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

Outcomes of reconstructive techniques in breast cancer using BCCT. core software

BACKGROUND

Surgery remains a priority for breast cancer treatment. This study aimed to compare the cosmetic outcomes of oncoplastic patients who had undergone breast-conserving surgery, mini-LDF (latissimus dorsi flap), and immediate implant reconstruction using both the Japanese scale and the BCCT.core (The Breast Cancer Conservative Treatment cosmetic results software) program and to validate this program.

PATIENTS AND METHODS

Patients who underwent surgery for breast cancer between 1997 and 2021 were retrospectively studied. Patients were divided into three groups: 1-those who had undergone breast-conserving surgery (245 patients, 71.3%), 2-those who had undergone mini-LDF after lumpectomy (38 patients, 11.02%), and 3- those who underwent reconstruction with implants after nipple-sparing mastectomy (61 patients, 17.68%). The patients were called for a follow-up examination, and their photos were taken. The photographs were shown to an independent breast surgeon and a plastic surgeon who was not included in the surgeries, and they were asked to evaluate and rate them according to the Japanese cosmetic evaluation scale. The same images were transferred to the computer and scored using BCCT.core.

RESULTS

The plastic and breast surgeon evaluation results showed no significant difference between the three cosmetic techniques (p = 0.99, 0.98). The results of BCCT.core software measurements were similar to the results of plastic and breast surgeons (p: 0.43).

CONCLUSION

Patients are more knowledgeable about cosmetic outcomes and expect more objective data. In this study, we used 3 different cosmetic evaluation scales. We found that these techniques give results that are compatible with each other in terms of evaluating the work done in a more concrete way. For this reason, we recommend the use of such software, which offers objective results in a subjective field such as aesthetics and is very easy to apply.

Quantitative assessment of breast volume changes after whole-breast irradiation for breast cancer using breast auto-segmentation

PURPOSE

This study aimed to quantitatively estimate the changes in breast volume associated with radiotherapy in patients undergoing breast-conserving surgery and whole-breast irradiation (WBI).

METHODS

Pre-WBI simulation computed tomography (CT) scans and post-WBI follow-up chest CT scans from a total of 1,151 breast cancer patients were analyzed using a deep-learning-driven auto-segmentation approach. The CT-based asymmetry index (CTAI) was calculated by dividing the volume of the irradiated breast by the volume of the contralateral breast. Significant breast shrinkage was defined as a CTAI < 0.85. To quantify changes in CTAI over the follow-up period, the CTAI ratio was determined as the post-WBI CTAI divided by the pre-WBI CTAI. A multivariate logistic regression analysis was conducted to identify potential variables associated with post-WBI significant breast shrinkage.

RESULTS

The median CTAI values for pre- and post-WBI CT scans were 0.973 (interquartile range: 0.887-1.069) and 0.866 (interquartile range: 0.773-0.967), respectively. The difference between them was statistically significant (p < 0.001). Following WBI, there was an increase in the rate of significant breast shrinkage from 16.3 to 44.8%. The CTAI ratio showed a negative association with the time interval (p < 0.001, Pearson r = - 0.310). In the multivariate logistic regression analysis, lower pre-WBI CTAI, younger age, and longer interval between CT scans were found to be significantly associated with a higher occurrence of post-WBI significant breast shrinkage.

CONCLUSION

Breast volume decreases following WBI, and this decrease is correlated with an increased duration after WBI. These findings highlight the long-term consequences of WBI on breast asymmetry.

A Novel, Deep Learning-Based, Automatic Photometric Analysis Software for Breast Aesthetic Scoring

Background  Breast aesthetics evaluation often relies on subjective assessments, leading to the need for objective, automated tools. We developed the Seoul Breast Esthetic Scoring Tool (S-BEST), a photometric analysis software that utilizes a DenseNet-264 deep learning model to automatically evaluate breast landmarks and asymmetry indices. Methods  S-BEST was trained on a dataset of frontal breast photographs annotated with 30 specific landmarks, divided into an 80-20 training-validation split. The software requires the distances of sternal notch to nipple or nipple-to-nipple as input and performs image preprocessing steps, including ratio correction and 8-bit normalization. Breast asymmetry indices and centimeter-based measurements are provided as the output. The accuracy of S-BEST was validated using a paired t -test and Bland-Altman plots, comparing its measurements to those obtained from physical examinations of 100 females diagnosed with breast cancer. Results  S-BEST demonstrated high accuracy in automatic landmark localization, with most distances showing no statistically significant difference compared with physical measurements. However, the nipple to inframammary fold distance showed a significant bias, with a coefficient of determination ranging from 0.3787 to 0.4234 for the left and right sides, respectively. Conclusion  S-BEST provides a fast, reliable, and automated approach for breast aesthetic evaluation based on 2D frontal photographs. While limited by its inability to capture volumetric attributes or multiple viewpoints, it serves as an accessible tool for both clinical and research applications.

Cosmetic Outcome and Toxicity After Stereotactic Accelerated Partial Breast Irradiation in Early Breast Cancer: A Prospective Observational Cohort Study

PURPOSE

The aim of this work was to prospectively evaluate the toxicity and cosmetic outcomes of 5-fraction, stereotactic, accelerated partial breast irradiation (APBI).

METHODS AND MATERIALS

This prospective observational cohort study enrolled women who underwent APBI for invasive carcinoma or carcinoma in situ of the breast. APBI was delivered using a CyberKnife M6 robotic radiosurgery system at 30 Gy in 5 nonconsecutive, once-daily fractions. Women undergoing whole breast irradiation (WBI) were also enrolled for comparison. Patient-reported and physician-assessed adverse events were recorded. Breast fibrosis was measured using a tissue compliance meter, and breast cosmesis was assessed using BCCT.core (an automatic, computer-based software). Outcomes were collected until 24 months posttreatment according to the study protocol.

RESULTS

In total, 204 patients (APBI, n = 103; WBI, n = 101) were enrolled. Regarding patient-reported outcomes, the APBI group reported significantly less skin dryness (6.9% vs 18.3%; P = .015), radiation skin reaction (9.9% vs 23.5%; P = .010), and breast hardness (8.0% vs 20.4%; P = .011) at 6 months than the WBI group. On physician assessment, the APBI group had significantly less dermatitis at 12 months (1.0% vs 7.2%; P = .027) than the WBI group. Any severe toxicities after APBI were rare in patient-reported outcomes (score ≥3, 3.0%) and physician assessments (grade ≥3, 2.0%). In the uninvolved quadrants, measured fibrosis in the APBI group was significantly lower than that in the WBI group at 6 (P = .001) and 12 (P = .029) months but not at 24 months. In the involved quadrant, measured fibrosis in the APBI group was not significantly different from that in the WBI group at any time. Cosmetic outcomes in the APBI group were mostly excellent or good (77.6%) at 24 months, and there was no significant cosmetic detriment from the baseline.

CONCLUSIONS

Stereotactic APBI was associated with less fibrosis in the uninvolved breast quadrants than WBI. Patients showed minimal toxicity and no detrimental effects on cosmesis after APBI.

Comparison of prone and supine positioning for breast cancer radiotherapy using REQUITE data: dosimetry, acute and two years physician and patient-reported outcomes

OBJECTIVE

Most patients receive whole breast radiotherapy in a supine position. However, two randomised trials showed lower acute toxicity in prone position. Furthermore, in most patients, prone positioning reduced doses to the organs at risk. To confirm these findings, we compared toxicity outcomes, photographic assessment, and dosimetry between both positions using REQUITE data.

METHODS

REQUITE is an international multi-centre prospective observational study that recruited 2069 breast cancer patients receiving radiotherapy. Data on toxicity, health-related quality of life (HRQoL), and dosimetry were collected, as well as a photographic assessment. A matched case control analysis compared patients treated prone (n = 268) versus supine (n = 493). Exact matching was performed for the use of intensity-modulated radiotherapy, boost, lymph node irradiation, chemotherapy and fractionation, and the nearest neighbour for breast volume. Primary endpoints were dermatitis at the end of radiotherapy, and atrophy and cosmetic outcome by photographic assessment at two years.

RESULTS

At the last treatment fraction, there was no significant difference in dermatitis (p = .28) or any HRQoL domain, but prone positioning increased the risk of breast oedema (p < .001). At 2 years, patients treated in prone position had less atrophy (p = .01), and higher body image (p < .001), and social functioning (p < .001) scores. The photographic assessment showed no difference in cosmesis at 2 years (p = .22). In prone position, mean heart dose (MHD) was significantly lower for left-sided patients (1.29 Gy vs 2.10 Gy, p < .001) and ipsilateral mean lung dose (MLD) was significantly lower for all patients (2.77 Gy vs 5.89 Gy, p < .001).

