Assessment of cosmetic outcome of oncoplastic breast conservation surgery in women with early breast cancer: A prospective cohort study

The Oncological and Surgical Outcomes of Immediate Oncoplastic Breast Reconstruction With Contralateral Breast Adjustment

BACKGROUND

Oncoplastic surgery is an expanding approach for managing breast conservation because it offers improved cosmetic outcomes while maintaining oncological safety.

OBJECTIVES

This study aimed to assess the oncological and surgical outcomes of patients who underwent oncoplastic procedures at a single institution.

METHODS

The study population includes all consecutive breast cancer patients who underwent lumpectomy followed by immediate oncoplastic breast reconstruction with contralateral breast adjustment between 2010 and 2021. Following IRB approval, patient demographics, tumor characteristics, surgical details, complications, and follow-up were evaluated for this group. Quality of life (QOL) and patient-reported outcome measures were assessed through questionnaires.

RESULTS

Following multidisciplinary tumor board discussion, 77 patients (82 breasts) underwent oncoplastic surgery. Of these, 92.2% underwent breast MRI prior to surgery with mean mass enhancement of 2.35 cm (range, 0-8.5 cm) and non-mass enhancement of 5.77 cm (range, 0-14 cm), and 44% presented with multifocal disease. The final positive surgical margin rate was 2.4%, and all conserved breasts received adjuvant radiation therapy. The 5-year local recurrence rate for invasive tumors was 4.1%. QOL scores were generally high, with most patients reporting good to excellent cosmetic outcomes and high personal satisfaction with breast appearance and softness. Physicians reported breast symmetry in 89.5%.

CONCLUSIONS

The findings suggest that oncoplastic surgery with contralateral breast adjustment is safe, effective, and an excellent option for breast cancer patients wishing for breast conservation even for large or multifocal masses, with favorable oncologic and cosmetic outcomes. The QOL analysis indicates high patient satisfaction. These results support the use of oncoplastic surgery in the management of breast cancer.

LEVEL OF EVIDENCE: 4

Advanced Autologous Lower Dermal Sling Technique for Immediate Breast Reconstruction Surgery in Small and Non-ptotic Breasts

Breast reconstruction with an autologous lower dermal sling (ALDS) is an established one-stage procedure in patients with moderate to large ptotic breasts. However, this technique is difficult to perform in small and non/minimally ptotic breasts. We describe our experiences from a single institution about a novel Advanced Autologous Lower Dermal Sling (A-ALDS) technique for reconstruction in small breasts. We performed one-stage nipple/skin sparing mastectomies in 61 patients with immediate reconstruction either by Conventional Immediate Breast Reconstruction Surgery or A-ALDS technique. Mean age of study patients was 46.9 years. We observed significantly better cosmetic score and lower immediate complication rate vis-a-vis skin necrosis, implant loss with the A-ALDS technique (i.e., nil versus 3 in Conventional Immediate Breast Reconstruction Surgery (IBRS)). Forty patients completed 12-month follow-up. The PROMs - Patient Reported Outcome Measures (Breast-Q) revealed good to excellent scores for satisfaction with breast, cosmetic outcome, and psychosocial well-being in patients operated with both these techniques. However, sexual well-being was significantly better in the A-ALDS group. The A-ALDS is a novel, cost-effective, and safe technique for immediate one-stage implant-based reconstruction for small breasts. It provides a dermal barrier flap and hence, ensures less complications, excellent cosmetic results, and patient satisfaction.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-022-01524-8.

Outcome reporting in therapeutic mammaplasty: a systematic review

BACKGROUND

Therapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated the oncological safety of TM but reporting of critically important outcomes, such as quality of life, aesthetic and functional outcomes, are limited, piecemeal or inconsistent. This systematic review aimed to identify all outcomes reported in clinical studies of TM to facilitate development of a core outcome set.

