All right, we're gonna just for time purposes we'll go right into our final session before
lunch, and this is kind of an interesting session based on that game game changing
philosophy that we wanted to emphasise. So there's 4,
there's 4 of us on this panel and we've each focused on a different area,
uh, breast aesthetics, breast reconstruction, breast oncology.
Uh, and we're gonna pick like 3 game changing papers in each of our practises,
uh, that we wanted to kind of share with you. So Yasin's gonna go first,
uh, and then we'll have hopefully Eric goes 2nd and then Michael 3rd,
and then I'll, I'll bring up the rear. It's great.
Many thanks for the invite. So, uh, game changing papers for me in the last
decade in oncoplastic breast surgery.
Is this working?
Yeah, so the one declaration is the book, but there's no conflict of interest.
The reason I chose those three papers is mainly because things have changed and evolved
significantly. We're moving from radical mastectomy only a few
decades ago now to extreme conservation, and there's not much data about extreme
conservation, and people are very reluctant to conserve certain patients,
especially while the multifocal.
disease and you will not find any prospective data on multifocal multicentric disease I think
except for the Alliance Z11102. So this is a smaller study.
It's a prospective for cohort study that has recruited nearly more than 200 patients,
more than the age of 40, 2 or 3% of breast cancer, at least one focus of invasive disease
that can be not positive.
And they did not change anything in their treatment.
They just conserved the breasts. If they have negative margins,
they continued with the usual radiation and systemic treatment like anything else like
their protocols, and their primary objective was to look at local recurrence rate and the
acceptable 5 year local recurrence rate for them was 8%,
while the secondary objective was the rate of. The conversion to mastectomy,
cosmetic outcomes, and adherence to protocols. They got 3 papers,
one from each for the secondary objective.
The rate of conservation and multifocal disease was successful in 93% of patients.
Nearly 2/3 had negative margins on the first go, and another 25% had negative margins on the
re-excisions. So this is doable.
The cosmetic outcome, because people think, oh, you're taking so much of the breast,
you will not have a good cosmetic outcome.
The second paper they looked at patient reported outcomes.
They were either good or excellent in 70% of patients over two years,
and people are always worried about delivering radiotherapy.
Especially with boost for multifocal and multiple beds of the tumour
and with the increasing radiation, the boost volume was associated with acute dermatitis but
not associated with overall worse cosmetic outcomes and it is doable.
And the primary objective was to look at local recurrence rate and that was presented in San
Antonio this year out of the 204 patients, 6 had local recurrences only.
That's 3.1%. That's much less than the 8% they were looking
for and much lower even if you have confidence in terms it's much lower than the significant
threshold. So this is doable.
A couple of little points from this paper is that in the initial recruitment they all.
Was included MRI scan in the last few months they said you can recruit patients without
doing MRI scans. The ones that had MRI scans,
they picked all the tumours. They had a recurrence rate of 1.7%.
The ones that did not have an MRI scans had a recurrence rate of 22% because they are missing
the tumours. And the conclusion that this is doable,
select your patients, and pre-operative MRI is very important and adjuvant other treatments
are very important. So the reason I chose this because we're
pushing boundaries, and this will push boundaries to Conserving more and more and the
best way is to try to keep the breast, avoid mastectomies.
And if you look at oncology trials, I want to mention two key trials for me.
One is the Catherine trial and one is the one the one is the CreatX trial.
And the reason for that is that when we start doing uh uh chemotherapy,
we're doing it to downstage inoperable to to be able to operate on them.
Then we started doing downstaging the, uh, operable to make them conservable.
Then now we're doing it not for that reason only, we're testing biology.
And PCR is very important to know the outcomes for the patient and also that will change
their outcome, their prognosis, further treatments.
So even the people that are very reluctant to give the adjuvant chemotherapy for certain bio
biologists now, you're giving them much worse outcome.
And if you're giving that chemotherapy, then you're done staging you will conserve more.
So, this is the Catherine, it's a phase 3 trial, it's an open label trial.
What they looked at is the adjuvant chemotherapy for HER2 positive disease.
If you have residual disease, then you have TDM1 or Herceptin.
And they noticed that the patients that had TDM one, the invasive disease recurrence or death
hazard ratio was halved.
So we're giving them much better survival, uh, uh, benefit.
You have much better prognosis.
So it's really a crime not to give them the adjuvant chemotherapy.
And when you're giving them the adjuvant chemotherapy, you're more likely to downstage
and with a HER2 positive disease. There's more than 50% chance of a complete
response, and that might make mastectomy mates also a bit less.
The other one is the Create X, which is a very similar study came from Japan that mainly
looked at triple negatives. So they pooled data for all types of cancers
and very similar to the Catherine, they looked at chemotherapy after.
Chemotherapy, if you have residual disease, they give them Keytibine,
and the triple negatives did much better. They had kids have cap yipines.
