The next session is uh about the best papers in aesthetic oncological and reconstructive
surgery. I will be sharing this uh session together with
Christoph Tausch and the first speaker is uh Mark Pacific.
Hi.
Hi, so, uh, we're kind of going back a little bit for,
uh, 10 minutes of aesthetics before you go back to oncological side of things.
So Marlene asked me to put through a range of papers that I think have influenced my practise.
Um, so I, I just looked, I mean there's so many papers out there and so many important ones,
so I just thought, what are the papers I regularly reference in lectures and um what are
the papers that I feel have changed my practise and really influenced them?
So I'm gonna go through them and as I said, I've got,
I know I've got 10 minutes, and I'll try and get through as many as I can.
So a very simple technique, uh, is Steve Merton's technique from Sydney,
the Capular hammock published some time ago, which is a simple,
excellent, reliable way of dealing with cordal implant malposition.
With a uh posteriorly based capsular flap, you dissect it from the chest wall and you suture
it up to support the capsule or the pocket in a higher position.
And of course we've heard lots about secondary breast implant surgery and variations of this
type, but even in incredibly thin capsules, it works really well,
particularly if you need to expand the upper pole with a capsulotomy.
I think that's a paper I'd um I I'd definitely recommend to you.
So that's number one.
Um, we've heard already from Charles about popcorn capsulroy.
It was published by, um, Brad Calabrese following hearing about it from Charles,
and the popcorn is incredibly useful as a technique in,
uh, revision implant surgery, uh, particularly with, as Charles said,
with the thin capsules, um.
It can help with uh shrinking down a er a pocket, you can do it selectively in different
areas of the pocket. Could we have the sound on actually for the
video? We, I know it didn't work for Chelsea yesterday,
so we'll see if it works for me.
I'm gonna have to start the video again, aren't I?
Bear with me. Let me just try that, cos if you haven't done
it, it is quite. Thank you.
There's the pope. Yeah Thank you.
Uh, so that was a pop that Charles was, uh, replacing yesterday with his pops,
as he said it. Um, but it, it really is, it can be quite loud,
but you do see this contraction of the, of the, um, of the capsule for those of you who don't
use it or who haven't done it.
Um, I don't do any more breast reconstruction anymore, but I suspect it could be a very
useful technique in revision, um, reconstruction cases as well,
um. It's quick, it's a lot quicker than all the
other types of capsularies we may perform, but often I combine it with different forms of
capsulotomy and capsulophies.
Um, and I can, you can, of course you can use it in a,
uh, as an adjunct to other techniques.
This is a paper I referenced earlier in my talk, and this is one I really think everyone should
be aware of, even if it's intuitive.
It's Craig Lake's paper from Sydney looking at the classification of the inframammary fold and
its impact on decision making with respect to whether or not to lower the crease and how
safely. Lower the crease.
Um, the main outcome was finding in the, as I said earlier,
the more developed the crease, the higher the risk of developing a double bubble if you lower
the crease with the take home message that their F3 classification crease or an F2B even.
Be very careful about lowering the crease cause you're highly likely to put that patient at
risk of double bubble.
I am not going to talk about these because Pat's going to be talking about these tomorrow,
but a huge, huge thank you and I think everyone, we're all indebted to you and your colleagues
for the amazing work you've done and you're continuing to do about systemic symptoms
associated with breast implants.
The conversation I'm able to have with patients now is so different from the conversation I had
2 or 3 years ago as a result of all this work, and if you haven't read the papers,
please read them. They are game changing and.
They are totally reframing the debate and for those potentially plastic surgeons who might
come to the BARTS meeting, Pat's colleague Caroline Glickman will be one of our speakers
as well, and I know there's already a lot of press interest in the work that they've been
doing. Something that we touched on earlier is um the
use of hypochlorous acid. I'm not sure how many people have started to
use this or adopting this.
Um this is, I think it to be something we're going to see increasingly in the US they've got
phase one, which is the um the branded hypochloric acid.
There are different formulations we can get here.
