Aesthetic results were more satisfactory after oncoplastic surgery than after total breast reconstruction according to patients and surgeons

Bilobed lateral artery perforator-based flap for partial breast reconstruction - Technique description and results from a ten-year cohort

INTRODUCTION

We present a new technique, the bilobed lateral artery perforator-based flap, for breast-conserving surgery of large central tumors or nearby, combining Zymany's bilobed flap and a Lateral Intercostal Perforator (LICAP) flap, and its 10-year outcomes.

MATERIALS AND METHODS

We studied 37 patients with malignant breast tumors near or involving the central skin, without ptosis or desire to correct it, who avoided mastectomy with this modified bilobed flap from 2013 to 2022. The same surgeon operated on them in different institutions. This research project was approved by our ethical committee (n. 2.322.212).

RESULTS

The mean age was 57.17 (±12.60) years. The mean specimen weight was 74.32 (±25.84)g, and the mean tumor size was 40.35 (±15.81) mm. Fourteen (37.84 %) tumors were larger than 5 cm and one was multicentric. Thirty-two (86.49 %) patients had invasive ductal carcinomas. Nipple areola complex was removed in 19 (51.35 %) cases due to clinical involvement, and immediately reconstructed in two cases with contralateral free grafting. Twenty-one (56.76 %) patients received neoadjuvant chemotherapy. Three (8.11 %) patients had immediate contralateral mastopexy. Radiotherapy was indicated in all cases. There were 3 (8.11 %) minor complications, one positive margin, and no surgical revisions. In a mean follow-up of 39.97 (±29.43) months, there were no local recurrences, 2 metastasis, and one death. Satisfaction and aesthetic results were good or excellent in most cases.

CONCLUSIONS

The new technique enabled breast conservation, with high rates of free margins, high levels of satisfaction, few complications in women with large central tumors on small breasts with limited ptosis.

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.

Understanding decision-making for and against oncoplastic breast-conserving surgery as an alternative to a mastectomy in early breast cancer: UK ANTHEM qualitative study

BACKGROUND

Oncoplastic breast-conserving surgery may allow women with early breast cancer to avoid a mastectomy, but many women undergo more extensive surgery, even when breast-conserving options are offered. The aim of the ANTHEM qualitative study was to explore factors influencing women's surgical decision-making for and against oncoplastic breast-conserving surgery.

METHODS

Semi-structured interviews were conducted with a purposive sample of women who had received either oncoplastic breast-conserving surgery or a mastectomy with or without immediate breast reconstruction to explore their rationale for procedure choice. Interviews were transcribed verbatim and analysed thematically. Trial registration number: ISRCTN18238549.

RESULTS

A total of 27 women from 12 centres were interviewed. Out of these, 12 had chosen oncoplastic breast-conserving surgery and 15 had chosen a mastectomy with or without immediate breast reconstruction. Overwhelmingly, women's decisions were guided by their surgical teams. Decision-making for and against oncoplastic breast-conserving surgery was influenced by three key inter-related factors: perceptions of oncological safety; the importance of maintaining/restoring femininity and body image; and practical issues. Oncological safety was paramount. Women who reported feeling reassured that oncoplastic breast-conserving surgery was oncologically safe were happy to choose this option. Those who were not reassured were more likely to opt for a mastectomy, as a perceived 'safer' option. Most women wished to maintain/restore femininity, with the offer of immediate breast reconstruction essential to make a mastectomy an acceptable option. Practical issues such as the perceived magnitude of the surgery were a lesser concern.

CONCLUSION

Decision-making is complex and heavily influenced by the surgical team. High-quality, accurate information about surgical options, including appropriate reassurance about the short- and long-term oncological safety of oncoplastic breast-conserving surgery is vital if women are to make fully informed decisions.

[Updated surgical indications and quality and safety indicators in the management of infiltrative breast carcinoma]

OBJECTIVES

Breast surgery is the cornerstone of breast cancer treatment. Its indications and procedures are constantly evolving. To update best practices, four questions were submitted to the Senology Commission (SC) of the Collège national des gynécologues et obstétriciens français (CNGOF), covering the indications and modalities of tumor surgery: (1) initially, (2) following neoadjuvant systemic treatment, (3) in case of local recurrence, and (4) the quality and safety of care indicators applicable to this surgery.

