Thank you so much for coming and welcome to this oncoplastic uh surgery session.
I'd like to introduce the first uh speaker. It's Ash uh Kotari,
and he will speak about intraoperative confirmation of resection margins and review of
the imaging devices.
Thank you, Ash. We, we don't have
another monitor today, next 10 minutes talking about intraoperative resection margins and
review of imaging devices. I don't know why I put if imaging devices.
It's off my disclosures again won't interfere with anything I tell you.
So we all know as breast surgeons, and I'm hoping the majority of your breast surgeons,
why it is important to have clear margins. We know it's important to have clear margins
because it prevents local regional relapse despite radiation therapy.
So even if you give radiation therapy and we talk about this in the end a little bit more
and you have positive margins, you have a higher risk of relapse.
Now we also know from histological studies, which were done way,
way back, that if you remove the tumour.
You don't leave a breast without cancer. At least 40% of them will have more cells
somewhere. We also know that the index quadrant is where
most of the recurrences happen despite clear margins.
So the clever people have said that there is residual cancer cells there,
but radiation therapy look after that.
And now we also know that it's not just having a cancer,
it's a biology that takes precedence.
And does the biology change recurrence?
And we look at that as well.
So whenever we go back and do a ression of margins because the pathologist says,
oh you're closed or your margin protocol, uh, makes you go back,
you find. This happening depending on your centre said
guys, it's about 14% when we go back for all cancers.
And that's across 5 surgeons, but if you look at his uh data,
it can go from 14% to as high as 40%.
So that's a lot of needless surgery to go back because when you go back 50% of your patients
will not have clear margins and interestingly we looked at guys' data now.
We do it every year, so we have a day where we look at all our data.
And our reception margins for invasive cancers was 14%.
If we removed all the margins that we went back for and didn't find cancer.
By changing our guidelines from 1 millimetre for invasive to knowing consumer.
So many would have had needless surgery, so all the surgeries were done.
So many had zero. The cancer, cancer was there if we changed our
margins. So margin width is important.
And that's why What is, what are the rules of engagement at the moment?
What are we looking at in terms of margin width because that is what's going to change.
If you have no inkant tumour and you have 1 millimetre and it's 0.7 millimetres.
You're going to go back and not find cancer. He's happy his patient's not going to go back
because he's got no in tumour, and you're going to be doing the more more surgeries,
so it's it's important to get the margins right.
So the NCCN Astro SSO, they all sat down in 2014 with Monica Morrow and Stu Schmidt,
and what they found was no tumour works for invasive.
2 millimetres works for DCIS, and when you have the mix of both,
the invasive margin, which is malter counts. I mean the no in tumour counts.
Europe said, OK, makes sense.
Let's hit our bandwagon to them.
The Saint Gallen's Consensus conference on two occasions endorsed this,
but we are Brexit.
We have to be different So we said, let's say 1 millimetre for everyone.
Now, in my centre, we've been 1 millimetre for invasive and 2 millimetres for DCS and we're
still that. We haven't changed.
Then in 2024 Nigel Bundrid came up with the paper and he said,
well, I don't agree with the two schmidt.
Uh, systematic review and meta-analysis.
I've got my own. If you read the paper, he recommends 2
millimetres, but if you read the ABS guidelines, they recommend 1 millimetre.
I don't know where or who woke up on the side of the bed that morning,
but it's 1 litre. And if it's DCI you talk to the patient as if
the MBT is not confusing enough.
Now let's confuse the patient.
So we don't have any coherent guidelines. Let's just say it's 1 millimetre.
And how do we find these guidelines? The pathology,
of course, imprint cytology, flown section, imaging and specimen radiography.
You have now micro CTs, you have MRI scans, and then you have the age-old ultrasound scan.
You have optical devices that use wavelengths of variable frequencies from visible
to infrared, and then they detect the margins using a lot of spectroscopy,
coherence tomography, confocal microscopy, some of the words I can't even say without taking a
pill in the morning. So you then have bioimpedance radio frequency
if you use margin probe, have you heard of margin probe,
that's what it does. It measures electrical impedance in in a tissue.
And you've got mass spectrometry spectrometry, which is,
again, these are all devices I'm mentioning because you should know about them,
but none of them actually use them. So we'll focus on the ones that we use.
None of them are gold standard. If you had a gold standard,
it would be frozen section and imprint cytology, because that's what everyone's competing
against. All of us think that our fingers are great.
None of us have a golden finger.
None of us can tell you that, OK, this margins clear even for palpable cancers as we'll see.
So the benefits of using any kind of interoperative imaging device is.
You want to reduce your margin positivity rate.
You're doing it inside the theatre, so you're improving efficiency and reducing operating
time because it's not going off for frozen section coming back.
If you're doing more than one margin and you're doing a central load and everything's going for
frozen section, you require 2 hours of theatre time just sitting there because then you might
have to go and do a clearance.
And then what happens to the patient after that? So it's a scheduling nightmare,
and we're a poor country. We can't afford frozen section,
let's face it. Lots of countries have chosen section and their
marginal accession rate is 0% to 1%.
A lot of Southeast Asian countries have have got that.
So depending.
On what you want, you want to reduce your risk of re-existence.
Also, medical legally now, we're doing more and more clipectomies,
we're doing microcalcifications. Did you get the calcium?
Was the coil in the calcium?
Did you take the right bit of calcium because you've got two areas of benign calcium and
malignant calcium. The clip was in the in the malignant area,
but you took the benign area out. This has happened.
I'm not just saying this was fun.
How do you get, how do you prove that you've got the right area out?
So that's important from a medical legal perspective as well.
So the age old and try tested devices specimen ideography.
So you take the specimen, you chuck it in, in that little.
Device there. Which is shielded and take.
basically a two dimensional image.
And if you look at the sensitive sensitivity and specificity,
it ranges from between 20 to 45 and 82 to 95.
The problem with 2D is dense tissue.
It's a two dimensional representation of a three dimensional specimen.
You may be misguided about which, which cavity you have to remove.
So the clever people said, let's do 3D tomosynthesis and this is what we have with
guys from 2016.
It's a Tomos and so it's basically you're doing a tomogram of the specimen.
So you now have a 3D rendition of that 2D image.
The benefits being, if you look at this.
That's your specimen because all of us think we take perfectly cylindrical specimens,
we don't. That's what a specimen actually looks like.
The problem is we don't see this because of the pancake phenomenon.
You take a specimen that's held nicely upright in the breast because of all the ligaments that
are supporting it in the connective tissue.
And then you chuck in an X-ray machine and that becomes that.
So it's called the pancake phenomenon.
And the pancake phenomenon means that the anterior and posterior margin suddenly become
closer to the tumour and the red margins spread out.
But when you've got that kind of cut, and that margin's positive,
when you look at that bit, because that's what you're going to look at a 2D,
you'll see it there. It's actually down there.
So that's the benefit of using.
3D tomosynthesis because you can do a more focused margin recision,
because it gives you two dimensional slices. You take the specimen and then you slice it at
2 every 2 millimetres.
And you know at what depth you have a positive margin.
So it reduces the amount of tissue that you need to take out because we all know that
breast conservation surgery results are directly proportional to the volume excised in
terms of cosmesis anaesthetics.
So, lots of data, please read this. I'm not gonna go through this in detail.
About a 50% reduction.
The centres that are using it, we used it, we got a 47% reduction.
Interestingly, The surgeons that had a higher re-excision rate,
including Mozart, were the ones that never used the 3D function.
They used to look at the 2D image.
I forget it was a 3D. Uh, Decide, oh, this is clear,
but if you, if you looked at their 3D pictures and then went and re-excised the bits,
our margin reexcision rate would have dropped to 2%.
So we're doing that bit of work. Also, I don't know if you know this,
but in the US it's mandatory for a specimen radiograph to be reported by a radiologist.
Here, we think we're good radiologists because we can do ultrasound,
we can report mammograms, and we can do excellent surgery.
So We don't send it.
When we got our radiologist to look at the images, we would have dropped our the excision
rate to 1%. So it's a 50% reduction if you've got a
radiologist to look at it. Again, this is more data to show you.
That don't believe everything you read.
Because this is the most recent 2024 randomised controlled trial for 3D tomosynthesis,
and it doesn't work. I know in my hands at guys it works.
It doesn't work. So it's all very individualised in what you do.
Something that we should all learn as breast surgeons, I think very,
very strongly I feel about this.
Intraoperative ultrasound scan benefit, it's there, it's available.
You just have to learn. You don't have to do diagnostic.
You don't, no one's gonna ask you, is this a U2 is U3?
Is it a yoid, is a fibroadenoma, is it cancer?
You want to see the tumour.
You want to localise where it is.
You want to find that clip. You don't need a 240 pound mag seat to find a
clip in lymph node. You can do intraoperative ultrasound,
you can do everything that you want for non-palpable tumours,
but you can also assess margins.
And since Maggie's, was she not here?
Oh, I use this, I included this paper just because I thought Maggie will be here.
So she's the first author on this paper as you can see,
and they did this meta-analysis looking at all the RCTs that have been done using
intraoperative ultrasound scan and it does work. It works for invasive.
It works for noninvasive.
It works for non-palpable tumours and also lo and behold,
works for palpable tumours. So again coming down to the fact that your
fingers are not golden fingers.
You can't tell that you've excise it, particularly because the ones that you are not
going to pick up is DCIS at the margins. You will catch all the invasive tumour,
but you miss the DCIS.
And here's more data. This is the cobalt trial.
What does this show? That if you use an ultrasound scan,
because you're now literally sculpting that wide local excision.
The volume that you remove is less, aesthetics are better.
