Factors Determining Esthetic Outcome after Breast Cancer Conservative Treatment

Capturing longer term surgical outcome measures as part of routine care of breast cancer patients

INTRODUCTION

The transition away from routine clinical follow up after breast cancer towards imaging surveillance and patient-initiated contact limits opportunities for patients and doctors to communicate about the long-term effects of treatment. The ABS oncoplastic guidelines (2021) recommend that post-operative 2D images and patient-reported outcomes (PROMs) are routinely collected but give no guidance as to how best to implement this.

METHODS

From December 2019 until March 2024, women due for their year 3 or 5 surveillance mammogram at The Royal Marsden Sutton site were invited to complete a BREAST-Q questionnaire and attend medical photography. Panel assessment of photographs was undertaken. Results were presented to the oncoplastic MDT, including summary PROMs and illustrative case presentations. Free-text comments were shared with the relevant teams. Associations between demographic or clinic-pathological factors and uptake were investigated.

RESULTS

Of the 1211 women invited, 246 patients (20.3 %) completed BREAST-Q questionnaires, 182 (15.0 %) attended for medical photography and 114 (9.4 %) completed both. Uptake was not associated with age, ethnicity or surgical factors but patients with higher BMI were less likely to respond to the questionnaire. Patients who had undergone complex oncoplastic procedures were more likely to respond than those who had simple procedures. Patient-reported outcome results were in line with the published literature.

CONCLUSION

Reviewing images with their paired PROMs and discussing free-text feedback was instructive for the team. Work is needed to identify barriers to patient participation and improve uptake to be representative of the overall patient population. Quantifying appearance in photographs would help summarise aesthetic outcome data.

The Impact of Breast-Conserving Surgery Re-excision on Patient-Reported Outcomes Using the BREAST-Q

BACKGROUND

Approximately 14% of women undergoing breast-conserving surgery (BCS) require re-excision to achieve negative margins following the Society of Surgical Oncology (SSO) and American Society for Radiation Oncology (ASTRO) margin guidelines, which may influence patient-reported outcomes (PROs). Few studies have assessed the impact of re-excision on PROs following BCS.

PATIENTS AND METHODS

Women with stage 0-III breast cancer undergoing BCS who completed a BREAST-Q PRO measure from 2010 to 2016 were identified from a prospective database. Baseline characteristics were compared between women who underwent one BCS and those who underwent ≥ 1 re-excision surgery for positive margins (R-BCS). Linear mixed models were used to analyze associations between number of excisions and BREAST-Q scores over time.

RESULTS

Of 2543 eligible women, 1979 (78%) had one BCS and 564 (22%) had R-BCS. Younger age, lower BMI, surgery pre-SSO Invasive Guidelines issuance, ductal carcinoma in situ (DCIS), multifocal disease, radiation therapy receipt, and endocrine therapy omission were more common in the R-BCS group. Breast satisfaction and sexual well-being were lower in the R-BCS group 2 years postoperatively. There were no differences in psychosocial well-being between groups over 5 years. On multivariable analysis, re-excision was associated with lower breast satisfaction and sexual well-being (p= 0.007 and p= 0.049, respectively), but there was no difference in psychosocial well-being (p= 0.250).

CONCLUSIONS

Women with R-BCS had lower breast satisfaction and sexual well-being 2 years postoperatively, but this difference did not remain long term. Psychosocial well-being in women who underwent one BCS were largely comparable over time to the R-BCS group. These findings may help in counseling women who are concerned about satisfaction and quality-of-life outcomes with BCS if re-excision is necessary.

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.

Safety of Reduction Mammaplasty and Mastopexy After Breast Conservation Therapy and Radiation Therapy: A Case Series

BACKGROUND

Conservative surgery and radiotherapy (CS + RT) have become the standard of care for early-stage breast cancer as an alternative to mastectomy. With the increasing rate of obesity and incidence of macromastia, surgeons increasingly encounter patients with a history of breast radiation desiring breast reduction. However, elective breast surgery after irradiation remains to be controversial due to known adverse effects of radiation, especially on wound healing, and unknown effects of lumpectomy on traditional pedicle choices. Herein, we present our experiences and outcomes of reduction mammaplasties and mastopexies in patients with breast cancer previously treated with CS + RT.

METHODS

Between 2009 and 2020, 13 patients undergoing reduction mammaplasty or mastopexy, who have previously underwent CS + RT with or without axillary surgery, were included in this study. Surgical techniques and complications, including delayed wound healing, infection, fat necrosis, and nipple-areolar necrosis, were recorded and analyzed based on the irradiated versus nonirradiated sides.

RESULTS

Of the 13 patients, delayed wound healing occurred in 7% on the irradiated side and 15% on the nonirradiated sides (P > 0.05). No significant correlation was observed between the number of complications and time of elective breast surgery from the last radiation therapy. Complications between irradiated and nonirradiated breasts did not significantly differ in both the reduction mammaplasty and mastopexy groups.

