Oncoplastic breast surgery – A guide to good practice

Training in oncoplastic surgery for mastologists

OBJECTIVE

The radical change in the treatment of breast cancer has promoted the necessity for more comprehensive training of the professionals involved, ensuring the preservation of oncological safety while also allowing for cosmetic interventions to benefit breast cancer survivors. The aim of this study was to present the methods employed in the training of breast surgeons, highlighting the importance of oncoplasty and breast reconstruction.

METHODS

A literature review was conducted in two databases, identifying articles related to medical education in the context of oncoplastic surgery and breast reconstruction. We also assessed the Brazilian experience in oncoplastic centers.

RESULTS

The basis for educational discussions was derived from 16 articles. We observed approaches that included hands-on courses utilizing simulator models, porcine models, cadaver labs, and fellowship programs. Positive outcomes were observed in Brazil, a fact based on seven oncoplasty training centers for senior mastologists and five training centers for junior mastologists. From 2009 to 2023, an estimated 452 seniors and 42 juniors received training, representing approximately 30% of mastologists in Brazil who have acquired training and experience in oncoplasty.

CONCLUSION

Despite the limited number of publications on training methods, oncoplastic centers have made significant progress in Brazil, establishing a successful model that can be replicated in other countries.

Dermoglandular advancement-rotation flap for conservative treatment of breast cancer - description of technique, objective and subjective assessments

Objective

to describe and evaluate the dermoglandular advancement-rotation flap with no contralateral surgery as a technique for the conservative treatment of breast cancer when skin or a large proportion of gland requires resection.

Patients/Methods

14 patients with breast tumors with a mean size of 4.2 cm and need for skin resection. The resection area is included within an isosceles triangle, with its apex located on the areola, which is the pivot for rotation of a dermoglandular flap released through a lateral extension along that triangle base. Symmetry before and after radiotherapy was objectively assessed by authors using the BCCT.core software, as well as subjectively by three experts and patients themselves using the Harvard scale.

Results

Experts considered the breast symmetry results to be excellent/good for 85.7% of patients in the early post-operative period and 78.6% in the late post-operative period. Excellent/good ratings provided by BCCT.core software amounted to 78.6% of cases in the early post-operative period and 92.9% in the late post-operative period. Symmetry was rated as excellent/good by 100% of patients.

Conclusion

Dermoglandular advancement-rotation flap technique with no contralateral surgery provides good symmetry when a large proportion of skin or gland requires resection on breast conservative cancer treatment.

Modern Breast Cancer Surgery 1st Central-Eastern European Professional Consensus Statement on Breast Cancer

This text is based on the recommendations accepted by the 4th Hungarian Consensus Conference on Breast Cancer, modified on the basis of the international consultation and conference within the frames of the Central-Eastern European Academy of Oncology. The recommendations cover non-operative, intraoperative and postoperative diagnostics, determination of prognostic and predictive markers and the content of cytology and histology reports. Furthermore, they address some specific issues such as the current status of multigene molecular markers, the role of pathologists in clinical trials and prerequisites for their involvement, and some remarks about the future.

Evaluation of the Surgical Outcomes of Breast Oncoplastic Techniques Carried Out by a General Surgical Oncologist

Background 

With recent advances in different breast cancer treatment modalities, breast conservation surgery (BCS) has gained popularity and has become the mainstay for the treatment of early breast cancer. The model of dedicated breast surgeons working in breast units is standard in some but not all countries. We have aimed to define surgical outcomes of oncoplastic breast surgery carried out by one general surgical oncologist.

Patients and methods

We have conducted a prospective non-randomised case series analysis to assess the oncologic and aesthetic outcome of tissue displacement oncoplastic breast techniques in managing unifocal early-stage breast cancer from January 2019 to January 2020.

One surgical oncologist with 23 years of surgical oncology experience carried out all operations.

Results

We have included 50 female patients treated with variant oncoplastic volume displacement techniques. We have used the round block technique in 20%, the batwing technique in 18%, lateral mammoplasty in 20%, and medial mammoplasty in 2%. We have also carried out wise pattern therapeutic mammoplasty with inferior pedicle in 20% (10 patients), and vertical mammoplasty with superior pedicle in 20% (10 patients).

While 8% of our patients had Clavien-Dindo system grade I Immediate complications, including the surgical site infection and postoperative seroma and haematoma, 2% of patients had grade II complications in the form of partial areola and nipple complex necrosis leading to delayed wound healing requiring secondary suturing. No delayed complications or mortalities were recorded.

Eight per cent of patients required re-excision to clear margins, 74% had excellent results, 24% had good results, and 2% had fair results. In addition, 64% were very satisfied with their results, 32% were satisfied, while 4% were not satisfied with aesthetic results.

