Advances in Breast Cancer - Imaging Surgery and Lymphoedema Management
Jasmine
Welcome to this evening's webinar, Advances in Breast Cancer - Imaging Surgery and Lymphoedema Management. My name is Jasmine, your RACGP representative for this evening. We are joined by our presenters, Dr Belinda Chan, Dr Karen Shaw and Associate Professor Louise Koelmeyer. Our facilitator this evening is Dr Miriam Grotowski. Before we get started, I would like to make an acknowledgement of country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to elders past, present and emerging. I myself am joining from Gadigal Land this evening in Sydney's inner west. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online this evening. I would like to introduce you to our presenters for this evening. Dr Belinda Chan is a highly trained specialist breast surgeon and provides the highest quality of comprehensive, informative patient care. She obtained her fellowship in General Surgery in 2011 with the Royal Australian College of Surgeons. Dr Chan is currently accredited and appointed at Macquarie University Hospital. Chris O'Brien Lifehouse Public and Private, Strathfield Private Hospital and BreastScreen, New South Wales. Dr Karen Shaw is a breast and general surgeon who has a special interest in breast surgery for both benign and malignant conditions. She is committed to effective communication with patients and their care team to optimise health outcomes. Louise is an occupational therapist with over 30 years of clinical experience in both public and private settings, specialising in lymphoedema management. As director of the Australian Lymphoedema Education, Research and Treatment Alert Program, Louise is involved in strategically managing and developing the education, research and treatment arms of the innovative multidisciplinary program. Last but not least, our GP facilitator for this webinar is Dr Miriam Grotowski. Dr Grotowski is a Senior Lecturer in Medicine at the University of Newcastle Department of Rural Health, based in Tamworth. Miriam graduated from UON with a Bachelor of Medicine in 1989, completed her FRACGP in 1995 and has undertaken a Diploma in Psychiatry. She completed her Masters in Medical Education through Dundee, UK in 2020. Welcome to our presenters and I will now hand over to Miriam to go through the learning objectives.
Dr Miriam Grotowski
Thank you, Jasmine, and I am joining you tonight from the lands of the Gamilaroi people up here in North West New South Wales. As we have these exciting guest speakers, we are going to be looking to discuss the different roles of imaging modalities when investigating breast cancer signs and symptoms. At the end of this webinar, you should be able to describe the newer functional based imaging techniques of MRI. You are going to have to help me here, Belinda. I will learn along with you.
Dr Belinda Chan
Mammogram.
Dr Miriam Grotowski
Thank you. Contrast enhanced mammogram. Discuss the various breast surgery operations from breast conservation techniques to types of breast reconstruction. Discuss the diagnosis and management of cancer related lymphoedema and non-cancer related lymphoedema and chronic oedemas and be able to discuss with your patients and your colleagues the importance of surveillance and early intervention in the management of cancer related lymphoedema. Without any further discussion from me, we are going to move on to Associate Professor Louise Koelmeyer and hear from her about lymphoedema.
Associate Professor Louise Koelmeyer
Thank you very much, Miriam and colleagues. Good evening. Thank you for joining us tonight. I would like to acknowledge the traditional custodians of where I am. I am on the Wallumedegal Clan of the Darug nation at Macquarie University, and I am delighted to be with you today to talk about updates in lymphoedema management. Miriam has already covered the learning outcomes that I am going to talk about tonight, but hopefully share with you about our ALERT program. The Australian Lymphoedema Education Research and Treatment Program known as the ALERT Program based at Macquarie University. I need you to stay alert for the next few minutes while we share and understand about lymphoedema. What are the latest innovations in lymphoedema assessment and management and also the clinical care that has really changed in the last few years that hopefully you as GPs are the centre for your patients coming to you with conditions of lymphoedema or other chronic oedemas and where particularly in the lower limb, a lot of differential diagnosis needs to take place. Our mission in the alert program is really delivering high standard personalised clinical care, evidence-based education that we train health professionals to become qualified and accredited in lymphoedema management. We are involved in innovative research in this area. This is the condition that we are talking about, and I know our breast surgeons will be focusing on potentially those at risk of arm lymphoedema or breast lymphoedema. In our program we assess and manage all types and stages of lymphoedema and lipoedema and other chronic oedemas. Why I am so passionate about this area of work is this condition affects individuals not only physically but functionally, psychologically and financially. There are lots of inequities in how we manage this condition across the country. It is really exciting that GPs can be engaged as we really try to improve the management of this condition and provide access to services to assess and manage this condition. When we talk about chronic lower limb swelling, I am sure you are seeing it every day in your practices and you have to determine that differential diagnosis of is this something that is a medical emergency, needs extensive medical treatment or something that needs to be managed by a lymphoedema practitioner. We know that chronic leg swelling is a prevalent health condition. I do not need to be telling GPs that. Hospitals and community aged care services, a quarter of the residents or patients have a chronic oedema in their lower limb. Half residents in aged care facilities and 100% of patients in wound treatment centres have a component of oedema. 20% have episodes of cellulitis in a 12 month period in a wound treatment centre and 90% of non-cancer related wounds also have oedema that needs to be addressed and managed. Otherwise, it becomes a long-term lymphoedema problem. As I have said, it impacts an individual's function and their quality of life. It is really associated with complications such as chronic wounds and cellulitis. Hospital costs for inpatient care, managing cellulitis is high. Sometimes if we manage the wound, we manage it with compression and early intervention, we can prevent hospitalisation and improve quality of life. It is really important that we get an accurate diagnosis of what is going on in the oedema and potentially all persistent oedema has a lymphatic component to it. We need to manage this conservatively. There are some surgical options but it is really managing it conservatively.