OK, randomised trial again.
And then you've got micro CT and ultrasound scan, and then if you look at all of them.
So specimen ideography, a micro CT and an ultrasound scan,
the best is still ultrasound scan.
And then you got deep learning. We heard the lecture yesterday.
It's come to ultrasound scan.
So this is not a very complicated picture, that is what the ultrasound is.
This is the ultrasound image with a truth map that means that is what A surgeon thinks that
is what AI oh sorry, that's what the radiologist thinks the tumour uh footprint is.
That's what AI thinks and that's what the overlap is.
So if you look there, the AI overlap.
Slowly improves or increases, and that is more accurate than that.
So the orange image is the AI and the blue image is the judges,
and if you look at the whole paper, the orange image makes much more is much more accurate.
So there's AI coming to this as well.
I don't know whether you know, but whole breast screening is also coming with ultrasound scan
and deep learning, and that is also very accurate.
The problem with ultrasound is we know it has to be sort of graphically visible.
Not all tumours are.
Microcalcifications is a problem, but you've got technological enhancements that are coming
in that will make microcalcifications easier to view and DCI possibly better to view because
better spatial recognition.
And then you've got margin probe. If you've gone up to the stand to have
breakfast or drinks, you'll see this. So the margin probe,
it's great, it's new.
Let's buy it. Let's look at the evidence.
So it takes about 20 minutes.
You have, I mean 10 minutes. You have to measure it within 20 minutes of the
excision and basically what it does is it applies an electrical field and then by
creating a paramagnetic field there, it measures what's what's bouncing back and then
it has this number which is programmed into the screen and depending on what the number is,
it tells you whether it's malignant or benign, OK.
So Guess when was the first trial for margin Pro?
It was done by Mark Till in Germany 2010.
14 years later, we're saying it's a new technology.
50% Look at the numbers, 15 patients.
great trial. But he got a 50% reduction.
Then you had this randomised control trial in 2014.
So the same thing. 20% reduction in positive margin rate,
but if you read the paper, that's my conclusion.
The absolute reduction is only 6%.
And now you've got the new thing that's come, because that's why they're relaunching it.
If you look at the ownership of the company, it's changed the owner from 2010 to 2014 to
2024. So the new owners are marketing as this is the
best thing that's happened since sliced bread.
And you've got this now.
Reducing the accession rate using margin probe, systematic review.
It shows a very good reduction.
The systematic review is consistent. It shows a 50%,
57% reduction, but no DCIS, no new adjuvant chemotherapy, which is now the bulk of our work.
No loans.
So it doesn't do good for everything.
It does do it for invasive cancers.
And then you've got Clear Course, which is the MRI system.
It's not here, it was here last year.
Uh, there are trials going on in the UK. I know Edinburgh is doing one.
I know Bedford is doing one, and I know we are interested in doing one.
The problem is this thing.
Guess how much that costs?
500 pounds.
The machine they'll give you for free.
Remember, they'll give it to you for free, but they'll make their money back on expendables.
Nothing in life is free. So you chuck the specimen in there.
It, it's an airtight device.
The specimen then looks like that because it's inked.
So as soon as you take it out, you ink it, you chuck it in there and then you it becomes a
vacuum and then it gives you pictures like this.
And that's the scale I think that the cutoff is there.
Anything above that colour is a positive margin.
And don't ask me how they worked this out. It's very,
very, very clever computer model modelling that they've done,
and they show you that's the positive margins, OK?
And then you re-excise that area there, and it uses diffusion weighting.
For those of you who don't know what diffusion weighting is,
you should, because MRI scans are becoming a mainstay in breast.
It basically measures how quickly water diffuses through tissue.
The more dense the tissue is, eye cancer, the slower it diffuses.
So that's simplified version of diffusion weighting.
Data. Studies again 2016, 2017, 2018.
Not much to gain from the sensitivity and specificity has stayed almost the same.
But here this trial shows that for invasive disease and for DCIS there's a 50% reduction.
And this is a new trial that's going on we don't need to go look at it,
but it's still to report.
Then you've got histolog again last year if you came here it was here confocal microscopy.
This is confocal microscopy on steroids, so it uses confocal laser scanning microscopy.
What does it do? It gives you the ability to look at bigger
specimens quickly. That's the only difference,
but what it does. If that's a specimen, that's the image it gives
you. If you look at that specimen, I don't know
whether it projects that there's micro classification there,
and that's what the microclassification you can see there.
Now we've done this trial for guys.
It sounds very, very clever.
But now you have to become not only a radiologist using ultrasound scan,
you also have to become a pathologist because you have to look at that image.
And decide is there cancer there.
So the learning, none of us learned.
It was with us for 6 months. We used to just ring the pathologist and say,
what do you think? So we used to carry on doing the other bits of
the surgery, and then she used to say, I think it's fine.
And, and most of it's, it's right, because if we look at the pathologist's view on their data.
So no retard meaning recession.
Necessary, unnecessary.
So when the pathologist looks at it, you have the least recision which are unnecessary.
And this is again the hibiscus trial which is done much earlier for the same same device.
Then you've got fluorescence guided imaging ICG can also be used basically you inject that and
then you shine a light at a particular frequency and you get that,
and that means that there's cancer cells there to remove again shows you very good specificity.
They'll only report that studies that are in their favour.
Remember that the ones that are not good get canned.
Done So, we've got these two which are, which are great,
new studies again, unnecessary.
margin assessment is not a perfect science.
I just want you to remember this.
A margin when you get a report, it's looked at only 0.2% of the specimen.
Again, if you don't cut it properly, that's what happens.
The same specimen up is 2 millimetres and lower down is 1 millimetre.
I'll just focus on this one slide.
So, we are talking so much about margin specificity and sensitivity.
The Dutch had not been re-exercising focally positive margins from
22003.
Higher local recurrence rates, zero survival difference, provided it's more than 4 it's less
than 4 millimetres focally invasive, whether it's DCIS or whether it's invasive.
And when we talk about shared decision making, this is what you need to tell the patients
because yesterday audit also showed you that when you omit radiation therapy in 17 overs.
Everyone's comfortable to do that.
Higher local recurrence and less um no difference in survival.
So that's me. Thank you very much.
Next one is the um identification of tumour.
Bad after uncoplastic section. Thank you,
Alessandro. OK, good morning to everyone.
I'm Doctor Descalic. I'm from Milan, European Institute of Oncology,
and today we will discuss dentification of tumour bed after oncoplastic resection.
So breast conservative surgery is a milestone in breast surgery introduced by Verne Fisher in
1976.
Nowadays it is widely applied in our hospital.
Thanks to screening mammography breast cancer is detected earlier stage and could be
removed sparing the breast.
Thanks to the synergy with plastic surgery, uh, oncoplastic is applied to correct the
deformities of the breast breast cancer and improve aesthetic outcomes,
adapting the contralateral breast.
Oncoplastic may include the volume displacement, breast reduction,
and the less common value replacement procedures.
Post-operative radiation therapy is an integral part of breast conservative therapy.
The tumour bed is an important target.
And it was demonstrated in several studies that the most of the local recurrence occur
at the vicinity uh of the tumour so margins are
important as we heard before.
Um, The target volume should take into account tumour size as well as
margin. The clinical target volume is considering
including 1.5 centimetres of breast tissue surrounding the primary tumour for a
boost and 2 cmers for partial breast radiotherapy.
How we could identify the tumour bed in early methods.
Were based on preoperative imaging and clinical photo with the
tumour marked on the skin and also with the uh uh on the position of the scar because
the incision was generally above the tumour but nowadays in the era of oncholastic CT
scan is required.
In fact, oncoplastic procedure, even if a lot to resect wide part of the breast,
introduces significant uncertainty in the tumour by location.
Preoperative images may misguide the radiation oncologist in identifying the tumour bed
due to distortion or reposition of the breast anatomy.
The tumour bad position can be shifted differently in the same oncoplastic procedure
depending on the resective volume, presence of the seroma,
and bleeding.
So, how we could help radiation oncology to identify tumour bed,
we should place intraoperative clip.
The optimal number of surgical clips to be placed is at least 4,
with 1 clip placed on each cavity side walls.
And additionally, we could um place another clip on the posterior margins.
Um, the comm communication between surgeon and radiotherapy is
crucial. In fact, when we brought our operative reports,
we should ideally include the tumours side and the location and a description
of the surgical procedure including oncoplastic procedure level,
incision, tissue that has been rotated, and explanation of clip placement.
Breast surgeon, radiation oncologist, and the keep, uh,
should have a basic knowledge of oncoplastic technique commonly performed in their
institution and ideally radiation oncologists and surgeons should attempt to establish a
common language for their lockering institution.
When oncoplastic procedure give an extensive rearrangement of tissue as in level
2 and level 3 oncoplastic procedure, it's very difficult to identify the tumour bed.
Uh, in this case, the radiation oncologist might have to consider the value of boost and
the eligibility of this patient.
In this study conducted by the Canadian Consortium, there is a recommendation to place
8 surgical crip to provide a realistic representation of bad tumour.
Nevertheless, even in this study, uh, also it improving
the number, uh, cannot fully capture the 3D deformation of the breast and
the relocation of the tumour bed.
Because as we well know.
Even placing more clip uh frequently clips are displaced into the breast also
into different breast quadrant.
So in this case breast surgery expertise is important.
In fact, the first goal is to obtain a radical resection with free margins in
this case has high priority, uh, when we associate oncoplastic
in effect a radical resection with free margins.
Should be more feasible in oncoplastic and reduce the need for a boost.