Conclusion

Based on our limited number of patients, we have found that tissue displacement oncoplastic techniques carried out by a general surgical oncologist are safe and reliable in providing satisfactory oncological outcomes with a low risk of delaying adjuvant therapy and acceptable aesthetic outcomes.

Aesthetic monitoring-based assessment of oncological safety of oncoplastic management of breast cancer: a multi-center research study

BACKGROUND

Oncoplastic Breast surgeries (OBS) in breast cancer have evolved to preserve the cancerous breast rather than its amputation to improve postoperative cosmetic results. The lack of evidence to support the oncological safety and benefits of OBS is questionable. In this study, we evaluate various aspects of oncoplastic surgeries with a focused monitoring of aesthetic results and oncological safety.

METHODS

This was a multi-center observational study focused on the statistics of data collected from cases who underwent oncoplastic surgeries from the cohort of breast cancer candidates at Mansoura University Hospitals/Egypt and King Faisal Medical Complex/KSA from January 2015 to June 2018. All data were analyzed carefully using SPSS v-26.

RESULTS

Eighty cases who underwent different oncoplastic surgeries were included and reviewed for the aesthetic outcome and oncological safety. The recurrence rate was found to be 2.5%. The breast impact treatment scale assessment method was used to analyze the aesthetic outcomes, and average scores were accepted in 90% of patients.

CONCLUSIONS

The oncoplastic breast surgeries are feasible and they had a high rate of oncological safety with the maintenance of good aesthetic outcomes and patient satisfaction.

Outcomes after mastectomy with immediate breast reconstruction for breast cancer in a multiethnic, middle-income Asian setting

BACKGROUND

Although immediate breast reconstruction is increasingly becoming popular worldwide, evidence from resource-limited settings is scarce. We investigated factors associated with immediate breast reconstruction in a multiethnic, middle-income Asian setting. Short-term surgical complications, timing of initiation of chemotherapy, and survival outcomes were compared between women undergoing mastectomy alone and their counterparts receiving immediate breast reconstruction.

METHODS

This historical cohort study included women who underwent mastectomy after diagnosis with stage 0 to stage IIIa breast cancer from 2011 to 2015 in a tertiary hospital. Multivariable regression analyses were used to assess factors associated with immediate breast reconstruction and to measure clinical outcomes.

RESULT

Out of 790 patients with early breast cancer who had undergone mastectomy, only 68 (8.6%) received immediate breast reconstruction. Immediate breast reconstruction was independently associated with younger age at diagnosis, recent calendar years, Chinese ethnicity, higher education level, and invasive ductal carcinomas. Although immediate breast reconstruction was associated with a higher risk of short-term local surgical complications (adjusted odds ratio: 3.58 [95% confidence interval 1.75-7.30]), there were no significant differences in terms of delay in initiation of chemotherapy, 5-year disease-free survival, and 5-year overall survival between both groups in the multivariable analyses.

CONCLUSION

Although associated with short-term surgical complications, immediate breast reconstruction after mastectomy does not appear to be associated with delays in initiation of chemotherapy, recurrence, or mortality after breast cancer. These findings are valuable in facilitating shared surgical decision-making, improving access to immediate breast reconstruction, and setting priorities for surgical trainings in middle-income settings.

Oncoplastic Breast-Conserving Surgery According to Tumor Location

The use of oncoplastic breast surgery is an essential cornerstone for breast cancer management. The main aim of breast cancer surgery is to obtain an adequate oncological safety margin. Still, the cosmetic outcome also seems important for social and psychological wellbeing and quality of life. After breast-conserving surgery, the remaining breast may be reconstructed with volume displacement or volume replacement techniques. A better cosmetic outcome can be achieved by selecting appropriate surgical techniques according to tumor location. In this review, we show each technique step-by-step based on the tumor's location for each quadrant. The most important thing is to select the technique first for oncological safety and then for better cosmesis.

Extreme Oncoplasty: Breast Conservation in Patients with Large, Multifocal, and Multicentric Breast Cancer

INTRODUCTION

Extreme Oncoplastic Breast Conservation Surgery (EOBCS) is offered in selected patients with multifocal or multicentric breast cancer (MFMC). Recent evidence has suggested that EOBCS may be a valuable resource for patients with MFMC who may avoid the risk associated with mastectomy in favour of the benefits of breast conservation without risking their oncological outcomes. Our study examined the practice of EOBCS in two regional breast units in Glasgow, United Kingdom.

MATERIALS AND METHODS

A prospectively collected database of 50 patients treated with EOBC in two breast units in Glasgow between 2007 and 2018 were evaluated, and clinical outcomes were observed.