Here are some of the associated symptoms. Swelling, heaviness, tightness, warmth, pain, it can have skin changes, skin integrity changes, function. People being able to fit on normal shoes, normal clothes. Just walking, getting up and off a chair, off the floor, off the toilet. As I have said, the complications including cellulitis, non-healing wounds, lymphorrhoea, all of these conditions impact individuals and then being able to function in their day-to-day life. Also impacts body image. People become almost recluse if they cannot get normal clothes, cannot get normal shoes and cannot get out doing their regular daily activities. This is the condition that I work in. Lymphoedema has expanded significantly over recent years in how we assess and manage it. We have very high tech imaging for assessment of lymphoedema, but really your thumb is the thing that you need and all of us have a thumb to do what we call the pitting test, where we press into the limb for 30 to 60 seconds to see if we have got pitting oedema. If we have got a big indentation that tells us there is some fluid there and often some dermal backflow. The tape measure is probably the badge of honour of being a lymphoedema practitioner. I obviously use a tape measure to measure and compare the swelling in the affected versus the unaffected limb. We do have other high tech screening imaging tools. We have got lymphoscintigraphy. A little bit painful and unless we do not know the cause of lymphoedema, I would not be necessarily referring patients for it. We have what we call bioimpedance spectroscopy, which is measuring extracellular fluid, comparing the at risk to the unaffected limb and a big component in the diagnosis of lymphoedema is listening to the person sitting in front of you. How long have they had the swelling? Did it come up quickly? Do they have redness? Episodes of cellulitis that they are reporting to you. Is it after a secondary cause of cancer-related treatment, surgery or radiation treatment? All of these things go into the clinical picture to help us assess and give a confirmed diagnosis of lymphoedema after we have done our due diligence and differential diagnosis to rule out potentially other conditions that need urgent medical treatment.
When we manage lymphoedema, we can manage it conservatively or surgically. Conservative is our main core aspect of managing oedema. We call it complex lymphoedema therapy. This is where we have a component of manual lymphatic drainage which is a type of massage technique. Compression therapy. Compression is the key to managing oedema, whether it is upper limb or lower limb oedema. Exercise. We all know the benefits of exercise, but helping the muscle pumping the lymphatics is really important. You have got patients sitting on chairs with their legs down. You get dependent oedema. We need to get them moving. Skin care. Looking after skin integrity is really important to prevent infections and ongoing education is really important both for the client, the patient living with this condition but their carers and of course our own health professionals who can all work very much as a multidisciplinary team to get the best result for the individual. This is a core basic management for lymphoedema and various combinations of this. Seeing an accredited lymphoedema practitioner, they are often allied health professionals. Occupational therapists, physiotherapists, registered nurses, podiatrists can all assess and manage lymphoedema. This is someone on the left who has got extensive clinical lymphoedema. A chronic condition, they need an intensive period of bandaging to reduce the swelling. Then we get them into a compression garment to maintain and control the swelling long time. Lymphoedema is a chronic condition and like you might have someone with diabetes, you manage them with insulin dependent on their blood sugar levels, compression is often the mainstay for managing lymphoedema. The dosage of compression is dependent on their symptoms and the type and stage of swelling that they present. Exercise is key. If somebody cannot wear compression, we need to get them moving to help pumping the lymphatic. Surgery is an option for lymphoedema, but only in a carefully selected group of people who have their lymphoedema assessed and managed by a multidisciplinary team. At Macquarie, we do three types of surgeries. Two surgeries are microsurgeries. Lymph node transfer and lymphovascular bypass surgery where we cut the lymph vessel where we have dermal back blown congestion and we connect it to a vein nearby. These surgeries are more experimental. The surgery on the left is what we call liposuction for lymphoedema. This is for very advanced lymphoedema where individuals develop a fatty adipose tissue in the limb rather than just fluid component. With that we remove suck out the fat through liposuction. We are not curing the lymphoedema by any of these surgeries but it certainly improves people's quality of life.