CONCLUSIONS

Reduction mammaplasty and mastopexy in patients with a history of lumpectomy and breast irradiation can be safely performed and should be considered in those experiencing macromastia or asymmetry post-CS + RT.

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.

Dual-Layer Rotation: A Versatile Therapeutic Mammoplasty Technique

Background

Multifocal or complex breast lesions are a challenge for breast-conserving surgery, particularly surgery in small breasts or those located in the upper inner quadrant. The dual-layer rotation technique exploits the idea of manipulating the skin and glandular tissue in separate layers to fill the resection cavity via vertical mammoplasty if skin excision is not required, except in the central area.

Methods

The authors performed a retrospective review of consecutive breast cancer patients who underwent DLR mammoplasty between 2017 and 2019 at a single institution. Clinical data, reoperations, surgical complications, delays in adjuvant treatments, and the need for late revisional surgery were evaluated. Aesthetic outcomes were evaluated objectively and subjectively from photographs.

Results

The study included 46 breasts of 40 patients. Tumors were located in the UIQ (30%, 14/46) or in multiple quadrants (22%, 10/46). One third (33%, 13/40) of the patients had a small breast cup size (A–B). Negative margins were primarily achieved in 45 of the 46 breasts. Major complications occurred in three patients, who needed reoperation, and adjuvant therapy was delayed for one of these patients. Late refinement surgery was needed for two patients. The objective and subjective aesthetic outcomes were good or excellent regardless of the tumor position.

Conclusion

As a novel oncoplastic approach, DLR mammoplasty offers a one-step procedure to treat selected breast cancer patients with challenging resection defects due to different breast sizes or lesion locations. The technique preserves the breast’s natural appearance.

Factors related to patient-reported cosmetic outcome after breast-conserving therapy for breast cancer

BACKGROUND

Multiple factors can affect cosmetic outcome after breast-conserving therapy. We investigated which combination of factors could optimally predict patient reported cosmetic outcome.

METHODS AND MATERIALS

Dutch patients treated with BCT between 2008 and 2013 were retrospectively analysed. Demographics, tumour characteristics, and treatment-related factors were obtained from available digital medical records. Patients were asked to indicate their degree of cosmetic satisfaction using the Harvard scale. Both univariable and multivariable logistic regression analyses were performed to create a prediction model.

RESULTS

The present study based on 220 patients shows that univariable analysis radiotherapy boost (OR 4.01 [1.85-8.70], p ≤ 0.001) and adjuvant chemotherapy (OR 2.67 [1.45-4.92], p = 0.002) were significantly associated with unsatisfactory cosmetic outcome. In multivariable analyses, only a radiotherapy boost remained significantly associated (OR 4.08 [1.76-9.49], p = 0.001) with poor cosmetic outcome, while adjuvant chemotherapy was no longer associated with it (OR 1.61 [0.81-3.24), p = 0.18). These two factors, together with tumour histology and lymph node staging, showed the highest predictive values, although the predictive property of the overall model was limited (AUC = 0.69).

CONCLUSION

In the present study, a variety of factors is explored. However, a radiotherapy boost was the only factor that was independently associated with a poor cosmetic outcome after BCT. This finding can be used for counselling in daily clinical practice. Creation of a prediction model will require further investigation.

Breast cancer patient-reported outcome of factors influencing cosmetic satisfaction after breast-conserving therapy

Background

The aim of this study was to investigate which factors patients considered to be important for determining the degree of cosmetic satisfaction with regards to perceived body image after previous breast-conserving therapy (BCT).

Methods

Outcomes considered relevant by the patients were first identified using interviews. A questionnaire based on this group input was then devised and added to the physician-based Sneeuw questionnaire. Next, a quantitative study using this questionnaire was conducted in Dutch patients treated at least 6 months earlier for (non-) invasive breast cancer by BCT. Exclusion criteria were: previous mastectomy or BCT of the contralateral breast, BCT with nipple resection, metastatic disease, local recurrence or (previous) plastic breast surgery. Descriptive statistics were used throughout.

Results

A total of 149 patients (aged 36–87 years) completed the questionnaire. From this focus group input, the top three factors in overall importance (important or very important) for satisfaction were: ‘wearability of bra’ (67%), ‘breast sensitivity’ (59%) and ‘asymmetry’ (51%). Younger patients (< 55 years) considered ‘breast size’ to be most important, whereas ‘wearability of bra’ was most frequently reported by older patients (> 55 years). Time since BCT did not significantly influence the rating of relevant factors.

