Oncoplastic surgery in breast conservation: a prospective evaluation of the patients, techniques, and oncologic outcomes

Comparison of Long-Term Oncological Outcomes in Oncoplastic Breast Surgery and Conventional Breast-Conserving Surgery for Breast Cancer: A Propensity Score-Matched Analysis

PURPOSE

The oncoplastic breast-conserving surgery (OPS) technique, combined with the principles of oncological safety and plastic surgery, results in complete tumor resection while preserving the natural appearance of the breast. The purpose of this study was to evaluate the long-term oncological results after OPS compared with conventional breast-conserving surgery (BCS) for early breast cancer.

METHODS

The medical records of patients who underwent breast cancer surgery and adjuvant radiation therapy at Seoul National University Hospital between 2011 and 2014 were reviewed. Ipsilateral breast tumor recurrence (IBTR)-free survival rate and recurrence-free survival (RFS) rates were compared between the OPS and BCS groups.

RESULTS

One-to-one propensity score matching was conducted, yielding 371 patients in each group. The mean tumor distance from the nipple was shorter, and the mean retrieved specimen size and pathologic tumor size, including ductal carcinoma in situ, were larger in the OPS group than in the conventional BCS group (p < 0.001). Surgical margin positivity was not significantly different between the two groups (p = 0.777). The surgical technique was not significantly associated with IBTR (OPS versus conventional BCS, 5-year survival rate, 96.9% vs. 98.6%; p = 0.355) and RFS (5-year survival rate, 92.9% vs. 94.5%; p = 0.357) on the log-rank test. Multivariate analysis revealed that OPS versus conventional BCS was not significantly associated with survival outcomes.

CONCLUSION

We observed no significant differences in long-term IBTR and RFS between the OPS and conventional BCS groups in this retrospective analysis. OPS can be an oncologically and surgically safe alternative option for conventional BCS for early breast cancer.

Outcome reporting in therapeutic mammaplasty: a systematic review

Background

Therapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated the oncological safety of TM but reporting of critically important outcomes, such as quality of life, aesthetic and functional outcomes, are limited, piecemeal or inconsistent. This systematic review aimed to identify all outcomes reported in clinical studies of TM to facilitate development of a core outcome set.

Methods

Medline, EMBASE, CINAHL and Web of Science were searched from inception to 5 August 2020. Included studies reported clinical outcomes following TM for adult women. Two authors screened articles independently for eligibility. Data were extracted regarding the outcome definition and classification type (for example, oncological, quality of life, etc.), time of outcome reporting and measurement tools.

Results

Of 5709 de-duplicated records, 148 were included in the narrative synthesis. The majority of studies (n = 102, 68.9 per cent) reported measures of survival and/or recurrence; approximately three-quarters (n = 75, 73.5 per cent) had less than 5 years follow-up. Aesthetic outcome was reported in half of studies (n = 75, 50.7 per cent) using mainly subjective, non-validated measurement tools. The time point at which aesthetic assessment was conducted was highly variable, and only defined in 48 (64.0 per cent) studies and none included a preoperative baseline for comparison. Few studies reported quality of life (n = 30, 20.3 per cent), functional outcomes (n = 5, 3.4 per cent) or resource use (n = 28, 18.9 per cent).

Conclusion

Given the oncological equivalence of TM and mastectomy, treatment decisions are often driven by aesthetic and functional outcomes, which are infrequently and inconsistently reported with non-validated measurement tools.

Oncoplastic Repair in Breast Conservation: Comprehensive Evaluation of Techniques and Oncologic Outcomes of 937 Patients

BACKGROUND

Breast-conserving surgery, especially with oncoplastic breast surgery (OBS), is becoming the standard of care in the surgical management of breast cancer. We investigated the applied technique of OBS and oncologic outcomes in a large series of patients.

PATIENTS AND METHODS

This study was conducted between January 2008 and June 2018 in two centers in Iran. Patients underwent OBS. Early and late postoperative complications, oncologic outcomes, and follow-up data were documented.

RESULTS

Nine hundred thirty-seven patients with a mean ± standard deviation age of 48.1 ± 11.3 underwent OBS. Most of the patients were diagnosed with early-stage disease, of which the most common pathology was invasive ductal carcinoma (83.3%). Lateral oncoplasty was the most commonly used OBS technique (324 cases, 34.6%). The most common complication was seroma formation. Reduction-type OBS technique had the highest rate of complications (13.1%). Thirty-four patients (5.4%) experienced local recurrence, with a median recurrence time of 26.4 months. Nine patients (1.3%) died from cancer recurrence.

CONCLUSION

OBS is a safe procedure with minor complications and good oncologic outcomes. These techniques can be applied to most patients who are candidates for breast-conserving surgery.

Increasing Role of Oncoplastic Surgery for Breast Cancer

PURPOSE OF REVIEW

The goals of surgery for breast cancer have remained the same over the years, to eliminate breast cancer from the breast with the least degree of deformity. With the current expectation of long-term survival after breast cancer treatment, more attention has turned to the cosmetic result of the surgical treatment. Whether lumpectomy or mastectomy, the need for aesthetic improvement was recognized by surgeons both in and outside the USA.

