Ten-year trend analysis of breast cancer, oncoplastic, and reconstructive breast surgery in a single institution (2010-2019), what has not changed?

PURPOSE

There has been a UK national directive to ensure that patients are offered reconstructive surgical options. We aimed to assess any change in oncoplastic practice over a 10-year period.

METHODS

The surgical management of 7019 breast cancers was retrospectively assessed at Nightingale Breast Centre, Manchester University UK, from 2010 to 2019. The procedures were categorised into breast conservative surgery (BCS) and mastectomy ± immediate reconstruction. The data were analysed using inclusion and exclusion criteria.

RESULTS

The overall rates of BCS and mastectomy were 60.1% and 39.9% respectively. No statistically significant change in the overall rates of BCS or mastectomy was observed over the last decade (p = 0.08). The rate of simple wide local excision (WLE) decreased from 98.7% to 89.3% (p < 0.001), whilst the rate of therapeutic mammoplasty (TM) increased from 1.3% to 8% (p < 0.01). The rate of chest wall perforator flaps (CWPF) changed from zero to account for 2.7% of all BCS by 2019. The overall rate of immediate breast reconstruction (IBR) did not significantly change over the study period, but it consistently remained above the national average of 27%. The rate of implant-based IBR increased from 61.3% to 76.5% (p = 0.012), whilst the rate of Latissimus Dorsi (LD) reconstruction decreased from 26.7% to 5.1% (p < 0.05). Additionally, the rate of nipple-sparing mastectomy significantly increased from 5.2% to 24%.

CONCLUSION

No significant changes in the overall rates of BCS was observed, the rates of advanced breast conservation techniques, nipple-sparing mastectomy, and implant-based IBR all have increased, whilst the use of LD reconstruction decreased.

Microsurgical training curriculum in a gynecological breast cancer center: a benefit for patients and surgeons?

PURPOSE

Autologous breast reconstruction improves patient satisfaction and quality of life after mastectomy. In Germany, free flap surgery and implant-based reconstruction is usually separate between reconstructive surgery and gynecology. Cooperation between the specialist disciplines and implementation of microsurgery into breast surgeon training could enhance surgical treatment for breast cancer patients. This evaluation is intended to demonstrate the learning progress within a microsurgical training program and the complication rate in relation to microsurgical experience.

METHODS

At the breast cancer center at Klinikum rechts der Isar, TU Munich, a three-stage training program for autologous breast reconstruction and microsurgery for gynecological breast surgeons was developed. Between 2019 and 2022, 74 women received autologous free flap breast reconstruction by a consistent team consisting of a gynecological surgeon in training and an expert microsurgeon. Peri- and postoperative data were collected to analyze the feasibility and safety of a microsurgical training in gynecology.

RESULTS

Within the training, operative steps of free autologous breast reconstruction were increasingly taken over by the gynecological surgeon in training. The analysis showed a decrease in operating times with consistently low complication rates during the training.

CONCLUSION

This study demonstrated that a training in free autologous breast reconstruction for gynecological surgeons is safely feasible through close cooperation between gynecological and reconstructive surgery.

Oncoplastic breast surgery to prevent "Bird's beak" deformity in the breast: a comparative retrospective study

PURPOSES

Breast deformity occurring in the lower pole after breast conserving surgery (BCS) is known as bird's beak (BB) deformity. This retrospective study evaluated the outcomes in breasts reconstructed with a conventional closing procedure (CCP) and a downward-moving procedure (DMP), respectively, after BCS.

METHODS

In CCP, the inferomedial and inferolateral portions of breast tissues were reapproximated toward the midline after wide excision to repair the breast defect. In DMP, the retro-areolar breast tissue was detached from the nipple-areolar complex after wide excision, and the upper pole breast tissue was moved downward to refill the breast defect.

RESULTS

CCP was performed in 20 patients (Group A), and DMP was performed in 28 patients (Group B). Although retraction of the lower part of the breast was postoperatively observed in 13 (72%) of 18 patients from Group A, it was observed in 7 (28%) of 25 patients in Group B (p < 0.05). The downward pointing of the nipple was observed in 8 (44%) of 18 patients from Group A and in 4 (16%) of 25 patients in Group B (p < 0.05).

CONCLUSIONS

DMP is more useful for preventing BB deformity than CCP.

Chest wall perforator flaps for partial breast reconstruction after conservative surgery: Prospective analysis of safety and reliability

INTRODUCTION

Breast-conserving surgery associated with adjuvant radiotherapy is the state of the art in the surgical treatment of breast cancer. Oncoplastic surgery through dermo-adipose flaps based in perforating arteries (muscle sparing flaps) for partial reconstruction is increasingly used as a good option for avoiding musculocutaneous flaps. In this study we evaluate the outcomes of the use of chest wall perforator flaps in the replacement of partial breast volume.

METHODS

A prospective cohort study of female patients that underwent a conservative oncoplastic surgery procedure with partial breast reconstruction using a dermo-adipose flap of perforating arteries of the chest wall was conducted between November 2020 and March 2022 at our centre. Primary outcomes were surgical morbidity, positive margins and reoperation rates. Characteristics associated with the occurrence of complications were further identified.

