Immediate reconstruction following breast-conserving surgery: management of the positive surgical margins and influence on secondary reconstruction

Oncoplastic reduction mammoplasty: Systematic review and proportional meta-analysis of surgical outcomes

BACKGROUND

Breast-conserving surgery is the standard of care for early-stage breast cancer but can often result in unsatisfactory cosmetic outcomes. Oncoplastic surgery aims to address these issues by combining local excision with plastic surgery techniques to improve oncologic and esthetic outcomes. By incorporating breast reduction techniques into cancer surgery, wider margins of excision can be achieved, leading to enhanced oncological safety and reduced recurrence rates without causing significant asymmetry. This systematic review and meta-analysis aims to provide an updated understanding of the surgical outcomes associated with oncoplastic reduction mammoplasty.

METHODS

A systematic review of the literature was conducted according to PRISMA guidelines. Articles reporting post-operative outcomes following the oncoplastic reduction mammoplasty were included. A proportional meta-analysis of post-operative complications was performed to obtain their proportions and 95% Confidence Intervals (CIs).

RESULTS

Eighteen studies met the inclusion criteria, representing a total of 2711 oncoplastic reduction mammoplasty procedures in 2680 patients. The overall complication rate was 20% (95% CI: 15-25%). The positive margin rate following oncoplastic reduction mammoplasty was 11% (95% CI: 6-17%). The re-excision rate was 6% (95% CI: 3-12%). The completion mastectomy rate was 3% (95% CI: 2-6%).

CONCLUSIONS

Oncoplastic reduction mammoplasty is a safe and effective alternative to mastectomy and traditional breast-conserving surgery in the treatment of early-stage breast cancers.

Chest wall perforator flaps in partial breast reconstruction after breast conservation surgery: an additional oncoplastic surgical option

Partial breast reconstruction using chest wall perforator flaps (CWPF) is a recent option used by breast surgeons, mainly for lateral quadrant defects with a relatively large volume of excision. We report a single-centre experience of CWPF with surgery details, complications, re-excision, aesthetic and oncological outcomes.

This was a prospective observational cohort study of patients who had undergone breast conservation surgery (BCS) plus CWPF reconstruction. All variables were recorded prospectively in the institutional database. A survey was done to analyse patient satisfaction at about 6 months after completion of radiotherapy.

Forty patients had CWPF based reconstruction in 3 years. 57.5 % of patients had lateral intercostal artery perforator (LICAP) flap, 5% had lateral thoracic artery perforator (LTAP) flap, 27.5% had combined LICAP plus LTAP and 10% patients had anterior intercostal artery perforator (AICAP) flap. Tumour excision cavity defect was of the lateral quadrant in 82.5%, central quadrant in 10% and medial quadrant in 7.5% of patients. The margin was positive for five patients, out of which four required cavity shave and one had a mastectomy. One patient had complete flap loss, and two patients developed surgical site infection. 96% of patients were satisfied with the scar, and 88% were happy with the treated breast in comparison to the opposite breast. 92% were comfortable going out in public and felt that in retrospect their decision not to have a mastectomy was correct. With a median follow up of 18 (10, 22) months, one patient died, and four had recurrences.

CWPF may be used for partial breast reconstruction in the small non-ptotic breast with excellent outcome and high patient satisfaction scores.

Objective assessment of flap volume changes and aesthetic results after adjuvant radiation therapy in patients undergoing immediate autologous breast reconstruction

BACKGROUND

The use of immediate breast reconstruction and adjuvant radiation therapy is increasing in breast cancer patients. This study aimed to analyze the aesthetic outcome and changes in flap volume in patients with breast cancer undergoing radiation therapy of the surgical site after immediate autologous tissue reconstruction.

METHODS

Immediate abdominal free flap breast reconstruction following unilateral mastectomy was performed in 42 patients; 21 patients received adjuvant radiation (study group) and 21 patients did not (control group). To compare flap volume, three-dimensional computed tomography (CT) was performed before and after radiation. Also, aesthetic analysis was performed in both groups to evaluate shape changes.

