Andrea Pusic MD, MD MHS FACS

Presentación del tema: "Andrea Pusic MD, MD MHS FACS"— Transcripción de la presentación:

1 What are the implications for reconstruction following contralateral prophylactic mastectomy?
Andrea Pusic MD, MD MHS FACS Associate Professor - Plastic and Reconstructive Surgery Dr. Andrea Pusic

2 Mastectomía profiláctica contralateral : ¿Cuáles son las implicancias para la Reconstrucción ?
Andrea Pusic MD, MD MHS FACS Associate Professor - Plastic and Reconstructive Surgery Dra. Cristina Maria Noblia Médica Cirujana Especialista en Mastología Departamento de Mastología Instituto de Oncología “Angel H. Roffo” Universidad de Buenos Aires

3 “La tasa de mastectomía bilateral aumentó significativamente en California desde 1998 a 2011 y esto no se asocia a una disminución de la mortalidad mayor a la lograda por la cirugia conservadora y radioterapia posterior. SO AS YOU’VE HEARD CPM ARE ON THE RISE AND WE DON’T REALLY KNOW WHY. IT SEEMS COMPLETELY COUNTERINTUITIVE THAT IN AN ERA OF MINIMALLY INVASIVE SURGERY, IN A TIME WHEN WHEN WE AS CANCER SURGEONS ARE STRIVING TO REMOVE ONLY WHAT STRICTLY NECESSARY THAT WOMEN THEMSELVES ARE CHOOSING MORE AGGRESSIVE SURGERY WITHOUT A SURVIVAL BENEFIT. Kurian A, JAMA Sept 2014

4 Tratamiento quirúrgico del estadio temprano del cáncer de mama National Cancer Database – American College of Surgeons FURTHER ILLUSTRATING THIS TREND, THIS IS STUDY PERFOMRED BY MY PARTNER AT MEMORIAL EVAN MATROS USING HTE National Cancer Data Base (NCDB) of the American College of Surgeons (ACoS) AND IN AN ANALYSIS OF 1.8 million patients, HERE IS WHAT THEY SAW Albornoz/Matros et al. PRS in press

5 Tratamiento quirúrgico del estadio temprano del cáncer de mama : Factores para someterse a CPM en comparación con BCS Variable % Age 32.2 Breast reconstruction availability 28.6 DCIS 4.6 Lobular histology 4.0 Race 3.8 Tumor size 3.7 Facility location 2.8 WELL WHAT ARE SOME OF CONSTRIBUTING FACTORS? IN DR. MATROS’S STUDY, ACCSS TO RECONTRUCTION EXPLAINED 28% OF THE VARIANCE IN THEIR MODEL. JUST LESS THAT PATIENT AGE – WITH YOUNGER AGE BEING ASSOCIATED TO THE DECISION TO HAVE CPM Pseudo R , c-statistic 0.75, n=1,149,395 Albornoz/Matros et al. PRS in press

6 Factores clinicos que contribuyen a la decisión para realizar mastectomía profiláctica contralateral
THIS HAS BEEN NOTED BY OTHER INVESTIGATORS – IN THIS STUDY IN 2011, ACCESS TO IMMEDIATE RECONSTURCTION WAS HIGHLY CORRELATED TO THE THE DECIONS TO UNDERGO CPM J Clin Onc 2011 June

7 ¿Cuales son las implicancias para la reconstrucción?
Las mujeres buscan cada vez más información sobre las opciones reconstructivas y sus resultados SO CLEARLY RECONSTRUCTION IS AN IMPORTANT FACTOR AND WHILE I’D DON’T’ FRANKLY THAT PLASTIC SURGEONS ARE DRIVING THIS, I DON’T HIGHLY HOW IMPORTANT ARE DISCUSSION IWHT PATIETNS ARE . WHICH BRING US TO HTE QUESTION THAT I AM ASKED EVERY DAY IN MY CLINIC BY CONTREMPLATING THIS. WHAT ARE THE IMPLLICATOIN FOR RECOSNTRUCTION?