CONCLUSIONS

Prone radiotherapy showed lower MLD and MHD compared to supine position, although the risk of developing breast oedema during radiotherapy was higher. At 2 years the photographic assessment showed no difference in the cosmetic outcome, but less atrophy was seen in prone-treated patients and this seems to have a positive influence on the HRQoL domain of body image.

Evaluation of Intraoperative Volumetric Assessment of Breast Volume Using 3D Handheld Stereo Photogrammetric Device

Methods for assessing three-dimensional (3D) breast volume are becoming increasingly popular in breast surgery. However, the precision of intraoperative volumetric assessment is still unclear. Until now, only non-validated scanning systems have been used for intraoperative volumetric analyses. This study aimed to assess the feasibility, handling, and accuracy of a commercially available, validated, and portable device for intraoperative 3D volumetric evaluation. All patients who underwent breast surgery from 2020 to 2022 were identified from our institutional database. Intraoperative 3D volumetric assessments of 103 patients were included in this study. Standardized 3D volumetric measurements were obtained 3 months postoperatively to compare the intraoperatively generated volumetric assessment. All of the study participants were women with a mean age of 48.3 ± 14.7 years (range: 20-89). The mean time for intraoperative volumetric assessment was 8.7 ± 2.6 min. The postoperative 3D volumetric assessment, with a mean volume of 507.11 ± 206.29 cc, showed no significant difference from the intraoperative volumetric measurements of 504.24 ± 276.61 cc (p = 0.68). The mean absolute volume difference between the intraoperative simulations and postoperative results was 27.1 cc. Intraoperative 3D volumetric assessment using the VECTRA H2 imaging system seems to be a feasible, reliable, and accurate method for measuring breast volume. Based on this finding, we plan to investigate whether volumetric objective evaluations will help to improve breast symmetry in the future.

Factors associated with unsatisfactory cosmetic results in oncoplastic surgery

INTRODUCTION

Oncoplastic surgery (OS) has expanded the indications for breast-conserving surgery associated with an adequate aesthetic result. However, few studies have described the factors associated with unsatisfactory cosmetic outcomes from this surgical modality.

MATERIALS AND METHODS

This is a cross-sectional prospective study that included patients undergoing breast-conserving surgery (BCS) with or without OS. The patients self-evaluated the cosmetic results of the breasts posttreatment and had them photographed. The photos were analyzed by BCCT.core. Individual and treatment factors (local and systemic) for all patients were evaluated. These factors were dichotomized according to the use of OS and to the cosmetic result (satisfactory and unsatisfactory). Categorical variables were tested for association with surgical outcome using the chi-square test while numerical variables using the Mann-Whitney U test. Variables with p <0,2 were selected for multivariate analysis.

RESULTS

Of the 300 patients evaluated, 72 (24,0%) underwent OS. According to the patient self-evaluations, an unsatisfactory cosmetic result from OS was significantly associated with younger age at diagnosis, higher body mass index (BMI) at the time of evaluation, larger tumor size and greater weight of the surgical specimen. According to the BCCT.core, only the laterality of the tumor (left) was significantly associated with an unsatisfactory cosmetic result. In logistic regression, considering OS as a control variable, the risk of an unsatisfactory outcome according to patient self-evaluation was related to the tumor ≥ T2 odds ratio (OR) 1,85 (1,027-3,34) and age at diagnosis < 40 [OR 5,0 (1,84-13,95)]. However, according to the software, the variables were associated with an increased risk of an unsatisfactory outcome were the time interval between surgery and evaluation [OR 1,27 (1,16-1,39)], the presence of lymphedema [OR 2,97 (1,36-6,46)], surgical wound infection [OR 3,6 (1,22-11,16)], tumor location on the left side [OR 3,06 (1,69-5,53)], overweight [OR 2,93 (1,48-5,8)] and obesity [OR 2,52 (1,2-5,31)].

CONCLUSION

There is no standard methodology for breast cosmesis evaluation, which influences the factors associated with unsatisfactory results. Younger patients and those with increased BMI, left breast cancer and extensive resections tend to present with unsatisfactory cosmetic results when OS is performed.

Aesthetic outcomes of breast-conserving surgery and oncoplastic surgery with the new scale named Quality of Life Questionnaire Breast Reconstruction Module-23

Purpose

Oncoplastic surgery (OPS) has been developed with the aim of improving breast-conserving surgery (BCS) to provide better aesthetic and functional outcomes for breast cancer patients. We aimed to compare overall quality of life (QoL) and satisfaction with breast reconstruction in patients undergoing BCS and OPS using the Quality of Life Questionnaire Core 30 (QLQ-C30) and recently validated QLQ-Breast Reconstruction module (QLQ-BRECON23).

Methods

A total of 87 patients were included in this single-center study between January 1, 2018 and December 31, 2021; 43 underwent OPS (49.4%) and 44 underwent BCS (50.6%). The data on patient, tumor, and treatment characteristics were obtained from the prospectively collected database at the hospital. QLQ-C30 and QLQ-BRECON23 were used to evaluate psychosocial well-being, fatigue symptoms, overall QoL, sexual well-being, sensation of the operative area, and satisfaction with the reconstruction.

Results

According to QLQ-C30 evaluation there were significantly better outcomes for patients treated with OPS than BCS in terms of psychosocial well-being, fatigue symptoms, and overall QoL (P = 0.005, P = 0.016, and P = 0.004; respectively), according to QLQ-BRECON23 evaluation there were also significantly better outcomes in terms of sexual well-being, sensation of the operative area, and satisfaction of the reconstruction (P < 0.001, P = 0.002, and P < 0.001; respectively).

Conclusion

We found that the overall QoL and satisfaction with breast reconstruction in patients undergoing OPS are better than those undergoing BCS. Our study is critical because it is the first study comparing OPS and BCS using the QLQ-BRECON23, which was recently validated.

Oncoplastic Breast Surgery: a Single-Institution Experience

Oncoplastic breast surgery involves immediate reshaping of the breast after tumor excision. It enables wider excision of the tumor while maintaining a satisfactory cosmetic outcome. One hundred and thirty seven patients underwent oncoplastic breast surgery at our institute between June 2019 and December 2021. The procedure performed was decided based on the location of tumor and volume of excision. All patient and tumor characteristics were entered into an online database. The median age was 51 years. The mean tumor size was 3.666 cm (± 0.2512). Twenty-seven patients underwent a type I oncoplasty, 89 patients type 2 oncoplasty, and 21 patients a replacement procedure. Only 5 patients had margin positivity out of which 4 patients underwent a re-wide excision with negative margins. Oncoplastic breast surgery is a safe and effective method to manage patients who need conservative surgery of breast tumors. It allows us to provide good esthetic outcome to the patients ultimately aiding in better emotional and sexual well-being.

Clinical assessment of breast symmetry and aesthetic outcome: can 3D imaging be the gold standard?

There is a lack of an accurate standardised objective method to assess aesthetic outcome after breast surgery. In this methodological study, we investigated the intra- and inter-observer reproducibility of breast symmetry and volume assessed using three-dimensional surface imaging (3D-SI), evaluated the reproducibility depending on imaging posture, and proposed a new combined volume-shape-symmetry (VSS) parameter. Images were acquired using the VECTRA XT 3D imaging system, and analysed by two observers using VECTRA Analysis Module. Breast symmetry was measured through the root mean square distance. All women had undergone bilateral risk-reducing mastectomy and immediate breast reconstruction. The reproducibility and correlations of breast symmetry and volume measurements were compared using Bland-Altman's plots and tested with Spearman's rank correlation coefficient. 3D surface images of 58 women were analysed (348 symmetry measurements, 696 volume measurements). The intra-observer reproducibility of breast symmetry measurements was substantial-excellent, the inter-observer reproducibility was substantial, and the inter-posture reproducibility was substantial. For measurements of breast volumes, the intra-observer reproducibility was excellent, the inter-observer reproducibility was moderate-substantial, and the inter-posture reproducibility was substantial-excellent. The intra-observer reproducibility of VSS was excellent while the inter-observer reproducibility was substantial for both observers, independent of posture. There were no statistically strong correlations between breast symmetry and volume differences. The intra-observer reproducibility was found to be substantial-excellent for several 3D-SI measurements independent of imaging posture. However, the inter-observer reproducibility was lower than the intra-observer reproducibility, indicating that 3D-SI in its present form is not a great assessment for symmetry.

