Oncoplastic breast surgery: current strategies

Comparison of the Preoperative MRI Evaluation of Glandular Tissue in Subcutaneous Mastectomy and its Influence on the Implant Volume

Background/Aim

This study examined the influence of preoperative MRI on the choice of implant volume in patients undergoing subcutaneous mastectomy with immediate breast reconstruction. It was postulated that preoperative MRI scans can adequately estimate glandular tissue, which in turn correlates with implant size.

Patients and Methods

Preoperative and postoperative MRI scans were used in oncological and prophylactical subcutaneous mastectomy scenarios in 67 cases at the Department of Gynaecology, Breast Cancer Center, University of Cologne, Germany. The preoperative MRI was used to estimate the resected tissue and the postoperative MRI was used to scan for residual glandular tissue. In addition, a correlation found by Malter et al. in 2021 was evaluated with the available data.

Results

Preoperative MRIs result in an adequate estimation of resected tissue. This in turn correlates with implant volume. The correlation by Malter et al. also holds when estimating implant volume. The likelihood of residual gland was low if the preoperatively estimate volume was removed.

Conclusion

Our results indicate that the use of preoperative and postoperative MRI scans for subcutaneous mastectomies is advantageous. We suggest a routine estimation of glandular tissue, especially for small breasts.

Immediate or delayed oncoplastic surgery after breast conserving surgery at the Netherlands Cancer Institute: a cohort study of 251 cases

PURPOSE

Oncoplastic surgery (OPS) after breast conserving surgery is preferably performed during the same operation. Offering delayed OPS instead of mastectomy to patients with a high risk of tumor-positive margins allows breast conservation with the option of margin re-excision during OPS, without having to dismantle the reconstruction. We aimed to evaluate surgical outcomes after immediate and delayed OPS.

METHODS

We included early-stage breast cancer patients who underwent OPS at the Netherlands Cancer Institute between 2016 and 2019. Patients were selected for delayed OPS after multidisciplinary consultation if the risk of tumor-positive margins with immediate OPS was considered significant (> 30%). Groups were compared on baseline characteristics and short-term surgical outcomes.

RESULTS

Of 242 patients with 251 OPS, 130 (52%) OPS had neoadjuvant chemotherapy. Immediate OPS was performed in 176 (70%) cases and delayed OPS in 76 (30%). Selection for delayed OPS was associated with tumor size (OR 1.03, 95% CI 1.01-1.04), ILC (OR 2.61, 95% CI 1.10-6.20), DCIS (OR 3.45, 95% CI 1.42-8.34) and bra size (OR 0.76, 95% CI 0.62-0.94). Delayed and immediate OPS differed in tissue weight (54 vs. 67 g, p = 0.034), tissue replacement (51% vs. 26%, p < .001) and tumor-positive margins (66% vs. 18%, p < .001). Re-excision was performed in 48 (63%) delayed OPS and in 11 (6%) immediate OPS. Groups did not differ in complications (21% vs. 18%, p = 0.333). Breast conservation after immediate and delayed OPS was 98% and 93%, respectively.

CONCLUSION

Performing delayed OPS in selected cases facilitated simultaneous margin re-excision without increasing complications, and resulted in an excellent breast conservation rate.

Therapeutic mammoplasty: a "wise" oncoplastic choice-lessons from the largest single-center cohort from Asia

Introduction

The majority of breast cancer patients from India usually present with advanced disease, limiting the scope of breast conservation surgery. Therapeutic mammoplasty (TM), an oncoplastic technique that permits larger excisions, is quite promising in such a scenario and well suited to breast cancer in medium-to-large-sized breasts with ptosis and in some cases of large or multifocal/multicentric tumors. Here, we describe our TM cohort of 205 (194 malignant and 11 benign) patients from 2012 to 2019 treated at a single surgeon center in India, the largest Asian dataset for TM.

Methods

All patients underwent treatment after careful discussions by a multidisciplinary tumor board and patient counseling. We report the clinicopathological profiles and surgical, oncological, cosmetic, and patient-related outcomes with different TM procedures.

Results

The median age of breast cancer patients was 49 years; that of benign disease patients was 41 years. The breast cancer cohort underwent simple (n = 84), complex (n = 71), or extreme (n = 44) TM surgeries. All resection margins were analyzed through intra-operative frozen-section assessment with stringent rad-path analysis protocols. The margin positivity rate was found to be 1.4%. A majority of the cohort was observed to have pT1-pT2 tumors, and the median resection volume was 180 cc. Low post-operative complication rates and good-to-excellent cosmetic scores were observed. The median follow-up was 39 months. We observed 2.07% local and 5.7% distal recurrences, and disease-specific mortality was 3.1%. At median follow-up, the overall survival was observed to be 95.9%, and disease-free survival was found to be 92.2%. The patient-reported outcome measures (PROMs) showed good-to-excellent scores for all types of TMs across BREAST-Q domains.

