I was doing my journal reading (and if you read my blogs, you know I love to read my journals), and one of the first articles was about Endoscope assisted total Mastectomy.
What?!
Endoscopes are tubes attached to a camera and light. We use them for minimally invasive surgery like gall bladder removal or brow lifts. I never thought of them to be used for breast cancer surgery to remove the breast. Endoscopes always seem like something we do to make a small incision and take out a small thing, not a small incision and take out a big thing.
But doing a mastectomy with a small scar in the armpit and sometimes at the areola is a thing.
This was in the Plastic and Reconstructive Surgery Journal, Feb 2021, “Endoscopy Assisted Total Mastectomy with and without Immediate Reconstruction An extended Follow Up Multi Center Study.”
Study:
- Prospective, multicenter study, from 2009-2018
- Clinical outcome, impact of different phases, oncologic results, and aesthetic outcomes were recorded.
- 436 Endoscopic mastectomy cases were done. 81% of these were nipple sparing, and 81% were skin sparing.
- 75% had immediate breast reconstruction (most of these were implant reconstruction, with about 20% being autologous reconstruction)
Findings:
- 2% had positive margins
- 5% had partial nipple loss
- 0.6% had total nipple loss
- 0.7% had implant loss
- Those in later phases had significantly decreased operative time and blood loss compared to those at the beginning of the study.
- Follow up was 22 months, 3% had locoregional recurrence, 0.7% had distant mets, and one death
Conclusion:
“This is a good technique for early breast cancer with high patient satisfaction.”
My thoughts?
This is only for people with small early stage cancers or who are doing prophylactic mastectomy. There can be no lymph node mets, no skin or chest wall invasion, no multifocal lesions, no other significant comorbidities (obesity, diabetes, smoker), and no involvement of the tumor with the nipple.
It is likely also best for women with small to medium breasts.
The issue is many of these women (small tumor, small breast) chose breast conservation surgery, where they do a lumpectomy with radiation. But many women may choose to do a lumpectomy because they are worried about the scars and look of a reconstruction. A minimally invasive scar and getting rid of your risk for any further breast cancer? no radiation either? That is appealing.
The technique is kind of brilliant. They use tumnescent (100-200cc) under the skin, just like we use in liposuction. This helps with blood loss and pain, and it also helps separate the breast tissue from the overlying skin and give you a good plane to operate in. For the posterior dissection (the bottom of the breast on top of your pectoral muscle) there is an incision in the armpit, where they dissect the breast off the pectoral muscle. They take the tissue out through the areola or the armpit, depending on the size of the breast. (In a cancer case, you can’t break up the tissue to get it out- it could cause cancer cells to shed). There was an incision at the nipple to get the subareolar breast tissue out in some centers. As you can imagine, this increases the risk of blood supply to the nipple.
It’s interesting, as I was in training to see the conversion from “open” surgery for gallbladders, where you had a huge scar slash on your belly, to laproscopic removal of gallbladders, where you have a tiny incision on your belly and belly button. Endoscopy/Laproscopy is not a new technique. Smaller scars are used routinely now for colon removal, uterus removal, appendixes. For some reason I didn’t think of it in the breast. Partially because it is for a cancer surgery. Partially because the breast can be big. But I can see how it is better in many ways—blood supply, less scar, prettier—for that smaller breasted, early breast cancer.
Fabulous.