So I'm gonna talk about sitting down and waiting for the next session.
We're a little bit uh um behind.
So we start the oncologic surgery session, and I asked Celia Leo to talk about treatment
options for the elderly and multiple morbidity.
You have 2 minutes I try my best.
These are my disclosures.
Um, I will start with some general aspects on the topic,
and then, of course, we have to consider um surgery in Breton Axilla,
and I will update the evidence concerning radiation therapy in the elderly patients as
well. Now, um, breast cancer incidence is strongly
related to age with highest incidence being seen in older people.
And as you can see in this graph here, every year, approximately 25% of new breast cancer
cases occurs in women aged 75 and older.
So we are talking about a large patient group here.
On the other hand, breast cancer specific survival rates are lower in the age of the
group 75+, and this is in part due to underrepresentation of older patients with
breast cancer in clinical trials. And this, as a consequence,
has led to undertreatment.
And on the other, on the other side, we also have to see,
or, or we see overtreatment that needs to be considered, especially in case of competing
mortality. Now, older women present with more advanced
disease, with larger median tumour size, higher rates of nodepositivity,
higher rates of locally advanced and metastatic disease, and this is in part due to lack of
screening in this age group, but also due to reduced breast awareness of these older women
from the women themselves, but also from their doctors.
Overall survival, and this is predictable, is inferior due to competing causes of death.
But however, it was also shown that that breast cancer specific survival is slower.
With all these facts, um, it suggested that these patients are not being given the optimal
standard of care treatment.
Now, before one starts, one has to ask the question, what age is old age and you will see
also from the clinical trials that there are different thresholds.
So the Oyoma and the um International Society of Geriatric Oncology.
Define old age as being 70 years and older.
However, chronological age is not always the same like the functional age.
So we have to assess comorbidities and also we have to assess survival um before we start a
therapy. Now, in 2021, the OSOMA and the International
Society of Geriatric Oncology SIOG, they updated the recommendations and they
recommend that screening, um they recommend screening for frailty in patients aged 70 years
and older to identify those that are at an increased susceptibility for stressors and
adverse outcome.
And then treatment can be tailored based on grouping of these patients in either being fit,
being pre-frail, or being frail.
Now, before we start therapy, we need to determine the patient's general health status
and her remaining life expectancy.
If you have a healthier, fit, older woman, then the decision is between lumpectomy,
mastectomy, and also between sentinel node biopsy, axillary dissection,
or no axillary dissection.
And what's also of note, older women should not be excluded from having reconstruction.
or oncoplastic surgery.
There are of course no prospective trials, but we don't have any um signs from a retrospective
analysis that there's a problem.
So it's an individual decision based on the patient's health,
her lifestyle, and also her expectations.
In contrast, patients with severe comorbidities and a limited life expectancy below the age of
5 years, it may be best to avoid surgery altogether.
And this is especially true for patients with uh with hormone receptor positive disease.
Here, primary endocrine treatment with an aromatase inhibitor is a good option,
and it has been shown that the median duration of responses,
uh, these aro aromatase inhibitors in this setting is up to 5 years.
So, in patients with a life expectancy of 5 years and more,
however, it has been shown that the local control and also survival benefit was seen in
uh when, when, um, or it was better to start with upfront surgery rather than just doing
primary endocrine therapy.
The isoma and SIOG recommend sentinel node biopsy remaining the standard of
care, sorry, remaining the standard of care for staging the axilla also in the elderly.
And for patients with a positive sent in their no completion axillary therapy is not always
needed. We discussed that before, and this is uh along
the lines, uh, what is in the general recommendations.
However, if it is needed, radiotherapy should be preferred to axillary clearance and
especially in cases with low axillary burden and hormone receptor positive disease,
these are the patients that require an endocrine therapy anyway.
And last but not least, axillary surgery can be omitted in patients with low low risk luminal
A-like tumours or with a short life expectancy.
Now in 2016, the Society of Surgical Oncology um launched their Choosing Wisely campaign and
um their first statement was, don't routinely use anti-9 node biopsy in clinical node
negative women, 70 years or older, this early stage hormone receptor positive HER2 negative
breast cancer. Why?
This is based on evidence from randomised controlled trials that did not show a
difference in overall survival or breast cancer specific survival in elderly patients with
early um breast cancer who either underwent an axillary surgery or did not have axillary
surgery. And I just want to mention the CAGB9343 trial
here. This was A trial in um low risk breast cancers,
where the patients either got, um, a radiation therapy or not.
And in this trial, a large proportion of patients did not undergo axillary surgery.
So, in this trial, we have patients without any axillary intervention,
and still, there were only 3% axillary relapses at 10 years.
It's of note uh of importance to, to state that all these randomised trials,
in all these trials, the patients received adjuvant endocrine therapy.
And of course, antiana node biopsy is appropriate when a decision regarding
chemotherapy depends on the nodal status information.
I want to show you some data.
The, uh, these data were just published earlier this year from the group of Walter Weber from
um Switzerland.
And they looked at their patient population and um looked whether they changed their approach
towards sentinel node biopsy in the elderly after this Choosing Wisely campaign was
published. And um what you can see is that before 2016,
they had 75% sentinel node biopsies in the elderly patients.
And after the um uh recommendation came, it actually increased.
So, The recommendation did not decrease in elderly patients with small node negative
breast cancers.
So why is there still such a large degree of this procedure?
It's certainly an uncertainty regarding the accuracy of chronological age as a procedures
specific cutoff value instead of patient's physiological age.
On the other hand, um, there is the perception of sentinel node biopsy as a low-risk procedure,
and there might also be psychological factors in that it promotes the patient's peace of mind
if she knows that the sentinel node is negative.
