Use of silicone implants after wide local excision of the breast

Partial Breast Reconstruction with Lateral Chest Wall Perforator Flap to Facilitate Breast Conservation in Breast Cancer: First 100 Cases with Cancer Outcomes at 8 Years Follow-Up and the Lessons Learned

Background

This is a prospective cohort study of partial breast reconstruction (PBR) with a lateral chest wall perforator flap (LCWPF) to facilitate breast conservation surgery (BCS) for women undergoing surgery for breast cancer. The study was undertaken to study the clinical and cancer outcomes.

Methods

Patients diagnosed with ductal carcinoma in situ (DCIS) or breast cancer who consented to undergo BCS with PBR with LCWPF were included in the study. A prospective database has been maintained to collect information on clinico-pathological features, complications, and follow-up. Patients were asked to complete an anonymised PROM questionnaire over the years. The hospital electronic records were interrogated for women who have completed 5 years follow-up to assess for development of recurrence/events.

Results

A total of 105 patients underwent PBR with LCWPFs between 2011 and 2018. Of these, 74% underwent cancer resection and PBR as one operation whilst 26% underwent PBR as a two-stage approach. The median tumor size on pre-op imaging was 30 mm for the one-stage approach and 39.5 mm for the two-stage approach (p-value=0.003). The complication rates were low and the re-operation rate for close margins was 10%, with 4% eventually requiring mastectomy. Good-to-excellent esthetic outcomes were reported in more than 80% of cases by patients and clinicians. The local recurrence rate (LR) was 2%, distant recurrence rate 10.5%, disease free survival (DFS) 86%, distant disease-free survival (DDFS) 89% and overall survival (OS) 94.8% at 4.5 years median follow-up. This procedure provides an effective oncological approach, avoiding mastectomy with a good-to-excellent cosmetic outcome. The follow-up data establishes the safety of this approach.

Discussion

This is the first published series of recurrence and survival data in patients undergoing PBR. We intend to continue with data collection to assess long-term outcomes beyond 10 years. The authors would recommend consideration of this technique to facilitate BCS and avoid mastectomy.

Registration

Not applicable.

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

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

The biplanar oncoplastic technique case series: a 2-year review

BACKGROUND

Oncoplastic techniques for breast reconstruction following partial mastectomy are now commonly included in the armamentarium of most reconstructive plastic surgeons. These techniques have been frequently used for women with large breast volume and less frequently used form women with small to moderate breast volume. Most women with smaller breast volumes have been typically considered for mastectomy. As an alternative to mastectomy, the biplanar technique was designed and described as an oncoplastic option. The purpose of this manuscript is to review our 2-year experience using this technique in a series of women with small to moderate breast volume.

METHODS

A retrospective review of patients who underwent oncoplastic surgery from 2011-2012 by the senior authors (RM and MYN) was completed. Ten patients were identified that had the biplanar technique involving glandular tissue rearrangement in conjunction with the immediate placement of a submuscular implant or tissue expander. Patient demographics, perioperative details, and post-operative outcomes were evaluated.

RESULTS

The mean age and BMI of the ten patients in the study was 56 years (range, 40-68 years) and 24.1 years (range, 20.3-28.6 years) respectively. The mean resection volume was 76.5 g (range, 25-164 g). Eight patients had placement of a permanent implant and two patients had placement of a tissue expander. The average volume of the implanted devices was 138 cc (range, 90-300 cc). In eight patients, a sheet of acellular dermal matrix was used. Immediate biplanar reconstruction was performed in seven patients and a staged-immediate biplanar reconstruction was performed in three patients. Complications included a positive margin on final pathology requiring mastectomy (n=1), infection (n=1), incisional dehiscence following radiation (n=1), and loss of nipple sensation (n=2). Follow-up ranged from 4.5-27 months (mean of 19.5 months).

CONCLUSIONS

The biplanar oncoplastic technique may represent a valuable option in women with small to moderate breast volumes that choose to have breast conservation therapy (BCT). This technique has demonstrated success with minimizing contour irregularities and maintaining breast volume. Based on our early experience, patient satisfaction is favorable.

