Endoscopy-assisted breast-conserving surgery for breast cancer patients

[Implementation and development of endoscopic benign breast lump resection and breast-conserving surgery for cancer]

Objective

To review the development of endoscopic techniques in breast surgery, focusing on their use in benign breast lump resection and breast-conserving surgery for cancer, and also summarize the development and application of these techniques in China, highlighting promotion and homogenization challenges and future directions.

Methods

A systematic review of relevant literature was conducted to trace the historical evolution, clinical applications, and related research of endoscopic techniques in breast surgery, emphasizing their advantages and disadvantages of endoscopic benign breast lump resection and breast-conserving surgery for cancer.

Results

Endoscopic benign breast lump resection and breast-conserving surgery for cancer have improved patients' postoperative psychological health and quality of life, particularly in scar-free surgery. However, challenges such as limited intraoperative visibility and prolonged surgery time lead to controversy in clinical practice.

Conclusion

Despite significant advancements, endoscopic techniques in breast surgery also face challenges. Future efforts should focus on technological improvements and clinical research to address these issues, promoting widespread application and standardization. The key to future development lies in the promotion and homogenization of these technologies.

Single-port three-dimensional (3D) endoscopic-assisted breast surgery-preliminary results and patient-reported satisfaction in 145 breast cancer and gynecomastia cases

BACKGROUND

Minimal-accessed (robotic and endoscopic) breast cancer surgery is increasingly performed due to better cosmetic results and acceptable oncological outcomes. This study aims to demonstrate the clinical safety and patient-reported cosmetic satisfaction of single-port three-dimensional endoscopic-assisted breast surgery (S-P 3D EABS), which is our new endoscopic surgical innovation, in both malignant and benign breast conditions.

METHODS

Patients who underwent S-P 3D EABS from 1 August 2018 to 31 July 2022 in a single institution were enrolled. Clinical outcomes of this procedure were retrospectively reviewed, and the patient-reported cosmetic satisfaction was evaluated by a questionnaire and reported herein.

RESULTS

During the study period, 145 patients underwent 164 procedures of S-P 3D EABS. One hundred fifty (91.5%) procedures were endoscopic-assisted nipple-sparing mastectomy (S-P 3D E-NSM; 117 therapeutic procedures for breast cancer, 13 prophylactic mastectomies, 20 procedures for gynecomastia). Fourteen (8.5%) procedures of endoscopic-assisted breast-conserving surgery (S-P 3D E-BCS) were performed (12 S-P 3D E-BCS, 2 S-P 3D E-BCS with 3D videoscope-assisted partial breast reconstruction, which was 1 case of latissimus dorsi flap and 1 case of omental flap). The mean operative time was 245 ± 110 min in S-P 3D E-NSM and 260 ± 142 min in S-P 3D E-BCS. The mean intraoperative blood loss was 49.7 ± 46.9 ml in S-P 3D E-NSM and 32.8 ± 17.5 ml in S-P 3D E-BCS. Subnipple biopsy showed positive malignancy in 3 (2.6%) S-P 3D E-NSM patients. None of the S-P 3D E-BCS patients found margin involvement; however, 3 (2.6%) reported margin involvement in S-P 3D E-NSM patients. Thirty-two complications were found (24.6%): 7 (5.3%) transient nipple-areolar complex (NAC) ischemia, 7 (5.3%) partial NAC necrosis, 1 (0.7%) total NAC necrosis, and 1 (0.7%) implant loss. During the mean follow-up time of 34 months, there were 2 (1.5%) patients with locoregional recurrence, 9 (6.9%) distant metastasis, and 2 (1.5%) mortality. 78.6% (77/98) of patients answering the cosmetic-evaluated questionnaire reported good and excellent overall satisfaction.

CONCLUSIONS

S-P 3D EABS is a novel surgical innovation, which is able to perform safely in either malignant or benign breast conditions and offer promising cosmetic results.

Endoscopy-assisted breast conservation surgery (E-BCS) vs conventional breast conservation surgery (C-BCS) technique for the management of early breast cancer: A systematic review and meta-analysis

BACKGROUND

Endoscopy-assisted breast conserving surgery (E-BCS) was developed over 10 years ago as a method for breast cancer treatment with the potential advantage of less noticeable scarring. However, the evidence supporting its superiority over conventional breast conserving surgery (C-BCS) remains unclear.