Just a story and this person, Sharne is very happy for me to share her story with you. She developed lymphoedema in her left leg after gynaecological cancer. She lived in far north Queensland and her leg there is 12.5 kg bigger than her other leg. She battled with lymphoedema over a number of years after not being able to wear her compression garments. She was a young mum. She had six children, she was a primary school teacher and she was having difficulty getting down on the floor to teach her Year 1 students. She was having difficulty getting out of the house and managing her family. She could not wear normal shoes. She could not wear normal clothes. She resorted to wearing maxi dresses and it affected her body image. Psychologically she was really unhappy with herself. She found out about our program and flew to Sydney for an assessment by our multidisciplinary team, and we considered her eligible for liposuction surgery. She waited about a 12 month period to come back to our program to have the surgery. The professor in the middle there is Professor Hakan Brorson from Sweden and he was the pioneer in the surgery for advanced lymphoedema. Our team went to Sweden to learn how to do this surgical technique and rehabilitation process for these types of patients, and Sharne underwent the surgery with us. We removed 2 L of fluid with an intensive bandaging period before she then underwent the liposuction surgery. When Sharne first came to our clinic, she could barely walk up the eight steps at the front of our clinic building because of carrying around that heavy 12.5 L of volume in her leg. Three months after surgery, we removed 10.5 L of fat during the surgery and three months after surgery, she has climbed to the top of the Sydney Harbour Bridge, which is 1387 steps, and she did that three months after her surgery. The photo on the bottom there, right, is showing her dressed in skinny jeans and she says, "I have to tell you, they are skinny jeans" because she is now able to fit into normal clothes. She is able to fit into normal shoes. We have not cured her lymphoedema because she is still wearing 70 mm of graduated compression garment under those skinny jeans. She has now regained her life and her quality of life and the number 52 and the medal around Professor Broughton's neck is actually Sharne's medal after completing running a marathon after undergoing this surgery with us. Just a good news story that there is hope for people with lymphoedema. By conservative treatment, we removed 2.5 L of fluid out of her leg, but because her leg became so fatty with adipose tissue, we were able to remove that and give her, her quality of life back.
Moving on to our second learning outcome for today. It is about prospective surveillance and early intervention model of care. This will flow very nicely into our breast surgeon's presentation who will follow me tonight. This is about trying to detect subclinical known as stage 0 lymphoedema or early stage 1 lymphoedema. The idea is that if we can detect lymphoedema at its very earliest stage before we see a volume change in the limb, the research internationally has shown us that we can potentially reverse the condition. So much easier to treat early stage lymphoedema than the chronic stage lymphoedema, like in Sharne. This model of care really aims to pick it up early, just like you do in breast cancer screening. We want to pick up lymphoedema early and we want to treat it early to prevent the long-term chronic condition. My vision that all individuals at risk of lymphoedema should have access to this model of care where we screen at baseline before they have had any cancer treatment and then at regular intervals, determining their risk for developing lymphoedema, working with a collaborative team and understanding what we do when someone presents or triggers the need for early intervention. This model of care has significant clinical and governance evidence both in Australia and internationally. Some of the key medical and key stakeholder bodies have position statements encouraging and endorsing that all individuals should have access to this model of care. I really urge you, if you have got patients coming to see you and they have had a cancer diagnosis and are at risk of lymphoedema, that you encourage them to be screened for lymphoedema as part of their cancer rehabilitation care. The research goes back from the early 2000s from Australian researchers to international large numbers of studies. We were involved in a study published by Ridnour in 2022 where we recruited 1200 women. At Macquarie, we recruited 450 of those 1200 women, and we showed significant outcomes from intervening early through a screening program for lymphoedema. It is a bit of a no brainer. If we can pick up something early and treat it much more effectively than the chronic condition and presentation, then we are on a winner not only to help the individual, but to improve their quality of life and help them as they recover going through their cancer treatment. Often individuals feel really ripped off when they have not been offered this model of care because to present with lymphoedema, it is often that daily reminder that they have had cancer. If we can prevent lymphoedema from developing, then they do not have to be looking at that compression garment in their arm every day. It is really important that we think about risk factors and really encouraging risk stratification because in my 30 years of working in this area, breast cancer treatment has changed significantly. Our surgical treatment has changed. As you are going to hear from our surgeons, our medical management has changed. Radiation treatment, chemotherapy has changed significantly. Lymphoedema is not going away. We need to potentially risk stratify our patients so that we can provide the appropriate education. We can screen and monitor individuals so that we can pick up the earliest signs. The top three there in our risk factors; the surgery regional node radiation and the taxane chemotherapies have been shown in the literature to be high risk factors for individuals going through breast cancer treatment. Interestingly though, those women who have had an episode of cellulitis in their breast or in their arm, those having a BMI over 30 and also interestingly, in a large study of 1200 women, those who lived in a rural area also showed higher risk for developing lymphoedema. I think that is interesting with our population across Australia that perhaps not being able to access the appropriate monitoring can actually put someone at a higher risk of developing lymphoedema.
