Improving breast cancer surgery: a classification and quadrant per quadrant atlas for oncoplastic surgery

Patient satisfaction after unilateral oncoplastic volume displacement surgery for breast cancer, evaluated with the BREAST-Q™

Background

Oncoplastic breast-conserving surgery allows larger resections in unfavorable locations, with an improved chance of preserving esthetics. Indications and timing for potential contralateral surgery to obtain symmetry are not clear. The aim of this study was to evaluate patient satisfaction after unilateral oncoplastic volume displacement surgery, to investigate potential risk factors for lower patient satisfaction and to assess patient wish for contralateral surgery.

Method

A cohort of 144 women, consecutively treated for breast cancer with unilateral breast-conserving oncoplastic volume displacement surgery, followed by radiotherapy and with an unoperated contralateral breast, was sent the BREAST-Q™ breast-conserving therapy (BCT) and a study-specific questionnaire. In all, 120 women (83%) responded. For these women, the median value for resected specimen weight was 92 g (range 14–345) and for the estimated percentage of the breast volume excised 15% (range 3–35%).

Results

The median patient-reported score for “Satisfaction with breast” (BREAST-Q™ BCT) was 74/100. Factors associated with a score below median value in a simple logistic regression model adjusted for age and BMI were axillary clearance (OR 2.46, 95% CI 1.09–5.56), neoadjuvant chemotherapy (OR 3.26, 95% CI 1.15–9.24), and low breast density (OR 2.32 95% CI 1.02–5.29). Thirteen women (11%) were interested in contralateral surgery.

Conclusion

Most patients in this study cohort, who had undergone breast-conserving therapy with oncoplastic volume displacement techniques, were satisfied with their breasts without surgery to the contralateral breast. This indicates that contralateral surgery to achieve symmetry only should be performed after individual evaluation and as a delayed procedure.

Single-Incision Approach for Breast-Conserving Surgery: Effectiveness, Complications and Quality of Life

OBJECTIVE

The aim of this study was to assess the success of tumor resection and its postoperative complications, satisfaction, and quality of life using a single-incision approach for breast-conserving surgery.

MATERIALS AND METHODS

This was an observational, prospective study conducted between 2015 and 2018. The study group consisted of patients in whom tumor extirpation and lymph node (LN) staging was performed using a single incision, while the control group consisted of patients who underwent a breast-conserving procedure with independent incisions. All patients were given the preoperative and postoperative module of the Breast-Q™ questionnaire.

RESULTS

Overall, 226 patients met the study's inclusion criteria, 152 of whom successfully underwent breast and LN removal using a single-incision approach (98.7% overall success). There were no significant differences in postoperative complications, although there was a greater tendency towards breast seroma in the study group and axillary neuralgia in the control group. Both groups presented a similar rate of breast and axillary salvage surgery. The postoperative Breast-Q™ questionnaire showed that the study group had greater satisfaction with both the breast and the information provided by the surgeon.

CONCLUSION

The single-incision approach is as effective as standard surgery, with custom incisions in terms of breast resection, LN staging, and complications. There was greater satisfaction with both the breast and the information provided.

Oncoplastic Level 2 Mammoplasty for Large DCIS: 5-Year Results

BACKGROUND

Oncoplastic surgery (OPS) allows wider resections with immediate breast reshaping by mammoplasty. This study reviews our experience with level 2 mammoplasties in patients with histology-proven pure ductal carcinoma in situ (DCIS).

METHOD

From a prospectively maintained database of 392 consecutive oncoplastic level 2 mammoplasties, 68 patients presented with pure DCIS. Involved margin rates and locoregional recurrence rates were calculated, with 76 months (0-166 months) median follow-up.

RESULTS

The mean pathological tumor size was 34 mm (median 26 mm, range 2-106 mm). The mean resection weight was 191 g (median 131 g, range 40-1150 g). Margins were clear in 58 cases (85.3%) and involved in 10 cases (14.7%). Margins were involved in 1 out of 54 (1.9%) cases with tumor size under 50 mm and in 9 out of 14 (64.3%) cases with tumor size higher than 50 mm (p < 0.001). On multivariable analysis, only tumor size > 50 mm [odds ratio (OR) 95.400; p < 0.001] was independently associated with involved margins. Seven patients had mastectomy. The overall breast conservation rate was 89.4%, and 100% for tumors less than 5 cm. There were three local recurrences. The 5-year cumulative incidence for local recurrence was 5.5% (0-11.5%).

CONCLUSIONS

OPS is a safe solution for large DCIS up to 50 mm, with an involved margin rate of only 1.9%, and can thus reduce the mastectomy rate in this group. As margin involvement significantly increases for tumors larger than 5 cm, better preoperative localization and/or wider excisions are necessary in this group.