OBJECTIVE

This study aims to compare the outcomes of E-BCS and C-BCS for the treatment of early breast cancer.

METHODS

A comprehensive search for relevant articles was performed using specific keywords in Medline, Scopus, ClinicalTrials.gov, and Cochrane Library PubMed up to October 17th, 2022. Clinical trials that compared E-BCS with C-BCS in early breast cancer patients were collected.

RESULTS

Our analysis of nine studies revealed that E-BCS was associated with shorter incision length [Mean Difference (MD) -6.50 cm (95% CI -10.75, -2.26), p = 0.003, I2 = 99%] and higher cosmetic score [MD 2.69 (95% CI 1.46, 3.93), p < 0.0001, I2 = 93%] compared with C-BCS. However, E-BCS had a longer operation time [MD 35.95 min (95% CI 19.12, 52.78), p < 0.0001, I2 = 93%] and greater drainage volume [MD 62.91 mL (95% CI 2.55, 123.27), p = 0.04, I2 = 79%]. There was no significant difference in blood loss volume (p = 0.06), drainage duration (p = 0.28), postoperative complications (p = 0.69), or local recurrence (p = 0.59) between the two groups.

CONCLUSION

Our study suggests that E-BCS offers a shorter incision length and better cosmetic outcome compared with C-BCS in the treatment of early breast cancer. However, E-BCS requires a longer operation time and has greater drainage volume. Further studies are needed to confirm these findings.

Comparing outcomes of single-port insufflation endoscopic breast-conserving surgery and conventional open approach for breast cancer

Background

In the surgical treatment of breast cancer, the goal of surgeons is to continually create and improve minimally invasive surgical techniques to increase patients’ quality of life. Currently, routine breast-conserving surgery is often performed using two obvious incisions. Here, we compare the clinical efficacy and aesthetic outcomes of a novel technique using one incision, called ‘single-port insufflation endoscopic breast-conserving surgery’ (SIE-BCS), vs. conventional breast-conserving surgery (C-BCS) in patients with early-stage breast cancer.

Methods

A total of 180 patients with stage I or stage II breast cancer participated in this study, of whom 63 underwent SIE-BCS and 117 underwent C-BCS. Logistic regression analysis was conducted to assess the risk of local recurrence and metastasis. Aesthetic outcomes were evaluated using the BREAST-Q scale.

Results

The mean operation time was significantly longer for SIE-BCS (194.9 ± 71.5 min) than for C-BCS (140.3 ± 56.9 min), but the mean incision length was significantly shorter for SIE-BCS than for C-BCS (3.4 ± 1.2 cm vs. 8.6 ± 2.3 cm). While both surgeries yielded similar BREAST-Q ratings for satisfaction with breasts and sexual well-being, SIE-BCS was associated with significantly better ratings for physical well-being (chest area) and psychological well-being. Additionally, SIE-BCS was associated with decreased rates of adverse effects of radiation. The preliminary analysis showed that SIE-BCS did not increase the risk of local recurrence or metastasis.

Conclusion

The novel single-port insufflation endoscopic assisted BCS technique is feasible, safe, and improves patients’ postoperative comfort and psychological well-being, as compared to the conventional technique.

Safety and Feasibility of Minimally Invasive (Laparoscopic/Robotic-Assisted) Nipple-Sparing Mastectomy Combined with Prosthesis Breast Reconstruction in Breast Cancer: A Single-Center Retrospective Study

BACKGROUND

Minimally invasive (robotic or laparoscopic-assisted) nipple-sparing mastectomy combined with prosthesis breast reconstruction (NSM-PBR) is associated with smaller scars and greater patient satisfaction. However, the oncological safety of minimally invasive NSM-PBR remains controversial.

PATIENTS AND METHODS

This was a retrospective study of patients with breast cancer who underwent breast reconstruction between 1 January 2006 and 20 February 2021. Demographic and clinicopathological characteristics, operation information, postoperative complications, and survival outcomes were analyzed.

RESULTS

In all, 292 patients underwent minimally invasive NSM-PBR and 205 underwent open NSM-PBR for breast cancer. In the minimally invasive NSM-PBR group, 268 (91.8%) patients underwent laparoscopy and 24 (8.2%) patients underwent robot-assisted NSM-PBR. Mean operation time in the minimally invasive NSM-PBR group was significantly longer than that in the open NSM-PBR group (P = 0.023). Mean intraoperative blood loss was significantly less in the minimally invasive NSM-PBR group (P < 0.05). There was no significant between-group difference in total complications. Similarly, there were no significant between-group differences in overall survival, recurrence-free survival, and local recurrence rate (P = 0.450, P = 0.613, and P = 0.679, respectively).