We developed and published this risk stratification. A bit of a traffic light symbol of green, amber and red. Looking at low, medium and high risk. Looking at if someone is at a low risk where they have just had a couple of sentinel nodes, they possibly do not need to be monitored as closely as someone in our high risk category who has had a complete auxiliary dissection, regional node radiation and taxane chemotherapy. It makes sense when you think of it like that, but I think we cannot just routinely give the same education to every person diagnosed with breast cancer. There are still lots of myths and misinformation out there about risk stratification, risk factors and the do's and don'ts about managing lymphoedema. Early intervention is quite simple. Exercise and the prescription or wearing of a compression sleeve and handpiece is what has been shown in the literature to prevent chronic lymphoedema. In the studies, it is wearing these garments for four to six weeks about 10 to 12 hours a day. These garments do need to be fitted appropriately, but very much show that we can get women out of these garments after an early intervention period. This is the model that we really promote and really flows into the surgeon's presentations. Ideally, we want a pre-cancer treatment assessment before they start their surgery or chemotherapy. We want to give them education. We want to be involved in the rehabilitation throughout their cancer journey so that we are also screening for musculoskeletal issues with shoulders after surgery, we are looking at breast oedema and the occurrence of breast oedema and management of that. We are looking at scar management and the whole person psychosocial management. If someone triggers the need for early intervention, we go straight into compression, exercise, skin care and then we get them back into the screening program when they come back to normal. As you can see here, it is much easier to treat someone on the left than someone who presents with chronic long-term lymphoedema. We can manage long-term lymphoedema, but it is much easier to pick it up very early. Just want to share a couple of innovations with our indocyanine green lithography technology that we use at Macquarie University. This is where in real time, we inject the ICG dye into the base of the hands or the feet of where somebody has lymphoedema and in real time we can see what is happening under the skin. We can see where there is area of dermal backflow or congestion. What we know is the way I was trained to manage lymphoedema 30 years ago, doing a massage technique, manual lymphatic drainage under the camera, we can see now that that was not doing anything. If your patients tell you they were told to pat the cat and a light effleurage massage technique for their lymphoedema arm or leg, we now know that that is not going to help drain the fluid through the congested dermal backflow area. What we have actually found through our research for someone who has upper limb arm lymphoedema, we have now found that nearly 80% of patients actually drain to the ipsilateral auxiliary region where they have had their complete nodal dissection, and less patients drain to these other drainage regions, which in the past we were draining fluid to. This has been a real eye opener to us because we used to also teach patients to drain down to the ipsilateral inguinal lymph nodes. Out of over 500 patients that we have done this testing for, absolutely zero cases drain to the ipsilateral inguinal. We now do not train therapists to drain that way. We certainly do not teach our patients to take fluid in that direction either. Similarly, with the legs, we have found now that we have these compensatory drainage regions where somebody has had a cancer related leg lymphoedema, we are now seeing that about 25% of them are draining across the contralateral inguinal lymph nodes. That is where we are finding we have changes in our management in regards to how we measure and organise compression garments to be able to cover the area where they have got the most congestion. This has been really eye opening for us. We then compare patients who have non-cancer-related lymphoedema. You can see with these patients that it is less than 10% are draining to that contralateral inguinal region. Again, this has been eye opening for us to understand where is the normal drainage pattern for the lymphatic system. Then when someone has a compromised drainage system, where is the lymph fluid most likely to drain? We then educate therapists, health professionals in lymphoedema management. We would encourage you if you have got health professionals who are interested to find out more about this, we are an accredited training provider at Macquarie University so that health professionals can be accredited so that you know that accredited lymphoedema therapist that you are working with have done the appropriate training to be able to assess and manage your patients so that they are safe and effective managing in the community. We are involved in a whole lot of research in our program. These are the key research areas that we are involved in and multidisciplinary program. We actually have patients flying in from all over the country and New Zealand to assess and manage, to come for our expertise, and I really look forward to answering any questions from you after our surgeons speak tonight. Thank you.
Dr Miriam Grotowski
Thank you, Louise. That was fantastic and really informative. Two things that I am going to take home from that one is that I can help reduce the inequality in our patients. Just having heard your presentation and understanding a much more strategic approach to assessing lymphoedema within my practice and there is over 100 GPs that have heard that as well. There will be an impact from this tonight. Thank you for that. I was absolutely reassured that the old technique of using my thumb, I do not need any special equipment, but I can use my thumb for 30 seconds to 60 seconds to absolutely assess lymphoedema and the presence of it. In fact, it is a simple in-office test that we can all do. There were so much more that was interesting. We do have a really good question, but I will leave it for you at the end. We will ask for you at the end. I think it is now time to move on to our surgeons. There is so much that we got in that that is practical and encouraging, Louise, for our patients with lymphoedema and I really enjoyed Sharne's story. I thought that was fantastic. Thank you for that. We are now going to welcome doctors Belinda Chan and Karen Shaw. Just while they are getting their slides up, I just encourage you, we have got one question in the question and answer section. Please do put some questions there. Those that we can answer during the course of the presentation, we will and otherwise we will back them up for some question time at the end. Without further ado, I hand over to Dr Belinda Chan and Dr Karen Shaw. Thank you.