Patients who undergo oncoplastic breast cancer procedure are not good candidates for partial
breast radiotherapy unless a limited volume displacement procedure was performed
and tumour bed can be identified accurately with appropriate margins.
In high risk breast cancer patients in whom the indication of boost is no
prior to the surgery, the surgical approach should be preplanned.
And indication for a booster should be defined for truly high risk patients
like women younger than 50 and with no free margins.
Looking at the future, the the use of breast MRI should aid to identify tumour bed
and as the new use of new product for tumour be marking like three dimensional be
absorbable tissue, but more studies are required to demonstrate the advantage of this
technique. So the conclusion of is
as these procedures aim to provide a better aesthetic outcomes after breast cancer surgery,
it's our responsibility to assure the safety.
The the procedure should be planned to ensure radical resection with the clear margins
and wide margins in high risk case to to reduce the need for a boost.
In fact, we should be avoided the need of a subsequent
mastectomy. In cases that the tumour bed is strongly
indicated, the radiation oncologist and the surgeon must work together to define the target
volumes. Close discussion and collaboration between the
radiation and oncologists are a key point of this speech.
Thank you very much.
So it's my great honour to introduce uh Professor Leo.
She's the current president of the Swiss Society of Sinology.
Thank you, uh, Connie to she'll talk about breast conserving surgery in small breasts.
What are the limits?
for your kind introduction. Um.
Yeah, so in the next couple of minutes, we will talk about small breasts and uh what can we do
with breast conserving surgery.
Here are my disclosures.
Now there are several factors that can influence the surgical approach in small
breasts. We have to make, of course, some oncological
considerations. We have heard a lot about about margins already,
so an unfavourable tumour to breast ratio makes it challenging to achieve clear surgical
margins and especially in small breasts there might be a higher likelihood of positive
margins, necessitating additional surgery or a switch to mastectomy altogether.
You of course also have to have aesthetic considerations.
If you remove more tissue from a small breast, there is a risk for substantial breast
asymmetry and deformity.
So oncoplastic surgery techniques that combine appropriate cancer surgery with plastic surgery
techniques may be necessary to optimise the cosmetic results.
And last but not least, of course we also have to consider patient patient expectations,
so it is crucial to set realistic expectations with your patients regarding the potential
cosmetic outcomes, and this also includes discussion of potential scars.
Now what is a small breast?
There is consensus in the literature that a small breast is around 250 cc cup size AB,
a medium sized breast is around 500 cc and a large breast is around 1000 cc.
Now it's not only about the breast size, but we also have to define how big is the defect.
So a defect is considered small if you remove less than 10 to 15% of the total breast
volume, and that will result in not much distortion or no distortion.
A defect is considered moderate if you remove 15 to 40% of the total breast volume and if you
don't do anything that will result in a moderate distortion.
And if you remove more than 40% that results in a large defect,
then you will have severe distortion if you don't apply oncoplastic surgery techniques.
Now, although this is probably preaching to the choir, I will mention the oncoplastic surgery
classification here.
We have volume displacement and volume replacement techniques,
and in volume displacement, if you remove less than 20% of the tissue,
then one can apply level one surgical techniques like local tissue rearrangements or
round block surgery, bed wing, mastopexy, and so on.
If you if you remove 20 to 50%, then we have to apply um level 2 surgeries,
including mastopexy designs and mammoplasty designs.
If you remove more than 50%, then we have to apply volume volume replacement,
and that means, for instance, local or regional flap reconstructions.
Now, the main option in small breasts is basically volume displacement techniques if you
have less than 20% of breast tissue removed, but if you remove more than 20%,
then you should turn to volume replacement techniques.
Now the selection criteria for oncoplastic procedure for oncoplastic surgery techniques in
patients with small breasts follow basically the rules as for moderate and large breasts as
well. So we have to consider tumour location,
excision volume, tumour to breast ratio, and also the glandular density.
And of course we also have to consider mastectomy.
In cases where the tumour to breast ratio is unfavourable or where achieving a satisfactory
cosmetic result is unlikely, mastectomy with immediate reconstruction might be the better
option for the patient. Now for women with small volume breasts and
moderate to large defects, you maintain probably the optimal breast shape if you
combine wide local excision and volume replacement.
So here one can use the local perforator flaps like ICAP,
my ICAP flaps, or if there is a need for a larger replacement,
if you have to remove more volume, then TP or latticsimus dorsi mini flaps might be applied.
Here's an example of a 45-year-old patient.
She had a multifocal ductal breast cancer in her left breast between the 3 o'clock and 6
o'clock position. Multiple nodules, the largest one was 2.5
centimetres. So the patient had small breasts.
She didn't want a mastectomy.
So she got a quadrantectomy and a volume replacement with a muscle sparing latissimus
dorsi flap, and this is her after one year after surgery,
after chemotherapy and post radiation therapy, and you can see the scar is neatly hidden
underneath the breast in the inframammary fold, and it extends to the back.
Here's another example of an older patient 3 centimetre tumour and also in a very difficult
tumour location in the lower outer quadrant, and she also didn't want to have a mastectomy,
so she had a quadrantectomy and a volume replacement with a like flap,
and this is the immediate result 2 weeks postoperatively, you see the scar here from the
like flap. This is not a scar.
This is just a superficial hematoma.
Now that replacement techniques work well in small breasts is not so surprising.
However, the question is, can volume displacement techniques also be applied?
And this is especially interesting for tumours in the upper quadrants and of course if you
have small to moderate defect sizes, you only excise less than 20% of tissue and there might
be patients who don't want replacement techniques.
Now I want to show you a publication from a Korean cohort.
They had 58 patients with tumours in the upper quadrants.
They only used displacement techniques.
The patients all had small to moderate sized breasts, less than 300 grammes,
and they removed less than 30% of the total breast volume.
Their median weight of the specimen was 80 grammes, so they used all the different um
displacement techniques that um that are known like the round block,
bat wing, tennis racket, rotational flaps and so on.
And what I want to show you here is that it is even possible to do displacement
techniques with larger tumours in small breasts.
So this is an example from their series where they use the dermo glandular rotational flap
for for a tumour that was located in the upper inner quadrant multifocal tumour,
and this is the preoperative marking and you see the axilla triangle to facilitate the
rotation into the defect.
The 20 months post-operative view shows an acceptable, very acceptable result,
um especially in regard to To the volume, but you also see the patient has to accept
a huge scar on top of the breast, and she has to know that before,
so one has to discuss it with her before.
These are other examples from the publication.
You you see a bat wing or a round block mastopexy, and what the authors also did,
they, they evaluated the overall cosmetic results after a year from the perspective of
the surgeon and the perspective of the patient, and all rated the result
excellent or good or not, more than 80% rated the result excellent or good.
Now another Korean cohort had a different approach.
They looked at what is a good size to excise with displacement techniques,
and their conclusion was less than 20% of breast tissue,
then you can use this volume displacement techniques.
What I want to show you here is that it's also possible to even use reduction mammoplasty.
This is a patient who had a tumour in the upper outer quadrant of the left breast,
and they used the vertical technique with an inferior pedicle to remove 5050 gramme specimen,
and this is the view one year after surgery and after radiation therapy.
So this is also possible.
So to summarise what I just said.
If you have a small breast with a small defect, then wide local excision plus volume
displacement works.
It depends upon the localization of the tumour, what kind of technique can be applied,
and then one can basically apply all the level 1 and even level 2 techniques.
Just quick some examples. This was a patient 51 years old with the DCIS
in the 5 o'clock position of the left breast.
Very small breast, so but the the tumour was not very,
very big, so we just thought about a good incision and did the lumpectomy and the
glandular reshaping and this is the result after surgery.
Another example of a 76 year old patient with a tumour in the left breast at the 3 o'clock
position, 2.5 centimetres.
This was a very small volume breast and with a moderate doses.
She did not want mastectomy. We just did a round block technique and this is
her two years after surgery, she also received radiation therapy and she did not wish for
symmetrization.
And another patient, 45 year old, also duct to breast cancer in her upper outer
quadrant of the left breast, 2.2 centimetres, but with an extensive DCIS component.
She also had a benign lesion in the other breast, so we decided to do a round block
technique on both sides.
This is her. I just saw her last week, uh, two years
post-surgery, chemotherapy and radiation therapy.
Now my take home messages volume replacement with local perforator flaps is usually the best
option for small non-totic breasts. However, volume displacement techniques also
work well in selected cases. Keep it simple where possible,
especially in the cases of very small cancers.
Sometimes simple glandular reshaping is sufficient.
Now the primary focus is always on an optimal oncological outcome and not necessarily on the
perfect breast shape.
However, even in small breasts, oncoplastic surgery can combine appropriate cancer surgery
with an acceptable aesthetic outcome.
The limits, the limits are basically the tumour size to breast size ratio and the expectations
of the patient, and mastectomy with reconstruction may be a better option in some
patients. Thank you very much for your attention.
We go back to, oh great, fantastic.
Hi Can you, can you hear us?
Can you hear me? Great, fantastic. Yes.
So thank you very much and I'm grateful for the technical team for helping.
I had a tiny heart attack for a minute.
And I'll be speaking about radiation planning following complex oncoplastic surgery.
And it was great hearing the talks previously.
So I hope you will find my talk complimentary to what was said before.
I have nothing to disclose.
And radiation therapy, including for breast cancer, has improved significantly.
Because as radiation oncotages, now we can see our target volumes.
We have CT-based planning in some centres or also MRI-based planning.
We look at the operative imaging.
And plan as opposed to historically that we did
landmark. Now we plan pair anatomy.
We no longer need to mark the skin or the scar because we can see.
