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NGUYEN VAN PHUNGSTUDY TO USE THE DEEP INFERIOR EPIGASTRIC PERFORATOR FLAP IN TREATMENT OF SEQUELAE OF BREAST CANCER SURGERY Speciality: SurgeryCode: 9720104 A thesis for the degree of DO

NGUYEN VAN PHUNG

STUDY TO USE THE DEEP INFERIOR EPIGASTRIC PERFORATOR FLAP IN TREATMENT

OF SEQUELAE OF BREAST CANCER SURGERY

Speciality: SurgeryCode: 9720104

A thesis for the degree of DOCTOR OF PHILOSOPHY

HA NOI - 2019

Academic Supevisor:

1 Vu Quang Vinh PhD., A/Prof

2 Tran Van Anh PhD., A/Prof

Reviewer 1:

Reviewer 2:

Reviewer 3:

This thesis will be defended at Military Medical University at

This thesis may be found at:

1 Vietnam National Library

2 Military Medical University Library

The prevalence of breast cancer has been increased andbecame the most common cancer in woman According to the WorldHealth Organization, breast cancer accounts for 25% of all cancers inwomen and there are an estimated of 1.7 million new casesworldwide each year The management of breast cancer requires thecoordination of many specialities, not only to prevent or eliminatethe tumor but also to deal with the sequelae, the effects psychologyand quality of life of patients after treatment Surgery treatment(total masectomy) is considered the key to treat breast cancer.However, it will lead to physical disability and may be possible tohave lymphatic edema on the side of the surgery in some patients,causing discomfort to the patient because the local deformity oflymphedema cannot be used to cover normal clothing Patientsfrequently have a feeling of their illness, loss of confidence in thebody, reduced fitness, fatigue and psychological decline therebyaffecting the quality of life of patients Therefore, breastreconstruction and treatment of lymphedema are important andconsidered as a stage of treatment for breast cancer Breastreconstruction and treatment of lymphedema will help solve theconsequences and compliacations of breast cancer surgery, helping

to improve the woman confidence and the quality of life

Breast reconstruction can be done by autograft or syntheticmaterials or by combining both In 1989, Koshima I et al for the firsttime successfully used deep inferior epigastric artery perforator flaps

In 1994, Allen R J described for the first time deep inferiorepigastric artery are use in breast reconstruction Because there aremany advantages such as relatively large tissue volume, goodaesthetics, minimally invase of flap removal, deep inferior epigastric

artery perforator flaps are increasingly used in breast reconstructionsurgery and is considered as the choice in some breast reconstructioncenters around the world

Recently, treatment of lymphedema with lymph graft surgery

is common in many centers around the world with very positiveresults Instead of simple lymph nodes flap surgery, the simultaneousimplementation of breast reconstruction by abdominal flap with thetransfer of petiole ingot lymph nodes has been recently applied insome centers around the world with encouraging initial results.Since 1988 breast reconstruction surgery has been performed

by latissimus dorsi muscle flap Recently, breast reconstructionsurgery has continuously developed with more difficult techniquessuch as the deep inferior epigastric artery perforator by microsurgery.However, there has been no report on the breast reconstruction bysimultaneous deep inferior epigastric artery perforator flaps andvascularized groin lymph node flap transfer Because the deepinferior epigastric artery perforator flaps also have manyabnormalities in anatomaical variants, blood supply area, identifyingthe main branch artery of this flap to safely lifting skin flap is still achallenge to plastic surgeons Therefore, the aims of this researchare:

1 To investigate the anatomical characteristics of deep inferior epigastric artery perforator in Vietnamese adult.

2 To evaluate the effectiveness of deep inferior epigastric artery perforator in treatment of sequelae of breast cancer surgery.

3.

CHAPTER 1 LITERATURE REVIEWS 1.1 SURGERY FOR BREAST CANCER

1.1.1 Radical mastectomy and extended radical mastectomy 1.1.2 Modified radical mastectomy

1.1.3 Breast conserving surgery

1.1.4 Skin - sparing mastectomy

1.1.5 Nipple and aerola - sparing mastectomy

1.2 BREAST RECONSTRUCTION AFTER BREAST CANCER SURGERY

1.2.1 Indication and contraindication

1.2.1.1 Indicaion

1.2.1.2 Contraindication

1.2.2 Timing of breast reconstruction

1.2.2.1 Immediate breast reconstruction

1.2.2.2 Delayed breast reconstruction

1.2.3 Types of breast reconstruction

1.2.3.1 Reconstruction with prosthetic implants

1.2.3.2 Reconstruction with latissimus dorsi myocutaneous flap 1.2.3.3 Reconstruction with pedicled transverse rectus abdominis myocutaneous flap

