Oncoplastic breast surgery for cancer: analysis of 540 consecutive cases [outcomes article]. Plast Reconstr Surg. 2010;125:454-462. [PMID: 20124831 DOI: 10.1097/prs.0b013e3181c82d3e]

Oncoplastic Level 2 Mammoplasty for Large DCIS: 5-Year Results

BACKGROUND

Oncoplastic surgery (OPS) allows wider resections with immediate breast reshaping by mammoplasty. This study reviews our experience with level 2 mammoplasties in patients with histology-proven pure ductal carcinoma in situ (DCIS).

METHOD

From a prospectively maintained database of 392 consecutive oncoplastic level 2 mammoplasties, 68 patients presented with pure DCIS. Involved margin rates and locoregional recurrence rates were calculated, with 76 months (0-166 months) median follow-up.

RESULTS

The mean pathological tumor size was 34 mm (median 26 mm, range 2-106 mm). The mean resection weight was 191 g (median 131 g, range 40-1150 g). Margins were clear in 58 cases (85.3%) and involved in 10 cases (14.7%). Margins were involved in 1 out of 54 (1.9%) cases with tumor size under 50 mm and in 9 out of 14 (64.3%) cases with tumor size higher than 50 mm (p < 0.001). On multivariable analysis, only tumor size > 50 mm [odds ratio (OR) 95.400; p < 0.001] was independently associated with involved margins. Seven patients had mastectomy. The overall breast conservation rate was 89.4%, and 100% for tumors less than 5 cm. There were three local recurrences. The 5-year cumulative incidence for local recurrence was 5.5% (0-11.5%).

CONCLUSIONS

OPS is a safe solution for large DCIS up to 50 mm, with an involved margin rate of only 1.9%, and can thus reduce the mastectomy rate in this group. As margin involvement significantly increases for tumors larger than 5 cm, better preoperative localization and/or wider excisions are necessary in this group.

Neoadjuvant Chemotherapy does not Increase Complications in Oncoplastic Breast-Conserving Surgery

BACKGROUND

Oncoplastic breast-conserving surgery (OBCS) broadens the indications for breast conservation. Neoadjuvant systemic chemotherapy (NAC) is used increasingly in the treatment of patients with early-stage and locally advanced breast cancer. This study aimed to evaluate the outcomes for patients who received NAC followed by OBCS.

METHODS

A retrospective chart review was performed for all patients who underwent OBCS involving the mastopexy/breast-reduction technique, including synchronous mastopexy/breast reduction for symmetry, at the University of Texas MD Anderson Cancer Center between January 2010 and January 2016. Patients who had received NAC were compared with those who had undergone surgery first. Demographic, treatment, and outcomes data were collected.

RESULTS

The study included 429 patients, corresponding to 713 breasts. Of these patients, 122, corresponding to 199 breasts, received NAC. The patients who received NAC were younger (p < 0.001) and had a more advanced cancer stage (p < 0.001). The overall complication rate per patient was 25.9%, with major complications occurring in 9.1% of the patients. After adjustment for risk factors, NAC was not shown to be associated with an increased risk of complications or delayed adjuvant radiation therapy (p = 0.37), irrespective of the chemotherapy regimen used or whether the interval between NAC and surgery was 4 weeks or longer.

CONCLUSIONS

In a high-volume center, OBCS can be performed safely for carefully selected patients after NAC without an increased risk of complications or delayed adjuvant radiation therapy. An interval of at least 4 weeks between completion of NAC and surgery can be regarded as safe irrespective of the chemotherapy regimen used.

The axillary flap in oncoplastic resection of breast cancers located in the upper-outer quadrants: a new surgical technique

Background

The combination of breast conserving surgery (BCS) with plastic surgery techniques has provided a useful surgical tool matching the radicality of the oncological excision with the preservation of breast cosmesis. Even though BCS represents a good option for surgical treatment of tumors located in these quadrants, wide excisions often necessitate breast reshaping in order to avoid nipple areola complex (NAC) displacement and skin retraction. We present a new surgical technique to repair upper-outer quadrants’ defects following breast cancer excision using dermo-glandular flaps and an axillary adipo-fascial flap.

Methods

During the period from January 2014 to December 2015, 168 patients with an upper-outer quadrant’s breast cancer have been treated in our Department. 83 women have been treated with the described oncoplastic technique and immediate contra-lateral symmetrisation and 85 women underwent standard BCS. We present surgical, oncological and cosmetic outcomes comparing our results with standard BCS.