And also, of course, we derive staging information from this procedure.
Now, let's switch gears and have a look at the recent evidence for radiotherapy in the elderly.
In this table, randomised trials of hormonal therapy and breast conserving surgery with or
without radiation in older women is summarised.
Before I uh come to the results, I just want to draw your attention to the old age.
So every um trial, defined it differently. In the KGB trial,
you were old when you were aged 70, in the Princess Margaret,
already aged 50 was old.
In the prime 2 trial, the, the threshold was 65 and the ABCSG trial postmenopausal
patients were defined as being older.
Now, the results, uh, all trials have in common that local regional recurrence without
radiotherapy is significantly higher.
However, they did not find any differences in overall survival.
So omitting radiotherapy in low-risk patients can be reasonable.
And um I want to show you the recently published 10 year data from the prime 2 trial.
In this trial, patients after breast conserving surgery got irradiated or did not get radiation
therapy. Women were 65 years or older.
They had a small tumours up to 3 centimetres, all got breast conserving surgery and um
axillary staging, so no negativity was required.
Patient had to be ER and or and or PR positive, and it was required to have clear excision
margins of at least 1 millimetre.
And all patients had to receive endocrine treatment.
So these are the 10 year data, and as you can see here for the local recurrence rate,
after 10 years, 9.5% in the patients that did not get radiation therapy,
0.9% in the patients with radiation therapy.
However, what one can also see is that there was no difference in overall survival,
18.8% versus 188.7%.
So the prime 2 trial provides further evidence um indicating that radiation therapy can be
omitted in elderly women 65 years and older, having low-risk uh tumours
and provided that they receive 5 years of endocrine therapy.
Now my conclusions.
It's necessary to prevent undertreatment, but also overtreatment in this patient population.
Treatment associated morbidity needs to be considered and competing mortality risks can
justify less aggressive approaches.
So we have to evaluate general health and perform geriatric assessment to assess the
frailty and the remaining life expectancy of the patients and then we individualise the
treatment concepts, of course, in line with general treatment recommendations for breast
cancer. Patient preferences and values, life expectancy,
predicted survival benefits, and also potential adverse effects of cancer-related toxicity and
quality of life should be carefully considered.
Thank you for your attention.
Thank you very much, Cornelia. We move right on with,
uh, Ash. Where's he got?
I hear you. Uh, the next topic are the margins,
which were discussed here extensively here, but, uh, bring us some new light on this.
I think I can just sit down because they spoke enough.
I'll try to give you a whistle of uh tour about intraoperative margins,
uh, intraoperative margin assessment, and these are my disclosures.
So why are we talking about intraoperative margins?
Why is it a big thing today? It's because There is now more and more
emerging evidence. I don't believe this paper,
but there is a, there is a body of evidence that says that breast conserving surgery is now
probably offering a survival benefit over mastectomies.
So we are trying to de-escalate surgery and do more and more breast conserving surgeries.
So we need to do the right thing for those patients and remove the tumour completely.
So the problem you have is taking too much, the, the balance of what you said.
If people take too much. So there's an aesthetic penalty that you pay
when you take wider margins, and that's why I need to get a balance.
But does El Dorado exist? El Dorado doesn't exist as you'll see.
Now, the reason why we're taking positive margins as Cornelia said,
is there's twice a two-fold higher risk of recurrence regardless of the age of the patient.
Tamoxifen does help, but when you're talking about omitting radiation therapy,
you're talking about the benefit and the risk of recurrence that may come further downstream.
When you talk about a negative margin, the pathologist, any good pathologist in the world
will tell you what I'm telling you is that there's no grossly positive margins.
There may be a small amount of residual disease in the breast that radiation therapy can treat.
OK. So a negative margin is a negative margin,
taken with a bit of pinch of salt.
Now, if you look at the systematic analysis of margin positivity,
it ranges.
Before the Americans changed the goalpost in 2014 with the SSOASTO guidelines,
they had about a 40% re-restriction rate.
They've come down to 20%. So let's just say it's anywhere between 14 and
20% all over the world. In the UK, it's about 20,
21%. When you do a recision of margins, more than
50% do not have disease, but the patient undergoes that anxiety,
there is a cosmetic penalty. If you put a flap in,
you have to take the flap down, you have to, you have to mitigate for these risks and
obviously a second operation is a, is a, is a risk for infections.
If you look broadly at what's available, you have pathological techniques,
you have imaging, you have optical imaging, you have bioimpedance or radio frequency,
and then you have mass spec uh spectrometry.
Let's just talk about a few of these very quickly because the whistle stop to,
like I said. So the accuracy of frozen section,
frozen section remains in the parts of the world that's available,
the gold standard for them because they don't have lots of the other technologies that are
expensive. And if you look at it, the sensitivity of uh
frozen section and specificity of frozen section is quite high.
So it comes to about 83% and 97%, which is quite high.
It brings down the reoperation rates significantly as you will see in this data.
The problem with frozen section is it does.
Cause some artefacts when you freeze, it takes about 20 to 30 minutes to do.
So if you give them lymph nodes and you give them margins to do,
that's an additional hour. It's a resource that certain countries can not
afford in terms of time.
Uh, it is expensive because it requires a pathologist, it requires a a person to sit
there. So it is obviously draining on resources,
which is, which are very scanty in the, in the UK.
We are a very third world country when it comes to pathology.
We don't have enough pathologists to give us roen section.
If we could, then that is something that we would consider.
If you add imprint cytology, which is basically taking the,
the, the, the tissue and rolling it on a slide, the, the cancer cells are not cohesive,
they're discohesive, so they'll shed, and you get imprint cytology,
which is also done on core biopsies, by the way, with the 98% concordance.
