Breast cancer

Women who wish to rapidly retake possession of their bodies after a mastectomy face the issue of whether or not to have a breast reconstruction. Out of the 20,000 mastectomies performed each year in France, 25% of patients choose to have a breast reconstruction (13% immediately following the removal and 12% within the next year). A breast implant placed under the pectoral muscle is the most commonly used reconstruction technique. An alternative to having a breast implant is a reconstruction using a DIEP flap (a strip of skin and fat) – a technique used in France since 1994. A DIEP flap is less invasive than a TRAM flap, which requires a strip of muscle/skin and the removal of part of the rectus abdominis muscle and its aponeurosis. A DIEP flap does not involve any muscle or aponeurosis.
Patients can be offered this surgical technique immediately after the mastectomy and even before any radiation therapy sessions, to avoid the trauma of losing a breast.

Reconstruction after mastectomy: breast implants are the most commonly used technique

Breast reconstruction is an integral part of the treatment of breast cancer and the care pathway of patients. A mastectomy (also called a mammectomy) is often perceived as a mutilation and has a major psychological and physical impact: shock associated with the loss of a breast, difference in volume between the two breasts and deformity.

To overcome this loss, a woman needs to rebuild herself “physically” and reconnect with her identity as a woman. And breast implants remain the most widely used cosmetic procedure for this purpose.

Limitations of breast implants and some drawbacks

Breast implants can involve some drawbacks and limitations, which should be taken into account, namely:

• Presence of a foreign body.
• Risk of capsular contracture (hardening of the breast).
• Rupture of the implant following a violent impact.
• Life of a breast implant limited to 10 years.
• Need to replace it after 10 years and therefore undergo further surgery.
• Perceived risks following health scandals.

In addition, when a breast implant has been placed, its shape does not change. That means that a disproportion or even asymmetry may be visible in women who put on or lose weight. Patients are therefore forced to maintain a body shape as similar to that at the time of the reconstruction.

Another technique: using a flap from the latissimus dorsi muscle

Breast reconstruction using a dorsal flap is another plastic and reconstructive surgical technique. It involves placing an implant and combining it with a muscle flap (removal of the latissimus dorsi muscle).

The traditional reconstruction using a latissimus dorsi muscle consists in transposing the flap by it rotating around its vascular pedicle. It does not involve the removal of a flap; the flap in this case is referred to as a pedicled flap with the placement of a breast implant (combined reconstruction).

Another technique consists in removing a paddle of muscle-skin-fat from the latissimus dorsi muscle, which can sometimes avoid the need to use an implant (autologous reconstruction).

Alternative to breast implants: DIEP flaps, natural breast reconstruction

This breast reconstruction technique has been used for around twenty years in France. A DIEP (Deep Inferior Epigastric Perforator Flap) flap consists in using cutaneous and fatty flaps from the abdomen, which are then re-vascularised in the breast via anastomosis. This is an autologous reconstruction, with tissue taken from the patient to reconstitute a breast, without the need for an implant. The procedure can be performed immediately after a mastectomy, even if the patient requires subsequent radiation therapy.

Benefits of DIEP flaps for patients:

• The breast is formed from cutaneous and fatty tissues from the woman (no foreign body is involved).
• It is natural and the reconstituted breast will evolve with the patient’s body throughout her life.
• Surgery can be performed at the same time as the mastectomy, which avoids the need for further surgery. When the patient wakes up, she will not be confronted with the psychological shock of having lost a breast.
• Patients may also opt to have a breast reconstruction at a later date.

Follow-up after surgery

Follow-up after surgery ranges from 24 to 48 hours, and a five-day hospital stay is required to ensure the vitality of the flap. Complications involved in DIEP flaps are mainly vascular: risk of flap necrosis (total or partial), fat necrosis, haematoma and venous congestion.

In all cases, a second operation is required to reconstruct the areola and nipple (areola/nipple plate) from the patient’s own tissues.

Why is the DIEP technique used so infrequently in France?

In France, this method was imported from the United States and used for the first time by Professor Laurent Lantieri, a surgeon specialising in reconstructive plastic surgery and in natural reconstruction techniques using microsurgery (Georges Pompidou Hospital in Paris).

This technique preserves the rectus abdominis muscles of the abdomen but the 10-cm incision can cause traction on the nerves linked to these muscles (impact on the tonicity of the abdomen).

As the surgery is particularly tricky, especially in the anastomosis phase (tissue re-vascularisation), it must be performed by a plastic surgeon who specialises in microsurgery and who masters this breast-reconstruction technique.

In France, only a few clinics and hospitals specialise in this type of breast-reconstruction surgery (Lyon, Toulouse, Marseilles, Paris, Villejuif) and few teams are trained in these cutting-edge techniques, which require considerable experience and training.

Fluorescence imaging for this type of microsurgery

To prevent the risk of necrosis associated with a DIEP flap, the FLUOBEAM® fluorescence imaging system developed by FLUOPTICS© is an innovation that helps surgeons in this breast-reconstruction technique.

Indocyanine green is a fluorescent (non-radioactive) agent that is injected into the patient. Combined with this fluorescence imaging device, it allows the surgeon to view in real-time the perfusion of the flaps and tissues at each stage of the operation. Surgeons can therefore select the best perfused sections and avoid any risk of necrosis by increasing the safety of the anastomosis phase.

The FLUOBEAM® fluorescence imaging device provides accurate information to surgeons on the vascularisation quality of the flaps.

