Flavia Kuroda

Evaluation of Aesthetic and Quality-of-Life Results after Immediate Breast Reconstruction with Definitive Form-Stable Anatomical Implants

Background: Although there are many reports on different techniques in breast reconstruction, there are few data regarding immediate breast reconstruction with definitive form-stable anatomical implants in terms of aesthetics and quality-of-life outcomes. Methods: Ninety-four patients underwent mastectomy with immediate breast reconstruction using anatomical implants and contralateral symmetrization. Aesthetic results were evaluated by three different methods: the patient’s self-report, the assessment of four independent specialists (two breast surgeons and two plastic surgeons from different institutions), and the BCCT.core software. Quality of life was evaluated by means of the BREAST-Q instrument. Results: Average age ± SD was 52.1 ± 11.6 years. Most of patients had medium size breasts and T1 tumors. Patients had evaluated their aesthetic results better than did software and specialists. There was no significant difference in the comparison between software and specialist’s evaluation. Multifactorial analysis showed that age older than 70 years and radiotherapy were significant risk factors for poor aesthetic outcomes after immediate breast reconstruction with implants. Considering quality of life, most of the patients were satisfied with their outcome and psychosocial and sexual well-being. Conclusion: Immediate breast reconstruction with implants and contralateral symmetrization had a positive impact on the quality of life and showed satisfactory outcomes when evaluated by subjective and objective methods.

Oncoplasty as the Standard of Care in Breast Cancer Surgery

© TOUCH MEDICAL MEDIA 2014 43 Abstract Oncoplastic surgery is redefining breast cancer surgery today. Despite the lack of randomised clinical trials, current evidence suggests at least equivalent oncological outcomes, reduced re-excision rates and superior aesthetic results. This review outlines the arguments for the superiority of this new approach over the current standard of care and discusses some of the difficulties with regards to training and mentoring the next generation of surgeons.

Oncoplastic and Reconstructive Anatomy of the Breast

Breast cancer surgery has gone through various changes and become more complex and biologically individualized. Although concern with local control of disease still persists, this is currently associated with an aesthetic–functional concept. Therefore, breast anatomy in the way it is traditionally approached needs updating. Form, volume, inframammary fold, height, and breast projection as well as the size and shape of the nipple and areola complex, liposubstitution level, and ptosis are some of the points concerning surface anatomy that have acquired more importance within the oncoplastic and reconstructive context. Similarly, the abdominal wall and the dorsal structure of the thorax must be part of the surgeon`s background, as one needs to have a full reconstructive and oncoplastic view in order to make more suitable surgical decisions. In this way, aesthetic–functional breast anatomy is essential to reconstructive breast cancer surgery. The spatial organization of the mammary ducts, the vascularization, and the innervation have relevant therapeutic implications in the era of sentinel node and oncoplastic surgery, so the reconstructive breast surgeon must be aware of all of these anatomic relationships. It is within such a perspective that this chapter has been developed.

Impact of preoperatory magnetic resonance imaging in oncoplastic surgery

Study carried out at Unidade de Mama do Hospital Nossa Senhora das Graças – Curitiba (PR), Brazil. 1Unidade de Mama, Hospital Nossa Senhora das Graças – Curitiba (PR), Brazil. 2Clínica de Diagnóstico Avançado por Imagem, DAPI – Curitiba (PR), Brazil. *Corresponding author: kfurlan@terram.com.br Conflict of interests: nothing to declare. Received in: 05/14/2017. Accepted in: 05/29/2017 Objetivo: Não há dados sobre o impacto da imagem de ressonância magnética (RM) na cirurgia oncoplástica. O objetivo deste trabalho foi avaliar o impacto da RM no planejamento cirúrgico e nas mudanças de conduta em pacientes com câncer de mama inicial e candidatas a realizar a cirurgia oncoplástica. Métodos: Trata-se de uma coorte prospectiva de 60 pacientes que foram candidatas à cirurgia oncoplástica entre janeiro de 2013 e julho de 2014. Todos elas foram submetidas a uma RM pré-operatória, além de mamografia (MG) e ultrassom (US). Qualquer tumor adicional na RM classificada como BIRADS 4-5 foi biopsiado ou marcado com carvão e ROLL para serem localizados durante a cirurgia. O impacto cirúrgico dos achados adicionais da RM foi avaliado quanto a mudanças para mastectomia ou ressecção mais ampla. Resultados: Das pacientes, 29/60 (48,3%) apresentaram achados adicionais na ressonância magnética, 16/29 (55%) foram tumores multifocais, 1/29 (3,4%) foi multicêntrico, 5/29 (17%) foram tumores contralaterais e 9/29 (31%) apresentaram tamanho de tumor maior que 10 mm na RM. Das 22 pacientes que apresentaram lesões adicionais na RM, 15 (68,2%) apresentaram carcinomas invasivos no exame anatomopatológico definitivo. A sensibilidade da RM foi maior na estimativa do tamanho do tumor. Das pacientes, 12/60 (20%) foram submetidas à mastectomia e 17/60 (28,3%) a ressecções mais amplas. Apenas 5% das pacientes apresentaram margens positivas em todo o grupo. No grupo de pacientes que apresentaram resultados adicionais na RM, apenas 3,4% tiveram margens positivas. Conclusões: A RM é melhor que a MG e o US na avaliação da extensão do tumor e na detecção de tumores multicêntricos, multifocais e bilaterais. Em consequência, contribuiu nesta série para um melhor planejamento cirúrgico na cirurgia oncoplástica com baixa taxa de margens comprometidas e reexcisão.