8 Opción 1: Reconstrucción con colgajo
Greater volume of tissue transfer Enhanced flap perfusion Avoids disruption of the medial inframammary fold VERY SIMPLY, THERE ARE 2 OPTIONS – FLAP RECONSTRUCTION BY ONE – OF WHICH THE MOST COMMON DONOR SITE IN THE ABDOMEN HERE COMPARING UNILATERA L TO BILATERAL, THE DIFFERENCE IN OR TIME WOULD BE 4-6 HRS VS 8-10 EITHER WAY THE ABDOMINAL SCAR LOOKS THE SAME BUT PATIENTS HAVING A BILATERAL PROCEDURE ARE A SOMEWHAT HIGHER RISK OF ABDOMAINAL MORBMIDIY SUCH AS HERNIA OR ABDOMINAL WEAKENESS.

9 Opción 2: expansor/implante
Reduced operating time No donor-site morbidity Good texture and sensation Reduced post-operative recovery THE OPTION IS IMPLANT RECONSTRUCTION WHICH IS GENERALY PERFOMRED AS A TWO STAGE PROCEDRUE WITH TISSUE EXPANDER FIRST THEN IMPLANT A FEW MONTH LATER. OR TIME IS SHORT AND NOT MUCH LONGER FOR 2 BREAST COMPARED ONE AND RISKS AND RECOVERY ARE FAIRLY SIMLARLY FOR ONE COMPARED TO 2 BREASTS

10 Más mujeres están eligiendo la reconstrucción con implantes
SO WHAT ARE WOMEN CHOOSING – IN THE US, LARGELY IMPLANTS Albornoz/Matros PRS 2013

11 El implante es la reconstrucción más utilizada para mastectomías bilaterales
* AND IS SHE IS A WOMAN IS HAVING BILATERAL MASTECTOMIES, SHE IS EVEN MORE LIKELY TO HAVE IMPLANT RECONSTRUCTION Albornoz/Matros et al. PRS 2013

12 ¿Por qué mastectomias bilaterales? La perspectiva de la paciente
SO GOING BACK AGAIN TO THE QUESTINO OF WHY ARE WOMEN WOMEN CHOOSING BILATERALS MASTECTOMIES – THERE ARE A NUMBER OF FACTORS BUT THE ONE THAT I’M ASKED MOST ABOUT IS RELATES TO SYMMETERY. PATIENTS WANT THEIR BREASTS TO MATCH.

13 ¿Qué técnica ofrece la mejor equiparación,simetrización (best match) ?
MASTECTOMIA UNILATERAL MASTECTOMIA BILATERAL COLGAJO ? IMPLANTE AND SO THIS IS WHAT I END UP DISUCSSION WITH THEM -- AND THE STANPOINT OF RECONSTURCTION THIS DISUCSSION END UP BEING SOMETHING OF 2 BY 2 TABLEES. WE CAN HELP WOMEN UNDERSTAND EXPECTED OUTCOMES IN EACH OF THESE CELLS USING BOTH PHOTOS AND PATIENTS RREPORTED OUTCOME DATA. STARTING WITH THE PRO DATA --

14 THE BREAST-Q IS A PRO INSTRUMENT THAT WE DEVELOPED AT MSK TO MEASURE OUTCOMES OF BREAST SURGERY FROM THE PT PERSPECTIVE.

15 This is the BREAST-Q satisfaction with breast scale
This is the BREAST-Q satisfaction with breast scale. This is what patients see and complete. It asks questions that range from ‘how do you like with your clothes on’ to ‘how soft is your reconstructed breasts’ to ‘how do you think you look naked.’ Patient responses to these questions are summed together to provide a summary score of A high number means higher satisfaction.

