Breast cancer: let's prepare breast reconstruction.

Transcription

1 Breast cancer: let's prepare breast reconstruction. Poster No.: C-2273 Congress: ECR 2011 Type: Educational Exhibit Authors: F. Bidault, M. Sahnoun, C. Balleyguier, S. Canale, B. Boulet, G. karsenti, F. Kolb, N. Leymarie, C. Dromain ; Villejuif/FR, 2 Villejuif Cedex 05/FR Keywords: Breast, CT-Angiography, Surgery DOI: /ecr2011/C-2273 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 20

2 Learning objectives To become familiar with DIEP flap (deep inferior epigastric perforator flap). To know how to perform the dedicated preoperative CT (computed tomography). To know the goals of this examination. To create useful VR (volume rendering) and MIP (maximum intensity projection) images to prepare surgery. Page 2 of 20

3 Background Fig. References: Department of Radiologie, Institut Gustave-Roussy - Villejuif/FR This refresher poster is based on local experience of breast cancer surgery and on an overview of literature. DIEP flap is an autologous abdominal-based flap. It combines advantages of autologous flaps without drawbacks of implants and muscular transpositions. The trouble is the harvesting time of this flap due to anatomical variability of perforator vessels. The purpose of the CT is to supply a pre-operative vascular map of perforator arteries. Plastic surgery takes a major place in breast cancer treatment. Plastic surgery after mastectomy is called breast reconstruction. Main techniques for breast reconstruction are [1]: - Prosthesis. Page 3 of 20

4 Advantage: simple. Drawbacks: must be removed in case of infection ; needs supple remaining skin ; risk of foreign body reaction ; discussion about silicone leak and autoimmune disease ; prosthesis replacement after ten years. - Flaps. Advantages : feasible with unsupple skin ; natural result stable along time ; volume follows patient weight modification ; absence of foreign body reaction (if made without prosthesis). Drawbacks: depending on surgical technique. Main types of flap are: - Flaps with prothesis. Keep prothesis drawbacks. - Classical autologous flaps without prothesis. ex : TRAM flap (transvers rectus abdominis muscle). Advantages of flaps. Drawbacks : functional consequences due to muscle transposition. - Recent autologous perforator flaps without prothesis. ex: DIEP flap (Deep Inferior Epigastric Artery Perforator flap) Variant of TRAM flap including only skin, subcutaneous tissue (without muscle) and vascular pedicle. Advantages of flaps without drawbacks of muscle transposition. Drawbacks: microanastomosis, individual variability in the vascular anatomy. [2]. DIEP flap is the aim of this poster (see images 1,2,3). Autologous flaps results are widely preferred by patients [3]. Preoperative imaging of abdominal wall allows to demonstrate individual perforator vessels pattern. The purpose of this poster is to describe DIEP flap and preoperative Computed Tomography (CT) imaging. Page 4 of 20

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8 Imaging findings OR Procedure details CT angiography of abdominal wall can be performed with a multidetector CT scanner. 10 cm above umbilical level until perineal level. Slice thickness = 0,625 mm, pitch Kv, 200 to 250 mas. Arterial time. Contrast: Ionidinated contrast agent (ex: 350 mg/ml). 1,5mL/kg. Flow rate : 3,5 ml/s. followed by saline injection (30mL,dual-head injector). Other injection example [4]. Treatment of images contains two steps: Identification of perforator vessels on average and MIP (Maximum Intensity Projection) images. Creation of a VR (Volume Rendering) image marked with the points of emergence of the perforator vessels on the fascia of the rectus abdominis muscle. See images 1 to 5. Peforator artery selection: Best arteries to be marked are (if available): Size: diameter > 1mm. Large subcutaneous distribution and branching pattern. Short intramuscular course. Intramuscular course surrounded by fat. Median branch of DIEA (less associated with motor nerve than lateral branch and best controlateral subcutaneous distribution). See images 6 to 8. Page 8 of 20

9 Advantages and drawbacks of CT and other imaging modalities: Computed tomography [5,6] Drawbacks: radiation, contrast agent. Advantages: reduces harvesting time of flap and post-operative complication rate; best than ultrasound for intramuscular course exploration. Magnetic Resonance [7] Advantage: No radiation. Drawbacks: magnetic field, 3Tesla needed. Doppler and duplex ultrasound [8] Advantages: availability. Drawbacks: needs well-trained operator, intramuscular course exploration. Digital arteriography Not used. Page 9 of 20

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18 Conclusion Main take home points: DIEP is a common and appreciated flap for breast reconstruction. Simple anatomy knowledge and CT technique allow radiologist to perform a pre-operative vascular map. Pre-operative CT reduces harvesting time of flap and post-operative complication rate. Research turns toward superficial inferior epigastric arteries (SIEA) and anastomosis between DIEA and SIEA systems. Page 18 of 20

19 Personal Information François Bidault (MD). Department of Radiology, Institut Gustave-Roussy. 38, rue Camille Desmoulins Villejuif, FRANCE. Page 19 of 20

20 References Cothier-Savey I, Rimareix F, Belichard C. Principes généraux de la chirurgie oncoplastique et de la reconstruction mammaire immédiate et différée. Encycl Méd Chir (Editions Scientifiques et Médicales Elsevier SAS, Paris, tous droits réservés), Techniques chirurgicales - Chirurgie plastique reconstructrice et esthétique , 2002,14 p. Moon HK, Taylor GI. The vascular anatomy of rectus abdominus musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg. 1988;82: Yueh JH, Slavin SA, Adesiyun T, et al. Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg. 2010;125(6): Cina A, Salgarello M, Barone-Adesi L, Rinaldi P, Bonomo L. Planning breast reconstruction with deep inferior epigastric artery perforating vessels: multidetector CT angiography versus Color Doppler US. Radiology. 2010;225(3): Blondeel PN, Arnstein M, Verstraete K, et al. Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg. 2000;106(6): Fansa H, Schirmer S, Frerichs O, Gehl HB. Significance of Abdominal Wall CT-Angiography in Planning DIEA Perforator Flaps, TRAM Flaps and SIEA Flaps. Handchir Mikrochir Plast Chir Sep 6. [Epub ahead of print] Chernyak V, Rozenblit AM, Greenspun DT, et al. Breast Reconstruction with Deep Inferior Epigastric Artery Perforator Flap: 3.0-T Gadoliniumenhanced MR Imaging for Preoperative Localization of Abdominal Wall Perforators. Radiology 2009; 250: Smit JM, Klein S, Werker PM. An overview of methods for vascular mapping in the planning of free flaps. J Plast Reconstr Aesthet Surg. 2010;63(9): Page 20 of 20