The role of reduction mammaplasty in oncology

Occult Pathologic Findings in Reduction Mammaplasty in 5781 Patients-An International Multicenter Study

Breast cancer is among the most commonly diagnosed cancers in the world, affecting one in eight women in their lifetimes. The disease places a substantial burden on healthcare systems in developed countries and often requires surgical correction. In spite of this, much of the breast cancer pathophysiology remains unknown, allowing for the cancer to develop to later stages prior to detection. Many women undergo reduction mammaplasties (RM) to adjust breast size, with over 500,000 operations being performed annually. Tissue samples from such procedures have drawn interest recently, with studies attempting to garner a better understanding of breast cancer’s development. A number of samples have revealed nascent cancer developments that were previously undetected and unexpected. Investigating these so-called “occult” findings of cancer in otherwise healthy patients may provide further insight regarding risk factors and countermeasures. Here, we detail occult findings of cancer in reduction mammaplasty samples provided from a cohort of over 5000 patients from 16 different institutions in Europe. Although the majority of our resected breast tissue specimens were benign, our findings indicate that there is a continued need for histopathological examination. As a result, our study suggests that preoperative imaging should be routinely performed in patients scheduled for RM, especially those with risk factors of breast cancer, to identify and enable a primary oncologic approach.

[An original oncoplastic reduction mammaplasty technique for breast cancers with high risk of incomplete excision]

Oncoplastic reduction mammaplasty (ORM), like breast-conserving treatments for cancer, has a risk of incomplete excision, and sometimes requires complementary mastectomy. In that case difficulties may occur due to skin shortness induced by recent surgery. Review of bibliography brings evidence that some factors are predictive of incomplete excision. When a patient has one or more of these factors, surgeon should anticipate complementary mastectomy. Horizontal ORM should be reminded for they allow secondary mastectomy in a horizontal way to be performed. An adaptation of the inverted T pattern is proposed, also permitting mastectomy in a horizontal way. These solutions allow neither to alter skin healing nor to compromise the future breast reconstruction.

Incidence of occult contralateral carcinomas of the breast following mastoplasty aimed at symmetrization

INTRODUCTION

Breast carcinomas are the most frequent form of cancer in French women. Following a total mastectomy, only an estimated 25% of patients wish to undergo breast reconstruction. After mammary volume reconstitution, the plastic surgeon often attempts to harmonize the two breasts by carrying out contralateral reduction mammaplasty (CRM). In the literature, the incidence of occult contralateral carcinomas incidentally discovered in surgical specimens ranges from 1.12 to 4.5%. The main objective of this study was to evaluate occurrence of carcinoma in the CRM specimens in the framework of a breast reconstruction operation. The secondary objective was to determine the consequences of the incidentally discovered carcinoma in the contralateral breast.

MATERIAL AND METHODS

This was a 6-year, bicentric, retrospective study involving women having undergone breast cancer surgery who later underwent contralateral reduction mammaplasty (CRM), that is to say reconstruction aimed at harmonization of the two breasts.

RESULTS

Three hundred and nineteen patients were included in the study. Mean age during the CRM was 55years (29-79). Mean weight of the surgical specimens was 323grams (12-2500). Incidence of occult carcinomas found in the specimens was 0.94% (3 patients). The mean age for these 3 cases was 58years (47-64). All 3 patients had superior pedicle mammaplasty. One of the patients benefited from monobloc resection with orientation of the surgical specimen. In the other 2 cases, there existed 3 surgical resection specimens; in one case, they were oriented; in the other, they were not. In all 3 cases, the histological findings were unifocal ductal carcinomas in situ (DCIS). Mean tumor size was 5.7mm (3-9). Only the patient having had monobloc resection with orientation of the specimen underwent salvage surgery, which consisted in partial mastectomy, otherwise known as secondary lumpectomy. Adjuvant radiotherapy was administered to all of the patients. After 17months of mean follow-up (12-22), no recurrence was found in any of the three cases.