Target we have better planning system and we do image guided uh therapy and
doing therapy and to plan the therapy so we cannot ignore what we see as radiation
oncologists no longer.
We also understand better the toxicity that is related to the dose,
dose response.
I spoke yesterday about partial breast irradiation and the boost volumes.
We can see the target volumes that we want to irradiate, but we understand that those
homogeneity.
And sub volumes, including that boost volume is highly important for the breast side effects
that and even long term toxicity and fibrosis, and it's extremely important to
have quality assurance and peer review so we cannot.
Ignore what we learned over the years, and this is really thanks to many
prospective clinical trials, including from the UK, as I mentioned before,
the Danish group, the URTC, many groups contributed to our knowledge.
And if I have to say what is the most important target volume of breast radiation,
it's the tumour bed.
As indicated in his talk, uh, we know that the tumour bed is the most important,
whether if you want just to irradiate the whole breast because you can unintentionally
underdose. You can see here in the dosimetry part of the
breast, this is an underdose of next to the tumour bed.
Or you can intentionally underdose in whole breast irradiation just because you're not
thinking about the tumour bed and you want to avoid the heart.
You can see here a medial located uh uh tumour bed.
tumour bed is highly important in high-risk patients because in those you want to identify
to boost them. And of course in partial breast radiation,
this is your target volume, you don't want to miss.
And we know from trials this is only a short summary, a partial table.
We have more data about that that almost 85% of uh ipsilateral
breast recurrences are at the area of the tumour bed whether or not if you
applied radiation and and also. Indicated this in his talk about the margins.
Even if you irradiate, you may reduce the rate of recurrence,
but the, you have a you have a recurrence mostly occurring at the area of the
tumour bed. And why is that?
So we have several studies that evaluated this, but one of the most famous.
This work is by Holland published in 1985.
These are patients that were actually eligible for breast conservation.
They had a unifocal disease and relatively low stage or T stage,
and he evaluated the mastectomy specimen as you can see here.
The percent of additional tumour foci according to the tumour size,
the index uh lesion, and the distance from the margin, and what is the probability to
have additional foci. So the larger the tumour.
Obviously, you, you'll have more uh more chances to have additional uh tumour forci
even more distant from the margins.
And how we define the tumour bed from a radiation oncologist's perspective,
what is my target volume?
So the tumour bed configuration is related to the margin.
The tumour bed size is related to the tumour itself and the margins,
and the tumour bed location is associated, of course, with the tumour location within the
breast, but with the type of surgery.
And how about configuration in size so you can see here in the,
in the slide that you have the tumour type of diagnosis.
The index lesion is in red, in, uh sorry, in orange, you can see the
subical foci around the tumour.
After surgery, you get the pathology report and you see uh uh whether or not you had
any additional tumour foci, but obviously not all were excised.
And what the patient had within residual tumour foci, this is our target
volume with additional enlarging around the index tumour and the potential
tumour foci that were excised.
So this is our target in blue. You can see the ideal.
Target volume for uh for the tumour bed we have an additional 1.5
margin in case of a boost and 2 centimetre margin in case of partial breast
irradiation minus the tumour free margin. So for us margins are important.
And this is an example for a simple breast conservation, a simple case to locate the
tumour bed because as a radiation oncologist, I look at the preoperative imaging and I make
sure that the imaging, I understand the operative note.
I understand what type. Surgery was performed and I see the tumour bed
that is very close or its exact location is the preoperative imaging.
So this is quite simple because the seroma, clips, and surgical changes correlate to the
preoperative imaging.
But this is, for example, is not a simple case to plan because this specific patient had a,
a, a large breast. We use the breast mask in our centre to raise
the breast and reduce the dose who The heart and lung,
but you can see that there is an area of an underdose near the tumour bed,
uh, and you can see the number of plans that are planners and we have uh reasonable
planners, uh, just to avoid this under. Those because you cannot avoid the physical
properties of radiation beam. You either burn the patient or have a hot spot,
and then you'll have fibrosis. So you need to find this delicate balance,
how to cover this area without having an overdose.
How about oncoplastic uh breast conservation surgery, and who,
who doesn't want uh perky breast and actually, uh, I heard this term,
uh, first in Eral courses by Linda Wilde when she said it.
And we need to remember that oncoplastic breast surgery is
Oncology comes first.
And this is a publication that Ash is one of the co-authors of this publication when we
uh explain what are the challenges uh for radiation therapy after aplastic surgery.
So these are some of the types of oncoplastic surgeries and approaches that you have,
and it was covered in the lectures before you have volume displacement,
volume replacement, but then the most important are Uh,
target volume for us, the tumour bed, where is that when you have all those procedures?
So this is an example from a nice publication from the UK,
a work by uh Awe and his group where they had the surgeons
delineate the tumour bed in patients who underwent plastic breast surgery and
compared to the uh delineations made by Radiation oncologists.
So this is a good way to understand each other discipline, and you can see here a CT scan of a
patient that uh underwent oncoplastic surgery with a flap,
and you can see the white arrows are the clicks and the area of the flap.
And you can see the differences between the radiation oncologists and the surgeons with
regards to delineation. The surgeons are the red delineation and the
radiation oncologists are in yellow.
At least they're in the same area. It's not always the same area,
I can tell you. And if you look closely, In red,
you see the miss volume by the radiation oncologist.
So if the surgeons are correct with regards to the actual tumour bed,
then the radiation oncologist missed part of the tumour bed.
So this patient is partly at risk for local recurrence, but if the
radiation oncologist arrives.
That the surgeon delineated too large and we know that a large boost volume
doubles or triples the chances for fibrosis and and side effects from radiation,
and we want to avoid that. We don't want to compensate the boost volume
due to uncertainty.
So this is actually an easy case for delineation after oncoplastic surgery because
here the clips are in the same area of the tumour bed and uh you cannot probably see it in
the slide, but you can see the changes in the flap, so uh uh you,
it's relatively easy.
What happens here?
This is an example that we use in our publication uh with Ash.
This is a a radiation planning CT of a young patient who underwent bilateral
surgery. She had left breast cancer, so the left is a uh
volume displacement procedure with mamma uh mammoplasty on the right side.
And in this patient, we do not have any, any surgical uh changes to
identify the tumour bed and when we ask the surgeon and they help us,
they, they could not either locate based on the change on CT because both breasts look the same.
So we had to omit a boost in this case, even though the patient had an indication for a
boost. This is an additional, as you can see here,
another young patient with a highly proliferative tumour,
you can see uh uh.
A is the PET CT showing you the, the PET avid tumour in the left breast.
Uh, you can see the axial planning CT scan and the patient had a
volume replacement with the silicon.
And, but we had to omit a boost in this case, because if you look at the
sagittals as nice, it, if we do, if we boost this patient,
um, then we need to include most of her breast volume and we will uh
significantly increase toxicity in this case.
So are the clips a good indicators for the tumour bed,
and this is a nice study that I often like to quote.
Uh, this group used a breast phantom.
With a tumour and a videotape the, the sur different oncoplastic surgery
procedures that were performed.
They had uh certain protocols for clipping the cases in order to follow
uh the locations of the clips according to the different uh manipulations done at surgery.
So you can see here the CT scan that was done before the surgery,
showing the tumour. You see the The CT scan that was done in the
phantom doing the cavity uh resection and you can see after closure
uh with the clips inside. So there were approximately,
I think more than 50 markers to mark the tumour bed, which is highly more compared to what we
normally use in clinic.
But when they analysed according to the uh location of the clips,
the video tapes, and according to the radiation oncologist delineations,
you can see here that there were significant differences.
And what worries us uh when they use the Videos to uh look at
the location of the tumour bed in the axial slice you can see,
see light blue that the tumour bed is actually fragmented in the axial
slice in some of the cases which we normally do not limit like this.
So the clip can shift in almost up to
2.5 centimetres uh within the breast away the tumour bed
and even a different quadrant, so we need to uh be aware of that.
So again, the tumour bed is the most important target volume for breast
irradiation, and in the case of whole breast irradiation, I would say it's the radiation
oncologist's responsibility to make sure it's covered wherever it is.
But when we want to plan for radiation boosts or partial breast irradiation,
we need to work closely with the surgeons.
And in case of a radiation boost, which these are high-risk patients.
I, I would say that we need desperately to improve.
We need to make sure that US surgeons plan surgery correctly to have the
tumor-free margins, because if we don't have tumor-free margin,
we will add to this group of patients that normally do not need a boost.
And if you cannot re-operate size the margin after oncoplastic surgery,
believe me, we do not have a clue where to radiate and where to.
So please do not add patient to the high risk group due to close or positive margin
and uh We need more research. There are new things to mark
the tumour bed, so we need to collaborate, uh, in order to manage to,
uh, mark the, the tumour bed correctly in those patients.
And there are some studies working on traoperative boost,
which might be the solution, uh, for the future.
In partial breast irradiation, again, we need to desperately improve because oncoplastic
breast surgery aimed to provide better aesthetic uh results and definitely partial
breast irradiation do the same. We know that from trials.
So when you operate, mark the tumour bed, have an operative node to indicate the surgical
manipulation. Because some of us, I hope all the radiation
oncologists bother to read and assist the radiation oncologist with delineation because I
often call my surgeons and they are my partners in those cases,
uh. Because partial breast irradiation should be uh
a way to improve the aesthetic outcomes.
And again, I recommend to you the, the, the planning way of import low trial because
this is the best way and the safest way in this setting, and we need more trials.
So what to do next Monday?
Next Monday, we need to identify before surgery the patients who are candidate of a boost
and make sure you had free margin.