Dr Belinda Chan
Thank you very much for inviting us. Sorry, we were a little bit late to get on. I am Belinda Dhan. I am a breast surgeon. This is Karen Shaw, my colleague. We work together at Macquarie University Hospital, and we were operating tonight. I myself also work at Chris O'Brien Lifehouse and Strathfield Private Hospital. I also work at BreastScreen over at RPA. Karen is based at the Northern Beaches Hospital as well. Tonight we are just going to talk together in one presentation, just a little bit more about breast imaging and give you a bit of update about some new techniques, particularly around functional based imaging or using contrast enhancement. Also, a bit about the surgical techniques that are being used more and more just so that you can understand the surgical scars that your patients will be presenting with. That is what we will be discussing tonight. Firstly, in terms of imaging the breast. There are basically two ways to look at it. Assessing the patients that are asymptomatic. These are the ones that fall into the screening category. BreastScreen New South Wales you probably all know that it is an active program from 50 to 74, in that the government is going to recruit patients every two years, going to chase your patients down with letters to remind them to go every two years. Patients feel like they do not get to do anything after 75, but there is actually no upper limit, so they can still go. It is an open ended screening program. Even if they have passed 75, it just means the government is not going to chase them down, but they are still able to access breast screening services. They just need to call and book an appointment. There is no upper limit to when to stop screening. When you get to 40 to 50, that is an interesting category of patients that we will be talking about a little bit more just because they are getting to the point where they still have a lot of breast density, but they are starting to accumulate risk factors in terms of having more family history, being perimenopausal, considering starting onto having more hormonal stimulation, either having had IVF or going through IVF at that stage or considering to wanting to go on to HRT. That gives a lot of hormonal drive to the breast tissue. Then you have got the group of under 40 year olds where nobody really knows what to do with them and do you bother even screening people that are under 40? Just this statistic that the National Breast Cancer Foundation relates that in 2020, 19,807 women were diagnosed with breast cancer, 99 were in their 20s and 889 were in their 30s. There is still a role for imaging and investigating women under 40, particularly if they do have risk factors, the biggest ones being family history and hormonal exposure. That is really the asymptomatic patients, and then you have got the symptomatic patients. For us, I know Karen and I, we will follow a symptom until we can have an answer for it. Whenever a patient has a breast symptom, you really need to keep going with your lines of investigation until you can justify why they have their symptoms. You can start with screening, which is your normal 2D mammogram, but pretty much for symptomatic patients they need a bit more for that. If that does not show anything and then we have got 3D breast mammogram, then we have got breast ultrasound which is also complementary to that. Nowadays, we have MRI and contrast-enhanced mammogram. They are probably the two biggest modalities that we have picked up using over recent years that has changed a lot. The others have been around a long time, but particularly contrast enhanced mammography, not so much the availability of MRI, but the access to Medicare rebate item numbers has really picked up who can have access to those types of scans.
That is just showing the difference between 2D to 3D. On the left, there is your standard 2D mammogram with 3D tomosynthesis, you can see a lot more detail. That turned out to be a benign lesion, but underneath all of this breast density was a spiculated lesion which was really more appreciated on tomosynthesis. Then this is showing now functional based imaging, enhancing contrast. This is doing your standard mammogram and when you add contrast. This is the iodine based contrast that we use for CT scans. It is injected and any abnormality will light up. You can see that it enhances the normal picture just the way using contrast in CT enhances and gives you a better picture for a CT scan, it does the same thing in mammograms.
Dr Karen Shaw
The beauty of the contrast enhanced mammogram is not so much for troubleshooting. It is wonderful for troubleshooting, but one of the big advantages if you find out someone is a little higher risk, they have got dense breasts. Their breasts are difficult. Then you can actually forward plan such that your ongoing surveillance imaging is all done in that one setting because they can have that contrast enhanced mammography and it counts as their regular mammogram tomosynthesis and a little bit extra. That is a nice option rather than adding a whole entire different modality. It is a bit complementary.
Biopsies of breast lesions. All of you will be familiar with this. It is sometimes a little bit difficult to know what type of biopsy is going to be best for the breast lesion that you have seen. As a general rule of thumb, we tend to prefer core biopsies just because the nature of them gives us more information which is naturally what we are after. That said, some lesions are not amenable to that. Breast imaging is becoming better and better. We are finding smaller and smaller lesions and we still need to find out what they are. Broadly speaking, the core biopsy is a larger gauge. They will take multiple passes. It gives you the structure as well as the cell type and a very confident answer of malignant versus benign. Particularly, we also want to know the type of malignancy. The type, the grade, if it is a lobular, is it ductal, is it in situ, is it invasive. There is so much information. It is really quite remarkable that we get from these tiny 2 mm little core biopsies. The fine needle biopsy is going to give you an answer of benign or malignant. What we often fall into the trap of is getting these atypical or insufficient answers. Those are the ones that are really quite problematic to troubleshoot. The fine needle biopsies are a little bit more sensitive for smaller lesions. Often the radiologists will lean towards doing that if they think that there is a reasonable chance they might, for example, miss a smaller lesion with a core biopsy. Often when I am in the situation of ordering the biopsies, I will specifically request that I would like it to be a core and then I will designate or fine needle if not technically feasible, please call me to discuss or something along the lines of that just so that we can make sure we get as much information with the one procedure because obviously it is uncomfortable for the patient to have done. It can be quite anxiety provoking for them waiting for the results. That tends to be the way I move forward, ordering biopsies. Cystic lesions are the other ones that fine needles are very useful for.
