Stefan Krämer

Breast-Conserving Treatment of Breast Cancer – Oncological and Reconstructive Aspects

Breast-conserving surgery combined with radiotherapy has become the treatment of choice for the majority of women presenting with primary breast cancer over the last 20 years. The extent of local excision remains a controversial issue in breast-conserving surgery. The wider the margins of clearance, the lower the risk of incomplete excision and thus of local recurrences, but the greater the amount of tissue removed, the higher the risk of visible deformity leading to an unacceptable cosmetic result. This clash of interests is most evident when attempting breast-conserving surgery in patients with smaller breast-tumor ratios. The widespread popularity of breast-conserving surgery has focused attention on new oncoplastic techniques that can avoid unacceptable cosmetic results. Partial mastectomy defects can be reconstructed by volume displacement, recruiting and transposing local glandular or dermoglandular flaps into the resection site, or by volume replacement, importing volume from elsewhere to replace the amount of tissue resected.

Autologous and alloplastic breast reconstruction--overview of techniques, indications and results.

It is important for any woman undergoing mastectomy to make an informed decision about reconstruction and to be provided with information about the technique, advantages and disadvantages. There is a high degree of patient satisfaction with breast reconstruction, but high levels of preoperative information and psychological support are necessary. Close collaboration between oncological and reconstructive surgeons or management by an oncoplastic breast surgeon, careful patient selection and counseling, and refinements in surgical techniques can provide a range of safe and predictable techniques for breast reconstruction. After modified radical mastectomy breast reconstruction involves replacement of breast skin and breast volume; after skin-sparing mastectomy only the replacement of breast volume is necessary. The most commonly used surgical techniques are tissue expansion, latissimus dorsi myocutaneous flap with or without implants, and the use of lower abdominal tissue. Until today, the pedicled TRAM flap is the standard method for autologous breast reconstruction.

Mammographisch/stereotaktisch gezielte Vakuum-/Exzisionsbiopsie Interventionelle Methoden in der Mammadiagnostik

ZusammenfassungSowohl im Rahmen der komplementären Mammadiagnostik (Klinik, Mammographie, Sonographie) einschließlich der dynamischen MRT als auch von Mammakarzinom-Screening-Projekten haben interventionelle Methoden wie die mammographisch/stereotaktisch gezielte Vakuum-/Exzisionsbiopsie ihren festen Stellenwert zur Vermeidung unnötiger offener Operationen und gehören zum klinischen Alltag. Unter Beachtung strenger Kriterien ist dies ein Weg, die Spezifität und den negativen Vorhersagewert in der Mammadiagnostik zu verbessern. Darüber hinaus sind interventionelle Methoden kostengünstiger, zeitsparender und mit geringerer Morbidität belastet als ein operativer Eingriff.AbstractAs well as in the complementary mamma diagnosis (clinical examination, mammography, sonography) including the dynamic MRI and the mammography screening projects the interventional methods like mammographically/stereotactically guided vacuumbiopsy/excisional biopsy are established methods to avoid unnecessary open operations and they are integrated in the clinical routine. By using strict criterias it is a way to improve the specificity and the negative predictive value in the mamma diagnosis. In addition the interventional methods requires less costs, less time and reduces the morbidity in comparison to an open operation.

Partial Mastectomy Reconstruction with Local and Distant Tissue Flaps

Breast-conserving surgery combined with radiotherapy has become the treatment of choice for the majority of women presenting with primary breast cancer over the last 20 years. The extent of local excision remains a controversial issue in breast-conserving surgery. The wider the margins of clearance, the less the risk of incomplete excision and thus of local recurrences, but the greater the amount of tissue removed, the higher the risk of visible deformity leading to an unacceptable cosmetic result. This clash of interests is most evident when attempting breast-conserving surgery in patients with smaller breast/ tumor ratios. The widespread popularity of breast-conserving surgery has focused attention on new oncoplastic techniques that can avoid unacceptable cosmetic results. Partial mastectomy defects can be reconstructed by volume displacement (recruiting and transposing local glandular or dermoglandular flaps into the resection site), or by volume replacement techniques. There is a wide spectrum of oncoplastic techniques which have been published during the last years necessitating a systematic structuring of these procedures in terms of indication, outcome, and technical details.

Intraoperative Strahlentherapie des Mammakarzinoms

In the systemic therapy of breast cancer, the tumor itself has become the specific target. If possible the surgical excision of breast carcinoma is restricted to the tumor site and aims at an R0 resection of the invasive and preinvasive portions of the carcinoma. Only percutaneous whole-breast radiotherapy irradiates the whole breast. The additional boost irradiation is targeted and significantly improves local control in all age groups. Due to the increased detection of small breast carcinomas in postmenopausal patients by mammographic screening, it is necessary to consider a change of the existing therapeutic practice. Published results of partial irradiation of the breast (intra- as well as postoperatively) show a very high degree of local control with follow-ups of up to 11 years. At present prospective and randomized studies investigate for which patients an intraoperative radiotherapy is sufficient as the sole irradiation method after previous surgery. Intraoperative radiotherapy as a boost preceding percutaneous whole-breast irradiation should already be possible according to a relevant statement of the DEGRO.In the systemic therapy of breast cancer, the tumor itself has become the specific target. If possible the surgical excision of breast carcinoma is restricted to the tumor site and aims at an R0 resection of the invasive and preinvasive portions of the carcinoma. Only percutaneous whole-breast radiotherapy irradiates the whole breast. The additional boost irradiation is targeted and significantly improves local control in all age groups. Due to the increased detection of small breast carcinomas in postmenopausal patients by mammographic screening, it is necessary to consider a change of the existing therapeutic practice. Published results of partial irradiation of the breast (intra- as well as postoperatively) show a very high degree of local control with follow-ups of up to 11 years. At present prospective and randomized studies investigate for which patients an intraoperative radiotherapy is sufficient as the sole irradiation method after previous surgery. Intraoperative radiotherapy as a boost preceding percutaneous whole-breast irradiation should already be possible according to a relevant statement of the DEGRO.