RESULTS

Fifty patients (median age 55) underwent EOBCS, of which 43 (86%) had invasive disease. Median tumour size was 55mm (50-90) and multifocal disease was identified in 22 (44%) patients. Nine patients (18%) were found to have positive margins and underwent a second procedure, with 6 (12%) proceeding to mastectomy. Five-year disease free survival rate was 91.5%, while cancer-specific survival was 95.7%.

CONCLUSION

EOBCS is oncologically safe in short-term follow-up. Large scale studies are required to confirm these preliminary results, in order to offer EOBCS as a valid option to patients with advanced or multifocal breast cancer.

Oncological safety and postoperative complications in oncoplastic breast surgery among Asian women: A single institutional review

Oncoplastic breast surgery (OBS) improves margin clearance and produces good esthetic outcome in breast cancer treatment. This study evaluates the complications and outcome of OBS in a multiracial patient cohort. Data of 421 patients between 2011 and 2018 were analyzed. The majority were Malays (41.8%), followed by Chinese (39.7%) and Indians (16.8%). Low local complications were noted, with no significant differences in disease-free survival (P = .927) and overall survival (P = .719) between low and high OBS levels. Shared decision-making in offering OBS for Asian women has potential to become a practical option in breast cancer treatment.

Lateral Thoracodorsal Flap Revisited: An Underappreciated Workhorse

BACKGROUND

Although, the lateral thoracodorsal flap is a well described technique, its utility seems to be lost in the ever evolving world of oncoplastic breast surgery. This study reviews the technique, its indications and limitations and the advantage of this technique.

METHODS

Between January 2016 and January 2018, data from 7 consecutive patients who underwent partial breast mastectomy with lateral thoracodorsal flap were enrolled. A wedge shaped flap was designed using the pinch test using the index finger and the thumb in small defects, while larger defects required a convex shaped incision with curved superior and inferior borders. Incision was made along the marked margins of the proposed flap and deepened to the underlying serratus anterior and latissimus dorsii muscle. The flap was transposed in the defect and the symmetry of mound between the two breasts confirmed in sitting and supine position.

RESULTS

All patients were satisfied by cosmetic outcomes on visual analog scale (VAS). Cosmetic results based on Harvard scale showed good to excellent scores. Evaluation by Breast Cancer Conservation Treatment (BCCT) core software illustrated good to excellent cosmetic outcomes. There was no delayed wound healing, marginal skin ornecrosis and no evidence of any fat necrosis in the follow up period.

CONCLUSION

The versatility of latissimus dorsii flap, good aesthetic and functional results and its simple execution made it an important option in the armamentarium of the oncoplastic breast surgeon. Also, morbidity of the donor site was minimized without sacrificing muscles or nerves.

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.

Analysing Breast Cancer Multidisciplinary Patient Management: A Prospective Observational Evaluation of Team Clinical Decision-Making

Background

Multidisciplinary team (MDT)-driven cancer care is a mandatory UK national policy, widely used globally. However, few studies have examined how MDT members make decisions as a team. We report a single-centre prospective study on team working within breast cancer MDT.

Methods

This was a prospective observational study of 10 breast MDT meetings (MDM). Trained clinical observer scored quality of presented information and disciplinary contribution to case reviews in real time, using a validated tool, namely Metric for the Observation of Decision-Making. Data were analysed to evaluate quality of team working.

Results

Ten MDMs were observed (N = 346 patients). An average of 42 patients were discussed per MDM (range: 29–51) with an average 3 min 20 s (range: 31 s–9 min) dedicated to each patient. Management decision was made in 99% of cases. In terms of contribution to case reviews, breast care nurses scored significantly (p < 0.05) lower (M = 1.79, SD = 0.12) compared to other team members (e.g. surgeons, M = 4.65; oncologists, M = 3.07; pathologists, M = 4.51; radiologists, M = 3.21). Information on patient psychosocial aspects (M = 1.69, SD = 0.68), comorbidities (M = 1.36, SD = 0.39) and views on treatment options (M = 1.47, SD = 0.34) was also significantly (p < 0.05) less well represented compared to radiology (M = 3.62, SD = 0.77), pathology (M = 4.42, SD = 0.49) and patient history (M = 3.91, SD = 0.48).

Conclusion

MDT evaluation via direct observation in a meeting is feasible and reliable. We found consistent levels of quality of information coverage and contribution within the team, but certain aspects could be improved. Contribution to patient review resides predominantly with surgeons, while presented patient information is largely of biomedical nature. These findings can be fed to cancer MDTs to identify potential interventions for improvement.