So the reason I chose those two trials also because they push people more to give more new
adjuvant chemotherapy, then you're more likely to have smaller tumours.
You're more likely to conserve the breast, and the best reconstruction is to keep the breast.
So biology is king.
When you understand biology, you'll be able to do less mastectomies,
and you do less mastectomies with better surgery.
We are extending indications, but we need more data to be able to extend more and more of
those indications and always use your oncologist.
Your oncologist is a very good surgical tool. It makes you like.
The oncologist will make your life much easier.
They'll make your tumours smaller. You'll do less in the breast,
you'll do less in the axilla. Thank you.
Uh, good morning again.
So I was asked to talk about the game changer papers in breast reconstruction.
I have no disclosures and first of all, I would, I would say that,
uh, in the past 10 years some of the major game changers in breast reconstruction include uh
trends and variations, long term and quality of life outcome studies,
uh, radiation injury, of course, perpetual pockets, mattresses and meshes,
implant-based reconstruction and BA ALCL.
Uh, enhanced recovery, uh, la of filling, free flaps and nipple a real complex neuritization,
lymphedema and robotics, and I think we will see more papers coming out from about these
three last topics in the coming years.
Uh, and then if we look at the, the, the, the game changer papers,
uh, uh, we did, um, we analysed several databases, uh,
but the one that really give us the biggest impact of,
uh, citations and everything is Scopus, um, platform, and here you can see again that there
are several papers, uh, where the.
Capus index is very high, talking about trends and variations in use of breast reconstructions
in patients with breast cancer undergoing mastectomy in the United States.
Then there are some other papers about outcomes again prepectoral B A LCL,
the EAS lapo filling, neurotization, and finally this one about lymphedema,
and I, in the in the interest of time, of course I also selected the three more important
papers that I wanna discuss with you.
The first one is, uh, was published in in JAMA Journal.
This is from the group, uh, from Andrea Pusi where they describe or they mention the,
the, the, the title is Long term patient reported outcomes in Postmastectomy breast
reconstruction. And uh the key points of these papers include
uh the the well first of all, all these patients underwent immediate breast
reconstruction using implant or autologous tissue after a mastectomy for cancer treatment
or prophylaxis.
Uh, it included 11 centres with 57 plastic surgeons across North America.
It's a prospective study and totally they analysed 213 women who underwent.
Reconstruction with implants in the close to 1500 and uh 522 patients had
a total of tissue reconstruction.
So here they use the breast cue outcome to analyse uh uh the the the outcome prior to and
two years after surgery and as we all know, the breast cue includes all these four domains uh
satisfaction with breast, psychological well-being, physical well-being,
and sexual well-being.
And uh 6060.5% of the patients completed the questionnaires at two years after
reconstruction and uh interesting here we can see that initially all patients had a similar
results at least during the first year, but over time the,
the, the psychological well-being changed also the satisfaction with the breast in patients
with autonomous reconstruction it was higher.
And also the sexual wellbeing was better when they use autonomous reconstruction.
So, um, I think the conclusion for this for this paper is that with these findings they we
can inform patients on, uh, their clinical conditions about the expected satisfactions and
the quality of the outcomes uh by using autologous versus implant-based procedures and
this can further support the adaptation of shared decision making in our clinical practise.
The second paper is about the prepectorial breast reconstruction,
the the direct to implant, uh, the safety outcomes and points and delineation of risk
factors. This paper was published in PRS and here,
uh, this, the authors did a retrospective analysis of the,
their, their, their like of the cases operated by two plastic surgeons,
um, they. He did a cohort of 114 perpectoral direct to
implant patients compared to 142 subpectoral direct to implant patients also,
and they, they analyse mostly the complications and uh covariate risk factors that they,
they, they observe uh on the long term.
And from this table you can see that uh what is really interesting is that the incidence of a
capsular contraction uh and revision were significantly different.
It was higher for the patients when they were a pectoral versus perpetual uh DTI.
So this is something that can be a little bit controversial and something we can discuss from
other papers that were published uh from other groups.
And the conclusion of this study is that a perpectorial DTA is safe and actually
uh given the the low morbidity and elimination of the animation deformity,
this perpectorial DTA reconstruction should be considered, uh,
especially when the mastectomy skin flap is robust.
And the last paper is uh again by it's it's about uh BA ALCL.
This is a paper published by Peter Cordeiro and his group from Memorial Slon Catering Cancer
centre. Uh, this is a prospective cohort study where
patients who underwent breast reconstruction by a single surgeon.
Uh, I think this is unique because it's a big number of cases,
as you will see, and, um.
Uh, the primary outcomes were incidence rate per person years and cumulative incidents,
and he has an experience of, uh, with, uh, 3,546 patients who underwent,
uh, more than 6000 breast reconstructions both for cancer treatment and prophylaxis,
and the medium follow up is 8.1 years.