Breast Imaging and Interventional Procedures – the Basis for Oncoplastic Breast Surgery

Preoperative staging of breast cancer based on breast imaging is mandatory. Breast imaging is a general term that encompasses mammography, breast sonography, and magnetic resonance tomography (MRT) of the breast (magnetic resonance mammography, MRM). It is known that earlier diagnosis of breast cancer is more likely to result in a favorable oncological outcome. In this context, use and limitations of MRM in diagnosis and staging of breast cancer as well as its influence on surgical procedures have to be discussed. Different interventional procedures have been developed. The histological results of interventional procedures guided by ultrasound, stereotactic mammography or MRT have to be integrated in planning surgical resection margins in oncoplastic breast-conserving surgery. Image-guided wire markings are an important tool for planning these surgical resection margins. This paper gives an overview on the importance of breast imaging, interventional procedures, and wire markings for breast-conserving surgical therapy.

Estimation of Worst Case Response Time boundaries in multi-core real-time systems

We address a novel probabilistic approach to estimate the Worst Case Response Time boundaries of tasks. Multi-core real-time systems process tasks in parallel on two or more cores. Tasks in our contribution may preempt other tasks, block tasks with semaphores to access global shared resources, or migrate to another core. The depicted task behavior is random. The shape of collected response times of a task within a processing time is multimodal. Extreme Value approaches need unimodal response time distributions to estimate the Worst Case Response Time of tasks. The new proposed method derives a set of three task set shapes from the source task set. It is used to minimize the uncertainty of random task behavior by maximizing the coverage of possible Worst Case Response Times. The case study evaluates the new proposed estimation method by the use of dynamically generated random tasks with varying task properties.

Vacuum-assisted breast biopsies (VAB) carried out on an open 1.0 T MR imager: Influence of patient and target characteristics on the procedural and clinical results

PURPOSE The study was conducted in order to assess the clinical impact of MRI-guided vacuum-assisted breast biopsies carried out using an open 1.0T open MRI-system. MATERIAL AND METHODS The clinical, imaging, interventional and histological data of all 132 patients with a first MRI-guided vacuum-assisted breast biopsy carried out between 07/2005 and 03/2012at the Radiological Department were extracted from the clinical files. The clinical outcome of patients with benign histological findings was assessed based on the clinical files and queries of the local gynecologists in charge. In the 103 interventional image data sets available target localization and target size were evaluated by two board-certified senior radiologists. Clinical data, lesion characteristics and interventional results were evaluated statistically using subgroup analyses. RESULTS 131 of 132 MRI-guided breast biopsies (99.2%) were carried out successfully. The median interventional duration was 30min (25%-percentile 25min, 75%-percentile 35min, maximum 75min). Minor complications occurred in 12 interventions of the 131 (9.2%). The histological work-up of the biopsy specimen showed benign results in 98 of 131 interventions (74.8%), lesions with uncertain biological potential in 5 biopsies (3.8%) and malignant findings in 28 biopsies (21.4%). There were 2 false negative histological findings. Neither the patient age nor the medical history nor the anticipated risk of developing breast cancer had an impact on the success rates and the complication rates. In the 103 interventions with available image data sets the maximum target lesion diameters were 1-5mm in 16 lesions (15.5%), 6-10mm in 41 lesions (39.8%) and 11-15mm in 29 lesions (28.2%). There was a positive correlation between the maximum diameters and the rate of malignancy of the target lesions (p=0.020) as well as a trend towards longer interventional procedure durations in smaller target lesions (p=0.183). CONCLUSION MRI-guided vacuum-assisted breast biopsy for suspicious breast lesions is a clinically safe and feasible method even in small target lesions when using an open high-field MRI-system.

Translationale Medizin steht im Vordergrund

„Illumination & Innovation – transforming data into learning“ so lautete das Motto der ASCO-Jahrestagung (29.5.–2.6.2015) in Chicago mit mehr als 37.000 Teilnehmern aus über 80 Ländern und fast 6.000 eingereichten Abstracts. Aus einer Vielzahl von Beiträgen zur gynäkologischen Onkologie haben unsere Experten einige neue Daten ausgewählt, welche die Behandlungsstandards in den nächsten Jahren verändern könnten.

Onkoplastische Brustchirurgie – Zielgerichtete Brustchirurgie angepasst an Tumorsitz und Tumor-Brust-Relation

Basierend auf einer individuellen Charakterisierung der Tumorbiologie des Mammakarzinoms werden zunehmend zielgerichtete Behandlungsstrategien eingesetzt. In einer uber 1000 Patienten mit Brusterhaltender Therapie (BET) umfassenden Studie haben wir die Systematik einfach zu beherrschender Techniken, angepasst an den Tumorsitz und an die Tumor-Brust-Relation, validieren konnen. Uber 60 % aller Tumoren liesen sich hierbei mit glandularer Rotationstechnik und uber 30 % mit dermo-glandularer Rotationsmastopexie, tumorlager-adaptierter Reduktionsplastik und lateralem Thoraxwand-Advancement-Lappen- (n. Rezai), bei hoher Patientenzufriedenheit, beherrschen. Nur in seltenen Fallen waren Volumen-Ersatz-Techniken aus anderen Donor-Regionen (Thorakoepigastrischer Lappen, Latissimus-dorsi-Lappen) erforderlich 4 5 8 .