Because most indications are known for surgery. The high risk patients are those who are
younger than 40, high grade proliferative tumour.
Some centres use triple negative, especially if they're high grade as one of the indications.
We, we want to reduce the cases that we need to boost just because of margin.
Mark and document your surgical approach and manipulation, and we need to work together
for after surgery all disciplines, breastpiriologists, pathologists,
and all relevant disciplines we need to work together with education as well.
This is a nice. Uh, here you can see a nice chapter written by
Nicola and other certain colleagues in radiation book about
oncoplastic breast conservation. We need to educate each other,
uh, discipline and perform, uh, um, mutual, uh, researcher.
Even just a practise within your clinic like a need performed with his colleague,
we should, the surgeon need to try to delineate. This is the best way to understand challenges
and radiation oncologist, and we, I hope we will also plan uh new trials
and new approaches in the future.
Thank you for listening.
So thank you. Um, unfortunately we have very progressive time
so we cannot ask you any questions, but thank you so much for joining us online.
59:59.909 --> 01:00:03.169 Um, you already introduced the next speaker actually on your slide.
01:00:03.310 --> 01:00:07.129 Uh, it's my pleasure, Nicola Roco, he will talk about uh recurrent,
01:00:07.270 --> 01:00:11.300 um, cancer after breast conserving surgery, how we manage it.
01:00:11.669 --> 01:00:14.149 Thank you. Thank you, thank you, Elizabeth for your kind
01:00:14.149 --> 01:00:16.030 introduction. Good morning, everyone.
01:00:16.649 --> 01:00:21.830 So, um, let's see. I have no conflict of interest to disclose.
01:00:22.159 --> 01:00:27.479 Let's see what is the best management for recurrent cancer following breast conservation
01:00:27.479 --> 01:00:29.919 surgery and and radiotherapy.
01:00:30.939 --> 01:00:37.280 Let's start from the uh from guidelines. These are the this is the last version of the
01:00:37.280 --> 01:00:38.719 NCCN guidelines.
01:00:39.080 --> 01:00:45.389 And you can see that for uh patients who already underwent breast conserving surgery for
01:00:45.389 --> 01:00:52.030 uh both in situ and uh invasive disease, you could consider if they did not have
01:00:52.030 --> 01:00:56.590 prior radiotherapy but this is the minority of the patients to repeat breast conserving
01:00:56.590 --> 01:01:01.500 surgery and surgical uh axillary staging and obviously radiotherapy,
01:01:01.729 --> 01:01:06.830 but if the patients already underwent radiotherapy and this is the prevalence of
01:01:06.830 --> 01:01:11.600 these patients. They advised to undergo total mastectomy and
01:01:11.600 --> 01:01:17.500 surgical axillary staging if they did not underwent already ALND.
01:01:18.040 --> 01:01:23.350 Anyway, you can see in the notes that in selected patients who already underwent
01:01:23.350 --> 01:01:29.040 radiotherapy and who declined mastectomy and meet consensus criteria for radiotherapy
01:01:29.040 --> 01:01:34.340 omission or they are candidated they could be possible candidates for partial breast
01:01:34.360 --> 01:01:38.219 radiation. Repeated breast conserving surgery and adjuvant
01:01:38.219 --> 01:01:43.459 partial breast irradiation could be considered anyway, the level of evidence is very low in
01:01:43.459 --> 01:01:48.199 this setting. If you look at the Italian um guidelines from
01:01:48.199 --> 01:01:53.139 the Italian Medical Association Medical Oncology Association.
01:01:53.580 --> 01:01:59.090 We can see that they advised that it's possible to consider a second conservative surgery
01:01:59.090 --> 01:02:04.449 obviously if the patients did not receive radiotherapy, but also in patients who had
01:02:04.449 --> 01:02:10.020 already undergone radiotherapy, the possibility of ra radiation of and partial breast radiation
01:02:10.250 --> 01:02:15.090 with external beam radiotherapy or brachytherapy may be considered even if this
01:02:15.090 --> 01:02:20.760 method is not free from complications with about 10% of delayed toxicity.
01:02:21.729 --> 01:02:28.169 Well, how to re-radiate these patients we have, we are lucky having or it on board
01:02:28.169 --> 01:02:31.209 even if online. I don't know if she will be able to.
01:02:31.770 --> 01:02:37.770 Uh, to, to be with us for the discussion she could go inside the the details of these
01:02:37.770 --> 01:02:43.729 techniques anyway we know there are no randomised control trial comparing standard
01:02:43.729 --> 01:02:48.810 mastectomy and breast conserving surgery followed by ray radiation for ipsilateral
01:02:48.810 --> 01:02:54.129 breast recurrence who uh have been initially treated with breast conserving surgery or
01:02:54.129 --> 01:02:57.879 radiotherapy. The most commonly used technique for ray
01:02:57.879 --> 01:03:04.879 radiation is multi-cathedral interstitial brachytherapy, but also 3D conformal
01:03:04.879 --> 01:03:10.919 external beam partial breast radiation with conventional fractionation is increasingly
01:03:10.919 --> 01:03:16.719 being used with low rates of toxicity and in breast tumour recurrence rates equivalent to
01:03:16.719 --> 01:03:18.520 those achieved with brachytherapy.
01:03:19.219 --> 01:03:25.899 Anyway, um, uh, also hyperfractionation with the 3D conformal external beam partial breast
01:03:26.139 --> 01:03:32.850 radiation has been considering in recent trials and ultra hypo fractionation regimens
01:03:32.850 --> 01:03:38.459 that is hyperfractionation, you know, 15 fraction daily and ultra hyperfractionation 5
01:03:38.459 --> 01:03:40.169 fraction every other day.
01:03:40.590 --> 01:03:46.979 And more recently also proton therapy is under investigation because protons could decrease
01:03:46.979 --> 01:03:51.179 toxicity, decreasing the dose delivered to normal tissues anyway.
01:03:52.899 --> 01:03:58.760 Uh, if we, um, if we have a recurrence and in breast recurrence,
01:03:58.959 --> 01:04:05.000 mastectomy is not the only option available, even if the level of available evidence for
01:04:05.000 --> 01:04:08.860 considering repeated breast conserving surgery and re-radiation is very low.
01:04:09.979 --> 01:04:16.260 And again, the choice of undergoing repeated conservative treatment or mastectomy
01:04:16.709 --> 01:04:22.629 represents a composite choice and is a matter of shared decision making again among the
01:04:22.629 --> 01:04:24.919 surgeon and the patient preferences.
01:04:25.229 --> 01:04:28.590 Could there be some selection criteria to be identified.
01:04:29.179 --> 01:04:34.689 Well, some studies also in this case low level of evidence identified patient age,
01:04:34.979 --> 01:04:41.129 um, older patients recurrent size, more or less than 2 centimetres longer disease free interval,
01:04:41.780 --> 01:04:45.370 more than 4 years for repeating breast conserving surgery,
01:04:45.699 --> 01:04:52.659 uh, or, um, histopathological characteristics could also be uh considered about the both the
01:04:52.659 --> 01:04:57.139 initial cancer and the recurrence. I'm talking about the biology of the tumour.
01:04:57.909 --> 01:05:04.750 Anyway, again, when we have grey areas and um we do not have high
01:05:04.750 --> 01:05:09.739 level of evidence for one treatment or the other, shared decision making should be the key,
01:05:10.229 --> 01:05:16.209 obviously. If both options are feasible, both from the
01:05:16.209 --> 01:05:19.770 point of view of the radiation oncologist and of the surgeon.
01:05:21.760 --> 01:05:27.830 We can go for a short decision making and if we opt together with the patient for a mastectomy,
01:05:27.919 --> 01:05:33.310 how to plan the best reconstruction? This is a very challenging situation for the
01:05:33.310 --> 01:05:35.739 breast ontoplastic and reconstructive surgeon.
01:05:36.030 --> 01:05:41.030 Do you need do we need to delay reconstruction in these patients who previously underwent
01:05:41.030 --> 01:05:43.179 breast conserving surgery or radiotherapy?
01:05:43.550 --> 01:05:45.389 Could we consider immediate surgery?
01:05:46.010 --> 01:05:52.020 And should we go for autologous tissues or we could consider implants also in these patients?
01:05:52.139 --> 01:05:57.580 Well, you all know this the reconstruction after a salvage mastectomy is challenging due
01:05:57.580 --> 01:06:00.629 to the prior radiation and increased rate of complications.
01:06:00.739 --> 01:06:03.844 Why? Because irradiation has a substantial effect on
01:06:03.844 --> 01:06:09.534 the soft tissue with chronic effects occurring several months to a year after irradiation,
01:06:09.544 --> 01:06:16.475 with chronic fibrosis for a fibrotrophic effect due to the release of bioactive cytokines.
01:06:16.949 --> 01:06:20.469 Depletion of parenchymal and stem cells, depletion of vessels.
01:06:20.590 --> 01:06:25.370 There is a reduced vascularity in these patients, and this chronic change could cause
01:06:25.370 --> 01:06:29.479 increased number of complications in these patients, both undergoing autologous tissue
01:06:29.479 --> 01:06:33.120 based reconstruction and implant-based reconstruction.
01:06:33.399 --> 01:06:37.709 Anyway, if we look at the literature, autologous breast reconstruction is considered
01:06:37.709 --> 01:06:40.790 as the procedure of choice for previously radiated patients.
