment may define critical treatment decisions which patients can benefit from a complete node dissection, which patients can avoid a complete node dissection if you had a low risk to you. And one positive note, perhaps you don't need more time. So which positive note patients can avoid axillary radiation therapy. That's another big question that we need to understand. The next line. I'm gonna turn this now over to Dr Beard and she's going to talk about some of the exciting things that we're doing in new treatments and treatments available for patients in today's world for breast conservation and breast care that can leave them with a more whole appearance and a better outcome for their for their livelihoods in their lives. Thank you. Abby. Yes. Thanks Dr cox and Dr Pernik. Oh and you guys did a great job summarizing a lot of dense but very important information in the treatment of breast cancer patients. Um So one of the first things we're going to talk about now is just sort of overall trends and surgical management of breast cancer patients as you can see on this slide back in the early nineties, shortly after the breast conservation therapy had come out, a lot of these women were really just so excited to have this option to have their breast safe. So they were offering and opting into this breast conservation therapy and the rates of mastectomy really dropped because if we said, you know, we can save your breast when these women were used to seeing their friends, their family members, mothers, sisters who had their breasts removed. Of course they jumped at this chance and for a long time that breast conservation was really the number one choice for patients. The vast majority wanted to have their breasts saved if possible. And then in the early two thousands we noticed a shift in that change and a lot more mastectomies were happening. Next slide, please. Mhm. And just another representation of that back from 1994 to 2003. When we looked, about two thirds of patients were getting breast conservation compared to one third getting mastectomies. When we look from 2005 to 2007, that essentially flip flopped. So a quarter were I'm sorry, 40% were getting Their breast conserving about 60% change to having mastectomies next slide. So we wanted to look a little bit more into why that was and when we looked at it, Mris had just started to come about and a lot of women were using mris to get their complete staging and we were finding extra spots in the breast leading to more biopsies or more confusion about how large lesions were. Were we able to truly save the breast? So a lot of women were opting to get mastectomies after their mris. Um plastic surgeons were really changing how they were doing their reconstruction. A lot of insurance companies weren't necessarily covering these procedures. So a lot of the patients were sort of trying to figure out how to get their breast cancer, taking care of and not have to worry about a future risk of cancer coming back. And the # one reason really was fear. And some of the things that were driving this fear about future recurrence were a lot of this had to do with the advent of online communities, chat communities, blogging things like that. People were able to talk to other women with breast cancer and hear their experience and here, you know, we all tell our patients all the time don't google, right, you're only gonna see bad things on the internet. So they were able to go on the internet and hear from women who had a recurrence, who had a bad experience with radiation, whatever it might have been. And they really were changing their minds away from this breast conservation and deciding to go forward with mastectomies. Next slide, please. Um, some of the things that we looked at that were predictors of whether or not a woman would get a mastectomy were aged less than 40 years. They have a very long life ahead of them. So they're just saying, you know what, I don't want to deal with the recurrence. I don't want to have any more mammograms. And think about that every year in my surveillance. Every year, um, the incidents of getting plastic surgery, increased tumor size and lymph vascular invasion. Any women that had positive for vascular invasion, large tumors or the option to have reconstructive surgery. They were all predictive factors leading that woman towards getting a mastectomy rather than saving their breasts. Next slide, please. And again, this is just another slide showing that the incidents of these uh, mastectomies was going up over time. Next slide. Um so when we look at just the prophylactic mastectomy rates on the contra lateral sign. So back in the mid-90s 1994-1998, bilateral mastectomy rates for down as low as 7% as we continue to go. You can see the timeline shift up to 2002, Up to 76% of women. We're having their contra lateral breast removed at the time of surgery. So that's 100 and 25% increase in mastectomies over that time. Next slide, please. Mhm. So what have we done for these women to help them? So, you know, we see lots more patients who want these mastectomies. And so now we have to try and manage their surgeries and give them the best cosmetic outcome possible. So one of the things that we did to help these women who wanted wanted bilateral mastectomies to make sure that they have the best cosmetic outcome was to start to change the way we did mastectomies. So we started doing these nipple sparing mastectomies, not for every woman. Some of the reasons, some of the indications for these nipple sparing mastectomies has to be a tumor at least two centimeters away from the nipple so that we know we have a nice zone of tissue and we can get an adequate margin and really keep that that you're off