Molier do one, not quite the same concentration, but the interesting.
Uh, evidence seems to be in these difficult cases of recurrent capsular contracture when
you're sort of backs against the wall, and I wonder if it's going to be the um replacement
for implant irrigation uh in the fullness of time.
Um, Marlene did ask me to do papers over the last 10 years,
but I'm afraid this is a little bit older because I think the most,
one of the most underutilised techniques in um tuberous breasts and other difficult breast
cases, but particularly tubers is a modified pocket flap.
This, it's not technically easy and it is an absolute disaster if it goes wrong,
cos you can hold a sort of a third of the breast in your hand,
devascularized if you don't get it right, but when it,
when you get it right. And it's not too difficult once you're just
comfortable with the planes.
It's amazing how much breast tissue you can unfurl and totally reshape and reposition the
inflammatory crease in a tuberous breast patient, and I think the um for me.
That's a very important part of my tuberous breast practise management which I use without
implants with the adjunct that it might require will be helped by a second stage of lifepa
filling in the lower pole, particularly if there's a slight contour irregularity.
Those are my papers, I hope they were helpful, thanks.
The next presentation, it's a presentation from Nicola Rocco,
uh, and he will introduce some papers.
For your introduction, hello again.
So I also had a look at literature uh as far as uh
oncological surgery breast oncological surgery is concerned and um I also choose
uh this paper selection according to.
The practise changing of these papers, so how they changed my practise in my
clinical and surgical daily practise, both from the point of view of surgical and oncological
outcomes and the patient reported outcomes point of view.
So having a close look to literature, you can see that the key words of the literature in
breast oncological surgery that has been published in the last 10 years is the
escalation, the escalation of axillary surgery, the escalation of breast surgery.
This is the key word, and we will go through, but why de-escalating surgery?
What are the advantages from an oncological point of view or from the patient reported
point of view of de-escalating breast surgery?
Well, recent evidence showed that breast conserving surgery and radiotherapy is
associated with the survival, potentially associated with the survival benefit when
compared with radical mastectomy.
Then patients undergoing breast concept in surgery shows reduced short and long term
surgical complications complications when compared with those undergoing mastectomy and
breast reconstruction.
And third, patients undergoing breast cancer surgery are more satisfied with cosmetic
outcomes and show better outcomes in terms of postoperative quality of life when compared
with mastectomy and reconstruction. So many reasons for de-escalating breast
surgery. Well, the first paper I would like to show to
you is the so-called Z11 102.
Uh, this is a multi-centric, uh, prospective trial, uh,
run across, uh, the United States, and it's, uh, has been published in 2023,
last, uh, in 2023 in April on the Journal of Clinical Oncology.
And this is a prospective single arm trial designed to evaluate the oncological outcomes
in patients undergoing breast conserving treatment for multiple ipsilateral breast
cancer, multicentric and multifocal disease.
They included 204 women aged 40 years and older with
2 to 34 of biopsy proven CN01 breast cancer who underwent
multiple lumpectomies with negative margins followed by whole breast irradiation and boost
to all lumpectomy beds. And well, um, breast cancer surgery with
adjuvant radiation with multiple lumpectomy size boost leads to an acceptably low five year
local recurrence rate of 3.1% also for multiple ipsilateral breast cancer.
So this evidence changed my practise because one.
A patient with multiple ipsilateral cancer, would have gone to a mastectomy field
before this evidence. So this evidence supports that breast
conserving therapy is a reasonable surgical option for women with 2 to 3 epsilateral falsa,
particularly among patients with disease evaluated with a preoperative MRI.
So the impact is that a mastectomy is not automatically required for patients with
multiple tumours in the same breast.
The strength of this paper is that it is a prospective single arm study with 204 women
with a median follow up of more than 5 years, but it also shows some weaknesses.
The findings regarding patients not undergoing a preoperative MRI are limited,
and we need a longer term follow up, particularly for luminal disease because we
know that luminal disease could also recur later on.
Then the second paper I selected is also from the United States,
is led by Henry Curer from the MD Anderson.