1.2.3.4 Reconstruction with free transverse rectus abdominis myocutaneous flap

1.2.3.5 Reconstruction with superficial inferior epigastric artery flap

1.2.3.6 Reconstruction with deep inferior epigastric perforators flap

1.3 LYMPHEDEMA AND BREAST RECONSTRUCTION 1.3.1 Upper extremity lymphedema after surgery for breast cancer

1.3.2 Lymphedema after breast reconstruction

1.3.3 Effect of breast reconstruction on preexisting lymphedema 1.3.4 Combining autologous breast reconstruction and vascularized lymph node transfer

1.4 DEEP INFERIOR EPIGASTRIC PERFORATOR FLAP 1.4.1 Definition of perforator, perforator flap and classification of perforator

1.4.1.1 Definition of perforator, perforator flap

1.4.4.3 Multidetector computed monography

1.4.5 Deep inferor epigastric artery perforator flap: Anatomical study and clinical application in breast reconstruction

B et al 1984, Moon H K et al 1988, Tuominen H P in 1992 In

1993, Itoh Y and Arai K revealed that the deep epigastric arteryseparated into two internal and external branches, and most of thetransverse branches originated from the outer branch In 2004Munhoz A M also showed in his study that the branch from theouter branch of the lower epigastric artery should be choosen toshorten the time of internal surgery In 2006, Holm C et al suggestedthat there should be a change in the perfusion of the transverse

arterial branch deep of Harmanpf Thus, the anatomical studies donot yet have uniformity in the perfusion partition of the flap, thedivision of branches of the deep epigastric artery and its perforatorsdistribution In Vietnam, there are several authors describing theepigastric arterial system but have not described in detail thecharacteristics of the transverse branches Therefore, in this topic,

we will study the characteristics anatomy, perfusion of deepepigastric perforators

1.4.5.2 Clinical application of deep inferior epigastric artery perforator in breast reconstruction

In 1989, Koshima I et al for the first time used the deepinferior epigastric artery perforator flaps to cover the oropharyngealdefect By 1992, Allen R J et al described the application of a deepinferior epigastric artery perforator in breast reconstruction In 1994,Bloodel P N et al performed the DIEP flap with two vascularprongs in breast reconstruction with good results In 2004, Guerra A

B et al reported using 280 strips of DIEP to reconstruct breast andboth sides with a success rate of 98.2% Also, in this year Gill P S.and CS reported the results of 758 flap DIEP in breast reconstructionwithin 10 years with a success rate of up to 97% In Vietnam, DIEPhas been used in breast reconstruction since 2007 and there havebeen some publications about the result of this flap However, thenumber of ties used in these publications is quite modest but alsoshows encouraging results, with a success rate of 80%

1.4.5.3 Using deep inferior epigastric artery perforator in

combination with inguinal vascularized groin lymph node flap transfer to reconstruct breast and treat lymphedema simultaneously

The combination of breast reconstruction and treatment ofupper limb edema after breast cancer surgery by inguinalvascularized groin lymph node flap transfer is first described bySaaristo AM et al in 2012 with promising results on 9 patients In

2013, Dancey A et al reported 18 cases of using DIEP in

combination with inguinal vascularized groin lymph node flaptransfer with the rate of improvement of lymphatic edema symptomsbeing 100% of cases Another study of 2015 by Nguyen A T et alshowed similar benefits in patients using combination of DIEP withgroin lymph node flap transfer to reconstruct breast and treatlymphedema simultaneously In 2016, De Brucker B B et alreported 25 cases with a symptom improvement rate of 21/25 cases.