The DIEP flap technique offers many benefits for patients who have undergone mastectomy following breast cancer. Many scientific and medical advances have been made in this type of reconstruction using microsurgery techniques, meaning that it is possible to significantly reduce the risk of complications (necrosis, venous congestion). The fluorescence imaging developed by FLUOPTICS© helps surgeons during surgery by providing them with more accurate information to ensure the perfect vascularisation of the flap.

To find out more, also read:

• Breast cancer: how to improve the patient’s care pathway
• What is DIEP?

Breast cancer

Each year, 54,000 new cases of breast cancer are diagnosed in France. It is the most common type of cancer in women and also the most diagnosed cancer in the world. Nearly one in nine women will be affected by breast cancer in her lifetime. And the risk increases after age 50.
If a breast ultrasound/mammography performed for a routine exam or a suspicious lesion reveals an abnormality, it is followed up with a pathological analysis of the biopsied tissue (“path” report) and the patient waits for an accurate diagnosis. In the meantime, the patient embarks on a trying and stressful journey.
For the well-being of the patient and the effectiveness of surgery, how can the care pathway be accelerated and improved?

Breast cancer: what is the path report?

When breast cancer is suspected, the oncologist performs a biopsy (a surgical procedure under local anesthesia) which provides an accurate diagnosis and an appropriate treatment. The surgeon removes the suspicious tissue and sends it to the pathology lab to be examined under a microscope.
In the care pathway of a patient, the pathological analysis, abbreviated as the path report, is the only exam that conclusively confirms the diagnosis of breast cancer.

Breast cancer biopsy: what is the role of the sentinel lymph node?

Once breast cancer is diagnosed, the oncologist must assess the extent of the tumor to establish the most appropriate treatment plan for the patient. Thanks to additional imaging procedures, the surgeon can also know if the cancer cells have spread to other organs. Breast cancer treatment plans are the subject of a multidisciplinary collaboration also known as a multidisciplinary consultation meeting.
Removal of the sentinel lymph node is a procedure in which the first lymph node that drains the tumor is detected and dissected.
The path exam then determines whether these lymph nodes contain (or don’t contain) cancer cells, i.e., metastases (called micrometastases or macrometastases). Based on this exam, the cancer surgeon will decide whether or not further treatment is needed after surgery.
If the lymph node is “positive”, the surgeon can propose lymph node dissection which is often combined with drug therapy or radiotherapy.

Impact of sentinel lymph node biopsy techniques on the patient’s care pathway

Sentinel lymph node biopsy is the cornerstone of the care pathway. In this delicate procedure requiring the surgeon to use the best possible techniques to detect and dissect it.
Several techniques are used for sentinel lymph node detection:

• Isotope mapping: A radioactive marker is injected into the breast to identify the sentinel lymph node using a gamma probe. Radioactivity level is detected by sound.
• Colorimetric method (blue dye): Blue dye is injected into the breast and colors the lymphatics and sentinel lymph node which are visible to the naked eye.
• Combination method: this is the reference technique. It combines the isotope method (radioactive marker) with the colorimetric method (blue dye).
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Nuclear medicine imaging, an effective but less convenient technique

In the isotope or combination method, a radioactive product is injected into the breast to enable detection and dissection of the lymph node.
To do this, the patient must go to a nuclear medicine center before her biopsy procedure.
Although conventionally used, this technique has some constraints and limitations:

• The solution must be injected before the biopsy procedure, usually the day before and no later than 90 minutes before the procedure.
• The appointment at the nuclear medicine center – which gives the injection – must therefore be coordinated with the biopsy schedule.
• Not all hospitals licensed to perform breast cancer surgery necessarily have a nuclear medicine department, which means that the patient may have to get her injection at another center, which may be far away.
• The patient is exposed to ionizing radiation (radioactivity).
• The medical team (nurses, doctors, surgeons) is also repeatedly exposed to the radioactivity present in the patients.
• The blue dye that is used can leave a tattoo mark on the skin, which may remain visible for several months or even years.
• The blue dye causes allergic reactions fairly frequently.

This complicated logistics is an additional source of stress for the patient and may result in delays in the care pathway.

Fluorescence imaging, the alternative for an accurate and inexpensive sentinel lymph node biopsy

To simplify the care pathway for patients with breast cancer, the National Cancer Institute recognizes the need for new, more efficient detection methods. The FLUOBEAM® fluorescence imaging system is one of these innovative techniques used in many hospitals and institutions including Hôpital Saint-Louis, and Hôpital Européen George Pompidou in Paris.
Thanks to injection of indocyanine green, this imaging technique allows the sentinel lymph node to be very clearly visualized by fluorescence. The system is designed to fit in the operating room environment to provide cancer surgeons with accurate, real-time images and information that is invisible to the naked eye: tissue perfusion, lymph node mapping, etc.
“Indocyanine green for detection of the sentinel lymph node in early breast cancer is feasible. It is accurate, safe and cheap”, explains Dr Charlotte Ngo Chirurgie, a Gynecological and Breast Cancer Surgeon at Hôpital Européen Georges Pompidou, Paris, France.

FLUOBEAM® alternative has several advantages:

• Performed in real time in the operating theatre and by the surgeon him/herself, it optimizes patient management:
  • quick to set up,
  • easy to use,
  • immediate visualization allowing sentinel lymph node biopsy.
• No additional stress for the patient.
• No exposure to ionizing radiation.

Once breast cancer is diagnosed, sentinel lymph node biopsy is a fundamental step. Analysis of the biopsied tissue will determine the future treatment plan. Alongside the conventional methods for performing sentinel node biopsy, the fluorescence imaging system developed by FLUOPTICS(S) (FLUOBEAM®) is an effective alternative which optimizes the patient’s care pathway.

Additional reading to go further:
Breast reconstruction post-mastectomy: the alternative to breast implants.