METHODS

Medline, EMBASE, CINAHL and Web of Science were searched from inception to 5 August 2020. Included studies reported clinical outcomes following TM for adult women. Two authors screened articles independently for eligibility. Data were extracted regarding the outcome definition and classification type (for example, oncological, quality of life, etc.), time of outcome reporting and measurement tools.

RESULTS

Of 5709 de-duplicated records, 148 were included in the narrative synthesis. The majority of studies (n = 102, 68.9 per cent) reported measures of survival and/or recurrence; approximately three-quarters (n = 75, 73.5 per cent) had less than 5 years follow-up. Aesthetic outcome was reported in half of studies (n = 75, 50.7 per cent) using mainly subjective, non-validated measurement tools. The time point at which aesthetic assessment was conducted was highly variable, and only defined in 48 (64.0 per cent) studies and none included a preoperative baseline for comparison. Few studies reported quality of life (n = 30, 20.3 per cent), functional outcomes (n = 5, 3.4 per cent) or resource use (n = 28, 18.9 per cent).

CONCLUSION

Given the oncological equivalence of TM and mastectomy, treatment decisions are often driven by aesthetic and functional outcomes, which are infrequently and inconsistently reported with non-validated measurement tools.

Oncoplastic breast-conserving surgery for women with primary breast cancer

BACKGROUND

Oncoplastic breast-conserving surgery (O-BCS) involves removing the tumour in the breast and using plastic surgery techniques to reconstruct the breast. The adequacy of published evidence on the safety and efficacy of O-BCS for the treatment of breast cancer compared to other surgical options for breast cancer is still debatable. It is estimated that the local recurrence rate is similar to standard breast-conserving surgery (S-BCS) and also mastectomy, but the aesthetic and patient-reported outcomes may be improved with oncoplastic techniques.

OBJECTIVES

Our primary objective was to assess oncological control outcomes following O-BCS compared with other surgical options for women with breast cancer. Our secondary objective was to assess surgical complications, recall rates, need for further surgery to achieve adequate oncological resection, patient satisfaction through patient-reported outcomes, and cosmetic outcomes through objective measures or clinician-reported outcomes.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via OVID), Embase (via OVID), the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov on 7 August 2020. We did not apply any language restrictions.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and non-randomised comparative studies (cohort and case-control studies). Studies evaluated any O-BCS technique, including volume displacement techniques and partial breast volume replacement techniques compared to any other surgical treatment (partial resection or mastectomy) for the treatment of breast cancer.

DATA COLLECTION AND ANALYSIS

Four review authors performed data extraction and resolved disagreements. We used ROBINS-I to assess the risk of bias by outcome. We performed descriptive data analysis and meta-analysis and evaluated the quality of the evidence using GRADE criteria. The outcomes included local recurrence, breast cancer-specific disease-free survival, re-excision rates, complications, recall rates, and patient-reported outcome measures.