01:06:40.840 --> 01:06:45.399 But again, The level of evidence is low. We do not have randomised controlled trial
01:06:45.399 --> 01:06:50.159 comparing implant-based and autologous tissue based reconstruction for this subgroup of
01:06:50.159 --> 01:06:53.600 patients. However, we know, we all know that a
01:06:53.600 --> 01:06:58.360 reconstruction could be challenging, uh, because more time consuming donor side
01:06:58.360 --> 01:07:03.840 morbidity should be always considered and it is not always applicable depending also on uh the
01:07:03.840 --> 01:07:07.399 availability of good donor sizes, the comorbidities of the patients and.
01:07:07.899 --> 01:07:13.169 Obviously, uh, again for patient wishes and shared decision making anyway,
01:07:13.300 --> 01:07:18.330 also for autologous tissue based reconstruction, a higher complication rate is reported in
01:07:18.330 --> 01:07:25.100 irradiated patients with increased rate of boundahins flap loss and also for flap for flip
01:07:25.100 --> 01:07:30.379 flap reconstruction, the intimal hyperplasia and the adventital fibrosis of the recipient
01:07:30.379 --> 01:07:34.219 vessels can lead to vascular obstruction and anastomosis failure.
01:07:35.419 --> 01:07:40.500 If we look at um um meta-analysis, a systematic review and the meta-analysis uh published in
01:07:40.500 --> 01:07:45.260 2015, uh, with 20 studies analysed no randomised control trial,
01:07:45.340 --> 01:07:50.659 only retrospective studies, retrospective case series almost or at least prospective
01:07:50.659 --> 01:07:56.340 noncomparative studies this meta-analysis confirmed that implant-based reconstruction in
01:07:56.340 --> 01:08:00.739 previously irradiated breast showed a significantly increased risk for any type of
01:08:00.739 --> 01:08:04.860 complications then the case is not treated with radiotherapy.
01:08:05.260 --> 01:08:07.989 And comparing implant based and autologous tissue base,
01:08:08.080 --> 01:08:13.850 autologous tissue reconstruction or a flap plus an implant showed a 92% and
01:08:13.850 --> 01:08:19.669 72% decreased risk of reconstructive failure respectively in previously radiated breast
01:08:19.669 --> 01:08:22.080 compared with implant-based reconstruction.
01:08:22.708 --> 01:08:28.668 Anyway, implant-based could be used despite a reported higher rate of complications and a
01:08:28.668 --> 01:08:32.309 slightly inferior a static result, implant-based reconstruction could be an
01:08:32.309 --> 01:08:37.269 alternative for patients who are not good candidates for a flap reconstruction who refuse
01:08:37.269 --> 01:08:39.338 autologous tissue based reconstruction.
01:08:39.588 --> 01:08:43.469 If you look at literature about implant-based reconstruction in this setting.
01:08:44.148 --> 01:08:48.838 We can find case theories, mostly retrospective studies, retrospective cohorts.
01:08:49.148 --> 01:08:54.068 We have the experience by, uh, Peter Cordero from the states with immediate two stage
01:08:54.068 --> 01:08:59.108 implant breast implant based reconstruction in these patients reporting high rate of
01:08:59.108 --> 01:09:04.988 successful reconstruction with good static results and only slightly inferior results when
01:09:04.988 --> 01:09:09.858 compared to non-irradiated breasts, but we're talking about 122 patients,
01:09:09.869 --> 01:09:13.429 uh, retrospectively collected and evaluated.
01:09:13.669 --> 01:09:16.209 What about ADMs? Well, we do not know.
01:09:16.299 --> 01:09:21.859 We do not have strong evidence to say if ADMs could improve results in this subgroup of
01:09:21.859 --> 01:09:24.819 patients. And what about the integration of the ADM in
01:09:24.819 --> 01:09:27.850 previously radiated mastectomy flaps? We don't know anyway,
01:09:28.399 --> 01:09:33.140 again, small cohorts, no comparison groups. We do not know if ADMs could help us in
01:09:33.140 --> 01:09:34.379 improving our results.
01:09:35.259 --> 01:09:39.250 And what about a direct to implant? We, we are talking about two stage implant
01:09:39.250 --> 01:09:41.529 based reconstruction. What about direct to implant breast
01:09:41.529 --> 01:09:45.129 reconstruction? One study in literature, no more than one study
01:09:45.129 --> 01:09:49.950 in this subset of patients, uh, study from Italy, uh,
01:09:50.129 --> 01:09:53.220 immediate direct to implant breast reconstruction is a preliminary,
01:09:53.290 --> 01:09:55.169 uh, experience on 18 women.
01:09:55.455 --> 01:10:00.145 Uh, with a mean follow up of 30 months of primarily direct to implant sub pectoral
01:10:00.754 --> 01:10:03.854 reconstruction, some muscular direct to implant reconstruction.
01:10:03.875 --> 01:10:10.634 Well, the authors reported that 22% of boundain, 17% of flap
01:10:10.634 --> 01:10:15.475 necrosis, and a 39% of capsular contractor in the long term.
01:10:16.149 --> 01:10:20.810 And in 3 patients, that is the 23% of this of this cohort,
01:10:21.109 --> 01:10:26.339 a lipofi, a fat grafting was used to announce the aesthetic outcome and to announce the skin
01:10:26.339 --> 01:10:29.459 quality of the skin. Anyway, all patients reported high level of
01:10:29.459 --> 01:10:35.450 satisfaction, but we are talking about a few patients with a a very short follow up.
01:10:35.700 --> 01:10:41.259 So we, we should also have a look to at fat grafting fat grafting.
01:10:41.549 --> 01:10:46.290 You know, could improve the quality of the skin thanks to the presence of the mesenchymal
01:10:46.290 --> 01:10:50.450 derived stem cells. So the use of fat grafting fat grafting could
01:10:50.450 --> 01:10:54.569 help reducing complications and failure rates of implant-based breast reconstruction.
01:10:55.330 --> 01:11:01.169 We have, um, we have some studies, some reports in the literature and could also help improving
01:11:01.169 --> 01:11:05.560 the cosmetic results, enhancing the thickness and the quality of the implant coverage.
01:11:06.709 --> 01:11:11.930 But uh we have also some reports in the literature, particularly from the group of the
01:11:11.930 --> 01:11:13.689 University of Florence in Italy.
01:11:14.310 --> 01:11:20.729 That are pro hypothesising that probably is the uh the fibrosis of the
01:11:20.729 --> 01:11:26.700 pectoralis major muscle, one of the major reasons associated with a higher capsular
01:11:26.700 --> 01:11:32.450 contractor rate in the subgroup of patients. So why not going prepectorally so we are
01:11:32.450 --> 01:11:36.729 pushing the indication for implant based reconstruction and proposing prepectoral
01:11:36.729 --> 01:11:40.549 reconstruction. No studies in literature on this,
01:11:40.919 --> 01:11:44.279 but we are trying it in uh my institution. We have,
01:11:44.290 --> 01:11:49.700 uh, our preliminary experience on only 16 patients who underwent previous breast
01:11:49.700 --> 01:11:56.040 conserving treatment with a mini interval to recurrence of 54 months or with a bronchitis.
01:11:56.234 --> 01:12:02.274 3, as I told you yesterday, we select patients and in particularly in this case because they
01:12:02.274 --> 01:12:07.754 already underwent uh radiotherapy, we selected patients for uh pre-pectoral approach only if
01:12:07.754 --> 01:12:13.964 the, the, um, thickness of the skin flap was more than 2 centimetres.
01:12:14.540 --> 01:12:19.819 Well, we, we did not have early complication. Only one seromatoma that was conservatively
01:12:19.819 --> 01:12:25.970 treated, treated, and at a follow up of only 18 months, so these are very preliminary results,
01:12:26.100 --> 01:12:31.259 we only had one capsular contractor. This is the patients who had uh radiotherapy on
01:12:31.259 --> 01:12:36.370 the left side in 2017. Then she had a nipsilla breast recurrence.
01:12:36.600 --> 01:12:39.459 She also underwent uh genetic testing during these years.
01:12:39.915 --> 01:12:46.345 So she uh underwent a bilateral uh therapeutic mastectomy on the left side
01:12:46.634 --> 01:12:52.595 and uh risk reducing on the right side with a triple pedicle skin reducing nipple sparing and
01:12:52.595 --> 01:12:55.194 immediate direct to implant prepectoral fracture.
01:12:55.234 --> 01:12:57.615 This is a very, very short term follow up.
01:12:58.104 --> 01:13:04.145 Anyway, we did not experience any particular early complications in our 16 patients,
01:13:04.154 --> 01:13:07.790 so. Going to a conclusion, in the case of second
01:13:07.790 --> 01:13:14.430 ipsilateral breast cancer event, keep in mind that salvage mastectomy is not the only
01:13:14.430 --> 01:13:17.220 option available. So in selected situation,
01:13:17.569 --> 01:13:24.270 always, uh, also comparing and having um uh proper discussion with
01:13:24.549 --> 01:13:26.750 your radiation oncologist and the patient.
01:13:27.009 --> 01:13:31.680 It is possible to consider a second conservative surgery and after a second
01:13:31.680 --> 01:13:35.589 conservative surgery in patients who already undergone radiotherapy,
01:13:35.720 --> 01:13:40.240 the possibility of partial breast radiation with both external beam radiotherapy and
01:13:40.240 --> 01:13:44.229 brachytherapy may be considered, but the level of evidence is very low,
01:13:44.680 --> 01:13:49.350 so. If a repeated conservative treatment is not
01:13:49.350 --> 01:13:55.109 desired or not feasible by the patient in a sure decision making and you perform a salvage
01:13:55.109 --> 01:13:58.779 mastectomy, we know that breast reconstruction could be challenging.
