Cosmetic assessment of breast-conserving surgery for primary breast cancer

A Clinical Analysis of Prognosis and Patient-Reported Outcomes of Oncoplastic Breast-Conserving Surgery for Early Breast Cancer: A Retrospective Cohort Study

PURPOSE

Approximately 25-30% of patients suffer from breast deformity and/or asymmetry after conventional breast-conserving surgery (CBCS). Generally, it is thought that oncoplastic breast-conserving surgery (OBCS) results in an improved cosmetic result; however, studies comparing the prognosis and aesthetic outcomes of CBCS and OBCS in early breast cancer (EBC) are inadequate.

METHODS

A total of 143 patients were included in this retrospective cohort study; 53 underwent OBCS and 90 underwent CBCS. The resected weight, complications, esthetic results, patient satisfaction, and recurrence rate were compared between the groups. Patient-reported outcomes (PRO) were assessed by the BREAST-Q questionnaire.

RESULTS

The mean age of the patients in OBCS group was 43.8 years. This was younger than that in CBCS group (49.1 years, p < 0.001). Postoperative complications (11.3% vs. 8.9%, p = 0.64) and re-excision (5.7% vs. 6.7%, p > 0.99) rates were similar. The OBCS group had higher breast satisfaction and psychosocial well-being than the CBCS group (75 vs. 63, p < 0.001 and 84 vs. 77, p = 0.05); however, sexual well-being (56 vs. 66, p = 0.05) and physical well-being (65 vs. 76, p < 0.001) were worse in OBCS. After 42.3 (range: 12.6-69.2)-month median follow-up, no difference in event-free survival (EFS) was demonstrated between the groups (p = 0.13).

CONCLUSION

Although OBCS has the better aesthetic outcomes and identical oncological safety in comparison with CBCS, the sexual and physical well-being in OBCS are not improved for Asian patients. Hence, choosing an appropriate procedure may be more important for the typically small to moderate-sized breasts characteristic of Asian females unlike Westerners.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Early Toxicity and Patient-Reported Cosmetic Outcomes in Patients Treated With Adjuvant Proton-Based Radiotherapy After Breast-Conserving Surgery

INTRODUCTION

To evaluate the dosimetric data, early toxicity, and patient-reported cosmetic outcomes in breast cancer patients treated with adjuvant proton-based radiotherapy (RT) after breast-conserving surgery.

MATERIALS AND METHODS

We performed a retrospective review of our institutional database to identify breast cancer patients treated with breast-conserving surgery followed by proton-based RT from 2015 to 2020. Patient-reported cosmetic outcomes were graded as excellent, good, fair, or poor. Early toxicity outcomes were graded by the treating physician during treatment. Dose-volume histograms were reviewed to obtain dosimetry data.

RESULTS

We identified 21 patients treated with adjuvant proton-based RT. Median whole breast dose delivered was 46.8 Gy (range, 40.0-50.4 Gy). Target volumes included the regional lymph nodes in 17 patients (81%). Seventeen patients (81%) received a lumpectomy boost. The median planning target volume V95 was 94% (range, 77%-100%), V100 71% (range, 60%-97%), V110 2% (range 0%-18%), and median max point dose was 115% (range, 105%-120%). The median ipsilateral breast V105 was 367.3 cc (range, 0-1172 cc) and V110 was 24.1 cc (range, 0-321.3 cc). Grade 2 and 3 dermatitis occurred in 62% and 14% of patients, respectively. Grade 2 and 3 pain was reported by 33% and 10% of patients, respectively. Median follow-up at the time of cosmetic evaluation was 27 months (range, 5-42 months). Four patients (21%) reported fair cosmetic outcome and 15 patients (79%) reported good or excellent cosmetic outcome. No poor cosmesis was reported.

CONCLUSION

Adjuvant proton-based radiotherapy after breast-conserving surgery is well tolerated with acceptable rates of acute toxicities and a high rate of good-to-excellent patient-reported cosmetic outcomes.

Simple oncoplastic breast defect closure improves long-term cosmetic outcome of breast conserving surgery for breast cancer: A randomised controlled trial

Introduction

Breast conserving surgery (BCS) is associated with unsatisfactory cosmetic outcomes in up to 30% of patients, carrying psychological and quality-of-life implications. This study compares long-term cosmetic outcomes after BCS for breast cancer with v without simple oncoplastic defect closure.

Methods

A randomised controlled trial was performed, recruiting patients who underwent BCS over four years and randomising to the “reshaping” group (closure of excision defect with mobilised breast tissue; n = 124) and to the “control” group (no attempt at defect closure; n = 109). The estimated excision volume (EEV) was <20% of breast volume (BV) in both groups. Photography and breast retraction assessment (BRA) were recorded preoperatively. Cosmetic outcomes were blindly assessed annually for five years by BRA, panel assessment of patients, and body image questionnaire (BIQ).

Results

There were no significant differences between the reshaping and control groups in mean age (52.4 v 53.0; p = 0.63), body mass index (27.8 v 27.7; p = 0.80), margin re-excision (9 v 9; p = 0.78), mean BV (562.5 v 590.3 cc; p = 0.56), mean EEV (54.6 v 60.1 cc; p = 0.14), mean EEV/BV ratio (11.2 v 11.0; p = 0.84), or mean specimen weight (52.1 v 57.7 g; p = 0.24). Reshaping group patients had significantly better outcomes compared to control group patients in terms of mean BRA (0.9 v 2.8; p < 0.0001), achieving a score of “good” or “excellent” by panel assessment at 5 years (75.8% v 48%, p < 0.0001), body image questionnaire top score at 5 years (66.9% v 35.8%; p = 0.0001).

Conclusions

Simple oncoplastic closure of defects after breast-conserving surgery improves long-term objective and subjective cosmetic outcomes.

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Breast-conserving cancer surgery can lead to unsatisfactory cosmetic outcomes.

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Simple oncoplastic closure improves long-term cosmetic outcomes.

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Objective and subjective cosmetic outcomes of oncoplastic closure are correlated.

Methods of Esthetic Assessment after Adjuvant Whole-Breast Radiotherapy in Breast Cancer Patients: Evaluation of the BCCT.core Software and Patients' and Physicians' Assessment from the Randomized IMRT-MC2 Trial

Simple Summary

To validate the BCCT.core software, the present analysis compares the esthetics assessment by the software in relation to patients’ and physicians’ rating in breast cancer patients after surgery and adjuvant radiotherapy. Agreement rates of the different assessments and their correlation with breast asymmetry indices were evaluated. The assessments of the software and the physicians were significantly correlated with all asymmetry indices, while for patients’ self-assessment, this general correlation was first seen after 2 years. Only a slight agreement between the BCCT.core software and the physicians’ or patients’ assessment was seen, while a moderate and substantial agreement was detected between the physicians’ and the patients’ assessments. The BCCT.core software is a reliable tool to measure asymmetries, but may not sufficiently evaluate the esthetic outcome as perceived by patients. It may be more appropriate for a long-term follow-up, when symmetry seems to increase in importance.