RESULTS

Forty-five patients underwent the procedure of interest during the study period. The mean age was 55 years. The median larger dimension of the tumor was 23 mm. Lateral intercostal artery perforator (LICAP), lateral thoracic artery perforator (LTAP), a combined flap and Anterior Intercostal Artery Perforator/Medial Intercostal Artery Perforator (AICAP)/(MICAP) were performed in 22, 16, 2 and 5 patients, respectively. The mean operative time was 126 min. A total of 9 (20.0%) patients required a reoperation after definitive diagnosis, 4 due to positive margins and 5 due to immediate/early surgical morbidity.

CONCLUSIONS

Local perforator flaps in oncoplastic breast-conserving surgery are a good option for immediate reconstruction after conservative surgery, showing low morbidity and favourable outcomes.

Long-Term Patient-Reported Outcomes Comparing Oncoplastic Breast Surgery and Conventional Breast-Conserving Surgery: A Propensity Score-Matched Analysis

INTRODUCTION

Oncoplastic breast surgery (OBS) combines plastic surgery techniques with conventional breast-conserving surgery (BCS) and expands BCS eligibility. Limited data are available on patient-reported outcomes (PROs) after OBS. Here we compare long-term PROs after OBS and BCS utilizing the BREAST-Q.

PATIENTS AND METHODS

Women undergoing OBS or BCS between 2006 and 2019 who completed ≥ 1 long-term BREAST-Q survey 3-5 years postoperatively were identified. Baseline characteristics were compared between women who underwent OBS/BCS. Women who underwent OBS were paired with those who underwent BCS using 1:2 propensity matching [by age, body mass index (BMI), race, T stage, and multifocality]. BREAST-Q scores were compared preoperatively and 3-5 years postoperatively.

RESULTS

A total of 297 patients were included for analysis (99 OBS/198 BCS). Women who underwent OBS were younger (p < 0.001) and had higher BMI (p = 0.005) and multifocal disease incidence (p = 0.004). There was no difference between groups in nodal stage, re-excision rates, axillary surgery, chemotherapy, endocrine therapy, or radiotherapy. After propensity matching preoperatively, women who underwent OBS reported lower psychosocial well-being (63 versus 100, p = 0.039) but similar breast satisfaction and sexual well-being compared with women who underwent BCS; however, only three patients who underwent BCS had preoperative BREAST-Q scores available for review. In long-term follow-up, women who underwent OBS reported lower psychosocial scores (74 versus 93, p = 0.011) 4 years postoperatively, but not at 5 years (76 versus 77, p = 0.83). There was no difference in long-term breast satisfaction or sexual well-being.

CONCLUSIONS

Women who undergo OBS present with a larger disease burden and may represent a group of non-traditional BCS candidates; they reported similar long-term breast satisfaction and sexual well-being compared with women who undergo BCS. While women who underwent OBS reported lower psychosocial well-being scores preoperatively and during a portion of the follow-up period, this difference was no longer seen at 5 years postoperatively.

How Can Oncoplastic Breast Surgery Contribute to the Management of Locally Advanced Breast Cancer in Sub-Saharan Africa?

Background

Because of resource constrains in sub-Saharan African countries, breast-conserving surgery (BCS) has no role in patients with locally advanced breast cancer (LABC) following neoadjuvant chemotherapy (NACT), and mastectomy remains the standard surgical treatment for these patients.

Objectives

The first objective of the study was to assess the safety of oncoplastic BCS in patients with LABC who showed good clinical response to NACT in a breast center with enhanced level of resources in Sudan. The second objective was to assess the cosmetic outcome.

Patients and Methods

Two hundred and fifty patients with LABC were treated with NACT at Khartoum Breast Care Center during the period 2013-2019. Out of this, 52 patients were surgically treated with oncoplastic breast-conserving surgery. Kaplan-Meier curve was used to calculate the survival rates. The cosmetic outcome was subjectively assessed by the Harris scale.

Results

The median follow-up period was 53 months. The 3- and 5-years distant metastasis-free survival rates were 92.9% and 82.2%, respectively. One patient developed regional recurrence, and 6 patients developed distant metastasis. Eighty percentage of patients were admitted to have good to excellent cosmetic outcome.

Conclusion

This Sudanese experience showed that oncoplastic BCS is oncologically safe and aesthetically satisfactory in patients with LABC who demonstrated good clinical response to NACT in a setting with enhanced levels of resources for breast cancer care.

'PartBreCon' study. A UK multicentre retrospective cohort study to assess outcomes following PARTial BREast reCONstruction with chest wall perforator flaps

BACKGROUND

Partial breast reconstruction with a pedicled chest wall perforator flap (CWPF) enables breast conservation in a higher tumour: breast volume ratio scenario. Since there is limited evidence, this retrospective cohort study aimed to ascertain immediate (30-days) and medium-term (follow-up duration) surgical outcomes.

METHODS

STROBE-compliant protocol ascertained CWPF outcomes between March 2011-March 2021. UK centres known to perform CWPF were invited to participate if they performed at least 10 cases. Data were retrospectively collected, including patient demographics, tumour and treatment characteristics, and surgical and oncological outcomes. Statistical analysis (R™) included multivariable logistic regression and sensitivity analysis.