You get almost the same concordance that you get.
So it adds value.
If you do an um an imprint cytology and a frozen section,
imprint cytology in its own, if you see, does add more value and reduce negative,
the, the reception rates.
More if you add both together, OK? So decrease from 27% to 6% if you do both
together. So it's a significant.
Now 27% is not 27% of all, it's 27% of the positive margins of frozen section,
which is a small number anyway.
Intraoperative ultrasound scan.
It's noninvasive.
It's easy to use. There is a learning curve.
You have to spend time. I know Stefan does interoperative radiotherapy.
Lots of people do it. Uh, you use interoperative radiotherapy.
uh Isabella, uh, Rubio uses it. Lots of people are using it.
It's a very cheaply available tool.
It's there. It's no cost, no radiation, no problem with
scheduling. And if, if you compare it to the standardised
one, which is the wire guided and the uh roll technique, you have a significant 3.7% versus
21% and 25% for wire guided.
So interpretive ultrasound scan is an available technique.
It's a cheap technique.
And the results of interpretive ultrasound scan, better cosmesis from the cobalt study,
because you're reducing your margin of your volume of excision,
because you're now less worried.
So you're doing an in vivo assessment and then an ex vivo assessment as well as the margins,
and that's how ultrasound scan works, OK?
I'm not reading the data out to you because that's something you guys can read,
but you need to understand why an ultra ultrasound scan is important compared to
everything else. But again, you have tumours like lobular
cancers, which are not very well seen on ultrasound scans.
So what would you do with that? What would you do with microcalcifications?
Now, clever companies like Canon have added philtres and added frequencies and then come up
with this micro pure system that shows you microcalcifications.
So there is an ability out there to hone the ultrasound scan even more to give you better
results, OK?
It comes second to frozen section, if you look at frozen section print cytology.
Then you've got the result, sorry, this is.
We shouldn't come to that. At the moment we've got this,
which is mammography.
So, we know that intraoperative specimen mammography is compared to taking the specimen
up to radiology, saves time and is also as accurate.
So get something in the OR is the message.
Now, what can you get?
You can get a facitron, which is basically A 2 dimensional view of a three dimensional organ,
which is what a mammogram is.
Mammograms, two dimensional mammograms don't pick up as much.
I'm not reading off the slide. You guys can read off the slide.
I'm just telling you what I, what I, I'm made out of this.
So two dimensional mammograms are criticised because they don't pick up or not as sensitive
enough. And that's the same problem that you have with
the Faxitron. You have a pancake phenomenon,
and with the pancake phenomenon in a two-dimensional, you'll always feel that the
margins are closed. You need to do an X-ray if you have
microcalcification, if you have clips, if you have coils,
because if the patient goes to court and says the wrong thing was taken out,
you need to show an X-ray and say, no, this is the right thing that was taken out.
It says 0 from the start. Are you see someone timing me?
The time is 000 from the start, so I don't know how long I'm taking.
OK, fine. Let's just go through this quickly.
So the answer to that, when we did for mammography, you have three dimensional,
uh, mammograms that came in. You have this machine called CupTech which is
upstairs. It takes a three dimensional view or digital
mammogram of your, your specimen.
If that's exactly what I'm saying in a two dimensional view,
that will project as that. You don't know at what level that is.
But in a three dimensional view, you know exactly where to take the margin,
and that's the benefit of having a three dimensional.
So, it does reduce your re-excision rates and you have a more directed targeted uh
re-excision, so you have less volume, better cosmesis.
Then you have the micro CT if you look at all the data of all the three,
unfortunately, ultrasound scores the top.
You have Clearcose, which is upstairs again. It's an MRI specimen MRI scan.
You take the specimen, you put it in that, you create a vacuum,
you paint it with all the margins, create a vacuum, and then you look at the images,
the images come up like this, this, this, these, these are pixels,
and you know exactly which one is red. That sensitivity has been set up by,
by studies done by Stefan Martel and other people in Israel.
So you know that that's the area that you need to reexcise and that is good concordants.
If you look at there, that's all there for clear sight,
clear coast. It used to be called clear sight,
it's called Clear coast. Don't get confused,
it's the same thing. Then you've got margin probe,
which is also the upstairs. What it looks at is radio frequency to measure
electrical impedance. And it looks at nuclear morphology,
membrane depolarization, tissue architecture, and then tells you how how how close your
margins are. So when the studies were done on this,
it was a fairly good study.
But what they concluded was that it can be used as an adjunct to what you already use.
So if you use CTech or Clearcot, then you can use this as an adjunct,
not as the uh modality.
And then someone mentioned this, which was Luiseel or Molly,
same techniques. You've got uh a dye which is injected,
it's patented, you don't know what it is.
You have a camera that measures the fluorescence, and that's how it looks.
And if you have these other margins, you excise them.
So the specificity is 85% sensitivity is quite low.
You don't know whether any uh uh artefacts will count for this.
They haven't looked at it. I spoke to these people when they were when
ASBLS but they don't have that data. It's fairly new.
And then you've got Histolog, again, something that Stefan,
I'm keeping on pointing him because he does lots of novel research.
So Stefan, Mark and everyone, we use it the guys Hislo scanner again.
It's uh ultrafast fluorescence confocal microscopy.
I hope you all know what confocal microscopy is.
So it looks at the specimen as a pathology, a slide looks like.
If the pathologist looked at it, they had very high concordance of positive negative,
but if you had the surgeons look at it when they started,
because there's a learning curve, you're not a pathologist, you're a surgeon.
You know when to cut grossly.
I don't, I still can't make out blue and red. I just look at it and say it looks lovely.
So that's If you look at that, as the, as the study progressed,
you had more and more uh of concordance with the surgeons.