It's a multicentric single arm phase two trial in seven centres in the USA,
including women aged 40 years or older with a unicentric CT12 N01 triple negative or
HER2 positive breast cancer who underwent primary systemic therapy.
And a residual breast lesion following uh primary systemic therapy,
less than 2 centimetres of imaging were included.
And well, all these patients had a biopsy, multiple biopsy with the 9
gauge needle of the tumour bed. If no invasive or in situ disease was
identified, breast surgery was omitted, so no surgery for these patients following primary
systemic therapy. And patients only underwent standard whole
breast radiotherapy plus a boost.
Well, uh, they, uh, included, they enrolled 50 patients with a median age of 62 years,
22 triple negative, 29 HER2 breast cancer, and a pathological complete response identified
with the vacuum assist breast uh core biopsy.
was identified in 31 patients and at a median follow up of 26.4 months no
ipsilateral breast tumour recurrences occurred in these 31 patients and no biopsy related
adverse events occurred. Obviously this paper did not change my practise,
obviously. We have some, we, we have many weaknesses.
We only have 50 patients enrolled and we have a median follow up of 26.4 months,
but this led to multiple trials. We now have in Italy in the European Institute
of Oncology another trial that is the Crazy Betty trial that is studying the same thing.
I don't, don't ask me why it's called Crazy Betty.
OK, anyway. We, um, and anyway, the impact is that a
complete response determined with a cyst core biopsy could also spare
patients from completely spare from surgery with promising promisingly early results.
And we also had another evaluation published on JAMA on JAMA network open
surgery. About the patient reported outcomes in this
population, and well, they considered that the decision regret scale,
the functional assessment of cancer therapy, lymphedema, and breast cancer treatment outcome
scales. And in the 31 patients who did not underwent
surgery, decisional comfort was high at the baseline with their choice and significantly
increased over time.
At 36 months post radiotherapy, the cosmetic score was 0.45 points higher
than baseline, and function, pain and edoema sub scores were not significantly different
than baseline. So the analysis of patient reported outcomes
demonstrating demonstrated a positive experience for these 31 patients with
improvements in decisional comforts over time.
Well, so these papers were, uh, studying and we're addressing the escalation of breast
surgery, but also the escalation of axillary surgery is one of the key elements of the
literature published in the last 10 years.
Why deescalating axillary.
We know that the extent of axillary surgery has a direct effect on breast cancer related
lymphedema, and axillary dissection, lymph node dissection causes a fourfold increase
in breast cancer related lymphedema compared to sentinel lymph node biopsy.
We have evidence that patients with more than 5 lymph nodes removed,
the rate of breast cancer related lymphedema was 18.
18.2% compared to 3.3% in those with less than 5 nodes removed.
So, and, and moreover, axillary lymph node dissection is associated with high rates of arm
pain, seroma, and infection. So many advantages in deescalating surgery also
from uh at the level of the axilla.
This is a landmark trial. All of you, I think you all know the,
the so-called Z11 trial published by first name Armando Giuliano from the United States again
published on the Journal of the American Medical Association in 2017.
This paper had with um a follow up of 10 years.
The aim of this paper was to uh consider and determine the overall survival of patients with
sentinel lymph node metastasis, treated with breast conserving therapy and sentinel lymph
node dissection alone without axillary lymph node dissection,
even if the patient shows uh showed uh um metastasis is up to 2 sentinel lymph nodes.
That is known inferior to that of women treated with axillary dissection.
Well, they included 856 women with a median follow up of 9.3 years,
and the overall survival for patients treated with sentinel lymph node dissection alone was
not inferior to those treated with completion axillary lymph node dissection 86.3% versus
83.6%.
So these findings do not support the use of axillary lymph node dissection when metastases
are found with sentinel lymph node sampling in up to 2 sentinel lymph nodes in women with CT1,
2 and 0 breast cancer undergoing breast conserving surgery and radiotherapy.
So the impact was very strong, the impact of this paper,
but it shows also, it showed also some weaknesses.