RESULTS

Across 15 centres, 507 patients with median age (54 years, IQR; 48-62), body mass index (25.4 kg/m2, IQR; 22.5-29), tumour size (26 mm, IQR; 18-35), and specimen weight (62 g, IQR; 40-92) had following flap types: LiCAP (54.1%, n = 273), MiCAP/AiCAP (19.6%, n = 99), LiCAP + LTAP (19.8%, n = 100) and TDAP (2.2%, n = 11). 30-days complication rates were in 12%: haematoma (4.3%, n = 22), wound infection (4.3%, n = 22), delayed wound healing (2.8%, n = 14) and flap loss (0.6%, n = 3; 1 full) leading to readmissions (2.6%, n = 13) and re-operations (2.6%, n = 13). Positive margins (n = 88, 17.7%) led to 15.9% (n = 79) re-excisions, including 7.5% (n = 37) at the planned 2nd of 2-stage surgery and 1.8% (n = 9) mastectomy. At median 23 months (IQR; 11-39) follow-up, there were 1.2% (n = 6) symmetrisations; recurrences: local (1%), regional/nodal (0.6%) and distant (3.2%).

CONCLUSIONS

This large multicentre cohort study demonstrates acceptable complication and margin re-excision rates. CWPF extends the range of breast conservation techniques. Further studies are required for long-term oncological outcomes.

Indocyanine green angiography in oncoplastic breast surgery, a prospective study

INTRODUCTION

The use of Indocyanine green angiography (ICG-A) in oncoplastic breast-conserving surgery (OBCS) has not yet been investigated. This prospective trial applied ICG-A in volume displacement and replacement OBCS to localize perforators and determine tissue supplied by the perforator. Furthermore, to investigate and correlate the intraoperative ICG-A to postoperative surgical site infection, skin necrosis, epidermolysis, and timely onset of adjuvant therapy.

METHODS

ICG-A was performed at three pre-set timepoints during surgery; after lumpectomy, upon dissection of possible perforators, and after wound closure. All patients were followed with clinical evaluations before surgery, 4 weeks, 4-6 months, and 12 months postoperatively.

RESULTS

Eleven patients were included: seven volume displacement and four volume replacement OBCS. ICG-A located the tissue supplied by the perforator and demonstrated sufficient perfusion in all cases. The ICG-A corresponded to the surgeons' clinical assessment. One patient developed a postoperative infection and seroma and was treated conservatively. No patients had postoperative necrosis, loss of reconstruction, or lymphedema of the arm. Edema of the breast occurred in four patients (36.4%). Scar assessments were significantly worse at 4-weeks and 4-6 months. The quality of life improved significantly during follow-up. Adjuvant treatment was administered timely in all cases.

CONCLUSION

ICG-A was feasible for OBCS in assessing intraoperative perfusion. Perfusion was sufficient in all patients and corresponded to the surgeon's clinical evaluation. No patients developed postoperative necrosis. Though edema of the breast occurred in 36.4%, a larger sample size is needed to investigate a possible correlation with ICG-A. Further studies, which includes patients requiring extensive tissue replacement challenging the borders of perfusion, are needed.

Implementation of a Breast Intraoperative Oncoplastic Form to Aid Management of Oncoplastic Surgery

INTRODUCTION

Oncoplastic breast conservation surgery (BCS) uses concurrent reduction and/or mastopexy with lumpectomy to improve aesthetic outcomes. However, tissue rearrangement can shift the original tumor location site in relation to external breast landmarks, resulting in difficulties during re-excision for a positive margin and accurate radiation targeting. We developed the Breast Intraoperative Oncoplastic (BIO) form to help depict the location of the tumor and breast reduction specimen. This study seeks to assess physician perspectives of the implementation outcomes.

METHODS

From February 2021 to April 2021, the BIO form was used in 11 oncoplastic BCS cases at a single institution. With institutional review board approval, surgical oncologists (SOs), plastic surgeons (PSs), and radiation oncologists (ROs) were administered a 12-question validated survey on Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM), using a 5-point Likert scale during initial implementation and at 6-month reassessment.

RESULTS

Twelve physicians completed the survey initially (4 SOs, 4 PSs, and 4 ROs). The mean scores for Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure were high (4.44, 4.56, and 4.56, respectively). Twelve completed the second survey (5 SOs, 3 PSs, and 4 ROs). The mean scores were marginally lower (4.06, 4.21, and 4.25). There were no significant differences when stratified by number of years in practice or specialty. Free text comments showed that 75% of physicians found the form helpful in oncoplastic BCS.

CONCLUSIONS

The data indicate high feasibility, acceptability, and appropriateness of the BIO form. Results of this study suggest multidisciplinary benefits of implementing the BIO form in oncoplastic BCS.

Quality of life and satisfaction of patients after oncoplastic or traditional breast-conserving surgery using the BREAST-Q (BCT module): a prospective study

INTRODUCTION

The oncoplastic conservative surgery was developed as a natural evolution of traditional surgery, attempting to improve the therapeutic and aesthetic outcomes where tumor resection could be followed by not-adequate results. Our primary aim is to evaluate how patient satisfaction and quality-of-life after conservative oncoplastic surgery, using BREAST-Q (BCT Module), change pre- and post-operatively. The secondary aim is to compare patient-reported outcome after oncoplastic or traditional conservative surgery.