16 What you see is a number of item that address all different aspect of a woman’s satisfaction with her breasts, so not just how they look but also how they feel. And these items are extend on a continue. At one end, we ask her how she feels she looks clothed and one the other, unclothed. Really, any reconstruction can look good clothed but only a really superior outcomes will satisfy a patient when she is naked in front of a mirror. The patient’s responses to these items are then summed and transformed into a score, where a higher number means greater satisfaction.

17 What you see is a number of item that address all different aspect of a woman’s satisfaction with her breasts, so not just how they look but also how they feel. And these items are extend on a continue. At one end, we ask her how she feels she looks clothed and one the other, unclothed. Really, any reconstruction can look good clothed but only a really superior outcomes will satisfy a patient when she is naked in front of a mirror. The patient’s responses to these items are then summed and transformed into a score, where a higher number means greater satisfaction.

18 RECONSTRUCCIÓN MAMARIA A TRAVÉS DEL TIEMPO
THIS IS A GRAPHIC OF A BREASTQ STUDY THAT I SHOWED YESTERDAY THAT IS KEY TO UNDERSTANDING LONG TERM OUTCOMES. Alderman et al. PRS 2009

19 Reconstrucción autologa unilateral
preop 1 año 2 años LET ME SHOW YOU NOW IN PHOTOS WHAT IT LOOKS LIKE TO MOVE ALONG EACH OF THOSE LINES. 4 años 8 años

20 Reconstrucción unilateral con implante
preop 1 año 2 años 4 años 8 años

21 Grado de satisfacción de la reconstrucción con implante
Mean BREAST-Q Satisfaction with Breasts 80 70 60 p = 0.001 50 Bilateral Reconstruction 40 Unilateral Reconstruction Silicone 30 20 GOING BACK INTO PRO DATA – THIS IS EXACTLY WHAT MONICA MORROW’S GROUP FOUND WHEN THEY SURVEY PATIENTS WITH UNILATERAL IMPLANTS Saline 10 N = 112 N = 182 Mean follow-up 4.5 years King, Morrow, SSO 2013 21

22 La reconstrucción mamaria bilateral con implantes da simetría
THE GROUP HAVE BILATERAL IMPLANT RECOSNTRUCTION IS GETTING BREASTS THAT MATCH AND THE MATCH IS RELATIVELY STABLE. AND NOW THAT WE ARE DOING MORE AND MORE NIP SPARING MASTECOMIES, THIS IS INCREASLING ATTATCIVE TO WOMEN Increasing nipple sparing mastectomy --- THIS IS HOW WE GET BREASTS THAT MATCH – BILATERAL IMPLANTS

23 Reconstrucción bilateral con implantes Colocación directa de implantes
AND ALSO THAT SOME WOMEN WILL NOW BE CANDIDATES FOR SINGLE STAGE, DIRECT IMPLANT PLACEMENT La opción de un solo procedimiento es atractivo para las mujeres

24 ¿Que técnica da la mejor simetría?
MASTECTOMIA UNILATERAL BILATERAL colgajo ? implante SO GOING BACK TO THE 2 BY 2 TABLE, HERE IS WHAT WE HAVE IN THE LONG TERM SO IS YOU ASK ME, WHAT ARE THE IMPLICATION FOR RECONTRCUTION, I WOULD SAY THAT ANY OF THESE 3 CELLS PROVIDE ACCEPATBEL DURABLE RESULTS. THIS CELL, UNILATERAL IMPLANT RECOSNTRUTION – NOT SO MUCH.

25 Conclusiones La mastectomía profiláctica contralateral es cada vez más común En parte , las mujeres se sienten motivadas por querer mamas simétricas La reconstrucción unilateral con implantes puede ser decepcionante a largo plazo

26 CONCLUSIONES Una excelente simetría a largo plazo se puede obtener con la mastectomía unilateral / reconstrucción con colgajo Barreras para la posibilidad de reconstrucción con colgajos pueden estar contribuyendo al aumento de la CPM y esto debe tenerse en cuenta.

27 Muchas gracias San Antonio Breast Cancer Symposium Dec 9-13, 2014
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