Abstract

The present analysis compares the esthetics assessment by the BCCT.core software in relation to patients’ and physicians’ ratings, based on the IMRT-MC2 trial. Within this trial, breast cancer patients received breast-conserving surgery (BCS) and adjuvant radiotherapy. At the baseline, 6 weeks, and 2 years after radiotherapy, photos of the breasts were assessed by the software and patients’ and physicians’ assessments were performed. Agreement rates of the assessments and their correlation with breast asymmetry indices were evaluated. The assessments of the software and the physicians were significantly correlated with asymmetry indices. Before and 6 weeks after radiotherapy, the patients’ self-assessment was only correlated with the lower breast contour (LBC) and upward nipple retraction (UNR), while after 2 years, there was also a correlation with other indices. Only a slight agreement between the BCCT.core software and the physicians’ or patients’ assessment was seen, while a moderate and substantial agreement was detected between the physicians’ and the patients’ assessment after 6 weeks and 2 years, respectively. The BCCT.core software is a reliable tool to measure asymmetries, but may not sufficiently evaluate the esthetic outcome as perceived by patients. It may be more appropriate for a long-term follow-up, when symmetry appears to increase in importance.

An Innovative Breast-Conserving Oncoplastic Technique for Treating Small to Medium Volume Breasts With a Tumor in the Lower Quadrant: The Folding Flap Technique

Background

Here, we describe an innovative oncoplastic technique for small to medium volume breasts with a tumor in the lower quadrant and this technique could provide sufficient tissue to avoid visible defects after tumor removal and help reshape the natural shape of the breast.

Methods

A detailed procedure for the folding flap technique is described step by step. Then, the results of a retrospective analysis of patients treated using this technique, including complications and disease recurrence rate, between January 2017 and November 2021 are reported. Aesthetic outcomes were evaluated on a 5-point scale proposed by the Paris Breast Center.

Results

A total of 52 patients underwent surgery with the folding flap technique, The average operation time was 98.4 min (range, 75–120 min), and the mean bleeding volume was 56.5 mL (range, 20–100 mL). A margin-positive result was confirmed in 1 patient who underwent re-excision. Short-term postoperative complications were observed in 7 patients, including 4 with fat liquefaction, 2 with seroma, and 1 with skin redness and swelling. No flap necrosis was observed. The median follow-up time was 28.6 months (range, 9–58 months), and 2 patients experienced local recurrence. The mean aesthetic score was 4.7 points, with 36 patients scoring 5 points and 26 patients scoring 4 points, respectively.

Conclusions

The folding flap technique, as an innovative and favorable oncoplastic technique for treating small- to medium-volume breasts with a tumor in the lower quadrant, could retain sufficient tissue to fill the residual cavity after the operation while improving the aesthetic outcome of the breast.

Well-Being, Depression, and Anxiety following Oncoplastic Breast Conserving Surgery versus Modified Radical Mastectomy Followed by Late Breast Reconstruction

Breast cancer requires complex clinical care. Well-being is an intricate concept, encompassing physical, functional, emotional, and social aspects. Background: This study aims to evaluate the relationship between the type of surgery our patients underwent and the timing of the reconstructive surgery with physical, emotional, social, and functional well-being. Furthermore, through our research we tried to identify potential mental health comorbidities in patients with breast cancer, clinical symptoms, and well-being in women with breast cancer, depending on the type of required surgery. Methods: The study included 69 women diagnosed with breast cancer, in stages I to III, divided in two groups: I—patients with oncoplastic breast-conserving surgery and contralateral correction surgery, for symmetry reasons; II—patients who underwent modified radical mastectomy and late breast reconstruction with contralateral symmetrisation. We evaluated socio-demographic aspects, alongside depression, anxiety, stress (DASS 21), and well-being (FACT-B). Data were statistically processed; statistical significance was set at p < 0.05. Results: Clinical elements of depression, anxiety, and stress were noted in both groups, without statistical significance (p > 0.05). Significant differences were found regarding psycho-emotional (p = 0.035) and functional well-being (p = 0.001), with higher scores for group I. The chi-square test indicated statistically significant differences (at p < 0.01) between the groups, regarding the frequency of scores on items B4 and B9 (FACT-B items, related to feminine aesthetics and desirability), with evidently higher scores in group I than in group II. Conclusions: The state of well-being, as well as the items related to femininity and sexuality had higher values in the group of women treated by oncoplastic conservative surgery compared to late reconstruction after modified radical mastectomy.

Optical tissue measurements of invasive carcinoma and ductal carcinoma in situ for surgical guidance

Background

Although the incidence of positive resection margins in breast-conserving surgery has decreased, both incomplete resection and unnecessary large resections still occur. This is especially the case in the surgical treatment of ductal carcinoma in situ (DCIS). Diffuse reflectance spectroscopy (DRS), an optical technology based on light tissue interactions, can potentially characterize tissue during surgery thereby guiding the surgeon intraoperatively. DRS has shown to be able to discriminate pure healthy breast tissue from pure invasive carcinoma (IC) but limited research has been done on (1) the actual optical characteristics of DCIS and (2) the ability of DRS to characterize measurements that are a mixture of tissue types.

Methods

In this study, DRS spectra were acquired from 107 breast specimens from 107 patients with proven IC and/or DCIS (1488 measurement locations). With a generalized estimating equation model, the differences between the DRS spectra of locations with DCIS and IC and only healthy tissue were compared to see if there were significant differences between these spectra. Subsequently, different classification models were developed to be able to predict if the DRS spectrum of a measurement location represented a measurement location with “healthy” or “malignant” tissue. In the development and testing of the models, different definitions for “healthy” and “malignant” were used. This allowed varying the level of homogeneity in the train and test data.

Results

It was found that the optical characteristics of IC and DCIS were similar. Regarding the classification of tissue with a mixture of tissue types, it was found that using mixed measurement locations in the development of the classification models did not tremendously improve the accuracy of the classification of other measurement locations with a mixture of tissue types. The evaluated classification models were able to classify measurement locations with > 5% malignant cells with a Matthews correlation coefficient of 0.41 or 0.40. Some models showed better sensitivity whereas others had better specificity.

Conclusion

The results suggest that DRS has the potential to detect malignant tissue, including DCIS, in healthy breast tissue and could thus be helpful for surgical guidance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13058-021-01436-5.

Effect of sequencing of preoperative systemic therapy on patients with locally advanced breast cancer

BACKGROUND

The study aims to perform a clinical trial to evaluate the effect of sequencing of systemic therapy on locally advanced breast cancer (LABC).

