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Oncoplastic surgery, which combines lumpectomy with reconstructive surgery, is an option for an increasing number of breast cancer patients. Vice-Chairman of the Department of Plastic Surgery at Cleveland Clinic, Risal Djohan, MD, joins the Cancer Advances podcast to discuss the latest techniques in oncoplastic surgery and which patients make ideal candidates.

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Newest Techniques in Oncoplasty

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 Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase I and Sarcoma Programs. Today I'm happy to be joined by Dr. Risal Djohan, Vice Chairman of the Department of Plastic Surgery. He's here today to talk to us about oncoplastic surgery. Welcome, Risal.

Risal Djohan, MD: Thank you. Thank you, Dr. Shepard. Thank you for the opportunity.

Dale Shepard, MD, PhD: Absolutely. So maybe to start out you can give us a little background. What's your role here at Cleveland Clinic.

Risal Djohan, MD: Great, thank you. My name is Risal Djohan. As mentioned, I'm a plastic surgeon at Cleveland Clinic. I've been working here at Cleveland Clinic for 17 years. My practice is heavily involved in reconstructive breast surgery, working cohesively and coherently with our surgical oncologist that is specialized in breast cancer.

So when patients are being treated for the breast cancer, we are approaching it with multi-disciplinary approach. A new patient with breast cancer will have multi-disciplinary visits with each of specialties, and therefore will see the plastic surgeons along with the breast surgeons. And we'd discuss regarding the options, what is the best possible options in treating their breast cancer. Along with potential reconstructions of the breasts, in putting it back together and making sure that patients are comfortable for the future outcome for aesthetic result, as well potential, what we call it, functional result.

Dale Shepard, MD, PhD: Perfect. So we have a variety of people that may be listening in. So maybe just to define terms, what is meant by oncoplastic surgery?

Risal Djohan, MD: So oncoplastic surgery, it is meanings that we are treating the breast cancer oncologically safe. But in the meantime, putting a plastic surgical reconstructions to rebuilding the breasts so that we can remove what is necessary to remove the cancer, and then rebuilding it in a way that we can restructure the breasts to be hopefully normal again.

So typically if you ask what is the candidates, who are the candidates, what type of patients, who are a candidate for this, typically patients who have larger breasts. The terminology on all of these patients usually have, they call it macromastia. And some of these patients who are having larger breasts, they even present to us typically what they call it symptomatic macromastia, because with the larger breast they have shoulder grooving, neck pain, shoulder pain, and has been a burden to carry a larger breast.

So on one of the occasion that we found out they have a lesion in the breast, so therefore a portion of the breast can be removed along with the breast reductions. And then therefore we can reduce the breasts at the area that is affected by the tumor, and the same time we can actually treat the other breast that normally we reduce anyway and become relatively symmetrical. And so therefore patients will have a treatment of breast cancer, as well as a breast reduction.

Dale Shepard, MD, PhD: And so it sounds like from what you just told us that some of these patients actually are perhaps not aware that they have a small cancer when they initially present to you. How often does this happen?

Risal Djohan, MD: So it is not often, but it's usually the other way around. Some of these patients who usually having routine mammogram, and then with the routine mammogram visits they've figure out, "Hey, you have a dense breast, or you have a potential lesions." And then they do biopsies and then the biopsy, "Oh, you have a cancer." And then during the discussion, "Oh yeah, I've been having a talk about reduction, the breast reductions."

And therefore then we'll continue to have a discussions. We can treat your cancer with removal of the tumor and the reductions. So what are the pertinent informations that is useful to know? Usually the breast cancer has to be unifocal, it's a focal lesions. So if a breast cancer has multiple different multifocality all over different parts of the breast, then there will be a different type of treatment, that will be mastectomy.

Therefore, we have a multi-disciplinary approach. We'll discuss with the oncologic breast surgeon, making sure that we can treat effectively. Making sure that the breast is localized in one area, that we can remove the cancers and reduce the same time.

Dale Shepard, MD, PhD: Is there a ratio of size of tumor to the size of breasts that is ideal for this kind of procedure?