So histolog scanner is something that is good as well.
And then this is something that we did at Guy's Hospital using PET scans and positron emission
tomography, but what we used were the Chenikov of the photons.
So they emit blue light, and we looked at the blue light fluorescence and not the,
not the pet, but obviously, this includes radiation, it includes one hour,
the patient has to sit in a room.
It's expensive. Anything to do with radiation is not something
that I like, but I did the study, so I have to show it.
Uh. We had a very good concordance.
Again, we had a problem with using diathermy. You had to use a knife,
you couldn't use diathermy over 40, you had to bring it down to 20.
So the, the company is working on all this, and hopefully, we have a new trial that's going on
with CLI, which is CLIA with a handheld probe, and we'll be able to publish.
At the end, to summarise, uh, there's a lot to cover.
I haven't covered micro CT and stuff like that because these are all and spectrometry because
these are all experimental. These are the ones that you could look at,
if you're looking at it now. So, If you use something that works for you,
stick to it, look at what's available, see how cost effective that is,
see how beneficial that is, and then adopt it. Don't just blindly adopt technology.
Use before you buy, try before you buy. If someone wants to try a new technology,
ask them to loan you the machine, do your own audits, compare it to standard of care,
and then, and then spend the money.
And you should be able to audit your results and reduce your margins because in the end,
the patients will benefit.
So, this is a very fast whistle stop tour because there's a lot to cover from the
discussion in the morning, I still haven't touched the surface,
but that's all I have time for. Thank you.
Thanks, Ash. Uh, the next, uh, talk will be about
roboticocystic mastectomy from Antonio Tresca.
Uh, I have, uh, Uh, so the first question is, uh, uh,
robotic mastectomy, is it feasible?
Uh, because I think nobody here, uh, have already seen,
uh, this kind of procedure.
So let me show you a very short video.
Uh, the concept is that we want to do a mini minimally invasive mastectomy with a
very small incision hidden, uh, uh, from the, uh, patient's bra.
So it is not visible for the patient when she look herself at the mirror.
So the incision is a maximum 3 centimetre.
Uh, if not, we will lose the cavity. So we have to reduce as much as possible the
incision and we use 2.5 3 centimetre incision because the breast doesn't have um
um a normal cavity, uh, uh, natural cavity, we have to,
uh, dissect the subcutaneous tissue.
Uh, to introduce the, the gas and the ne cavity and to work with the robotic endoscopic
instruments. Uh, so we create some, uh, we, we use some,
uh, uh, um, saline solution with adrenaline to reduce, uh,
bleeding, uh, during, uh, uh, the initial procedure.
Uh, we create some tunnels, uh, with a closed meal.
Uh, this is a blind, uh, this is a blind procedure, and we just use it to,
uh, to, um, to let the gas, uh, go in the subcutaneous area.
Then we use a monoport, which is, uh, a study for peri umbilical laparoscopy,
but we use it for a mastectomy.
Then, uh, we dock the da Vinci XI robots.
And uh uh then the endoscopic part of the operation can start.
Uh, you can see in a transluminations the, uh, uh, instruments inside of,
uh, of the breast, and this is the vision. Imagine that you have a 3D vision,
uh, with the colours are very brilliant and, uh, how can I say,
the vision it's very, very comfortable, much more than in an open technique.
At the beginning, I was scared about vessels, and when then I understand that this vessel
usually you can't see it in open surgery.
So, uh, the time of, of endoscopic operation is done.
If the gland is big, you have some problem to remove the gland because the incision is very,
very, very small. This case was a C C breast and,
uh, uh, actually at the beginning in 2014, we were used to make a reconstruction with the
retropectoral implant actually.
Uh, the majority of our patients undergo to, uh, prepa or or reconstruction without the mesh.
Uh, we use a polytech implants at the moment and the operation,
uh, uh, uh, is very, it is feasible.
But uh tell me something, uh, do you like this uh uh this patient?
This is the same patient of the movie.
Well, there are some defects as you can see, uh, but uh you can also see the incision there on
the right side, on the, on the.
Here you can see a little uh small incision, but I think it's a good result.
This is after one year.
Is it safety in terms of uh in terms of uh surgical outcome?
Uh, well, uh, International multi-entered bullet analysis enrolled a total of
755 procedures, 755 uh robotic uh mastectomy,
and, uh, um, all patients underwent to die.
To implant reconstruction. Unfortunately, the reconstruction type was uh
uh this homogeneous.
Uh, some patients underwent to retropectora, some patients underwent to prepectora.
Some patients underwent to, uh, other kind of reconstruction, then we will see later.
But at the end, uh, robotic nipospering mastectomy had a favourable surgical outcome
compared to open.
This, uh, uh, is also confirmed from a meta-analysis, uh,
uh, very recent meta-analysis, even if in the randomised control trial,
the, uh, complication rate between group open and group robotics were exactly the same,
uh, but in a case control study not randomised, uh, uh,
there was a, a sort of, uh, um, uh, lesser rate of necrosis,
uh, uh, in the roboticospheric mastectomy group.
Uh, and what in terms of oncological outcome, because, uh,
you know, we are not, uh, doing surgery to do surgery.
We are we are doing surgery to take care about patients with breast cancer.
So I don't have a um a clear response of that, but this is the most significant result we have
in uh in our, in our experience.
Uh, in a randomised controlled trial, the median follow up actually is 4.5 years and
there are no differences in terms of overall survival in terms of disease-free survival for
invasive breast cancer.
Uh, uh, in this randomised controlled trial, um, we, uh,
firstly evaluate the, um, quality of life outcome and not the oncological one,
because, uh, the two groups in this study were very, very small because we had 40 patients in
the open arm and 40 patients in the robotic arm.