METHODS

LABC patients (n = 733) underwent the combination of external beam radiation therapy, chemotherapy, and breast-conservation surgery with difference sequences. Biopsy followed by histopathological examinations was used to assess treatment responses. The primary end point is ipsilateral local recurrence or death. The secondary end points include the incidence and severity of acute and late side effects, cosmesis, and cumulative incidence of regional recurrence and distant metastasis, and survival. The effects of sequence of therapies on the side effects and treatment outcomes were compared.

RESULTS

Patients with preoperative systemic treatment, that is, chemotherapy and radiotherapy performed ahead of surgery, had less fibrosis and pain, and showed higher satisfaction regarding the breast conservation. Preoperative systemic treatment also led to better survival of the patients.

CONCLUSIONS

Preoperative systemic therapy is beneficial to alleviate side effects and improve the breast conservation, treatment outcome, and survival of LABC patients.

Efficacy of intraoperative specimen radiography as margin assessment tool in breast conserving surgery

PURPOSE

To explore the ability of intraoperative specimen radiography (SR) to correctly identify positive margins in patients receiving breast conserving surgery (BCS). To assess whether the reoperation rate can be reduced by using this method.

METHODS

This retrospective study included 470 consecutive cases receiving BCS due to a primarily diagnosed breast cancer. SR was carried out in two planes, assessing the specimen regarding the presence of the lesion and its relation to all margins. If indicated, re-excision of selective orientations was advised. Under consideration of gross inspection and the SR-findings, it was up to the surgeon whether to perform re-resections. The recommendations for re-excision were, separately for each orientation, compared to the histopathological results, serving as gold standard.

RESULTS

Intraoperative SR was performed in 470 cases, thus 2820 margins were assessed. Of those, 2510 (89.0%) were negative and 310 (11.0%) positive. SR identified 2179 (77.3%) margins correctly as negative, whereas 331 (11.7%) clear margins were misjudged as positive. Of 310 infiltrated margins, SR identified 114 (4.0%) correctly, whereas 196 (7.0%) infiltrated margins were missed. This resulted in a sensitivity/specificity of 36.8%/86.8% and PPV/NPV of 25.6%/91.8%. Through targeted re-resections positive margins could be reduced by 31.0% [310 to 214 (7.6%)]. On case level, the rate of secondary procedures could be reduced by 37.0% [from 162 to 102 (21.7%)].

CONCLUSIONS

SR is a helpful tool to identify infiltrated margins and to reduce the rate of secondary surgeries by recommending targeted re-excisions of according orientations in order to obtain a final negative margin status.

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

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

Cosmetic outcome as rated by patients, doctors, nurses and BCCT.core software assessed over 5 years in a subset of patients in the TARGIT-A Trial

Background

The purpose of this research was to assess agreement between four rating systems of cosmetic outcome measured in a subset of patients with early breast cancer participating in the randomised TARGIT-A trial. TARGIT-A compared risk-adapted single-dose intra-operative radiotherapy (TARGIT-IORT) to whole breast external beam radiotherapy (EBRT).

Methods

Patients, their Radiation Oncologist and Research Nurse completed a subjective cosmetic assessment questionnaire before radiotherapy and annually thereafter for five years. Objective data previously calculated by the validated BCCT.core software which utilizes digital photographs to score symmetry, colour and scar was also used. Agreement was assessed by the Kappa statistic and longitudinal changes were assessed by generalized estimating equations.

Results

Overall, an Excellent-Good (EG) cosmetic result was scored more often than a Fair-Poor (FP) result for both treatment groups across all time points, with patients who received TARGIT-IORT scoring EG more often than those who received EBRT however this was statistically significant at Year 5 only. There was modest agreement between the four rating systems with the highest Kappa score being moderate agreement which was between nurse and doctor scores at Year 1 with Kappa = 0.46 (p < 0.001), 95% CI (0.24, 0.68).

Conclusion

Despite similar overall findings between treatment groups and rating systems, the inter-rater agreement was only modest. This suggests that the four rating systems utilized may not necessarily be used interchangeably and it is arguable that for an outcome such as cosmetic appearance, the patient’s point of view is the most important.

Trial Registration

TARGIT-A ISRCTN34086741, Registered 21 July 2004, retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s13014-018-0998-x) contains supplementary material, which is available to authorized users.

Long-term cosmesis following a novel schedule of accelerated partial breast radiation in selected early stage breast cancer: result of a prospective clinical trial

PURPOSE

There is controversy regarding the cosmetic outcome after accelerated partial breast radiation (APBR). We report the cosmetic outcome from a single-arm prospective clinical trial of APBR delivered using intensity-modulated radiation therapy (IMRT) in elderly patients with stage I breast cancer (BC), using a novel fractionation schedule.

MATERIALS AND METHODS

Forty-two patients aged ≥65, with Stage I BC who underwent breast-conserving surgery were enrolled in a phase I/II study evaluating a 2-week course of APBR. Thirty eligible patients received 40 Gy in 4 Gy daily fractions. Cosmetic outcome was assessed subjectively by physician/patient and objectively by using a computer program (BCCT.core) before APBR, during, and after completion of the treatment.

RESULTS

The median age was 72 years, the median tumor size was 0.8 cm, and the median follow-up was 50.5 months. The 5-year locoregional control in this cohort was 97% and overall survival 87%. At the last follow-up, patients and physicians rated cosmesis as 'excellent' or 'good' in 100% and 91 %, respectively. The BCCT.core program scored the cosmesis as 'excellent' or 'good' in 87% of the patients at baseline and 81% at the last follow-up. The median V50 (20 Gy) of the whole breast volume (WBV) was 37.2%, with the median WBV V100 (40 Gy) of 10.9%.

CONCLUSION

An excellent rate of tumor control was observed in this prospective trial. By using multiple assessment techniques, we are showing acceptable cosmesis, supporting the use of IMRT planned APBR with daily schedule in elderly patients with early stage BC.

Selection of oncoplastic surgical technique in Asian breast cancer patients

BACKGROUND

Oncoplastic surgery is being increasingly performed in Korean women; however, unlike Westerners, Korean women usually have small to moderate-sized breasts. To achieve better outcomes in reconstructed breasts, several factors should be considered to determine the optimal surgical method.

METHODS

A total of 108 patients who underwent oncoplastic surgery from January 2013 to December 2016 were retrospectively investigated. We used various methods, including glandular tissue reshaping, latissimus dorsi (LD) flap transposition, and reduction oncoplasty, to restore the breast volume and symmetry.