PATIENTS AND METHODS

We enrolled 647 patients who underwent traditional conservative surgery or oncoplastic surgery from January 2020 to December 2022. Only 232 women (35.9%) completed the BREAST-Q questionnaire on a web-based platform, at the preoperative phase and 3 months after treatment.

RESULTS

The average score of "Psychosocial well-being" and "Satisfaction with Breasts" 3 months after surgery showed a statistically significant improvement, while the average score for "Physical well-being: Chest" at 3 months showed a worsening compared to the baseline. "Sexual well-being" did not show statistically significant change. A significant difference between the post-operative outcome of oncoplastic surgery and traditional surgery was observed only for Physical well-being (better for traditional surgery).

CONCLUSIONS

The study showed significant improvement in patient-reported outcomes 3 months after the surgery, except for physical discomfort that increases especially after oncoplastic surgery. Furthermore, our data, as well as many others, point to the appropriateness of using OCS where there is an effective indication, while the perspective of patients cannot find significant superiority over TCS in any of the areas analyzed.

Oncoplastic Breast Surgery: a Single-Institution Experience

Oncoplastic breast surgery involves immediate reshaping of the breast after tumor excision. It enables wider excision of the tumor while maintaining a satisfactory cosmetic outcome. One hundred and thirty seven patients underwent oncoplastic breast surgery at our institute between June 2019 and December 2021. The procedure performed was decided based on the location of tumor and volume of excision. All patient and tumor characteristics were entered into an online database. The median age was 51 years. The mean tumor size was 3.666 cm (± 0.2512). Twenty-seven patients underwent a type I oncoplasty, 89 patients type 2 oncoplasty, and 21 patients a replacement procedure. Only 5 patients had margin positivity out of which 4 patients underwent a re-wide excision with negative margins. Oncoplastic breast surgery is a safe and effective method to manage patients who need conservative surgery of breast tumors. It allows us to provide good esthetic outcome to the patients ultimately aiding in better emotional and sexual well-being.

Oncoplastic and reconstructive breast surgeon performance and impact on breast reconstructions: Clinical outcomes, learning curve, and patients' satisfaction

BACKGROUND

Compared to mastectomy alone, the addition of breast reconstruction could improve quality of life and it is usually performed by two-team approach, which consisted of both breast surgeons and plastic surgeons. This study aims to illustrate the positive impacts of the dual-trained oncoplastic reconstructive breast surgeon (ORBS) and reveal the factors influencing reconstruction rates.

METHODS

This retrospective study enrolled 542 breast cancer patients who undergone mastectomy with reconstruction performed by a particular ORBS between January 2011 and December 2021 at a single institution. Clinical and oncological outcomes, impact of case accumulation on performance and patient-reported aesthetic satisfactions were analyzed and reported. Furthermore, in this study 1851 breast cancer patients treated with mastectomy combined with or without breast reconstructions, which included 542 performed by ORBS, were reviewed to identify factors affecting breast reconstructions.

RESULTS

Among the 524 breast reconstructions performed by the ORBS, 73.6% were gel implant reconstructions, 2.7% were tissue expanders, 19.5% were transverse rectus abdominal myocutaneous (TRAM) flaps, 2.7% were latissimus dorsi (LD) flaps, 0.8% were omentum flaps, and 0.8% involved LD flaps and implants. There was no total flap loss in the 124 autologous reconstructions, and the implant loss rate was 1.2% (5/403). Patient-reported aesthetic evaluations showed that 95% of the patients were satisfied. As the ORBS's accumulated case experiences, the implant loss rate decreased, and the overall satisfaction rate increased. According to the cumulative sum plot learning curve analysis, it took 58 procedures for the ORBS to shorten the operative time. In multivariate analysis, younger age, MRI, nipple sparing mastectomy, ORBS, and high-volume surgeon were factors related to breast reconstruction.

CONCLUSION

The current study demonstrated that a breast surgeon after adequate training could become an ORBS and perform mastectomies with various types of breast reconstruction with acceptable clinical and oncological outcomes for breast cancer patients. ORBSs could increase breast reconstruction rates, which remain low worldwide.

Aesthetic, Quality-of-Life, and Clinical Outcomes after Inferior Pedicle Oncoplastic Reduction Mammoplasty

BACKGROUND

Oncoplastic breast surgery is more likely to achieve superior aesthetic outcomes compared to lumpectomy alone. Oncoplastic reduction mammoplasty (ORM) is a volume displacement oncoplastic technique that combines lumpectomy and reduction mammoplasty. Data on aesthetic and quality-of-life (QoL) outcomes after ORM are scarce in the literature. Based on a literature review, this present study reports outcomes on the largest group of ORM patients to date.

METHODS

A retrospective review was conducted of all patients who underwent ORM between 2011 and 2018 at a tertiary care centre. Patients were excluded if no pedicle information was available or did not undergo post-operative radiotherapy. All patients with available post-operative photographs were aesthetically evaluated by four blinded, independent investigators blinded based on breast symmetry, nipple symmetry, and overall appearance. The BREAST-Q (breast conserving module) was used to assess QoL outcomes.