RESULTS

There was a 12.3% flap volume reduction after the completion of radiation in the experimental group that was significantly greater than the 2.6% volume reduction observed in the non-radiation group (P<0.01). There was no significant difference in the short- and long-term aesthetic results between the groups.

CONCLUSIONS

When performing immediate autologous breast reconstruction, 14% volume overcorrection is recommended for patients in whom adjuvant radiation therapy is anticipated to improve aesthetic outcomes.

Positive Margin Re-Excision Following Immediate Autologous Breast Reconstruction: Morbidity, Cosmetic Outcome, and Oncologic Significance

BACKGROUND

Acquisition of negative resection margins is paramount in the surgical management of operable breast cancer. Management of positive margins following mastectomy and immediate breast reconstruction is presently poorly defined.

OBJECTIVES

The present study aims at defining morbidity and cosmetic sequela of re-excision procedures aimed at clearing involved mastectomy margins in the setting of immediate autologous breast reconstruction. Oncologic outcomes are recorded.

METHODS

A retrospective study of patients that underwent skin-sparing mastectomy followed by immediate deep inferior epigastric perforator flap breast reconstruction was performed. Patients found to have positive mastectomy margins underwent margin re-excision during a separate procedure. Method of positive margin exposure and resection is described. Flap morbidity and cosmetic outcome following margin re-excision was compared between reconstructed breasts that underwent re-excision vs those reconstructed after prophylactic mastectomy (controls). Cancer recurrence was recorded during the follow-up period.

RESULTS

Thirty-six (2.5%) out of 1443 patients were found to have positive mastectomy margins following immediate breast reconstruction between May 2007 and November 2012. Location of positive margins was evenly distributed in all breast regions. Although flap morbidity was similar, a trend (P > 0.05) toward higher seroma formation and fat necrosis was reported in breasts following re-excision vs controls. With a mean follow-up period of 28 months, cosmetic outcome between breasts that underwent re-excision vs controls were similar. Cancer recurrence was reported in 3 (8.3%) patients.

CONCLUSIONS

Re-excision of positive mastectomy margins following immediate autologous breast reconstruction requires a multidisciplinary approach and may be performed with minimal additional morbidity while preserving optimal cosmetic outcome.

LEVEL OF EVIDENCE

3.

Oncoplastic breast surgery in the setting of breast-conserving therapy: A systematic review

Breast-conserving therapy (BCT), or breast-conserving surgery with adjuvant radiation therapy, has become a standard treatment alternative to mastectomy for women with early-stage breast cancer after many long-term studies have reported comparable rates of overall survival and local control. Oncoplastic breast surgery in the setting of BCT consists of various techniques that allow for an excision with a wider margin and a simultaneous enhancement of cosmetic sequelae, making it an ideal breast cancer surgery. Because of the parenchymal rearrangement that is routinely involved in oncoplastic techniques, however, the targeted tissue can be relocated, thus posing a challenge to localize the tumor bed for radiation planning. The goals of this systematic review are to address the challenges, outcomes, and cosmesis of oncoplastic breast surgery in the setting of BCT.

Nipple areola complex sparing mastectomy

Breast conservative therapy (BCT) is established as a safe option for most women with early breast cancer (BC). The best conservative mastectomy that can be performed, when mastectomy is unavoidable, is nipple-areola-complex sparing mastectomy (NSM), which allows the complete glandular dissection preserving the skin envelope and the nipple areola complex. In the treatment of BC, the cosmetic outcomes have become fundamental goals, as well as oncologic control. NSM is nowadays considered an alternative technique to improve the overall quality of life for women allowing excellent cosmetic results because it provides a natural appearing breast. The breast surgeon must pay attention to details and skin incision must be planned to minimize vascular impairment to the skin and the nipple. Preservation of the blood supply to the nipple is one of the most important concern during NSM because nipple or areolar necrosis is a well-described complication of this surgery. Another issue associated with the nipple preservation and the surgical technique is oncological safety related to nipple-areola-complex (NAC) involvement in patients with invasive BC. The authors present their experience on 252 NSM performed in the Breast Surgery Unit in Forlì. Careful selection of patients for this surgical procedure is imperative and many patients are not ideal candidates for this procedure because of concerns about nipple-areolar viability as women with significant large/ptotic breast, pre-existing breast scars and history of active cigarette smoking. To extend the benefits of nipple preservation to patients who are perceived to be at higher risk for nipple necrosis the authors describe technical modifications of NSM to allow nipple preservation and obtain good cosmetic outcomes.