Conclusion

Patients consider ‘wearability of bra’, ‘breast sensitivity’ and ‘asymmetry’ as the most important factors when assessing their satisfaction with regards to cosmetic outcome and body image. These factors should be addressed in routine clinical practice during (pre) counseling.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12282-021-01287-0.

Cosmetic Consequences of Breast-Conserving Treatment for Breast Cancer: Something Worth Talking About

BACKGROUND

Breast-conserving treatment (BCT) for breast cancer can lead to deformation of the treated breast, resulting in patient dissatisfaction with the final cosmetic outcome. Currently, literature on the specific information needs of patients concerning the cosmetic effects of BCT is lacking. The aim of the present study was to investigate the information needs of breast cancer patients regarding the long-term cosmetic outcome after BCT.

SUBJECTS, MATERIALS, AND METHODS

The data from 115 women who had undergone BCT in a general teaching hospital breast cancer unit in The Netherlands were studied. Structured questionnaires and semi-structured interviews were conducted between October 2012 and April 2013. A mixed model of quantitative and qualitative research was used to explore patient-reported information needs. A phenomenological approach was used to analyze the qualitative data.

RESULTS

This study shows that women undergoing BCT want to discuss long-term cosmetic effects. Most patients appreciate such information immediately after the diagnosis. Patients indicated that it is also important to pay attention to the cosmetic effects during the follow-up visits, because deformation of the breast can also occur at a later stage. Furthermore, half the patients indicated that they would not likely raise the subject of cosmetic effects of the treatment themselves.

CONCLUSION

Breast cancer patients have a need for long-term attention for cosmetic outcome of BCT, which should be tailored during the treatment and follow-up process.

IMPLICATIONS FOR PRACTICE

Currently, no literature exists concerning patients' needs for information regarding the cosmetic effects of breast-conserving therapy (BCT). Bringing up the cosmetic effects of BCT by health care professionals does not appear to be a standard part of treatment and follow-up. It is expected that the quality of care and life will be improved by providing information and guidance regarding the cosmetic outcome of BCT within the existing structure of the breast cancer pathway. Discussion and visualization of the cosmetic effects prior to treatment will lead to more realistic expectations, and as a result, secondary interventions, such as partial prostheses and plastic surgery, may be easier to discuss and accept.

Breast Shape Analysis With Curvature Estimates and Principal Component Analysis for Cosmetic and Reconstructive Breast Surgery

Background

Breast shape is defined utilizing mainly qualitative assessment (full, flat, ptotic) or estimates, such as volume or distances between reference points, that cannot describe it reliably.

Objectives

The authors quantitatively described breast shape with two parameters derived from a statistical methodology denominated by principal component analysis (PCA).

Methods

The authors created a heterogeneous dataset of breast shapes acquired with a commercial infrared 3-dimensional scanner on which PCA was performed. The authors plotted on a Cartesian plane the two highest values of PCA for each breast (principal components 1 and 2). Testing of the methodology on a preoperative and posttreatment surgical case and test-retest was performed by two operators.

Results

The first two principal components derived from PCA characterize the shape of the breast included in the dataset. The test-retest demonstrated that different operators obtain very similar values of PCA. The system is also able to identify major changes in the preoperative and posttreatment stages of a two-stage reconstruction. Even minor changes were correctly detected by the system.

Conclusions

This methodology can reliably describe the shape of a breast. An expert operator and a newly trained operator can reach similar results in a test/re-testing validation. Once developed and after further validation, this methodology could be employed as a good tool for outcome evaluation, auditing, and benchmarking.

Level of Evidence 4

Development of a normal tissue complication probability model for late unfavourable aesthetic outcome after breast-conserving therapy

PURPOSE/OBJECTIVES

To develop a normal tissue complication probability (NTCP) model for late unfavourable aesthetic outcome (AO) after breast-conserving therapy.

MATERIAL AND METHODS

The BCCT.core software evaluated the AO using standardized photographs of patients treated between 2009 and 2014. Dose maps in 2 Gy equivalents were calculated assuming α/β = 3.6 Gy. Uni- and multivariable logistic regression analysis was performed to study the predictive value of clinicopathological and dosimetric variables for unfavourable AO. The Lyman Kutcher Burman (LKB) model was fit to the data with dose modifying factors (dmf). Model performance was assessed with the area under the curve (AUC) of the receiver operating characteristic curve and bootstrap sampling.

RESULTS

Forty-four of the 121 analysed patients (36%) developed unfavourable AO. In the optimal multivariable logistic regression model, a larger breast volume receiving ≥55 Gy (V55), a seroma and an axillary lymph node dissection (ALND) were independently associated with an unfavourable AO, AUC = 0.75 (95%CI 0.64;0.85). Beta-estimates were -2.68 for β₀, 0.057 for V55, 1.55 for seroma and 1.20 for ALND. The optimal LKB model parameters were EUD_3.6(50) = 63.3 Gy, n = 1.00, m = 0.23, dmf(seroma) = 0.83 and dmf(ALND) = 0.84, AUC = 0.74 (95%CI 0.61;0.83).