the nipple base. The tumor size has to be fairly small uh and not extensive throughout the breast, no skin or nipple involvement, clinically negative nodal basin. And then in terms of the woman's breasts, she has to have minimal toasts of the breast and have a smaller breast size. So A. B. And even some smaller C. Cups are really the ideal patients for this. Um This is a great option for patients who are B. R. C. A. Positive with smaller breasts as they don't have any of these tumors to worry about. So we can give them a really nice cosmetic outcome going forward when they get their prophylactic surgeries. Next slide, please. This is just a photo of a woman in the operating room. Just to give you an idea of how we perform these. So we've marked down the mid line that line across the breastbone. And those circular incisions are sort of marking out the extent of the breast tissue. You can see that white line is showing you seven centimetres. We start our incision about seven centimeters off the midline and extend that incision out laterally along the infra mammary fold. So it's really nicely hidden in the natural body crease. So when you look at the patient head on, all you really see is her own natural skin, her own natural nipple and the scar is completely hidden after that surgery. Next slide please. Uh This is just a photo showing reconstruction. So what the plastic surgeons can do is once we've removed all of the breast tissue they use our same incision. They'll lift up the pectoral major muscle and they can place the implant underneath that pec muscle. Next slide please. And that's just showing sort of an image of the final reconstruction. So what we'll do is then they'll place an a small strip of KAZ matrix or a leader or some sort of dermal matrix to help close the defect and accommodate an implant without stretching that muscle too much so that a woman who gets one of these operations can have an implant done at the same time completing her reconstruction in one stage. Next slide please. And this is just a vaginal view showing how that implant pushes the muscle tissue up against the skin so it's directly adjacent to the skin and nipple. That underlying picture Alice muscle is now going to provide your new blood supply for your skin flap and for your nipple. And then you can see the matrix there holding the implant in as almost a sling to keep it from dropping down and having sagging of those implants. As time goes on. Next slide, please. Next slide please. So this is a woman who on the left was her original pre op photos. She often to have a skin and infiltrating mastectomy on the right. This is two months after her reconstruction with a tram flap and you can see her incisions are completely hidden. She actually has a much perkier, much fuller breast, much nicer looking profile than what she had before her cancer. Next slide please. Some of the biggest complications we see with this surgery or skin related. If we don't have a good opposition of that muscle to the overlying skin and nipple that can affect the blood supply. So the most common complication we see with this is epidermal ISIS, or skin sloughing of the skin flap. Uh Then would be partial nipple necrosis, Which usually just means that very tip of the nipple will get very dark and slough off. And total nipple necrosis is one of the more devastating complications that we see with this. But that really only happens in about 2% of patients. Um You know, this is something that we counsel the patients about going into the procedure, the risk of having that nipple loss and what we can do to sort of try and salvage the nipple or what will happen if we see this next slide please. And this is just a photo showing you actually on the inferior portion of the breast. You can see a little bit of that epidermal ISIS. Just some scabbing and skin sloughing. And just the tip of that nipple has that dark sloughing skin that's gonna scab off. And you can see below that there's a rim of pink healthy tissue. So this wouldn't be complete nipple necrosis. This would just be partial nipple necrosis. She'll keep her normal nipple. It just won't project out quite as much as it did when she originally presented next slide, please. So and follow up of these women after about a year and a half, what we found was a 2% overall recurrence rate. Our biggest concern obviously was recurrence in the breast in recurrence at that nipple that we were trying to save. So only about 1.6% of patients had a local recurrence. The most common was in the breast within about 1.5 centimeters of where the original tumor was located. Actually the next most common site would be bone or lung Mets followed by axillary or super curricula, lymph nodes, and then the chest wall or the areola. So as long as you choose your patients wisely, they don't have extensive disease and they have a two centimeter separation from the tumor site to the nipple. There really is not a high risk of recurrence happening at that routine nipple. Next slide, please. Uh This is a woman who had a nipple sparing mastectomy with immediate implant replacement. That slide on the left is her. About three weeks after surgery. You can see she still has some of that resolving bruising with that yellow green issue. And that's her on the right. One year later. She's very happy. She didn't have to do any other reconstruction. She had those implants put in immediately and that's what she needed bushes. One surgery to be done to help her feel like she had recovered from all of this. Next slide, please. Uh This is that same patient. Just some profile views to show you the projection of her nipple as well as the projection of her breast. She was very happy with her shape. Next