RESULTS

Two-hundred-and-sixteen consecutive patients (223 breasts) were included. Macromastia (cup size D or higher) was present in 173 patients (80.1%). Inferior pedicle ORM was utilized in 179 (80.3%) breasts. Eighty-eight patients (40.7%) were aesthetically evaluated, of whom 69 patients (78.4%) had "good", "very good", or "excellent" grades in all aesthetic categories. Seventy-five patients (85.2%) had "good" or better grades in overall appearance. Preoperative ptosis grade, cup size, presence of post-operative complications, and breast specimen weight had no significant correlations with aesthetic grades. Inferior pedicle ORM was associated with a higher "satisfaction with breast" Q-score (p=0.017) compared to other pedicle approaches.

CONCLUSION

Inferior pedicle ORM achieves objectively excellent aesthetic outcomes and high patient satisfaction with the reconstruction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Long-term course of the changes in the nipple position after breast-conserving surgery

PURPOSE

Even if favorable cosmetic outcomes are obtained shortly after breast-conserving surgery (BCS), cosmetic changes may occur up to several years after BCS. In the present study, we evaluated cosmetic changes while focusing on changes in the nipple position after BCS.

METHODS

We examined the long-term course of changes in the nipple position over time after BCS using the proportion of the distance between the sternal notch and nipple (PDSN) in 196 patients. We also evaluated risk factors for long-term nipple position changes.

RESULTS

The median follow-up period was 9.9 years. Nipple position changes occurred within eight years after BCS and seemed to plateau beyond that point. The body mass index (BMI), breast size, proportion of excision volume and axillary treatment were significantly associated with the nipple position changes within one to five years after BCS. The BMI, breast size, axillary treatment, chemotherapy and hormonal therapy were significantly associated with the nipple position changes within five to eight years after BCS.

CONCLUSIONS

After BCS, the nipple position changes occur within about eight years. Obesity, large breast size, large excision volume, axillary treatment, chemotherapy and hormone therapy were factors that affected the treated breast shrinkage and increase in the left-right difference after BCS.

The iTOP trial: Comparing immediate techniques of oncoplastic surgery with conventional breast surgery in women with breast cance - A prospective, controlled, single-center study

INTRODUCTION

Oncoplastic techniques allow resection of larger tumors, permitting breast conservation in cases otherwise requiring mastectomy. We sought to prospectively compare quality of life (QoL) in patients undergoing oncoplastic surgery as compared to conventional breast conservation (CBC) or mastectomy is lacking.

METHODS

Patients diagnosed with BIRADS IV-VI lesion were eligible if resection of ≥10% of the breast volume was planned. Patients were allowed to decide whether they wanted to undergo CBC or oncoplastic breast conservation (OBC). Patients who underwent mastectomy and immediate breast reconstruction (IBR) were also included for comparison. The primary endpoint was breast self-esteem using the Breast Image Scale (BIS) at 12 months, secondary endpoints were perioperative morbidity and QoL using the BREAST-Q questionnaire.

RESULTS

From 2011 to 2016, 205 patients were included in the study. 116 patients (56.6%) received CBC, 46 (22.4%) OBC and 43 (21%) MIBR. Women in the OBC group were more likely to have tumors ≥ 2cm than those in the CBC group (34.7% vs. 17.5%, respectively). Women who underwent MIBR were more likely to have tumors > 5cm than those in the CBC and OBC groups (23% vs 1% and 10%, respectively). The BIS and BREAST-Q improved in each group after 12 months but did not differ significantly between groups at any time point. Surgical complications (seroma, bleeding, infection, necrosis) were numerically more likely in the OBC and MIBR groups.

CONCLUSION

OBC and the MIBR allow for resection of larger tumors with a similar quality of life as CBC.

The benefits of dual-consultant operating in complex breast reconstruction: A retrospective cohort comparison study

BACKGROUND

Dual-consultant operating (DCO) has been introduced in a multitude of surgical specialities. This retrospective cohort comparison study seeks to delineate any benefits DCO may confer on list utilisation, patient safety and training opportunities.

METHODS

A retrospective cohort comparison of all free-flap breast reconstruction cases conducted at a single centre by five consultant plastic surgeons in the period May 2016-May 2020.

RESULTS

A total of 281 patient records were used for analysis; 146 cases were dual consultants compared with 135 single consultants, representing 186 and 158 free flaps, respectively. Patient demographics were near identical in terms of patient age, BMI and ASA grade. Operating times were significantly reduced for both unilateral (mean reduction 59.49 min) and bilateral cases (mean reduction 38.14 min) with the presence of dual consultants. The mean length of stay for dual-consultant cases was on average 0.35 days less than for single consultant cases (p = 0.04). Dual-consultant case complications were less severe than those of single consultant cases (mean Clavien-Dindo severity 1.35 vs 0.96, p = 0.05). The rates of trainee one-to-one consultant training were increased in dual-consultant cases when preparing vessels (0.08 vs 0.35, p=<0.01) and performing anastomosis (0.63 vs 0.77, p = 0.03).

CONCLUSIONS

DCO for complex breast reconstruction confers significant benefits to operating time, list utility and patient safety whilst protecting training opportunities for trainees. Plastic surgery departments looking to redesign services in the post-SARS-CoV-19 era should consider its adoption into their enhanced recovery protocols.