Long-term course of the changes in the nipple position after breast-conserving surgery

PURPOSE

Even if favorable cosmetic outcomes are obtained shortly after breast-conserving surgery (BCS), cosmetic changes may occur up to several years after BCS. In the present study, we evaluated cosmetic changes while focusing on changes in the nipple position after BCS.

METHODS

We examined the long-term course of changes in the nipple position over time after BCS using the proportion of the distance between the sternal notch and nipple (PDSN) in 196 patients. We also evaluated risk factors for long-term nipple position changes.

RESULTS

The median follow-up period was 9.9 years. Nipple position changes occurred within eight years after BCS and seemed to plateau beyond that point. The body mass index (BMI), breast size, proportion of excision volume and axillary treatment were significantly associated with the nipple position changes within one to five years after BCS. The BMI, breast size, axillary treatment, chemotherapy and hormonal therapy were significantly associated with the nipple position changes within five to eight years after BCS.

CONCLUSIONS

After BCS, the nipple position changes occur within about eight years. Obesity, large breast size, large excision volume, axillary treatment, chemotherapy and hormone therapy were factors that affected the treated breast shrinkage and increase in the left-right difference after BCS.

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

Objective

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

Patients/Methods

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

Results

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

Conclusion

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

Partial Breast Irradiation Versus Whole Breast Irradiation for Early Breast Cancer Patients in a Randomized Phase III Trial: The Danish Breast Cancer Group Partial Breast Irradiation Trial

PURPOSE

On the basis of low risk of local recurrence in elderly patients with breast cancer after conservative surgery followed by whole breast irradiation (WBI), the Danish Breast Cancer Group initiated the noninferiority external-beam partial breast irradiation (PBI) trial (ClinicalTrials.gov identifier: NCT00892814). We hypothesized that PBI was noninferior to WBI regarding breast induration.

METHODS

Patients operated with breast conservation for relatively low-risk breast cancer were randomly assigned to WBI versus PBI, and all had 40 Gy/15 fractions. The primary end point was 3-year grade 2-3 breast induration.

RESULTS

In total, 865 evaluable patients (434 WBI and 431 PBI) were enrolled between 2009 and 2016. Median follow-up was 5.0 years (morbidity) and 7.6 years (locoregional recurrence). The 3-year rate of induration was 9.7% for WBI and 5.1% for PBI (P = .014). Large breast size was significantly associated with induration with a 3-year incidence of 13% (WBI) and 6% (PBI) for large-breasted patients versus 6% (WBI) and 5% (PBI) for small-breasted patients. PBI showed no increased risk of dyspigmentation, telangiectasia, edema, or pain, and patient satisfaction was high. Letrozole and smoking did not increase the risk of radiation-associated morbidity. Sixteen patients had a locoregional recurrence (six WBI and 10 PBI; P = .28), 20 patients had a contralateral breast cancer, and eight patients had distant failure (five WBI and three PBI). A nonbreast second cancer was detected in 73 patients (8.4%), and there was no difference between groups.

CONCLUSION

External-beam PBI for patients with low-risk breast cancer was noninferior to WBI in terms of breast induration. Large breast size was a risk factor for radiation-associated induration. Few recurrences were detected and unrelated to PBI.

Preoperative robotic radiosurgery for early breast cancer: Results of the phase II ROCK trial (NCT03520894)

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Preoperative partial breast irradiation treats well-defined target.

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Stereotactic body radiation therapy have been routinely implemented in clinical practice.

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No acute toxicity greater than grade 2 was recorded.

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A single 21 Gy dose preoperative robotic radiosurgery represents a feasible technique.

Background and purpose

Preoperative partial breast irradiation (PBI) has got the advantage of treating a well-defined target. We report the results of the phase II ROCK trial (NCT03520894), enrolling early breast cancer (BC) patients treated with preoperative robotic radiosurgery (prRS), in terms of acute and early late toxicity, disease control, and cosmesis.

Material and methods

The study recruited between 2018 and 2021 at our Radiation Oncology Unit. Eligible patients were 50 + years old BC, hormonal receptors positive/human epidermal growth factor receptor 2 negative (HR+/HER2-), sized up to 25 mm. The study aimed to prospectively assess the toxicity and feasibility of a robotic single 21 Gy-fraction prRS in preoperative setting.

Results

A total of 70 patients were recruited and 22 patients were successfully treated with pRS. Overall, three G1 adverse events (13.6 %) were recorded within 7 days from prRS. Three events (13.6 %) were recorded between 7 and 30 days, one G2 breast oedema and two G1 breast pain. No acute toxicity greater than G2 was recorded. Five patients experienced early late G1 toxicity. One patient reported G2 breast induration. No early late toxicity greater than G2 was observed. At a median follow up of 18 months (range 6–29.8), cosmetic results were scored excellent/good and fair in 14 and 5 patients, respectively, while 3 patients experienced a poor cosmetic outcome.

Conclusions

ROCK trial showed that a single 21 Gy dose prRS represents a feasible technique for selected patients affected by early BC, showing an acceptable preliminary toxicity profile.

Evaluation of breast cosmetic changes with a computer-software; the breast cancer conservative treatment cosmetic results (BCCT. core) in hypofractionated whole breast irradiation after breast-conserving surgery-supplementary analysis of multicenter single-arm confirmatory trial: JCOG0906

BACKGROUND

A good cosmetic outcome has been defined as an important endpoint in breast-conserving therapy (BCT). Various evaluation methods have been studied, but the optimal method has yet to be identified. The present supplementary analysis of JCOG0906 focused on comparing evaluation methods for breast cosmetic outcomes following hypofractionated whole breast irradiation (HFWBI) to examine whether a computer-software (the Breast Cancer Conservative Treatment cosmetic results [BCCT. core])-based program evaluation (CE) can be used for Asian women in clinical trials of BCT.

METHODS

Of 306 women, 292 underwent institutional evaluation (IE) for breast cosmetic outcomes before (pre) and 3 years after (post) HFWBI using a 4-point scale (excellent/good/fair/poor), and they were evaluated by CE and a central panel evaluation (PE) on the same scale using 292 pairs of pre/post-HFWBI photographs. PE was performed twice by consensus of the same two experts with a 3-year interval. CE was assessed individually by two radiation oncologists, an expert and a non-expert. Intra-observer variability and inter-observer variability were calculated using the kappa (k) and weighted kappa (wk) statistics.

RESULTS

The agreement between the first and second PE using pre/post-HFWBI photographs was moderate (k = 0.60, wk = 0.64. k = 0.53, wk = 0.60). The agreement between the expert and non-expert on CE was substantial (k = 0.72, wk = 0.76. k = 0.72, wk = 0.77). The inter-observer variability of CE was smaller than the intra-observer variability of PE.

CONCLUSION

CE with BCCT. core was considered a reproducible and an appropriate evaluation method for Asian women in clinical trials of BCT, when breast cosmetic changes were compared between pre/post therapy.

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.

Symmetry of Nipple Position After Bilateral Nipple-Sparing Mastectomy and Implant-Based Reconstruction: The Impact of Reconstructive Method

PURPOSE

Asymmetry of nipple position is common in the female population. There are scant data on the impact of bilateral nipple-sparing mastectomy (NSM) and immediate implant-based reconstruction on nipple asymmetry.

METHODS

A retrospective review was performed of an institutional review board approved prospective database of NSM and immediate implant-based reconstruction was performed. BCCT.core software was used to examine preoperative and postoperative nipple asymmetry. It directly calculates the quantitative differences in nipple position between the breasts expressed as breast retraction assessment (BRA). Nipple to sternal notch (N-SN) asymmetry was calculated from the collected data.

RESULTS

Sixty-eight patients undergoing bilateral NSM and implant reconstruction were reviewed. Reconstructive methods were tissue expander (TE) 39 (57.4%) and direct to implant (DTI) (prepectoral 13, submuscular 16) 29 (42.6%). The TE group had greater body mass index (BMI) (23.5 vs 22.1, P = 0.02), mastectomy weight (390.7 vs 243.8, P = 0.001) and higher preoperative N-SN asymmetry (TE 0.89 vs DTI 0.59, P = 0.02). Ten patients received radiation (TE group 4, DTI group 6). The TE group had larger implant size (479.1 vs 375.0, P = 0.0001). Overall, TE reconstruction resulted in an increase in nipple asymmetry (mean BRA: preoperative, 1.50 vs postoperative, 1.65), which was not significant. Direct to implant reconstruction increased nipple asymmetry: mean N-SN asymmetry preoperative 0.59 versus postoperative 0.97 (P = 0.04) and mean BRA scores 1.40 and 1.82 (P = 0.06). Both implant locations in the DTI group resulted in an increase in postoperative asymmetry but was significant for the prepectoral group: mean BRA preoperative 1.19 versus postoperative 1.85, P = 0.02 and mean N-SN asymmetry preoperative 0.48 vs postoperative 0.94, P = 0.04. Radiation impacted the final mean BRA score: radiation 2.24 versus no radiation 1.63 (P = 0.05).