Delayed Breast Reconstruction

Although immediate breast reconstruction after mastectomy is oncologically safe for most patients, its use remains low worldwide. In addition, there are many disparities in its availability which are related to race, sociodemographic factors, and financial and cultural barriers. Then, delayed breast reconstruction remains an option for many patients. There are some surgical procedures that have minor risks, and many of them can be performed in day surgery, like expanders and definitive implants. However, in irradiated patients, it is necessary to do breast reconstruction with autologous flaps. So, the aim of this chapter was to cover the indications, preoperative evaluation, operative techniques, and complications related to delayed breast reconstruction.

Resultados do exame intraoperatório do linfonodo sentinela na Unidade de Mama do Hospital Nossa Senhora das Graças em Curitiba

A biopsia do linfonodo sentinela (LS) e o procedimento padrao para as pacientes com axila clinicamente negativa. O seu exame intraoperatorio ainda gera dificuldades na sua abordagem. Assim, o objetivo deste estudo foi avaliar a eficacia desse exame no câncer de mama. Foram avaliadas 342 pacientes que foram operadas na Unidade de Mama do Hospital Nossa Senhora das Gracas em Curitiba (PR), no periodo de 2000 a 2012. No exame intraoperatrorio eram rea lizados cortes longitudinais, ao longo do maior eixo, a cada 2 ou 3mm. Em seguida eram feitos imprints em cada face de cada fatia e, entao, realizavam se cortes histologicos em criostato em tres niveis. Tanto os imprints quanto os cortes eram corados com azul de toluidina. Em sua maio ria eram tumores T1c (n=151), e 60 (17,5%) delas apresentaram axila comprometida no exame definitivo. A acuracia foi de 92%, o valor preditivo negativo, de 91% e a taxa de falso negativo, de 8%. Nao foram encontrados fatores de risco significativos para falencia da tecnica dentro dos parâmetros estudados.(AU) Sentinel node (SN) biopsy is the standard of care for patients with clinically negative axilla. However, in traoperatory pathological exam remains as a controversial issue. So, the aim of this study was to evaluate its efficacy in 342 breast cancer patients operated at the Hospital Nossa Senhora das Gracas Breast Unit in Curitiba (PR), in the period between 2000 2012. In the intraoperatory evaluation, all SNs were cutted in the major axis, in three levels, combining frozen sections with imprints, using toluidin blue. The majority of patients were T1c (n=151), and 60 (17.5%) had positive axila in the definitive pathology evaluation. Accuracy was 92%, predictive negative value was 91%, and false negative rate was 8%. We did not find any significant risk factor for false negative SN in this series.(AU)

One-Stage Breast Reconstruction with Definitive Form-Stable Implants

Immediate breast reconstruction with anatomic form-stable implants, associated with skin-sparing and nipple-paring mastectomies, is one of the greatest advances in oncoplastic and reconstructive breast cancer surgery. It has a low level of complications and decreases both the time spent in reconstructive surgical procedures and the number of surgical procedures for most patients. Surgical revisions of the reconstruction are still needed in some cases and are one of the greatest limitations. However, these are surgical procedures that have minor risks, and many of the procedures can be performed with the patient under local anesthesia. Currently, this is our most commonly used technique owing to its practicality, low level of long-term complications, and satisfactory aesthetic outcomes.

Clinical and Pathological Evaluation of 102 Patients with Internal Mammary Node Metastases in a Single Breast Unit

INTRODUCTION: Although incidence of internal mammary node (IMN) recurrence is only 0.1%, and almost all of these patients have systemic disease, it has an important prognostic value when both axillary and IMN are positive. But routine sentinel node (SN) biopsy of IMN is not standard practice and warrants further investigation of patients who may benefit of this procedure. METHODS: 561 patients with invasive carcinomas who underwent to Patey’s mastectomy (between 1987 and 2004) and skin-sparing mastectomy (after 2004) between 1987 and 2012 in HNSG Breast Unit in Curitiba (Brazil) were included in this study, and underwent to a routine IMN biopsy in the second and third intercostal space, together with complete axillary dissection in 3 Berg’s levels. After 1997 only patients with positive SN underwent to this procedure. RESULTS: 102 patients (18%) in this group had positive IMN. The age ranged from 28 to 85 years, with a median of 52 (sd=12) years. 94 (92%) were invasive ductal carcinomas, 6 (6%) invasive lobular carcinomas, 1 (1%) mucinous invasive carcinoma, and 1 (1%) medullary carcinoma. Most of the tumors were T2 (57%) and T3 (21%), and only 3% were T1. Lymphovascular invasion was found in 99 (97%) in this group. 9 (9%) patients had no positive axillary nodes, and for those with both axillary and IMN positive, median of compromised nodes was 9 (sd=12), 22% of IMN positive had 1-3 compromised axillary nodes, 48% had 4-10, and 31% had more than 10. In the follow-up, 57 (56%) died with disease, 22 (22%) were alive without disease, 5 (5%) were alive with disease, and 22 (22%) lost follow-up. CONCLUSIONS: IMN was positive in more advanced and aggressive tumors. Implication of these results to IMN adjuvant radiotherapy needs further investigation.