Results

At a mean follow-up of 27 months loco-regional recurrences in the two groups were comparable. Short-term complication rates were comparable between the two groups. Re-intervention rates for positive margins were significantly higher in the standard BCS group. The overall satisfaction with cosmetic outcome both assessed by the patient and the surgeon was significantly higher in the oncoplastic group.

Conclusions

The proposed oncoplastic technique represents a safe and effective solution for reshaping that follows upper-outer breast cancer wide excision, achieving comparable complication rates, lower re-intervention rates for positive margins and better cosmetic results when compared with standard BCS.

Paving the way for changing perceptions in breast surgery: a systematic literature review focused on oncological and aesthetic outcomes of oncoplastic surgery for breast cancer

BACKGROUND

The emphasis on aesthetic outcomes and quality of life after breast cancer surgery has motivated breast surgeons to develop oncoplastic breast conserving surgery (OPS). Training programs are still rare in most countries, and there is little standardization, which challenges the scientific evaluation of these techniques. This systematic review aims to assess oncological and cosmetic outcomes of OPS.

METHODS

After a strict selection process with precise inclusion and exclusion criteria, oncologic and aesthetic outcomes of oncoplastic surgery were searched, using the MEDLINE database up to September 30th, 2017. Available published literature was classified in levels of evidence. After a thorough screening process, only studies with the best level of evidence were included on selection. Systematic reviews and meta-analyses were not included for methodological reasons.

RESULTS

Titles and abstracts of 2.854 citations were identified and after screening 15 prospective studies including 1.391 patients were reviewed and scored in detail. Local relapse was found in 2.8% of cases with a wide range of follow-up (from 6 to 74 months). Close margins were retrieved in 11% of cases and positive margins in 9.4% of cases. Mastectomy was implemented in 6.9% of breast cancer patients to whom OPS was performed. Good cosmetic outcomes were detected in 90.2% of patients undergoing OPS, leaving open issues for who should perform cosmetic evaluation and which method should be used.

CONCLUSION

Tumor margins, mastectomy rates, and cosmetic outcomes of OPS have to be further improved by standardizing various aspects of OPS. Research efforts should focus on level I evidence assessing both oncological and aesthetic outcomes of OPS and survival rates.

Paradigm shift in the local treatment of breast cancer: mastectomy to breast conservation surgery

There have been fundamental changes in the approach to breast cancer management over the last century but the primary objective of achieving oncological safety remains unchanged. This evolution is highlighted with a summary of the key evidences in support of the oncological safety of breast conserving surgery (BCS) in early breast cancer (EBC) management. We will also discuss the increasingly pivotal role that neoadjuvant chemotherapy (NACT) may play, in the local treatment of EBC and locally advanced breast cancer (LABC) and the long-term surgical and oncological outcomes.

Breast conservation versus mastectomy in patients with T3 breast cancers (> 5 cm): an analysis of 37,268 patients from the National Cancer Database

PURPOSE

Breast conservation therapy (BCT) is standard for T1-T2 tumors, but early trials excluded breast cancers > 5 cm. This study was performed to assess patterns and outcomes of BCT for T3 tumors.

METHODS

We reviewed the National Cancer Database (NCDB) for noninflammatory breast cancers > 5 cm, between 2004 and 2011 who underwent BCT or mastectomy (Mtx) with nodal evaluation. Patients with skin or chest wall involvement were excluded. Patients having clinical T3 tumors were analyzed to determine outcomes based upon presentation, with those having pathologic T3 tumors, subsequently assessed, irrespective of presentation. Overall survival (OS) was analyzed using multivariable Cox proportional hazards models, with adjusted survival curves estimated using inverse probability weighting.

RESULTS

After exclusions, 37,268 patients remained. Median age and tumor size for BCT versus Mtx were 53 versus 54 years (p < 0.001) and 6.0 versus 6.7 cm (p < 0.001), respectively. Predictors of BCT included age, race, location, facility type, year of diagnosis, tumor size, grade, histology, nodes examined and positive, and administration of chemotherapy and radiotherapy. OS was similar between Mtx and BCT (p = 0.36). This held true when neoadjuvant chemotherapy patients were excluded (p = 0.39). BCT percentages declined over time (p < 0.001), while tumor sizes remained the same (p = 0.77). Median follow-up was 51.4 months.

CONCLUSIONS

OS for patients with T3 breast cancers is similar whether patients received Mtx or BCT, confirming that tumor size should not be an absolute BCT exclusion. Declining use of BCT for tumors > 5 cm in younger patients may be accounted for by recent trends toward mastectomy.

Oncoplastic approach to excisional breast biopsies: a randomized controlled, phase 2a trial

BACKGROUND

Oncoplastic surgery has been used in breast cancer patients for better cosmetic outcome over the last decades. The aim of this prospective randomized study is to show its place in excisional breast biopsy.