Rhomboid Flap Technique in Breast-conserving Surgery: An Alternative Method for the Reconstruction of Lumpectomy Defects

OBJECTIVE

We aimed to present our experience with rhomboid flap reconstruction, which is a simple technique, in breast cancer patients who underwent breast-conserving surgery.

METHODS

We reviewed the medical records of 13 patients with breast cancer who underwent rhomboid flap reconstruction. The patients were evaluated for tumor size, safe surgical margin, and other clinical and pathological features.

RESULTS

The mean age of the patients was 43.1 years (range: 28-69 years). The mean tumor diameter was 30.8 mm (range: 15-60 mm). The mean of the safe margin of resection was evaluated to be 17.8 mm (range: 5-30 mm). Re-excision was required for one patient in the same session.

CONCLUSION

Rhomboid flap reconstruction can facilitate the applicability of breast-conserving surgery in early breast cancer patients with large tumor-to-breast-size ratio or tumors close to the skin.

Oncoplastic breast surgery: indications, techniques and perspectives

Breast-conservation surgery (BCS) is established as a safe option for most women with early breast cancer. Recently, advances in oncoplastic techniques have reduced surgical trauma and thus are capable of preserving the breast form and quality of life. In spite of the most BCS defects can be managed with primary closure, the aesthetic outcome may be unpredictable. Oncoplastic reconstruction may begin at the time of BCS (immediate), weeks (delayed-immediate) or months to years afterwards (delayed). With immediate reconstruction, the surgical process is smooth, since both procedures can be associated in one operative setting. Additionally, it permits wider excision of the tumor, with a superior mean volume of the specimen and potentially reducing the incidence of margin involvement. The oncoplastic techniques are related to volume displacement or replacement procedures including local flaps, latissimus dorsi myocutaneous flap and reduction mammaplasty/masthopexy. Regardless of the fact that there is no consensus concerning the best approach, the criteria are determined by the surgeon's experience and the size of the defect in relation to the size of the remaining breast. On the basis of our 15-year experience, it is possible to identify trends in types of breast defects and to develop an algorithm for immediate BCS reconstruction on the basis of the initial breast volume, the extent/location of glandular tissue ressection and the remaining available breast tissue. The main advantages of the technique utilized should include reproducibility, low interference with the oncologic treatment and long-term results. Surgical planning should include the patients's preferences, and chiefly addressing individual reconstructive requirements, enabling each patient to receive an individual "custom-made" reconstruction.

Determinants of optimal mastectomy skin flap thickness

Background

There is a limited evidence base to guide surgeons on the ideal thickness of skin flaps during mastectomy. Here the literature relevant to optimizing mastectomy skin flap thickness is reviewed, including anatomical studies, oncological considerations, factors affecting viability, and the impact of surgical technique and adjuvant therapies.

Methods

A MEDLINE search was performed using the search terms ‘mastectomy’ and ‘skin flap’ or ‘flap thickness’. Titles and abstracts from peer-reviewed publications were screened for relevance.

Results

A subcutaneous layer of variable thickness that contains minimal breast epithelium lies between the dermis and breast tissue. The thickness of this layer may vary within and between breasts, and does not appear to be associated with obesity or age. The existence of a distinct layer of superficial fascia in the breast remains controversial and may be present in only up to 56 per cent of patients. When present, it may not be visible macroscopically, and can contain islands of breast tissue. As skin flap necrosis occurs in approximately 5 per cent of patients, a balance must be sought between removing all breast tissue at mastectomy and leaving reliably viable skin flaps.