CONCLUSIONS

The complication, recurrence, and mortality rates in minimally invasive NSM-PBR group were comparable to those in open NSM-PBR group. Our preliminary results are encouraging and suggest that minimally invasive NSM-PBR affords good cosmetic results and its oncological safety is comparable to that of open surgery.

Current Trends in and Indications for Endoscopy-Assisted Breast Surgery for Breast Cancer

Endoscopic oncoplastic breast surgery represents a minimal invasive approach with the aim of both safe excision of cancer and preserving the breast shape. It has less noticeable scar, excellent cosmetic outcomes, high patient satisfaction rate. Recently, relative long-term follow-up results have been reported to be very safe (Soybir and Fukuma, J Breast Health 11:52-58, 2015; Fan et al., Chin Med J 122:2945-2950, 2009; Jiang, Zhonghua Wai Ke Za Zhi 45:439-441, 2007).Operative techniques for both endoscopic breast-conserving surgery and endoscopic nipple/areola/skin-sparing mastectomy have been described in detail. Two different working planes in which one of them is subcutaneous and the other one is sub-mammary planes are being used during the surgery. Surgical technique needs some instruments such as endoscopic retractor, light guided specific mammary retractor, wound protector, and energy device such as bipolar scissor, Harmonic Scalpel, LigaSure, Thunderbeat. Endoscopic breast retractors provide magnified visualization and extensive posterior dissection facility. Tunneling method and the hydro-dissection simplify the technique in the subcutaneous field (Soybir and Fukuma, J Breast Health 11:52-58, 2015; Fan et al., Chin Med J 122:2945-2950, 2009). Oncoplastic reconstruction techniques are also applied after the tumor resection by endoscopic method. The complication rate of endoscopic breast surgery is similar with the rate of open breast surgery. Quite successful local recurrence, distant metastasis, and overall survival rates have been declared. However, it looks reasonable to wait for the results with longer follow-up before having a judgement about oncologic efficiency and safety of the endoscopic breast cancer surgery (Tamaki et al., Nihon Geka Gakkai Zasshi 103(11):835-838, 2002; Leff et al., Breast Cancer Res Treat 125(3):607-625, 2011; Fukuma, Nihon Geka Gakkai Zasshi 116(5):316-319, 2015).Recently some surgeons reported about robotic nipple sparing mastectomy and immediate breast reconstruction with Gel implant procedure. Nevertheless, experience with application of a robotic surgery platform in the management of breast cancer is limited. From the preliminary experiences, R-NSM and IBR with Gel implant is a safe procedure, with good cosmetic results, and could be a promising new technique for breast cancer patients indicated for mastectomy (Lai et al., Ann Surg Oncol 26(1):42-52, 2019).

Evolution of minimal access breast surgery

Surgical management of breast cancer has been evolving rapidly over the past 20-30 years. Prior to this, conventional surgical options were limited to either a mastectomy or breast conserving surgery. The demand for better aesthetic outcomes had driven the development of oncoplastic breast conserving surgery where glandular rearrangement or replacement coupled with thoughtfully placed incisions became the standard approach to breast conserving surgery. As breast surgeons and patients demand for improved aesthetic outcomes, minimally invasive or minimal access breast surgery has gained much attention over the past two decades, from endoscopic assisted to robotic-assisted breast surgery more recently. However, there has been a lack of review articles discussing this relatively recent but under-reported subset of surgical techniques in the management of breast cancer. This article aims to discuss the concept and development of minimal access breast surgery along with a review of current literature on its indications, techniques and outcome measures as well as a discussion on the strengths, limitations as well as future directions. Continued improvement in techniques and advancement of technology will definitely increase the likelihood of minimal access techniques being placed as the standard of care in the management of breast cancer.