Conclusion

We conclude that in India, a country where women present with large and locally advanced tumors, TM safely expands the indications for breast conservation surgery. Our results show oncological and cosmetic outcomes at acceptable levels. Most importantly, PROM scores suggest improved overall wellbeing and better satisfaction with the quality of life. For patients with macromastia, this technique not only focuses on cancer but also improves self-image and reduces associated physical discomfort often overlooked by women in the Indian setting. The popularization of this procedure will enable Indian patients with breast cancer to receive the benefits of breast conservation.

Breast Tissue Restoration after the Partial Mastectomy Using Polycaprolactone Scaffold

As breast conserving surgery increases in the surgical treatment of breast cancer, partial mastectomy is also increasing. Polycaprolactone (PCL) is a polymer that is used as an artifact in various parts of the human body based on the biocompatibility and mechanical properties of PCL. Here, we hypothesized that a PCL scaffold can be utilized for the restoration of breast tissue after a partial mastectomy. To demonstrate the hypothesis, a PCL scaffold was fabricated by 3D printing and three types of spherical PCL scaffold including PCL scaffold, PCL scaffold with collagen, and the PCL scaffold with breast tissue fragment were implanted in the rat breast defect model. After 6 months of implantation, the restoration of breast tissue was observed in the PCL scaffold and the expression of collagen in the PCL scaffold with collagen was seen. The expression of TNF-α was significantly increased in the PCL scaffold, but the expression of IL-6 showed no significant difference in all groups. Through this, it showed the possibility of using it as a method to conveniently repair tissue defects after partial mastectomy of the human body.

An Innovative Breast-Conserving Oncoplastic Technique for Treating Small to Medium Volume Breasts With a Tumor in the Lower Quadrant: The Folding Flap Technique

Background

Here, we describe an innovative oncoplastic technique for small to medium volume breasts with a tumor in the lower quadrant and this technique could provide sufficient tissue to avoid visible defects after tumor removal and help reshape the natural shape of the breast.

Methods

A detailed procedure for the folding flap technique is described step by step. Then, the results of a retrospective analysis of patients treated using this technique, including complications and disease recurrence rate, between January 2017 and November 2021 are reported. Aesthetic outcomes were evaluated on a 5-point scale proposed by the Paris Breast Center.

Results

A total of 52 patients underwent surgery with the folding flap technique, The average operation time was 98.4 min (range, 75–120 min), and the mean bleeding volume was 56.5 mL (range, 20–100 mL). A margin-positive result was confirmed in 1 patient who underwent re-excision. Short-term postoperative complications were observed in 7 patients, including 4 with fat liquefaction, 2 with seroma, and 1 with skin redness and swelling. No flap necrosis was observed. The median follow-up time was 28.6 months (range, 9–58 months), and 2 patients experienced local recurrence. The mean aesthetic score was 4.7 points, with 36 patients scoring 5 points and 26 patients scoring 4 points, respectively.

Conclusions

The folding flap technique, as an innovative and favorable oncoplastic technique for treating small- to medium-volume breasts with a tumor in the lower quadrant, could retain sufficient tissue to fill the residual cavity after the operation while improving the aesthetic outcome of the breast.

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.

Evaluation of the Surgical Outcomes of Breast Oncoplastic Techniques Carried Out by a General Surgical Oncologist

Background 

With recent advances in different breast cancer treatment modalities, breast conservation surgery (BCS) has gained popularity and has become the mainstay for the treatment of early breast cancer. The model of dedicated breast surgeons working in breast units is standard in some but not all countries. We have aimed to define surgical outcomes of oncoplastic breast surgery carried out by one general surgical oncologist.

Patients and methods

We have conducted a prospective non-randomised case series analysis to assess the oncologic and aesthetic outcome of tissue displacement oncoplastic breast techniques in managing unifocal early-stage breast cancer from January 2019 to January 2020.

One surgical oncologist with 23 years of surgical oncology experience carried out all operations.