CONCLUSIONS

Patients who underwent TE reconstruction had significantly larger breasts and greater preoperative N-SN asymmetry than the DTI group. Despite this, the TE group resulted in mild increase in nipple asymmetry. Both implant locations in DTI reconstruction resulted in increased postoperative asymmetry but was significant for the prepectoral group. Radiation therapy has a significant impact of nipple asymmetry.

A Novel Validated Breast Aesthetic Scale

BACKGROUND

Breast aesthetics impacts patients' quality of life after breast reconstruction, but patients and surgeons frequently disagree on the final aesthetic evaluation. The need for a comprehensive, validated tool to evaluate breast aesthetics independently from the patient motivated this study.

METHODS

The 13-item Validated Breast Aesthetic Scale was developed after several internal meetings, and worded to be understood by a nonspecialist. Three items are common for both breasts, with the remaining being side-specific. To test the internal consistency of the scale subitems, postoperative photographs after different breast reconstruction techniques were graded by a six-member panel. To test interrater and intrarater correlation across time, four physicians evaluated the results of abdominally based breast reconstructions following nipple-sparing mastectomies.

RESULTS

Graded aesthetic outcomes of 53 patients showed that the Cronbach alpha of the subitems of the scale was 0.926, with no single item that, if excluded, would increase it. Twenty-two patients underwent aesthetic outcomes grading at four different time points. The mean overall appearance was 3.71 ± 0.62. The mean grade for overall nipple appearance was 4.0 ± 0.57. The coefficient alpha of the panel overall aesthetic grade across different time points was 0.957; whereas intragrader reliability for graders 1 through 4 individually showed alpha coefficients of 0.894, 0.9, 0.898, and 0.688, respectively. Similar results were found for the other items of the scale.

CONCLUSIONS

The proposed aesthetic scale evaluates different aspects of the breast reconstruction aesthetic result with excellent internal consistency among its subitems. Grading by a gender-balanced, diverse four-member panel using postoperative photographs showed higher reliability and reproducibility compared to single graders.

The Impact of Tissue Expander Nipple Asymmetry on Final Implant Symmetry After Bilateral Nipple Sparing Mastectomy

BACKGROUND

Asymmetry of nipple position is common in the female population and very difficult to correct after nipple sparing mastectomy (NSM). There are scant data on the impact of tissue expander (TE) nipple asymmetry on final implant nipple symmetry after bilateral NSM.

METHODS

A retrospective review of an institutional review board-approved prospective database of NSM and immediate 2-stage implant reconstruction between June 2014 and December 2019 was performed. BCCT.core software was used to examine TE and final implant nipple asymmetry as well as relative breast implant position. Horizontal and/or vertical asymmetry and breast retraction assessment (BRA) were evaluated. Moderate asymmetry was defined as ≥1 cm and severe asymmetry as ≥2 cm. Lower breast contour ≥1 cm defined implant malposition.

RESULTS

Twenty-three patients met the inclusion criteria. Linear regression analysis showed a significant relationship between TE BRA and final BRA (R2 = 0.2321, P = 0.02) with a mean TE BRA of 2.04 and a mean final BRA of 1.53 (P = 0.05). Tissue expander nipple asymmetry was predictive of final BRA score: no TE asymmetry, 0.87, versus TE nipple asymmetry, 1.67 (P = 0.02). Tissue expander lower breast contour ≥1 cm occurred in 8 patients (36.4%) and was associated with implant nipple asymmetry in 7 (87.5%). The second stage of reconstruction significantly improved the nipple asymmetry in those with TE malposition (TE BRA, 2.34, vs final BRA, 1.67; P = 0.05). Two patients who received radiation had increased BRA scores (radiation, 2.14, vs no radiation, 1.47; P = 0.004).

CONCLUSIONS

Tissue expander nipple asymmetry as measured by BRA score or nipple asymmetry was predictive of final nipple symmetry. The second stage of TE reconstruction improves the nipple asymmetry. Final implant exchange can allow for pocket and implant manipulation, improving nipple symmetry. Radiation therapy to TE reconstruction has a negative impact on nipple symmetry after the final stage.

Innovative Standards in Oncoplastic Breast Conserving Surgery: From Radical Mastectomy to Extreme Oncoplasty

BACKGROUND

Oncoplastic breast conserving surgery (OBCS), which is the current procedure of choice for eligible BC patients, describes a philosophy that prioritizes oncologic and cosmetic outcomes. However, knowledge gaps regarding training, acceptance, and practice preclude standardization and make it difficult to design algorithmic guidelines to optimize individualized management in the era of precision medicine.

SUMMARY

The harmony between patient expectations and oncologic goals creates the state of the art of OBCS. Nevertheless, to achieve these goals, multidisciplinary approach is a must. Surgical decisions require a comprehensive evaluation including patient factors, tumor biology, genetics, technical considerations, and adjunct therapies. Moreover, the quality-of-life (QOL) issues should be considered as the highest level of priority with a shared decision making instituted on realistic discussions with the patient.

KEY MESSAGES

The standardization in OBCS should be initiated via defining a breast surgeon who should gain theorical and practical competence on techniques via national or international educational programs. The algorithmic patient assessment with appropriate documentation before and after surgery should be established. A simple and safe global lexicon should be designed regarding techniques to be proposed and quality metrics to be considered. Additionally, international multicenter prospective trials should be instituted to overcome knowledge gaps. It is evident that OBCS is the perfect union of science with art. Nevertheless, at the very end, the question is not the nature of the surgeon/artist who would be the extremist, the innovator, or the conservative, but the patient's satisfaction, prognosis, and QOL that conclude the cascade of state of the art of OBCS.

Intraoperative 3D Comparison of Round and Anatomical Breast Implants: Dispelling a Myth

Background: Thanks to 3D imaging, it is possible to measure the influence of different parameters on breast augmentation. In this study, we compare the effect of different shapes and sizes of breast implants on the topography of the resulting breast. Furthermore, the impact of different breast implants on inter-landmark distances and on changes of the nipple position was assessed. Methods: This interventional prospective study was carried out on 10 female patients after collecting informed consent. 3D scans of the native and augmented breasts were performed intraoperatively with small, medium, and large sizes of both anatomical and round implants, resulting in a total of n = 130 single breast scans. These scans were analyzed for topographic shift quantification, nipple migration, and inter-landmark distances of the breast. Results: Implant size, but not implant shape leads to significant topographic shifts of the breast (p < 0.001 and p = 0.900, respectively). Both round and anatomical implants lead to a significantly higher volumetric increase in the upper quadrants compared to the lower quadrants (p < 0.001). Nipple migration into the superomedial quadrant was seen in about 90% of augmentations. No evident differences in inter-landmark distances were observed when round and anatomical implants of different sizes were compared. Conclusions: Implant size rather than shape influences the postoperative aesthetic results. No significant difference in topographic shift was found comparing round and anatomical implants, suggesting that both implant shapes result in comparable aesthetic outcomes.

An Intraoperative Measurement Method of Breast Symmetry Using Three-Dimensional Scanning Technique in Reduction Mammaplasty

BACKGROUND

Intraoperative symmetrical assessment plays a decisive role in the aesthetic results of reduction mammaplasty, but it depends mostly on the surgeons' experience that may be biased by individual subjective factors. This study was intended to propose an objective method based on a hand-held three-dimensional (3D) scanner to assist intraoperative symmetrical assessment, aiming to achieve better aesthetic results in reduction mammaplasty.

METHODS

Sixty patients were enrolled in the study from April 2018 to January 2020. Intraoperative 3D scanning was routinely performed on 29 patients (study group) to assist symmetrical adjustments during breast shaping. 3D surface scanning data of both groups were obtained at 3 months postoperatively to objectively assess breast symmetry. Postoperative symmetry scores in five aspects, including nipple-areolar complex position, inframammary-fold height, breast size, shape, and footprint, were rated by six independent observers based on anonymized photographs to subjectively evaluate pre- and postoperative breast symmetry of the two groups.

RESULTS

The bilateral breast volume difference of the study group was significantly smaller than the control group (39.1 vs. 113.3 cm³, p = 0.001), as well as the difference in nipple to inframammary-fold distance (2.79 vs. 7.43 mm, p = 0.01). The observer-reported results showed that breast reduction significantly improved postoperative symmetry in all five aspects compared with preoperative symmetry in the study group (P<0.001). Furthermore, postoperative symmetrical ratings of all five aspects in the study group were statistically better than the control group (P<0.05).