MAIN RESULTS

We included 78 non-randomised cohort studies evaluating 178,813 women. Overall, we assessed the risk of bias per outcome as being at serious risk of bias due to confounding; where studies adjusted for confounding, we deemed these at moderate risk. Comparison 1: oncoplastic breast-conserving surgery (O-BCS) versus standard-BCS (S-BCS) The evidence in the review found that O-BCS when compared to S-BCS, may make little or no difference to local recurrence; either when measured as local recurrence-free survival (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.61 to 1.34; 4 studies, 7600 participants; very low-certainty evidence) or local recurrence rate (HR 1.33, 95% CI 0.96 to 1.83; 4 studies, 2433 participants; low-certainty evidence), but the evidence is very uncertain due to most studies not controlling for confounding clinicopathological factors. O-BCS compared to S-BCS may make little to no difference to disease-free survival (HR 1.06, 95% CI 0.89 to 1.26; 7 studies, 5532 participants; low-certainty evidence). O-BCS may reduce the rate of re-excisions needed for oncological resection (risk ratio (RR) 0.76, 95% CI 0.69 to 0.85; 38 studies, 13,341 participants; very low-certainty evidence), but the evidence is very uncertain. O-BCS may increase the number of women who have at least one complication (RR 1.19, 95% CI 1.10 to 1.27; 20 studies, 118,005 participants; very low-certainty evidence) and increase the recall to biopsy rate (RR 2.39, 95% CI 1.67 to 3.42; 6 studies, 715 participants; low-certainty evidence). Meta-analysis was not possible when assessing patient-reported outcomes or cosmetic evaluation; in general, O-BCS reported a similar or more favourable result, however, the evidence is very uncertain due to risk of bias in the measurement methods. Comparison 2: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy alone O-BCS may increase local recurrence-free survival compared to mastectomy but the evidence is very uncertain (HR 0.55, 95% CI 0.34 to 0.91; 2 studies, 4713 participants; very low-certainty evidence). The evidence is very uncertain about the effect of O-BCS on disease-free survival as there were only data from one study. O-BCS may reduce complications compared to mastectomy, but the evidence is very uncertain due to high risk of bias mainly resulting from confounding (RR 0.75, 95% CI 0.67 to 0.83; 4 studies, 4839 participants; very low-certainty evidence). Data on patient-reported outcome measures came from single studies; it was not possible to meta-analyse the data. Comparison 3: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy with reconstruction O-BCS may make little or no difference to local recurrence-free survival (HR 1.37, 95% CI 0.72 to 2.62; 1 study, 3785 participants; very low-certainty evidence) or disease-free survival (HR 0.45, 95% CI 0.09 to 2.22; 1 study, 317 participants; very low-certainty evidence) when compared to mastectomy with reconstruction, but the evidence is very uncertain. O-BCS may reduce the complication rate compared to mastectomy with reconstruction (RR 0.49, 95% CI 0.45 to 0.54; 5 studies, 4973 participants; very low-certainty evidence) but the evidence is very uncertain due to high risk of bias from confounding and inconsistency of results. The evidence is very uncertain for patient-reported outcome measures and cosmetic evaluation.

AUTHORS' CONCLUSIONS

The evidence is very uncertain regarding oncological outcomes following O-BCS compared to S-BCS, though O-BCS has not been shown to be inferior. O-BCS may result in less need for a second re-excision surgery but may result in more complications and a greater recall rate than S-BCS. It seems that O-BCS may give better patient satisfaction and surgeon rating for the look of the breast, but the evidence for this is of poor quality, and due to lack of numerical data, it was not possible to pool the results of different studies. It seems O-BCS results in fewer complications compared with surgeries involving mastectomy. Based on this review, no certain conclusions can be made to help inform policymakers. The surgical decision for what operation to proceed with should be made jointly between clinician and patient after an appropriate discussion about the risks and benefits of O-BCS personalised to the patient, taking into account clinicopathological factors. This review highlighted the deficiency of well-conducted studies to evaluate efficacy, safety and patient-reported outcomes following O-BCS.

Factors influencing decisions on contralateral symmetrisation procedure among patients with breast cancer

INTRODUCTION

Oncoplastic breast conserving surgery (OBCS) can cause breast asymmetry. Although contralateral breast surgery to achieve symmetry was offered to these patients, the uptake of symmetrisation was variable. We aimed to determine the factors that deter patients with breast cancer undergoing OBCS from taking up symmetrisation.

METHODS

All patients with breast cancer who underwent OBCS of displacement type but no symmetrisation were prospectively surveyed to explore social, economic, psychological and physical reasons against symmetrisation.

RESULTS

28 patients participated in a survey administered at a mean 21.6 (range 2-47) months after OBCS. A combination of factors, such as worry and desire to treat breast cancer first (67.9%), not being overly concerned about breast cosmesis (57.1%) and fear of pain from additional operation (28.6%) deterred patients from immediate symmetrisation. Worry and desire to treat breast cancer first was the most important single factor for 50% of patients. Reasons for no delayed symmetrisation included not being overly concerned about breast cosmesis (70.4%), fear of breast cancer recurrence (48.1%) and being happy with current breast cosmesis (33.3%), with the former two reasons equally cited as the single most important deterrent by 30% of patients each.