The Influence of Surgical Specialty on Oncoplastic Breast Reconstruction

BACKGROUND

The integration of oncological surgery with reconstructive techniques has gained popularity in the treatment of breast cancer. oncoplastic reconstruction after partial mastectomy can be performed by the breast surgeon or in cooperation with a consulted plastic surgeon. This study aims to objectively assess the differences in outcomes for partial mastectomy and subsequent oncoplastic reconstruction performed by either general surgery alone or in combination with a plastic and reconstructive surgery team.

METHODS

Unilateral oncoplastic breast reconstruction cases were extracted from the National Surgical Quality Improvement Program databases from 2005 to 2017. Outcomes of cases performed by the general surgery team alone were compared with those in which the partial mastectomy was performed by the general surgeon with subsequent reconstruction performed by plastic surgeons. To account for cohort baseline differences, propensity score-matched analysis was performed.

RESULTS

In total, 4,350 patients were included in this study; 3,759 procedures were performed by general surgery alone versus 591 combined with plastic surgery. The analysis of propensity score-matched cohorts, comprising 490 patients each, showed no statistical difference in the risk for postoperative complications when surgery was performed by either of the 2 specialty services. A longer operative time and length of stay were found in the group reconstructed by plastic surgeons.

CONCLUSIONS

This study found no significant differences in adverse postoperative outcomes for oncoplastic reconstructions after partial mastectomy between the 2 groups. The data may indicate collaboration between both surgical specialties in oncoplastic breast care was not associated with increased morbidity in these patients.

The axillary flap in oncoplastic resection of breast cancers located in the upper-outer quadrants: a new surgical technique

Background

The combination of breast conserving surgery (BCS) with plastic surgery techniques has provided a useful surgical tool matching the radicality of the oncological excision with the preservation of breast cosmesis. Even though BCS represents a good option for surgical treatment of tumors located in these quadrants, wide excisions often necessitate breast reshaping in order to avoid nipple areola complex (NAC) displacement and skin retraction. We present a new surgical technique to repair upper-outer quadrants’ defects following breast cancer excision using dermo-glandular flaps and an axillary adipo-fascial flap.

Methods

During the period from January 2014 to December 2015, 168 patients with an upper-outer quadrant’s breast cancer have been treated in our Department. 83 women have been treated with the described oncoplastic technique and immediate contra-lateral symmetrisation and 85 women underwent standard BCS. We present surgical, oncological and cosmetic outcomes comparing our results with standard BCS.

Results

At a mean follow-up of 27 months loco-regional recurrences in the two groups were comparable. Short-term complication rates were comparable between the two groups. Re-intervention rates for positive margins were significantly higher in the standard BCS group. The overall satisfaction with cosmetic outcome both assessed by the patient and the surgeon was significantly higher in the oncoplastic group.

Conclusions

The proposed oncoplastic technique represents a safe and effective solution for reshaping that follows upper-outer breast cancer wide excision, achieving comparable complication rates, lower re-intervention rates for positive margins and better cosmetic results when compared with standard BCS.

Paving the way for changing perceptions in breast surgery: a systematic literature review focused on oncological and aesthetic outcomes of oncoplastic surgery for breast cancer

BACKGROUND

The emphasis on aesthetic outcomes and quality of life after breast cancer surgery has motivated breast surgeons to develop oncoplastic breast conserving surgery (OPS). Training programs are still rare in most countries, and there is little standardization, which challenges the scientific evaluation of these techniques. This systematic review aims to assess oncological and cosmetic outcomes of OPS.

METHODS

After a strict selection process with precise inclusion and exclusion criteria, oncologic and aesthetic outcomes of oncoplastic surgery were searched, using the MEDLINE database up to September 30th, 2017. Available published literature was classified in levels of evidence. After a thorough screening process, only studies with the best level of evidence were included on selection. Systematic reviews and meta-analyses were not included for methodological reasons.

RESULTS

Titles and abstracts of 2.854 citations were identified and after screening 15 prospective studies including 1.391 patients were reviewed and scored in detail. Local relapse was found in 2.8% of cases with a wide range of follow-up (from 6 to 74 months). Close margins were retrieved in 11% of cases and positive margins in 9.4% of cases. Mastectomy was implemented in 6.9% of breast cancer patients to whom OPS was performed. Good cosmetic outcomes were detected in 90.2% of patients undergoing OPS, leaving open issues for who should perform cosmetic evaluation and which method should be used.

CONCLUSION

Tumor margins, mastectomy rates, and cosmetic outcomes of OPS have to be further improved by standardizing various aspects of OPS. Research efforts should focus on level I evidence assessing both oncological and aesthetic outcomes of OPS and survival rates.