Lateral chest wall perforator flaps in partial breast reconstruction

BACKGROUND

Breast conserving surgery (BCS) has been a standard procedure for the treatment of breast cancer instead of mastectomy whenever possible. Lateral chest wall perforator flaps are one of the volume replacement techniques that participate in increasing the rate of BCS especially in small- to moderate-sized breasts with good cosmetic outcome. In this study, we tried to evaluate the outcome of those flaps as an oncoplastic procedure instead of the conventional flaps.

METHODS

This study included 26 patients who underwent partial mastectomy with immediate reconstruction using lateral chest wall perforator flaps in the period from October 2019 to November 2020. The operative time, techniques, and complications were recorded. The cosmetic outcome was assessed 3 months post-radiation therapy through a questionnaire and photographic assessment.

RESULTS

Lateral intercostal artery perforator (LICAP), lateral thoracic artery perforator (LTAP) and combined flaps were performed in 24, 1, and 1 patients, respectively. The mean operative time was 129.6 ± 13.2 min. The flap length ranged from 10 to 20 cm and its width from 5 to 9 cm. Overall patients' satisfaction was observed to be 88.5% as either excellent or good and the photographic assessment was 96.2% as either excellent or good.

CONCLUSIONS

Lateral chest wall perforator flaps are reliable and safe option for partial breast reconstruction with an acceptable aesthetic outcome. In the era of oncoplastic breast surgery, they deserve to gain attention especially with the advantages of some modifications added to the classic technique.

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.

Advanced breast conservation and partial breast reconstruction - a review of current available options for oncoplastic breast surgery

Breast cancer is the most common cancer affecting one in three women with new cancer diagnosis in England. Breast-conserving surgery is the primary surgical option in a vast majority of these patients. Use of oncoplastic techniques in breast conservation surgery has significantly improved the aesthetic outcomes without compromising the oncological safety of cancer resections. Oncoplastic breast-conserving surgery (OPBCS) has transformed the specialty with a paradigm shift in ideology and the recognition that aesthetic and oncological resections are synonymous when planning surgical intervention for patients with breast cancer. The two main options for OPBCS are therapeutic mammoplasty and partial beast reconstruction using pedicle-based flaps. This review aims to highlight key concepts in OPBCS demonstrating an overview of these surgical techniques, their safety, outcomes and the emergence of extreme oncoplastic breast surgery.

Oncoplastic breast surgery combining partial mastectomy with resection of double equilateral triangular skin flaps

The treatment of early breast cancer using oncoplastic breast surgery (OBS) has been gradually increasing in popularity and is recognized for its efficacy in local control and excellent cosmetic results. We herein report a useful technique for obtaining symmetry of the breast shape for an early breast lesion located in an outer area, close to the nipple-areola, in a Japanese patient with ptotic, fatty breasts. We designed two equilateral triangles: one just upon the resected area and the other on the axilla. They were located on a straight line, with one top pointed to the cranial side and one to the caudal side. A crescent area around the areola was de-epithelialized in the 12 o’clock and 6 o’clock directions. Columnar-shaped breast tissue and an equilateral triangular skin flap and fatty tissue were removed together. To fill the defect, a skin-glandular flap was slid horizontally after suturing the inframammary line. Although an incision scar was formed on the breast and lateral chest wall in a Z-shape, this new technique was able to achieve not only cancer control but also excellent cosmetic results.

Prediction of Local Recurrence After Oncoplastic Breast Surgery: Analysis of a Large Cohort

BACKGROUND

Oncoplastic breast surgery (OBS) is becoming an acceptable procedure for the surgical treatment of breast cancer; however, its safety and recurrence rate still need further clarification. This study evaluates the rate of local recurrence and its predictive factors after OBS in a large series of patients. Materials and methods This study was conducted between January 2008 and June 2018 in two centers in Iran. Patients underwent OBS, and baseline characteristics were recorded. Patients underwent regular follow-up; local recurrence rate, median time, and the hazard ratio of predictive factors were calculated. Also, a multivariate analysis was performed. Results A total of 676 patients with a mean age of 48 ± 10.7 y were included. The median follow-up time was 26.4 (first, third IQR: 13.2, 45.6) mo, and 37 (5.5%) patients were diagnosed with local recurrence. The median time to local recurrence was 22.0 (first, third IQR: 16.0, 32.8) mo. Pathological N stage, neoadjuvant chemotherapy, overexpression of HER2, and one surgery technique was associated with a higher risk of recurrence, while the expression of estrogen receptor and progesterone receptor (PR) decreased the risk of recurrence. PR status, neoadjuvant chemotherapy, and pathological N stage remained significant in the final model for recurrence on multivariate analysis. Conclusion OBS is a safe technique with an acceptable risk of local recurrence. PR status, neoadjuvant chemotherapy, and pathological N stage can predict recurrence in these patients with an acceptable power.

Should oncoplastic breast conserving surgery be used for the treatment of early stage breast cancer? Using the GRADE approach for development of clinical recommendations

Introduction

The potential advantages of oncoplastic breast conserving surgery (BCS) have not been validated in robust studies that constitute high levels of evidence, despite oncoplastic techniques being widely adopted around the globe. There is hence the need to define the precise role of oncoplastic BCS in the treatment of early breast cancer, with consensual recommendations for clinical practice.