RESULTS

The mean weight of the tumor specimens was 40.46 g, and the ratio of the tumor specimen weight to breast volume was 0.12 g/mL in the patients who underwent glandular tissue reshaping (n=59). The corresponding values were 101.47 g and 0.14 g/mL, respectively, in the patients who underwent reduction oncoplasty (n=17), and 82.54 g and 0.20 g/mL, respectively, in those treated with an LD flap (n=32). Glandular tissue reshaping was mostly performed in the upper outer quadrant, and LD flap transposition was mostly performed in the lower inner quadrant. No major complications were noted. Most patients were satisfied with the aesthetic results.

CONCLUSIONS

We report satisfactory outcomes of oncoplastic surgical procedures in Korean patients. The results regarding specimen weight and the tumor-to-breast ratio of Asian patients will be a helpful reference point for determining the most appropriate oncoplastic surgical technique.

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

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

Aesthetic result after breast-conserving therapy is associated with quality of life several years after treatment. Swedish women evaluated with BCCT.core and BREAST-Q™

Purpose

A gold standard for evaluation of aesthetic outcome after breast-conserving therapy (BCT) is still lacking. The BCCT.core software has been developed to assess aesthetic result in a standardised way. We aimed to study how the result of BCCT.core after BCT is associated with quality of life, measured with the BREAST-Q™, a validated questionnaire.

Methods

Women eligible for BCT were consecutively recruited between February 1st 2008 and January 31st 2012 (n = 653). Photographs of 310 women, taken one year after BCT, were evaluated using the BCCT.core software. The postoperative BCT module of the BREAST-Q™ questionnaire was administered by mail and 348 questionnaires were returned (median 5.5 years after BCT). In all, 216 women had both BCCT.core results and completed BREAST-Q™ questionnaires available.

Results

The results from the BCCT.core evaluation were: excellent n = 49 (15.8%); good n = 178 (57.4%); fair n = 73 (23.5%); poor n = 10 (3.2%). The median BREAST-Q™ score for satisfaction with breasts was 66 [interquartile range (IQR) 57–80] and for psychosocial well-being 82 (IQR 61–100). Poor/fair results on BCCT.core were associated with Q-scores below median for both satisfaction with breasts [odds ratio (OR) 3.4 (confidence interval (CI) 1.7–6.8)] as well as for psychosocial well-being [OR 2.2 (CI 1.1–4.2)].

Conclusions

A statistically significant association between BCCT.core results one year after BCT and quality of life ratings using BREAST-Q™ several years later is shown in this study. This implies that the BCCT.core may be valuable in BCT follow-up and used as a standardised instrument in the evaluation of aesthetic results.

Oncoplastic Surgery for Upper/Upper Inner Quadrant Breast Cancer

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

Objective decision making between conventional and oncoplastic breast-conserving surgery or mastectomy: An aesthetic and functional prospective cohort study

BACKGROUND

Breast-conserving surgery (BCS) is considered the standard treatment for early-stage breast cancer. However, fair to poor cosmetic outcomes following conventional BCS have been observed in as many as one-third of cases. The aim of this study was to determine the critical tumor-to-breast volume ratio for each quadrant of the breast beyond which conventional BCS would no longer offer acceptable cosmetic and functional results or satisfactory quality of life for the patient.

METHODS

A prospective cohort study was performed between December 2011 and December 2013 involving 350 patients younger than 70 years with early-stage unifocal (T ≤ 30 mm) breast cancer who underwent wide excision and axillary sentinel lymph node biopsy followed by whole-breast irradiation. Using validated panels and software (the Breast Cancer Treatment Outcome Scale [BCTOS], EORTC Cancer Quality of Life Questionnaire number C30-BR23, and Breast Cancer Conservative Treatment - cosmetic results [BCCT.core] software), quality of life and aesthetic and functional parameters and their changes in correlation to the percentage of breast volume excised were statistically analyzed.

RESULTS

The maximum percentages of breast volume that were resectable by conventional BCS without resulting in unacceptable aesthetic and functional outcomes or decreased quality of life were 18-19% in the upper-outer quadrant (p < 0.0001), 14-15% in the lower-outer quadrant (p < 0.0001), 8-9% in the upper-inner quadrant (p < 0.0001), and 9-10% in the lower-inner quadrant (p < 0.0001).

CONCLUSION

Aided by the calculated cut-off values for each breast quadrant, breast surgeons might render more objective decisions regarding performing conventional BCS, using oncoplastic techniques or choosing mastectomy with immediate reconstruction.

Replacement of the tumor bed following oncoplastic breast-conserving surgery with immediate latissimus dorsi mini-flap

The aim of the present study was to evaluate the geographic variability of the tumor bed following oncoplastic breast-conserving surgery (OP-BCS), and to assess its relevance for radiotherapy planning. In this prospective study, pre- and postoperative computerized tomography (CT) scans of 22 patients with early-stage breast cancer were fused. The preoperative gross tumor volume or excisional biopsy cavity were contoured under the guidance of preoperative radiological images. Postoperative lumpectomy cavities were contoured under the guidance of surgical clips. The conformity index (CI) was calculated and defined on a scale between 0 and 1, where 0 indicated no overlap and 1 indicated 100% concordance. Associations between CI and the number of clips, time interval between surgery and CT scans, pathological tumor size and age were assessed using independent sample testing. The median CI was 0.07 (in five cases, 1, and in eight cases, 0). The lumpectomy cavity shifted from the primary location in 36.4% of the cases. Median shifts between the isocenters of pre- and postoperative volumes were measured as 1.02 cm (range, 0.4-4.43 cm) in the x, 1.07 cm (range, 0.05-5.67 cm) in the y, and 1.12 cm (range, 0-3.75 cm) in the z directions. Only the clip number was determined to be significantly associated with CI (P=0.017). Pre- and postoperative tumor bed volumes were fully superposed in five of the 22 cases. The present study has shown that the tumor bed is markedly replaced following OP-BCS with latissimus dorsi mini-flap (LDMF) reconstruction. Special care should therefore be taken when defining the lumpectomy cavity following OP-BCS with LDMF reconstruction.

The breast cancer conservative treatment. Cosmetic results - BCCT.core - Software for objective assessment of esthetic outcome in breast cancer conservative treatment: A narrative review

BACKGROUND AND OBJECTIVE

Cosmetic outcome of breast cancer conservative treatment (BCCT) remains without a standard evaluation method. Subjective methods, in spite of their low reproducibility, continue to be the most frequently used. Objective methods, although more reproducible, seem unable to translate all the subtleties involved in cosmetic outcome. The breast cancer conservative treatment cosmetic results (BCCT.core) software was developed in 2007 to try to overcome these pitfalls. The software is a semi-automatic objective tool that evaluates asymmetry, color differences and scar visibility using patient's digital pictures. The purpose of this work is to review the use of the BCCT.core software since its availability in 2007 and to put forward future developments.

METHODS

All the online requests for BCCT.core use were registered from June 2007 to December 2014. For each request the department, city and country as well as user intention (clinical use/research or both) were questioned. A literature search was performed in Medline, Google Scholar and ISI Web of Knowledge for all publications using and citing "BCCT.core".