Oncoplastic and reconstructive breast surgery in Canada: breaking new ground in general surgical training

Summary

Oncoplastic breast surgery combines certain plastic surgery procedures with a breast cancer resection to minimize the cosmetic penalty. We compared current practices in breast surgery in Canada and the UK, looking at the classification of oncoplastic breast surgery, management of larger tumours that would otherwise mandate a mastectomy, and the breast surgeon’s role in immediate breast reconstruction. Reconstructive breast surgery has always fallen within the domain of the plastic surgeon, but surgical subspecialization and more focused fellowship training have meant that breast surgeons with the appropriate skillset can offer these procedures. This evolution of the breast surgeon has led to the birth of a new field of breast surgery known as oncoplastic and reconstructive breast surgery. Those tasked with developing surgical training programs in Canada must now decide whether to train breast surgeons in these techniques to improve long-term quality of life among Canadian patients with breast cancer.

Resection margins and local recurrences in breast cancer: Comparison between conventional and oncoplastic breast conserving surgery

BACKGROUND

This retrospective cohort study aims to compare surgical margins, reoperations and local recurrences after conventional or oncoplastic breast conservation surgery (BCS). Furthermore, we aim to investigate differences between various oncoplastic techniques.

MATERIAL AND METHODS

We reviewed 1800 consecutive patients with primary invasive breast cancer (N = 1707) or ductal carcinoma in situ (N = 93) who underwent BCS at Helsinki University Hospital between 2010 and 2012.

RESULTS

Conventional BCS was performed in 1189 (66.1%) patients, oncoplastic BCS in 611 (33.9%). Various oncoplastic techniques were used. Patients with oncoplastic BCS had more often multifocal (p < 0.001), larger (p < 0.001), palpable tumours (p < 0.001) with larger resection specimens (p < 0.001). The amount of resected tissue varied substantially depending on the oncoplastic technique. Patients treated with oncoplastic BCS were younger (p < 0.001) and their tumours were more aggressive according to histological grade (p < 0.001), T-stage (p < 0.001), Ki-67 (p < 0.001) and lymph node status (p < 0.001). There was no difference, however, in surgical margins (p = 0.578) or reoperation rates (p = 0.430) between the groups. A total of 152 (8.4%) patients were reoperated because of insufficient margins, 96 (8.1%) in the conventional, 56 (9.2%) in the oncoplastic BCS group. The median follow-up time was 75 (2-94) months. There was no difference in local recurrence-free survival between the conventional and oncoplastic BCS groups (log-rank test, p = 0.172).

CONCLUSIONS

Oncoplastic BCS was used for larger, multifocal and more aggressive tumours. Nevertheless, no difference in reoperation rate or local recurrences were found. Oncoplastic BCS is as safe as conventional BCS enabling breast conserving for patients who otherwise were candidates for mastectomy.

The Modified Lateral Intercostal Artery Perforator Flap

Background

The main surgical options for treatment of breast cancer are breast-conserving surgery and mastectomy. BCS aims to achieve complete excision of the tumor while achieving a pleasing cosmetic result. Excision of tumors in the lateral aspect of the breast has been associated with issues such as contour deformities and asymmetry. Development of volume replacement techniques such as the lateral intercostal artery perforator flap (LICAP) aimed to address these issues. Our modification of the traditional LICAP offers a less visible scar, good access to the axilla, and no need to reposition the patient.

Methods

All patients undergoing a modified LICAP were identified from our database. The lateral intercostal artery perforators were marked with ultrasound and 2 "lazy S" lines were drawn to mark the flap. The wide local excision (with or without axillary surgery) was performed and the flap mobilized to fill the defect.

Results

Twenty-two patients underwent modified LICAP in 14 months. The mean specimen weight was 86 g. Four patients (18%) had a re-excision for positive margins. Nineteen patients had axillary surgery performed at the time of their modified LICAP flap. No patients had a scar that extended posterior to the posterior axillary line; no patients required a separate incision for axillary surgery; and no patients needed to be repositioned intraoperatively.

Conclusions

Our early experience with this innovative procedure has been favorable. The perioperative complication rate is low. Due to the relatively short follow-up, longer term outcomes such as postradiotherapy appearance are yet to be determined.

A cost-utility analysis comparing large volume displacement oncoplastic surgery to mastectomy with free flap reconstruction in the treatment of breast cancer

PURPOSE

Breast cancer surgical treatment may include large volume displacement oncoplastic surgery (LVOS) or mastectomy with free flap reconstruction (MFFR). We investigated the cost-utility between LVOS versus MFFR to determine which approach was most cost-effective.

METHODS

A literature review was performed to calculate probabilities for clinical outcomes for each surgical option (LVOS versus MFFR), and to obtain utility scores that were converted into quality adjusted life years (QALYs) as measures for clinical effectiveness. Average Medicare payments were surrogates for cost. A decision tree was constructed and an incremental cost-utility ratio (ICUR) was used to calculate cost-effectiveness.