In fact, we know. That this study had a high attrition bias,
loss of patients loss to follow up, and micrometastasis was in up to and not
micrometastasis where in up to 40% of included patients, and there were also no details on
radiotherapy fields because radiotherapy could strongly impact on these outcomes if also the
axilla was under uh was submitted to radiotherapy following surgery.
So very recently published last April, the Sennoak trial,
a trial that had the aim with Jana de Boniface from Sweden as first daughter,
had the aim to validate the results from previous trials.
They referred to the Z11 trial, but also the Synoder 1 trial conducted in Italy.
In a large cohort focus on patients with sentinel lymph node micrometastasis and to
extend the eligibility criteria to not perform axillary lymph node dissection also for
patients undergoing mastectomy, those with sentinel node extracapsular extension in 3
tumours and in men, well.
Uh, so this trial, the, the authors included, uh, T1 to T3,
so not only T1 to T2 patients, breast cancer with one or two sentinel lymph node
micrometastasis randomly assigned to completion aci or lymph node dissection or its omission.
And well, they included 2540 patients across five countries in Europe
and at a median follow up of 46.8 months, the five years recurrence free survival was
89.7% in the sentinel lymph node only group and 88.7% in the
axillary dissection group.
So the hazard ratio for recurrence or death was significantly below the pre-specified
non-inferiority margin. So strong impact confirming the Z11 results.
This is also in a large population compared with the Z.
but also in this case 89.9% patients underwent radiotherapy, including also nodal
target volume. So there could also be a role of radiotherapy
in these outcomes in reaching these outcomes and also 88.4% in the dissection group
underwent radiotherapy.
Last paper I selected is the sound trial. I think all of you know this a further
step into de-escalation, omitting sentinel lymph node,
not omitting axillary lymph node dissection. We completely omit sentinel lymph nodes with
the results of this. So to determine the aim is to determine if the
omission of axillary surgery is not inferior to sentinel lymph node biopsy in patients with
small breast cancer and a negative result of preoperative ultrasonography,
axillary ultrasonography.
This is a randomised trial published last November.
Including 1,463 women of any age with breast cancer up to 2 centimetres and
negative preparative axillary ultrasound, and these patients were randomised to receive
sentinel lymph node biopsy or nothing, no axillary surgery.
And well, at a median follow up of 5.7 years, the decent disease free survival was 97.7%
in a sentinel lymph node group and 98% in the no axillary surgery group,
a significant result with only 1.7% lo regional relapses in the group who
underwent sentinel lymph node biopsy and 1.6% in the no axillary surgery group.
So strong impact, but.
Considering that you can omit axillary surgery whenever the lack of the pathological
information does not affect the postoperative treatment plan in terms of adjuvant treatments,
so this is a randomised trial.
The weakness is that included patients are at low risk of recurrence in the short term,
so we should need longer term, longer follow up.
Also this study had another substudy according study addressing patient reported
outcomes published on the European Journal of Surgical Oncology.
That showed that patients undergoing sentinel lymph node biopsy had a significantly higher
rate of disability in the early postoperative period compared to patients who did not have uh
any axillary surgery so the avoidance of sentinel lymph node biopsy might translate into
a considerable reduction of physical and emotional distress.
So in conclusion, the literature is going in the direction of de-escalating surgery.
And this could be a great advantage both in oncological outcomes,
surgical outcomes, and patient reported outcomes.
Thank you.
Uh, about oncological topics and now we go back to reconstructive topics by
Elizabeth Capos from Puzzle.
But before she starts, I just wanna remind you that uh we have the group photo after finishing
this panel. So don't leave yet.
Hello everyone, thank you so much to the organising committee for inviting me.
It's a true honour to be here.
And um so Marlen asked me to present to you the most important papers on reconstructive breast
surgery, and that's what I'm trying to do.
I have no conflict of interest to disclose.
So when talking about comparing uh surgeon versus uh patient reported outcomes,
we really have to look back about 15 years.