Oncologic and Cosmetic Outcomes of Oncoplastic Breast Surgery in Locally Advanced Breast Cancer After Neoadjuvant Chemotherapy, Experience from a Developing Country

Oncoplastic surgery (OPS) has emerged as a new approach for extending breast conserving surgery (BCS) possibilities, reducing both mastectomy and re-excision rates, while avoiding breast deformities. OPS is based upon the integration of plastic surgery techniques for immediate reshaping after wide excision for breast cancer. This is a prospective feasibility cohort study of oncoplastic breast surgery after neoadjuvant chemotherapy that was carried at the National Cancer Institute, Cairo University and included 70 patients. The primary outcome was the local recurrence rate. Secondary outcomes included survival and margins obtained as well as cosmetic outcomes. Survival analysis was performed. Oncoplastic breast surgery did not compromise oncologic safety in the patients included in the study. It even allowed wider margins of resection which could be associated with better oncologic outcomes. At the same time, it gave a better cosmetic outcome and therefore higher patient satisfaction. Oncoplastic breast surgery includes a wide spectrum of surgical techniques, ranging from the basic level I techniques in breast conserving surgery to the more complex procedures of level II which are broadly classified into volume replacement (therapeutic mammoplasty) and volume displacement procedures. We suggest that oncoplastic breast surgery techniques should be the standard of care in breast surgery. They are the basis for breast conserving surgery techniques in early breast cancer. In our experience, oncoplastic surgery is feasible in locally advanced tumours after downstaging with neoadjuvant chemotherapy without compromising the oncologic safety.

Training oncoplastic breast surgeons: the Canadian fellowship experience

BACKGROUND

Oncoplastic breast surgery combines traditional oncologic breast conservation with plastic surgery techniques to achieve improved aesthetic and quality-of-life outcomes without sacrificing oncologic safety. Clinical uptake and training remain limited in the Canadian surgical system. In the present article, we detail the current state of oncoplastic surgery (ops) training in Canada, the United States, and worldwide, as well as the experience of a Canadian clinical fellow in ops.

METHODS

The clinical fellow undertook a 9-month audit of breast surgical cases. All cases performed during the fellow's ops fellowship were included. The fellowship ran from October 2015 to June 2016.

RESULTS

During the 9 months of the fellowship, 67 mastectomies were completed (30 simple, 17 modified radical, 12 skin-sparing, and 8 nipple-sparing). The fellow participated in 13 breast reconstructions. Of 126 lumpectomies completed, 79 incorporated oncoplastic techniques.

CONCLUSIONS

The experience of the most recent ops clinical fellow suggests that Canadian ops training is feasible and achievable. Commentary on the current state of Canadian ops training suggests areas for improvement. Oncoplastic surgery is an important skill for breast surgical oncologists, and access to training should be improved for Canadian surgeons.

Comparison of 5-year oncological outcomes of breast cancer based on surgery type

BACKGROUND

A standardized classification system for breast surgery that incorporates oncoplastic techniques is needed. We classified the surgical techniques for breast cancer treatment into five groups according to the extent of surgery and reconstructive methods, i.e. conventional breast-conserving surgery, partial mastectomy with volume displacement, partial mastectomy with volume replacement, simple mastectomy and total mastectomy with immediate reconstruction. We then evaluated the oncological outcomes for each of the five groups.

METHODS

We analysed clinical data and 5-year oncological results from patients with breast cancer who underwent breast surgery with reconstruction between 2008 and 2013. Local recurrence, distant metastasis and overall survival were investigated.

RESULTS

In total, 1469 patients had 1504 breast surgeries performed with a mean follow-up of 72.40 ± 16.76 months. There were 35 cases (2.3%) of locoregional recurrence and 85 cases (5.7%) of distant metastasis, and the 5-year overall survival rate was 98.6%. No statistically significant differences were observed in local recurrence, distant metastasis or death among the five surgical technique groups (P = 0.218, 0.518 and 0.450, respectively).

CONCLUSION

Oncological outcomes among all patients and within each surgical technique group were excellent during the 5-year follow-up period. No significant differences in oncological results were observed among the five surgical technique groups.

National trends and regional variation in immediate breast reconstruction rates

BACKGROUND

Previous studies have identified variation in immediate reconstruction (IR) rates following mastectomy for breast cancer across English regions during a period of service reorganization, a national audit and changing guidelines. This study analysed current variations in regional rates of IR in England.

METHODS

Patient-level data from Hospital Episode Statistics were used to define a cohort of women who underwent primary mastectomy for invasive or in situ breast carcinoma in English National Health Service (NHS) hospitals between April 2000 and March 2014. A time series of IR rates was calculated nationally and within regions in 28 cancer networks. Regional IR rates before and after the national audit were compared, using logistic regression to adjust for patient demographics, tumour type, co-morbidity and year of mastectomy.