01:13:58.950 --> 01:14:02.220 Autologous breast reconstruction is the procedure of a choice,
01:14:02.390 --> 01:14:04.740 even if we do not have good quality of evidence.
01:14:05.189 --> 01:14:08.709 But thanks to the evolution of surgical techniques, thanks to the evolution of the
01:14:08.709 --> 01:14:12.799 mastectomy, we. For nowadays, previous radiotherapy does not
01:14:12.799 --> 01:14:15.560 preclude the patient obviously from an immediate reconstruction.
01:14:15.640 --> 01:14:21.080 You should not go for a delayed reconstruction, but the reconstructive choice for previously
01:14:21.080 --> 01:14:26.439 radiated patients could more and more follow the same decision making as for women who did
01:14:26.439 --> 01:14:30.839 not undergo radiotherapy, also considering, as I showed you an immediate implant based
01:14:30.839 --> 01:14:35.080 reconstruction, also considering a prepectoral approach anyway.
01:14:35.549 --> 01:14:40.950 As already or it told in the previous talk, a close collaboration between the surge the
01:14:40.950 --> 01:14:47.390 surgeon and the radiation oncologist should be uh imperative to ensure optimal breast cancer
01:14:47.390 --> 01:14:48.589 treatment. Thank you.
01:14:53.020 --> 01:14:55.580 That was the last figure Benjamin Safati.
01:14:56.520 --> 01:15:00.600 Talking about the reducing skin envelope in mastectomy.
01:15:00.680 --> 01:15:02.589 Thank you. Hello everybody.
01:15:02.839 --> 01:15:05.589 My name is. I'm a plastic surgeon.
01:15:05.919 --> 01:15:12.759 I work in, uh, Gustavussy in Paris, and Gustavussy is a really magic place because in
01:15:12.759 --> 01:15:16.649 Gustav Bussy plastic surgeon does everything. We do the mastectomy,
01:15:16.720 --> 01:15:20.160 we do the lumpectomy, and we do breast construction and narcoplastic surgery.
01:15:20.930 --> 01:15:24.439 So I have a small experience in in in case of uh can,
01:15:24.470 --> 01:15:26.750 can, can I have the picture on the screen?
01:15:28.129 --> 01:15:29.160 I, you need to click.
01:15:34.859 --> 01:15:39.060 I try I can speak like that, no problem.
01:15:39.270 --> 01:15:43.020 So we will, we will focus on the patients.
01:15:43.470 --> 01:15:48.899 OK, so we focus the patient with cancer because for the procreatic surgery we have time.
01:15:49.029 --> 01:15:53.879 We can do the breast reduction. We wait between 3 to 6 months and we,
01:15:53.890 --> 01:15:55.930 we do the mastectomy and immediate breast reconstruction.
01:15:56.500 --> 01:15:59.890 So the question is when we need to do a skin reducing mastectomy.
01:16:00.149 --> 01:16:04.750 We need that when we, we know that we at the end of the mastectomy we will have an excess of
01:16:04.750 --> 01:16:08.759 skin and it won't fit with, with the size of the implant.
01:16:09.029 --> 01:16:13.100 So let's start with the easy case with this patient, she has a loose skin,
01:16:13.310 --> 01:16:18.470 a small ptosis, and we know that at the end of the mastectomy directly in the OR we have an
01:16:18.470 --> 01:16:21.540 excess of skin, but we know for young patients.
01:16:22.560 --> 01:16:28.580 We can have quite good results because the mastectomy by itself will reduce the skin with
01:16:28.580 --> 01:16:35.040 this we we have we have a very good skin retraction just with the
01:16:35.040 --> 01:16:39.200 mastectomy. So for very smalltosis for young patients,
01:16:39.359 --> 01:16:45.189 don't try it at the end of the surgery to remove skin just wait and you will have a huge
01:16:45.189 --> 01:16:47.870 attraction to correct the optosis. Something is wrong.
01:16:49.169 --> 01:16:52.000 So what's happened with this kind of patient?
01:16:52.359 --> 01:16:55.919 Very large breasts, the real big toes.
01:16:56.169 --> 01:16:58.560 How can, can do we can we do that?
01:17:00.379 --> 01:17:05.930 Especially about the nipple in my institute we decide not to keep the nipple for this patient
01:17:06.299 --> 01:17:11.720 because when we do a mastectomy you feel like this guy on one side you have your aesthetic
01:17:11.720 --> 01:17:18.040 way you want to have a very thick skin flap to to have a very beautiful result and to avoid
01:17:18.040 --> 01:17:21.810 skin necrosis, but on the other side you have your oncologic mind.
01:17:22.540 --> 01:17:28.740 And on the on this side you want to have to let very, very thin skin flap so you need to find a
01:17:28.740 --> 01:17:34.419 good balance between the these these these two aspects in your mind.
01:17:35.200 --> 01:17:38.140 That's why we decide to sacrifice the nippera complex.
01:17:38.470 --> 01:17:42.209 So we will speak about the different techniques we have to reduce the skinen.
01:17:43.069 --> 01:17:47.140 This is what a lot of surgeon does, and you won't do it anymore.
01:17:47.350 --> 01:17:53.709 It's a very large elliptic, uh, skin rejection. You will correct the so we reduce the volume.
01:17:54.500 --> 01:18:00.390 And After You have also the Inverity
01:18:01.609 --> 01:18:06.520 mastectomy. And you have also the vertical we speak about
01:18:06.520 --> 01:18:11.350 this together when you do the very large elliptic uh skin reduction,
01:18:11.470 --> 01:18:13.470 you have not a very good result.
01:18:13.759 --> 01:18:17.109 Most of the time you have a dog here on the lateral part of the breast,
01:18:17.479 --> 01:18:21.790 and you need to make a larger scar to correct the dog here.
01:18:23.140 --> 01:18:27.930 Also, when you do this kind of a scar, even if the shape of the breast is good,
01:18:28.140 --> 01:18:31.689 you see the scar when the patient wear a bra.
01:18:31.899 --> 01:18:36.279 So please avoid this large amount of rejection when you do the mastectomy,
01:18:36.339 --> 01:18:38.020 even if you want to correct thetosis.
01:18:39.580 --> 01:18:42.450 What we have also we have the inverted mastectomy.
01:18:42.540 --> 01:18:47.290 Everybody knows that everybody knows that this is quite difficult surgery,
01:18:47.540 --> 01:18:52.609 but this is the best way to optimise the breast reshaping and what is good is when you will do
01:18:52.899 --> 01:18:57.410 the breast immetrization, you will have the same scar on on both breasts,
01:18:57.740 --> 01:19:00.379 but everybody knows this kind of results.
01:19:01.569 --> 01:19:06.689 Everybody has seen that and I have to say I don't do it anymore because I had a lot of
01:19:06.689 --> 01:19:13.479 problems with university except when you want let 1 or 2 centimetre of of fat under the
01:19:13.479 --> 01:19:19.680 skin but really I, I, I decided to not do that for conservation because she might need
01:19:19.680 --> 01:19:23.689 chemotherapy and radiotherapy and we have a a delay with that.
01:19:24.500 --> 01:19:29.259 Just to show you the pre-op marking because my friend on the screen because you do that and he
01:19:29.259 --> 01:19:30.740 has quite good it. This is Nicola.
01:19:31.830 --> 01:19:36.049 So the idea is to draw the projection of the manifold.
01:19:36.299 --> 01:19:42.220 This is the limit, and you don't have to go further to avoid scar when you do the
01:19:43.259 --> 01:19:47.009 construction. So we try to go 2 centimetres lower.
01:19:47.220 --> 01:19:48.540 It will be the upper.
01:19:49.259 --> 01:19:53.129 Limit of the reaction and if at the end you have a dog here,
01:19:53.250 --> 01:19:58.899 you can reject until the superior limits but try to not go further the superior limit to
01:19:58.899 --> 01:20:02.379 avoid scar when you when you you do the reconstruction.
01:20:02.899 --> 01:20:04.970 So you draw the vertical line.
01:20:05.959 --> 01:20:12.759 As as before and also try to not and to think about when you will close the skin you want
01:20:12.759 --> 01:20:14.189 to avoid any tension.
01:20:14.439 --> 01:20:21.279 This is the key of of uh to avoid skin necrosis and if you're afraid about about the tension in
01:20:21.279 --> 01:20:24.120 the skin, put an expander, OK?
01:20:24.560 --> 01:20:26.589 So we will do 2 centimetres here.
01:20:27.680 --> 01:20:31.470 It will be the lower part of the complex reconstruction.
01:20:32.000 --> 01:20:35.970 The the vertical scar will be between 7 to 8 centimetres.
01:20:36.399 --> 01:20:39.479 Why? Because after a mastectomy you will have a huge
01:20:39.479 --> 01:20:42.649 contraction and at the end it will be between 5 to 6 centimetres.
01:20:44.850 --> 01:20:48.529 And you draw the latter part like a classical breast reduction.
01:20:48.879 --> 01:20:54.620 So the idea of the drawing is to avoid to put a scar above the final reconstruction of the
01:20:55.140 --> 01:21:00.870 complex. The surgery is quite easy, especially for her.
01:21:00.879 --> 01:21:06.540 She, she has a very, very large nip complex so you try to do the mastectomy only through the
01:21:06.540 --> 01:21:09.970 area. If you need, you can do a vertical scar.
01:21:10.899 --> 01:21:15.450 See here it was a old video, so we put the expander behind the muscle,
01:21:15.459 --> 01:21:20.060 but now we put all the expander above the muscle and we put an expander to avoid.
01:21:20.459 --> 01:21:23.680 Uh, skin tension when you, when we, we close it.