And it was in 2009, most of you know that, of course, when the breastscue was first
introduced by Andrea and her team.
And this really laid the foundation for patients, patient centred outcome research.
And then in the 10 years after that, um, they were able to analyse the data,
published and to create normative data that we can relate our results to and compare them.
So this has really led to the wide use and application of the breast cue in surgical
outcome research as part of the gold standard.
Most of you of course are familiar with the rescue, but for the younger ones who maybe
aren't, it's really different subquestionnaires that you can use either all together or just
some of them, and you can use them for any research that you do for free.
You have to register on the website and it's really easy to use and implement.
It's quite amazing what the introduction of the rescue did when you look at the exponential
increase in the use of proms from 2009 to today.
It's really an exponential increase in us using it.
To publish our results. So although in the beginning there were some
questions if if this is really feasible and sensible to do,
but this graph pretty much shows that there's a high demand for it.
It is actually feasible and it's also highly valuable.
So because I was asked to really compare those two, the surgeon reported and the patient
reported outcomes. I'm first going to concentrate on the surgeon
reported outcomes and of course like the previous speakers,
it's not about trying to show you. The important papers but rather bring across
some important messages.
And when you look at certain reported outcomes in reconstructive surgery,
very often it's about the comparison of autologous versus implant-based reconstruction.
And there is really some consensus about the pros and cons of course of these two different
techniques in autologous reconstruction and the papers pretty much aligned there.
There are more short term complications.
It is more technically challenging because of advanced microsurgical skills that you need,
and there's also still a lengthier hospital stay, although this has really significantly
been improved since fast recovery schemes have been introduced in many places.
And then when you look at implant based reconstruction, there are more long term
complications, more revision surgeries, but you don't need microsurgical training,
which is why it is actually much more frequently used in the patients,
and there are several papers suggesting a higher long term costs because of these
revision surgeries and more visits of the patients coming back.
So again, when comparing those two different perspectives of looking at our outcomes,
it's really the rescue which has led to a novel understanding how we should measure our
outcomes and question if it's really enough just to look at our objective measurements
without including the patient's view.
But when looking then at patient reported outcomes and comparing them to how we look at
outcomes, the key question for me was really what important factors do influence or seem to
influence when looking at the literature those patient reported outcomes.
And something was very clear when looking at the literature mastectomy without
reconstruction always scores the lowest, so there's clear evidence supporting what we are
doing, promoting reconstruction after following breast cancer,
and then when comparing different subgroups without reconstruction,
mastectomy with reconstruction, or breast conserving surgery.
It's interesting, and this was already pointed out by the previous speaker and also by you
before that breast conserving surgery scores higher when looking at patient reported
outcomes compared to mastectomy and reconstruction.
So for the patient seems to be very important and whenever possible and feasible in a
sensible way to actually be able to conserve the breast using the different techniques of
oncoplastic breast conserving surgery.
And this goes in line with what those colleagues published because we know that of
course preservation of at least parts of the breast and of regional local regional
reconstruction usually leads to a better breast and nipple sensation,
although we have really advanced our techniques and also re-innovating and reconstructive
breast, but it still scores lower than when you can actually preserve
the sensation to begin with, and this should be the goal and seems to be very important for the
patients. And then comparing from a patient's point of
view autologous versus implant-based reconstruction, it's again Andrea's team.
They looked at a lot of patients over 1600, and they could show that autologous reconstruction
from a patient's point of view does go higher than implant-based reconstruction.
And this was confirmed by many other colleagues and the large series that you see here,
but the main take home message here from this graph is again that generally patient reported
outcomes are really high after after reconstruction, be it autologous or
implant-based, and all the autologous scores higher, also implant based reconstruction
results in high patient reported outcomes.
So there is somewhat of a consensus in literature that from a patient's point of view,
autologus does score higher, but the main thing is really being able to offer uh most patients
whenever it's oncologically also safe uh uh reconstruction.
So this is the, I think, most important point, how do we bring these together?
The surgeon reported outcomes and the patient reported outcomes.