RESULTS

The decision tree demonstrates associated QALYs and costs with probabilities used to calculate the ICUR of $3699/QALY with gain of 2.7 QALY at an additional cost of $9987 proving that LVOS is a cost-effective surgical option. One-way sensitivity analysis showed that LVOS became cost-ineffective when its clinical effectiveness had a QALY of less than 30.187. Tornado Diagram Analysis and Monte-Carlo simulation supported our conclusion.

CONCLUSION

LVOS is cost-effective when compared to MFFR for the appropriate breast cancer patient.

CLINICAL QUESTION/LEVEL OF EVIDENCE

II.

Extreme oncoplasty: Expanding indications for breast conservation

INTRODUCTION

Presence of multiple lesions and/or tumor span ≥5 cm are traditional indications for mastectomy. Patient desire for breast conservation has increased the interest in extreme oncoplastic breast conserving surgery (EOBCS) to avoid mastectomy; however, perioperative outcomes in this population have not been well described.

METHODS

This is an observational cohort of breast cancer patients with multiple lesions and disease span ≥5 cm who underwent EOBCS. Patient demographics, disease span, margin width, mastectomy and re-excision rates, and cosmesis were evaluated.

RESULTS

One hundred-eleven patients underwent EOBCS between 2012 and 2017. Eighty-two patients presented with multifocal or multicentric disease with an average of 3.2 lesions per breast spanning 57.1 ± 23.6 mm. Eighteen patients presented with unifocal tumors measuring an average of 67.6 mm (range 50-160 mm) on imaging. Eleven patients with an imaging size of <5 cm had a disease span ≥5 cm on final pathology. No tumor on ink occurred in 87 (78.3%) patients. Fifty-seven (51.4%) patients had additional surgery for inadequate margins. Fifteen (12.6%) patients elected to have mastectomy while 42 (37.8%) patients opted for re-excision. Good to excellent cosmetic results were reported in 95% of patients who ultimately achieved breast conservation. Recurrence rate was 1.1% in patients who completed EOBCS and adjuvant radiation therapy.

CONCLUSION

EOBCS can allow for breast conservation in patients who are traditionally counseled to undergo mastectomy. Although the re-excision rate was significant, most patients ultimately achieved breast conservation with adequate margins. Further study is warranted to determine the long-term oncologic outcomes of this approach.

Oncoplastic breast-conserving surgery: More relevant than ever? Results of a survey among breast surgeons

PURPOSE

Oncoplastic breast-conserving surgery has been part of clinical routine for several years without an internationally accepted nomenclature, standardization or a systematic evaluation of single surgical procedures.

METHODS

We carried out a structured survey of breast surgeons (n = 50) during the annual meeting of the German Society for Senology in Berlin 2017. In the run-up to the event, 10 questions were determined and released for an anonymous survey during the consensus meeting.

RESULTS

Most surgeons participating in the consensus meeting had an expertise of more than 200 oncologic breast surgeries in the last 3 years and approved the need of a higher rate of standardization in oncoplastic techniques. From the oncological standpoint, oncoplastic surgery is considered safe with a comparable rate of compilations as seen in conventional breast-conserving procedures. Most surgeons approve that using oncoplastic surgery, higher rates of breast conservation and improved aesthetic results can be accomplished. The majority of the participants would endorse a more systematic review of subjective aesthetic results in clinical routine.

CONCLUSIONS

A higher degree in standardization of oncoplastic breast surgery is required for surgical-technical, educational, and scientific reasons as well as for a more differentiated monetary compensation of the surgical procedures. This process has already been started.

[Current situation of breast reconstruction after breast cancer in Reunion Island]

OBJECTIVES

The aim of this study is to describe the current trends of breast reconstruction (BR) and breast oncoplasty (BO) for breast cancer patients in Reunion Island.

METHODS

This is a multicenter retrospective descriptive study of all BR and BO surgeries in 2016. We studied the first stage of BR that corresponds to the choice of surgical technique. Patient's age, care center, technique and duration of surgery, complications and their risk factors were reviewed. Patient satisfaction was assessed using the modified BREAST-Q^©.

RESULTS

In 2016, BR rate over total mastectomy was 47.6% and BO rate was 6.3% over partial mastectomy. Among the 92 patients included, 25 immediate BR were performed (84% in private institution) and 44 delayed BR (67% in public hospital). Although prosthetic techniques were the most used, satisfaction seems to be better with autologous techniques.

CONCLUSIONS

The ratio of BR is high in Reunion Island with a wide range of techniques but uneven practice. Conversely, BO's ratio is low and improvement is needed.

Development and psychometric evaluation of a Dutch-translated shorter Breast Cancer Treatment Outcome Scale (Dutch BCTOS-13)

PURPOSE

To create a Dutch translated short version of the Breast Cancer Treatment Outcome Scale (BCTOS) and validate it in patients who have completed both breast conserving surgery and adjuvant radiotherapy.

