Oncoplastic Surgery in Surgical Treatment of Breast Cancer: Is the Timing of Adjuvant Treatment Affected?

Impact of chemotherapy delay on long-term prognosis of laparoscopic radical surgery for locally advanced gastric cancer: a pooled analysis of four randomized controlled trials

BACKGROUND

Adjuvant chemotherapy following curative surgery for locally advanced gastric cancer (AGC) significantly improves long-term patient prognosis. However, delayed chemotherapy (DC), in which patients are unable to receive timely treatment, is a common phenomenon in clinical practice for various reasons. This study aimed to investigate the impact of DC on the prognosis of patients with stage II-III locally AGC and explore the associated risk factors.

METHODS

Data from four prospective studies were included in the pooled analysis. The planned chemotherapy (PC) group was defined as the time interval between surgery and the first chemotherapy ≤ 49 d, while the DC group was defined as the time interval between surgery and chemotherapy > 49 d. The prognosis, recurrence, and risk factors were compared, and a nomogram for predicting DC was established.

RESULTS

In total, 596 patients were included, of whom 531 (89.1%) had PC and 65 (10.9%) had DC. Survival analysis revealed that the 5-year overall survival (OS) and disease-free survival (DFS) were significantly lower in the DC group than those in the PC group (log-rank P < 0.001). Cox univariable and multivariable analyses showed that DC was an independent risk factor for OS and DFS in stage II-III patients (P < 0.05). Based on the significant factors for DC, a prediction model was established that had a good fit, high accuracy (AUC = 0.780), and clinical applicability in both the training and validation sets.

CONCLUSION

Delayed chemotherapy after gastrectomy is associated with poor long-term prognosis in patients with locally advanced stage II-III GC disease. But standardized, full-cycle adjuvant chemotherapy after surgery may play a remedial role, and can to a certain extent compensate the poor effects caused by delayed chemotherapy.

Complications after Oncoplastic Breast Reduction and Impact on Time to Adjuvant Therapy

Background

Although lumpectomy with oncoplastic breast reduction (OBR) improves cosmetic results and ameliorates symptomatic macromastia, associated complications may delay adjuvant therapy.

Methods

This was a single-institution, retrospective study of OBRs (2015-2021). A major complication was defined as need for IV antibiotics, and/or operation under general anesthesia. Association of complications with delay to adjuvant therapy (chemotherapy, radiation) was assessed.

Results

In total, 282 patients were included. The major complication rate was 3.9%, and overall complication rate was 31.2%. The most common complication was incisional dehiscence (23.4%). Body mass index [BMI >35 (P < 0.0001)], diabetes (P = 0.02), and HgbA1c [>6.5 (P = 0.0002)] were significantly associated with having a major complication. The occurrence of any complication was associated with a delay in time to radiation (median 7 versus 8 weeks, P < 0.001). The occurrence of a major complication was associated with a more meaningful delay to radiation (median 7 versus 15 weeks, P = 0.002). Occurrence of any complication, or a major complication, was not associated with delay to chemotherapy.

Conclusions

The overall complication rate observed after OBR falls within the range reported in the literature. Patients with a BMI more than 35, diabetes, and/or HgbA1c more than 6.5 were at increased risk for a major complication, which was associated with a meaningful delay to radiation. Consideration may be given to partial mastectomy alone without oncoplastic reduction in patients with small tumors when the priority to avoid radiation delay is high (eg, high-risk tumors), or the risk of delay is high (eg, diabetic or BMI >35).

Oncoplastic breast surgery versus conventional breast conserving surgery - a prospective follow-up study of subjective loco-regional late morbidity