CONCLUSION

Incidence of occult contralateral breast carcinomas after symmetrization CRM approximates 1%. Our observations are in agreement with the data in the literature. Incidence is greater than in mammaplasty carried out for esthetic or functional reasons; this is probably due to the higher age and the previous breast cancer history of the breast reconstruction population. Monobloc resection and orientation of the surgical specimens with surgeon's knots facilitate precise pinpointing of the occult carcinoma. A secondary lumpectomy may take place when margins of excision are invaded or inadequate.

Update on breast reconstruction techniques and indications

Breast reconstruction is considered as part of the breast cancer treatment when a mastectomy is required. Implants or expanders are the most frequent techniques used for the reconstructions. Expander provides usually a better symmetry. A contralateral mastoplasty often is required to improve the symmetry. The nipple areola complex, which can be preserved in certain conditions, is usually removed and can be reconstructed in a second stage under local anesthesia. In case of radical mastectomy and/or radiotherapy, a musculocutaneous flap, such as rectus abdominis or latissimus dorsi autologous flaps, is required. When microsurgical facilities are available, free or perforator flaps respecting the muscle are preferred to decrease the donor site complications. In situ carcinomas or prophylactic mastectomy can be reconstructed immediately as well as invasive carcinoma according to the recent literature. Locally advanced breast cancer can be reconstructed after complete oncologic treatment. Radiotherapy of the thoracic wall is proposed in case of lymph node metastases, raising the discussion about the technique choice and the timing of the reconstruction. Plastic surgery procedures can improve the cosmetic results of the conservative surgery, also extending its indications and reducing both mastectomy and reexcision rates. Oncoplasty techniques are becoming more and more sophisticated, requiring the skill of trained plastic surgeons. Numerous publications confirm the psychosocial benefit resulting from the breast reconstruction.

Oncoplastic surgery: the evolution of breast cancer treatment

Oncoplastic surgery is an establish approach that combines conserving treatment for breast cancer and plastic surgery techniques. It allows wide excisions and prevents breast deformities by immediate reconstruction of large resection defects. The procedures are mostly useful for resection of 20-40% of the breast - a group of patients normally treated by mastectomy in the past. Four features are integral to oncoplastic breast surgery: (i) Appropriate surgery for cancer excision. (ii) Partial reconstruction to correct wide excision defects. (iii) Immediate reconstruction with the full range of available techniques. (iv) Correction of volume and shape asymmetries relative to the contra-lateral healthy breast. There are two fundamentally different approaches: (i) volume-replacement procedures, which combine resection with immediate reconstruction by using local flaps (glandular, fasciocutaneous, and latissimus dorsi mini-flaps), and (ii) volume-displacement procedures, which combine resection with a variety of different breast reduction and reshaping techniques, according to the location of the tumor. Oncoplastic surgery increases the oncological safety of breast-conserving treatment because a much larger breast volume can be excised and wider surgical margins can be achieved. Moreover, a "surgical screening" of the contra-lateral breast allows the diagnosis of occult cancers. Among oncoplastic approaches, a very unique technique is the possibility of implant use (augmentation mammaplasty) in case of quadrantectomy and simultaneous delivery of intraoperative radiotherapy to the tumor bed.

Assessment of immediate conservative breast surgery reconstruction: a classification system of defects revisited and an algorithm for selecting the appropriate technique

BACKGROUND

Although various techniques have been used for breast conservation surgery reconstruction, there are few studies describing a logical approach to reconstruction of these defects. The objectives of this study were to establish a classification system for partial breast defects and to develop a reconstructive algorithm.

METHODS

The authors reviewed a 7-year experience with 209 immediate breast conservation surgery reconstructions. Mean follow-up was 31 months. Type I defects include tissue resection in smaller breasts (bra size A/B), including type IA, which involves minimal defects that do not cause distortion; type IB, which involves moderate defects that cause moderate distortion; and type IC, which involves large defects that cause significant deformities. Type II includes tissue resection in medium-sized breasts with or without ptosis (bra size C), and type III includes tissue resection in large breasts with ptosis (bra size D).