So established, um, oncological outcome in this is so small group,
it's not, sorry.
It's not so easy, but it's something that we can observe in this moment.
Uh, the randomised controlled trial was closed in 2019,
and, uh, this is one of the most important results of this,
of this randomised controlled trial that wanted to establish why we have to spend more money
for robotic mastectomy.
And uh let me say that we use some validated questionnaire.
This questionnaire, the upwards body image scale is the one who is recommended by the RTC
all of you knows and uh in this uh uh questionnaire which is comparable with other
studies, of course, um uh let me say that the blue oops,
the blue one, the blue one is uh um um the um
uh.
So Sorry, I don't remember.
The, yes, the, the blue one is the open surgery and the red one is robotic mastectomy and you
can see, uh, a statistically significant difference you know,
overall, uh, in the overall quality of life. And this is after one year and uh it's a very
good uh good results.
In terms of a breast cu that I know, uh breast cue is not the best questionnaire that we can
use, but we have to use some questionnaires.
And uh as you can see in the rectangle is a robotic mastectomy.
And the patient after surgery feels like, like before surgery.
As you can see in Blutaggle, uh, in Blutaggle, they feel,
uh, uh, after the, the surgery, they feel like women that had to go to a mastectomy.
And this is a very important result and these results are statistically significant for what
concerning sexual well-being and satisfaction with the breast.
And this result is also after one year, and this is a very impressive result.
Uh, but, uh, how can I learn to do robotics if I, if I want to start?
Uh, there is a, a robotic mastectomy guide, so you can start studying,
you can start, uh, studying all the procedure from the beginning until the end.
You can go to, uh, cadaveric uh uh lab, but after coronavirus,
we had some problem with cadavers, so we stopped this procedure.
Because we couldn't use in Italy or also in Europe, we couldn't use cadavers because of
coronavirus, so we moved to the master trainer that all of you know that it is used to learn
in plastic uh reconstructive surgery.
So we started to use robotics on a uh master trainer, and that was a very big success.
Can you see this is the uh inside parts uh and it is lovely and funny.
If you want to master classes, uh, I have a master class in Italy.
Uh, the next one is, uh, in, uh, Paris with uh our friend Benjamin Serfaty that all of you
know, in, uh, uh, Gustavrossy, and it will be, uh, next,
uh, next, uh, uh, summer.
And, uh, what to say.
What for? So we have to say that uh this operation is
approved uh in Europe.
Uh, and it is approved for prophylactic mastectomy because,
uh, oncological data are still not so sure.
We have still have to wait sometimes and enlarge, uh,
the, the cases to be very sure that there won't be differences between open and robotic
mastectomy. Uh, many, many people came in Milan,
in Paris, uh, in the places where they do robotic mastectomy to see,
have a look, to touch with their hands and uh to have a,
a personal opinion.
Uh, I had, we had my group had the opportunity to go to teach around the world robotic
mastectomy during these 9 years and actually if you want a robotic mastectomy,
you can go in one of the city and ask for a robotic mastectomy after 9 years.
It's uh this is the uh uh situation and uh these are the important studies
running in North America, in Canada.
In Mayo Clinic, MD Anderson, and some other, other, um,
important hospital in US.
And also they are studying at the next generation robot which is called SP uh system.
And what about SP system? We moved some years ago to uh Cadaveric models.
We, uh, developed a robotic mastectomy guide also for SP which is pretty ready,
and we started with also Benjamin Serfaty, some very crazy mastectomy on a cadaveric models
such as peri umbilical mastectomy and so on, which, uh,
which have some problem to be uh uh to make a reconstruction because you cannot make.
Yes, but there are many, many people needing, uh, um,
double mastectomy for g gynecomastia. It doesn't want to make a reconstruction data.
So, uh, could be also an indication for that.
This is the new robot.
It's a single tube of 2 cm, 2 centimetre where you can have the camera and they have a snake
movement and you can have 3 instruments in 2 centimetre.
Uh, so can be available also for breast of this kind of surgery,
but We are just at the beginning.
Can you see this? This is a crab.
This is a robot and it, and this is a pen, OK?
Uh, what is happening in our world is that, uh, um, research in terms of uh
magnetization, robotization and so on is going very, very fast.
So we have to be there to understand how can help us that want to,
uh, beat breast cancer.
Finally, Next, so we uh went to a reverse expansion.
There was a very good presentation yesterday on that, so all of you know it,
and this is the result.
Right or left, it's one mastectomy.
It's right. Thank you.
Thank you very much. Please,
Antonio, have a seat with us.
Thank you. Fascinating.
So we're coming to the last talk before we might have some minutes of discussion.
Uh, I would invite, uh, Maurice again, uh, for the nipple sparing mastectomy and the
challenges in the large optic breast, please.
All right. OK, perfect.
I'll have to go kind of quickly because of time considerations, but I'm gonna talk about uh
mastectomy techniques to preserve the nippleloreolar complex and the not so simple
patient. It's not going to be the run of the mill
mastectomy. These are gonna be more challenging cases.
These are my disclosures.
So, some patients with large breasts want to preserve the nipple,
but we all know that the blood supply after a mastectomy to the nipple with standard
techniques is going to be very compromised. So we have to try to do something in order to
make that uh be oncologically safe, but also anatomically safe so that we can preserve
perfusion. So what are some of the options?
Well, you can do simultaneous mastectomy.
And reconstruction in some patients, but you have to have a,
have a, a plan for the mastectomy. It has to be the right skin design.
Uh, maybe it'll be a super real or excision like a bat wing excision pattern,
uh, above the reel extending out laterally, or maybe it'll be an infrare or vertical excision
to lift the nipple areolar complex, uh, or maybe it'll be an inverted T type of pattern or
maybe uh a free nipple graft where we do the mastectomy reconstruction.