METHODS

The CNGOF SC essentially based its responses on the clinical practice recommendations and guidelines of the French Cancer Institute concerning invasive carcinomas of the breast. Exclusion criteria were carcinoma in situ, sarcoma and axillary surgery.

RESULTS

To define the type of breast surgery, knowledge of four parameters is essential: the patient's level of risk, the presence of metastases, the size of the breast tumor and its focality (assessed by the clinical/mammography/ultrasound tripod). (1) In the case of initial management, the 6 indications for mastectomy are patient choice (particularly in case of high risk), contraindication to radiotherapy, inflammatory cancer (T4d), surgery with positive margins (after several surgical intervention), surgery that cannot be performed as a monobloc in the case of tumors with multiple foci, and poor expected aesthetic results. All other situations should be treated conservatively. (2) The same criteria apply after neoadjuvant systemic treatment, with conservative treatment still possible whatever the size (excluding carcinomatous mastitis) and focality of the initial tumor. (3) In case of local recurrence, total mastectomy is the reference treatment, with a second conservative treatment reserved for patients with no risk factors for a second recurrence, and no poor prognostic factors, after validation in a multidisciplinary meeting. (4) Four quality and safety indicators apply to breast surgery: it must be performed after obtaining a histological diagnosis, within less than 6 weeks of mammography, in a single surgery in over 80% of cases, and followed by local radiotherapy in the case of conservative treatment.

CONCLUSION

The indications and modalities of breast surgery are evolving rapidly. To improve aesthetic results, oncoplastic techniques, immediate breast reconstruction, and preservation of the skin or nipple-areolar complex need to be further developed and evaluated in the long-term. These developments must necessarily be accompanied in France by a training policy for breast surgeons.

Extreme oncoplasty: past, present and future

Breast surgery has evolved from mastectomy to breast-conserving surgery (BCS). Breast oncoplastic surgery later emerged with the inclusion and development of techniques used in plastic surgery for breast neoplasms. Recently, a new paradigm has been considered for mastectomy candidates with large multifocal and multicentric tumours, designated extreme oncoplasty (EO), which has allowed new techniques to be applied to tumours that would have been ineligible for BCS before. There are few publications and no uniform descriptions grouping all the technical possibilities and new indications together. We performed this a review with the objective of evaluating the indications and surgeries performed in the EO context, representing a new perspective for BCS. We observed new indications as extensive microcalcifications, locally advanced breast carcinoma with partial response to chemotherapy, small to moderate-sized non-ptotic central tumours and extreme ptosis. Small breasts are able for EO since the presence of ptosis. New surgeries are reported as disguised geometric compensation, perforators flaps, local/regional flaps, latissimus dorsi miniflap and partial breast amputation. It is important to decrease barriers to oncoplastic surgery if we want to increase the use of EO and BCS rates.

A clinical perspective on oncoplastic breast conserving surgery

Breast conserving surgery (BCS) plus radiation treatment is the favored alternative for mastectomy in patients with breast cancer. To allow for breast conservation in patients with large invasive tumors and poor response to neoadjuvant systemic treatment (NST) or patients with extensive ductal carcinoma in situ (DCIS), oncoplastic breast conserving surgery (OPBCS) techniques are introduced. OPBCS allows for breast conservation in a selective group of breast cancer patients who initially would have been treated with mastectomy due to the unfavorable tumor-to-breast ratio. With OPBCS, the oncological tumor excision is combined with plastic surgical breast conservation techniques without compromising oncological safety and maintaining aesthetic outcomes by preserving the shape of the breast. OPBCS should however not be applied to all breast cancer patients and the selection of patients who benefit from OPBCS and the timing of OPBCS are best discussed in a multidisciplinary team (MDT). Caution is required in patients with higher risk of positive margins [e.g., multifocal breast cancer, invasive lobular carcinoma (ILC), larger tumors and DCIS]. In these patients, delayed OPBCS is recommended to facilitate re-excision and maintain excellent breast conserving rates. Despite proven benefits in selected patients, the increase in the adoption of OPBCS is relatively low. This article provides a clinical perspective on OPBCS.