Results

We have included 50 female patients treated with variant oncoplastic volume displacement techniques. We have used the round block technique in 20%, the batwing technique in 18%, lateral mammoplasty in 20%, and medial mammoplasty in 2%. We have also carried out wise pattern therapeutic mammoplasty with inferior pedicle in 20% (10 patients), and vertical mammoplasty with superior pedicle in 20% (10 patients).

While 8% of our patients had Clavien-Dindo system grade I Immediate complications, including the surgical site infection and postoperative seroma and haematoma, 2% of patients had grade II complications in the form of partial areola and nipple complex necrosis leading to delayed wound healing requiring secondary suturing. No delayed complications or mortalities were recorded.

Eight per cent of patients required re-excision to clear margins, 74% had excellent results, 24% had good results, and 2% had fair results. In addition, 64% were very satisfied with their results, 32% were satisfied, while 4% were not satisfied with aesthetic results.

Conclusion

Based on our limited number of patients, we have found that tissue displacement oncoplastic techniques carried out by a general surgical oncologist are safe and reliable in providing satisfactory oncological outcomes with a low risk of delaying adjuvant therapy and acceptable aesthetic outcomes.

Impact of Oncoplastic Breast Surgery on Rate of Complications, Time to Adjuvant Treatment, and Risk of Recurrence

Background

The aim of this study was to compare the risk of complications and recurrence between oncoplastic and conventional breast surgery.

Methods

This is a retrospective analysis of a consecutive series of 436 patients with stage I-III breast cancer who underwent surgery at the University Hospital of Basel between 2011 and 2018.

Results

The nipple/skin-sparing mastectomy (NSM/SSM) group showed significantly more delayed wound healing (32.7 vs. 5.8%, p < 0.001) and skin necrosis (13.9 vs. 1.9%, p = 0.020) compared to conventional mastectomy (CM), which corresponded to significantly higher odds of short-term complications (OR 2.34, 95% CI 1.02-5.35, p = 0.044). The incidence rate of long-term morbidity in oncoplastic breast-conserving surgery (OBCS) was significantly higher compared to conventional breast-conserving surgery (CBCS; 25.5 vs. 11.3 per 100 patient years [PY], p < 0.001), in particular concerning chronic pain (13.3 vs. 6.6, p = 0.011) and lymphedema (4.1 vs. 0.4, p = 0.003). Seroma as a long-term morbidity occurred more often in the CM group compared to the NSM/SSM group (5.8 vs. 0.5 per 100 PY, p = 0.004). Patients received adjuvant treatment earlier after CM compared to NSM/SSM (HR 1.83, 95% CI 1.05-3.19, p = 0.034). There were no significant differences in the incidence of positive margins nor in the odds of recurrence after OBCS versus CBCS and after NSM/SSM versus CM.

Conclusions

Even though the present study confirmed expected differences in complications and morbidity, it suggested that oncoplastic surgery is oncologically safe. Patients undergoing NSM/SSM should be followed closely to allow early detection and treatment of frequently associated complications and ensure timely start of adjuvant therapy.

Evolving Trends in Surgical Management of Breast Cancer: An Analysis of 30 Years of Practice Changing Papers

The management of breast cancer has evolved into a multidisciplinary evidence-based surgical speciality, with emphasis on conservative surgery. A number of landmark trials have established lumpectomy followed by radiation as the standard of care for many patients. The aim of this study is to construct a narrative review of recent developments in the surgical management of breast cancer and how such developments have impacted surgical practice. A comprehensive literature search of Pubmed was conducted. The latest search was performed on October 31^st, 2020. Search terms “breast cancer” were used in combinations with specific key words and Boolean operators relating to surgical management. The reference lists of retrieved articles were comprehensively screened for additional eligible publications. Articles were selected and reviewed based on relevance. We selected publications in the past 10 years but did not exclude commonly referenced and highly regarded previous publications. Review articles and book chapters were also cited to provide reference on details not discussed in the academic literature. This article reviews the current evidence in surgical management of early-stage breast cancer, discusses recent trends in surgical practice for therapeutic and prophylactic procedures and provides commentary on implications and factors associated with these trends.

Psychological and Aesthetic Outcomes in Breast Cancer Patients

Background:

Patients who undergo breast cancer treatment require psychosocial and aesthetic rehabilitation. Advantages of breast reconstruction in-patient rehabilitation are well known. Oncoplastic organ-preserving surgery offers aesthetically better results, yet is often considered less safe than more radical procedures. We compared the aesthetic and psychological outcomes in patients undergoing breast reconstruction and oncoplastic breast cancer treatment.