METHODS

An oncoplastic approach excision was compared with conventional excisional breast biopsies. The study included 80 patients, of whom half received oncoplastic intervention and half received the conventional. The primary endpoint was the cosmetic result. Patient, surgeon and independent observers rated the results on a four-point scale. Scores other than self-perceived were based on third-month medical photographs.

RESULTS

Between May 20, 2015 and April 27, 2016, 40 patients were randomly assigned to oncoplastic biopsy and 40 patients were assigned to conventional excisional biopsy. Median follow-up was 5.6 months (IQR 3.0-6.0). Self-perceived perfect scoring for general cosmetic outcome was found significantly higher after oncoplastic biopsy (73 0.5%) comparing with control group (32.4%) (p = 0.001). This impact did not change after adjusting patients for potential confounders. Margin clearance rates in malignant cases were comparable in both arms (p = 0.999); four patients in oncoplastic biopsy group (40%) and three patients in control group (33%) had positive margins.

CONCLUSIONS

The oncoplastic biopsy achieved better cosmetic results with similar surgical margin positivity rates when compared with conventional breast biopsy. It may be a better biopsy option used for patients requiring excisional breast biopsy.

Oncoplastic Breast Reconstruction: Should All Patients be Considered?

Oncoplastic surgery of the tissue defect from partial mastectomy should be considered for all patients. It can result in in significant asymmetries from scar contraction, skin tethering, and alterations in the nipple areolar complex location. Indications, risks, and benefits are discussed. Optimal procedures are described, considering resected specimen volume, primary tumor location, tumor to breast size ratio, and the impact on the nipple areolar complex. Indications for plastic surgery consultation and joint surgery are discussed. Surgical management includes incision planning, preservation of the nipple areolar complex pedicle and position, patient positioning, incision location, and recovery.

Should age impact breast cancer management in young women? Fine tuning of treatment guidelines

Despite breast cancer being uncommon in young women, it is still the most frequent cancer diagnosed in women aged 15–39 years, and the leading cause of death in this age group in high-income countries, after accidents and self-injury. The present review summarizes the most recent guidelines and offers an expert perspective on the many challenges associated with treatment of young women with breast cancer. We will especially focus on early breast cancer, exploring the specificities of the diagnostic process, imaging techniques, locoregional and systemic treatments, and the added value of dedicated multidisciplinary teams. Specific differences in adjuvant treatment between premenopausal and postmenopausal women, especially regarding endocrine therapy, will be addressed in detail. Research questions and current gaps in important fields, such as the paucity of age-specific data regarding antihuman epidermal growth factor receptor 2 (anti-HER2) therapy and gene panels such as OncotypeDX or MAMMAPRINT will be highlighted. A consistent part of this review is dedicated to the issues defining ‘young women’, such as fertility preservation, managing long-term side effects of oncological treatments and genetic counselling, by detailing current strategies and future perspectives.

Wide Local Excision Versus Oncoplastic Breast Surgery: Differences in Surgical Outcome for an Assumed Margin (0, 1, or 2 mm) Distance

INTRODUCTION

Oncoplastic breast surgery (OBS) can be applied in larger tumors or in patients with high tumor-to-breast ratio without compromising oncologic safety. Inherent larger excisions may increase the probability of clear margins. We compare postoperative outcomes between simple wide local excision (WLE) and OBS assuming 3 different margin distances.

PATIENTS AND METHODS

Single oncoplastic surgeon data between April 2014 and September 2016, including tumor and treatment details, for WLE or OBS were reviewed. Relative incidence of margin positivity at 3 assumed distinct margin distances (2, 1, and 0 mm) and reexcision rates were compared. Statistical comparisons were performed by the Student t and chi-square tests.

RESULTS

Available data from 201 patients revealed similar patient age and respective tumor phenotypes between 2 cohorts (166 WLE and 35 OBS). Though both the preoperative (30 vs. 16 mm, P < .001) and postoperative tumor (30 vs. 19 mm, P = .001) sizes were greater in the OBS group, margin positivity rates were significantly lower, at 1 mm (5.7% vs. 20.8%, P = .036). Though similar rates of reexcision were observed, completion mastectomies were required in 5.4% of WLE versus 0 OBS. Similar rates of margin positivity and reexcision were observed between mammoplasties and chest wall perforator flaps.

CONCLUSION

OBS is not inferior to standard WLE at providing a safe and clear oncologic margin regardless of margin distance (up to 2 mm) despite larger tumor size. The additional benefit of improved cosmesis, particularly in patients with larger tumor-to-breast ratio, offers a suitable and safe alternative, thus increasing patient choice and reducing the incidence of reexcision and completion mastectomy.