And then kind of just concluding what I showed you, it's really autologous from a surgeon's
point of view, more more problems on the short term while implant-based is clearly more
problematic in the long term. And then when looking at patients' preferences,
it should whenever. to maintain the breast integrity so to rather
use breast conservation techniques, oncoplastic breast conservation techniques rather than
mastectomies if not necessary, and then to potentially favour somewhat autologous versus
over implant based reconstruction.
So it seems also when looking at these two other publications that interestingly patient
satisfaction seems to be much more influenced by many different factors and not just the
aesthetic outcome, but mainly as plastic surgeons seem to focus very much on the
aesthetic outcome. Um, and there's another recent publication
confirming that, and interestingly, patients seem to score much higher in their satisfaction,
uh, than our surgeons being much more critical when looking at the same,
uh, results.
So generally what I would like to bring across is really,
yes, breast reconstruction has shown over the last decade that it does improve quality of
life for our patients, so we should continue to go down that road.
There's no single ideal breast reconstruction.
of the other colleagues have also mentioned that before it's very important to personalise
the treatment and to actually individually counsel the patient and for that I'm convinced
it's very important to be to work in a team where you can actually offer all the different
options because only then how you counsel the patient will not be biassed but what you prefer
to do um and then when using autologous breast reconstruction you should only do it if there's
a pseudoblonoy to really avoid complications.
So this minimising of complications should be something that we push even further.
We have achieved some success there, but we should minimise them.
It's a surgery about quality of life and improving the quality of life,
and we know that whenever they Complications this will reduce surgeon and patient reported
outcomes. For those of you who haven't done it yet,
the goal should be to implement POMs in your clinical practise and then of course also in
your research. And I think as it was also mentioned in the
previous session, the alignment of patients and surgeons' expectations,
I think this will really help us to improve the outcomes on both sides.
So thank you very much for your attention and come visit us in Basel.
OK, so we have 5 minutes for questions and comments.
Uh, do you have any comments?
I wanted only to ask Nicola about the last trial you introduced,
the sound trial.
Did you change your practise after the publication of Oreste Gentilini?
Yes, partially, not completely. We are considering to.
the sound criteria as I underlined whenever the lack of information about the status of
the actual status of the axilla will not influence my the the adjuvant treatment for
that specific patients so we are considering omitting surgical staging
of the axilla in postmenopausal women with luminal cancers,
but not for other groups of patients at the moment.
Uh, I have a question for Elizabeth.
Uh, I mean, it was very nice presentation. I really enjoy it,
but on the other hand, I think it's difficult to compare groups sometimes because there are
many techniques also for autologous and also for for implant.
So you need to break down a little bit the, the groups and did you find something specific
about this, uh, topics?
Yeah, I mean, it's, it really depends on what you look at mainly for example when you compare
different groups of autonomous reconstruction.
It used to be very clear that the donor side, for example,
the inner thigh, is much less favourable than the abdominal area,
but also there I think it's a real evolvement that has taken place.
So there are two recent good papers that actually show that this has also been decreased
significantly. So that's why again I think it's just so
important then to look individually at the patient and decide what's best for her and not
try to. Impose what you think it's best to combine
evidence and your clinical practise.
Uh, and the same would be for implant-based reconstruction.
Now there is less, um, practise on having two stage breast reconstruction with implants or
all plastic materials versus one stage and going in DTI.
I mean, there, there, there's been a lot of comparison between these kind of techniques in
the last 5 years perhaps, and I mean there's gonna be where I'm somewhat biassed because
it's actually a study from Basel, but that was shown also by the previous speaker.
We're doing this randomised controlled trial to show to answer the question,
is it pre or sub pack and it's also a call to maybe to everyone here that I think it's
really feasible to do these randomised control trials also in our surgical practise and we
have to push for it and it's hard and it takes a lot of work,
but that's in the end how we can answer really important questions without just telling how we
do it. Other questions from the auditorium.
You wanna have lunch seems so OK, so thank you very much again for your nice presentations.