RESULTS

Between 2000 and 2014, a total of 167 343 women had a mastectomy. The national IR rate was stable at around 10 per cent until 2005; it then increased to 23·3 per cent by 2013-2014. Preaudit (before January 2008), adjusted cancer network-level IR rates ranged from 4·3 to 22·6 per cent. Postaudit (after April 2009) adjusted IR rates ranged from 13·1 to 36·7 per cent, with 20 networks having IR rates between 15 and 24 per cent. The degree of change was not greatest amongst those that started with the lowest IR rates, with four networks with the largest absolute increase also starting with relatively high IR rates.

CONCLUSION

The national IR rate increased throughout the study period. Substantial regional variation remains, although considerable time has elapsed since a period of service reorganization, guideline revision and a national audit.

Observed outcomes on the use of oxidized and regenerated cellulose polymer for breast conserving surgery - A case series

BACKGROUND

Oxidized regenerated cellulose polymer (ORCP) may be used for reshaping and filling lack of volume in breast-conserving surgery (BCS). The study aimed to observe both the aesthetic and diagnostic outcomes in patients with different age, BMI, breast volume, and breast tissue composition over 36 months after BCS with ORCP.

PATIENTS AND METHODS

18 patients with early breast cancer and with proliferative benign lesions underwent BCS with ORCP that was layered in three-dimensional wafer, and placed into the Chassaignac space between the mammary gland and the fascia of pectoralis major with no fixation. After surgery, patients started a clinical and instrumental 36-month follow-up with mammography, ultrasonography, magnetic resonance imaging (MRI) and cytological examination with fine needle aspiration when seroma occurred.

RESULTS

Below the median age of 66 years old no complications were observed even in case both of overweight, and large breasts with low density. Over the median age seromas occurred with either small or large skin retraction, with the exception of 1 patient having quite dense breasts and low BMI, which had no complications. In elderly patients, 1 case with quite dense breasts and high BMI showed severe seroma and skin retraction, while 1 case with low BMI and less dense breasts highlighted milder complications.

CONCLUSION

During 36 months after BCS with ORCP, a significant correlation between positive diagnostic and aesthetic outcomes and low age, dense breasts, and low BMI of patient was observed. Despite of the few number of cases, either low BMI, or high breast density improved the aesthetic outcomes and reduced the entity of complications even in the elderly patients.

The Role of Oncoplastic Breast Surgery in Breast Cancer Treatment

The aim of this study is to discuss indications, advantages, disadvantages, oncologic and aesthetic results of Oncoplastic Surgery (OBS). Pubmed and Medline database were searched for articles published between 1998 and 2014 for keywords: oncoplastic breast surgery, therapeutic mammoplasty, oncoplastic breast reduction, synchrenous reconstructions. Role of OBS in breast cancer surgery, its aspects to be considered, its value and results have been interpreted. This technique has advantages by providing more extensive tumourectomy, yielding better aesthetic results compared with breast conserving surgery, allowing oncoplastic reduction in breast cancer patients with macromastia, with higher patient satisfaction and quality of life and by being inexpensive due to single session practice. As for its disadvantages are: re-excision is more difficult, risk for mastectomy is higher, it is depent on the Surgeron's experience, it has a risk for delay in adjuvant therapies and its requirement for additional imaging studies during management. Main indications are patients with small tumour/breast volume, macromastia, multifocality, procedures which can disrupt breast cosmesis such as surgeries for upper inner breas tquadrient tumours. Contraindications are positive margin problems after wide excision, diffuse malign microcalsifications, inflammatory breast cancer, history of radiotherapy and patients' preferences. Despite low evidence level, Oncoplastic Breast Surgery seems to be both reliable and acceptable in terms of oncologic and aesthetic aspects. Oncoplastic Breast Surgery increase the application rate of breast conserving surgery by obviating practical limitations and improve the results of breast conserving surgery. Correct patient and technique choice in OBS is vital for optimization of post surgical.

Evaluation of patient knowledge, desire, and psychosocial background regarding postmastectomy breast reconstruction in Hungary: a questionnaire study of 500 cases

BACKGROUND

According to European guidelines, breast cancer patients requiring mastectomy should be informed about available options regarding breast reconstruction. There are clear differences in the quality standards of oncoplastic care throughout Europe, with slight improvements in Central European countries like Hungary. The aim of the present investigation was to evaluate patients' knowledge and demand for postmastectomy breast reconstruction, as well as their psychosocial background regarding decision-making.

MATERIAL AND METHODS

A questionnaire containing 15 structured questions was given to 500 breast cancer patients on the day before undergoing mastectomy. The questions focused on the emotional impact of the malignant disease and the loss of a breast; the importance of environmental conditions; the desire for breast reconstruction; and patients' knowledge and sources of information about the procedure. All answers were statistically analyzed in the context of patient age, marital status, educational level, and place of residence.