CONCLUSION

A combination of factors may deter patients from symmetrisation. The most significant factors deterring OBCS among patients were worry and desire to treat breast cancer first for immediate symmetrisation, and not being overly concerned about breast cosmesis and fear of breast cancer recurrence for delayed symmetrisation. Reassurance of these patients may increase their uptake of symmetrisation, thereby improving patient cosmesis and satisfaction.

Paving the way for changing perceptions in breast surgery: a systematic literature review focused on oncological and aesthetic outcomes of oncoplastic surgery for breast cancer

BACKGROUND

The emphasis on aesthetic outcomes and quality of life after breast cancer surgery has motivated breast surgeons to develop oncoplastic breast conserving surgery (OPS). Training programs are still rare in most countries, and there is little standardization, which challenges the scientific evaluation of these techniques. This systematic review aims to assess oncological and cosmetic outcomes of OPS.

METHODS

After a strict selection process with precise inclusion and exclusion criteria, oncologic and aesthetic outcomes of oncoplastic surgery were searched, using the MEDLINE database up to September 30th, 2017. Available published literature was classified in levels of evidence. After a thorough screening process, only studies with the best level of evidence were included on selection. Systematic reviews and meta-analyses were not included for methodological reasons.

RESULTS

Titles and abstracts of 2.854 citations were identified and after screening 15 prospective studies including 1.391 patients were reviewed and scored in detail. Local relapse was found in 2.8% of cases with a wide range of follow-up (from 6 to 74 months). Close margins were retrieved in 11% of cases and positive margins in 9.4% of cases. Mastectomy was implemented in 6.9% of breast cancer patients to whom OPS was performed. Good cosmetic outcomes were detected in 90.2% of patients undergoing OPS, leaving open issues for who should perform cosmetic evaluation and which method should be used.

CONCLUSION

Tumor margins, mastectomy rates, and cosmetic outcomes of OPS have to be further improved by standardizing various aspects of OPS. Research efforts should focus on level I evidence assessing both oncological and aesthetic outcomes of OPS and survival rates.

Reconstruction in Breast Conservation Therapy-Single Tertiary Care Institution Experience with 472 Patients

Breast conservation therapy (BCT) is now internationally accepted treatment for early breast cancer. Despite of high incidence of carcinoma breast in India, BCT rates are very low as compared to the west. In this article, we wish to share our experience of breast conservation with oncoplasty in Indian women. A retrospective analysis of case records of patients treated with oncoplastic breast conservation from January 2009 to June 2014 in a single surgical oncology unit in a tertiary cancer institute. Demographic patient data, stage of disease, location of primary tumour, use of neo-adjuvant chemotherapy if received, tumour size and breast size ratio, reconstruction method used, post-operative complications and aesthetic score of patients were analysed. Various methods of oncoplasty and partial breast reconstruction used are discussed. Four hundred and seventy-two patient records were found suitable for analysis. Most common stage of presentation was T2N0 in 189 patients (40%). Forty-one patients received neo-adjuvant chemotherapy (NACT). Tumour arising in upper outer quadrant was most common site, seen in 268 (56.7%). The most common method of reconstruction was volume displacement, done in 57.6% patients. Overall surgical complications included wound infection with or without dehiscence, seroma formation, partial flap necrosis and fat necrosis. Cosmesis was found to be excellent in 23.09% and good in 58.47% at 6-month follow-up. Breast conservation with oncoplasty is oncologically safe for early breast cancer treatment and has good cosmetic outcome with high patient satisfaction rates. Its practice should be encouraged in Indian set-up also.