CONCLUSIONS

An NTCP model for late unfavourable AO after breast-conserving therapy was developed including seroma, axillary lymphadenectomy and V55.

A new approach for modeling patient overall radiosensitivity and predicting multiple toxicity endpoints for breast cancer patients

INTRODUCTION

Evaluation of patient characteristics inducing toxicity in breast radiotherapy, using simultaneous modeling of multiple endpoints.

METHODS AND MATERIALS

In 269 early-stage breast cancer patients treated with whole-breast irradiation (WBI) after breast-conserving surgery, toxicity was scored, based on five dichotomized endpoints. Five logistic regression models were fitted, one for each endpoint and the effect sizes of all variables were estimated using maximum likelihood (MLE). The MLEs are improved with James-Stein estimates (JSEs). The method combines all the MLEs, obtained for the same variable but from different endpoints. Misclassification errors were computed using MLE- and JSE-based prediction models. For associations, p-values from the sum of squares of MLEs were compared with p-values from the Standardized Total Average Toxicity (STAT) Score.

RESULTS

With JSEs, 19 highest ranked variables were predictive of the five different endpoints. Important variables increasing radiation-induced toxicity were chemotherapy, age, SATB2 rs2881208 SNP and nodal irradiation. Treatment position (prone position) was most protective and ranked eighth. Overall, the misclassification errors were 45% and 34% for the MLE- and JSE-based models, respectively. p-Values from the sum of squares of MLEs and p-values from STAT score led to very similar conclusions, except for the variables nodal irradiation and treatment position, for which STAT p-values suggested an association with radiosensitivity, whereas p-values from the sum of squares indicated no association. Breast volume was ranked as the most significant variable in both strategies.

DISCUSSION

The James-Stein estimator was used for selecting variables that are predictive for multiple toxicity endpoints. With this estimator, 19 variables were predictive for all toxicities of which four were significantly associated with overall radiosensitivity. JSEs led to almost 25% reduction in the misclassification error rate compared to conventional MLEs. Finally, patient characteristics that are associated with radiosensitivity were identified without explicitly quantifying radiosensitivity.

Batwing Mastopexy as Oncoplastic Surgical Approach to Periareolar Tumors in Upper Quadrants

Aims and background

Batwing mastopexy (BWM) is an oncoplastic technique most commonly used in the treatment of 12 o'clock periareolar tumors. The aim of this study was to assess the early cosmetic results of BWM performed for periareolar lesions located in the upper quadrants, i.e. from 10 to 2 o'clock position.

Methods and study design

A prospective analysis of a preliminary group of 35 women with periareolar intraductal or invasive breast cancer in the upper quadrants was done. All patients underwent wide lumpectomy with clear margins followed by BWM in order to obtain favorable cosmesis. For invasive cancers axillary biopsy or dissection was performed by separate incision. Cosmetic outcome was assessed 4 weeks after surgery by the patient with reference to breast shape, nipple-areola complex (NAC) position and scar arrangement. The result was rated as poor, medium or good for each parameter.

Results

There were no poor ratings of cosmetic outcome. The result was rated as medium by 5 women (14%) regarding breast shape and by 3 regarding NAC position (9%). The remaining women evaluated these parameters as good (86% and 91%, respectively). In contrast, scar arrangement was assessed as good by 26 patients (74%), medium by 8 (23%), and poor by 1 (3%). All women rating scar arrangement as other than good had a lesion located in the upper lateral quadrant. Considering the reasons for the relatively low scar acceptance by these women, the only important cause of disappointment was the placement of one of the radial parts of the scar in the area of decolletage in the upper medial quadrant.

Conclusions

BWM allows to achieve favorable breast shape and NAC position for lesions located in the upper quadrants regardless of the medial or lateral side. However, when performed in the lateral quadrant it produces a scar that can be hard to accept for some women.

Implant-Based Breast Reconstruction Using a Polyester Mesh (Surgimesh-PET): A Retrospective Single-Center Study

BACKGROUND

Although the introduction of acellular dermal matrices is considered one of the most important advancements in alloplastic breast reconstruction, costs and local policy limit their use in Italy. The purpose of this study was to assess short-term outcomes following Surgimesh-PET-based breast reconstruction.

METHODS

A single-center, retrospective, case-control study was performed from January 1, 2012, to December 31, 2013, by enrolling 206 breast reconstructions performed in 196 patients after oncologic (n = 200) or prophylactic (n = 6) mastectomy. Group A included 63 patients who underwent 70 immediate Surgimesh-PET-assisted breast reconstructions, and group B included 133 patients who underwent 136 standard breast reconstructions.

