Inside the OR: Endoscopic Nipple-Sparing Mastectomy Explained

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepherd, a Medical Oncologist Co-Directing the Cleveland Clinic Sarcoma Program. Today, I'm happy to be joined by Dr. Paula Escobar, a Breast Surgical Oncologist here at Cleveland Clinic. She's here today to talk about endoscopic nipple-sparing mastectomy. Welcome.

Paula Escobar, MD: Thank you. Thank you for the invitation.

Dale Shepard, MD, PhD: Absolutely. Maybe to start off, maybe give us a little idea of what you do here at Cleveland Clinic? And what's your role here?

Paula Escobar, MD: Here at the Cleveland Clinic, I'm one of the breast surgical oncologists. Basically, we take care of breast cancer patients. We also do some surgeries for benign breast patients that need surgery. And one of the other surgeries that we do, is we do surgery for patients that are at high risk of developing a breast cancer. We do risk the reducing surgery, which is called usually informally prophylactic surgery.

Dale Shepard, MD, PhD: Excellent. Well, today we're going to talk about this nipple-sparing mastectomy endoscopic procedure. Maybe there's a lot of different people who might be listening. Give us an idea like what's traditional surgery? And then, how have we flexed into making these changes?

Paula Escobar, MD: Maybe I need to give a little bit of a background. 1999 was the first nipple-sparing mastectomy reported. And after that, Dr. Crow, here at the Clinic, he was one of the pioneers of this technique, and he developed the nipple-sparing mastectomy. He developed an open or conventional nipple-sparing mastectomy in which patients who wanted a breast reconstruction and wanted to preserve all the envelope of the breast, it could be preserved. The breast was then reconstructed.

As opposed to that, what we're doing right now is the same technique but with a different tool. It's not really a super different technique, it's basically the same surgery with a different tool. And what we do it is with a minimally invasive approach, meaning less scar in the breast.

Dale Shepard, MD, PhD: We here on this podcast, we've had a lot of discussions about endoscopic kinds of surgery. Give us a little bit of an idea, from a practical standpoint, what that's like for patients. You mentioned less invasive. What does it look like? What does that procedure... How does it vary?

Paula Escobar, MD: The procedure varies. We start doing the procedure in a similar way as the open or conventional nipple-sparing mastectomy, we do a very small incision. The scar and the incision will be situated not in the breast, it will be situated in the midaxillary line hidden by the arm or sometimes in the submammary fold a little bit later, so it's going to be completely invisible. And then, after we start doing an open dissection to begin with, then we inflate the breast or we expand the breast with CO2. And then we introduce our laparoscopic instruments through a single incision and we take the breast inside out. Imagine taking the pillow from a pillowcase. We just keep the pillowcase and we remove the pillow. Then the plastic surgeons would put in another pillow, so you will have a reconstructed breast with an invisible scar.

Dale Shepard, MD, PhD: And then, while we're talking about that reconstructive piece, are there differences in how that reconstruction happens, when it happens? What does that look like for patients?

Paula Escobar, MD: We try always to do immediate breast reconstruction at the time of the mastectomy, but since we are doing this technique through a smaller incision, the plastic surgeons have to adjust to a small incision now. So they have to change a little bit the reconstruction. We work very closely to the plastic surgeons. Part of our training was to train with the plastic surgeons, so we could do this approach as a minimally invasive breast surgery.

Dale Shepard, MD, PhD: As you've develop this procedure, you're forcing the plastic surgeons to learn new things too.

Paula Escobar, MD: Absolutely. Yes. We had to force the plastic surgeon into this technique.

Dale Shepard, MD, PhD: About this technique, give us a little bit of an idea about the history of this. How new is this? How has this developed?