And put the nipple back on as a graph assuming it's staged,
or safe. And then there's stage techniques where we
might do a reduction or an oncoplastic procedure first and then come back uh and
do the mastectomy before the patient may or may not need radiation.
And there's the concept of a nipple delay, which was,
it's not new, it's been around for quite some time.
Doctor Giuliano kind of described this years ago, but it's still something that can be
considered. Uh, so the way a nipple delay works,
um, Is that you would make an incision either below the nipple and then undermine the nipple
to disrupt the deep blood supply so that the nipple now gets used to surviving on its
peripheral circulation.
Very simple concept.
That's basically how it works. This is basically the technique.
You just make a vertical infrarear or a subarear incision and then just with a blade
just divide everything underneath it. The nipple will still stay alive because it's
got its subdermal plexus keeping it going.
So the Mayo Clinic, these are, this is an old paper.
Well, this is a paper from 2013, but a lot of these patients were operated on in the 60s by
Doctor Woods, who was at Mayo Clinic doing nipple sparing mastectomies way before it
became popular in the United States.
And he was basically doing inverted T techniques with nipple preservation.
He was making an IMF incision with periaolar deepithelialization.
And his complication rate was pretty low. You know,
it was about 2 out of 64, so, you know, less than, uh,
less than 3%, uh, and partial nipple necrosis was probably in the 5 or 6% range.
So pretty good results and you know, these were the techniques that he was using.
Kind of an inframammary type approach that you can see there with periareolar excision and
then inverted T techniques with nipple areolar preservation on a deepithelialized pedicle,
which, you know, we'll kind of get into and these were some of his results.
Uh, looking at patients who had mastopexy type, uh, mastectomies with the subsequent
scars, you know, the top patient is a patient who is symmetric,
the bottom patient is asymmetric.
You can modify your techniques based on how much skin you removed.
It's pretty straightforward, but you can get nipple survival if you uh exercise proper
technique. Um, Scott Speer at Georgetown did the staged
approach where he was doing a oncoplasty or a breast reduction,
uh, before mastectomy.
And he did this in about 24 breasts and again had good results.
There were some patients that had partial nipple necrosis,
uh, but it was a, a nice strategy and we would wait at least 4 weeks after that oncoplastic
procedure or reduction before we would do the nipple sparing mastectomy.
The longer you wait, the better off you are, but 4 weeks would be the absolute earliest that
we would consider. Otherwise, there's just too much inflammation
and uh you may have some problems with the nipple, and these were just Um,
his, his patients preoperatively, uh, this patient was gonna get a,
a circum vertical mastopexy. Here she is following the circumvertical
mastopexy.
Here she is preoperatively for the nipple sparing mastectomy and then tissue expander and
then ultimately implant reconstruction.
So a staged process, it is an extra operation, but that way you get to safely preserve the
nipple areolar complex.
Free nipple grafting, not a, not a new strategy, uh.
Your previous experience with 3 patients 5 graphs.
This is just a published report in case anybody wanted to have access to it,
but it's a pretty straightforward operation. Just make sure that you defat that nipple quite
a bit. And then this is the dreaded complication of
nipple areolar necrosis or partial nipple necrosis, which whenever you do these things,
you have to talk to these patients about this risk.
Just some clinical case examples. I'm gonna go through this quickly.
This is a patient who's going to have a supra areolar skin excision.
So I'm not a big fan of uh incisions that are going adjacent to the areola because sometimes
you will have some delayed healing because you're disrupting that subdermal plexus and in
a more ptotic breast, you are going to disrupt the blood supply perhaps a little bit more than
what some of the other techniques. So we're gonna do this in two stages.
Usually it's just a simple incision pattern. The mastectomy is done.
We typically will, you know, do these in a sub-pectoral plane because of the blood supply
issue. I will come in and then excise additional skin
based on how I think we need to re-drape that mastectomy skin envelope and then close
everything like this here.
And then here she is 2 weeks post-op. I show this because sometimes the reality is,
is there will be delayed healing of the nipple areolar complex,
but luckily this was all superficial.
Uh, so you can see what she looks like at 2 weeks on the right and left side.
Here she is a month out, she's almost healed, uh, and here she is at 6 weeks,
and, you know, she's essentially healed. So the nipple has survived,
not a great result, but I just want to show you because I don't have too many of these
supraolar excisions, but you can see what she looks like post-op 6 weeks and then pre-op what
she looked like as well.
Uh, vertical excision. So sometimes, you know,
when you do a vertical excision mastectomy, you're taking an ellips out like this and then
you're closing it in a straight line. What that does is essentially lengthen the
inframammary portion of the breast and raises the nipple areolar complex.
So when a patient with ptosis like This you could get nipple elevation with an infrareer uh
excision. Now you should also do a nipple delay in
somebody like this if you are going to do that approach, just so you can increase the
likelihood. So the delay is done beforehand,
the excision is going to be an ellipse.
Here she is preoperatively and if you look at her measurements,
her sternal notch of the nipple distance was 27 centimetres on both sides,
very otic, not, it's gonna be a risky nipple spraying mastectomy through traditional IMF
approach, but with this infrareel or excision following nipple delay,
you can do the mastectomy and then what you can do is that you have a lot of mobility of that
mastectomy skin flap. You can place your tissue expander.
And then you can re-drape the mastectomy skin over that expander,
position the nipple where you want, and get good healing,
and then come back and do fat grafting, permanent implant placement.
And then you can get a breast now that's no longer toic where the uh nipple arear complex
has been significantly elevated. So now she's at 22 centimetres.