Background and aim: Few studies have focused on the symptoms of loco-regional morbidity in shoulders, arms, and breasts related to oncoplastic breast surgery (OPS). This study aimed to determine if a difference exists in the prevalence or variety of subjective symptoms of shoulder, arm, and breast morbidity in patients undergoing OPS compared with patients receiving conventional breast conserving surgery (C-BCS). Cosmetic result and body image were included as secondary endpoints.Methods: This prospective follow-up study with 18 months of questionnaire-based follow-up included women with breast cancer or ductal carcinoma in situ. They were divided into two groups - C-BCS or OPS - depending on type of surgery performed. Furthermore, patient, disease, and treatment characteristics were recorded.Results: Among 334 completers, 229 (69%) received C-BCS and 105 (31%) received OPS. Participants were comparable regarding age, comorbidity, BMI, re-excision rate (15-16%), and axillary surgery. As for tumor characteristics, a more advanced disease stage was shown in the OPS than in the C-BCS group with larger tumor and lumpectomy size, more multifocality, and the corresponding following systemic adjuvant therapy.The questionnaire revealed that the two groups were comparable with no significant differences in frequency or variety of symptoms of shoulder and arm morbidity. Overall, participants were highly satisfied with the cosmetic results in both groups and no significant inter-group differences were observed.Conclusion: In patients with larger tumors, breast conserving surgery utilizing oncoplastic techniques yields results regarding subjective shoulder, arm, and breast morbidity as well as cosmetic outcome comparable with those of C-BCS performed on smaller tumors.Trial registration: ClinicalTrials.gov, registration number: NCT02159274 (2014).HIGHLIGHTSSubjective symptoms of shoulder, arm, and breast morbidity are comparable when oncoplastic breast surgery is compared to conventional breast conserving surgery.The variety of symptoms of shoulder and arm morbidity following oncoplastic surgery does not differ from symptoms following conventional breast conserving surgery.The cosmetic outcome following oncoplastic breast surgery is comparable to breast conserving surgery without oncoplastic techniques.

Assessing the effect of a hands-on oncoplastic surgery training course: A survey of Canadian surgeons

BACKGROUND

The adoption of oncoplastic surgery in North America is poor despite evidence supporting the benefits. Surgeons take courses to acquire oncoplastic techniques, however, the effect of these courses is unknown. This study aimed to assess the impact of a hands-on oncoplastic course on surgeons' comfort with oncoplastic techniques and rate of adoption of these techniques in their practice.

MATERIAL AND METHODS

An online 10-question survey was developed and distributed to surgeons who had participated in a hands-on oncoplastic course offered in Ontario, Canada. Categorical data were reported using frequencies and percentages.

RESULTS

A total of 105 surveys were sent out of which 69 attending surgeons responded (response rate: 65.7%). All respondents stated cosmesis was of the utmost importance in breast conserving surgery. The most common oncoplastic techniques they currently use included glandular re-approximation (98.4%), undermining of skin (93.6%), undermining of the nipple areolar complex (63.4%), and de-epithelialization and repositioning of the nipple areola complex (49.2%). Only 26% of respondnets stated they used more advanced techniques such as mammoplasty. Sixty percent of surgeons reported they used oncoplastic techniques in at least half of their cases. Ninety-two percent of respondents stated that the hands-on course increased the amount of oncoplastic techniques in their practice. At least 70% of respondents stated they would do another hands-on course. The main factor that facilitated the uptake of oncoplastic techniques was a better understanding of surgical techniques and planning.

CONCLUSION

A hands-on oncoplastic course helps surgeons adopt oncoplastic surgery techniques into their clinical practice. This teaching model allows surgeons to become comfortable with a variety of techniques. This study supports the relevance of a hands-on oncoplastic course to enhance the availability of safe oncoplastic surgery for breast cancer patients.

Immediate Contralateral Mastopexy/Breast Reduction for Symmetry Can Be Performed Safely in Oncoplastic Breast-Conserving Surgery

BACKGROUND

Oncoplastic breast-conserving surgery expands the indications for breast conservation. When performed using modified mastopexy/breast reduction techniques, the optimal timing of the contralateral symmetrizing mastopexy/breast reduction remains unclear. This study examined the effect of the timing of symmetrizing mastopexy/breast reduction on oncoplastic breast-conserving surgery outcomes.

METHODS

A retrospective study was conducted of all patients who underwent oncoplastic breast-conserving surgery using mastopexy/breast reduction techniques at a single center from 2010 to 2016. Patients who received synchronous (immediate) contralateral breast symmetrizing mastopexy were compared with those who underwent a delayed symmetrizing mastopexy procedure. Demographic, treatment, and outcome data were collected. Descriptive statistics were used and multivariate analysis was performed to evaluate the various relationships.