CONCLUSIONS

Intraoperative 3D scanning provided a reliable method to assist symmetry adjustments and ensure better postoperative breast symmetry in reduction mammaplasty.

LEVEL OF EVIDENCE IV

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

Oncoplastic Mammoplasty with disguised geometric compensation

OBJECTIVE

To evaluate the results of a cohort of patients submitted to a new technique of oncoplastic mammoplasty, referred to as Disguised Geometric Compensation Mammoplasty (GCM), which is suitable for tumours involving the glandular tissue in the pillars of the mammoplasty.

MATERIALS AND METHODS

Twenty-five breast tumours involving the pillars of the mammoplasty were included, 20 (80.0%) invasive ductal carcinomas, 3 (12.0%) phyllodes tumours, 1 (4.0%) invasive lobular carcinoma, and 1 (4.0%) in situ ductal carcinoma. Preoperative markings followed the "Wise-pattern" technique. The resection of the tumour in the pillar, preserving the overlying skin, was geometrically compensated with a corresponding area coming from the lower poles, which folded over itself and maintained the skin vascularity in the pillar. One patient was converted to classic GCM due to a positive skin margin in the frozen section. Another patient combined a Classic GCM for the inner quadrants and a Disguised GCM for the outer quadrants on the same breast. One patient decided to undergo a bilateral mastectomy after some months because of a BRCA 1 mutation. Immediate fat grafting was done in one case. Approval from the ethics committee: n. 2.322.212.

RESULTS

Mean age was 47.0 ± 9.5 years. Mean clinical tumour size was 47.2 ± 22.2mm before chemotherapy and 36.7 ± 22.5mm, after. There were 11 (44.0%) locally advanced and 1 (4.00%) multicentric tumours. Nine (36.0%) were submitted to neoadjuvant chemotherapy. Adjuvant treatment was indicated according to the necessity. Ptosis was corrected in all cases. The aesthetic results were rated as excellent or good in 21 (95.5%) cases, by the Harris scale and the BCCT.core. The BREAST-Q scores for the satisfaction with the breasts and satisfaction with outcomes were 81.5 (±15.0) and 90.4 (±11.7), respectively. Intraoperative frozen sections were done in 12 (48%) cases. There was 1 (4.0%) focus of DCIS in the skin margin treated with radiotherapy. Minor complications occurred in 6 (24.0%) patients. There was 1 (4.0%) local recurrence treated with radical mastectomy, and 1 (4.0%) metastasis after 3 months. No deaths were observed within a mean follow-up time of 16.3 ± 11.4 months.

CONCLUSIONS

The disguised geometric compensation mammoplasty allowed breast conservation in situations requiring large resection in the pillars of the mammoplasty, with a high rate of free margins, correction of ptosis, satisfactory symmetry, and few complications.

New criteria for breast symmetry evaluation after breast conserving surgery for cancer

OBJECTIVE

to evaluate symmetry after breast-conserving surgery (BCS) for cancer.

METHODS

a prospective study of patients undergoing BCS. These patients were photographed using the same criteria of evaluation. The references points used were the nipple height difference (NH), the nipple-manubrium distances (NM), nipple-sternum distances (NS) and the angle between the intramammary fold and the nipple (nipple angle; NA). ImageJ software was used. Three breast symmetry models were evaluated: excellent/others (model 1), excellent-good/others (model 2) and others/poor (model 3). The ROC curve was used to select acceptable criteria for the evaluation of symmetry. Decision tree model analysis was performed.

RESULTS

a total of 274 women were evaluated. The BCCT.core result was excellent in 5.8% (16), good in 24.1% (66), fair in 46.4% (127) and poor in 23.7% (65). The difference in NH was associated with good breast area (0.837-0.846); acceptable differences were below 3.1 cm, while unacceptable values were greater than 6.4 cm. Differences in the NM were associated with average breast area (0.709-0.789); a difference in value of less than 4.5 cm was acceptable, while values greater than 6.3 cm were unacceptable. In the decision tree combined model, a good-excellent outcome for patients with differential (d) dNH = 1 (0 to 5.30 cm) and dNM ≠ 3 (<6.28 cm); and for a poor/poor result, values dNM = 3 (> 6.35).

CONCLUSIONS

the results presented here are simple tools that can assist the surgeon for breast symmetry evaluation.

Breast softness in patients randomised to postmastectomy breast reconstruction with an expander prosthesis or DIEP flap

Background

Objectively measured breast softness in reconstructed breasts and its relation to patients’ subjective satisfaction with breast softness has not yet been investigated. The aim of this study was to evaluate breast softness in patients 1 year following delayed breast reconstruction with an expander prosthesis (EP) or deep inferior epigastric perforator (DIEP) flap, using objective and subjective methods.

Methods

Seventy-three patients were randomised to breast reconstruction with an EP or DIEP flap between 2012 and 2018. Of these, 69 completed objective evaluation at a mean of 25 (standard deviation, SD 9.4) months following breast reconstruction. Objective evaluation included measurements of breast volume, jugulum-nipple distance, clavicular-submammary fold distance, ptosis and Baker scale grading. Breast softness was assessed with applanation tonometry. Subjective evaluation was performed using the BREAST-Q questionnaire.

Results

Objectively, DIEP flaps were significantly softer than EP breast reconstructions. Non-operated contralateral breasts were significantly softer compared with reconstructed breasts. In the subjective evaluation, the median score on the question (labelled 1.h) “How satisfied or dissatisfied have you been with the softness of your reconstructed breast (s)?” was higher in the DIEP flap group corresponding to greater satisfaction in this group. A fair correlation was found between the applanation tonometry and the patient-reported satisfaction with the reconstructed breast’s softness (rs = 0.37).

Conclusions

In terms of breast softness, breast reconstructions with DIEP flaps result in more satisfied patients. Concerning applanation tonometry as an objective tool for softness assessment, future studies on interobserver agreement are warranted.

Level of evidence: Level I, therapeutic study

Oncoplastic Surgery in Breast-Conserving Treatment: Patient Profile and Impact on Quality of Life

BACKGROUND

Breast-conserving treatment (BCT) provides better quality of life (QL) than mastectomy without reconstruction. Oncoplastic surgery (OS) encompasses a series of surgical techniques, increasing the indications for BCT, but few studies have evaluated the impact on QL in patients who undergo BCT with OS.

MATERIALS AND METHODS

A prospective, cross-sectional study was conducted in women who underwent BCT. We evaluated the characteristics of patients who underwent BCT with and without OS and the associated QL. QL was assessed through the EORTC QLQ-30, EORTC QLQ-BR23, and Breast Cancer Treatment Outcome Scale (BCTOS) questionnaires.

RESULTS

A total of 300 patients underwent BCT, 72 underwent breast OS, and 37 underwent bilateral surgery. Patients who underwent OS were younger (p = 0.004), had a higher level of education (p = 0.01), had a smaller time interval since the end of treatment (p = 0.02), had tumours with greater dimensions (p = 0.003), and were more likely to receive neoadjuvant chemotherapy (p = 0.05). Based on the QL questionnaires, no difference was observed between the groups. Breast symmetry was not associated with high patient satisfaction (p = 0.55).

CONCLUSION

Despite the fact that OS was performed in patients with worse tumour conditions and in more demanding patients, OS allowed similar cosmetic results to classical BCT.

Considerations in Oncoplastic Surgery

The development of oncoplastic surgery (OPS) is one of the greatest achievements for the treatment of breast cancer. OPS combines oncological resection with plastic surgery techniques in a single procedure to allow the excision of tumors without compromising cosmetic outcome. It allows better aesthetic-functional outcomes and consequently an improvement of the psychological aspects of patients with breast cancer.OPS begins with preoperative design considering breast volume, tumor size, and location and distance from nipple of the tumor, with clinical breast examination and image studies. Various techniques of volume replacement and volume displacement methods described here can help the decision-making process so the best results concerning the aesthetic-functional aspects can be achieved.The outcome measurement of the oncoplastic breast surgery consisted of local recurrence, cosmesis, and patients satisfaction. In OPS for breast cancer patients, aesthetic assessment could be performed by various methods. And questionnaires on quality of life can be applied as a scientific method to assess results. In this chapter, we introduced our results of assessment of both aesthetic and QOL outcomes in OPS patients.