[Oncoplastic approach in breast cancer surgery--a new challenge for the future breast surgeon?]

The future challenge of breast surgery, the so-called oncoplastic approach is reviewed in this article. The authors discuss the most frequently applied surgical techniques as well as their indications. Medline and pubmed search was carried out using the following keywords and cross-references: "oncoplastic breast surgery", "breast reconstruction", "breast conserving surgery" and "reduction mammoplasty". Original and review papers published in English language and their references were included. In the literature surprisingly, a large variety of breast oncoplastic surgical procedures has been described. Although reconstructions with local flaps are relatively easy procedures, proper indications for these are critical in order to improve cosmesis after breast conservation. Applications of pedicled flaps are technically more demanding, and only properly trained oncoplastic breast or plastic surgeons are able to provide the possibly best aesthetic outcome after mastectomy or breast conserving surgery. Finally, carrying out free flap reconstructions after mastectomy should be assigned exclusively to plastic surgeons qualified in microsurgical techniques, and not to surgical oncologists. As conclusions oncoplastic approach will be an integral element of the surgical treatment of breast cancer in the future. Breast oncoplastic training is an interdisciplinary task, which combines surgical oncological management of breast cancers with aesthetic/reconstructive breast surgery.

New trends in breast cancer management: is the era of immediate breast reconstruction changing?

OBJECTIVE

Review of available literature on the topic of breast reconstruction and radiation is presented. Factors influencing the decision-making process in breast reconstruction are analyzed. New trends of immediate breast reconstruction are presented.

SUMMARY BACKGROUND DATA

New indications for postmastectomy radiation have caused a dramatic increase in the number of radiated patients presenting for breast reconstruction. The major studies and their impact on breast cancer management practice are analyzed. Unsatisfactory results of conventional immediate reconstruction techniques followed by radiotherapy led to a new treatment algorithm for these patients. If the need for postoperative radiation therapy is known, a delayed reconstruction should be considered. When an immediate reconstruction is still desired despite the certainty of postoperative radiotherapy, reconstructive options should be based on tissue characteristics and blood supply. Autologous tissue reconstruction options should be given a priority in an order reflecting superiority of vascularity and resistance to radiation: latissimus dorsi flap, free TRAM or pedicled TRAM without any contralateral components of tissue, pedicled TRAM/midabdominal TRAM, and perforator flap.

CONCLUSIONS

When the indications for postoperative radiotherapy are unknown, premastectomy sentinel node biopsy, delayed-immediate reconstruction, or delayed reconstruction is preferable.

Latissimus dorsi mini-flap: a technique for extending breast conservation

The latissimus dorsi (LD) flap was first used in patients for breast reconstruction in 1896. More recently it has been used to fill defects after quadrantectomy or very wide excision. We have developed a two stage procedure for excision of large breast cancers which would otherwise require mastectomy. The first stage is a wide excision of the cancer without removal of the overlying skin. Thirty patients with large localized operable breast cancer underwent wide local excision followed 5 to 10 days later in 25 patients who had clear histological margins by an axillary dissection with transfer of the LD muscle and overlying fat into the defect in the breast (mini-flap). The cosmetic outcome of these 25 patients who underwent mini-flap were compared with age matched patients having a standard wide local excision and axillary node clearance or mastectomy and immediate breast reconstruction. The volume of tissue excised in patients having their defects filled by LD mini-flap was significantly greater than those women undergoing standard wide excision, p<0.001. Compared with patients who had a mastectomy and immediate breast reconstruction, patients who had mini-flaps reported a better treated breast shape, p=0.04, a greater resemblance to the opposite breast, less self consciousness and less change in attitude of their spouse, p=0.03 and they were more likely to choose the same operation in future compared with patients having immediate whole breast reconstruction, p=0.02. Results as rated by patients in the mini-flap group were similar to those women treated by standard wide local excision. Only one patient in the mini-flap group felt sexually inhibited. When wide local excision and LD mini-flap is performed as a two stage procedure, it is an oncologically safe technique and extends breast conservation to women with larger tumours. The cosmetic outcomes appear better than those following the alternative of mastectomy and immediate breast reconstruction.