Methods:

In total, 1130 patients who received either breast reconstruction or oncoplastic breast cancer surgery were included in the study. Patients were classified into two groups. Group 1 included 510 patients who received breast reconstruction surgery. Group 2 included 620 patients who received oncoplastic surgery. The following aspects were compared between the two groups: demographics, tumor progression, and immunohistochemical aspects, complications, hospitalization stay, and psychological and aesthetic outcomes.

Results:

Patients in the oncoplastic group showed statistically significant higher psychosocial and aesthetic outcomes, as well as lower incidence of complications, revision rate, disease progression, and recurrence. The majority of oncoplastic patients were treated in early stages of breast cancer.

Conclusion:

Offering superior treatment results, oncoplastic organ-preserving surgery should be favored in patients with earlier stages of cancer progression.

A Strategic Approach to Nipple-sparing Mastectomy Reconstruction with a Wide-based Inframammary Fold Flap

The single biggest advancement in the aesthetic outcome of breast reconstruction following mastectomy has been the contribution of nipple-sparing mastectomy. By preserving the nipple–areolar complex, patients do not experience the same sense of loss that is observed in the setting of skin-sparing mastectomy. Despite this significant contribution, the challenge remains as to how surgeons can extend this option to larger-breasted patients or patients with significant breast ptosis. Several strategies have been described, including reduction mammoplasty before mastectomy, bipedicled simultaneous mastopexy with mastectomy, and free nipple grafting. The authors have developed a novel approach to nipple-sparing mastectomy that preserves the nipple–areolar complex on a wide-based inframammary fold (IMF) flap and uses indocyanine green perfusion imaging to successfully and reliably perform nipple-sparing mastectomy with immediate reconstruction in larger-breasted ptotic patients. Six patients underwent bilateral nipple-sparing mastectomies and immediate breast reconstruction with a wide-based IMF flap. All patients underwent immediate reconstruction with prepectoral placement of tissue expanders to treat either breast cancer or ductal carcinoma in situ (DCIS), and all patients successfully completed exchange of expander to implant. There were no complications with infection, seroma, mastectomy flap, or nipple necrosis. Aesthetic results were in line with other nipple-sparing techniques. The wide-based IMF flap with nipple preservation is a viable option for larger-breasted ptotic patients who might not otherwise be candidates for nipple-sparing mastectomy. The approach described is a combination of surgical technique and indocyanine green perfusion technology to deliver reproducible results, with an emphasis on surgical safety and avoidance of complications.

National Consensus on Oncoplastic Breast Conserving Surgery in Turkey: Position Paper for the Standardization of Surgical Practice

Objectives

The algorithms that define most of the application of oncoplastic breast conserving surgery (OBCS) in breast cancer patients are not clearly defined. Therefore, a consensus survey was conducted between the leading and experienced breast surgeons and oncoplastic breast surgeons in Turkey on the controversial areas of oncoplastic breast surgery.

Material and Methods

This consensus survey was carried out on-line through the Consensus software program (www.consensuss.com) under the roof of Turkish Federation of National Societies for Breast Diseases (TFNSBD). After finalizing each proposition, web-based remote access consensus process was performed on the Likert scale using Delphi method with the Consensus (www.consensuss.com) software program. Through the related software, an invitation was sent to 111 people who had at least 5 years of general surgery expertise in Turkey, and who devoted more than 50% of their daily clinical practice to the treatment and surgery of breast diseases.

Results

Sixty-two out of 111 people accepted to participate in the panel and made an on-line evaluation. According to the consensus results; Lumpectomy area should be done by placing the clips on at least four walls of the cavity, if the margin of the tumor is clear in central tumors, the distance between the tumor and the nipple is not significantly important, oncoplastic techniques may be used in patients with locally advanced breast cancer after neoadjuvant chemotherapy, in patients who have macromastia with ductal carcinoma in situ or breast cancer, OBCS techniques can be performed, and OBCS should be evaluated in terms of breast aesthetics. After OBCS, re-excision can be performed at a re-do setting in cases with involved surgical margins.

Conclusion

Our consensus results may provide a basis for the development of some standards in OBCS.