RESULTS

No significant differences between groups occurred for early postoperative complications (p = 0.610), major complications that required surgical revision (p = 0.887), volume (p = 0.498) or width of the prosthesis (p = 0.201), skin-sparing mastectomy (p = 0.315), or axillary surgery (p = 0.265). Multivariate logistic regression showed that prior radiotherapy was the only significant variable for early postoperative complications in both whole series (p = 0.011) and group B (p = 0.046), whereas body mass index greater than 25 was an independent predictor in group A (p = 0.041). Prior radiotherapy was the only variable that reached statistical significance in the multivariate model for major complications in the whole series (p = 0.005).

CONCLUSIONS

Short-term outcomes of Surgimesh-PET-based alloplastic breast reconstruction are promising. Further studies are needed to evaluate the long-term results of this surgical approach.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

Initial experience of the BREAST-Q breast-conserving therapy module

PURPOSE

The most recently developed module of the BREAST-Q, a validated patient outcome measure, is for patients who have undergone breast-conserving therapy (BCT) for cancer. This aim of this study was to assess patient satisfaction and quality of life after BCT using BREAST-Q, investigate clinical risk factors for lower satisfaction and explore the relationship between patient satisfaction with the appearance of their breasts and the other domains of the BREAST-Q.

METHODS

Women who had undergone unilateral BCT in the preceding 1-6 years were invited to participate at the time of their annual surveillance mammogram. Clinicopathological data were collected from an electronic database. Linear regression was used to evaluate risk factors for lower satisfaction. Spearman's rho correlation coefficients were calculated to evaluate the relationship between domains.

RESULTS

200 women completed the questionnaire. Mean age was 60 years (SD 11.1). Time from surgery was 35.5 months (SD 17.8). Median score for 'Satisfaction with breasts' was 68 (interquartile range 55-80). Lowest scores were for 'sexual wellbeing' (57, IQR 45-66). On multivariate analysis, BMI at the time of surgery (p = 0.002), delayed wound healing (p = 0.001) and axillary surgery (p = 0.003) were independent risk factors for lower satisfaction. There was significant correlation between 'Satisfaction with breasts' and all other BREAST-Q domains.

CONCLUSION

High BMI, delayed wound healing and axillary surgery are risk factors for lower patient satisfaction. This first publication reporting the whole dataset for the BREAST-Q BCT will serve as a benchmark for future studies of patient satisfaction following BCT.

Prospective study of postoperative whole breast radiotherapy for Japanese large-breasted women: a clinical and dosimetric comparisons between supine and prone positions and a dose measurement using a breast phantom

BACKGROUND

This prospective study aimed to compare dose volume histograms (DVH) of the breasts and organs at risk (OARs) of whole breast radiotherapy in the supine and prone positions, and frequency and severity of acute and late toxicities were analyzed.

METHODS

Early-stage breast cancer patients with large breasts (Japanese bra size C or larger, or the widest measurements of the bust ≥ 95 cm) undergoing partial mastectomy participated in this study. CT-based treatment plans were made in each position, and various dosimetric parameters for the breast and OARs were calculated to compare the supine and prone radiotherapy plans. The actual treatment was delivered in the position regarded as better.

RESULTS

From 2009 to 2010, 22 patients were prospectively accrued. Median follow-up period was 58 months. The homogeneity index and lung doses were significantly lower in the prone position (P = 0.008, P < 0.0001 and P < 0.0001, respectively). Cardiac dose showed no significant differences between two positions. By comparing two plans, the prone position was chosen in 77 % of the patients. In the prone position, ≥ grade 2 acute dermatitis were seen in 47 % of patients treated, whereas 20 % of the patients treated in the supine position had grade 2 and no cases of grade 3, although without a statistical significance of the rates of ≥ grade 2 acute dermatitis between the two positions (P = 0.28). The actual dose measurement using a breast phantom revealed significantly higher surface dose of the breast treated in the prone position than that in the supine position.

CONCLUSIONS

Breast irradiation in the prone position improves PTV homogeneity and lowers doses to the OARs in the Japanese large-breast patients. However meticulous positioning of the breast in the prone board avoiding the bolus effect is necessary to prevent acute dermatitis.

Single dose IOERT versus whole breast irradiation : Cosmetic results in breast-conserving therapy

BACKGROUND

Scarce data are available about the cosmetic result of single dose intraoperative electron radiotherapy (IOERT) in breast-conserving radiotherapy.

METHODS AND MATERIALS

We included 71 breast cancer patients. Breast-conserving surgery and sentinel node procedure had started almost 3 years earlier. Subsequently, 26 patients were treated with IOERT and 45 patients received postoperative whole breast irradiation (WBI). For both groups we determined seven dimensionless asymmetry features. We compared the subjectively and the objectively derived cosmetic scores with each other.