METHODS

The BCTOS consists of items comparing the treated with the untreated breast. After forward and backward translation, we tested the BCTOS-12 plus 5 additional items. Two-hundred breast cancer patients treated with breast conserving therapy (BCT) between January 2016 and December 2017, were asked to complete the BCTOS items twice with a 2 week interval. The EORTC QLQ-BR23 breast and arm symptoms subscales were completed once in parallel. Feasibility was assessed by missing or non-unique answer rates and content validity with floor and ceiling effect analysis. Construct validity was evaluated with 1) principal component analysis (PCA) 2) convergent validity and 3) known groups comparison (clinical validity differentiating between patients with and without locoregional side effects). From all potential items with good feasibility, content and construct validity, items were selected for the Dutch BCTOS based on clinical validity. The relation to the EORTC QLQ-BR23 subscales and reliability was tested for the new Dutch BCTOS.

RESULTS

Hundred and one of 200 (50.5%) approached patients participated in this study, with follow-up after surgery ranging from 5 to 29 months. Feasibility was high (1.5% missing answers). Content validity testing showed a floor effect > 20% in all 17 items. PCA showed that all items loaded well (> 0.4) into the assigned subscale and revealed two distinct subscales: cosmesis and function. Based on clinical validity, item "breast shape" was replaced by "breast elevation/position" and "overall skin appearance". Very good clinical validity (Cohen's d = 1.38) was found for the new Dutch BCTOS-13. Correlation to the EORTC QLQ-BR23 subscales was high (ICC = 0.65-0.85) for both subscales. Test-retest reliability (Cohen's d = 0.105) and internal consistency (Cronbach's α =0.90) were excellent.

CONCLUSIONS

Psychometric evaluation of a newly developed Dutch BCTOS-13 questionnaire in BCT patients showed excellent results, that were slightly better than the original BCTOS-22 and the shortened BCTOS-12. The good clinical validity makes the BCTOS-13 a useful tool to identify patients with unfavourable cosmetic and functional outcomes, requiring specific attention.

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.

Evaluating the current evidence to support therapeutic mammoplasty or breast-conserving surgery as an alternative to mastectomy in the treatment of multifocal and multicentric breast cancers

The oncological safety of treating multiple ipsilateral breast cancers (MIBCs) with types of breast conserving surgery (BCS) compared to mastectomy remains uncertain. This is predicated on the absence of any randomised controlled trials or high-quality protocol defined prospective cohort studies. A single recently published systematic review by the first author, reports its summarised results in this review. Fundamentally the important question is the evaluation of clinical safety following BCS compared to mastectomy for treating MIBC, which is reported in only six studies. Consequently, current evidence doesn't support the latest St Gallen consensus suggesting the possibility of using BCS to treat all MIBC. There is minimal comparative outcomes data on multicentric (MC) cancers compared to multifocal (MF) cancers comparing BCS or mastectomy. There is also poor evidence of clinical outcomes following therapeutic mammoplasty (TM) for MIBC compared to mastectomy. The potential recommendation of two potential radiotherapy boosts to separate lumpectomy sites following BCS for MC cancers remains a novel treatment concept whose feasibility will be evaluated in the forthcoming NIHR funded randomised feasibility trial called MIAMI. This is a world first attempt to assess the feasibility of a randomised trial design alongside the on-going Alliance registry study (ACOSOG, American College of Surgeons Oncology Group Z11102) in the USA, in which there is no comparative evaluation of mastectomy outcomes. The MIAMI trial aims to assess the clinical safety of multiple lumpectomies combined with TM compared to the standard of mastectomy in MIBC stratified by MF or MC cancers. There is limited evidence on the impacts of inter-tumoral heterogeneity relating to breast cancer subtypes in relation to individualised treatments and recommendations for types of breast surgery. Recent studies have highlighted the potential contributions of stromal epigenetic changes that are currently poorly understood regarding their contributions to either clinical unifocal or MF cancers.