In summary, about the biopsy. If you have got a larger lesion then it is an easier target for a core biopsy. Having all that information about the lesion which Karen mentioned in terms of the receptors and the type of cells that you have. Is it lobular, is it ductal? In the recent shift towards giving a lot more neoadjuvant therapies or giving chemotherapy or targeted therapy prior to surgery. All that information is really pertinent for the oncologist. They need that to be able to tailor the medication that the patients get. Core biopsy has really become standard in breast cancer diagnosis and treatment. For the smaller cancer lesions that may be harder to sample just by sheer size, they still may be an option for surgery rather than neoadjuvant therapy first. Sometimes even with the smaller lesions, patients may want to have neoadjuvant treatment. They might want to have genetic testing or have that time to do gene testing before undergoing surgery. Having all that information about the cell type and what type of neoadjuvant treatment you can give them can still be helpful. There is a big shift towards early referrals to breast specialists in order to be able to discuss the treatment options. It is not as simple as it used to be where someone was diagnosed with or thought they had a breast cancer and then they just go off and have surgery and then they would go and have chemo and then they would go and have radiotherapy and hormones. There are a lot of options now. A lot of different treatment pathways. Early referral is definitely recommended. Intermediate lesion. Tumours that are 10 to 15 mm sometimes can still be treated with neoadjuvant treatment in terms of neoadjuvant chemotherapy and sometimes downsizing these tumours can change your options. If it was 15 mm tumour in a small breast, someone might choose to have neoadjuvant treatment to try and shrink down a tumour, so that they can try and save their breast and have breast conservation. If there is lymph node involvement, potentially having neoadjuvant treatment first so you can shrink down the disease burden in the axilla and potentially save them from an auxiliary clearance and downsize their surgery from a clearance down to a targeted dissection.
Dr Karen Shaw
What are the options for contrast based imaging? Broadly speaking, this is MRI or contrast enhanced mammography. Who and what is suitable for each person is a little bit of a minefield from time to time. You will often find it might be clinician specific because it depends very much on what your local radiology practice is an expert in. We are very lucky here because we have a lot of local radiology practices that are very familiar with breast MRI and contrast enhanced mammography. I have to say by far and large, MRI is probably more common at this point in time. I do not know if you would agree with that, but contrast enhanced mammography is gaining popularity and that is to do with the machinery that different radiology practices have because they have to have a particular type of mammogram machine. They have to have the right technicians, all the equipment as well as the radiologists and MRI can be a little bit problematic in terms of costing. Some providers will have Medicare rebate coils where we can access lower priced MRIs. Other practices are not able to offer that, so that can affect what you decide to do. The contrast enhanced mammogram is a really good tool to exclude or to look at and find a cancer. The MRI I would say is probably more useful for us as surgeons because it gives you that structural 3D picture. It also looks at both wrists and both lymph nodes. Obviously, the mammogram looks at breasts as well but not so much the lymph nodes. If you have got someone with an equivocal node or you want some further information then you might lean towards an MRI.
Dr Belinda Chan
This is just the different views that you get in an MRI. Essentially it is enhancement based. You can see examples of tumours here. The shape of the breast here represents how the patients are positioned for MRI. For the MRI they are lying face down and their breasts go into a cone and they go into a tunnel. It can be a bit of a problem if patients are claustrophobic because they have to go into the MRI tunnel. If they are very big breasted, sometimes the breast does not actually fit into the cone. You can see it at the top here, these breasts are pretty squashed, and it takes a lot longer. It is about 30 to 40 minutes to do a full breast MRI, but it does enhance and light up very clearly. As Karen said, it shows up the anatomy very nicely. This is example of contrast enhanced mammogram. At the top is your standard mammogram. This is from one of the papers that I quoted that this is a patient that has had neoadjuvant treatment. On the left is the diagnosis and the degree of enhancement and then after neoadjuvant, this is helping to assess disease.
Dr Karen Shaw
The bottom row is contrast enhanced, and the top row is your normal.