Structured-light surface scanning system to evaluate breast morphology in standing and supine positions

Breast shapes are affected by gravitational loads and deformities. Measurements obtained in the standing position may not correlate well with measurements in the supine position, which is more representative of patient position during breast surgery. A dual color 3D surface imaging system capable of scanning patients in both supine and standing positions was developed to evaluate the effect of changes in body posture on breast morphology. The system was evaluated with  breast phantoms to assess accuracy, then tested on ten subjects in three body postures to assess its effectiveness as a clinical tool. The accuracy of the system was within 0.4 mm on average across the model. For the human study, there was no effect of body posture on breast volumes (p value > 0.05), but we observed an effect of completeness of breast scans on body posture (p value  < 0.05). Post-hoc tests showed that the supine position and the standing position with hands at the waist differed significantly (p value  < 0.05). This study shows that the system can quantitatively evaluate the effect of subject postures, and thereby has the potential to be used to investigate peri-operative changes in breast morphology.

Batwing mammoplasty: a safe oncoplastic technique for breast conservation in breast cancer patients with gigantomastia

BACKGROUND

Surgical management of breast cancer with gigantomastia can be challenging when planning breast conservation, as major breast reduction is required. Complex oncoplastic procedures can carry an additional surgical risk in this situation. We suggest batwing mammoplasty as a simple and safe oncoplastic procedure for those patients.

MATERIALS AND METHODS

Fourteen patients with gigantomastia diagnosed with breast cancer were included in this prospective cohort study. All underwent batwing mammoplasty and contralateral symmetrisation procedure between May 2016 and June 2018. Patient satisfaction assessed by the Breast-Q questionnaire.

RESULTS

All patients had a body mass index above 30kg/m2 with a mean of 36.7kg/m2 (range 31.6-44.9kg/m2). The mean distance from midclavicular point to nipple was 42cm (range 38-50cm). The mean operative time was 83 minutes for procedures done by a single surgeon. Mean specimen weight was 1.2kg (ranging from 1.035-1.63kg). Postoperative complications occurred in 14.2% of patients. Nipple-areola complex viability was not compromised nor sensation impaired. The mean Breast-Q score for patient satisfaction with breasts was 68.6 (range 61-74). The mean score for physiological wellbeing was 77.3 (range 64-84) and the mean score for physical wellbeing was 35 (range 31-40).

CONCLUSION

Batwing mammoplasty is a safe and simple oncoplastic procedure in patients who have breast cancer with gigantomastia. It has short operative time and low complications rate. In our cohort of patients, there was no delay in the delivery of adjuvant treatment. The cosmetic outcome was favourable with a high patient satisfaction.

Increasing Role of Oncoplastic Surgery for Breast Cancer

PURPOSE OF REVIEW

The goals of surgery for breast cancer have remained the same over the years, to eliminate breast cancer from the breast with the least degree of deformity. With the current expectation of long-term survival after breast cancer treatment, more attention has turned to the cosmetic result of the surgical treatment. Whether lumpectomy or mastectomy, the need for aesthetic improvement was recognized by surgeons both in and outside the USA.

RECENT FINDINGS

Oncoplastic surgery combines the skills of the cancer surgeon with those of the plastic surgeon. Sometimes, this means a team approach with a breast surgeon and a plastic surgeon both performing their mutual skills for the patient. Other times, the properly trained breast surgeon may perform some of the plastic techniques at the time of cancer surgery. Breast surgeons are rapidly gaining the ability to improve the post-cancer treatment appearance. To simplify the classification of oncoplastic techniques, we have used lower level, upper level, and highest level. The assignment of techniques to levels is based on both the technique and the surgeon's training and experience. Much data has accumulated demonstrating the safety and efficacy of the "aesthetic cancer cure." We describe the development of oncoplastic surgery, the techniques available, matching the right candidate with the right technique, and some comments about the future. It is clear from both clinical benefit and patient satisfaction that oncoplastic breast cancer procedures are here to stay. Plastic surgeons will likely focus on the upper- and highest-level procedures while breast/general surgeons will learn lower-level procedures and some of upper-level procedures as needed by their locale. Opportunities to educate breast/general surgeons in these techniques will continue to increase over the next several years. Formal education in oncoplastic surgery during breast fellowships will be necessary to catch up with the rest of the surgical world outside the USA.

Comparison between ultrasound-guided aspiration performed using an intravenous cannula or a conventional needle in patients with peri-prosthetic seroma

BACKGROUND

Peri-prosthetic seroma after implant insertion for breast reconstruction is a common but difficult-to-manage complication. This study aimed to compare peri-prosthetic seroma duration and the number of aspirations associated with intravenous cannula with those associated with conventional needle.

METHODS

Seventy-one patients who underwent skin- or nipple-sparing mastectomy and implant insertion were treated for peri-prosthetic seroma. When peri-prosthetic seroma was detected, ultrasound-guided aspiration was performed either by using an intravenous cannula (n = 35) or a conventional needle (n = 36); however, the method adopted was randomly selected. We analyzed the participants' clinicopathologic factors after medical record review.