slide please. This is a woman who was diagnosed with a BRC mutation at the age of 17. She opted to have her surgery immediately after finishing high school. This photo was taken about 2.5 years after her surgery on routine follow up. So again, her scars completely hidden her own natural nipples. She was incredibly happy with the size and shape of her breasts. That 19. Next slide please. That's obviously something that's devastating for a lot of women to get this diagnosis of a BRC mutation and she really wanted to be proactive but also at the same time understood that she was a 19 year old girl and wanted to have the look and shape and feel of breast like every other 19 year old girl would have. So next slide please Again, just another woman who had a bilateral nipple sparing mastectomies with immediate implant reconstruction. She's a marathon runner. So that's why she has some of those stretch marks on her breasts. But otherwise she was incredibly happy with her outcome. There. Next slide please. And this is a woman with larger breasts obviously who had skin nipple sparing mastectomy. You can see on the right, she's had a little bit of slipping of her implant after her reconstruction. But that's something that the plastic surgeons can work with and can actually revise that and lift that implant back up in the future. If need be next slide please. Uh So this woman had teardrop shaped implants. We don't do too many of these anymore. The breast on the left actually is uh you can see the teardrop has shifted a bit and she has almost a bulge there in the center because her teardrop shifted from projecting to the upper outer section of the breast, Down towards the center. Next slide, please. And this is a woman who had again, bilateral nipple sparing mastectomies with immediate implant placement. What's interesting about her is that as she had capsule contracture over time, that implant has shifted more immediately. You can see her scars projecting out laterally. Those were hidden in the infirmary fold. But as she scarred in that implant has moved centrally, you can see the scars a little more prominently. So this is again something that the plastic surgeons can work with to try and help release some of that scar, either with upsizing or with adding fat grafting to that. To help give her that fuller appearance on the outer side of the breast and help those scars get back hidden in the breast folds. Next slide, please, I was just looking at our age. So some of the other things that we've been doing now, we've pushed the envelope, we started doing the nipple sparing mastectomy. What we're doing now is what are called uncle plastic procedures. And these are essentially mixing a breast reduction or a plastic surgery, cosmetic procedure with your cancer operation. Um So the best candidates for this have larger breasts. Even patients with multifocal or very lateral disease are very central disease. So two of the most common described incisions are the battling incision dr cox has added his spin to it rather than battling since it's women's cancer. He calls it the Angel Wing procedure. One of the other patterns that we use often as the wise reduction pattern which is sort of the standard breast reduction incision that you see for your patients. So essentially what we're doing is marking the cancer as we do our cancer operation. Either us or in conjunction with plastic surgery, will come in and have them get a breast lift and a breast reduction at the same time. So we've treated their cancer, we've given them adequate margins and then we've also given them a procedure that lets them keep their own natural breasts but they're lifted there, you know, reduced whatever it is, they need to feel a little bit better about themselves. Um Some of the things that we're doing for these patients to allow them to get partial breast radiation and avoiding that whole breast radiation impossible is placing special catheters for the breaking therapy or that partial breast radiation at the time of their uncle plastic procedure so that we can still locate that tumor bed, make sure that we radiate the target area that we want to, that specific lumpectomy site. We don't lose it as we shift around the breast tissue so we can give them the best uncle logic outcome with the fewest number of cosmetic problems in the future. Another thing that we do is called the Goldilocks procedure. This is an interesting procedure that was originally done for women who were obese with diabetes, high blood pressure, heart problems, other complications that would make them sort of poor candidates to have reconstruction essentially. We make a D. Epithelial ist flap of the infirmary breast skin and we use that to fold in on itself and create a small ridge so that when they wear prosthetic there's something to hook the prosthetic to rather than a flat chest wall where those prosthetics can ride up throughout the day and be very problematic for women. Next slide please. So this is just a photo showing some of the preoperative markings for this angel wing or uncle plastic reduction. So what you can see in the center that crescent just over the nipple, that's how the nipple is going to be raised. That's where the final nipple position will be. And those side markings on either side, the wings of the angel, so to speak. That's where we're going to take out skin and take out some of that breast tissue. And what we can do is as we're taking out that tissue that we're planning to reduce wherever the tumor is located. We will add that into our reduced specimen as we lift the breast, lift the nipple and give you that reduction. Next slide, please. And this is showing her on the table. You can see her wire coming out