Conclusion

The variable and unpredictable thickness of the breast subcutaneous layer means that a single specific universal thickness for mastectomy skin flaps cannot be recommended. It may be that the plane between the subdermal fat and breast parenchyma is a reasonable guide for mastectomy flap thickness, but this may not always correspond to a subcutaneous fascial layer.

Current aspects of therapeutic reduction mammaplasty for immediate early breast cancer management: An update

Breast-conservation surgery (BCS) is established as a safe surgical treatment for most patients with early breast cancer. Recently, advances in oncoplastic techniques are capable of preserving the breast form and quality of life. Although most BCS defects can be managed with primary closure, the aesthetic outcome may be unpredictable. Among technical options, therapeutic reduction mammaplasty (TRM) remains a useful procedure since the BCS defect can be repaired and the preoperative appearance can be improved, resulting in more proportional breasts. As a consequence of rich breast tissue vascularization, the greater part of reduction techniques have based their planning on preserving the pedicle of the nipple-areola complex after tumor removal. Reliable circulation and improvement of a conical shape to the breast are commonly described in TRM reconstructions. With an immediate approach, the surgical process is smooth since both procedures can be carried out in one operative setting. Additionally, it permits wider excision of the tumor, with a superior mean volume of the specimen and potentially reduces the incidence of margin involvement. Regardless of the fact that there is no consensus concerning the best TRM technique, the criteria is determined by the surgeon’s experience, the extent/location of glandular tissue resection and the size of the defect in relation to the size of the remaining breast. The main advantages of the technique utilized should include reproducibility, low interference with the oncological treatment and long-term results. The success of the procedure depends on patient selection, coordinated planning and careful intra-operative management.

Intraoperative imprint cytology and frozen section pathology for margin assessment in breast conservation surgery: a systematic review

BACKGROUND

Achieving negative surgical margins is critical to minimizing the risk of tumor recurrence in patients undergoing breast conservation surgery (BCS) for a breast malignancy. Our objective was to perform a systematic review comparing reexcision rates, sensitivity and specificity of the intraoperative use of the margin assessment techniques of imprint cytology (IC) and frozen section analysis (FSA), against permanent histopathologic section (PS).

METHODS

The databases PubMed, Web of Knowledge, Cochrane Library and CINAHL Plus were searched for literature published from 1997 to 2011. Original investigations of patients who underwent BCS for breast cancer that evaluated margin assessment with PS and/or IC or FSA were included. Of 182 titles identified, 41 patient cohorts from 37 articles met inclusion criteria: PS (n = 19), IC (n = 7) and FSA (n = 15). Studies were summarized qualitatively using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cohort studies and the Strength of Recommendation Taxonomy (SORT) numerical scale for diagnostic studies.

RESULTS

The final reexcision rates after primary BCS were 35 % for PS, 11 % for IC (p = 0.001 vs. PS) and 10 % for FSA (p < 0.0001 vs. PS). For IC, reexcision rates decreased from 26 to 4 % (p = 0.18) and for FSA, reexcision rates decreased from 27 to 6 % (p < 0.0001). The pooled sensitivity of IC and FSA were 72 and 83 %. The pooled specificity of IC and FSA were 97 and 95 %. The average length of each technique was 13 min for IC and 27 min for FSA.

CONCLUSIONS

Patients who underwent BCS with intraoperative IC or FSA to assess negative surgical margins had significantly fewer secondary surgical procedures for excision of their breast malignancies.