RESULTS

Descriptive statistical results of the answers to all questions, as well as associations of the different aspects of the decision-making process, are presented.

CONCLUSIONS

Hungarian breast cancer patients have very limited knowledge regarding breast reconstruction. We confirmed that patients scheduled for mastectomy have a great degree of anxiety due to their disease and breast loss. Almost 50% of the responders declared their desire for postmastectomy breast reconstruction. Patient's age, residence, educational level, marital status, and profession were confirmed as predictive factors in the decision-making process for breast reconstruction.

Dermoglandular rotation flaps for breast-conserving therapy: aesthetic results, patient satisfaction, and morbidity in comparison to standard segmentectomy

We compared a dermoglandular rotation flap (DGR) in the upper inner, lower inner, and upper outer quadrant regarding similar aesthetic results, patient satisfaction, and comfort after breast-conserving therapy with standard segmentectomy (SE). Between 2003 and 2011, 69 patients were treated with breast-conserving surgery using DGR for cancers with high tumor-to-breast volume ratios or skin resection in the three above mentioned quadrants; 161 patients with tumors in the same quadrants were treated with SE. The outcome of the procedures was assessed at least 7 months after completed radiation therapy using a patient and breast surgeon questionnaire and the BCCT.core software. Symmetry, visibility of the scars, the position of the nipple-areola complex, and the appearance of the treated breast were each assessed on a scale from 1 to 4 by an expert panel and by the patients. Univariate and multivariate analysis were used to evaluate the relationship between patient-, tumor-, and treatment-dependent factors and patient satisfaction. 94.2% of the patients with rotation flaps and 83.5% of the patients with lumpectomy were very satisfied with the cosmetic appearance of their breast. Younger patient age was significantly associated with a lower degree of satisfaction. DGR provides good cosmetic results compared with SE and shows high patient satisfaction despite longer scarring and higher median resection volume.

Oncoplastic breast surgery in Australia and New Zealand-2014 and beyond

Oncoplastic breast surgery (OBS) is an established field of surgery bringing together oncological and reconstructive principles to the surgical management of breast disease, which is yet to make inroads into some areas of Australia and New Zealand (A&NZ). Both patients and medical fraternity are supportive of these approaches and improved quality of life and aesthetic outcomes resulting from their application. Oncological outcomes have been shown to be no different when these oncoplastic approaches are utilised. There is a broad interest amongst breast surgeons regarding OBS and development of their own skills. However a new and improved method of training the current and the next generation of breast surgeons is required. This has already begun in some countries such as the UK, but is slower in A&NZ region. Some of the obstacles in training of OBS to the next generation of surgeons are discussed and highlighted.This year first steps in formalised training approaches are being made. The future of breast surgery is likely to involve OBS as part of mainstream surgical management of breast disease.

Oncoplastic breast conserving surgery

Oncoplastic breast conserving surgery is a fundamental component of the repertoire for the management of breast cancer. It facilitates removal of large volumes of breast tissue, and can improve cosmetic outcomes and patient satisfaction whilst maintaining good oncological principles, reducing re-excision and mastectomy rates and assisting in adjuvant radiotherapy planning. We review the various techniques for oncoplastic breast conserving surgery that have emerged over recent years and describe their utilisation in excising tumours from various locations within the breast, and the pertinent patient specific factors that must be considered in technique selection. Finally complications and the evidence for the oncological safety specific to this type of surgery are discussed.

The attitude and perception of breast reconstruction by general surgeons in Saudi Arabia

BACKGROUND AND OBJECTIVES

Post-mastectomy breast reconstruction surgery had always been integral part in the approach to a patient with breast cancer. It is our aim of this study to report in a simplistic manner the variability in the perception and practice by surgeons surrounding breast reconstruction.

DESIGN AND SETTINGS

This is a descriptive cross-sectional survey targeting a sample of general surgeons in 6 tertiary hospitals in Saudi Arabia from April 2012 to October 2012.

METHODS

A questionnaire adopted from the one designed by Spyrou et al was distributed to our sample of surgeons. It primarily focused on the surgeon's attitude and perception of breast reconstruction surgery after mastectomy.

RESULTS

A total of 51 general surgeons were included in the study. Most of them, 24 (47.1%), worked in teaching hospitals. Thirty-six (70.6%) surgeons had a special interest in breast cancer management. Eighteen of them (35.5%) referred their patients for breast reconstruction. We observed that the surgeons of high-referral tendency were generally females (P=.016). More than half (33 [64.7%]), thought that a general surgeon is the one responsible for counseling patients. The majority (47%), disagreed with the notion that breast reconstruction can interfere with host defenses. Yet, (76.5 %) were concerned about masking local recurrence of the cancer, and 21 (41.2%) reported that patients refused such type of surgery. Forty-eight (94.1%) agreed that breast reconstruction has psychological benefits.