RESULTS

During this period 102 centers have requested the software essentially for clinical use. The BCCT.core software was used in 19 full published papers and in 29 conference abstracts.

CONCLUSIONS

The BCCT.core is a user friendly semi-automatic method for the objective evaluation of BCCT. The number of online requests and publications have been steadily increasing turning this computer program into the most frequently used tool for the objective cosmetic evaluation of BCCT.

Long-term objective esthetic outcome after breast-conserving therapy

The prediction of unfavorable long-term esthetic outcome (AO) is important for patient consultation. We aimed to analyze variables characterizing the improvement and impairment of AO over time after breast-conserving surgery. A subgroup of a prospective, monocenter cohort study was analyzed to evaluate the results of the BCCT.core software (Breast Cancer Conservative Treatment.cosmetic results) which was used to objectively assess the AO before (n = 356), shortly after (n = 294) and in median 3 years after surgery (n = 356). We analyzed potential influencing factors (such as body mass index, (y)pT-stage, weight of resected specimen, etc.) on the AO using logistic regression analyses (n = 256). Finally, we tried to characterize groups of patients with improving or impaired AO over time (n = 294). Predictors for an unfavorable AO were an axillary lymphadenectomy (OR = 4.05), a tumor in the 12 o'clock position (OR = 2.22), a tumor stage larger or equal to (y)pT2 stage (OR = 2.11), and a surgical specimen weight >75 g (OR = 2.71). Patients with lower specimen weight were more likely to improve in the long-term follow-up (p = 0.018), whereas patients with a higher (y)pT-stage tended to become impaired with time. Although overall AO decreased over time, nearly half of the patients with an unfavorable AO shortly after surgery improved in the long-term follow-up. Predictors of unfavorable AO can be used in patient consultation preoperatively to prepare them for the postsurgical period and/or to recommend surgical alternatives (e.g., more complex oncoplastic techniques). Knowledge of improvement and impairment may help patients and physicians in the postsurgical consultation setting.

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.

Preoperative prediction of cosmetic results in breast conserving surgery

BACKGROUND

Preoperative objective predictions of cosmetic result after breast conserving surgery (BCS) has the potential to aid in surgical treatment decision making. Our aim was to investigate the predictive value of tumor volume in relation to breast volume (TV/BV ratio) for cosmetic result.

METHODS

Sixty-nine invasive breast cancer women with preoperative MRI and treated by BCS and radiotherapy in 2007-2012 were prospectively included. Simple excision or basic oncoplastic techniques were used, but no volume displacement. TV/BV ratio was measured in the MRI while 3D-projected in virtual reality environment (I-Space). Cosmetic result was assessed by patient questionnaire, panel evaluation, and breast retraction assessment (BRA). Quality-of-life was assessed by EORTC QLQ-C30 and BR23.

RESULTS

Intraobserver and interobserver correlation coefficients for tumor and breast volume were all >0.95. Increasing TV/BV ratio correlated with decreasing cosmetic result as determined by patient, panel, and BRA. TV/BV ratio was a significant independent predictor for the panel evaluation (P=0.028), as was tumor location (P<0.05), and together they constituted a good prediction model (AUC 0.83).

CONCLUSIONS

TV/BV ratio was a precise and independent predictor for cosmetic result determined by a panel and can be used as preoperative prediction tool to enable more informed surgical treatment decision making.

A cosmesis outcome substudy in a prospective, randomized trial comparing radioguided seed localization with standard wire localization for nonpalpable, invasive, and in situ breast carcinomas

BACKGROUND

The primary study objective was to compare the cosmetic result of radioguided seed localization (RSL) with wire localization (WL).

METHODS

A subgroup of patients enrolled in a multicentered, randomized trial comparing WL with RSL participated. Frontal photographs were taken 1 and 3 years postsurgery. The European Organization for Research and Treatment of Cancer Cosmetic Rating System was used to evaluate cosmesis outcomes by the patient and a panel of 5 raters.

RESULTS

The study enrolled 73 patients (WL, n = 38; RSL, n = 35). Most patients rated their overall cosmesis as "excellent" or "good" (76% WL, 80% RSL). Patient and panel ratings on all cosmetic outcomes were similar between groups. Multivariable regression for overall cosmesis found larger specimen volume and reoperation to be predictors of worse ratings.

CONCLUSIONS

All cosmetic outcomes assessed were similar after WL and RSL. The comparable outcomes may reflect similar reoperation rates and volumes of excision between groups.

Mammotome-assisted endoscopic breast-conserving surgery: a novel technique for early-stage breast cancer

Background

Because of its minimally invasive and highly accurate nature, the use of Mammotome, a vacuum-assisted breast biopsy device has proven beneficial to the treatment of benign breast lesions. Taking advantage of endoscopic and Mammotome techniques together, we utilized the Mammotome device for therapeutic excision of malignant lesions in breast-conserving surgery (BCS).

Methods

Between December 2009 and January 2010, two patients with early breast cancer received Mammotome-assisted endoscopic BCSs. Under ultrasound monitoring, the Mammotome system dissected the surrounding tissue and freed the tumor en bloc leaving negative margins; endoscopic axillary lymph node dissection then followed.

Results

The operation time was less than 180 minutes and the mean blood loss was 60 ml. The post-operative pathology report confirmed two patients to have invasive ductal carcinoma, one without axillary lymph nodes metastasis (0/11) and the other with one lymph node metastasis (1/21). No adverse events were noted. During a mean follow-up of 26.5 months, no evidence of recurrence or metastasis was found. The patients were satisfied with the cosmetic results.

Conclusions

Mammotome-assisted endoscopic surgery appears to be a valuable option for early breast cancer. The long-term therapeutic effect remains to be confirmed.

[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.

Cosmetic outcomes following head and neck melanoma reconstruction: The patient's perspective

BACKGROUND

While studies have compared aesthetic outcomes following wide local excision of head and neck melanoma, none have evaluated this important outcome from the patient's perspective. Indeed, one could argue that the psychosocial impact of head and neck melanoma excision and reconstruction is more accurately assessed by deriving patient-based as opposed to surgeon-based outcome measures.

OBJECTIVE

To evaluate aesthetic outcomes following wide local excision of head and neck melanoma from the patient's perspective.

METHODS

Fifty-one patients who underwent excision of 57 head and neck melanomas followed by immediate closure by primary repair, skin grafting, local flap coverage or free tissue transfer were asked to complete a written survey at least six months after their surgery. A visual analogue scale (VAS) was used to assess the patient's perception of appearance alteration, satisfaction with his or her appearance, and emotional impairment. An ordinal scale was used to evaluate several criteria of the reconstructive outcome (pain, itching, colour, scarring, stiffness, thickness and irregularity).