Optimise not compromise: The importance of a multidisciplinary breast cancer patient pathway in the era of oncoplastic and reconstructive surgery

Modern breast cancer care is a complex multidisciplinary undertaking in which the integrated function of multiple constituent parts is critical, and where changes to one therapeutic component may profoundly influence the delivery and outcomes of another. Oncoplastic and reconstructive breast surgery has evolved in the era of longer survival rates for women with breast cancer and aims to enhance oncological and cosmetic outcomes. However, concurrently there has been an expansion in the indications for post-mastectomy radiation therapy (Abdulkarim et al., 2011; Early Breast Cancer Trialists' Collaborative Group (EBCTCG), 2014; Poortmans et al., 2015; Wang et al., 2011), the recognition of several biologically distinct breast cancer subtypes (Perou et al., 2000; Sørlie et al., 2001, 2003; Cheang et al., 2008, 2009; Sotiriou et al., 2003; Millar et al., 2011; Blows et al., 2010; Schnitt, 2010; Haque et al., 2012; Dai et al., 2015) and the development of recommendations for prophylactic surgery for high-risk women, including BRCA-mutation carriers (James et al., 2006; Domchek et al., 2010). Primary systemic therapy is increasingly utilised yet has varying efficacy depending on tumour biology (Cortazar et al., 2014). In this paper we review the evidence which informs the multidisciplinary team opinion in the era of oncoplastic and reconstructive breast surgery. We aim to describe an optimal multidisciplinary approach which balances competing risks of multimodal therapies to optimise oncological and cosmetic outcomes.

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

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

Reconstruction in Breast Conservation Therapy-Single Tertiary Care Institution Experience with 472 Patients

Breast conservation therapy (BCT) is now internationally accepted treatment for early breast cancer. Despite of high incidence of carcinoma breast in India, BCT rates are very low as compared to the west. In this article, we wish to share our experience of breast conservation with oncoplasty in Indian women. A retrospective analysis of case records of patients treated with oncoplastic breast conservation from January 2009 to June 2014 in a single surgical oncology unit in a tertiary cancer institute. Demographic patient data, stage of disease, location of primary tumour, use of neo-adjuvant chemotherapy if received, tumour size and breast size ratio, reconstruction method used, post-operative complications and aesthetic score of patients were analysed. Various methods of oncoplasty and partial breast reconstruction used are discussed. Four hundred and seventy-two patient records were found suitable for analysis. Most common stage of presentation was T2N0 in 189 patients (40%). Forty-one patients received neo-adjuvant chemotherapy (NACT). Tumour arising in upper outer quadrant was most common site, seen in 268 (56.7%). The most common method of reconstruction was volume displacement, done in 57.6% patients. Overall surgical complications included wound infection with or without dehiscence, seroma formation, partial flap necrosis and fat necrosis. Cosmesis was found to be excellent in 23.09% and good in 58.47% at 6-month follow-up. Breast conservation with oncoplasty is oncologically safe for early breast cancer treatment and has good cosmetic outcome with high patient satisfaction rates. Its practice should be encouraged in Indian set-up also.

Aesthetic outcome following breast-conserving surgery assessed by three evaluation modalities in relation to health-related quality of life

Background

The aim of this study was to compare the agreement between three different methods for evaluation of aesthetic outcome following breast-conserving surgery and adjuvant radiotherapy: a patient questionnaire, panel evaluation of photographs and the software BCCT.core. A further aim was to examine how these modalities predict health-related quality of life as measured by the validated Breast-Q™ questionnaire.

Methods

At 1-year follow-up after breast-conserving surgery, patients completed a study-specific questionnaire. Postoperative photographs were evaluated using the software BCCT.core. A panel of three healthcare professionals assessed preoperative and postoperative photographs. Agreement between methods was assessed using Spearman's correlation coefficients (rs). The Breast-Q™ questionnaire was sent to study participants. The ability of the different evaluation methods to predict Q-scores for the health-related quality-of-life (HRQoL) domains satisfaction with breasts and psychosocial well-being was investigated using receiver operating characteristic (ROC) curves.

Results

A total of 532 patients undergoing breast-conserving surgery were examined before surgery. At 1-year follow-up, 334 patients completed the study-specific questionnaire. Postoperative photographs from 310 patients were evaluated using BCCT.core. The panel of healthcare professionals assessed photographs from 215 patients. Agreement between the different evaluation modalities was poor. The strongest agreement was noted between the panel evaluation for symmetry and BCCT.core results (rs = 0·59, P &lt; 0·001). The Breast-Q™ questionnaire was returned by 348 patients. Patient satisfaction ratings at 1-year follow-up best predicted long-term HRQoL measured using the Breast-Q score, both in terms of satisfaction with breasts (area under the curve (AUC) 0·80, P &lt; 0·001) and psychosocial well-being (AUC 0·73, P &lt; 0·001).

Conclusion

There is currently no ideal method for evaluating aesthetic outcome after breast-conserving surgery and adjuvant radiotherapy. These results emphasize the use of patient-related outcome measures.

Current practice and short-term outcomes of therapeutic mammaplasty in the international TeaM multicentre prospective cohort study

BACKGROUND

Therapeutic mammaplasty, which combines breast reduction and mastopexy techniques with tumour excision, may extend the boundaries of breast-conserving surgery and improve outcomes for patients, but current practice is unknown and high-quality outcome data are lacking. This prospective multicentre cohort study aimed to explore the practice and short-term outcomes of the technique.