Dr Belinda Chan
You can see on the left the initial tumour, and after treatment you can see the response and the tumour is being clipped and is much smaller and not as bright as it used to be. The benefit of contrast mammogram is that it directly correlates the position of a lesion to the mammogram. If you are finding or you are chasing down lesions that are on mammogram, you can directly correlate. Whereas the MRI positions the patient in a different way. Sometimes the correlation for instance a mammogram lesion at 8 o'clock might be seen at 7 o'clock or 9 o'clock on an MRI. That is breast imaging. We have got a couple of case studies that we will go through at the end. We are just going to quickly do a bit about breast surgery.
Dr Karen Shaw
Breast conservation surgery techniques have really changed over recent years. Oncoplastic surgery or oncoplastic breast surgeons is a term that you may or may not be familiar with, but in summary, it means we are still removing all of the breast tumour and doing good cancer surgery, but we use plastic surgery techniques to reshape or reconstruct the breast. That might include doing a reduction technique at the time of your lumpectomy. There are other techniques like round block mammoplasty, and then occasionally we will use perforator flaps which are local flaps, borrowing a bit of tissue from nearby to fill the defect of where we have done the lumpectomy. Those abbreviations there, like LICAP, AICAP, MICAP are just to do with the location of where the tissue is being borrowed from. It has actually allowed us to really extend who we can offer breast conservation surgery to because we are able to take out much bigger lesions, bigger areas and maintain the breast volume and shape. Coming with those techniques are lots of different scar patterns. I think that can be really tricky, particularly for GPs in the community to really know what we have done underneath that scar because we are mobilising tissue. The scar might not be actually where the cancer was as it traditionally used to be with radial incisions and the like. Just for example, and I am not sure it projects all that well, but the diagram in the top right of the screen is just a summary of per quadrant of the breast, the various options of incisions that we may choose to use.
Dr Belinda Chan
In terms of reconstruction after a mastectomy, there is a lot more availability and choice nowadays, either in the immediate or delayed phase to do a breast reconstruction, and pretty much most patients should be able to be offered immediate breast reconstruction, but there are some circumstances where it is not always appropriate, and, it does depend on whether the skin and the nipple can be saved or not, whether immediate breast reconstruction is appropriate because we need am adequate skin coverage to be able to reconstruct underneath that. After neoadjuvant therapy, we can often do an immediate all in one surgery, so that is another role for giving systemic treatment first prior to doing an operation, and the other question for the oncologist is whether they need tissue diagnosis like the histopathology to make decisions about treatment which will drive whether or not they can have reconstruction up front, so basically the two types of looking at breast reconstruction. It is either implant based or autologous or your own tissue based. Tissue expanders two stages, so it is a temporary implant that is adjustable so that you can expand or you can deflate as much or as little as you need, or you can have a silicone implant that is put directly inside and then using your own tissue so these abbreviations again are different types of harvest or donation locations, which we will show you. This is implant based reconstruction. The implants most people nowadays will be putting this pre pectoral. You will find fewer implants going in under the pectoralis mainly for the animation. Even though it does give a nicer, smoother takeoff, but it has been shown to have slightly inferior overall aesthetic in terms of the pectoralis movement with moving the implant, and there has there is some data to say that the patients get less capsular contracture if it is a pectoral implant as well. That is when it sits underneath this skin flap, and this is your tissue expander and it has got this port which is accessed through a needle on the outside, and this is how we expand and deflate. If you want to stretch the skin to make a bigger pocket to be able to put in a bigger implant, you can pump it up with more saline. If patients are going through radiotherapy and the skin gets becomes quite stressed and swollen and tight and there is a lot of pressure, you can deflate the expander and take out some saline and give the skin a bit of a rest. These are examples of implants and tissue expanders that have been placed either with nipple preservation or one on the right is with nipple sacrifice and a reduction as well at the same time.
Dr Karen Shaw
Autologous breast reconstruction again has really varied roles and outcomes. I think we are using it more and more with modern day surgery techniques, it is much more accessible to most of our patients because a cohort of the plastic surgeons are really specialising in this. The most common autologous breast reconstruction would be a DEP flap or a deep inferior epigastric perforator flap, and that is shown there in the top left hand corner of the screen where it is a bit like a tummy tuck except these the fat the subcutaneous tissue is then placed up in the either with its skin if you have had a simple mastectomy before or without it is skin in the skin pocket to recreate that breast contour. It is a really good option for women that are having a delayed reconstruction, for women that need radiotherapy, but obviously the patient needs to have enough tissue to donate and that is sometimes not the case. Some of our patients are quite thin. It is longer surgery than implant based reconstruction, and the recovery time is also what is a major difference between implant based reconstruction and autologous reconstruction. The examples there are just showing some of the other flaps down in the middle lower line is the TUG, the DUG and the BUG flaps, which are all gracilis flaps, and they are probably less common. They are sites that we tend to use when there is not enough abdominal fat or if the abdominal fat has already been used, for example, for a contralateral reconstruction earlier in that patient's life, but the outcomes can be very nice. They are long lasting. They do not need replacing where implants do. So there are lots of benefits.