RESULTS

Forty-two patients (82.4%) completed the survey. There were significant correlations between VAS scores reported for appearance alteration, satisfaction with outcome and emotional impairment (P=0.001). Patients who received skin grafts reported significantly unfavourable VAS scores compared with other methods of reconstruction (P=0.046). Moreover, skin grafts received significantly worse ordinal scale ratings for itching (P=0.043), colour (P=0.047), scarring (P=0.003) and stiffness (P=0.041) compared with other methods of reconstruction. Both skin grafts and free flaps were reported to have significantly less favourable thickness (P=0.012) and irregularity (P=0.036) than primary closure or local tissue transfer. There was no significant difference between patients undergoing primary closure with local tissue transfer (P>0.413). Other factors related to the patient's VAS scores included location of the melanoma (P=0.033), size of defect (P=0.037) and recurrence of melanoma (P=0.042).

CONCLUSION

The degree of emotional impairment following reconstruction of head and neck melanoma excision defects was correlated with the patient's perception of appearance alteration. From the patient's perspective, primary closure and local tissue transfer appeared to result in the highest aesthetic satisfaction.

Long-term cosmetic changes after breast-conserving treatment of patients with stage I-II breast cancer and included in the EORTC 'boost versus no boost' trial

BACKGROUND

In breast cancer treated with breast-conserving radiotherapy, the influence of the boost dose on cosmetic outcome after long-term follow-up is unknown.

PATIENTS AND METHODS

We included 348 patients participating in the EORTC 'boost versus no boost' mega trial with a minimum follow-up of 6 years. Digitalised pictures were analysed using specific software, enabling quantification of seven relative asymmetry features associated with different aspects of fibrosis.

RESULTS

After 3 years, we noted a statistically significantly poorer outcome for the boost patients for six features compared with those of the no boost patients. Up to 9 years of follow-up, results continued to worsen in the same magnitude for the both patient groups. We noted the following determinants for poorer outcome: (i) boost treatment, (ii) larger excision volumes, (iii) younger age, (iv) tumours located in the central lower quadrants of the breast and (v) a boost dose administered with photons.

CONCLUSIONS

A boost dose worsens the change in breast appearance in the first 3 years. Moreover, the development of fibrosis associated with whole-breast irradiation, as estimated with the relative asymmetry features, is an ongoing process until (at least) 9 years after irradiation.

The impact of the sentinel node concept on the aesthetic outcome of breast cancer conservative surgery

BACKGROUND

The sentinel node (SN) concept has brought numerous advantages to women with breast cancer. Sparing axillary node anatomy and physiology may enhance the cosmetic results of breast cancer conservative surgery, either owing to less breast edema or to a better tolerance to the effects of surgery and radiotherapy. Our aim was to compare the cosmetic outcome of two randomized groups of patients, on a subjective and objective basis.

METHODS

A consecutive series of breast cancer patients (n = 60) submitted to partial mastectomy plus axillary dissection or partial mastectomy plus SN biopsy (included in a randomized trial) was photographed. Photos were analysed in three ways: by seven different observers according to seven features from poor to excellent; two observers estimated the percentage of breast retraction assessment (pBRA); or by the BCCT.core 1.0(®) software.

RESULTS

The panel subjective analysis showed a benefit in terms of the skin colour for the patients submitted to SN biopsy only. This group of patients did not show any advantage in terms of pBRA estimates even after the complex BCCT.core appraisal.

CONCLUSIONS

The sentinel node concept is not associated with improvements in the aesthetic outcome of breast cancer conservative treatment.

Oncoplastic surgical techniques for personalized breast conserving surgery in breast cancer patient with small to moderate sized breast

Oncoplastic surgery has revolutionized the field of breast conserving surgery (BCS). The final aims of this technique are to obtain an adequate resection margin that will reduce the rate of local recurrence while simultaneously improving cosmetic outcomes. To obtain successful results after oncoplastic surgery, it is imperative that patients be risk-stratified based on risk factors associated with positive margins, that relevant imaging studies be reviewed, and that the confirmation of negative margins be confirmed during the initial operation. Patients who had small- to moderate-sized breasts are the most likely to be dissatisfied with the cosmetic outcome of surgery, even if the defect is small; therefore, oncoplastic surgery in this population is warranted. Reconstruction of the remaining breast tissue is divided into volume displacement and volume replacement techniques. The use of the various oncoplastic surgeries is based on tumor location and excised breast volume. If the excised volume is less than 100 g, the tumor location is used to determine which technique should be used, with the most commonly used technique being volume displacement. However, if the excised volume is greater than 100 g, the volume replacement method is generally used, and in cases where more than 150 g is excised, the latissimus dorsi myocutaneous flap may be used to obtain a pleasing cosmetic result. The local recurrence rate after oncoplastic surgery was lower than that of conventional BCS, as oncoplastic surgery reduced the rate of positive resection margins by resecting a wider section of glandular tissue. If the surgeon understands the advantages and disadvantages of oncoplastic surgery, and the multidisciplinary breast team is able to successfully collaborate, then the success rate of BCS with partial breast reconstruction can be increased while also yielding a cosmetically appealing outcome.

Comparative study of surgical margins and cosmetic outcome in lumpectomy versus segmental resection in breast cancer

OBJECTIVE

The aim of the present retrospective study was to compare two breast-conserving techniques, segmental resection and standard lumpectomy, for the treatment of breast cancer regarding their oncological safety. Quality of life aspects were evaluated by assessing the respective postsurgical cosmetic results.

PATIENTS AND METHODS

190 women with breast cancer located in the superior and lateral quadrant were included in the study. Sixty patients were treated with segmental resection (group 1), whereas 130 underwent standard lumpectomy (group 2). Tumor sizes were determined and excised tissue specimens were analyzed for positive or negative resection margins. Patients were given a 16-item questionnaire for the postsurgical self-assessment of the cosmetic outcome.

RESULTS

No statistically significant difference was found concerning the number of positive resection margins between the groups (25 vs. 30%, p = 0.46). Exceptions were ventral margins, which predominated in group 2 (p = 0.016). Group 1 revealed a significantly larger maximum tumor size with negative margins as compared to group 2 (26.6 vs. 17.0 mm). General satisfaction with the cosmetic results was comparable between groups.

CONCLUSIONS

Segmental resection surgery, as a method of breast conservation therapy, can be used to treat larger breast lesions as compared to standard lumpectomy.

Do reexcisions impair aesthetic outcome in breast conservation surgery? Exploratory analysis of a prospective cohort study

PURPOSE

Reexcision is a clinically relevant aspect of oncological breast conservation surgery. The influence of reexcision on aesthetic outcome is described differently in the literature. Our aim was to analyze this question in a well-defined cohort with standardized study instruments.