RESULTS

There were 429 patients (713 breasts) included in the study; of these, 284 patients (568 breasts) underwent oncoplastic breast-conserving surgery involving mastopexy/breast reduction techniques and immediate symmetrizing mastopexy, and 145 patients underwent delayed contralateral symmetrizing mastopexy. The overall complication rate was similar between the immediate and delayed groups (25.4 percent versus 26.9 percent, respectively; p = 0.82), as was the major complication rate (10.6 percent versus 6.2 percent; p = 0.16). Complications resulted in a delay in adjuvant therapy in 18 patients (4.2 percent); in two patients (0.7 percent), this delay resulted from a complication in the contralateral symmetrizing mastopexy breast. Immediate contralateral symmetrizing mastopexy was not associated with increased risk of complications per breast (p = 0.82) or delay to adjuvant therapy (p = 0.6).

CONCLUSION

Contralateral mastopexy/breast reduction for symmetry can be performed at the time of oncoplastic breast-conserving surgery in carefully selected patients without significantly increasing the risk of complications or delay to adjuvant radiation therapy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

[Prognosis impact of breast cancer adjuvant radiotherapy delay]

OBJECTIVES

To evaluate delay to access to adjuvant radiotherapy for women with breast cancer and to study impact on prognosis.

METHODS

A restrospective descriptive study in the teaching hospital of Tours between 1st January 2007 and 31th December 2013. All women managed for an invasive breast cancer during this period were included with exclusion of women with indication of chemotherapy (neoadjuvant/adjuvant). Delay between surgery and radiotherapy were recorded. Overall survival and recurrence free survival were used to evaluate the impact of delays on prognosis.

RESULTS

Of the 1855 women with an invasive breast cancer, 904 (48.7%) had an adjuvant radiotherapy without chemotherapy. In the whole population, a delay surgery-radiotherapy>90 days was found as an independent factor negatively impacting recurrence free survival (HR=2.12 [1.03-4.36] p=0.04). In the group of patient with a breast conservative surgery, a delay surgery-radiotherapy>65 days was found as an independent factor negatively impacting recurrence free survival with HR=2.29 [1.16-4.54], p=0.02. A delay surgery-radiotherapy>70 days was found as an independent factor negatively impacting Overall survival and HR=3.41 [1.005-11.62], p=0.04.

CONCLUSION

Delay to access to adjuvant radiotherapy is an independent factor impacting patient's survival, especially in the case of breast conservative therapy.

Oncoplastic breast surgery does not delay the onset of adjuvant chemotherapy: a population-based study

BACKGROUND

Only a few studies of limited size have examined whether oncoplastic breast surgery delays the onset of adjuvant chemotherapy as compared to conventional breast surgery. We investigated whether oncoplastic breast surgery causes a delay in the onset of adjuvant chemotherapy in comparison to lumpectomy and mastectomy.

MATERIAL AND METHODS

The study is a population-based cohort study. Within the nationwide registry of the Danish Breast Cancer Group (DBCG), we identified 1798 patients who received adjuvant chemotherapy following mastectomy, lumpectomy or oncoplastic breast surgery for early and unilateral invasive breast cancer. Women treated with neoadjuvant chemotherapy were excluded.

RESULTS

We found no significant difference between the three groups (mastectomy, lumpectomy, oncoplastic breast surgery) in the time from biopsy to surgery (mean time 17.9, 17.0 and 18.3 days, respectively), the time from surgery to onset of adjuvant chemotherapy, nor total time from biopsy to the onset of adjuvant chemotherapy (mean time 52.7, 51.9 and 53.2 days, respectively).

CONCLUSIONS

Our study shows that oncoplastic breast surgery does not delay the onset of adjuvant chemotherapy in comparison with mastectomy and lumpectomy. Accordingly, patients should not be excluded from treatment with oncoplastic breast surgery due to concerns of delay in adjuvant chemotherapy.

Current Practices and Barriers to the Integration of Oncoplastic Breast Surgery: A Canadian Perspective

BACKGROUND

Despite the safety and popularity of oncoplastic surgery, there is limited data examining utilization and barriers associated with its incorporation into practice. This study examines the use of oncoplastic techniques in breast conserving surgery and determines the barriers associated with their implementation.