RESULTS

Eighteen percent of patients presented type I, where a lateral thoracodorsal flap and a latissimus dorsi flap were performed in 68 percent. Forty-five percent presented type II defects, where bilateral mastopexy was performed in 52 percent. Thirty-seven percent of patients presented type III distortion, where bilateral reduction mammaplasty was performed in 67 percent. Thirty-five percent of patients presented complications, and most were minor.

CONCLUSIONS

An algorithm based on breast size in relation to tumor location and extension of resection can be followed to determine the best approach to reconstruction. The authors' results have demonstrated that the complications were similar to those in other clinical series. Success depends on patient selection, coordinated planning with the oncologic surgeon, and careful intraoperative management.

Management algorithm and outcome evaluation of partial mastectomy defects treated using reduction or mastopexy techniques

BACKGROUND

Reconstruction of the partial mastectomy defect has become increasingly popular because of poor cosmetic results in select patients. The purpose of this series was to try to create a treatment algorithm based on patient selection, diagnosis, margins, and recurrence in an attempt to maintain oncologic safety, as well as to improve esthetic outcome.

METHODS

A retrospective review of all patients treated at Emory University Hospital with partial mastectomy and reduction/mastopexy was performed. Reconstruction was performed either simultaneously or following confirmation of negative histologic margins.

RESULTS

Sixty-three women were included in the series. Histology was invasive carcinoma (n = 33), ductal carcinoma in situ (DCIS) (n = 20), fibroadenoma (n = 6), and benign breast tissue (n = 4). The Wise pattern was used 84% of the time (n = 53/63). The most common tumor location was upper outer quadrant, and the various pedicles used were superomedial (n = 22), inferior (n = 20), central (n = 7), and other (n = 14). Eight patients had reduction/mastopexy once final pathology confirmed negative margins. The average biopsy weight was 236 g. Total specimen weight on the tumor side was 762 g and 858 g on the contralateral side, to accommodate for radiation fibrosis. Immediate complications were seen in 22% of cases and included delayed healing (n = 9), infection (n = 1), partial nipple loss (n = 1), hematoma (n = 1), and skin necrosis (n = 1). In patients with breast cancer (n = 53), 26% required either fine needle aspiration or excisional biopsy for cancer surveillance postoperatively. Oncoplastic surgery was the definitive procedure 93% of the time. Completion mastectomy with reconstruction was required in 4 patients, 3 for positive margins extensive DCIS and 1 for residual microcalcifications (stereobiopsy DCIS) despite adequate specimen radiograph and negative margins initially. All 4 patients who failed the combined approach were younger women with the diagnosis of extensive DCIS. The locoregional recurrence rate was 2%, and all patients had no evidence of disease at an average follow-up of 3.25 years.

CONCLUSION

Therapeutic mammaplasty is a useful procedure for shape and symmetry preservation in women with large or ptotic breasts. Versatility exists using various pedicles and skin patterns to reconstruct all breast shapes and defect locations. Younger patients with extensive DCIS are poor candidates for simultaneous reconstruction, and should be deferred until confirmation of negative margins. If surgical management of residual disease requires completion mastectomy, immediate reconstruction is possible, with skin preservation and no adverse effects.

Reliability of inferior dermoglandular pedicle reduction mammaplasty in reconstruction of partial mastectomy defects: surgical planning and outcome

The objective of this study is to describe the surgical planning of the inferior dermoglandular pedicle (IDP) technique and its outcome following partial mastectomy reconstruction. A total of 26 patients with breast cancer underwent immediate IDP reconstruction. IDP was indicated to reconstruct superior/central breast defects. Postoperative complications were evaluated and information on esthetic result and satisfaction were collected. About 57.6 percent had tumors measuring 2cm or less (T1). Immediate complications occurred in 34.2 percent with skin necrosis in 11.4 and dehiscence in 7.6 percent. Late complications were observed in 11.4 percent. The cosmetic result was considered to be good or very good in 88.4 percent and the majority of patients were satisfied. All complications were treated by conservative approach. IDP is a reliable technique and should be given consideration in cases of superior/central quadrant reconstruction. The success of the procedure depends on patient selection and careful intra-operative management.