METHODS

A total of 439 patients from a prospectively followed cohort were included in this analysis. Aesthetic results were assessed by the Breast Cancer Treatment Outcome Scale (BCTOS) aesthetic status. Dates of assessments were shortly after surgical interventions and before surgery. Group comparison was performed between patients with reexcisions (80 cases; 18%) and patients without reexcision (359 cases; 82%). We considered variables of differing distribution between the two groups that could hypothetically influence BCTOS aesthetic status in a nonparametric analysis of covariance (ANCOVA).

RESULTS

The aesthetic status of patients with reexcisions was found to be significantly worse than for patients with a single breast conservation surgery (P < 0.0001) when tested by a nonparametric ANCOVA model. Because patients with reexcisions had more noninvasive tumors (25% vs. 8%, P = 0.0001) and tumors were larger in patients with reexcision (P = 0.01), we included these variables as possible covariates in the multivariate model. The model was adjusted for the BCTOS aesthetic status before and shortly after the first surgery.

CONCLUSIONS

Our findings suggest that reexcision in breast conservation surgery impairs aesthetic outcome, at least when assessed shortly after surgery.

Assessment of cosmesis after breast reconstruction surgery: a systematic review

BACKGROUND

Breast reconstruction (BR) is undertaken to improve cosmetic outcomes, but how this is optimally assessed is uncertain. This review summarises current methods for assessing cosmesis after reconstructive surgery and makes recommendations for future practice.

METHODS

A comprehensive systematic review identified all studies with 20 or more participants that evaluated the cosmetic outcome of BR. Four evaluation criteria (reporting of study inclusion criteria, type and timing of BR and timing of assessment) were used to assess study quality. Articles reporting at least three of the four criteria were considered robust and further summarised to report methods of cosmetic assessment, assessor details and the scoring systems used.

RESULTS

122 primary papers assessed cosmesis in 11,308 women with median follow-up of 28.8 months (range 18.0-42.9 months). Cosmesis was assessed by either healthcare professionals or patients in 33 (27.1%) and 37 studies (30.3%), respectively, and by both professionals and patients in 52 (42.6%). Professional assessments included 43 (40.2%) clinical, 49 (45.8%) photographic and 13 (12.1%) geometric assessments conducted by between 1 and 26 observers. Surgeons were most frequently involved in assessments (n = 71, 67.6%), but in 38 (36.1%) papers the assessor's profession was not reported. Twenty-seven (25.7%) papers used previously published assessment scale. Patients' views were assessed in 89 studies, using questionnaires (n = 63) or interviews (n = 12); 14 (15.7%) did not report how patients' views were obtained.

CONCLUSIONS

Current methods for assessing the cosmetic outcome of BR vary widely. A valid patient-centred assessment method is required to fully understand the outcomes of BR and to inform decision-making.

Clinical outcomes of video-assisted skin-sparing partial mastectomy for breast cancer and immediate reconstruction with latissimus dorsi muscle flap as breast-conserving therapy

BACKGROUND

Skin-sparing partial mastectomy (SSPM) has yet to be investigated as a breast-conserving therapy for early-stage breast cancer. We report the clinical outcomes for video-assisted SSPM (VA-SSPM) with immediate breast reconstruction using autogenous tissue.

METHODS

VA-SSPM is indicated for early-stage breast cancer arising in the upper-outer or lower-outer quadrant without skin involvement. An incision is placed along the midaxillary line, and SSPM is performed under endoscopic guidance using subcutaneous tunneling and lifting methods. Through the same incision, a latissimus dorsi muscle flap is harvested for breast reconstruction. From January 2000 to October 2007, 168 patients (Tis, n = 24; T1, n = 37; T2, n = 107) underwent VA-SSPM, and morbidity, curability, and postoperative patient satisfaction were investigated.

RESULTS

Postoperative complications included skin necrosis (2.4%, n = 4) and muscle flap necrosis (0.6%, n = 1), but no severe complications were observed. After a mean follow-up of 58.6 months, eight patients (4.8%) experienced local recurrence. Sixty-month distant metastasis-free survival rates for Tis, T1, and T2 were 100%, 97%, and 83.3%, respectively, with an overall rate of 88.4%. Furthermore, overall survival rates for Tis, T1, and T2 were 100%, 94.1%, and 94.4%, respectively, with an overall survival rate of 95% for all patients. A patient satisfaction survey showed that 81.6% of patients evaluated the surgery as "good."

CONCLUSIONS

VA-SSPM for early-stage breast cancer improves cosmetic results and achieves high patient satisfaction without increasing local or distant organ recurrence. This method offers a useful local therapy for early-stage breast cancer.

Aesthetics in breast conserving therapy: do objectively measured results match patients' evaluations?

BACKGROUND

To analyze the relationship of objective and subjective evaluation tools of breast aesthetics, we compare the results of the BCCT.core (breast cancer conservative treatment.cosmetic results) software, a semiautomated objective symmetry evaluation tool, with those of the Aesthetic Status of the BCTOS (Breast Cancer Treatment Outcome Scale) patient questionnaire.

MATERIALS AND METHODS

We included 128 patients with one-sided, primary breast cancer, treated conservatively in a prospective, exploratory study in order to assess the inter-rater reliability of the BCCT.core and the agreement between the BCCT.core and the BCTOS preoperatively, shortly and 1 year after surgery. Therefore, we use agreement rates, multiple (mk), and weighted (wk) kappa coefficients as statistical methods. Furthermore, we analyzed patient-, tumor-, and therapy-related variables as possible covariates to explain agreement.

RESULTS

The inter-rater reliability for the semiautomated BCCT.core is very good with agreement rates up to 84% (mk = 0.80). The agreement rates of the BCCT.core and the BCTOS Aesthetic Status range between 35 and 44% subject to the different times of assessment (wk = 0.34 at best). Moreover, the patients judge their aesthetic outcome more positively than the software. None of the considered patient-, tumor-, and therapy-related covariates turned out to explain agreement.

CONCLUSION

The BCCT.core is a reliable instrument that shows fair agreement with patient's perspective.

Effect of Esthetic Outcome After Breast-Conserving Surgery on Psychosocial Functioning and Quality of Life

Purpose

Although breast-conserving surgery (BCS) is often assumed to result in minimal deformity, many patients report postoperative breast asymmetry. Understanding the effect of asymmetry on psychosocial functioning is essential for patients to make an informed choice for surgery.

Patients and Methods

All women who underwent BCS at the University of Michigan Medical Center (Ann Arbor, MI) during a 4-year period were surveyed using a mailed questionnaire (N = 714; response rate = 79.5%). Women were queried regarding five aspects of psychosocial functioning: quality of life (QOL), depression, fear of recurrence, stigmatization, and perceived change in health status. Postoperative breast asymmetry was assessed using items from the Breast Cancer Treatment and Outcomes Survey. Multiple regression was used to examine the relationship between breast asymmetry and each outcome, controlling for age, time from surgery in years, race, education level, disease stage, surgical treatment, and the occurrence of postoperative complications.