RESULTS

There were no significant intergroup differences in mean age (P = .052), mean body mass index (P = .601), total clinical tumor size (P = .107), pathologic tumor size (P = .269), specimen weight (P = .147), implant size (P = .313), or operation time (P = .595). However, the mean total peri-prosthetic seroma volume was significantly higher (105.80 vs 88.58, P = .015) but the number of aspirations was lower (4.48 vs 5.80, P = .043) in the intravenous cannula group than in the conventional needle group. Mean peri-prosthetic seroma volume per aspiration was nonsignificantly higher in the intravenous cannula group (26.92 vs 19.14, P = .291).

CONCLUSION

Ultrasound-guided aspiration performed using an intravenous cannula was comparable to the procedure performed using a conventional needle. Furthermore, the former method can be safer and effective alternative to manage peri-prosthetic seroma.

Outcomes of immediate oncoplastic surgery and adjuvant radiotherapy in breast cancer patients

BACKGROUND

Oncoplastic surgery techniques lead to a rearrangement of the breast tissue and impede target definition during adjuvant radiotherapy (RT). The aim of this study was to assess local control rates after immediate oncoplastic surgery and adjuvant RT.

METHODS

This study comprises 965 patients who underwent breast-conserving therapy and adjuvant RT between 01/2000 and 12/2005. 288 patients received immediate oncoplastic surgery (ONC) and 677 patients breast-conserving surgery only (NONC). All patients were treated with adjuvant external tangential-beam RT (total dose: 50/50.4 Gy; fraction dose 1.8/2.0 Gy). An additional boost dose of 10-16 Gy to the primary tumor bed was given in 900 cases (93.3%). Local control rates (LCR), Progression free survival (PFS) and overall survival (OS) were assessed retrospectively after a median follow-up period of 67 (Q25-Q75: 51-84) months.

RESULTS

No significant difference was found between ONC and NONC in regard to LCR (5-yr: ONC 96.8% vs. NONC 95.3%; p = 0.25). This held also true for PFS (5-yr: ONC 92.1% vs. NONC 89.3%; p = 0.09) and OS (5-yr: ONC 96.0% vs. NONC 94.8%; p = 0.53). On univariate analyses G2-3 (p = 0.04), a younger age (p = 0.01), T-stage (p < 0.01) lymph node involvement (p < 0.01) as well as triple negative tumors (p < 0.01) were identified as risk factors for local recurrence. In a propensity score stratified Cox-regression model no significant impact of oncoplastic surgery on local control rate was found (HR: 2.05, 95% CI [0.93; 4.51], p = 0.08).

CONCLUSION

Immediate oncoplastic surgery seems not to affect the effectiveness of adjuvant whole breast RT on local control rates in breast cancer patients.

A Novel Level I Oncoplastic Surgery Technique for Tumors Located in UIQ of the Breast Far from the Nipple: The "Cross" Technique

Breast surgery was revolutionized with the use of oncoplastic reshaping techniques minimizing breast deformities and esthetic complications. However, the application of the current oncoplastic techniques becomes challenging in some situations such as small-size breasts and when the tumors are located in special locations of the breast, for example, upper inner quadrant. In this article, an optimized oncoplastic technique named the "Cross" technique is introduced to overcome the abovementioned problems in the surgery of breast tumors located in the upper inner quadrant far from the center of the breast. Nineteen oncoplastic surgeries were performed by the same breast surgeon. The mean diameter and weight of the excised specimens were 20 mm and 74 g. The mean age of the patients was 51 years. Clear surgical margins were obtained in all patients. There was no marked deformity in the breast after surgery. The optimized technique produced promising results in our hands when applied to a selected group of patients. Moreover, the technique was found to reduce the need for revision surgery in ptotic breasts, as the alteration in the shape of the breast undergoing surgery is not significant enough to introduce asymmetry to the breasts.