Surgical techniques for personalized oncoplastic surgery in breast cancer patients with small- to moderate-sized breasts (part 2): volume replacement

Oncoplastic breast surgery has become a popular choice of treatment for breast reconstruction after mastectomy. There are two different techniques in oncoplastic surgery depending on the volume of the excised breast tissue. One is the volume displacement procedure, which combines resection with a variety of different breast-reshaping and breast-reduction techniques; the other is the volume replacement procedure in which the volume of excised breast tissue is replaced with autologous tissue. In this study, current authors performed various volume replacement techniques based on the weight of the excised tumor and its margin of resection. We used a latissimus dorsi myocutaneous flap for cases in which the resection mass was greater than 150 g, and for cases in which the resection mass was less than 150 g, we used a regional flap, such as a lateral thoracodorsal flap, a thoracoepigastric flap, or perforator flaps, such as an intercostal artery perforator flap or a thoracodorsal artery perforator flap. In the patients with small to moderate-sized breasts, when a postoperative deformity is expected due to a large-volume tumor resection, the replacement of non-breast tissue is required. Many of whom have small breasts, oncoplastic volume replacement techniques in breast-conserving surgery allow an extensive tumor excision without concern of compromising the cosmetic outcome and can be reliable and useful techniques with satisfactory aesthetic results.

Outcome analysis of immediate and delayed conservative breast surgery reconstruction with mastopexy and reduction mammaplasty techniques

BACKGROUND

Bilateral mammaplasty or mastopexy is frequently used for oncoplastic objectives. However, little information has been available regarding outcome following immediate and delayed reconstruction.

METHOD

Patients were divided into Group I (immediate reconstruction) and Group II (delayed reconstruction). Retrospective review was performed to compare complications, length of hospital stay, revision surgeries, and satisfaction. The associations between the complications with potential risk factors (timing, age, body mass index, smoking, and comorbid medical conditions) were analyzed.

RESULTS

There were a total of 144 patients with a mean follow-up of 47 months. Of the 106 patients in Group I, complications occurred in 24 (22.6%), skin necrosis was observed in 7.5%, fat necrosis in 5.6%, and 6.6% patients developed local recurrence. Mean period of hospitalization was 1.89 days. Of the 38 patients of the Group II, complications occurred in 12 (31.5%), skin necrosis was observed in 7 (18.4%), fat necrosis in 4 (10.5%), and 5.2% patients developed local recurrence. Mean period of hospitalization was 1.35 days. Increased length of hospital stay greater than 1 day (P < 0.001) and the number of revision surgeries (P = 0.043) were associated with the timing of the reconstruction. In univariate analysis, no difference between groups was found with respect to complication incidence (P = 0.275); however, after adjusting for other risk factors, the probability of complications tend to be higher for Group II (OR = 2.65; 95% confidence interval = 1.01-7.00; P = 0.049).

CONCLUSIONS

On the basis of the results of our study, the probability of complications tends to be higher for delayed reconstructions, and it is demonstrated that obesity and smoking are risk factors for complications. Ultimately, these data may facilitate the provision of individualized risk information for shared medical decision-making.

The expression of PCNA, c-erbB-2, p53, ER and PR as well as atypical hyperplasia in tissues nearby the breast cancer

To examine the proper margin for breast conservative surgery in Chinese women population. 40 breast cancer specimens were collected and each sample was dissected into several groups: primary tumor group, 1 cm paracarcinoma, 2 cm paracarcinoma, 3 cm paracarcinoma and excessive 3 cm paracarcinoma groups. The immunohistochemistry staining was performed to measure the expression levels of proliferating cell nuclear antigen (PCNA), c-erbB-2, p53, estrogen receptor (ER) and progesterone receptor (PR). The gene expressions of PCNA, c-erbB-2, and p53 gradually decreased with the increased distance from primary tumor (P < 0.05). The 1 and 2 cm paracarcinoma group (no differences between the two, P > 0.05) showed higher risk factors (c-erbB-2, p53) than the 3 cm and excessive 3 cm paracarcinoma groups (P < 0.05). The expression of PCNA, ER, and PR showed no correlation with cancer progression (P > 0.05). Beyond the paracarcinoma 2 cm distance, the tissues showed significant decreases in tumor gene expression, which could represent the appropriate region for breast conservative surgery.