Immediate breast reconstruction with omental flap for luminal breast cancer patients: Ten clinical case reports

RATIONALE

Luminal subtype breast cancer, accounting for 70 to 80% of all breast cancers, has been reported to be associated with good prognosis. However, for the patients with large mass or worse mass position, omental flap transplantation may provide a new option for breast reconstruction.

PATIENT CONCERNS

Ten patients (6 luminal B1, 2 luminal B2, 2 luminal A), were enrolled into the study, between January 23, 2015 and August 22, 2016. The mean age was 34.6 ± 6.96 (24-44) years old. Immunohistochemistry demonstrated that the tumor cells were positive for estrogen receptor and progestrone receptor.

DIAGNOSES

According to the clinicopathological features, diagnosis of breast cancer patients were made.

INTERVENTIONS

Breast-conserving surgery, laparoscopic greater omentum harvest and vascular anas-tomosis were carried out orderly. Postoperative operative results, cosmetic outcomes, complications, as well as blood supply were investigated for surgery evaluation. Reasonable chemotherapy and irradia-tion were adopted to patients according to the pathological condition.

OUTCOMES

We successfully accomplished breast reconstruction by omental flap transplantation, ex-cept one failed case because of the necrosis of omentum and changed to fat transplantation. The volumes and symmetry of breasts were all satisfied. The blood supply was detected to be fluent. Only one case of slight hematoma and another case of one distant metastasis were observed during fol-low-up period. No arm mordities or arm movement restriction occurred after surgery. Moreover, radia-tion therapy and chemotherapy had no clear effects on the reconstructed breast.

LESSONS

Immediate breast reconstruction surgery by transplanting omental flap for luminal breast cancer patients can be considered successful based on the excellent clinic outcome.

Oncoplastic round block technique has comparable operative parameters as standard wide local excision: a matched case-control study

BACKGROUND

Although oncoplastic breast surgery is used to resect larger tumors with lower re-excision rates compared to standard wide local excision (sWLE), criticisms of oncoplastic surgery include a longer-albeit, well concealed-scar, longer operating time and hospital stay, and increased risk of complications. Round block technique has been reported to be very suitable for patients with relatively smaller breasts and minimal ptosis. We aim to determine if round block technique will result in operative parameters comparable with sWLE.

METHODS

Breast cancer patients who underwent a round block procedure from 1st May 2014 to 31st January 2016 were included in the study. These patients were then matched for the type of axillary procedure, on a one to one basis, with breast cancer patients who had undergone sWLE from 1st August 2011 to 31st January 2016. The operative parameters between the 2 groups were compared.

RESULTS

22 patients were included in the study. Patient demographics and histologic parameters were similar in the 2 groups. No complications were reported in either group. The mean operating time was 122 and 114 minutes in the round block and sWLE groups, respectively (P=0.64). Length of stay was similar in the 2 groups (P=0.11). Round block patients had better cosmesis and lower re-excision rates. A higher rate of recurrence was observed in the sWLE group.

CONCLUSION

The round block technique has comparable operative parameters to sWLE with no evidence of increased complications. Lower re-excision rate and better cosmesis were observed in the round block patients suggesting that the round block technique is not only comparable in general, but may have advantages to sWLE in selected cases.

Breast cancer: An overview of published Indian data

The Incidence of breast cancer has been steadily increasing in the last two decades, more so in urban areas of the sub-continent. Cancer ceters across the country have large numbers of patients being treated with multiple publications in this field. Inspite of paucity of prospective data and randomised clinical trials from India, there are large number of retrospective publications on various aspects of the disease including pathology, radiology, surgery, chemotherapy, radiation, palliative care and alternatitive treatment modalities. These published data provide an insight into the trends of breast cancer in the country and this comprehensive data review of Indian data will provide a basis for designing trials relevant to our population and planning health care.

Are Breast Surgical Operations Clean or Clean Contaminated?