Oncoplastic Surgery: Keeping It Simple With 5 Essential Volume Displacement Techniques for Breast Conservation in a Patient With Moderate- to Large-Sized Breasts

Oncoplastic surgery is an evolving field in breast surgery combining the strengths of breast surgical oncology with plastic surgery. It provides the surgeon the ability to excise large areas of the breast in the oncologic resection without compromising, and possibly improving, its aesthetic appearance. The purpose of this review is to provide a guide that could help a breast surgeon excise breast cancer in most areas of the breast using 5 oncoplastic techniques. These techniques would be used depending primarily on the location of the cancer in the breast and also on the size of the tumor.

Oncoplastic breast conserving surgery with tailored needle-guided excision

Background

Breast conserving surgery (BCS) administered with oncoplastic approach (OBCS), when it is required, is currently the gold standard for the treatment of early breast cancer. Wire-guided localization (WL) is the most popular technique used to help surgeon in breast cancer excision. Currently, a universal and undeniable goal is to minimize the rate of positive margins and re-excision operation after BCS improving cosmetic outcome and decreasing health care costs. This study is aimed to report our experience combining OBCS and tailored WL as surgical approach for early breast cancers.

Methods

We performed a retrospective study on 148 breast cancer patients who were treated with OBCS and tailored WL, which consists in individualization of the number and location of wires depending on patient particularities, in our Breast Unit from March 2013 to December 2015. A multivariate analysis was used to determine the association between clinic-pathologic variables, which can be known preoperatively, and margin status.

Results

The rate of affected margins was 13.5% and 10.8% patients underwent re-interventions for oncologic reasons. Multifocality was strongly associated with involved margins [odds ratio (OR) 4.67].

Conclusions

OBCS together with tailored WL obtains an acceptable rate of positive margins and high rate of final BCS.

Updated Evidence on the Oncoplastic Approach to Breast Conservation Therapy

The oncoplastic approach to breast conservation therapy has become a useful and popular option for women with breast cancer who wish to preserve their breast. The initial driving forces were aimed at minimizing the potential for a breast conservation therapy deformity; however, various other benefits have been identified that include broadening the indications for breast conservation therapy in some patients and improved margin control. The various techniques can be categorized into glandular rearrangement techniques such as breast reductions usually in patients with larger breasts or flap reconstruction such as the latissimus dorsi muscle usually in patients with smaller breasts. As the acceptance continues to increase, we are starting to see more outcomes evidence in terms of patient satisfaction, quality of life, complications, and recurrence, to further support the safety and efficacy of the oncoplastic approach.

Oncological safety and cosmetic outcomes in oncoplastic breast conservation surgery, a review of the best level of evidence literature

Oncoplastic breast conservation surgery (OBCS) is increasingly becoming part of routine breast cancer surgical management. OBCS may be viewed as an extension of standard breast conservation surgery for resecting tumors of larger sizes without compromising on cosmetic outcome, or as an alternative to mastectomy. High quality evidence to support the oncological safety and benefits of OBCS is lacking. This review will focus on the best available level of evidence and address key issues regarding oncological safety in OBCS, such as tumor resection margins and re-excision rates, local recurrence and patient outcome, postoperative complications and adjuvant therapy delivery, and briefly discuss cosmetic outcome in OBCS. Comparative observational studies and systematic review report no poorer outcomes compared with standard breast conservation surgery. More evidence needs to be generated to support the oncological safety and improved aesthetic outcome. Prospective data collection will significantly contribute to the generation of stronger evidence.

Oncoplastic round block technique has comparable operative parameters as standard wide local excision: a matched case-control study

BACKGROUND

Although oncoplastic breast surgery is used to resect larger tumors with lower re-excision rates compared to standard wide local excision (sWLE), criticisms of oncoplastic surgery include a longer-albeit, well concealed-scar, longer operating time and hospital stay, and increased risk of complications. Round block technique has been reported to be very suitable for patients with relatively smaller breasts and minimal ptosis. We aim to determine if round block technique will result in operative parameters comparable with sWLE.

METHODS

Breast cancer patients who underwent a round block procedure from 1st May 2014 to 31st January 2016 were included in the study. These patients were then matched for the type of axillary procedure, on a one to one basis, with breast cancer patients who had undergone sWLE from 1st August 2011 to 31st January 2016. The operative parameters between the 2 groups were compared.

