Innovations in Breast Cancer Surgery

Educational Objectives

The goal of this program is to improve management of breast cancer using minimally invasive surgery. After hearing and assimilating this program, the clinician will be better able to:

1. Implement innovations in breast reconstruction techniques to optimize patient outcomes.

Summary

Introduction: advancements in targeted systemic cancer treatments and innovations in reconstructive surgery and anesthesia have significantly transformed breast cancer care; improved treatment responses facilitate down staging; reconstructive techniques enhance patient outcomes; non-narcotic anesthesia protocols minimize adverse effects and hospital stays

Nipple-sparing mastectomy: Peled et al (2012) reported a local recurrence rate of 3% over 3 yr; Moo et al (2016) observed a recurrence rate of 2% at 3 yr; Smith et al (2018) demonstrated local recurrence rate of 2.6% at 20-mo follow-up; the adoption of nipple-sparing mastectomies is influenced by surgeon experience and expertise; in patients with wide areolas or recent pregnancies, a 2 stage nipple sparing mastectomy procedure is performed; the tumor is removed and followed by sentinel node biopsy, breast reduction, and lift; after 3 mo, the patient returns for the nipple sparing mastectomy

Prepectoral reconstruction: refers to the placement of the implant over the muscle; advantages include reduced dissection, increased patient comfort, and faster recovery; prepectoral reconstruction may lead to a more natural looking result, and reduced pain; a small percentage of patients may require fat injections to address rippling; visible movement of implants during exercise is a common issue with subpectoral placement (animation effect); 3 dimensional camera technology allows for visualization of postoperative outcomes, facilitating collaborative decision-making between the patient and surgeon about implant size and appearance and ensuring that patient expectations are aligned with achievable results

Nerve preservation and restoration: advancements may address the issue of post-mastectomy numbness; Peled et al (2023) showed that >80% of patients who underwent neurotization techniques (eg, nerve sparing, grafting) experienced restoration of sensation (measured by moving and pressure points) 9 mo after surgery

Perioperative pain management: adverse effects of narcotics include confusion, drowsiness, nausea, constipation, euphoria, and slowed breathing; long lasting liposomal bupivacaine may reduce pain; Nguyen et al (2023) showed 30% reduction in pain scores at 72 hr and 45% decrease in opioid consumption, with reduced nausea, and vomiting, and decreased length of stay; King et al (2020) showed that an opioid free anesthesia protocol incorporating acetaminophen, celecoxib, and gabapentin significantly reduced nausea, vomiting, pain, and hospital stays compared with traditional anesthesia; Armstrong et al (2023) demonstrated the feasibility of same day discharge after double mastectomy with implant reconstruction

Multicentric breast cancer: the American College of Surgeons Oncology Group Z11102 study by Boughey et al (2023) examined the effectiveness of lumpectomy and radiation therapy as an alternative to mastectomy for multicentric breast cancer; patients >40 yr of age with 2 to 3 sites of cancer >2 cm apart were included; local recurrence rate was <8% at 5 yr, which decreased to 1.7% with preoperative magnetic resonance imaging; the conversion rate to mastectomy was 7%; the SOUND trial by Gentilini et al (2023) found that omitting sentinel lymph node biopsy did not significantly influence recurrence, disease free survival and mortality in patients with small (T1 lesions) and clinically node negative breast cancer

Readings

Boughey JC, Rosenkranz KM, Ballman KV, et al. Local recurrence after breast-conserving therapy in patients with multiple ipsilateral breast cancer: Results from ACOSOG Z11102 (Alliance). Journal of Clinical Oncology. 2023;41(17):3184-3193. doi:10.1200/jco.22.02553; Doremus NV, Vega K, Tecce MG, et al. Expanding the use of nipple sparing mastectomy: A review of the indications and techniques. Surgical Oncology Insight. 2024;1(3):100062. doi:10.1016/j.soi.2024.100062; Peled AW, Von Eyben R, Peled ZM. Sensory outcomes after neurotization in nipple-sparing mastectomy and implant-based breast reconstruction. Plastic & Reconstructive Surgery Global Open. 2023;11(12):e5437. doi:10.1097/gox.0000000000005437; Sbitany H, Piper M, Lentz R. Prepectoral breast reconstruction: A safe alternative to submuscular prosthetic reconstruction following nipple-sparing mastectomy. Plastic & Reconstructive Surgery. 2017;140(3):432-443. doi:10.1097/prs.0000000000003627.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Tousimis has received compensation for educational teaching at Medtronic and has been a faculty member at Axogen. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Tousimis was recorded at Cleveland Clinic Cancer Conference: Innovations in Multidisciplinary Care, held November 1-3, 2024, in Hollywood, FL, and presented by Cleveland Clinic. For information on upcoming CME activities from this presenter, please visit clevelandclinicmeded.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

ON160903

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.