Long-term oncological results of breast conservative treatment with oncoplastic surgery

Oncoplastic surgery combining breast conservative treatment (BCT) and plastic surgery techniques may allow more extensive breast resections and improve aesthetic outcomes, but no long-term oncological results have been published. Long-term oncologic results of 148 consecutive BCT with concomitant bilateral plastic surgery have been analysed and were compared to historical data of BCT trials. Median follow-up was 74 months. Complete excision was obtained in 135 patients (91%); focally involved margins in 8 (5%); and close (<2 mm) margins in 5 (3%). Five patients developed ipsilateral recurrence (3%), 19 (13%) developed distant metastasis and 11 patients died (7.53%). Patients with tumours larger than 2 cm were at greater risk of local recurrences and distant metastasis. Long-term oncologic results of BCT with oncoplastic surgery are comparable with the results of BCT randomized trials.

Technical tricks to improve the cosmetic results of breast-conserving treatment

The paper describes different manoeuvres and surgical details that may help the general surgeon to improve the aesthetic outcomes after breast-conserving treatment for cancer. Among them, the pre-operative planning, the position of the patient in the operative room, the mobilisation of the glandular tissue when the tumour has been removed. All these manoeuvres contribute to achieving better symmetry with the healthy breast and to improve the final aesthetic result, minimising the surgical conflict between large resections and defects for optimal control of local disease and the consequent breast deformities.

Symmetrization reduction mammaplasty combined with sentinel node biopsy in patients operated for contralateral breast cancer

BACKGROUND AND OBJECTIVES

Occult invasive cancer found in reduction mammaplasty specimen in the contralateral breast in breast cancer patients requires axillary lymph node dissection (ALND) to assess the lymph node status. Routine Sentinel node (SN) biopsy in these patients may avoid secondary ALND when an occult cancer is found and the SN is negative in the permanent histological examination.

METHODS

One hundred sixty-nine breast cancer patients underwent contralateral reduction mammaplasty for symmetrization and with SN biopsy of the non-cancer breast. SN mapping was done using a vital blue dye alone (n = 136) or in combination with a radiocolloid (n = 33).

RESULTS

A mean number of 1.4 SNs (range 1-3 SNs) was identified in 158 of 169 patients (identification rate 93.5%). One of 158 patients revealed a positive SN but no tumor was found in the reduction mammaplasty/mastectomy specimen, whereas the SN was negative in 157 patients. Histological examination of the 169 reduction mammaplasty specimen revealed 5 occult invasive cancers and 4 patients with high grade DCIS but due to a negative SN biopsy the patients were spared a secondary ALND.

CONCLUSION

The small number of patients with occult contralateral cancers may not warrant routine SN mapping in patients scheduled for contralateral reduction mammaplasty.

Determining the optimal approach to breast reconstruction after partial mastectomy

BACKGROUND

Unfortunately, patients who desire repair of contour deformities after partial mastectomy usually present after radiation therapy, which may increase the risk of complications and result in a poor aesthetic outcome. The authors reviewed their experience with repair of partial mastectomy defects to determine the optimal approach to breast reconstruction after partial mastectomy.

METHODS

Sixty-nine patients who underwent repair of a partial mastectomy defect and received radiation therapy were included in this analysis. The reconstructive techniques were categorized as local tissue rearrangement (LTR), breast reduction, or use of a latissimus dorsi myocutaneous flap or thoracoepigastric skin flap (hereafter referred to as "flap").