RESULTS

For four asymmetry features we noted significantly smaller differences for patients treated with IOERT when compared to those treated with WBI: relative breast contour difference, relative breast area difference and relative breast overlap difference. After correcting for excision volume a significant difference was noticed also for relative lower breast contour. For the IOERT group the cosmetic scores "excellent or good" as determined by each patient and one physician were 88 and 96 %, respectively. When the overall cosmetic scores for patients treated with IOERT and WBI were compared to those of the objectively derived scores, there was a fair level of agreement.

CONCLUSION

For patients treated with IOERT we noted less asymmetry and high rates of "good or excellent" subjectively derived cosmetic scores. The level of agreement between the subjectively and the objectively derived cosmetic scores was limited. Due to the small sample size and the design of the study no definitive conclusions can be drawn.

Delphi Consensus Recommendations: Intraoperative Technique and Postoperative Management of Patients with Natrelle 410 Implants

Background:

Anatomically shaped, form-stable Natrelle 410 breast implants were approved in Europe in 1993 and in the United States in 2013. Although general guidelines for breast augmentation are available, the distinctive characteristics of Natrelle 410 warrant specific guidelines for this device. The goal of this study was to generate consensus recommendations for intraoperative technique and postoperative management with Natrelle 410 in primary breast augmentation.

Methods:

Surgeons were invited to participate in the study, which used a modified Delphi method. Participants completed 2 rounds of online surveys; the second survey (Recommendations Survey) was generated based on first survey results. Respondents also listed top priorities for use of Natrelle 410.

Results:

Participants (n = 22) reached consensus on 15 of 18 perioperative and surgical techniques; dual-plane placement, tight pockets, and limiting the boundaries of dissection were among intraoperative techniques considered most important for Natrelle 410. Consensus was reached for 18 of 32 items regarding postoperative management and 6 of 9 open-ended postoperative activity restrictions. Consensus on activity restrictions with specified time limits were similar to consensus recommendations on general restrictions. Top participant-identified intraoperative and postoperative management practices for Natrelle 410 were dual-plane placement of the implant and wearing a bra postoperatively, respectively.

Conclusions:

The Delphi method identified consensus recommendations on a broad range of intraoperative techniques and postoperative management practices for primary breast augmentation with Natrelle 410. These recommendations and priorities provide surgeons with a framework that, together with the surgeon’s experience, will contribute to optimal clinical outcomes with Natrelle 410.

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.

In Search of a Gold Standard Scoring System for the Subjective Evaluation of Cosmetic Outcomes Following Breast-Conserving Therapy

The absence of a widely accepted method for aesthetic evaluation following breast-conserving surgery for breast cancer limits the ability to evaluate cosmetic outcomes. In this study, two different panel scoring approaches were compared in an attempt to identify a gold standard scoring system for subjectively assessing cosmetic outcomes following breast-conserving therapy. Standardized photographs of each participant were evaluated independently by twelve health care professionals involved in breast cancer diagnosis and treatment using the Danoff four-point scale. Individual Danoff scores were combined using two methods, a random sample "three-panel" score and an iterative "Delphi-panel" score, in order to create a final cosmetic score for each patient. Agreement between these two aggregative approaches was assessed with a weighted kappa (wk) statistic. Patient and professional recruitment occurred at two separate tertiary care multi-disciplinary breast health centers. Women with unilateral breast cancer who underwent breast-conserving therapy (segmental mastectomy or lumpectomy and radiotherapy) and were at least 2 years after radiotherapy were asked to participate. Ninety-seven women were evaluated. The Delphi approach required three rounds of evaluation to obtain greater than 50% agreement in all photographs. The wk statistic between scores generated from the "three-panel" and "Delphi-panel" approaches was 0.80 (95% CI: 0.71-0.89), thus demonstrating substantial agreement. Evaluation of cosmetic outcomes following breast-conserving therapy using a "three-panel" and "Delphi-panel" score provide similar results, confirming the reliability of either approach for subjective evaluation. Simplicity of use and interpretation favors the "three-panel" score. Future work should concentrate on the integration of the three-panel score with objective and patient-reported scales to generate a comprehensive cosmetic evaluation platform.

Systematization of Oncoplastic Surgery: Selection of Surgical Techniques and Patient-Reported Outcome in a Cohort of 1,035 Patients

Introduction

Functional and aesthetic outcome after breast-conserving surgery are vital endpoints for patients with primary breast cancer. A large variety of oncoplastic techniques exist; however, it remains unclear which techniques yield the highest rates of local control at first surgery, omission of reexcision or subsequent mastectomy, and merits the highest degree of patient satisfaction.

Methods

In this retrospective case cohort trial with a customized investigational questionnaire for assessment of patient satisfaction with the surgical result, we analyzed 1,035 patients with primary, unilateral breast cancer and oncoplastic surgery from 2004 to 2009.