METHODS

A 13-item survey was mailed to all registered general surgeons in Ontario, Canada. The survey assessed surgeon demographics, utilization of specific oncoplastic techniques, and perceived barriers.

RESULTS

A total of 234 survey responses were received, representing a response rate of 32.2 % (234 of 725). Of the respondents, 166 surgeons (70.9 %) reported a practice volume of at least 25 % breast surgery. Comparison was made between general surgeons performing oncoplastic breast surgery (N = 79) and those who did not use these techniques (N = 87). Surgeon gender, years in practice, fellowship training, and access to plastic surgery were similar across groups. Both groups rated the importance of breast cosmesis similarly. General surgeons with a practice volume involving >50 % breast surgery were more likely to use oncoplastic techniques (OR 8.82, p < .001) and involve plastic surgeons in breast conserving surgery (OR 2.21, p = .02). For surgeons not performing oncoplastic surgery, a lack of training and access to plastic surgeons were identified as significant barriers. For those using oncoplastic techniques, the absence of specific billing codes was identified as a limiting factor.

CONCLUSIONS

Lack of training, access to plastic surgeons, and absence of appropriate reimbursement for these cases are significant barriers to the adoption of oncoplastic techniques.

The Role of Oncoplastic Breast Surgery in Breast Cancer Treatment

The aim of this study is to discuss indications, advantages, disadvantages, oncologic and aesthetic results of Oncoplastic Surgery (OBS). Pubmed and Medline database were searched for articles published between 1998 and 2014 for keywords: oncoplastic breast surgery, therapeutic mammoplasty, oncoplastic breast reduction, synchrenous reconstructions. Role of OBS in breast cancer surgery, its aspects to be considered, its value and results have been interpreted. This technique has advantages by providing more extensive tumourectomy, yielding better aesthetic results compared with breast conserving surgery, allowing oncoplastic reduction in breast cancer patients with macromastia, with higher patient satisfaction and quality of life and by being inexpensive due to single session practice. As for its disadvantages are: re-excision is more difficult, risk for mastectomy is higher, it is depent on the Surgeron's experience, it has a risk for delay in adjuvant therapies and its requirement for additional imaging studies during management. Main indications are patients with small tumour/breast volume, macromastia, multifocality, procedures which can disrupt breast cosmesis such as surgeries for upper inner breas tquadrient tumours. Contraindications are positive margin problems after wide excision, diffuse malign microcalsifications, inflammatory breast cancer, history of radiotherapy and patients' preferences. Despite low evidence level, Oncoplastic Breast Surgery seems to be both reliable and acceptable in terms of oncologic and aesthetic aspects. Oncoplastic Breast Surgery increase the application rate of breast conserving surgery by obviating practical limitations and improve the results of breast conserving surgery. Correct patient and technique choice in OBS is vital for optimization of post surgical.

Proper timing of adjuvant chemotherapy affects survival in patients with stage 2 and 3 gastric cancer

BACKGROUND

Adjuvant chemotherapy improves survival in patients with gastric cancer. However, the relationship between the timing of adjuvant chemotherapy and survival has not been investigated.

METHODS

Patients with D2-resected stage 2 and 3 gastric cancer that received adjuvant chemotherapy from 2005 to 2011 at Yonsei University Health System were included. The patients were grouped according to intervals between surgery and adjuvant chemotherapy.

RESULTS

Among 840 patients, the interval from surgery to the start of adjuvant therapy was less than 4 weeks in 337 (40.1 %) patients (early group), 4-8 weeks in 467 (55.6 %) patients (intermediate group), and more than 8 weeks in 36 (4.3 %) patients (late group). The 5-year RFS was 55.7 % in the early group, 54.4 % in the intermediate group, and 43.6 % in the late group (p = 0.076). The corresponding 5-year OS rates were 63.4, 62.8, and 51.7 % (p = 0.037).

CONCLUSIONS

There is insufficient evidence to suggest starting adjuvant chemotherapy within 4 weeks after surgery for patients with D2 resected stage 2 and 3 gastric cancer. However, delayed treatment of adjuvant chemotherapy after 8 weeks showed worse survival outcomes than early and intermediate treatment initiation, suggesting that adjuvant chemotherapy should be considered start within 8 weeks after radical resection.