Results

Women with pronounced breast asymmetry were significantly more likely to feel stigmatized as a result of their breast cancer treatment (odds ratio [OR] = 4.58; 95% CI, 2.77 to 7.55) and less likely to report unchanged or improved health after treatment (OR = 0.43; 95% CI, 0.27 to 0.66). Minimal breast asymmetry was associated with higher QOL scores (86.3 v 82.4, P < .001). Finally, women with pronounced breast asymmetry were more likely to exhibit depressive symptoms (minimal asymmetry, 16.2%; moderate asymmetry, 18.0%; pronounced asymmetry, 33.7%, Wald test = 16.6; P = .002).

Conclusion

Pronounced breast asymmetry after BCS is significantly correlated with poor psychosocial functioning. Identifying patients at risk for postoperative asymmetry at the time of consultation may allow for improved referral for supportive counseling, prosthetics, and reconstruction.

Turning subjective into objective: The BCCT.core software for evaluation of cosmetic results in breast cancer conservative treatment

Twelve expert observers from nine different countries convened in a workshop to evaluate the validity of the Breast Cancer Conservative Treatment. Cosmetic results (BCCT.core) software, an objective method for the aesthetic evaluation of breast cancer conservative treatment. Experts were initially asked to subjectively classify the aesthetic results of 30 photographed cases submitted to breast cancer conservative treatment according to the four-point Harris scale. It was pre-established that if at least two-thirds [Cardoso MJ, Cardoso J, Santos AC, Barros H, Oliveira MC. Interobserver agreement and consensus over the esthetic evaluation of conservative treatment for breast cancer. Breast 2005] of participants provided the same classification this would be considered a consensual evaluation for that case. For cases where such agreement was not reached, consensus was obtained using a nominal group technique. Experts then individually performed objective evaluation of the same set of photographs using the BCCT.core software. This provides an automatic rating of aesthetic results, once scale and reference points in the photograph have been chosen. Agreement between observers, between each observer and the consensus, for computer evaluation obtained by the different participants and between software and consensus was calculated using multiple kappa (k) and weighted kappa (wk) statistics. In the subjective assessment, first-round consensus was achieved in 17 (57%) cases. Overall interobserver agreement was fair to moderate (k=0.40, wk=0.57). In the objective assessment there was a higher level of concordance between participants (k=0.86, wk=0.90). Agreement between software and consensus classification was fair (k=0.34, wk=0.53), but was higher in the 17 cases that reached first-round consensus (k=0.60, wk=0.73). Merging the two middle classes of the Harris scale, to form a three-point scale, led to an improvement of all non-weighted measures of agreement. These results show that the BCCT.core software provides consistent evaluation of cosmesis. It has the potential to become a gold standard method for assessment of breast cosmesis in clinical trials, as it can be used simultaneously by a panel of observers from different parts of the world to provide more reliable assessments than has been possible previously.

Radiotherapy for Ductal Carcinoma In Situ

AIMS

The introduction of breast screening mammography has led to an increase in the diagnosis of ductal carcinoma in situ (DCIS). Mastectomy gives high rates of local control. However, most cases are suitable for local excision. The aim of this article is to review the role of radiotherapy in the treatment of DCIS after breast conserving surgery.

MATERIAL AND METHODS

A review of the literature relating to radiotherapy and DCIS RESULTS: The published trials show that adjuvant radiotherapy after breast conserving surgery halves the ipsilateral recurrence rates of DCIS and invasive cancer. No subgroups have been reliably identified that do not benefit from adjuvant radiotherapy. Risk factors for recurrence are discussed.

DISCUSSION

All patients with DCIS have potential benefit to gain from adjuvant radiotherapy. However, radiotherapy also has adverse effects and represents over-treatment from many women. Support should be given to current trials which are assessing endocrine treatment of DCIS, and whether radiotherapy can reasonably be omitted in lower risk disease.

Interobserver agreement and consensus over the esthetic evaluation of conservative treatment for breast cancer

Twenty-four experts from 13 different countries were asked to evaluate photographs taken of 60 women following conservative breast cancer treatment. The esthetic result of each case was classified as poor, fair, good or excellent. Agreement was evaluated using the kappa (k) and weighted kappa (wk) statistics, for all observers, male and female participants, those younger and older than 50 years, those seeing more than 250 cases a year, and those with previous publications in this area. Consensus was obtained by way of a modified Delphi approach, when more than 50% of participants provided the same classification. In a second round, consensual cases were disclosed and a revised opinion was asked in non-consensual ones. Agreement between all participants was fair (k=0.24, wk=0.37) and remained within the same range (k=0.20-0.31, wk=0.31-0.45) in the subgroups analyzed. First round consensus was obtained in 46 out of 60 cases (77%) and in the second round in 59 out of 60 cases (98%). Evaluation of the esthetic results of conservative treatment for breast cancer is only fairly reproducible when performed by experts working in different geographical areas. Consensus is obtainable if a relatively low threshold of agreement is considered acceptable.

A subjective rating scale for evaluating the appearance outcome of autologous breast reconstruction

BACKGROUND

Subjective evaluations of the appearance outcome of autologous breast reconstruction are usually performed by surgeons and not by patients. Such surgeon-based evaluations are rarely reproducible and show little interobserver agreement. Among existing patient-based subjective scales, none has been tested for reliability, and no study to date has evaluated the reliability when both surgeons and patients use the same scale.

METHODS

The authors developed a new instrument for assessing the appearance of autologous breast reconstruction. The instrument's use by four plastic surgeons and 36 transverse rectus musculocutaneous flap patients was assessed for test-retest reliability, internal consistency, surgeon-patient and surgeon-surgeon interobserver agreement, and interitem correlation.

RESULTS

The instrument demonstrated high overall internal consistency when used by patients (Cronbach alpha = 0.92). Test-retest reliability on each aesthetic subitem in the scale was higher among patients than among surgeons (weighted kappa range, 0.57 to 0.88 versus 0.25 to 0.66). Interrater agreement was poor among both patients and surgeons (weighted kappa, 0.0 to 0.39). Poor correlation was found between surgeons' evaluations of aesthetic subitems and patients' overall appearance and overall satisfaction scores.

CONCLUSIONS

The instrument both demonstrates better internal consistency and is more reliable when used by patients to evaluate their own reconstructions. By contrast, the instrument's use by surgeons is not as internally consistent and reproducible. The poor interobserver agreement among surgeons and the weak correlation between surgeon and patient evaluations suggest that patient input regarding item-specific criteria should be included in evaluations of breast reconstructions.