Risal Djohan, MD: That is excellent question. Usually up to 20% of the volume of the breast. So we remove the area of the cancer and the surrounding area so that we can have a clean margin. So we have oncologically safe margins to make sure there is no potential surrounding tissue that is spread, and then we remove that up to 20%. The remainder of the breast, which is about 80% can make it up, rearrange the breast, and becoming aesthetically pleasing again.

And hopefully, I mentioned before about functional. One of the function of the breast is that you want to maintain sensory. So making sure that the area of the tumor not compromising where the area of the nerve and the blood supply to the nipple, so we won't compromise the functionality of the breast.

Dale Shepard, MD, PhD: Realizing on the medical oncology side that breast cancers have a lot of difference in terms of likelihood for recurrence and things like that. Are there any histologies that are more or less likely to be amenable to this procedure?

So a triple-negative breast cancer that might be more likely to spread, are we doing those procedures in those patients as well or?

Risal Djohan, MD: Typically, as mentioned before, unifocal and as well as the biologic of the tumor, they will determine that. And definitely therefore in sub special like you are, medical oncology and in surgical oncology, and even the radiation oncology. Because any of these patients, after the treatment of oncoplasty, is for sure they have to have radiation.

So all of those thing would come together and discuss, and maybe even a tumor board, making sure that is oncology really safe for the patient. So definitely you are correct, certainly we discuss with any type of the cancers which one that will be suitable for this treatment.

Dale Shepard, MD, PhD: And when we think about just logistics, you've mentioned people come to clinic and they see a variety of specialists. In terms of the surgery itself, this happens at the same time as the removal of the tumor. This isn't a staged procedure, this is all at one time, is that correct?

Risal Djohan, MD: Usually it's one time. The only time that we do it staged is when we think that, hey, maybe best to do the other side, the normal side, at a different stage. Because sometimes when we have to remove the breast, we mentioned up to 20%. And then after that, we need to have radiations.

The effect of radiation, sometimes it may further shrink the volume of the breasts. And then when we do the reduction the same time, we usually estimate the contralateral normal sides to estimate its size, but we don't know how much of the shrinkage from radiation will happen. Some patients actually prefer to have the contralateral side done at the different time.

But typically, yes, you're correct. We do at the same time, to provide easy scheduling, as well as easy for the patient for symmetry. But some other patients, they have the choice of having it done at same time or separately.

Dale Shepard, MD, PhD: And how about outcomes? I presume that outcomes are equivalent?

Risal Djohan, MD: Yeah, so the outcome has been great. In fact, because when removal of the tumor, and sometimes when you just close it up by itself, you don't actually mobilize the surrounding tissue to take over area of the vacancy. If you have a large vacancy then you can have potential seroma, and after radiation it can get a sunken appearance.

So by relocating the surrounding breast to take over the void area, that means we are avoiding potential of a divot in the future. If we do comparative studies, certainly we haven't done it yet, we want to do it for the future. Yes, the outcome usually, it's much, much better.

Dale Shepard, MD, PhD: What are the advances at this point? What's being worked on to improve the technique? Where are we?

Risal Djohan, MD: Currently, the future stagings of this kind of surgery is to have what we call it margin assessment. As mentioned before, we look at during the surgery, we assess the tumor margins with, they call it, frozen sections. But who knows, there is actually a recent development that we can utilize special goggles that we can have a staining that we can see during the surgery precisely the margins.

So they call it a tumor marker margins, so a visual guided surgery. So we maybe created some kind of protein that has certain antibodies that latch to the tumor, and then we inject it, infiltrate it. And then you can use special goggles that will actually give a special fluorescent-guided removal of the tumor. That is excellent, that's the way for the future. We're excited to wait for that availability.

Dale Shepard, MD, PhD: Impressive. Now these sort of procedures, are these routinely done in the community or are these mostly at centers that have more infrastructure?

Risal Djohan, MD: Definitely you need to have collaboration between the oncologic surgeon and the plastic surgeon, and available at the same place. We can actually use this procedure, even in the ASC. These patients sometimes can be as outpatient surgery, can be going home the same time.