In 2017 Akita S and et al reported 27 patients with lymphatic edemaafter breast cancer surgery treated with inguinal lymph graft, ofwhich 13 patients had breast reconstruction combined with DIEPflap The author found that in the group using DIEP flap combinedgroin lymph node flap transfer, lymphatic function improvedcompared to patients with groin lymph node flap transfer only.Chang E I and CS in a 2018 report also showed the reliability andeffectiveness of simultaneous use of DIEP and inguinal lymph graft

At the same time, the author also provided the role of inguinal lymphnodes examination by means of preoperative diagnostic imaging,especially MDCT In Vietnam so far, there have been no reports ofcombining the use of DIEP flap and inguinal lymph node grafting inbreast reconstruction and simultaneous treatment of lymphedema

CHAPTER 2 OBJECTS AND METHODS 2.1 OBJECTS

2.1.1 Anatomical study

2.1.1.1 Anatomical cadaver study

Anatomical characteristics of the deep epigastric arteries inthe abdomen were studied on 20 fresh cadavers of adult Vietnamesewho are preserved cold - 300 C at the Anatomy Department of HoChi Minh University of Medicine and Pharmacy

- Selection criteria: Vietnamese fresh cadavers ≥ 18 years old,preserved in cold, non-injury in the lower abdomen or andominalmiddle incision without injury of low abdominal quarant

- Exclusion criteria: previous surgery at the abdominal wall or anydisease that change anatomical structure of the vascular systemprovided for the lower abdominal wall.

2.1.1.2 Anatomical study of patients

- Multiple detector computed tomography (MDCT) before surgery

to examine the anatomical characteristics of deep epigastric vascularbundles and perforators

- Fluorescence intra-arterial injection to evaluate blood supply offlaps

2.1.2 Clinical research

30 female patients with breast reconstruction surgery bydeep inferior epigastric artery perforator flap after breast cancersurgery were studied at Binh Dan Hospital, City Hospital ofMedicine and Pharmacy University, Ho Chi Minh City and NationalBurn Hospital from November 2011 to September 2016

2.1.2.1 Selection criteria

- Patients who undergo breast cancer surgery with or withoutlymphadenopathy complication desired to reconstruct breast byautologous graft

- There is an excess of skin and fat in the low abdomen

2.1.2.2 Exclusion criteria

- There is not excess of skin and fat in the low abdomen

- Previous surgery with abdominal skin flap, deep inferior epigastricartery perforator flap or abdominal reconstruction surgery

- Infectious condiditon of the abdominal wall

- Patients with lesions, scars in the abdominal area, in which can notfind the branch of deep epigastric artery to perform DIEP flap

- Patients have lower lymphatic edema, intact bilateral inguinallymph nodes (for breast reconstruction combined with inguinallymph graft)

2.2 MEANS AND MATERIAL

2.2.1 Means and materials for anatomical study

2.2.2 Means and materials for clinical research

cm, 8 cm This circle is below the umbilical cord to determine thedistribution of the perforators One-third middle inguinal incisionwas made to explore the deep epigastric arteries No 20 catherter isinserted in the vein, fixed and injected with Barisulphat contrast dyemixed with blue Methylene into the vein (10 ml green Methylene /

100 ml Barrisulphat) Observe the drug infiltration of skin flap Thecadaver is cold preserved for 24 hours After 24 hours, the flap wasdissected from outside to inside to evaluate the characteristics ofdeep epithelial vascular bundles and perforators such as: original,number, diameter, length, position, distribution

+ Blood vessels was examined before surgery by multiple detectorcomputed tomography (MDCT) (n = 19 with Toshib's MDCT 128Aquilon, carried out after injecting 1.5 ml / kg of Ultravist contrastmaterial 300 with 4 ml / sec speed into peripheral veins Position,origin, pathway and anatomical changes of transverse branches, deepepigastric artery, deep epigastric vein was studied in over 19 patients

- Evaluate the blood supply of perforator for flap and vascular networks

+ Skin flap angiography was performed after surgery (n = 8) withToshiba digital radiograph with parameters 100 Kv, 100 mA at theMedic Medical Diagnostic Center.

+ MDCT scan of skin flap was performed after dissect on cavaders(n = 12) with MDCT 128 Aquilon Toshiba to investigate the innercircuit network at the Medic Medical Diagnostic Center

+ The perfusion was assessed during surgery with fluoresceine (n =15) after an isolated vein dissection Intravenous fluoresceine 15mg /

kg weight was performed after a negative test Take a picture of theflap in the dark before injecting and after injecting 20 minutes underthe Wood light

- Recipient area preparation:

+ The breast preparation: remove the old scar, the damage fromradiation therapy and send it to do pathological evaluation The area

to receive the flap was dissect to the muscle layers, up to the groove

on the new breast, down to the groove under the new breast In thecase of lymph grafting, the cavity will be removed to the armpit toprepare the graft site