Application value of laparoscopy in radical mastectomy and omental breast reconstruction

Application value of laparoscopy in radical mastectomy and omental breast reconstruction was explored. The medical records of 104 patients undergoing radical mastectomy and omental breast reconstruction from July 2015 to August 2017 in Inner Mongolia Xing'an League People's Hospital were retrospectively analyzed. Fifty-three patients undergoing laparoscopic surgery were the experimental group and 51 patients undergoing open surgery were the control group. The surgery conditions, upper limb function, postoperative complications, volume similarity between unilateral subcutaneous glands and autologous omentum, cosmetic excellent rate and treatment satisfaction were observed. The surgical duration of the patients in the experimental group was significantly longer than that in the control group, but the intraoperative blood loss was less and hospital stay was significantly shorter than that in the control group (P<0.05). The improvement of upper limb function in the experimental group was significantly better than that in the control group (P<0.05). The cosmetic excellent rate in the experimental group was significantly higher than that in the control group (P<0.001). The incidence of postoperative complications in the experimental group was significantly less than that in the control group (P<0.001). The satisfaction degree of patients in the experimental group was significantly higher than that in the control group (P<0.001). Filling the autologous omentum while excising the unilateral mammary gland is an equivalent replacement, which can make the appearance of the breast on the operation side similar to that on the healthy side, thus improving the excellent rate of breast beauty and patient satisfaction.

Long term effects of modern breast cancer surgery

Breast cancer surgery includes a wide array of surgical treatment options. Not only does it involve the oncologic excision of the breast cancer disease but it also involves the reconstruction of the breast. Surgical treatment options vary with regards to the size of the tumor relative to the size of the breast further complicated by the preferences of the patient and the ability of the available surgeon(s). The goal of this paper is to highlight major long-term effects, positive and negative, of modern breast cancer surgery.

The evolution of mastectomy surgical technique: from mutilation to medicine

Breast surgeries for cancer and tumors were first described approximately 3,000 years ago, and since that time the standard of management has changed dramatically. From Egyptian papyri to Hippocratic theory, from Galen's dissections to Halsted's radical mastectomy, and from sentinel lymph node mapping to the development of nipple-sparing mastectomies, this review starts at the beginning and highlights breakthroughs and innovation in technique and medicine that have fundamentally changed the way breast cancer is managed. The progression depicted in this review acts as a proxy to the management of other complex diseases. Breast cancer was initially managed with operative extirpation alone, but now requires a multidisciplinary team across various surgical, medical, psychological, and social specialties in order to produce the best outcomes for our patients.

Oncoplastic Reduction Pattern Technique Following Removal of Giant Fibroadenoma

Objective: Oncoplastic surgery was developed to allow for large tumor excision and immediate breast reconstruction with the goal of optimal breast shape and symmetry. Although initially used in women who underwent lumpectomy for breast malignancy, these techniques can be useful for cosmetic issues caused by benign breast disease. We describe a modification of an inferior pedicle with Wise-pattern reduction mammoplasty for oncoplastic reconstruction of a giant fibroadenoma. Methods: A 30-year-old woman with size 32 DD breasts was referred by the surgical oncologist with a biopsy-proven fibroadenoma of the right breast. Surgical oncology excised the mass, and immediate reconstruction was performed with an inferolateral pedicle Wise-pattern reduction technique. Results: Immediately postoperatively, the patient showed excellent symmetry. Follow-up postoperatively showed good wound healing, preserved symmetry, and a viable, sensate nipple. Conclusions: Oncoplastic breast reconstruction in a reduction pattern technique after giant fibroadenoma removal provides an excellent outcome, allowing for improved symmetry.

Minimalist breast conserving surgical approaches for inferiorly sited cancers

Contemporary data suggests that breast conservation treatment (BCT) may confer a survival advantage when compared to mastectomy. Hence, it would be logical to adopt strategies which increase eligibility of successful BCT without compromising oncologic principles or cosmetic outcome. With respect to achieving good aesthetics, inferiorly sited breast cancers pose a particular technical challenge. A vast array of techniques, collectively referred to as oncoplastic breast surgery (OBS) have been developed to minimise post treatment distortion. The purported advantages of these approaches are the acquisition of wider margins and reduced re-excision rates. However, to date, there is a lack of data demonstrating significant reduction in local recurrence and overall survival when compared with less extensive procedures. In this review, "minimalist" procedures are described where strict oncologic criteria of clear margins are fulfilled and acceptable cosmesis are simultaneously achieved. These techniques offer less tissue loss, less extensive parenchymal mobilisation and shorter operating times without compromising margin status and aesthetics. They involve the combination of innovative incision designs and certain parenchymal resection patterns. Incision designs include the boomerang, golf-tee, anchor and arrowhead incisions which have been previously described but not widely used. Parenchymal resection patterns follow the "sick lobe hypothesis". These techniques, termed "reductionist", or "minimalist" comprising approaches where breast conserving surgery is condensed to its irreducible elements, offer alternatives which align with contemporary objectives of surgery where optimal survival outcomes are achieved through individualised procedures resulting in reduced iatrogenic impact. This logically allows scope for de-escalation of surgical therapy for breast cancer.