Reliability of the BCCT.core software in evaluation of breast cosmesis - A systematic review

Breast cancer conservative treatment software (BCCT.core) has the potential to provide objective results using digital photographs, thus increasing the reliability, limiting the subjective interpretation and standardising the evaluation of breast cosmesis in patients. The aim of this systematic review was to summarise the empirical evidence regarding the agreement between the BCCT.core and other methods used by health professionals and patients to assess breast cosmesis. The Ovid MEDLINE, Embase, CINAHL, PsycINFO and Scopus databases were systematically searched for studies comparing the agreement between BCCT.core and other methods used to assess breast cosmesis. A total of 14 studies involving 2703 patients were included in the review. In studies where patients undertook self-assessment, the percentage agreement ranged from 69.2% to 74.8% and the kappa values ranged from slight (k = 0.12) to fair agreement. There was a low correlation between the BCCT.core and the Harvard scale when patients assessed cosmetic outcomes using photographs of their breasts (r = 0.165). A 75% and 42.8% agreement was reported in studies where clinicians assessed breast cosmesis by directly visualising the patients' breasts and photographs, respectively. Assessment of breast cosmesis by the expert panel using patient photographs reported a percentage agreement ranging from 25% to 83%. The results of this systematic review demonstrated an overall agreement of fair to moderate between the BCCT.core and the subjective scales used to assess breast cosmesis. However, clinician experience and patient values should be considered in clinical decision-making.

Evaluation of aesthetic outcomes of breast-conserving surgery by the surgeon, nurse, and patients: An analysis

BACKGROUND

Evaluation of the cosmetic outcome after breast-conserving surgery (BCS) differs depending on the evaluator. We performed a clinical trial to examine the differences between assessments of cosmetic outcomes performed by a surgeon, patients, and a nurse as a third party after BCS; the evaluation was performed two times (at 3 months and 9 months after surgery). Similarly, we identified factors most significantly affecting the overall cosmetic outcomes.

METHODS

Sixty-eight patients with primary breast cancer who had undergone BCS between September 2017 and December 2018 were consecutively enrolled in the study. Breast shape, symmetry, hardness, scarring, and overall outcomes were evaluated by a surgeon, patients, and a nurse via a questionnaire.

RESULTS

Intraclass correlation coefficients (ICCs) for the 3- to 9-month comparisons of the surgeon, patients, and nurse were 0.73, 0.64, and 0.29, respectively. The ICCs for the surgeon-patient, nurse-patient, and surgeon-nurse comparisons (3 months/9 months) were 0.49/0.44, 0.34/0.10, and 0.41/0.51, respectively. The partial regression coefficient for shape was 0.45 (p = 0.003)/0.61 (p = 0.001), 0.37 (p = 0.005)/0.50 (p < 0.001), and -0.08 (p = 0.48)/0.58 (p < 0.001) for evaluations performed by the surgeon, patients, and nurse, 3 months and 9 months, respectively.

CONCLUSION

With reproducibility, only moderate agreement was observed between the surgeon and the patients. Breast shape was identified as the most important factor affecting cosmetic outcomes.

A Free Tool for Breast Aesthetic Scale Computation

BACKGROUND

Our work describes the concept of Breast Aesthetic Scale (BAS) as a score for quick and simple objective assessment of results in cosmetic breast surgery. It is obtained by running a software program that we created, based on the previous concept of Objective Breast Cosmesis Scale (OBCS). This was previously described to be used in the context of conservative breast cancer treatment to objectively assess the degree of asymmetry. We describe the implementation of BAS algorithm and study its reproducibility in a set of images.

METHODS

A new multiplatform software was developed by us and named Breast Aesthetic Scale Calculator (BAS-Calc), which can be executed on Windows Mac, and Linux. A set of 25 photographs were studied with this software twice by 2 different surgeons. Intrarater and interrater variability were studied, as well as concordance with categorization by another symmetry assessment software available called Breast Analyzing Tool®.

RESULTS

Concordance among raters was excellent (intraclass correlation coefficient = 0.953; Lin concordance and correlation coefficient = 0.950), as well as intrarater (0.952 and 0.965). Categorization of both systems (Breast Analyzing Tool and BAS-Calc) showed almost perfect concordance (Cohen κ = 0.920).

CONCLUSIONS

Objective estimation of symmetry after breast surgery can be assessed with BAS-Calc. The "symmetric" and "asymmetric" categories are accurately discriminated by this free software, and it can be used by surgeons as a simple method for objective assessment of results in cosmetic breast surgery.

Cosmetic Outcomes and Symmetry Comparison in Patients Undergoing Bilateral Therapeutic Mammoplasty for Breast Cancer

Background

Breast-reduction techniques are increasingly used in oncoplastic breast surgery. Bilateral therapeutic mammoplasty has the benefit of decreasing breast volume, enabling resection of larger tumors, and the potential to assure good postoperative symmetry. The aims of this study were to objectively asses the cosmetic outcomes of therapeutic mammoplasty in patients with breast cancer, using the breast cancer conservative treatment cosmetic results (BCCT.core) software, to compare this score with the surgeon’s score and the patient’s assessment, and to evaluate if other defined parameters have an impact on cosmetic outcomes. The secondary aim was to compare breast symmetry pre- and postoperatively.

Materials and Methods

We enrolled 146 consecutive patients with primary breast cancer who underwent therapeutic mammoplasty between 2011 and 2018 in Kristianstad Central Hospital, Sweden. We retrospectively collected data from patients’ records. We analyzed the BCCT.core score using postoperative photographs to objectively evaluate cosmetic outcomes on a four-grade scale and compared with preoperative photographs to evaluate symmetry. Cosmetic outcomes were also assessed subjectively by patients and surgeons, using a 10-point Likert scale.

Results

The majority of patients (89%) had good or excellent BCCT.core scores, which correlated with surgeons’ scores, rs =  − 0.22 (p < 0.001). Overall, patients were more satisfied with the cosmetic outcomes than the surgeons (p < 0.001). Evidence supporting an association between the defined clinicopathological variables, for example, tumor size, and cosmetic outcomes, was weak.

Conclusion

Therapeutic mammoplasty yields a very good cosmetic outcome, evaluated both by subjective and objective measurements. Importantly, symmetry can be improved in patients with asymmetry.

Supplementary information

The online version contains supplementary material available at (10.1007/s00268-020-05941-0).

Intensity Modulated Radiation Therapy (IMRT) With Simultaneously Integrated Boost Shortens Treatment Time and Is Noninferior to Conventional Radiation Therapy Followed by Sequential Boost in Adjuvant Breast Cancer Treatment: Results of a Large Randomized Phase III Trial (IMRT-MC2 Trial)

PURPOSE

In the modern era, improvements in radiation therapy techniques have paved the way for simultaneous integrated boost irradiation in adjuvant breast radiation therapy after breast conservation surgery. Nevertheless, randomized trials supporting the noninferiority of this treatment to historical standards of care approach are lacking.

METHODS

A prospective, multicenter, randomized phase 3 trial (NCT01322854) was performed to analyze noninferiority of conventional fractionated intensity modulated radiation therapy with simultaneous integrated boost (IMRT-SIB) to 3-D conformal radiation therapy with sequential boost (3-D-CRT-seqB) for breast cancer patients. Primary outcomes were local control (LC) rates at 2 and 5 years (noninferiority margin at hazard ratio [HR] of 3.5) as well as cosmetic results 6 weeks and 2 years after radiation therapy (evaluated via photo documentation calculating the relative breast retraction assessment [pBRA] score [noninferiority margin of 1.25]).

RESULTS

A total of 502 patients were randomly assigned from 2011 to 2015. After a median follow-up of 5.1 years, the 2-year LC for the IMRT-SIB arm was noninferior to the 3-D-CRT-seqB arm (99.6% vs 99.6%, respectively; HR, 0.602; 95% CI, 0.123-2.452; P = .487). In addition, noninferiority was also shown for cosmesis after IMRT-SIB and 3-D-CRT-seqB at both 6 weeks (median pBRA, 9.1% vs 9.1%) and 2 years (median pBRA, 10.4% vs 9.8%) after radiation therapy (95% CI, -0.317 to 0.107 %; P = .332). Cosmetic assessment according to the Harvard scale by both the patient and the treating physician as well as late-toxicity evaluation with the late effects normal tissues- subjective, objective, management, analytic criteria, a score for the evaluation of long-term adverse effects in normal tissue, revealed no significant differences between treatment arms. In addition, there was no difference in overall survival rates (99.6% vs 99.6%; HR, 3.281; 95% CI: -0.748 to 22.585; P = .148) for IMRT-SIB and 3-D-CRT-seqB, respectively.

CONCLUSIONS

To our knowledge, this is the first prospective trial reporting the noninferiority of IMRT-SIB versus 3-D-CRT-seqB with respect to cosmesis and LC at 2 years of follow-up. This treatment regimen considerably shortens adjuvant radiation therapy times without compromising clinical outcomes.