+ Blodd vessles preparation: The internal mammary artery and vein

or the external one, and the head vein are also surgically used as agood source of grafting when it is not affected by radiation

- Flap dissection:

+ Breast reconstruction, not accompanied by upper limblymphedema (19 patients), use of DIEP flap alone: make incision tofacial layer, skin flap is lifted from the outer to the outer edge of therectus abdominis It must be careful to avoid hurting the majorperforator Select 1 or 2 major perforators with accompanied veins,dissect along them to the starting position is the lower epigastricbundle, loosen and cut the other perforators The rectus abdominismuscle is opened vertically to dissect the lower epigastric vein to theoriginal side to ensure that the vein is long enough

+ Breast reconstruction in combination with upper limb edema (11patients), use the DIEP flap with transfer of inguinal lymph nodes:The part of the inguinal lymph nodes is dissected along thereconstructed breast, taken from the skin to facial layer, includinginguinal lymph nodes Superficial epigastric artery or externalpudendal artery with inguinal lymph nodes flaps were dissected

- Microsurgerical anastomosis and breast reconstruction:

+ Microsurgerical anatomosis: flap will be temporarily fixed; thevascular anastomosis was performed with 9.0-10.0 prolene undermicrosurgery

+ In the case of inguinal lymp graft: the lymph node and surroundingtissue will be fixed to the armpit after peeling the epidermis

+ Breast reconstruction: The flap is calibrated to create new breastsbased on opposing breasts and check again in the half-sitting posture.The flap is fixed 2 layers after placing the drain

- Check the flap circulation by observing the skin color of flap,Doppler ultrasound examination Tape the incision

Post-operation care:

2.3.2.4 Monitoring indicators and methods for evaluating results

 Monitoring indicators:

 Evaluating postoperative results:

 Evaluation of breast reconstruction surgery results:

 Shor-term follow-up (within 6 months):

 Good: Completely living flaps, well-scarred incisionswithout inflammation

 Moderate: the flap has a condition of nourishment or partialnecrosis at the end of the end or flap, fat necrosis, hematoma orwound infection

 Poor: Necrotic flap over 1/3 of area or whole, must befiltered and replaced by another method

 Long-term follow-up (after 6 months):

 Good: The flap is soft, the color is in harmony with thesurrounding, the breast volume is proportional to the opposingbreast, the breast is clear and symmetrical, the scars are small, theabdomen scar is small, the abdominal shape slim, not leavingsequelae at the place for flap

 Moderate: The flap is slightly soft, the color is lessharmonious than the surrounding, the breast volume is lessdisproportionate than the opposing breast, the breast is clear but less

or disproportionate compared to the opposing breast, the scar is bad ,

in breast or abdominal wall, less distorted abdominal shape,abdominal wall where the flap has a pasty state, reduced sensation

 Poor: The flap is not soft, the color is not in harmony withthe surrounding, the volume of breast imbalance is clear compared tothe opposing breast, the underside of the breast is unclear, the scar inthe breast orin the abdomen is convex or hypertrophy, distinctlydeformed abdominal form, herniated abdominal wall, loss of feeling

of abdominal wall

 Evaluation of the results of lymph node transplantation after 6months according to the following levels:

 Good: Soft edema, relieve pain, reduce the circumference ofthe hand, the side of the legs will not match.

 Medium: Soft limbs relieve pain, the circumference of thehands remains unchanged, the legs on the sides do not match

 Poor: Hands fit better or / and match the right leg for lymphnodes

2.3.3 Statistical analyses

Statistical analyses were performed with Stata 13.0

CHAPTER 3 STUDY RESULT 3.1 STUDY RESULT OF ANATOMY

3.1.1 Characteristics of deep epigastric arteries vessels and perforators

3.1.1.1 Classical dissection on cadavers:

- Characteristics of deep epigastric arteries: Results of all DIEA are

derived from external pelvic arteries They located behind rectusabdominis 77.5% or inside this muscle 22.5% The average diameter

of DIEA is 2.2 ± 0.2 mm DIEA with 1 main branch is 52.5%, 2main branches are 42.5% and 3 branches are 5%

Table 3.4 Characteristics of deep inferior epigastric artery

perforators

Characteristics Right

(n=88)

Left (n=89)

Common (n=177)

Dominant (n=40)

- From lateral branch 12 (13,6%) 21 (23,6%) 33 (18,6%) 5 (12,5%)

- From medial branch 13 (14,8%) 25 (28,1%) 38 (21,5%) 11