Inadequate margins of excision when undergoing mastectomy for breast cancer: which patients are at risk?

BACKGROUND

We analyzed the margin status and risk factors for inadequate margins among patients who underwent skin-sparing mastectomies (SSM) and traditional total mastectomies (TM).

MATERIALS AND METHODS

Patients undergoing mastectomies from 2003 to 2009 were included. Margins of excision were considered positive if carcinoma was at an inked margin and were considered close if such disease was within 2 mm of an inked margin.

RESULTS

A total of 426 patients were identified. The mean age was 60 years and 90% were white. Mean tumor size was 2.6 cm and 44% had multiple ipsilateral carcinomas. Of 426 patients, 177 (42%) underwent SSM with reconstruction and 249 (58%) TM. The rate of positive or close margins on the initial specimen was 29% for SSM vs. 12% for TM (P < 0.01), and the rate of reoperation for margins was 7% for SSM vs. 2% for TM (P < 0.01). Logistic regression analysis revealed that independent risk factors for initial close or positive margins included SSM (odds ratio 2.36, 95% confidence interval [95% CI] 1.05-5.30), multiple ipsilateral tumors (OR 2.12, 95% CI 1.05-4.24), and upper-inner quadrant location (OR 2.58, 95% CI 1.07-6.19). Mean follow-up time was 28 months, and the local recurrence rate was 0.9%. Local recurrence rates were not different for those undergoing SSM (1.1%) vs. TM (0.8%, P = NS).

CONCLUSIONS

Mastectomy patients undergoing SSM, with multiple ipsilateral tumors, and/or upper-inner quadrant disease are at significantly higher risk for inadequate margins of excision. These patients warrant more vigilant intraoperative attention to margin status to ensure adequate margins at the end of the first operation.

Standardized and reproducible methodology for the comprehensive and systematic assessment of surgical resection margins during breast-conserving surgery for invasive breast cancer

BACKGROUND

The primary goal of breast-conserving surgery (BCS) is to completely excise the tumor and achieve "adequate" or "negative" surgical resection margins while maintaining an acceptable level of postoperative cosmetic outcome. Nevertheless, precise determination of the adequacy of BCS has long been debated. In this regard, the aim of the current paper was to describe a standardized and reproducible methodology for comprehensive and systematic assessment of surgical resection margins during BCS.

METHODS

Retrospective analysis of 204 BCS procedures performed for invasive breast cancer from August 2003 to June 2007, in which patients underwent a standard BCS resection and systematic sampling of nine standardized re-resection margins (superior, superior-medial, superior-lateral, medial, lateral, inferior, inferior-medial, inferior-lateral, and deep-posterior). Multiple variables (including patient, tumor, specimen, and follow-up variables) were evaluated.

RESULTS

6.4% (13/204) of patients had positive BCS specimen margins (defined as tumor at inked edge of BCS specimen) and 4.4% (9/204) of patients had close margins (defined as tumor within 1 mm or less of inked edge but not at inked edge of BCS specimen). 11.8% (24/204) of patients had at least one re-resection margin containing additional disease, independent of the status of the BCS specimen margins. 7.1% (13/182) of patients with negative BCS specimen margins (defined as no tumor cells seen within 1 mm or less of inked edge of BCS specimen) had at least one re-resection margin containing additional disease. Thus, 54.2% (13/24) of patients with additional disease in a re-resection margin would not have been recognized by a standard BCS procedure alone (P < 0.001). The nine standardized resection margins represented only 26.8% of the volume of the BCS specimen and 32.6% of the surface area of the BCS specimen.

CONCLUSION

Our methodology accurately assesses the adequacy of surgical resection margins for determination of which individuals may need further resection to the affected breast in order to minimize the potential risk of local recurrence while attempting to limit the volume of additional breast tissue excised, as well as to determine which individuals are not realistically amendable to BCS and instead need a completion mastectomy to successfully remove multifocal disease.