of the inferior portion of the breast going up to about where that arrow is, where that that's where the tumor is actually located. So we're just going to include that in our reduction specimen as we take out all of that tissue that were simply reducing for a cosmetic procedure. Next slide please. And this is on the left, just showing pre op markings on the right is showing obviously her breasts are reduced, their lifted, her nipples are back in a normal position. They're no longer topic and she has a much more pleasant outcome. And she gets all the benefits of having a breast reduction as well, improvements in her back pain and neck pain and shoulder pain. Next slide please. This is similar procedure except instead of using that angel wing for thinner women that don't have as much of that lateral breast tissue that needs to be excised at the same time we do what's called the wise pattern reduction or the keyhole reduction. So you can see again that crescent is where the nipple will sit. Once we're done with the procedure that wedge or keyhole at the bottom is where the tissue is that will take out that inferior tissue and again the same outcome with that nice lifted breast. The nipple is up and rather than being tonic and kind of sagging down, she ends up with this perkier more reduced breast. Next slide please. And this is a final surgery outcome. So you can see the incisions are around the nipple. You have that small line on the inferior breast and then another small scar or tea or anchor along the inferior fold that's fairly well hidden. So in low cut shirt swimsuits, anything like that strapless tops, there's no scars, everything's hidden underneath. Next slide, please. This is a photo just illustrating that goldilocks mastectomy. Again. Obviously this woman is fairly obese. I believe she had pretty poorly controlled diabetes as well. That made her a fairly bad candidate for reconstruction. So we use that inferior skin of the breast to make a small fold there some women like that as simply feeling like they have a breast and they don't wear a prosthetic. Other women will wear their prosthetic a lot more comfortably once they have this flap in place. Next slide please. That's just another projection of it. Next slide. Uh So this is showing a goldilocks infra mammary reconstruction. So what we do is similar to our skin and nipple sparing mastectomy when we talked about using the cosmetic matrix to help hold the implant in. Now what we'll do for these women is will perform the the epidural realization of their own breast skin. And then we use that d epithelial eyes skin flap as our sort of matrix as our biologic matrix. So that will get tucked in and that's what's going to hold the implant up during the reconstruction. So we're avoiding using any foreign body any of that very expensive and actually on back order and difficult to get at times cosmetic matrix for the plastic surgeons. Next slide please. And this is a woman who's had that procedure done. So she's still obviously mid reconstruction. She's had her mastectomy is done. She has her inferior political flap in her implant. There she is just waiting to finish her treatment so that she can get her nipples put on in the future. Next slide please. So some of the things that we talk about survivorship that's sort of feeling happy healthy and whole after your cancer treatments and how do you come out on the other side and get back to your old self. So one of the things that we like to stress for patients is healthy eating habits, healthy lifestyle choices. And one thing that we really found is that something as simple as 30 minutes of walking a day can help reduce your risk of even developing breast colon or prostate cancer by 30%. So that's obviously great advice for male and female patients. And then breast cancer survivors. We talked about doing this 30 minutes of walking a day because that can reduce their risk of recurrence by up to 70%. Next slide, please. So one of the things that we deal with on a daily basis is that a woman with a breast problem and we're not even talking about cancer in this sense, just a breast problem is the most anxious patient in all of medicine. Next slide, please. The only thing that these women remember at the beginning of their diagnosis and their journey on this breast cancer treatment is the caring attitude of the physician and the amount of time it felt like the physicians spent with that patient. So all three of us really try and do the best we can to provide this caring environment, this caring attitude for these patients. And we really like to take our time with these women, go over all of their treatment options. Talk to them about all of these things. Talk to them about their anxieties and their fears and all of the other aspects of breast cancer treatment that don't always get addressed. Next slide, please. Um so when we talk to women, we did a study Dr. did a study and looked at 350 women who were five years out of their breast cancer diagnosis. None of these women had any evidence of recurrence and they were all doing well from their treatments and they just asked them to look back at the time of their breast cancer diagnosis and think about how it affected them, 88% of them said it was equivalent to the loss of a child, 12%, the other 12%, not in that group said it was the equivalent of losing their spouse or their home. In 100% of women, this was a life changing event. It made them change their priorities and reassess their focus on their everyday living. For all of the women, they said the emotional recovery of this diagnosis took about two years and for that that was defined as breast cancer was not the first thing that I thought of when I woke up