METHODS

Consecutive patients undergoing therapeutic mammaplasty at participating centres between 1 September 2016 and 30 June 2017 were recruited to the study. Demographic, preoperative, operative, oncological and complication data were collected. The primary outcome was unplanned reoperation for complications within 30 days of surgery. Secondary outcomes included re-excision rates and time to adjuvant therapy.

RESULTS

Overall, 880 patients underwent 899 therapeutic mammaplasty procedures at 50 centres. The most common indications were avoidance of poor cosmetic outcomes associated with standard breast-conserving surgery (702 procedures, 78·1 per cent) or avoidance of mastectomy (379, 42·2 per cent). Wise-pattern skin incisions were the most common (429 of 899, 47·7 per cent), but a range of incisions and nipple-areola pedicles were used. Immediate contralateral symmetrization was performed in one-third of cases (284 of 880, 32·3 per cent). In total, 205 patients (23·3 per cent) developed a complication, but only 25 (2·8 per cent) required reoperation. Median postoperative lesion size was 24·5 (i.q.r. 16-38) mm. Incomplete excision was seen in 132 procedures (14·7 per cent), but completion mastectomy was required for only 51 lesions (5·7 per cent). Median time to adjuvant therapy was 54 (i.q.r. 42-66) days.

CONCLUSION

Therapeutic mammaplasty is a safe and effective alternative to mastectomy or standard breast-conserving surgery. Further work is required to explore the impact of the technique on quality of life, and to establish cost-effectiveness.

A cost-utility analysis comparing large volume displacement oncoplastic surgery to mastectomy with single stage implant reconstruction in the treatment of breast cancer

BACKGROUND

For larger cancers in moderate to large breast sized women, breast surgical cancer treatment may include large volume displacement oncoplastic surgery (LVOS) or mastectomy with single stage implant reconstruction (SSIR). Often in the case of LVOS, reduction mammaplasty designs are used in the oncoplastic reconstructions with a contralateral symmetry operation. The goal of this study was to investigate the cost-utility between LVOS versus SSIR to determine which approach is cost-effective in the treatment of breast cancer.

METHODS

A review of the literature was performed to determine baseline values and ranges. An average national Medicare payment rates using DRG and CPT codes were used for cost assessment. After constructing a decision tree, an incremental cost-utility ratio (ICUR) was calculated comparing the difference for both surgical options in costs by the difference in clinical-effectiveness. To validate our results, we performed one-way sensitivity analyses in addition to a Monte-Carlo analysis.

RESULTS

An ICUR of $546.81/QALY favoring LVOS was calculated based off of its clinical-effectiveness gain of 7.67 QALY at an additional cost of $4194. One-way sensitivity analyses underscored the degree by which LVOS was cost-effective. For example, LVOS became cost-ineffective when a successful LVOS cost more than $50,000. Similarly, probabilistic sensitivity analysis using Monte-Carlo simulation showed that even with varying multiple variables at once, results tended to favor our conclusion supporting the cost-effectiveness of LVOS.

CONCLUSIONS

For the appropriate patients with moderate to large sized breasts with breast cancer, large volume displacement oncoplastic surgery is cost-effective compared to mastectomy with single staged implant reconstruction.

Long term effects of modern breast cancer surgery

Breast cancer surgery includes a wide array of surgical treatment options. Not only does it involve the oncologic excision of the breast cancer disease but it also involves the reconstruction of the breast. Surgical treatment options vary with regards to the size of the tumor relative to the size of the breast further complicated by the preferences of the patient and the ability of the available surgeon(s). The goal of this paper is to highlight major long-term effects, positive and negative, of modern breast cancer surgery.

Basic Oncoplastic Surgery for Breast Conservation: Tips and Techniques

BACKGROUND

The demand for oncoplastic breast surgery has increased significantly in recent years. However, these procedures are often not taught in standard training for breast surgeons, and a simple guide for surgeons to start performing basic oncoplastic breast surgery techniques is not available.

METHODS

The basic concepts of oncoplastic breast surgery and the tools needed prior to starting these types of procedures are discussed, and the procedure, in a stepwise pattern, for the building blocks of oncoplastic techniques is outlined.

RESULTS

The importance of oncoplastics from a quality of life and oncologic standpoint are described. Key concepts are defined and the decision on when it is necessary to consult reconstructive plastic surgery is delineated. The basic necessities for oncoplastic breast surgery, including patient photographs, important intraoperative tools, anatomic knowledge, and patient selection, are discussed. The building block procedures include aesthetic scar placement, parenchymal closure, deepithelialization, and donut therapeutic mastopexy, which are described in detail.

CONCLUSIONS

Oncoplastic breast surgery techniques and clinical reasoning build on one another, allowing a surgeon to move from level I to level II oncoplastic procedures. Even the most basic level I breast conservation oncoplastic skills can improve a patient's cosmetic outcome and are easily learned by a general surgeon.