RESULTS

Fifty patients underwent immediate reconstruction before radiation therapy, and 19 underwent delayed reconstruction after radiation therapy. The reconstructive techniques in patients with immediate reconstruction were local tissue rearrangement in 28 percent, breast reduction in 66 percent, and flaps in 6 percent. In patients with delayed reconstruction, 32 percent had local tissue rearrangement, 42 percent had breast reduction, and 26 percent had flaps. The complication rates for immediate and delayed reconstruction were 26 percent and 42 percent, respectively. Overall, and in the setting of immediate reconstruction, the flap technique was associated with a higher complication rate than local tissue rearrangement and breast reduction. However, in the setting of delayed reconstruction, the flap technique was associated with a lower complication rate than the other two techniques. Fifty-seven percent of the immediate reconstructions performed with the local tissue rearrangement or breast reduction technique, but only 33 percent of the immediate reconstructions performed with the flap technique, were associated with an excellent or good aesthetic outcome.

CONCLUSION

Immediate repair of partial mastectomy defects with local tissues results in a lower risk of complications and better aesthetic outcomes than immediate repair of partial mastectomy defects with a latissimus dorsi flap.

Comparative study of surgical margins in oncoplastic surgery and quadrantectomy in breast cancer

BACKGROUND

Oncoplastic surgery for breast cancer is a novel concept that combines a plastic surgical procedure with breast-conserving treatment to improve the final cosmetic results. The aim of this study was to evaluate the oncological safety of oncoplastic procedures by studying the status of the surgical margins of the excised tumor specimen in comparison with standard quadrantectomies.

METHODS

Thirty consecutive breast cancer patients undergoing oncoplastic surgery (group 1) and 30 patients undergoing standard quadrantectomy (group 2) were prospectively studied with regard to the stage of breast cancer, the surgical procedures performed, the volume of breast tissue excised, and the histopathology of the tumor specimen, with specific details on surgical margins.

RESULTS

Patients who underwent oncoplastic surgery (group 1) were younger (mean age, 48.73 years) than patients who had a classic quadrantectomy (group 2; mean age, 55.76 years; P = .022). The mean volume of the excised specimen in group 1 was 200.18 cm(3), compared with 117.55 cm(3) in group 2 (P = .016). Surgical margins were negative in 25 cases out of 30 in group 1 and 17 out of 30 in group 2 (P = .05). The average length of the surgical margin was 8.5 mm in group 1 and 6.5 mm in group 2, but the difference was not statistically significant (P = .074).

CONCLUSIONS

Oncoplastic surgery adds to the oncological safety of breast-conserving treatment because a larger volume of breast tissue can be excised and a wider negative margin can be obtained. It is especially indicated for large tumors, for which standard breast-conserving treatment has a high probability of leaving positive margins.

Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas

OBJECTIVE

To assess the oncologic and cosmetic outcomes in women with breast carcinoma who were treated with breast-conserving therapy using oncoplastic techniques with concomitant symmetrization of the contralateral breast.

SUMMARY BACKGROUND DATA

Although breast-conserving therapy is the standard form of treatment for invasive breast tumors up to 4 cm, in patients with large, ill-defined, or poorly situated tumors, cosmetic results can be poor and clear resection margins difficult to obtain. The integration of oncoplastic techniques with a concomitant contralateral symmetrization procedure is a novel surgical approach that allows wide excisions and prevents breast deformities.

METHODS

This is a prospective study of 101 patients who were operated on for breast carcinoma between July 1985 and June 1999 at the Institut Curie. The procedure was proposed for patients in whom conservative treatment was possible on oncologic grounds but where a standard lumpectomy would have led to poor cosmesis. Standard institutional treatment protocols were followed. All patients received either pre- or postoperative radiotherapy. Seventeen patients received preoperative chemotherapy to downsize their tumors. Mean follow-up was 3.8 years. Results were analyzed statistically using Kaplan-Meier estimates.

RESULTS

Mean weight of excised material on the tumor side was 222 g. The actuarial 5-year local recurrence rate was 9.4%, the overall survival rate was 95.7%, and the metastasis-free survival rate was 82.8%. Cosmesis was favorable in 82% of cases. Preoperative radiotherapy resulted in worse cosmesis than when given postoperatively.