Methods

A panel of world-renowned breast specialists was convened to evaluate evidence, express personal viewpoints and establish recommendations for the use of oncoplastic BCS as primary treatment of unifocal early stage breast cancers using the GRADE approach.

Results

According to the results of the systematic review of literature, the panelists were asked to comment on the recommendation for use of oncoplastic BCS for treatment of operable breast cancer that is suitable for breast conserving surgery, with the GRADE approach. Based on the voting outcome, the following recommendation emerged as a consensus statement: Oncoplastic breast conserving surgery should be recommended versus standard breast conserving surgery for the treatment of operable breast cancer in adult women who are suitable candidates for breast conserving surgery (with very low certainty of evidence).

Discussion

This review has revealed a low level of evidence for most of the important outcomes in oncoplastic surgery with lack of any randomized data and absence of standard tools for evaluation of clinical outcomes and especially patients’ values.

Despite areas of controversy, about one-third (36%) of panel members expressed a strong recommendation in support of oncoplastic BCS. Presumably, this reflects a synthesis of views on the relative complexity of these techniques, associated complications, impact on quality of life and costs.

Can we rely on surgical clips placed during oncoplastic breast surgery to accurately delineate the tumor bed for targeted breast radiotherapy?

PURPOSE

Oncoplastic breast surgery (OBS) is gaining popularity among surgeons for breast-conserving surgery treatments. OBS relies on complex relocation and deformation of breast tissue involving the tumor bed (TB). In this study, we investigate the validity of using surgical clips with OBS for accurate TB delineation in adjuvant, targeted breast radiotherapy.

METHODS

Different OBS techniques were simulated on realistic breast phantoms. Surgical clips were used to demarcate the TB. Following tumor resection and closure, the true TB (TB_True) was extracted. Each phantom was CT imaged at several phases of surgery in order to record pre- and post-OBS closure surgical clip displacements. Two senior radiation oncologists (ROs) were asked to delineate TBs on CTs by relying on surgical clips placed as per standard protocol, and by referring to operative notes. Their original contours, as well as those expanded using 5-15 mm margins, were compared with the accurate TB_True using the dice similarity coefficient (DSC), Hausdorff Distance (HD), and over- and under-contoured volumes. Inter- and intra-RO contour agreements were also evaluated.

RESULTS

Post-OBS surgical clips were significantly displaced outside the original breast quadrant. Inter- and Intra-RO TB contours were consistent, yet systematically differed from TB_True (DSC values range = 0.38 to 0.69, and maximum HD range = 17.8 mm to 38.0 mm). Using expansion margins did not improve contour congruence and caused significant over-contoured volumes.

CONCLUSION

Following OBS, surgical clips alone are not reliable radiographic surrogates of TB locations and accurate TB delineation is challenging. For complex OBS cases, indication of any type of partial breast irradiation is very questionable.

Transposition flap for the oncoplastic reconstruction of outer quadrant breast defects

Plastic surgical principles are incorporated with breast conservation surgery (BCS) for cancer to improve aesthetic outcomes. In developing countries, average tumour size is larger at presentation resulting in larger resections often, including overlying skin. LD flap has been the workhorse of partial breast reconstruction. We present an easy and effective alternative to LD flap for carefully selected cases of outer quadrant breast tumours. We report 41 cases of local transposition flap from the lateral chest wall for oncoplastic restoration post BCS, performed between January 2016 and February 2020, at our institution. The median age was 49 years (28-63). Twenty-six patients underwent upfront surgery and 15 after neoadjuvant chemotherapy (NACT). The average pathological tumour size was 2.9 cm (median 2.7 and range 1.1-6) and 1.5 cm (median 1.8 and range 0-3.5) for upfront and post-NACT groups, respectively. The median volume of the resected specimen was 277.8 ml and 253.2 ml for upfront and post-NACT groups, respectively. Three patients (7.5%) had a microscopic positive margin requiring margin revision. Three (7.5%) patients had post-operative minor wound complications and were managed conservatively. At a median follow-up of 14 months (1-36), only 2/19 (10.5%) patients had clinical fat necrosis. Local transposition flap from the lateral chest wall based on dermal and subdermal plexus, carefully designed in selected patients, can be used effectively for the reconstruction of outer quadrant breast defects. It is easy to learn, offers good cosmetic outcome, avoids the morbidity and time of LD flap and saves LD flap for future use.

Patient Satisfaction Following Level II Oncoplastic Breast Surgery: A Comparison with Mastectomy Utililizing the Breast-Q Questionnaire will be published in Surgical Oncology

INTRODUCTION

Oncoplastic breast surgery (OBS) is increasingly used to decrease the deformity in breast conserving therapy (BCT) for breast cancer. We aimed to evaluate patient reported satisfaction following level II OBS and mastectomy utilizing the BREAST-Q questionnaire.

METHODS

Patients who underwent level II OBS BCT and those who underwent mastectomies were distributed the BREAST-Q post-reduction/mammoplasty module. Clinicopathological data were collected from review of patient charts. Results were scored using the standardized scoring system (Q-score). Results of the OBS group were compared to those in the mastectomy group.