Dale Shepard, MD, PhD: So really it certainly doesn't add any real time to the patient's time in the hospital after surgery or things like that.

Risal Djohan, MD: That's correct.

Dale Shepard, MD, PhD: No, that's great. What else is new from a surgical standpoint? So certainly the margins that seems like a really important thing.

Risal Djohan, MD: Yeah.

Dale Shepard, MD, PhD: Is there anything else being done in terms of ... Is there anything with 3D modeling or ... You mentioned about predicting its size and things like that.

Risal Djohan, MD: Exactly. We are currently working on the 3D modeling. And in fact, a lot of times we do a 3D print. We are trying to see if we can do 1 3D print so that we can even making strategic planning, where is the area of the tumor being removed, how much potential margin needs to be removed. Where are area of the remainder of breast tissue needs to be mobilized, so that we can move into the area of that breast.

Dale Shepard, MD, PhD: It's impressive. And that helps with the planning of the surgery for the removal of the tissue from the breast that's affected by cancer. Are you also doing modeling to try to predict ... You mentioned before about after radiation, you might have changes. Are you able to do modeling to make those changes as well?

Risal Djohan, MD: Yes. In fact, the incision planning, where can we make the incision? Where can we make the incisions is not only aesthetically pleasing, but also oncologic safety. Making sure that we provide access for the breast surgeons, for the oncologic surgeon, to really making sure that if tumor is close to the skin, we have to include the area of the skin to be removed within the incision where we can relocate the breast.

Dale Shepard, MD, PhD: And so you've mentioned before, where oftentimes you're taking out a tumor or you're doing a breast reduction. If a patient has a local recurrence, is this something that can be done a second time? Can you go back and repeat the same procedure, assuming you have enough breast tissue?

Risal Djohan, MD: Very good question. So quite difficult to go back ever. It's a small area. So during the surgery, we provide clips. We put the clips where the area are being removed, the area of the margins.

But however, after relocations of the tumor, sometimes it may be difficult to determine, okay, is it safe to assume that was the area of the positive margins? Then usually, if it is positive, then we may need to convert into mastectomy. But however, the clips are very helpful for the radiation treatment as mentioned before, that these patients, after the lumpectomy, they concentrate the radiation where the area of the clips.

Dale Shepard, MD, PhD: Certainly you never really know what you get into until you're there. How well can we predict the ability to do these procedures?

Risal Djohan, MD: So the accuracy of the plan within surgery usually is about 95% accuracy that we can do it. Because with the technology MRI, as well as multi-disciplinary discussions, has been really, really great. This has been really effective.

Dale Shepard, MD, PhD: So when we think about patients, we talked about size, we talked about histology. Are there any other factors? It sounds like this doesn't really change the underlying procedure, it doesn't lengthen procedure for instance, to any appreciable extent.

Are there any patient factors that would say, "No, this patient not a good candidate." So if someone's listening or they're thinking, "Well, maybe we'll send them and see what kind of assessment we can have," anybody that might be a bad idea to send?

Risal Djohan, MD: Well, number one is making sure that, again, oncologically safe, not a multi-focal, it's unifocal. And number two is making sure patient's healthy enough to undergo a surgery. The surgery typically takes her about three to four hour surgery, and making sure they're within a safety conditions that undergo at about three to four hour surgery.

But again, three to four hour surgery, they can be outpatient surgery. We do provide block, regional block, by infiltrated the area of surgical site, with numbing medications that will last for about one to two days, usually up to 72 hours of feeling comfortable. So by doing so we can minimize the utilization of opioids to reduce potential consumptions of unnecessary opioids after the surgery.

Dale Shepard, MD, PhD: That's great. So it sounds like this is certainly something that can have a huge impact on patients with the right characteristics, so I appreciate your insights. Thanks for joining us.

Risal Djohan, MD: Thank you.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget, you can access real-time updates from Cleveland Clinic's Cancer Center experts on our Consult QD website, at consultqd.clevelandclinic.org/cancer. Thank you for listening, please join us again soon.

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A Cleveland Clinic podcast for medical professionals exploring the latest innovative research and clinical advances in the field of oncology.
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