CONCLUSION

In Saudi Arabia, general surgeons have a high concern about masking local recurrence of the cancer despite the lack of evidence in the published reports. Nevertheless, less than half of the surgeons referred their cases for breast reconstruction. We recommend establishing national efforts to educate on the benefits of breast reconstruction and establish a tumor conference protocol on breast reconstruction including all involved specialties (oncologists and general and plastic surgeons).

Is immediate autologous breast reconstruction with postoperative radiotherapy good practice?: a systematic review of the literature

BACKGROUND

There remains controversy as to whether immediate autologous breast reconstruction with postoperative radiotherapy is associated with acceptable complications and aesthetic outcomes. This systematic review analyses the literature regarding outcomes of immediate autologous breast reconstruction with postoperative radiotherapy compared with no radiotherapy, as well as with delayed autologous breast reconstruction following post-mastectomy irradiation.

METHODS

Pubmed (1966 to October 2012), Ovid MEDLINE (1966 to October 2012), EMBASE (1980 to October 2012), and the Cochrane Database of Systematic Reviews (Issue 10, 2012) were searched. Overall complications (including fat necrosis), fat necrosis, revisional surgery, loss of volume, and aesthetic outcome, were analysed individually. Comparable data from observational studies were combined for meta-analysis where possible and quality assessment of the studies was performed.

RESULTS

The majority of studies of immediate autologous breast reconstruction and postoperative radiotherapy reported satisfactory outcomes (19 of 25 studies; n=1,247 patients). Meta-analysis of observational studies demonstrated no significant differences in total prevalence of complications (p=0.59) or revisional surgery (p=0.38) and a summary measure for fat necrosis favouring the group without radiotherapy (OR 2.82, 95% CI 1.35-5.92, p=0.006). The majority of studies comparing immediate reconstruction and postoperative radiotherapy with delayed reconstruction following post-mastectomy radiotherapy (10 of 12 observational studies; n=1,633 patients) reported satisfactory outcomes following immediate reconstruction. Meta-analysis of observational studies demonstrated no significant difference in overall incidence of complications (p=0.53) and fat necrosis (OR 0.63, 95% CI 0.29-1.38, p=0.25), and a summary measure for revisional surgery (OR 0.15, 95% CI 0.05-0.48, p=0.001) favouring the delayed surgery group. No randomised-controlled trials met the inclusion criteria, and all of the observational studies included were missing more than one important component for reporting of observational studies.

DISCUSSION

The majority of studies reported satisfactory outcomes and a similar incidence of complications for immediate autologous breast reconstruction and adjuvant radiotherapy when compared with no radiotherapy or delayed reconstruction following radiotherapy; the proportion that required revisional surgery was higher though for immediate than delayed breast reconstruction. The findings are limited by the paucity of high quality data in the published literature, and until better data is available the findings of this review suggest that immediate autologous breast reconstruction should at least be considered when adjuvant chest wall radiotherapy is anticipated.

Breast conservation surgery: state of the art

Breast conservation surgery is available to the vast majority of women with breast cancer. The combination of neoadjuvant therapies and oncoplastic surgical techniques allows even large tumours to be managed with a breast-conserving approach. The relationship between breast size and the volume of tissue to be excised determines the need for volume displacement or replacement. Such an approach can also be used in the management of carefully selected cases of multifocal or multicentric breast cancer. The role of novel techniques, such as endoscopic breast surgery and radiofrequency ablation, is yet to be precisely defined.

Oncoplastic multidisciplinary meetings: a necessity or luxury?

Although there is scant evidence to support multidisciplinary meetings in any cancer specialty, they are now regarded as best practice. We believe the oncoplastic multidisciplinary meeting plays a similarly important role, consolidating oncoplastic multidisciplinary working and allowing transparent decision making, standardisation of care and recording of results. This may drive oncoplastic surgery to an evidence-based position from which oncoplastic excellence can be achieved.

Metachronous melanoma in breast reconstruction patients

The incidence and mortality due to malignant melanoma has increased three- to four-fold across males and females in England and Wales over the past thirty years. Ninety percent of patients with primary melanoma have no clinical evidence of lymphadenopathy at presentation. In this paper we describe our management of impalpable axillary melanoma deposits in a patient with a pedicled latissimus dorsi (LD) flap reconstruction to the ipsilateral breast. No such case has been previously described in the literature.

Clinical series of oncoplastic mastopexy to optimize cosmesis of large-volume resections for breast conservation

BACKGROUND

Oncoplastic mastopexy has been popularized as a method to hide the cosmetic effects of central or large-volume resections associated with breast conservation surgery for breast cancer.