This and, and, and the results show that 10 women develop LCL after immediate exposure of
11.5 years.
Uh, and overall, overall, the risk of, uh, ALCL is uh 1 in
355 women, which is, uh, something that was a little bit high for according
to to to previous studies.
This is the, the, the, the collection of the 10 cases that developed the LCL.
You can see here at what time they developed it, what kind of uh clinical presentation the
patients had. And um and uh the the then he shows that again
the incidence is uh 1 out of 355 patients which in conclusion is higher than
previously reported and this result can help inform implant choice for women undergoing
breast reconstruction.
That's it. Thank you very much. Mm.
So again back to oncology, um, I went through my mind and said what are the papers
that influenced me most in the recent years and I got uh this list but I have to discuss only a
few of them of course. But you can see there's different kinds of
studies. The Mindex study, it's a multi-gen test where
we decide how to use chemotherapy or mainly not to use chemotherapy in many patients.
Then of course the lymph node studies that I showed here,
the ECOSO, the Amoros, TAD is coming up and it is there.
Then a lot of things about neurogen chemotherapy.
It influences our daily practise because we have low low regional recurrence rates.
I will show you that we have a newer regimen.
Uh, and of course we, we treat less, we, we operate less.
We have new surgical margin guidelines. It's not new anymore.
It's 9 years now published.
Uh, but also other things like, like surgery in metastatic cancer.
We had a lot of studies going on there, but there was this randomised trial that showed no
benefit for the surgery of the primary in a, um, advanced cancer.
But then also things like re-irradiation, can you do that?
Uh, can you do a second breast conserving surgery?
It goes into the direction that Yazan showed us, and of course,
uh, Angelina Jolie, of course this influenced us all.
So, uh, one of the messages I want to give is that less axillary dissections will be done or
are being done. And this was based on the EOSO 1011,
and here you see on the left the 10 year outcome data.
I show you the 10 year data because in the beginning the study was heavily criticised
mainly in other parts of the world because it had many,
many problems. But after all, the study was randomised and
even after 10 years you didn't see a thing, a single thing.
There is no risk in not doing axillary surgery in limited amount of axillary metastatic
disease and the other paper, the Amaros trial from the Netherlands and other countries showed
that radiotherapy can compensate for auxiliary dissection.
It's equally effective and it doesn't have that much of a lymphoedema.
So we know, and this was a shift of a paradigm that some tumour will be left in the axilla,
but we don't care anymore because radiotherapy and systemic treatments will take care of that
and we're going the next steps, but the definitive studies regarding this topic are out
there but not not finished and not published.
The next thing is that new advent treatment is in many patients the preferred approach
nowadays. Even if you can do these operations,
we can do oncoplastic, we can do larger tumours, everything, but still,
if the tumour biology is triple negative, HER2 positive, if we have a high probability that
the patient will respond to those treatments, please go first for chemotherapy because we
have PCR rates of up to 70%, for example. Here this is on the top on the
bottom right here. This is from the train to study from the
Netherlands and it's 70% PCR rates and this was a regimen without an intracycline,
so the patient maybe will not lose her hair even.
And the next thing is that we don't have higher local recurrence rates.
We can be safe of that. This is a study from Texas,
from Elizabeth Mittendorf.
She showed in many different stages and groups that the risk for local recurrence is the
tumour biology, what is the tumour and not the kind of the surgery.
And of course, as Yazan mentioned already, these PCR rates or non-PCR rates inform about
our later adjuvant therapy.
A new thing, a quite new thing, is the partial breast re-irradiation.
This is only a phase 2 trial, but still it changed a lot in our practise.
It's a small trial and we have to absolutely wait for more data.
But this group, Arthur was the author, they showed that they could do
90% 2nd breast conservation and after 5 years of follow up only 5% of second
local recurrences, and this is something that we might explore and discuss with some of our
patients and what I want to say is that local recurrence is not any more automatically a way
to a mastectomy. And to finish, of course you all know of this.
I don't have to to to go into detail.
Uh this is just one of the papers that showed that in our practises the risk reducing
mastectomy and contralateral mastectomy rates have gone up,
have have doubled, and uh we we show we every patient who comes to us gets a screening
instrument and then we do genetic counselling, testing, etc.
so this is a huge, huge part of our daily practise.
Thank you. I can use starts
on. OK
Do you guys have the last set? there we go.
So I'm gonna go quickly on mine.
I'm focusing on aesthetics, uh, so these were just kind of,
so there were 6 articles I looked at, but I'm gonna kind of take the 1st 3 and kind of get
into those in a little bit more detail. The the first one I wanted to focus on with
aesthetics is the one that was recently published in the aesthetic journal by uh Patty
McGuire and Carolyn.