RESULTS

22 patients were included in the study. Patient demographics and histologic parameters were similar in the 2 groups. No complications were reported in either group. The mean operating time was 122 and 114 minutes in the round block and sWLE groups, respectively (P=0.64). Length of stay was similar in the 2 groups (P=0.11). Round block patients had better cosmesis and lower re-excision rates. A higher rate of recurrence was observed in the sWLE group.

CONCLUSION

The round block technique has comparable operative parameters to sWLE with no evidence of increased complications. Lower re-excision rate and better cosmesis were observed in the round block patients suggesting that the round block technique is not only comparable in general, but may have advantages to sWLE in selected cases.

Patient-Reported Outcomes Are Better after Oncoplastic Breast Conservation than after Mastectomy and Autologous Reconstruction

Supplemental Digital Content is available in the text.

Oncoplastic breast-conserving surgery (OBCS) avoids mastectomy for larger tumors, but patient-reported outcomes are unknown.

Laser interstitial thermotherapy application for breast surgery: Current situation and new trends

While breast specialists debate on therapeutic de-escalation in breast cancer, the treatment of benign lesions is also discussed in relation to new percutaneous ablation techniques. The purpose of these innovations is to minimize potential morbidity. Laser Interstitial ThermoTherapy (LITT) is an option for the ablation of targeted nodules. This review evaluated the scientific publications investigating the LITT approach in malignant and benign breast disease. Three preclinical studies and eight clinical studies (2 studies including fibroadenomas and 6 studies including breast cancers) were reviewed. Although the feasibility and safety of LITT have been confirmed in a phase I trial, heterogeneous inclusion criteria and methods seem to be the main reason for LITT not being yet an extensively used treatment option. In conclusion, further development is necessary before this technique can be used in daily practice.

Oncoplastic breast conservation surgery is oncologically safe when compared to wide local excision and mastectomy

BACKGROUND

Support for the oncological safety of oncoplastic breast conservation surgery (OBCS) is mostly based on evidence comparing recurrence rates after OBCS to wide local excision (WLE). However, OBCS is often indicated for larger cancers and oncological results should also be compared to patients treated with mastectomy. In this study we compared recurrence and survival following OBCS, mastectomy and WLE.

METHODS

Patients treated with OBCS between 2009 and 2012 were identified from a prospectively maintained database. For comparison, consecutive patients treated with WLE or mastectomy with or without immediate reconstruction (Ms ± IR) over the same time period were identified. Histological variables of patients were compared using Fisher Exact or Chi squared tests, and recurrence and survival were compared using Kaplan-Meier and Cox regression survival analysis.

RESULTS

980 patients' data were analysed (OBCS: n = 104; WLE: n = 558; Ms ± IR: n = 318). Tumour size, grade, nodal status, ER, and PR expression of patients treated with OBCS were all significantly more adverse compared with patients treated with WLE (p < 0.001). These histological variables were similar in patients treated with Ms ± IR and OBCS. 5-year local recurrence rates were similar in all three groups (WLE: 3.4 per cent, OBCS: 2 per cent, Ms ± IR: 2.6 per cent; log rank = 0.973), while distant recurrence rates were higher after Ms ± IR and OBCS (Ms ± IR:13.1 per cent, OBCS:7.5 per cent, WLE:3.3 per cent; log rank: p < 0.001).

CONCLUSION

OBCS is oncologically safe in patients even when histological results are similar to patients treated with Ms ± IR.

Oncoplastic Surgery for Upper/Upper Inner Quadrant Breast Cancer

Tumors located in the upper/upper inner quadrant of the breast warrant more attention. A small lesion relative to the size of breast in this location may be resolved by performing a level I oncoplastic technique. However, a wide excision may significantly reduce the overall quality of the breast shape by distorting the visible breast line. From June 2012 to April 2015, 36 patients with breast cancer located in the upper/upper inner quadrant underwent breast-conservation surgery with matrix rotation mammoplasty. According to the size and location of the tumor relative to the nipple-areola complex, 11 patients underwent matrix rotation with periareolar de-epithelialization (donut group) and the other 25 underwent matrix rotation only (non-donut group). The cosmetic results were self-assessed by questionnaires. The average weights of the excised breast lumps in the donut and non-donut groups were 104.1 and 84.5 g, respectively. During the 3-year follow-up period, local recurrence was observed in one case and was managed with nipple-sparing mastectomy followed by breast reconstruction with prosthetic implants. In total, 31 patients (88.6%) ranked their postoperative result as either acceptable or satisfactory. The treated breasts were also self-evaluated by 27 patients (77.1%) to be nearly identical to or just slightly different from the untreated side. Matrix rotation is an easy breast-preserving technique for treating breast cancer located in the upper/upper inner quadrant of the breast that requires a relatively wide excision. With this technique, a larger breast tumor could be removed without compromising the breast appearance.