Dr Miriam Grotowski
Just a quick question, a quick case study because we really need to move on to some really good questions. So this may help okay. We might hold it and just see how the questions go in bringing out perhaps some of the areas people wanted a bit of clarification. We have got a couple of questions for you, Belinda and Karen around screening and who is appropriate for screening? I will just give the two to you that are go together and one is that if a patient has breast implants, could they have mammograms for screening, so I will get you to answer that, so they hear it from the experts, and the other one is one of the doctors notes that they have had a few patients who will not have mammograms due to pain, and they were wondering at whether MRIs will miss any lesions that a mammogram or an ultrasound would pick up, so I will give you those two questions and then we have got a couple more after that.
Dr Karen Shaw
They are both really good questions and probably common things that all of the attendees as well as ourselves come across. It is safe to have a mammogram when you have implants in. I think traditionally there was a lot of fear and reservation around that, but modern day mammography machines have a lot of feedback. They can manipulate the compression settings. It is, of course, I would say a little bit more uncomfortable because of the necessity to do what is called a push back view where they do position the implant back off the breast tissue, but it is a very safe and appropriate thing to do in your patients with implants. The second question about mammograms being painful is again very common. Mammography is an excellent tool and nothing really quite replaces it perfectly is what I would say. I think all of those breast imaging modalities are complementary, but none on its own is sufficient, but particularly mammography is really good at picking up microcalcifications or very early signs of DCIS, which is when we want to be finding things. MRI can show DCIS as well. It shows up as non-mass enhancement, but a lot of the low to intermediate grade DCIS might not show on MRI, so you might miss those sorts of things if you are proceeding with an MRI only. I think it is a discussion to have with the patient, and obviously you need to stratify their risk. If they were really high risk, I would probably be a little bit more suggestive of going with the mammogram, perhaps trying a different centre that is very experienced, that might make them feel a bit more comfortable because there are circumstances where it is absolutely necessary but happy to be corrected.
Dr Belinda Chan
There are the newer machines, the machines that do 3D tomosynthesis do not have as much compression, and I think here in Macquarie they have got a new machine where the patient can actually direct the degree of compression as well.
Dr Miriam Grotowski
They are great answers. I think what we might do just quickly we have got one question for Associate Professor Louise to that I think is a great question, and if we have any time at the end, I will come back to something for you both Belinda and Karen, but that was a great presentation with some really useful information and updated information about all the things that we are seeing with our patients with breast cancer, the changes in the approach to breast cancer management and the steps that happen, and I think I took home from your talk that we really need to make sure that we have early referral and that we as practitioners understand what options are out there for our patients so we can help be part of that support during a time that is really quite tumultuous for any of our patients when there is a diagnosis of breast cancer, so thank you for that. Louise, if you are there, I did just want to I think there was a great question for you. We were going to put up some information about how they can refer to your centre, but there was a great question from Concetta who was talking about, she is a Breastfeeding medicine specialist and GP who has got extra training in that, and she mentioned that her mastitis protocol or that of the international collaboration she belongs to the advises lymphatic massage for the management of mastitis, and you have now mentioned that that manual massage may not actually be doing anything, and I think she wanted you to comment on that, and I thought it was a great question, so if you are happy to do that and if we could get you to stop sharing Belinda, just so that Jasmine can put up how to refer to the Macquarie Centre around lymphatic treatments because that was also requested.
Associate Professor Louise Koelmeyer
Thanks, Miriam. It is a great question and I will say that the manual lymphatic drainage is still a really important tool in management of lymphoedema. Just what we have changed based on our ICG research is the pressure and the speed that we do the massage, so thank you for so I can clarify that. We would be encouraging manual lymphatic drainage massage and with your mastitis patients as well, but rather than MLD is a really gentle fluoride. We would actually be doing it firmer and slower, obviously with mastitis. you are not wanting to cause pain and particularly if there is an area of significant inflammation, I would be a little bit cautious, but certainly with lymphoedema and lymphatic massage draining, we would do firm and slow massage rather than a light gentle effleurage technique that we previously did, and now that we see under the camera is not actually moving the lymph fluid through the superficial system.
Dr Miriam Grotowski
That is great. Thank you Louise, and we are finishing right on that 8:30 but we have had some fantastic conversation, great questions and really appreciate the presentations from Belinda and Karen and Louise. It has just been fantastic to do it. I will let Jasmine do the final thank you.
Jasmine
It was really informative. Thank you everyone for speaking. I wanted to extend my thanks to Belinda, Karen, Louise and Miriam for presenting and also to everyone who joined us online. We do hope you enjoyed the session. I know I did, and you also enjoy the rest of your evening. On another note, a friendly reminder that this is a CPD accredited activity, so please complete the survey that follows the webinar. Once the webinar ends, you will automatically be redirected to complete the survey. We will also be including a link to the survey in an email that we will be sending out tomorrow, and we will also include these slides in there as well for a resource. Whenever you need to do the survey, you only need to complete it once. That brings us to the end of our session, thank you and good night everyone.