Development of video-assisted breast cancer surgery: Initial experience with a novel method for creating working space without prior liposuction

Endoscopic techniques are promising in breast surgery. In order to create working space, liposuction is widely used in video-assisted breast surgery (VABS). However, the use of liposuction is likely associated with side effects that may partly limit the application of VABS. Therefore, a new technique of endoscopic axillary lymphadenectomy without prior liposuction was developed by our group. A total of 106 female patients underwent VABS, with special adaptation of the video-assisted surgical procedures previously described. Differing from other endoscopic surgery techniques, our adaptations of VABS included the selection of the working instruments, trocar placement, creation of working space, order of axillary lymph node dissection and method of mastectomy. The operative time was 50–180 min (mean, 85.5 min). The intraoperative blood loss ranged from 20 to 100 ml (mean, 48 ml). The mean lymph node number harvested was 11.5 (range, 6–31). No serious intra- or postoperative complications were recorded. There was no axillary tumor relapse, trocar site tumor implantation or upper limb edema. Without prior liposuction, our new technique of VABS reduced the blood loss volume, endoscopic surgery time, total volume of drainage fluid and, most importantly, the risk of port-site metastases. This new technique appears to have great clinical potential and good prospects for future endoscopic breast surgery development.

Damage effect of high-intensity focused ultrasound on breast cancer tissues and their vascularities

BACKGROUND

High-intensity focused ultrasound (HIFU) is a noninvasive therapy that makes entire coagulative necrosis of a tumor in deep tissue through the intact skin. There are many reports about the HIFU's efficacy in the treatment of patients with breast cancer, but randomized clinical trials are rare which emphasize on the systematic assessment of histological changes in the ablated tumor vascularities, while clinical trials utilizing bevacizumab and other anti-angiogenic drugs in breast cancer have not demonstrated overall survival benefit. The purpose of this study is to evaluate the damage effect of HIFU on breast cancer tissues and their vascularities.

METHODS

Randomized clinical trials and the modality of treat-and-resect protocols were adopted. The treated outcome of all patients was followed up in this study. The target lesions of 25 breast cancer patients treated by HIFU were observed after autopsy. One slide was used for hematoxylin-eosin (HE) staining, one slide was used for elastic fiber staining by Victoria blue and Ponceau's histochemical staining, and one slide was used for vascular endothelial cell immunohistochemical staining with biotinylated-ulex europaeus agglutinin I (UEAI); all three slides were observed under an optical microscopic. One additional slide was systematically observed by electron microscopy.

RESULTS

The average follow-up time was 12 months; no local recurrence or a distant metastatic lesion was detected among treated patients. Histological examination of the HE slides indicated that HIFU caused coagulative necrosis in the tumor tissues and their vascularities: all feeder vessels less than 2 mm in diameter in the insonated tumor were occluded, the vascular elasticity provided by fibrin was lost, the cells were disordered and delaminated, and UEAI staining of the target lesions was negative. Immediately after HIFU irradiation, the tumor capillary ultrastructure was destroyed, the capillary endothelium was disintegrated, the peritubular cells were cavitated, and the plasma membrane was incomplete.

CONCLUSIONS

HIFU ablation can destroy all proliferating tumor cells and their growing vascularities simultaneously; this may break interdependent vicious cycle of tumor angiogenesis and neoplastic cell growth that results in infinite proliferation. While it cannot cause tumor resistance to HIFU ablation, it may be a new anti-angiogenic strategy that needs further clinical observation and exploration. Furthermore, the treatment indications of HIFU ablation were reviewed and discussed in this manuscript.

Endoscopy Assisted Oncoplastic Breast Surgery (EAOBS)

Endoscopic oncoplastic breast surgery represents a minimal invasive approach with the aim of both removing cancer safely and also restoring the breast image. It has less noticeable scar, excellent cosmetic outcomes, high patient satisfaction rate and recently reported relatively long term safety. Operative techniques for both endoscopic breast conserving surgery and endoscopic nipple/areola/skin sparing mastectomy have been described in detail. Two different working planes in which one of them is subcutaneous and the other one is sub-mammary planes are being used during the surgery. Surgical techniqe needs some instruments such as endoscopic retractor, light guided specific mammary retractor, wound protector and bipolar scissor. Endoscopic breast retractors provide magnified visualization and extensive posterior dissection facility. Tunneling method and hydrodissection simplify the technique in the subcutaneous field. Oncoplastic reconstruction techniques are also applied after the tumor resection by endoscopic method. Complication rates of endoscopic breast surgery are similar to open breast surgery rates. Quite succesful local recurrence, distant metastasis and overall survival rates have been declared. However it looks reasonable to wait for the results with longer follow-up before having a judgement about oncologic efficiency and safety of the endoscopic breast cancer surgery.