The breast surgeries are classically taught as clean surgical procedures. The infection rates following breast surgery ranges from 3 to 15 %, which is much higher than infection rates after clean surgery (ranging from 1.5 to 3 %). This high infection rate following breast surgery can be explained by opening of the ductal system to outside world through nipple similar to the gastrointestinal and genitourinary system. We conducted a systematic review of infection following breast surgeries. We searched various randomized controlled trials, meta-analysis, and Cochrane Reviews over PubMed and Medline via the Internet. These evidences were found to support the thesis, "Breast surgeries need to be reclassified as clean-contaminated". We recommend the use of prophylactic antibiotics in breast surgery.

Oncoplastic breast surgery: initial experience at the Centro Clinico de Estereotaxia-CECLINES, Caracas, Venezuela

BACKGROUND

Breast-conserving surgery (BCS) may sometimes lead to deformities in the remaining breast. Oncoplastic surgery (OPS) aims to improve our aesthetic results even in the case of major volume resections. The purpose of this study is to provide an objective evaluation of our initial experience with OPS, mainly based on the levels of satisfaction reported by both patients and surgeons.

PATIENTS AND METHODS

This prospective study was performed at CECLINES in Caracas, Venezuela, between January 2011 and October 2012. It involved 107 consecutive patients in two groups: 52 patients with level II OPS versus 55 patients with 'standard' BCS (SBCS). We evaluated the level of satisfaction and cosmetic outcome at 6 and 12 months post-operation using a score from 1 (bad) to 5 (excellent). The cosmetic score was recorded during the follow-up by the surgeon, by phone calls, and photographs were reviewed by a panel of four observers.

RESULTS

The participation rate in the cosmetic outcome/level of satisfaction evaluation was 100% at 6 months and 96.2% at 12 months. The average tumour size was 23 mm [standard deviation (SD): 13.5] for the OPS group versus 17.6 mm (SD: 8.3) for the SBCS group (p = 0.017). The average weight for the surgical specimen was 101 g (range: 30-512 g) in the OPS group versus 60.4 g (range: 20-135 g) in the SBCS group (p = 0.004). The OPS techniques most performed were round block 40.3% (21/52), inverted T mammoplasty 26.8% (14/52) and vertical scar mammoplasty 15.3% (8/52). Of all the patients, 51.9% (27/52) had symmetrisation procedures performed distributed according to the period of the study: 77.2% (17/22) in 2011, 56.6% (17/30) in 2012, and 18.1% (6/33) in 2013. The rate of complications was 5.7% (3/52) in the OPS group and 0% for the SBCS group (p < 0.005). The average cosmetic score at 6 months by patients in the OPS group was 4.4; patient satisfaction scores of 4 (good) and 5 (excellent) were 88.4%. In the SBCS group at 6 months, the mean score reported by patients was 4.2, with scores 4-5 being 83.4% (p = 0.644). The cosmetic score by surgeons in the OPS group at 6 months was 4.5; the surgeon satisfaction scores of 4-5 were 94.2%. In the SBCS group, the surgeons' mean score at 6 months was 4.1, with 84.5% of scores being 4 or 5 (p < 0.005). The final cosmetic score by patients in the OPS group at 12 months was 4.5; patient satisfaction scores of 4-5 were 90.4%. In the SBCS group, the final mean score at 12 months by patients was 4.2, with 77.5% of scores being 4 or 5 (p < 0.005). The final cosmetic score by surgeons in the OPS group at 12 months was 4.5; surgeon satisfaction scores of 4-5 were 92.3%. In the SBCS group, the surgeons' final mean score at 12 months was 4.1, with 84.5% of scores being 4 or 5 (p < 0.005).

CONCLUSIONS

OPS provides good satisfaction rates. An SBCS when an OPS is not indicated mostly results in good satisfaction levels and cosmetic scores. Usually, the results remain stable after 6 months. The use of OPS allows the excision of bigger lesions and surgical specimens. Symmetrisation procedures are not always required. With the appropriate patient selection, the rate of complications is low for both OPS and SBCS.