Anatomic and terminological description and processing of breast pathologic specimens from oncoplastic large volume displacement surgeries

Oncoplastic surgery provides breast cancer patients with greater aesthetic satisfaction without compromising disease-free survival or overall survival rate. Large volume displacement oncoplastic surgical techniques have become increasingly popular as a strategy for improving aesthetic outcomes and extending the option of breast conservation therapy. They often involve breast reduction or mastopexy reconstructive techniques to facilitate resection of large breast volumes on the side of the breast cancer and accompanied with symmetry contralateral breast reductions or mastopexies. However, dissection of large volume displacement oncoplastic surgical specimens presents unique challenges. Compared with traditional mastectomy specimens, they are relatively complicated, which requires the pathologist to understand the surgical procedure and the anatomy of the specimens. Given this, we introduce the standard anatomical and terminological description for the breast pathologic specimens of five large volume displacement oncoplastic surgical techniques commonly performed in our institution for breast cancer management. The individual surgical specimen is composed of one or several components, which include lateral wall, superior keyhole, medial wall, lateral wing, inferior pole, and medial wing. We also present specimen documentation and sectioning procedures used in our institution. The advantages for the patient provided by large volume reduction oncoplastic surgery must be supported by proper evaluation of the surgical pathology specimen. Therefore, we recommend that each section taken from the oncoplastic specimen be labeled as to its specific location in the specimen components. Standardized nomenclature and technique will assist pathologists in accurately evaluating the surgical margins.

Technique for single axillary incision robotic assisted quadrantectomy and immediate partial breast reconstruction with robotic latissimus dorsi flap harvest for breast cancer: A case report

RATIONALE

The clinical application of robotic surgery in breast conserving surgery or volume replacement with robotic latissimus dorsi flap harvest (RLDFH) has been rarely reported. In this study, we report the preliminary experience and clinical outcome of robotic assisted quadrantectomy (RAQ) and immediate partial breast reconstruction (IPBR) with RLDFH.

PATIENT CONCERN

Decreasing and avoid back scar length after latissimus dorsi flap harvest.

DIAGNOSES

One 28 years old female with left breast cancer underwent RAQ and IPBR with RLDFH. Initially, she was diagnosed with left breast infiltrating carcinoma that was clinical stage T3N1M0 and triple negative.

INTERVENTIONS

Neoadjuvant chemotherapy consisting of 4 cycles of epirubicin and cyclophosphamide followed by 4 cycles of docetaxel was performed. Breast magnetic resonance imaging showed residual breast cancer about 4.5 cm over the left upper outer quadrant of the breast. Sentinel lymph node biopsy showed no lymph node metastasis. RAQ, which took 82 minutes, was performed first, and the resected breast specimen's weight was 203 gm. She received IPBR with RLDFH, which took 97 minutes.

OUTCOMES

The overall blood loss was 40 mL. The final pathology result was ypT2 (4.2 cm)N0 (sn0/3)M0 and stage IIA. The resection margin was free of tumors. The post-operative recovery was smooth except for seroma formation over the back, which was relieved after repeated aspiration at an outpatient clinic. The patient was satisfied with the post-operative scar and aesthetic outcome. No local recurrence, distant metastasis or case mortality was found during 5 months of follow-up.

LESSONS

RAQ and IPBR with RLDFH is a safe alternative for small-to-medium-breast-size women with breast cancer who desire breast conservation and are indicated for volume replacement with autologous latissimus dorsi flap.

Oncoplastic Breast Reconstruction: Should All Patients be Considered?

Oncoplastic surgery of the tissue defect from partial mastectomy should be considered for all patients. It can result in in significant asymmetries from scar contraction, skin tethering, and alterations in the nipple areolar complex location. Indications, risks, and benefits are discussed. Optimal procedures are described, considering resected specimen volume, primary tumor location, tumor to breast size ratio, and the impact on the nipple areolar complex. Indications for plastic surgery consultation and joint surgery are discussed. Surgical management includes incision planning, preservation of the nipple areolar complex pedicle and position, patient positioning, incision location, and recovery.

Oncoplastic Surgery: Keeping It Simple With 5 Essential Volume Displacement Techniques for Breast Conservation in a Patient With Moderate- to Large-Sized Breasts

Oncoplastic surgery is an evolving field in breast surgery combining the strengths of breast surgical oncology with plastic surgery. It provides the surgeon the ability to excise large areas of the breast in the oncologic resection without compromising, and possibly improving, its aesthetic appearance. The purpose of this review is to provide a guide that could help a breast surgeon excise breast cancer in most areas of the breast using 5 oncoplastic techniques. These techniques would be used depending primarily on the location of the cancer in the breast and also on the size of the tumor.