Extreme oncoplastic breast surgery: A case report

•

Many oncoplastic approaches have been proposed for breast cancer surgery but few have been described for multicentric cancers.

•

“Extreme oncoplastic surgery” allows successful breast conservation in selected patients with multicentric tumors.

•

We present an application of oncoplastic breast surgery in a case of multicentric breast cancer with optimal outcomes.

Introduction

So called “extreme oncoplastic surgery” is emerging as a new promising concept in breast cancer surgery allowing successful breast conservation in selected patients with multicentric tumors.

Presentation of case

We report the case of a 48-year-old woman presenting with a multicentric breast cancer and successfully treated with an oncoplastic technique consisting in three radical lumpectomies followed by breast reshaping and simultaneous contralateral symmetrization.

Discussion

According to our experience, oncoplastic conserving breast surgery could represent a better option than the combination of mastectomy, reconstruction and radiation therapy, in terms of quality of life for selected patients affected by multicentric breast cancer.

Conclusion

The surgical treatment for multicentric breast cancers remains controversial even though emerging evidences show good oncological and aesthetic outcomes following oncoplastic conserving breast surgery.

Oncoplastic breast surgery in the setting of breast-conserving therapy: A systematic review

Breast-conserving therapy (BCT), or breast-conserving surgery with adjuvant radiation therapy, has become a standard treatment alternative to mastectomy for women with early-stage breast cancer after many long-term studies have reported comparable rates of overall survival and local control. Oncoplastic breast surgery in the setting of BCT consists of various techniques that allow for an excision with a wider margin and a simultaneous enhancement of cosmetic sequelae, making it an ideal breast cancer surgery. Because of the parenchymal rearrangement that is routinely involved in oncoplastic techniques, however, the targeted tissue can be relocated, thus posing a challenge to localize the tumor bed for radiation planning. The goals of this systematic review are to address the challenges, outcomes, and cosmesis of oncoplastic breast surgery in the setting of BCT.

Optimising Breast Conservation Treatment for Multifocal and Multicentric Breast Cancer: A Worthwhile Endeavour?

BACKGROUND

Breast conservation treatment (BCT) is an accepted treatment modality for early breast cancer. However, multifocal and multicentric breast cancer (MFMCBC) is a relative contraindication to BCT. This study was performed to compare BCT rates in MFMCBC and unifocal tumours and its outcomes.

METHODS

A retrospective analysis was performed for patients with breast malignancies who underwent operative treatment between 2009 and 2011. Successful BCT was defined as the ability to obtain clear margins for all tumour foci through a single incision with acceptable resultant cosmesis.

RESULTS

A total of 160 patients were analysed, of which 40 were MFMCBC. Thirty-four of the 40 patients with MFMCBC underwent BCT (85 %). After a mean follow-up period of 55 months, there were no local recurrences in patients with MFMCBC.

CONCLUSION

BCT was achieved in 85 % of the patients with MFMCBC in this cohort without evidence of poorer local control. Further investigation is needed to confirm this finding for its potential contribution to improved survival outcomes.

The role of oncoplastic breast conserving treatment for locally advanced breast tumors. A matching case-control study

Background

Breast conserving surgery (BCS) after neoadjuvant chemotherapy (NC) in patients with locally advanced breast cancer (LABC) is an infrequent procedure. In these patients the association with BCS and oncoplastic surgery (OS) is reported as a possible procedure in case-series, but there are limited case-control studies.

Methods

A matched case-control study evaluated LABC submitted to NC and BCS. We evaluated 78 patients submitted to doxorubicin-cyclophosphamide regimen followed by paclitaxel regimen. The match case-control proportion was 2:1 and the patients were selected by tumor size, clinical T stage and year of diagnosis.

Results

52 underwent classic BCS and 26 OS. The average size tumor was 5.25 cm and 88.5% of the tumors were larger than 3 cm. The clinical and pathological group characteristics were similar, except the weight of surgical specimens (p = 0.004), and surgical margins (p = 0.06), which were higher in OS group. The rate of complete pathologic response was 26.9%. 97.4% received postoperative radiotherapy. At 67.1 months of follow up, 10.2% had local recurrence (LR) and 12.8% locoregional recurrence (LRR) and 19.2% died because disease progression. The overall survival at 60 months was 81.7%. After surgery the disease free-survival at 60 months was 76.5%. The was no difference between groups related to pathologic response (p = 0.42), LR (p = 0.71), LRR (p = 1.00), overall survival (p = 0.99) and disease specific survival (p = 0.87).