Paula Escobar, MD: This technique, the way we do it right now, probably has five years. Minimally invasive breast surgery has started, I would say it started in the Asian countries 20 years ago. But they didn't have the technology that we do right now, so they were using mechanical arms to lift the breast a little bit, so they had some complications in the skin flaps of the mastectomy in the nipples. And they did there because the patients were smaller, smaller breasts, different body habitus. This technique kicked up in Europe, so in France, in Spain, in Italy, there are some people doing it. They are also doing robotic surgery over there. They began doing it with the way we're doing it right now and we are learning to do it. We use, as I mentioned, CO2. We expand the breast as it would be like in an abdominal laparoscopic surgery, and we introduce the instruments through a little small incision.

Dale Shepard, MD, PhD: How pervasive is this procedure? Are lots of surgeons doing this? Is this more at specialized centers? How easy is it for patients to get this procedure?

Paula Escobar, MD: As of right now, it's not very easy to access to this procedure because there are very few surgeons in the US doing it. The people who train in the US went outside, and they trained basically outside, the first ones. They brought the technique back. And there are some courses that are happening here in the US. There have been three already. There has been hands-on simulated model courses, and the surgeons have been learning how to do it. I would say it's a handful of surgeons as of right now doing this surgery.

And this is why we're super excited, because here at the Cleveland Clinic we're pioneering this technique. And I had the opportunity to help collaborate, to train my colleagues here at the Clinic. A bunch of us went to one of these courses. Several of us are now training this technique.

Dale Shepard, MD, PhD: That's great. You um, much like we've heard a lot about endoscopic procedures, we've heard about robotic procedures, and you mentioned robotic surgery. How does robotic surgery for breast cancer compare to endoscopic surgery?

Paula Escobar, MD: Your question is so appropriate. Thank you very much for bringing that up. Robotic surgery is great for the breast, but it takes a long time. You need a robot. The learning curve is not short. And it's not FDA approved right now. If you wanted a robotic surgery right now, you will have to be undergoing a surgery which is on a trial. Very limited places here in the US are doing it right now. It will be FDA approved, it's not right now.

As opposed to endoscopic surgery, for endoscopic surgery we don't need any special tools. All the instruments and the things we're using as instruments in the OR are already available because they're using it for abdomen surgery, for hernia. So, everything is there. We didn't have to buy anything in particular at the clinic to start doing it. So it was easier, I would say, to implement this robotic. The cost, of course, is less, you don't need a robot. And the operating time of endoscopic surgery is when you're experienced similar to open or conventional surgery, which is also a super great advantage.

Dale Shepard, MD, PhD: Really, the investment, if you will, from an endoscopic surgery is that training part.

Paula Escobar, MD: Exactly.

Dale Shepard, MD, PhD: Yeah. When we think about this procedure, are there any cancer characteristics that would make this you know sort of an unfavorable procedure, either location of tumor, size of tumor? Are there things that would sort of force you into an open procedure instead of an endoscopic procedure?

Paula Escobar, MD: For breast cancer, basically the indications are very similar to the conventional nipple-sparing mastectomy. In an endoscopic or in a conventional nipple-sparing mastectomy, if the tumor, for example, is involved in the skin, you wouldn't leave the skin. You will have to remove it. Same thing with the muscle. If the tumor is super close to the muscle or the tumor is super close to the nipple, or if the tumor is involving the skin, these patients are not very good candidates for this open or endoscopic technique.

Dale Shepard, MD, PhD: All right. Access, for instance, isn't an issue because of your ability to, like you said, insufflate and get where you need to go. When we think about not tumor characteristics, patient characteristics. So, if somebody's listening in, say, "Hey, I'd like my patient to go talk to you or your colleagues about this procedure." Are there certain patient characteristics that make for a good candidate for this, or certain patient characteristics that we really shouldn't be trying this procedure?

Paula Escobar, MD: Yes, there are patients that have better characteristics to be candidates for the surgery. These are patients that have breasts which are not super big. We can do the cap A, the cup B, the cup C. As of our learning curve right now is on the starting point, we are not able to do bigger breasts right now. The other important thing is that we do it on patients that don't have a big ptosis. We do it with no ptosis or ptosis grade one or two, because otherwise the nipple or the cosmetic result is not going to be very good.