01:21:23.950 --> 01:21:29.810 OK, so you see we have a dog here on the upper pole, but we know that we have something more
01:21:29.810 --> 01:21:35.970 to remove if we need to to remove the dog here, OK, but we know that we are the,
01:21:36.080 --> 01:21:41.850 the upper limit and we close it and you see no tension at all if we have a tension can deflate
01:21:41.850 --> 01:21:43.779 the expander and.
01:21:44.709 --> 01:21:48.450 And you do really a tailor-made pockets.
01:21:49.850 --> 01:21:52.089 To avoid skin necrosis, OK?
01:21:53.060 --> 01:21:59.589 You draw the, the, the, the limit of, of your debitation and try to not remove
01:21:59.589 --> 01:22:03.229 skin. All the skin you need to remove just debitize
01:22:03.229 --> 01:22:06.709 it, OK? You will keep the solar plexus and you have a
01:22:06.709 --> 01:22:11.859 better um vasation of your skin flap. OK.
01:22:15.930 --> 01:22:20.890 So you see we have quite good results. We can shape the breast exactly where as you
01:22:20.890 --> 01:22:24.049 want, but just to show you this patient, we made a mistake.
01:22:24.399 --> 01:22:29.259 You see the scar is above the final reconstruction of the complex.
01:22:29.569 --> 01:22:35.609 That's why when you do your blood drawing, try to not and to to to localise what is the
01:22:35.609 --> 01:22:41.430 projection of the. The techniques I learned from my friend who was
01:22:41.430 --> 01:22:45.250 a virtual surgeon who passed away a few years ago.
01:22:45.620 --> 01:22:52.180 It was a it is a circum vertical and this is what I use now for all the big and breasts,
01:22:52.200 --> 01:22:57.270 and I have to say with that I have no just to show you the,
01:22:57.279 --> 01:23:02.720 so the idea is to keep all the skin you need. It depends how much you want to correct the sis.
01:23:03.379 --> 01:23:04.859 So you, you start by.
01:23:06.040 --> 01:23:09.580 Creating like a teardrop on the lateral part.
01:23:09.799 --> 01:23:13.709 The idea is to avoid any scar in the cleavage.
01:23:13.959 --> 01:23:15.270 You have to focus on this.
01:23:15.560 --> 01:23:20.799 So if you do that that at the end, you will have a big dog here at the internal part of of
01:23:20.799 --> 01:23:22.180 this excision.
01:23:22.720 --> 01:23:27.270 So the idea is to remove the dog here, not horizontally but vertically.
01:23:27.520 --> 01:23:34.350 If you, if you do that, it's like a L shape and you will avoid any scar on on the cleavage.
01:23:34.799 --> 01:23:38.609 With that, we have a very low risk of um of skin necrosis.
01:23:39.759 --> 01:23:43.259 And I have to say I do that now for almost all all my patients.
01:23:43.819 --> 01:23:47.430 So as I said, you, you, you try to not remove the skin,
01:23:47.950 --> 01:23:49.899 you, you start with DPTization.
01:23:51.100 --> 01:23:55.200 OK, after for sure we we infiltrate, we do the mastectomy with a scissor.
01:23:56.660 --> 01:24:01.229 And really the idea is to keep all the skin you need and if you have if you have an excessive
01:24:01.229 --> 01:24:04.459 skin, just dissipitize it, OK?
01:24:05.540 --> 01:24:08.930 So don't do the elliptic excision.
01:24:09.220 --> 01:24:15.220 If you are brave, do the verity, but in my hand, I do the 2nd vertical and I have to say I'm
01:24:15.220 --> 01:24:18.100 quite happy. If I need to correct more stosis,
01:24:18.180 --> 01:24:20.120 I just remove more more skin.
01:24:20.459 --> 01:24:21.899 OK, so we do the desipation.
01:24:23.609 --> 01:24:25.169 We start after that.
01:24:28.000 --> 01:24:32.109 Doing the mastectomy and the idea is to keep the dissipated tissue,
01:24:32.319 --> 01:24:37.040 OK? Sometimes we use this device the device and use
01:24:37.040 --> 01:24:41.310 so you cut in the middle to let the dis tissue under your scar.
01:24:41.560 --> 01:24:46.640 You create an excess of skin just under the under the scar if you have any problem,
01:24:46.839 --> 01:24:50.000 you have a small amount of dissippetized tissue under your incision.
01:24:50.359 --> 01:24:54.709 We done the mastectomy. This is a surg and mesh around the implant.
01:24:55.399 --> 01:25:01.149 We, um, I don't put expander with this incision because I'm not afraid anymore of skin necrosis.
01:25:02.200 --> 01:25:09.129 And I close it Directly on the on the on the nipple on the breast and if
01:25:09.129 --> 01:25:12.609 I have. Uh, loose skin, I can remove it.
01:25:12.620 --> 01:25:17.459 I can just wait for the after the mastectomy because really few weeks after you will have a
01:25:17.459 --> 01:25:18.470 huge retraction.
01:25:18.779 --> 01:25:22.970 And so the idea is to make a vertical scar like this, not horizontal,
01:25:23.580 --> 01:25:25.089 to keep the cleavage.
01:25:27.020 --> 01:25:34.009 Safe from uh from um from scar and the same story OK we dissipatedize
01:25:34.009 --> 01:25:35.009 this area.
01:25:42.649 --> 01:25:44.720 It always seems longer when you do the lecture.
01:25:46.390 --> 01:25:51.350 OK. We we do that and at the end you close it and
01:25:51.350 --> 01:25:55.560 you, you, you use a stapler to check the tension on the skin and,
01:25:55.589 --> 01:25:57.060 and the shape of your breast.
01:25:57.310 --> 01:26:00.859 OK? This is the final look you see no scar at all
01:26:01.229 --> 01:26:06.229 on, on the cleavage even if she have, she, she has a big difficulty with with the dress,
01:26:06.270 --> 01:26:11.390 OK, so you have to focus on the cleavage and avoid scar on it.
01:26:12.200 --> 01:26:18.160 So as I said, my first choice is the second vertical and uh I really encourage you to to
01:26:18.160 --> 01:26:23.009 try it because it's very, very easy and no risk of of of of skin necrosis.
01:26:23.700 --> 01:26:26.169 And I also want to invite you. I will speak about this,
01:26:26.180 --> 01:26:30.000 uh, this afternoon about my next meeting the minimal invasive breast meeting.
01:26:30.089 --> 01:26:35.560 We'll speak about endoscopic robotic surgery, but also all breast cancer surgery under local
01:26:35.560 --> 01:26:38.180 anaesthesia. We do now mastectomy and immediate breast
01:26:38.180 --> 01:26:43.910 breast reconstruction under local anaesthesia and a lot of uh techniques and malevany surgery.
01:26:44.129 --> 01:26:51.069 Thank you very much. Thank
01:26:51.069 --> 01:26:54.020 you, Benjamin. Please, all the speakers, we are late actually,
01:26:54.149 --> 01:26:56.279 but a couple of questions I think are.
01:26:57.560 --> 01:27:02.899 Mandatory. From the floor there is someone that have
01:27:02.899 --> 01:27:04.229 questions for our speakers.
01:27:04.620 --> 01:27:05.450 I will sit there.
01:27:15.399 --> 01:27:15.649 You, you, you, you, you ladies can. No, not enough women first I will say that.
01:27:15.669 --> 01:27:19.370 No, no, no, no you. I'm gonna stand no no no no I can stand there.
01:27:20.890 --> 01:27:24.129 um, so I have a question for uh for Benjamin.
01:27:24.620 --> 01:27:29.209 Um, you said that you don't keep the nipple anymore, that you always remove it,
01:27:29.220 --> 01:27:32.930 but on the picture you showed, sorry, can we have the audience quiet please?
01:27:33.100 --> 01:27:38.529 Sorry, um, on the picture you showed it was actually quite not a long distance,
01:27:38.620 --> 01:27:41.509 so I'm wondering. Why you always remove it?
01:27:41.560 --> 01:27:43.919 I mean, I totally agree. If there's a large distance,
01:27:43.970 --> 01:27:50.529 but in a case like that where it's not a large distance, the video I show you the concern was
01:27:51.870 --> 01:27:58.049 was involved with the cancer, but as I said, I tried almost all the kind of flap,
01:27:58.950 --> 01:28:01.620 try to save the complex and at the end.
01:28:02.189 --> 01:28:08.009 I I was not happy with most of the time also the shape of the breast when you at the end,
01:28:08.100 --> 01:28:13.209 the knee para complex is not exactly at the place you you want it to be because at the end
01:28:13.209 --> 01:28:17.500 after the mastectomy you have a huge section and sometimes the nee para complex if you keep
01:28:17.500 --> 01:28:23.140 it goes up it's quite impossible to to to to to to lay down to put it down so.
01:28:23.740 --> 01:28:27.819 I, I try to remove it and and do the reconstruction after that because it's very
01:28:27.819 --> 01:28:33.810 difficult to know exactly the final position of of this the complex and the availability also.
01:28:34.560 --> 01:28:39.600 Yeah, I, I agree very patotic patience, but I, I still also used to,
01:28:40.049 --> 01:28:42.959 yeah, I like to preserve it if it's for sure, if you can for sure.
01:28:43.410 --> 01:28:45.560 Any questions from the audience for the speakers?
01:28:48.709 --> 01:28:49.740 Everyone wants lunch.
01:28:50.990 --> 01:28:54.459 No, no, no, no, no, it's OK then it's lunchtime actually.
01:28:57.790 --> 01:29:01.660 Yeah, thanks a lot for you. Can you take a picture of all of us.