Conclusion

This study corroborates the fact that OS is a safety procedure for LABC, offering the similar oncologic results observed in patients submitted to classic BCS.

•

A matched case-control study evaluates oncoplastic techniques for locally advanced breast cancer.

•

The size of tumors were bigger than other series.

•

The matched case-control study was selected base on tumor size and year of diagnosis to decrease possible bias selection.

•

The security of this procedure was evaluated based a long follow up.

•

Oncoplastic surgery has the same results than conventional breast conserving surgery for locally advanced breast tumors.

Operative and Oncologic Outcomes in 9861 Patients with Operable Breast Cancer: Single-Institution Analysis of Breast Conservation with Oncoplastic Reconstruction

BACKGROUND

Oncoplastic reconstruction is an approach that enables patients with locally advanced or adversely located tumors to undergo breast conserving surgery (BCS). The objectives were to identify the use of BCS with oncoplastic reconstruction (BCS + R) and determine the operative and oncologic outcomes compared with other breast surgical procedures for breast cancer.

METHODS

This retrospective cohort study interrogated a single institution's prospectively maintained databases to identify patients who underwent surgery for breast cancer between 2007 and 2014. Surgeries were categorized as BCS, BCS + R, total mastectomy (TM), or TM with immediate reconstruction (TM + R). Demographic and clinicopathologic characteristics and postoperative complications were analyzed.

RESULTS

There were 10,607 operations performed for 9861 patients. Median follow-up was 3.4 years (range, 0-9.1 years). The use of BCS + R had a nearly fourfold increase in the percentage of all breast cancer surgeries during the study period; 75 % of patients who underwent BCS + R had a T1 or T2 tumor. There was no difference in the use of BCS + R compared with BCS for any quadrant of the breast except the lower outer quadrant (11.1 vs. 6.8 %; p < .0001). BCS + R had a lower rate of seroma formation (13.4 vs. 18 %; p = .002) and positive or close margins compared with BCS (5.8 vs. 8.3 %; p = .04). There was no difference in overall survival or recurrence-free survival when comparing BCS and BCS + R.

CONCLUSIONS

Patients undergoing BCS + R are not disadvantaged in terms of complications and short-term (3-year) outcomes compared with BCS patients or patients who underwent TM.

Breast-conserving surgery using an inframammary fold incision technique for breast cancer

BACKGROUND

Breast-conserving surgery is an established alternative for the majority of women with early stage breast cancer. Consensus on negative margins (no ink on tumour) for invasive cancer makes mutilating extensive lumpectomies unnecessary. Several breast-conserving surgical methods are described in the literature. The aim of this study was to describe and evaluate a technique using the inframammary fold incision.

METHODS

Twenty-seven patients with suspected breast cancer (stage I-II) underwent breast-conserving surgery using the inframammary fold incision. Data regarding tumour characteristics, margin status, complications, oncologic and aesthetic outcome was analysed retrospectively.

RESULTS

After a median follow-up of 35 months, 23 of the 24 patients with breast cancer (95.8%) had no evidence of disease. Post-operative complications (as defined by infection requiring antibiotic treatment and/or seroma requiring drainage) were seen in three of the 27 patients (11.1%). The final pathological examination revealed a positive excision margin in four patients (16.7%). Post-operative evaluation with the BREAST-Q™ BCT module showed a mean RASCH score of 72.5 regarding 'Satisfaction with breast'. The aesthetic result with a hidden scar is exemplified.

CONCLUSION

Breast-conserving surgery using the inframammary fold incision seems to be a safe method with better cosmesis; however, further research is needed.

Oncoplastic breast conserving surgery: Volume replacement vs. volume displacement

Oncoplastic breast conserving surgery (BCS) has emerged as a third option between conventional BCS and mastectomy. Oncoplastic BCS includes two fundamentally different approaches: volume replacement and volume displacement. The former involves partial mastectomy and immediate reconstruction of the breast with the transposition of autologous tissue from elsewhere, while the latter involves partial mastectomy and using the remaining breast tissue to fill the defect resulting from extirpation of the tumor. There are several benefits associated with oncoplastic BCS. First, it allows partial mastectomy without cosmetic penalties, and can achieve better cosmetic outcomes than total mastectomy with immediate breast reconstruction. Second, it avoids the need for total mastectomy in an increasing number of patients without compromising local control. Third, partial breast reconstruction is less extensive and has fewer complications than conventional procedures. Partial mastectomy and partial breast reconstruction can be carried out either simultaneously as a one-stage procedure, or using a two-stage approach. Although patients prefer a one-stage procedure, it requires intraoperative confirmation of complete tumor excision using frozen-section analysis. Moreover, oncoplastic BCS requires combined skills, knowledge, and understanding of both oncological and plastic surgeries, which may be optimally achieved by an oncoplastic surgeon.