CONCLUSIONS

The use of oncoplastic techniques and concomitant symmetrization of the contralateral breast allows extensive resections for conservative treatment of breast carcinoma and results in favorable oncologic and esthetic outcomes. This approach might be useful in extending the indications for conservative therapy.

Breast reconstructive techniques in cancer patients: which ones, when to apply, which immediate and long term risks?

Breast reconstruction is considered as part of the breast cancer treatment when a mastectomy is required. The techniques available today, allow reconstruction of the breast even in almost all the cases even in poor local conditions. In 60-70% of the cases, the reconstruction can be performed with an implant inserted behind the pectoralis muscle. Special implants called expanders, are inflatable progressively in the postoperative course thanks to a reservoir located subcutaneously. They provide a progressive distention of the teguments and a more natural shape after substitution of the expander with a definitive implant. The symmetry is usually obtained thanks to a contralateral plastic surgery, which allows at the same time histological check up of the glandular tissue of the opposite breast. The nipple areolar complex is usually reconstructed in a second stage under local anesthesia, using local flaps for the nipple and a tattoo for the colour of the areola. In 30% of the cases, especially after radiotherapy when a salvage mastectomy is required, a flap reconstruction is preferred. The autologous tissue reconstruction with the rectus myocutaneous flap gives excellent cosmetic results and the most natural shape for the breast. But it is a more demanding technique requiring a good experience. In some occasions, the reconstruction with the latissimus flap can also be autologous but usually requires the addition of prosthesis. In most cases, the reconstruction can be performed immediately. The delayed reconstruction is usually preferred when the adjuvant chemotherapy should be delivered as soon as possible after the mastectomy. Complications of the reconstruction such as local necrosis or infections, leading to implant removal or revision of the flap could be detrimental to the patient in delaying the start of the chemotherapy. It is not recommended to reconstruct the breast immediately in case of locally advanced breast cancer. Partial breast reconstruction using plastic surgery procedures can also be performed in case of quadrantectomy in order to obtain a better cosmetic result. Local glandular flaps, as well as specific incisions according to the location of the tumor in the breast allow the reshaping of the breast even in case of large resection and, therefore, provide an opportunity to increase the number of conservative treatment indications, especially in case of in-situ carcinomas.

Integration of plastic surgery in the course of breast-conserving surgery for cancer to improve cosmetic results and radicality of tumor excision

Integration of plastic surgery is currently widely practiced in cases of mastectomy. Immediate breast reconstruction with an implant or autologous tissue procedures is frequently proposed to the patient before the mastectomy. However, breast conserving surgery (BCS) is recognized as the treatment of choice in most cancers: breast conservation is proposed in more than 70% of the patients with primary cancer treated at the European Institute of Oncology in Milan. This high percentage of preservation has been made possible by the integration of plastic surgery at the time of primary surgery. The size of the tumorectomy remains a matter of discussion. Based on the Milan II trial and Holland's pathological studies, Veronesi recommended so-called "local radical surgery." For a tumor 1 cm in size, a free margin of 2 cm produces a final specimen at least 5-6 cm in diameter. In small or medium-sized breasts, such a resection results in a wide glandular defect and poor esthetic results if direct closure is carried out. Plastic surgery derived from reduction mammaplasty procedures allows much better final cosmetic results, which is the goal of conservative treatment. In 25% of our patients treated with BCS, the plastic surgeon is called upon by the general surgeon to close the glandular defect. However, such glandular remodeling changes the size and position of the breast. Therefore, in 15% of these cases a symmetry procedure is performed on the opposite breast. The reduction procedure in the opposite breast should be taken as a good opportunity to check the glandular tissue. Special attention should therefore be given to the contralateral mammogram in order to focus the glandular resection on the most dubious areas. Occult carcinomas, half of them infiltrating, were found in 4% of a series of 350 symmetry procedures performed during breast reconstruction at the Gustave Roussy Cancer Institute. In conclusion, close collaboration between oncologists and plastic surgeons is required not only to obtain the best cosmetic results but also to allow improved radicality of the tumor resection and a histological check-up of the contralateral breast.