So we got 5 centimetres of nipple elevation using this technique.
Inverted T mastopexy. Uh, so this is a patient morbidly obese,
BMI of 38, wants mastectomy but also wants nipple preservation.
Normally, we would say it's not a good idea. You should just have a,
a skin sparing mastectomy.
But we were trying these new techniques and uh decided to do this through an inverted T
approach. So I draw the marks.
Uh, and we get everything teed up. OK. So basically what we'll do is take her to the
operating room and I'm going to start the operation for the breast surgeon where we'll
make an incision around the nipple areolar complex.
I'll completely deepithelialize this area to be excised with the The surgeon will then do the
mastectomy through this upper incision extended all the way out and leave that entire
lower mastectomy skin flap deepithelialized on a pedicle.
So this is what it looks like afterwards.
OK, so this is the frontal view and then this is the backside view.
And you can see here the critical portion is to not undermine here.
So if you go below the inframammary fold and divide those intercostal vessels,
especially the 5th anterior intercostal.
Then the likelihood of keeping that nipple alive is going to be significantly reduced.
So the key is to try to maintain perfusion by maintaining the integrity of that fifth
anterior intercostal. And we, we've studied this,
we've looked it up. It's a vessel that exists and you can confirm
its presence by doing perfusion imaging. So whenever you do this technique,
I highly recommend perfusion imaging and you know, one of the things to um Keeping,
so you kind of look at the inflow.
OK, so everything is lighting up, the ICG is fluorescing, the nippleurear complex is getting
inflow, but you also want to make sure it gets outflow.
So what you end up doing is you just follow it over time and you can see how it now it's
starting to fade as I advance the movie.
So blood's going in, blood's coming out. If it's just one,
if it gets in but can't get out, the nipple's gonna die.
Uh, if, uh, it retains the dye at full colour, it's just not draining adequately and the
nipple's not going to die. In that situation,
just take it off and put it on as a free nipple graft or just do it as a skin sparing
mastectomy. Uh, so here we are, we've got everything back
in place. Here she is immediately post-op.
Here she is postoperative day 3. I wanted to show an early post-op because the
nipples are viable, the right one's struggling a little bit,
the left one looks fine, and then at 6 months, looks like she had a breast reduction.
So, implant-based reconstruction, nipple sparing and severe mammary hypertrophy.
Staged oncoplasty. So this is a patient who's going to have a,
uh, she's uh got left breast cancer. We're gonna do oncoplasty.
We're gonna do reductions on both sides in preparation for nipple sparing.
So we've got our inverted T patterns marked. You can see where her tumour is on that left
side, upper inner quadrant.
Here she is following. This is postoperative day 3.
Things are still a little swollen, a little bruised, but the nipples are alive.
Here she is now 6 months later, we're gonna do a nipple sparing mastectomy through an
inframammary incision and we're gonna do bilateral deep flap reconstruction.
You know, here she is postoperative day one, so you can see that everything looks alive.
The inframammary incision is healing, and then here she is 1 year out.
She's had some weight loss, but uh, you saw how large and otic she was preoperatively.
We've significantly reduced the breast, and we've maintained the original nipple areolar
complex in its original position.
Another patient. This is a woman who's had a previous reduction
5 years prior.
Now she's got right breast DCIS. She wants nipple preservation.
Uh, she's got significant hypertrophy, very dense tissue,
kind of a risky, uh, nipple sparing mastectomy.
Now her upper pole, lower pole ratios, her nipple is very high.
So her upper pole ratio is about 35%, lower pole ratio is about 65%.
So the question in your mind is, gosh, can we save the nipple?
Can we not save the nipple?
So we went. In the operation thinking we'll try to save it.
We'll do some perfusion imaging. We'll see what happens.
We'll approach it through an inframammary incision.
If it doesn't work, then I'm gonna convert it to an inverted T type pattern just so we can go
ahead and contour the breast so it looks more natural.
But we are gonna do intraoperative spine.
So again, you know, we do imaging mainly just to make sure that we have
perfusion. Oh.
I wonder why it's not. Yeah.
You, you're gonna have to trust me on this one. There was perfusion,
but I was not, it's so funny cause it always worked, but now it's not uh.
Any anyway, that is strange. But anyway, there was perfusion to the nipple
arear complex.
So, uh, What we ended up doing was doing a horizontal wedge excision.
So it was about an 18 by 5 centimetre area of the lower pole I excised.
Just to redrape the tissue and that way I can position the nipple right in the light right
location. So now our upper pole, lower pole ratios are
about 50/50. So when you look at the nipple on side view,
it's about the mid portion of the breast. It's not the upper portion of the breast.
So save the nipple, plus we made her look significantly better.
She's thrilled with this. The only, I just did this case maybe 6 weeks
ago, but I wanted to include it.
And finally, free nipple grafting. This poor lady,
um, she's only 33 years old, gestational macromasia, extremely painful breasts.
They never went back down after she delivered a child.
So the plan on her was to do a subcutaneous Goldilocks type mastectomy with free nipple
graft because that's, and she, she really wanted to do everything to try to save it.
We kind of went in thinking we can do it as a reduction.
There's no way you can do a reduction on somebody who's this dense.
These breasts are so dense. It's, it, it's almost difficult to even get
through with a cautery or a blade.
So we did this through an inverted T approach. This is the,
you can see the weight, 1765 and 1810, but this is what she looked like.
Uh, you know, a couple of weeks after the, uh, uh, after the nipple graft,
and then this is what she looked like one year post-op.
So a significant implant, you know, a much more natural breast,
essentially had a mastectomy with free nipple grafting.
So in that large ptotic breast, free nipple grafting is an option.