MATERIALS AND METHODS

This review was undertaken to study the uses and limitations of these techniques in providing adequate breast conservation lumpectomy for breast cancer of any stage in a single surgeon's practice. A review of breast cancer cases March 2004 through December 2009 were analyzed for the use of oncoplastic reconstruction in breast conservation surgery.

RESULTS

A total of 167 patients had lumpectomies during this period associated with oncoplastic mastopexy reconstruction. The average age was 55.6 years with a range of 33-85 years. Stage 0 breast cancer accounted for 33 cases (19.8%), and 134 cases were invasive cancers stages 1-3 (stage 1, 34.1%; stage 2, 30.6%; and stage 3, 15.6%). The most common oncoplastic techniques used were, in order of frequency: batwing mastopexy, parallelogram mastopexy, and Modified Wise pattern mastopexy. Positive or close margins (≤ 2 mm) were present in 37 of 167 cases (22%). Positive margins were most associated with higher stage, positive nodes, positive lymphovascular invasion (LVI), use of neoadjuvant chemotherapy, and larger initial T stage, positive estrogen receptor (ER), and younger age. Of these higher stage, node positive, and use of neoadjuvant chemotherapy were statistically significant in this small series (P values = 0.034, 0.016, and 0.022, respectively). Ki-67 and HER2 status were not associated with positive margins. Positive margins were manageable by local re-excision of a solitary face of the prior resection wall in more than 2/3 of cases to achieve negative pathologic margins. Only 11 of 167 required mastectomy because of failure to achieve adequate margins for oncologic control.

CONCLUSIONS

Oncoplastic mastopexy allows the surgeon to address large tumors or tumors in cosmetically difficult sites adequately for breast conservation. Careful margin marking and re-excision of close or positive margins is still often feasible to achieve adequate negative margin with acceptable cosmesis in spite of the large initial volumes of resection.

Measuring the influence of colleagues on a consultant team's use of breast conserving surgery

OBJECTIVES

The aim of this study was to examine potential reasons why the use of breast conserving surgery (BCS) for breast cancer varies substantially between hospital teams in England, and in particular to examine whether colleague influence has a role in influencing BCS rates locally.

METHODS

Routinely collected Hospital Episode Statistics (HES) data relating to 420 surgical teams in England who performed more than ten breast cancer operations during the financial year 2006/07 were used to identify predictors of team BCS use. Team BCS rates (as a proportion of all types of breast excision surgery) were subject to a regression analysis that incorporated, as independent variables, a range of patient, organizational, and local demographic factors, as well as the BCS rate of colleagues working alongside them in the same hospitals(s).

RESULTS

After adjusting for the effects of other variables, BCS use by colleagues working in the same hospital(s) was a significant predictor of a team's own BCS rate (standardized b = 0.224; p < .001), denoting a typical 3 percent increase in a team's BCS rate for every 10 percent increase in the BCS rate of colleagues.

CONCLUSIONS

The practice of colleagues seems to have a measurable influence upon a surgical team's BCS usage. Guidance from HTA organizations can set national standards about the use of new techniques and innovations, but dissemination can be either slowed down or accelerated by the influence of local colleagues. A strategy of disseminating guidance through professional networks or "local champions" could be a powerful avenue for change.

Evolution of breast cancer management in Ireland: a decade of change

BACKGROUND

Over the last decade there has been a paradigm shift in the management of breast cancer, subsequent to revised surgical oncology guidelines and consensus statements which were derived in light of landmark breast cancer clinical trials conducted throughout the latter part of the 20th century. However the sheer impact of this paradigm shift upon all modalities of treatment, and the current trends in management of the disease, are largely unknown. We aimed to assess the changing practices of breast cancer management over the last decade within a specialist tertiary referral Breast Cancer Centre.

METHODS

Comparative analysis of all aspects of the management of breast cancer patients, who presented to a tertiary referral Breast Cancer Centre in 1995/1996 and 2005/2006, was undertaken and measured against The European Society for Surgical Oncology guidelines for the surgical management of mammographically detected lesions [1998].

RESULTS

613 patients' case profiles were analysed. Over the last decade we observed a dramatic increase in incidence of breast cancer [>100%], a move to less invasive diagnostic and surgical therapeutic techniques, as well as increased use of adjuvant therapies. We also witnessed the introduction of immediate breast reconstruction as part of routine practice

CONCLUSION

We demonstrate that radical changes have occurred in the management of breast cancer in the last decade, in keeping with international guidelines. It remains incumbent upon us to continue to adapt our practice patterns in light of emerging knowledge and best evidence.

Oncoplastic surgery for breast cancer

Higher levels of evidence proving difficult