Improved accuracy of breast volume calculation from 3D surface imaging data using statistical shape models

Background

Three-dimensional (3D) scanning is an established method of breast volume estimation. However, this method can never be entirely precise, since the thoracic wall cannot be imaged by the surface scanner. Current methods rely on interpolation of the posterior breast border from the surrounding thoracic wall. Here, we present a novel method to calculate the posterior border and increase the accuracy of the measurement.

Methods

Using principal component analysis, computed tomography images were used to build a statistical shape model (SSM) of the thoracic wall. The model was fitted to 3D images and the missing thoracic wall curvature interpolated (indirect volumetry). The calculations were evaluated by ordinary least squares regression between the preoperative and postoperative volume differences and the resection weights in breast reduction surgery (N = 36). Also, an SSM of the breast was developed, allowing direct volumetry. Magnetic-resonance images (MRI) and 3D scans were acquired from 5 patients in order to validate the direct 3D volumetry.

Results

Volumetry based on a SSM exhibited a higher determination coefficient (R² = 0,737) than the interpolation method (R² = 0,404). The methods were not equivalent (p = 0.75), suggesting that the methods significantly differ. There was no influence of BMI on the correlation in either method. The MRI volumetry had a strong correlation with the 3D volumetry (R² = 0,978).

Conclusion

The SSM-based method of posterior breast border calculation is reliable and superior to the currently used method of interpolation. It should serve as a basis of software applications aiming at calculation of breast volume from 3D surface scanning data.

3-Dimensional objective aesthetic evaluation to replace panel assessment after breast-conserving treatment

BACKGROUND

Two-thirds of patients with early breast cancer undergo breast-conserving treatment (BCT). Aesthetic outcome is important and has long term implications for psychosocial wellbeing. The aesthetic goal of BCT is symmetry for which there is no gold-standard measure. Panel scoring is the most widely adopted assessment but has well-described limitations. This paper describes a model to objectively report aesthetic outcome using measures derived from 3-dimensional surface images (3D-SI).

METHOD

Objective measures and panel assessment were undertaken independently for 3D-SI of women who underwent BCT 1-5 years previously. Univariate analysis was used to test for association between measures and panel score. A forward stepwise multiple linear regression model was fitted to identify 3D measurements that jointly predicted the mean panel score. The fitted model coefficients were used to predict mean panel scores for an independent validation set then compared to the mean observed panel score.

RESULTS

Very good intra-panel reliability was observed for the training and validation sets (wκ = 0.87, wκ = 0.84). Six 3D-measures were used in the multivariate model. There was a good correlation between the predicted and mean observed panel score in the training (n = 190) and validation (n = 100) sets (r = 0.68, r = 0.65). The 3D model tended to predict scores towards the median. The model was calibrated which improved the distribution of predicted scores.

CONCLUSION

A six-variable objective aesthetic outcome model for BCT has been described and validated. This can predict and could replace panel assessment, facilitating the independent and unbiased evaluation of aesthetic outcome to communicate and compare results, benchmark practice, and raise standards.

Quantitative 3-Dimensional Photographic Assessment of Breast Cosmesis After Whole Breast Irradiation for Early Stage Breast Cancer: A Secondary Analysis of a Randomized Clinical Trial

Purpose

Our purpose was to use 3-dimensional (3D) surface photography to quantitatively measure breast cosmesis within the framework of a randomized clinical trial of conventionally fractionated (CF) and hypofractionated (HF) whole breast irradiation (WBI); to identify how 3D measurements are associated with patient- and physician-reported cosmesis; and to determine whether objective measures of breast symmetry varied by WBI treatment arm or transforming growth factor β 1 (TGFβ1) status.

Methods and Materials

From 2011 to 2014, 287 women age ≥40 with ductal carcinoma in situ or early-stage invasive breast cancer were enrolled in a multicenter trial and randomized to HF-WBI or CF-WBI with a boost. Three-dimensional surface photography was performed at 3 years posttreatment. Patient-reported cosmetic outcomes were recorded with the Breast Cancer Treatment Outcome Scale. Physician-reported cosmetic outcomes were assessed by the Radiation Therapy Oncology Group scale. Volume ratios and 6 quantitative measures of breast symmetry, termed F1-6C, were calculated using the breast contour and fiducial points assessed on 3D surface images. Associations between all metrics, patient- and physician-reported cosmesis, treatment arm, and TGFβ1 genotype were performed using the Kruskal-Wallis test and multivariable logistic regression models.

Results

Among 77 (39 CF-WBI and 38 HF-WBI) evaluable patients, both patient- and physician-reported cosmetic outcomes were significantly associated with the F1C vertical symmetry measure (both P < .05). Higher dichotomized F1C and volumetric symmetry measures were associated with improved patient- and physician-reported cosmesis on multivariable logistic regression (both P ≤ .05). There were no statistically significant differences in vertical symmetry or volume measures between treatment arms. Increased F6C horizontal symmetry was observed in the CF-WBI arm (P = .05). Patients with the TGFβ1 C-509T variant allele had lower F2C vertical symmetry measures (P = .02).

Conclusions

Quantitative 3D image-derived measures revealed comparable cosmetic outcomes with HF-WBI compared with CF-WBI. Our findings suggest that 3D surface imaging may be a more sensitive method for measuring subtle cosmetic changes than global patient- or physician-reported assessments.

Use of Symmetry Assessment Methods in the Context of Breast Surgery

BACKGROUND

Different procedures are available to help clinicians evaluate symmetry and cosmetic results in an objective manner after conservative breast cancer surgery. However, there are no similar methods in esthetic breast surgery, where the subjective assessment of the surgeon or the patient is usually considered the gold standard. The aim of this study is to evaluate the application of four software programs in the context of esthetic breast surgery and contrast their results with those of the subjective evaluation by a series of healthcare professionals.

MATERIALS AND METHODS

Sixty cosmetic breast surgery images were studied using four software programs considered appropriate for the objective evaluation (BCCT3.core^®, Breast Analyzing Tool^®, Objective Breast Cosmesis Scale^® and GBAI-Global Breast Asymmetry Index^®). The same cases were assessed by a group of 100 health professionals through an online survey as a subjective evaluation method.

RESULTS

Concordance among participants was high (κ = 0.753) as well as between three of the objective methods (BSI, OBCS, GBAI), but not with the BCCT parameter. There was no association between objective and subjective methods studied by the survey, according to the logistic regression model. The "symmetry" and "asymmetry" categories were accurately distinguished by the objective methods.

CONCLUSIONS

Objective evaluation in esthetic breast surgery has less variability than subjective assessment, and the estimation is possible through certain software previously restricted to conservative breast cancer surgery.

LEVEL OF EVIDENCE IV

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

Aesthetic results following breast cancer surgery: A prospective study on 6515 cases from ten Italian Senonetwork breast centers

Breast cancer treatment has deeply changed in the last decades, since clinical and oncological cure cannot be achieved without patient's satisfaction in term of aesthetic outcomes. Several methods have been proposed to objectively assess these results. However, Italian breast centers have not yet agreed on measurable, reproducible and validated aesthetic outcome indicators to monitor their performance.

METHODS

The study was designed and conducted by Senonetwork, a not-for-profit association of Italian breast centers. Ten breast centers were selected based on specific eligibility criteria. This multicentre observational prospective study recruited 6515 patients with diagnosis of in situ or invasive breast cancer who underwent breast surgery in the years 2013-2016. Thirteen indicators of aesthetic results and of related quality of care were analyzed. Data collection and analysis were conducted using a common study database.

RESULTS

On average, seven out of ten centers were able to collect data on the proposed indicators with a proportion of missing values < 25%. By expert consensus based on study results, some seven indicators have been defined as "mandatory" while the remaining six have been defined as "recommended" because they require further refinement before they can be proposed for monitoring aesthetic outcomes or because there are doubts on the feasibility of data collection. The minimum standard is reached for 5 of 13 indicators. This finding and the wide range between centers reveal that there is ample room for improvement.

CONCLUSIONS

From the present study useful measurable aesthetic parameters have emerged, leading to the definition of target objectives that breast centers can use for benchmarking and improvement of quality of care.

Toxicity and cosmetic outcome after hypofractionated whole breast irradiation and boost-IOERT in early stage breast cancer (HIOB): First results of a prospective multicenter trial (NCT01343459)

BACKGROUND AND PURPOSE

To assess the role of intraoperative radiation with electrons (IOERT) as tumor bed boost followed by hypofractionated whole breast irradiation (HWBI) after breast conserving surgery (BCS) of patients with low to intermediate risk breast cancer focusing on acute/late toxicity and cosmetic outcome.