The TeaM (Therapeutic Mammaplasty) study: Protocol for a prospective multi-centre cohort study to evaluate the practice and outcomes of therapeutic mammaplasty

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Multicentre prospective study involving breast and plastic surgical units across the UK.

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Will produce valuable data regarding the practice and outcomes of therapeutic mammaplasty.

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Will inform decision-making and lead to future definitive study.

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Will strengthen the collaborative network to facilitate the delivery of future projects.

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Will increase awareness of the techniques among trainees such that participation is educational.

Introduction

Wide local excision and adjuvant radiotherapy is the standard of care for early breast cancer. For large tumours, however, mastectomy is frequently recommended as conventional breast-conserving techniques often result in poor cosmetic outcomes. Therapeutic mammaplasty (TM) may extend the boundaries of breast-conserving surgery by combining breast reduction and mastopexy techniques with tumour excision, preserving a natural breast shape and avoiding the need for mastectomy. The prevalence of this operative option among surgeons in the UK and its success rate are unknown. The TeaM study is a multicentre prospective study that aims to investigate the practice and outcomes of TM.

Methods and analysis

Breast centres performing TM will be invited to participate through the research collaborative network and the professional associations. All patients undergoing TM between September 2016 and March 2017 will be included. Demographic, operative, oncological and complication data within 30-days of surgery will be collected. The primary outcome will be unplanned re-operation for complications. Secondary outcomes will include unplanned readmission, re-excision rates and time to adjuvant therapy. Prospective data on 500 patients from 50 centres are anticipated. Exploratory analyses will identify predictors for complications and inform the design of a definitive study.

Ethics and dissemination

Research ethics approval is not required for this study. This has been confirmed by the on-line Health Research Authority decision tool. This study will provide novel information regarding the practice and outcomes of TM in the UK. This will inform decision-making for patients and surgeons and inform future research. Dissemination of the study protocol will be via the Mammary Fold Academic and Research Collaborative, the Reconstructive Surgery Trials Network and the professional associations, the Association of Breast Surgery and British Association of Plastic, Reconstructive and Aesthetic Surgeons. Results will be presented at relevant surgical conferences and published in peer-reviewed journals.

Adipose regeneration and implications for breast reconstruction: update and the future

The evolution of breast reconstruction and management of breast cancer has evolved significantly since the earliest descriptions in the Edwin Smith Papyrus (3,000 BC). The development of surgical and scientific expertise has changed the way that women are managed, and plastic surgeons are now able to offer a wide range of reconstructive options to suit individual needs. Beyond the gold standard autologous flap based reconstructions, regenerative therapies promise the elimination of donor site morbidity whilst providing equivalent aesthetic and functional outcomes. Future research aims to address questions regarding ideal cell source, optimisation of scaffold composition and interaction of de novo adipose tissue in the microenvironment of breast cancer.

Observed outcomes on the use of oxidized and regenerated cellulose polymer for breast conserving surgery - A case series

BACKGROUND

Oxidized regenerated cellulose polymer (ORCP) may be used for reshaping and filling lack of volume in breast-conserving surgery (BCS). The study aimed to observe both the aesthetic and diagnostic outcomes in patients with different age, BMI, breast volume, and breast tissue composition over 36 months after BCS with ORCP.

PATIENTS AND METHODS

18 patients with early breast cancer and with proliferative benign lesions underwent BCS with ORCP that was layered in three-dimensional wafer, and placed into the Chassaignac space between the mammary gland and the fascia of pectoralis major with no fixation. After surgery, patients started a clinical and instrumental 36-month follow-up with mammography, ultrasonography, magnetic resonance imaging (MRI) and cytological examination with fine needle aspiration when seroma occurred.

RESULTS

Below the median age of 66 years old no complications were observed even in case both of overweight, and large breasts with low density. Over the median age seromas occurred with either small or large skin retraction, with the exception of 1 patient having quite dense breasts and low BMI, which had no complications. In elderly patients, 1 case with quite dense breasts and high BMI showed severe seroma and skin retraction, while 1 case with low BMI and less dense breasts highlighted milder complications.

CONCLUSION

During 36 months after BCS with ORCP, a significant correlation between positive diagnostic and aesthetic outcomes and low age, dense breasts, and low BMI of patient was observed. Despite of the few number of cases, either low BMI, or high breast density improved the aesthetic outcomes and reduced the entity of complications even in the elderly patients.