You know, bottom line is you can do nipple sparing, uh,
in a largerhotic breast, you are gonna have to come up with the right strategy.
Maybe it's gonna be a nipple delay, maybe it's gonna be an inverted T.
Maybe it's gonna be a free nipple graft. You have to talk to the patients about these
options. If the breast surgeons and plastic surgeons
where I work, you know, we've discussed these things and,
and, and then move forward.
Thank you very much.
We have time for 1 or 2 quick questions from the audience,
please.
Let's talk. Oh yeah, no, microphone is not working.
No perfusion. The shout the nipple lived maybe.
They are criticising it because of the decisions they are doing it because they get
bored of the standard one or the routines.
And also because of the scar, does it worth it? Like, do we need as a surgeon to go to more
complicated, uh, approach, uh, just for the scar or not,
you know, some surgeons they are doing thyroidectomy through transaxillary approach.
Uh, and, uh, also regarding the quality of life, I can't see what this approach should
offer uh more than the standard one to have a better quality of life.
How did you measure that?
And uh also to be fair, I think you need to tell us about the timing and the cost comparing
to the standard. Thank you.
Thank you. Thank you very much.
So this doesn't work.
Um, thank you very much. Um, well, uh,
regarding the, um, type of, uh, type of measure for satisfaction,
uh, after, um, after, uh, a robotic mastectomy, um, we usually the
standard questionnaires, the pros, uh, like, uh, breast cue,
like, uh, the body image scale, the hops with, uh, questionnaire,
other authors, uh, use other questionnaires.
Uh, it is clear that there is not one way to measure the satisfaction of the patient,
and each way to measure the satisfaction of the patient, uh,
can fail. So, uh, we know it.
And, uh, I agree that, uh, when I offer to a woman I mean invasive,
mastectomy, uh, she will be, uh, after the operation satisfied because she,
she think that she, she had the, the best way to.
But this is enough.
This is enough for a woman that wants to have uh the less invasive uh mastectomy.
So if you want to prove, you cannot.
Uh, 2nd, 2nd question, uh, some surgeons prefer to do this,
some surgeons prefer to do that.
I totally agree. I have my, um, also, uh, uh, I do my choice
every day. Uh, when I do an open mastectomy, I choose one
incision, then another, because I prefer that or I prefer.
So there is not one way to do things, and I agree with the surgeon that I'm not comfortable
with robotics even if they have never tried, but I can understand.
Uh, for the last question, uh, what about the costs?
Uh, the costs, uh, are, you know, different between, uh,
uh, countries, different inside of a country are different between hospitals.
So, uh, we conducted at the European Institute of Oncology in Milan as a study in,
in our hospital, and, uh, uh, the medial cost for an open surgery with
reconstruction was for, uh, unilateral mastectomy.
Uh, was €3800 and for a robotic it was 7000. So the
difference was, uh, uh, something like €2200 for a,
for a robotic mastectomy.
And every time I ask to the women here, uh, can you give me €2200 to receive a mini invasive
mastectomy? And everyone responds, Yes, I will.
Uh, you have to think that I come, uh, in a country where we,
uh, for Christmas, we do, uh, Christmas lunch and we spend €2000 for Christmas lunch.
So it's to say that in some countries the value of a robotic mastectomy is acceptable.
The cost of robotic fasting and duration of operation, the in the randomised controlled
trials, so for an expert keep, not during the learning curve,
the duration of uh operation was 3 hours and 30 minutes, uh,
from skin to skin with the reconstruction.
And uh there was a difference, statistically difference between uh uh open and robotics.
The open was 2 hour and 18, so the difference is 1 hour and 18.
What we take from your answer is if we do robotic surgery,
we have to skip Christmas lunch.
Exactly, exactly. OK, that is the last question,
but excuse me, a short question question and very short,
very short question to Mr. Tueska.
I don't know if some of you remember, but uh, 20 years ago we started to do axillary
dissection with endoscopic technique.
So we learned the technique, we use that, but we had to stop.
A few years because we have some relapse on the skin and some relapse under the skin and the
axilla. So, in my opinion, the robotic is really nice,
but I think you have to make a difference between prophylactic and cancer.
And you know there is a grey zone between cancer cells and CO2.
So do you have enough follow up time to be sure that there is
no risk in the cancer patients, not prophylactic, as,
as we have. With the axillary dissections through
endoscopic 20 years ago because I, I totally agree as you know,
uh, as you know, uh, follow up for breast cancer must be long,
long and long so we still don't have data on the longer terms.
We just have, uh, the first results of this very.
More randomised controlled trial which say that it is safety but also we have some other uh
other uh trials with consecutive patients and the follow up the medium follow up it's around
4 or 5 years.
It is not enough and the volume of patients enrolled in this technique is not enough to
answer this question. But CO2 is the same that they use for all the
oncological endoscopic surgery. It means in the abdomen,
in the thorax, in the, uh, uh, oral cavity in that they use,
uh, CO2, it is the same CO2.
Today there is not a hospital that doesn't perform a,
a resection of the colon with endoscopic surgery, pancreas,
liver, everything with endoscopic, and in terms of kind of tumour cells,
the uh epidermal, uh, uh, cells.
Also, other, uh, similar breast cancer are, uh, eradicated with endoscopic surgery.
So why it should be different?
Why there is no evidence in literature that CO2 is against,
uh, against the, uh, the, the surgery.
Um, um, I, I agree with you. I'm sorry, sorry,
we, we have to stop now. Sorry, is it laparoscopic is similar to the
laparoscopic colon resection. You just take it back and you take it out and
everything is OK. There should be no problem.
So we have to close the session now. Thank you for the experts to tell us your
expertise and thanks for the audience. Thank you.