MATERIAL AND METHODS

In 2011, a prospective multicenter trial (NCT01343459) was started. Treatment consisted of BCS, IOERT (11.1 Gy) and HWBI (40.5 Gy in 15 fractions). In a single-arm design, 5-year IBR-rates are benchmarked by a sequential ratio test (SQRT) against best published evidences in 3 age groups (35-40 y, 41-50 y, >50 y). Acute/late toxicity and cosmesis were evaluated by validated scorings systems.

RESULTS

Of 627 eligible patients, 44 were excluded, leaving 583 to analyze. After a median follow-up (FUP) of 45 months (range 0-74), for acute effects CTCAE-score 0/1 was noted in 91% (end of HWBI) and 92% (4 weeks later), respectively. Late toxicity Grading 0/1 (mean values, ranges) by LENT-SOMA criteria were observed in 92.7% (89-97.3) at 4/5 months, rising to 96.5% (91-100) at 6 years post HWBI. Baseline cosmesis after wound healing prior to HWBI was scored as excellent/good in 86% of cases by subjective (patient) and in 74% by objective (doctor) assessment with no impairment thereafter.

CONCLUSIONS

Acute and late treatment tolerance of a combined Boost-IOERT/HWBI regimen is excellent in short/mid-term assessment. Postoperative cosmetic appearance is not impaired after 3 years FUP.

Five-Year Results of the Preoperative Accelerated Partial Breast Irradiation (PAPBI) Trial

PURPOSE

In this multicenter phase 2 feasibility study, we investigated the impact of preoperative accelerated partial breast irradiation (PAPBI) on local control, breast fibrosis, and cosmetic outcome.

METHODS AND MATERIALS

Women aged >60 years with an invasive, unifocal (mammography and magnetic resonance imaging), nonlobular adenocarcinoma of the breast were treated with PAPBI. Six weeks after radiation therapy, a wide local excision was performed. Radiation therapy consisted of 10 × 4 Gy (2010-2013) or 5 × 6 Gy (after 2013) to the tumor (gross target volume) with a 25 mm margin (20 mm from gross target volume to clinical target volume, 5 mm planning target volume).

RESULTS

One hundred thirty-three patients treated between 2010 and 2016 were analyzed with a median follow-up of 5.0 years (0.9-8.8 years). Seventy-eight (59%) patients were treated with 10 × 4 Gy in 2 weeks and 55 (41%) patients with 5 × 6 Gy in 1 week. Eighteen postoperative complications (14%) occurred in 15 patients (11%). The proportion of patients with no to mild fibrosis in the treated part of the breast at 2 years and later time points was around 90%. Cosmesis improved over time in several patients: excellent to good cosmetic score as rated by the physician was 68% at 6 months and 92% at 5 years. Seventy-seven percent (6 months) to 82% (5 years) of patients were "satisfied" or "very satisfied" with their cosmetic outcome. Three recurrences were detected in the biopsy track and 1 recurrence in the ipsilateral breast.

CONCLUSIONS

PAPBI is a feasible method with a low postoperative complication rate, limited fibrosis, and good to excellent cosmetic outcome. The local recurrence rate was 3% at 5 years; however, no local recurrences were observed since removal of the needle biopsy track.

Nipple malposition after bilateral nipple-sparing mastectomy with implant-based reconstruction: Objective postoperative analysis utilizing BCCT.core computer software

Nipple-sparing mastectomies (NSMs) are accepted as safe oncologic procedures for select patient populations, but objective evaluation of aesthetic outcomes has not been clearly established. The purpose of this study was to utilize BCCT.core computer software to objectively evaluate NAC malposition following bilateral NSM with implant reconstruction and compare the analysis to an expert panel. Postoperative photographs of 43 patients who underwent bilateral NSM were analyzed with the BCCT.core and by an expert panel of plastic surgery residents and attendings. The panel was asked to only evaluate nipple asymmetry and position. The intraclass correlation coefficient (ICC) was used to determine interrater reliability (n = 12) and between expert panel ratings and BCCT.core ratings. Statistics were performed using SPSS statistical package version 24.0. The ICC for the expert panel interrater reliability was excellent (ICC = 0.941, 95% CI: 0.912-0.964). The analysis between BCCT.core individual parameters, specifically the breast retraction assessment (ie, BRA score = the difference in nipple position between the two breasts assessing breast symmetry) and expert panel, showed statistically significant positive correlation. The parameters provided by the BCCT.core software were correlated with both the mean expert panel rating and BCCT.core ratings. Therefore, it is plausible that BCCT.core parameters could be used to objectively quantify NAC malposition/asymmetry and guide treatment in patients undergoing bilateral NSM with implant reconstruction.

Evolution, current challenges, and future possibilities in the objective assessment of aesthetic outcome of breast cancer locoregional treatment

The Breast Cancer overall survival rate has raised impressively in the last 20 years mainly due to improved screening and effectiveness of treatments. This increase in survival paralleled the awareness over the long-lasting impact of the side effects of treatments on patient quality of life, emphasizing the motto “a longer but better life for breast cancer patients”. In breast cancer more strikingly than in other cancers, besides the side effects of systemic treatments, there is the visible impact of surgery and radiotherapy on patients’ body image. This has sparked interest on the development of tools for the aesthetic evaluation of Breast Cancer locoregional treatments, which evolved from manual, subjective approaches to computerized, automated solutions. However, although studied for almost four decades, past solutions were not mature enough to become a standard.

Recent advancements in machine learning have inspired trends toward deep-learning-based medical image analysis, also bringing new promises to the field of aesthetic assessment of locoregional treatments. In this paper, a review and discussion of the previous state-of-the-art methods in the field is conducted and the extracted knowledge is used to understand the evolution and current challenges. The aim of this paper is to delve into the current opportunities as well as motivate and guide future research in the aesthetic assessment of Breast Cancer locoregional treatments.

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Past, present and future of objective assessment of aesthetic outcome of breast cancer treatments.

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Critical discussion of the role and impact of deep-learning-based methodologies in the field.

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Recommendation for future efforts in the objective assessment of aesthetic outcome of breast cancer treatments.

REQUITE: A prospective multicentre cohort study of patients undergoing radiotherapy for breast, lung or prostate cancer

PURPOSE

REQUITE aimed to establish a resource for multi-national validation of models and biomarkers that predict risk of late toxicity following radiotherapy. The purpose of this article is to provide summary descriptive data.

METHODS

An international, prospective cohort study recruited cancer patients in 26 hospitals in eight countries between April 2014 and March 2017. Target recruitment was 5300 patients. Eligible patients had breast, prostate or lung cancer and planned potentially curable radiotherapy. Radiotherapy was prescribed according to local regimens, but centres used standardised data collection forms. Pre-treatment blood samples were collected. Patients were followed for a minimum of 12 (lung) or 24 (breast/prostate) months and summary descriptive statistics were generated.

RESULTS

The study recruited 2069 breast (99% of target), 1808 prostate (86%) and 561 lung (51%) cancer patients. The centralised, accessible database includes: physician- (47,025 forms) and patient- (54,901) reported outcomes; 11,563 breast photos; 17,107 DICOMs and 12,684 DVHs. Imputed genotype data are available for 4223 patients with European ancestry (1948 breast, 1728 prostate, 547 lung). Radiation-induced lymphocyte apoptosis (RILA) assay data are available for 1319 patients. DNA (n = 4409) and PAXgene tubes (n = 3039) are stored in the centralised biobank. Example prevalences of 2-year (1-year for lung) grade ≥2 CTCAE toxicities are 13% atrophy (breast), 3% rectal bleeding (prostate) and 27% dyspnoea (lung).

CONCLUSION

The comprehensive centralised database and linked biobank is a valuable resource for the radiotherapy community for validating predictive models and biomarkers.

PATIENT SUMMARY

Up to half of cancer patients undergo radiation therapy and irradiation of surrounding healthy tissue is unavoidable. Damage to healthy tissue can affect short- and long-term quality-of-life. Not all patients are equally sensitive to radiation "damage" but it is not possible at the moment to identify those who are. REQUITE was established with the aim of trying to understand more about how we could predict radiation sensitivity. The purpose of this paper is to provide an overview and summary of the data and material available. In the REQUITE study 4400 breast, prostate and lung cancer patients filled out questionnaires and donated blood. A large amount of data was collected in the same way. With all these data and samples a database and biobank were created that showed it is possible to collect this kind of information in a standardised way across countries. In the future, our database and linked biobank will be a resource for research and validation of clinical predictors and models of radiation sensitivity. REQUITE will also enable a better understanding of how many people suffer with radiotherapy toxicity.