and the last thing on my mind when I went to bed throughout the day, that wasn't even to get to a point where they didn't think about breast cancer at all. That was just where it wasn't the main focus of their day. All of these patients really benefits from some anti anxiety medications. And what we do in our practices offers annex to the patients that they're able to take it just to help really allay some of those fears and it's on an as needed basis to help them get to sleep, help them, you know, sort of a lay some of that anxiety just so they can get back to doing some of their daily functions. Next slide please. And then I'll send it back to dr cops to talk about our new breast center. So all that being said with partnership with Tampa General which has been just a remarkable partnership. They have the story of this uh new breast clinic on the Brookside Trace in Trace court in Tampa which is up across the street from the um Freedom High School is really a vision. I've had for many many years the day I needed to leave the area where I was practicing, one of my patients came in and said you wouldn't know anybody that needs a breast or needs a clinic do you dr cox? And I said, yeah I do. And from that a year and a half later we had a contract for them to lease their building that they had built from with Tampa General. We have imaging, yeah ultrasound mammogram. And the FBI machines soon to be acquired for this facility on the right hand side we have four exam rooms with double entry doors that make our all of our rooms HIPPA compliant. You can see the beauty that we've designed into the facility as you look at the registration desk in the opening for you. And then on the left hand side we have three treatment rooms where we can do immediate Kourtney, two biopsies or surgical re excisions for margins and other things that are LTD in office procedures. But we're open for business. Just been open a week and we're certainly happy to welcome any and all patients and referrals to our center, all three of us, doctor Per Nika and dr Beard and myself see patients there uh and were there all week, five days a week. So any time you want to send a patient over, Just give us a call at the listed number there of (813) 660 6150. And we'll make it our priority to see that patient. As you understand they are the most anxious people we know that. Mhm. Thank you so much. Doctor cox and dr Beard and dr perricone. This was such an informative session. We have two questions in the bank. I'd like to start with the first question and please attendees. Um If you would like to ask the physicians anything, please use your chat and Q. And A box. Now the first question is how soon after a mastectomy can you have reconstructive surgery? Should that be the route that the patient would like to take? I'll take a short stab at that one and then I'll let the rest of them answer. Usually a minimum time would be about three months. If you've had to have any kind of radiation, they generally would want to wait a minimum of six months and sometimes up to a year for the for the skin to soften and so forth. But in reality it can be it can be done 3-4 months after the original surgery to allow the wounds to soften and to be pliable so that they can stretch skin and move things around effectively. Okay, Are you ready for question 2? What do you do with a woman with bi rads three imaging and has multiple cysts and lesions? Oh abby. I'm dr Franken. This is I'm sorry, I screwed it up. You never mess anything up. Trust. So this is an excellent example of the utility of the molecular breast imaging the N. B. Because we can take a busy breast one where it's even beyond fiber cystic. More than just cysts. The disorganization and the breast is pretty profound and we can do an M. B. And identify even small. The FBI doesn't care about breast density, scarring implants or this busy breast. What it cares about is if there's cancer there, if there's a small cancer there even a tiny cancer there and so I would I would go straight to FBI with that. Another important thing you mentioned in your talk the timber that we saw on that Mbia image was 2.1 mm. It was tiny, tiny and that was that was detectable very, very easily. If the FBI is done and it's negative, it carries a 98.8% negative predictive value. That means you have less than 1.2% chance that you would have missed any kind of a cancer. It's a very unique test and its it measures mitochondrial activity. So it's right down into what do you have each cell within the breast. Which to me makes a big difference in terms of being able to identify things and give a patient a real sense of security that hey, it was negative. Um there's no singular test, mammogram three D. Mammogram MRI Ultrasound that has a 98.8% negative predictive value. Uh There's no singular test that's as accurate, sensitive and specific as an FBI exam. And I'm championing bringing this to technology to Tampa Bay because it really hasn't existed Here to four in this area. And we will have Eventually a new machine here at Tampa General in our new breast center and will be available to patients at a reasonable cost, less than $500. And you can do four MBS for what it would cost for one MRI and get more information out of it on top of that. Excellent. Thank you so much. Those were the last of our questions. And thank you again everyone that joined us tonight. This was a great lecture and thank you doctors again for gracing us with all your knowledge. Thank you for having us, of course. Thank you everyone. Final thoughts. Thank you, appreciate it. Like I say, breast cancer is our passion. Yeah. Thank you so much. Good night. Take care. Thank you. Bye. Bye. Published June 4, 2021 Created by