Results

Analysis of patient reported outcome (PRO) revealed that 88 % of the cohort was satisfied with their aesthetic result using oncoplastic techniques following the concept presented. These results also were achieved in difficult tumor localizations, such as upper inner and lower inner quadrant. Conversion rate from breast-conserving therapy to secondary mastectomy was low at 7.2 % (n = 68/944 patients). The systematization of oncoplastic techniques presented—embedded in a multimodal concept of breast cancer therapy—facilitates tumor control with a few number of uncomplicated techniques adapted to tumor site and size with a median resection of 32 (range 11–793) g. Five-year recurrence rate in our cohort was 4.0 %.

Conclusions

Patient´s satisfaction was independent from age, body mass index, resection volume, tumor localization, and type of oncoplastic surgery (p > 0.05). We identified postoperative pain as an important negative impact factor on patient´s satisfaction with the aesthetic result (p = 0.0001).

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-015-4396-4) contains supplementary material, which is available to authorized users.

Novel 10-fraction Breast Irradiation in Prone and Supine Position: Technical, Dosimetric and Clinical Evaluation

Background

The aim of this study was to evaluate retrospectively the planned dose distribution and acute toxicity of adjuvant hypofractionated whole breast radiotherapy (RT) delivered in the prone vs. supine position.

Methods

Twenty-four patients were enrolled; 12 underwent adjuvant RT with a supine setup and 12 with a prone setup. We included patients according to breast volume (≥500 mL), disease stage (≤pT2/pN1), and clinical/biological features. Patients received a regimen of 35 Gy in 10 fractions for 2.5 weeks, and a concomitant boost of 3/4 Gy in 1 fraction/week. Target coverage was assessed by volume, V90, V95, V100, V103 and V105. Heart, LADCA and ipsilateral lung doses were evaluated according to volume, maximum dose, mean dose, V14, V10 and V5. We evaluated acute skin toxicity during RT, at the end of treatment, and after 1 month according to RTOG scales.

Results

Radiobiological equivalence was warranted with satisfactory BED values: considering α/β = 4 for breast cancer, the 10-fraction schedule equaled 74 or 77 Gy depending on the boost dose (3 Gy vs. 4 Gy, respectively). Toxicity was low and similar for supine and prone treatments. Dose sparing was significant in the ipsilateral lung in the prone position (median Dmax: 28.7 Gy vs. 38.4 Gy; median Dmean: 0.8 Gy vs. 6.3 Gy; median V14:0.6% vs. 13.5%; median V5: 0 vs. 19.3%, p<0.001).

Conclusions

This novel 10-fraction schedule is feasible and well tolerated; the prone position allows better saving of OARs, with a statistically significant value for the ipsilateral lung.

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.

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.

Prone versus supine position for adjuvant breast radiotherapy: a prospective study in patients with pendulous breasts

PURPOSE

To analyze dosimetric parameters of patients receiving adjuvant breast radiotherapy (RT) in the prone versus supine position.

METHODS AND MATERIALS

Forty-one out of 55 patients with pendulous breasts and candidates for adjuvant RT were enrolled in the study after informed consent. They underwent computed tomography (CT)-simulation in both prone and supine position. Target and non target volumes were outlined on CT images. Prescribed dose was 50 Gy delivered by two tangential photon fields followed by 10 Gy electron boost. Target coverage and dose homogeneity to clinical target volume (CTV) and planning target volume (PTV) were assessed by V95, V105 and V107 and dose to lung, heart and left anterior descending coronary artery (LAD) by V5, V10, V20, and mean and maximum dose. Data were analyzed by Student's t-test.

RESULTS

CTV and PTV coverage was significantly better in supine than in prone position. Lung V5, V10, and V20 were significantly lower in prone than in supine position. Heart V5, V10, V20, and LAD mean and maximum dose, in the 17 patients with left breast tumor, were lower in prone than in supine position, but without statistical significance. Based on treatment planning data and on treatment feasibility, 29/41 patients (70.7%) were treated in prone position. Acute and late toxicities of patients treated in prone and in supine position were not statistically different.

CONCLUSION

Prone position is a favorable alternative for irradiation of mammary gland in patients with pendulous breasts and in our series was adopted in 71% of the cases.

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.

Prone whole-breast irradiation using three-dimensional conformal radiotherapy in women undergoing breast conservation for early disease yields high rates of excellent to good cosmetic outcomes in patients with large and/or pendulous breasts

PURPOSE

To report our institution's experience using prone positioning for three-dimensional conformal radiotherapy (3D-CRT) to deliver post-lumpectomy whole breast irradiation (WBI) in a cohort of women with large and/or pendulous breasts, to determine the rate of acute and late toxicities and, more specifically, cosmetic outcomes. We hypothesized that using 3D-CRT for WBI in the prone position would reduce or eliminate patient and breast size as negative prognostic indicators for toxicities associated with WBI.