Uh, Glickman really looking at whether a capsulectomy has any potential benefit,
uh, in patients who are reporting these BII symptoms.
So this has always been an ongoing debate and the questions like should we take out the
capsule? Should we not take out the capsule?
What's the answer? Well, this is a study that really I think,
uh, looked at some of the key points, so they looked at 150.
Patients, uh, and they took questions of all these patients and then they evaluated these
patients at various points preoperatively and then again at 3 and 6 weeks,
6 months and 1 year and the bottom line was that the type of capsulectomy,
whether it was total intact, total or partial all showed similar symptom improvement.
So when you see these patients with breast implant illness and they say I want an on block
capsulectomy, it's nonsense. You don't, you don't ever have to go there.
You partial mastectomy or partial capsulectomy, uh, or total makes it makes no difference.
The outcomes are the same, so I think this is kind of an important game changing paper.
Uh, the next one was Bill Adams' paper looking at strategies to reduce the incidence of
implant contamination, and I think this was an important paper because they looked at 42,000
patients and they looked at a number of different factors,
and this is where the whole 14 point plan, uh, was really kind of born,
but it's really based on.
A number of studies and best practises. Some of these studies were legitimate
randomised studies, and some of them were just retrospective anecdotal,
but you know, the role of antibiotics and nipple shields and a traumatic dissections,
they're all things that make sense, but he put it all together into one paper,
and I don't know that I necessarily agree with every single point,
uh, like maybe a dual. Pocket playing in some cases that may turn out
fine but as we just heard from Charles Rehnquist sometimes staying above the muscle
may have advantages as well so you know there's surgeon judgement that goes into all of these
things, but avoidance of drains and augmentation, layered closure prophylactic
antibiotics again controversial, but it's based on reducing the risks of uh bacterial
contamination. And uh the final paper that I wanted to talk
about was, you know, we're now practising in an area, an era of,
you know, anatomic preservation, so with perforator flaps and less muscle dissection so
I like this because it really talked about the role of subfascial augmentation combined with
fat grafting and. You know, Doctor Rehnquist talked about how
he's transitioned now to this subglandular plane, whether it's sub glandular or subfascial
it's really just semantics, but the key is that you can use round implants because that's all I
really have to use, uh, where I practise and stay in that sub or prepectoral plane and
combine it with fat grafting and you can get.
Very good results. Uh, they looked at 156 patients,
low complication rates, and really just demonstrated that composite augmentation in
that subglandular plane with round implants and fat can work very well,
you know, so I don't, I in my practise I don't have to use an anatomic implant.
You can still do get good results with with round implants.
So that's that's it. I wanted to kind of make it brief.
I don't know how much time we have for questions because I know we're kind of going
into the uh lunch break, but does anybody have any questions,
anything they'd like to share any papers that really stand out as a game changer in your
practises? Does anybody do any of
the panellists, I think we can kind of cut things short if we kind of run out of time.
I think we've covered the highlights. Is there anything anybody would,
you know, wanna say and, uh, and follow up to what we were just saying that of course there
are many papers that are really game changers, but, uh,
uh, if you look at the at the um.
Citations number of citations or you wanna analyse which have the biggest impact of course
the ones that were published like uh uh in the first years of last decade have more
citations than the ones that were published recently so it's difficult to to to go to take
this as an observation to say these are the ones that really have more impact but I think
that's why we need to analyse them and to.
According to what we know, we can, we, we selected the ones that we thought were more,
more, um, important. Yeah, I mean we can go back to Karl Hartramp
and the tram flap that was a game changer, you know, Bob Allen and the deep flap,
that was a game changer.
Andy Salzburg and pre-pectoral re those were game changers,
and they were 2030, 40 years ago.
So this is, this is a continuum, it's an evolution.
I mean there's gonna be a lot of game changers in the years to come.
Anyway, with that, let's just kinda wrap up the morning, uh,
enjoy your lunch. Oh, there is a question I didn't.
Um, in part of our ERAS programme, we've incorporated two things.
One is a preoperative body wash, so using the Nesquip, um,
surgical site reduction, um, package, which is a preoperative chlorhexidine body wash.
So we've got our infection rate down to less than 1% for both breast cancers and cosmetic
procedures. And also combining that with the use of TXA,
so reducing a hematoma rate.
And readmission rate for hematoma, again, now less than 1%.
So using TXA 1 gramme, 1 intra-opt and two post-ops.
So the two simple things that we've incorporated in our practise from the NEquip
programme, and I think there's a lot to be seen for that.
The Clawhex body wash is 35 cents a bottle, which is pretty affordable.
The hospital's happy to pay for that in our system.
Yeah, and I would agree. I mean TXA is a potential game changer that
really works, you know, so.
I mean there aren't too many things that really work that really works.
So, OK, well enjoy your lunch break everybody. Thank you.