RECENT FINDINGS

Oncoplastic surgery combines the skills of the cancer surgeon with those of the plastic surgeon. Sometimes, this means a team approach with a breast surgeon and a plastic surgeon both performing their mutual skills for the patient. Other times, the properly trained breast surgeon may perform some of the plastic techniques at the time of cancer surgery. Breast surgeons are rapidly gaining the ability to improve the post-cancer treatment appearance. To simplify the classification of oncoplastic techniques, we have used lower level, upper level, and highest level. The assignment of techniques to levels is based on both the technique and the surgeon's training and experience. Much data has accumulated demonstrating the safety and efficacy of the "aesthetic cancer cure." We describe the development of oncoplastic surgery, the techniques available, matching the right candidate with the right technique, and some comments about the future. It is clear from both clinical benefit and patient satisfaction that oncoplastic breast cancer procedures are here to stay. Plastic surgeons will likely focus on the upper- and highest-level procedures while breast/general surgeons will learn lower-level procedures and some of upper-level procedures as needed by their locale. Opportunities to educate breast/general surgeons in these techniques will continue to increase over the next several years. Formal education in oncoplastic surgery during breast fellowships will be necessary to catch up with the rest of the surgical world outside the USA.

Visualized oncoplastic surgery of the breast I: inferior and medial quadrantectomy

Surgical treatment of breast cancer has changed during the last few decades. Long-term evaluation of several studies performed worldwide have confirmed that conservative surgery (CS) and radical mastectomy have similar survival rates. Due to CS being the gold standard for treatment for most women with breast cancer, advances in materials, mastectomy and reconstructive surgery techniques, now give us the possibility to perform on our patients a great outcome with oncological security. Both advances, in plastic and oncologic surgery, created a new discipline, called oncoplastic breast surgery, that allow surgeons to resect large breast specimens preventing subsequent deformities with the correct previous planning. This is particularly important when more than 30% of the breast volume will be resected because it allows for planning CS depending on the site of the lesion and for establishing the limits between CS and mastectomy.

A Novel Level I Oncoplastic Surgery Technique for Tumors Located in UIQ of the Breast Far from the Nipple: The "Cross" Technique

Breast surgery was revolutionized with the use of oncoplastic reshaping techniques minimizing breast deformities and esthetic complications. However, the application of the current oncoplastic techniques becomes challenging in some situations such as small-size breasts and when the tumors are located in special locations of the breast, for example, upper inner quadrant. In this article, an optimized oncoplastic technique named the "Cross" technique is introduced to overcome the abovementioned problems in the surgery of breast tumors located in the upper inner quadrant far from the center of the breast. Nineteen oncoplastic surgeries were performed by the same breast surgeon. The mean diameter and weight of the excised specimens were 20 mm and 74 g. The mean age of the patients was 51 years. Clear surgical margins were obtained in all patients. There was no marked deformity in the breast after surgery. The optimized technique produced promising results in our hands when applied to a selected group of patients. Moreover, the technique was found to reduce the need for revision surgery in ptotic breasts, as the alteration in the shape of the breast undergoing surgery is not significant enough to introduce asymmetry to the breasts.

Idiopathic granulomatous mastitis: A systematic review of 3060 patients

Idiopathic granulomatous mastitis is a rare benign breast disease. A systematic review was designed. Clinical and therapeutic characteristics were analyzed. Human Development Index (HDI) was used to define two groups of study: group A (very high and high HDI) and group B (medium and low HDI). Corticosteroid therapy was done in 69% group A and 78% group B. Surgery was done in 63% in group A and 83% in group B. Antibiotics were used in 68% group A and 88% group B. There is no consensus about optimal treatment for granulomatous mastitis.

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.

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.

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

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The size of tumors were bigger than other series.

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

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

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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.

Evaluation of therapeutic mammoplasty techniques in the surgical management of female patients with idiopathic granulomatous mastitis with mild to moderate inflammatory symptoms in terms of recurrence and patients' satisfaction

BACKGROUND

Although idiopathic granulomatous mastitis (IGM) affects young females, its surgical management usually leads to disfigurement of the breasts.

OBJECTIVES

To assess the use of therapeutic mammoplasty techniques for management of IGM in terms of recurrence and postoperative patients' satisfaction.

METHODS

This prospective clinical study included thirteen patients who were diagnosed histologically as IGM. Patients with moderate to large breasts, who had a breast mass between 20-50% of the breast size with failed medical treatment or intolerability to steroids were subjected to therapeutic mammoplasty techniques. Only patients with large breasts were offered contra-lateral reduction mammoplasty to resume symmetry and achieve better aesthetic results.

RESULTS

Early postoperative bleeding that was encountered in one patient (7.7%) was the only serious postoperative complication. Patient was re-operated and the bleeder was secured. Recurrence occurred in 2 patients (15.4%) at 16 and 24 months after the operation. Kyungpook National University Hospital (KNUH) breast reconstruction satisfaction questionnaire used to assess patients' satisfaction 6 months after the operation and revealed that 10 patients (76.9%) were satisfied after the operation.

CONCLUSION

Using therapeutic mammoplasty techniques in surgical management of IGM in moderate to large breasts seems justifiable with good results regarding recurrence and postoperative patients' satisfaction.