Versatility of therapeutic reduction mammoplasty in oncoplastic breast conserving surgery

Oncoplastic breast conserving surgery is the gold standard approach for the surgical treatment of early breast cancer. There is a well defined technique named “therapeutic mammoplasty” which is characterized for using a reduction mammaplasty technique to treat breast cancer conservatively. In our current practice, “therapeutic mammoplasty” or therapeutic reduction mammaplasty is our favorite oncoplastic breast conserving approach which it used in almost half of our patients. This technique is very versatile allows us the resection of tumors located in all breast quadrants of patients with moderate-to large-sized breasts. We describe a series of 57 patients who were treated using a therapeutic reduction mammaplasty. All surgical procedures were carried out by one comprehensive breast surgeon who planned and designed the surgery performing both oncologic and reconstructive procedures. Surgical margins were insufficient in eight patients (14%). Nine patients (15.8%) had a complication in early postoperative period and in one of them adjuvant radiotherapy was delayed four months due to a wound dehiscence. The rate of synchronous contralateral symmetrization was 31.6%. Our conclusion is that reduction mammaplasty is a useful and safe skill to treat breast cancer conservatively playing a very important role therefore it must be situated in the priority of learning objectives.

Oncoplastic surgery and radiation therapy for breast conservation: early outcomes

PURPOSE

To analyze a multidisciplinary community experience with oncoplastic breast surgery (OBS) and postoperative radiation therapy (RT).

METHODS

The records of 79 patients with localized breast cancer who underwent OBS+RT were reviewed. OBS included immediate reconstruction and contralateral mammoreduction. All patients had negative surgical margins. Whole-breast RT was delivered without boost. A subset of 44 patients agreed to complete a validated quality of life survey pre-RT, post-RT, 6 months after RT, and at final follow-up assessing cosmesis and treatment satisfaction.

RESULTS

Sixty-seven patients (85%) were white. Median age was 62 years. Median interval between OBS and RT start was 9.6 weeks. Median RT dose was 46 Gy. Fourteen patients (18%) developed surgical toxicities before RT. Five patients (6%) developed RT toxicities. Physician rating of cosmesis post-RT was: 3% excellent, 94% good, and 4% fair. Cosmesis was rated as excellent or good by 87% of patients pre-RT, 82% post-RT, 75% at 6 months, and 88% at the final follow-up. Treatment satisfaction was rated as "total" or "somewhat" by 97% of patients pre-RT, 93% post-RT, 75% at 6 months, and 96% at final follow-up. No significant relation was found between patient or treatment-related factors and toxicity. Local control is 100% at median follow-up of 2.9 years.

CONCLUSIONS

OBS followed by RT resulted in acceptable toxicity and favorable physician-rated cosmesis in this large community series. Patients' ratings of cosmesis and treatment satisfaction were initially high, decreasing at 6 months, returning near baseline at final follow-up.

Reexcision for positive margins in breast cancer: A predictive score of residual disease

BACKGROUND

Guidelines recommend re-excision if resection margins are positive in lumpectomy for breast cancer. However, residual disease (RD) is not always found. The aim of our study was to develop a score to predict RD in re-excision specimens.

MATERIALS AND METHODS

We carried out a multicenter, retrospective study with two population groups. The 'modeling' group was composed of 148 patients treated in the Centre Hospitalier Poissy-St-Germain or the Georges Pompidou European Hospital and the 'validation' group was composed of 67 patients treated in Curie Institute. The score was built with a logistic regression model.

RESULTS

Factors independently associated with RD were: a cumulative length of all positive margins>5 mm, invasion by ductal carcinoma in situ only, a pathological tumor size>30 mm and a pathological tumor size<30 mm with a discrepancy of >50% between pathological and radiological tumor size. The 7-point score allowed the classification of patients into three risk groups for RD: low (16% of patients experienced RD), moderate (65%) and high (100%). The areas under the ROC curve of the score and the logistic model were 0.72(95%CI:0.68-0.75,p = 0.60). The proportion of RD in each group of the validation population (25%, 48%, and 100% in the low, moderate and high group, respectively) confirmed the accuracy of the score in an independent population.

CONCLUSIONS

This score enables the identification of patients at high risk of RD but it cannot provide guidance for the decision to undertake re-excision surgery in the low-risk group. Further studies are needed to test the score in extensive datasets and better identify low-risk patients.