Dale Shepard, MD, PhD: About the patient experience, smaller incision, how does this translate to time for the procedure, time for recovery? What are the advantages from a patient's standpoint in terms of having the procedure itself?

Paula Escobar, MD: The advantages for the patients are, first, cosmetic outcome. The cosmetic outcome is super good. Secondly, the scar is hidden, invisible. Thirdly, given this is a minimally invasive approach, probably it's very similar to what happened before with the open laparoscopic appendectomies of all bladders. The patients recover in a quicker way, probably less pain. And particularly in the breast, there are some studies which are preliminary that say that patients have better sensation in the nipple and in the mastectomy skin flap. We have to do trials to perform trials, quality trials in the future. Because those trials have been really, since this technique is new, been going on, but this is part of our future trials. But patients experience for the first patients that we have done, the patients are very happy with the procedures and they recovered very quickly.

Dale Shepard, MD, PhD: And then, I guess this has been done, you said in Asian countries, then in Europe. In terms of the long-term outcomes, in terms of oncology outcomes, data looks promising?

Paula Escobar, MD: We first started doing open conventional nipple-sparing mastectomy, and the oncological safety was proven by data. And this is the same technique, again, done by a different tool. Even maybe it's a little bit better. Because since this is super visualized and magnified in a screen in the OR, everybody is watching what I'm doing. The way I'm handling the mastectomy skin flap is probably much better because I have a better visualization, even myself. I don't know if you have the opportunity to watch a nipple-sparing mastectomy. We do a small incision through the inframammary fold, and then we open and we remove all the breast through a small incision that our visualization is very limited. With this new technique, I have a much better visualization, so I can see the breast tissue, and I can remove in a better way the tissue behind the nipple or the axillary tail.

Dale Shepard, MD, PhD: That's excellent. The thing that oftentimes plagues us with procedures and things we're trying to do, insurance coverage. Are there any issues with coverage with this as a different technique than our usual open procedures?

Paula Escobar, MD: We haven't had any problems with insurance coverage. We don't have a code. This is so new that we don't have a specific code for it right now, so it will be charged as a skin-sparing mastectomy.

Dale Shepard, MD, PhD: Yeah. Excellent. I guess, when we think of these new developments, what's next? What's the next-

Paula Escobar, MD: Next step?

Dale Shepard, MD, PhD: What's the next step?

Paula Escobar, MD: We already performed a nipple-sparing mastectomy endoscopically, and we retrieved the sentinel node endoscopically assisted. That was a new step as well. Meaning, doing all the breast surgery through this single incision, even the lymph nodes. Probably the following step will be the axillary dissection. And we are planning to do a lumpectomy right now for, again, specific patient that have specific located tumors in the inner portions of the breast. So instead of giving you a scar in the breast, we'll give you a scar in the axilla, and we'll remove through that small hole in the axilla. And we can also expand this, and we already did one case as well in a man who had a gynecomastia. We did the kind of gynecomastia with this technique as well.

Dale Shepard, MD, PhD: That's excellent. Do you see this as becoming widely adopted as a new standard as people get trained?

Paula Escobar, MD: I think it will happen, again, the same thing that happened many years ago when someone said, "Ooh, I want to do a laparoscopic cholecystectomy." There are going to be early adopters and there are going to be the detractors of the technique. But at the end of the day, the patient's experience and the outcomes, and when the patients begin to recover more quickly and we are providing better care for the patients, I think it's going to be adopted.

Dale Shepard, MD, PhD: Yeah, that's great. Sounds like a great new technique. Sounds like it's certainly better for patients in terms of the ability to have better recovery times and scars, and things like that. Appreciate you innovating on this and coming, giving us your insights.

Paula Escobar, MD: Thank you very much. I think this is the era of minimally invasive surgery, and breast is going to be part of it.

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