METHODS AND MATERIALS

From 1998 to 2006, 110 cases were treated with prone WBI using 3D-CRT. The lumpectomy, breast target volumes, heart, and lung were contoured on all computed tomography scans. A dose of 45-50 Gy was prescribed to the breast volume using standard fractionation schemes. The planning goals were ≥95% of prescription to 95% of the breast volume, and 100% of boost dose to 95% of lumpectomy planning target volume. Toxicities and cosmesis were prospectively scored using the Common Terminology Criteria for Adverse Effects Version 3.0 and the Harvard Scale. The median follow-up was 40 months.

RESULTS

The median body mass index (BMI) was 33.6 kg/m(2), and median breast volume was 1396 cm(3). The worst toxicity encountered during radiation was Grade 3 dermatitis in 5% of our patient population. Moist desquamation occurred in 16% of patients, with only 2% of patients with moist desquamation outside the inframammary/axillary folds. Eleven percent of patients had Grade ≥2 late toxicities, including Grade 3 induration/fibrosis in 2%. Excellent to good cosmesis was achieved in 89%. Higher BMI was associated with moist desquamation and breast pain, but BMI and breast volume did not impact fibrosis or excellent to good cosmesis.

CONCLUSION

In patients with higher BMI and/or large-pendulous breasts, delivering prone WBI using 3D-CRT results in favorable toxicity profiles and high excellent to good cosmesis rates. Higher BMI was associated with moist desquamation, but prone positioning removed BMI and breast size as factors for poorer cosmetic outcomes. This series adds to the growing literature demonstrating that prone WBI may be advantageous in select patients.

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.

Breast reduction in the irradiated breast: evidence for the role of breast reduction at the time of lumpectomy

Given the high incidence of breast cancer in our society, it is common to encounter patients with macromastia who desire breast reduction after breast-conserving therapy by lumpectomy and radiation. We hypothesize that radiation leads to a significant increase in postoperative complications after breast reduction. All patients with a history of unilateral breast lumpectomy and radiation who subsequently underwent bilateral breast reduction by a single surgeon from 2004 to 2008 were retrospectively reviewed. Outcomes including cellulitis, wound breakdown, seroma, and need for repeat operations were compared between the radiated and nonradiated breast. The Fisher's exact test was used for statistical analysis. Twelve patients (mean age, 57 years) underwent bilateral breast reduction a mean of 86 months after unilateral lumpectomy and radiation. The nonradiated breasts had no complications postoperatively. The radiated breasts had a significant increase in complications with a total of five breasts (42%, p<0.04) having postoperative complications including cellulitis in two breasts, seroma requiring drainage in five breasts, two cases of fat necrosis, and one case of wound dehiscence. This resulted in two admissions for intravenous antibiotics and two repeat operative procedures. Additionally, three patients had significant breast asymmetry or contour deformities after reduction requiring operative revisions. Breast reduction after radiation leads to a significant increase in complications. Given this data, patients with macromastia undergoing breast conservation therapy for cancer should be considered for reduction at the time of lumpectomy and prior to radiation.

[Reduction mammaplasty in breast cancer surgery]

Reduction mammaplasty techniques enable the breast cancer surgeon to provide an integral surgical treatment, thus significantly increasing and improving surgical options. These techniques are used to correct problems after the conservative treatment of type 1 breast cancer and to achieve symmetry between the breasts after mastectomy. They are also the basis of cosmetic reconstruction techniques in conservative oncoplastic surgery.

Towards an intelligent medical system for the aesthetic evaluation of breast cancer conservative treatment

OBJECTIVE

This work presents a novel approach for the automated prediction of the aesthetic result of breast cancer conservative treatment (BCCT). Cosmetic assessment plays a major role in the study of BCCT. Objective assessment methods are being preferred to overcome the drawbacks of subjective evaluation.

METHODOLOGY

The problem is addressed as a pattern recognition task. A dataset of images of patients was classified in four classes (excellent, good, fair, poor) by a panel of international experts, providing a gold standard classification. As possible types of objective features we considered those already identified by domain experts as relevant to the aesthetic evaluation of the surgical procedure, namely those assessing breast asymmetry, skin colour difference and scar visibility. A classifier based on support vector machines was developed from objective features extracted from the reference dataset.

RESULTS

A correct classification rate of about 70% was obtained when categorizing a set of unseen images into the aforementioned four classes. This accuracy is comparable with the result of the best evaluator from the panel of experts.

CONCLUSION

The results obtained are rather encouraging and the developed tool could be very helpful in assuring objective assessment of the aesthetic outcome of BCCT.