RESULTS

A total of 88 patients who underwent level II OBS and 101 patients who underwent mastectomy completed the questionnaire. Mann-Whitney odds estimator demonstrated higher satisfaction with breasts (1.51, 95% CI [1.04-2.25], p = 0.026) and higher psychosocial well-being (1.51, 95% CI [1.04-2.15], p = 0.022) in those who underwent OBS compared to mastectomy.

CONCLUSION

Results demonstrate a high satisfaction with breasts and improved psychosocial wellbeing in patients who underwent level II OBS compared to those undergoing mastectomy. These results demonstrate that OBS should be considered in patients where mastectomy otherwise would be necessary. Further larger multi-institutional studies are necessary to examine the effect of OBS on the quality of life of breast cancer patients.

Oncoplastic breast surgery combining partial mastectomy with V-rotation mammoplasty for breast cancer on the upper inner area of the breast

The treatment of early breast cancer using breast conservation therapy (BCT) commonly ensures local control and acceptable cosmetic results. We herein report a useful technique for obtaining symmetry of the breast shape and a level inframammary line and nipple-areola that achieved excellent results. Four Japanese patients with early breast cancer located on the upper inner area of the breast were enrolled into this study. De-epithelialized skin close to the resected area and skin from the epigastric area with subdermal fatty tissue were moved to repair the defect. Oncoplastic breast surgery (OBS) combining partial mastectomy with the V-rotation mammoplasty technique was useful for patients with breast cancer on the upper inner area of minimal ptotic breasts.

Patient satisfaction after breast cancer surgery : A prospective clinical trial

BACKGROUND

This study investigated the impact of curative breast cancer surgery on patient satisfaction concerning cosmetic results and quality of life (QoL).

METHODS

In this study 61 participants completed questionnaires to evaluate their QoL and patient satisfaction with cosmetic results following breast cancer surgery. Cosmetic outcomes were evaluated by the breast surgeon and an independent breast specialist using the Harris scale and the breast analyzing tool (BAT).

RESULTS

Of the participants 71% completed all 4 follow-up visits, 38 (62%) patients received breast-conserving therapy (BCT) and 23 (38%) received a mastectomy. Surgery-associated complications arose in 2.6% of the patients who received BCT and 17.4% of patients who received a mastectomy. No significant differences in QoL between BCT patients and mastectomy patients were observed immediately after surgery, or after 6 and 12 months. Breast asymmetry, measured using the BAT score, and QoL scores were worst immediately after surgery. The surgeon rated the cosmetic results as better compared to the independent breast expert (p = 0.001). Furthermore, patients aged over 60 years old were less satisfied with the cosmetic outcome compared to younger patients at the time of discharge (p = 0.024). Patients who received a mastectomy were less satisfied when the resected volume was higher.

CONCLUSION

Patient satisfaction was lowest immediately after surgery but improved during the following months, despite continued breast asymmetry. For mastectomy patients, a lower resected volume led to a higher satisfaction with cosmetic results. Satisfaction is subjective and cannot be determined from the esthetic satisfaction of the surgeon or using an objective tool measuring breast asymmetry.

Oncoplastic breast surgery combining partial mastectomy with a triangular skin resection and re-centralization of the nipple-areola

The treatment of early breast cancer using breast conservation therapy (BCT) commonly ensures local control and acceptable cosmetic results. We herein report a useful technique to obtain symmetry of the breast shape and a level inframammary line and nipple-areola, which achieved excellent results. Six Japanese patients with early breast cancer located on the upper area of the breast were enrolled into this study. A triangle-shaped area of skin was removed together with cancerous and healthy-surrounding breast tissue. Two crescents were designed and de-epithelialized in the directions of 9 o'clock and 3 o'clock. The width of the crescent was decided to be the same as a half or the length of the base of a triangle to be removed. After partial mastectomy, the inner and outer glandular flaps were horizontally sutured. The operations were simple to perform and were not associated with any postoperative complications. Oncoplastic breast surgery combining partial mastectomy with triangular skin resection and re-centralization of the nipple-areola was useful for patients with breast cancer on the upper quadrant area of non-ptotic breasts.

Oncoplastic Repair in Breast Conservation: Comprehensive Evaluation of Techniques and Oncologic Outcomes of 937 Patients

BACKGROUND

Breast-conserving surgery, especially with oncoplastic breast surgery (OBS), is becoming the standard of care in the surgical management of breast cancer. We investigated the applied technique of OBS and oncologic outcomes in a large series of patients.

PATIENTS AND METHODS

This study was conducted between January 2008 and June 2018 in two centers in Iran. Patients underwent OBS. Early and late postoperative complications, oncologic outcomes, and follow-up data were documented.

RESULTS

Nine hundred thirty-seven patients with a mean ± standard deviation age of 48.1 ± 11.3 underwent OBS. Most of the patients were diagnosed with early-stage disease, of which the most common pathology was invasive ductal carcinoma (83.3%). Lateral oncoplasty was the most commonly used OBS technique (324 cases, 34.6%). The most common complication was seroma formation. Reduction-type OBS technique had the highest rate of complications (13.1%). Thirty-four patients (5.4%) experienced local recurrence, with a median recurrence time of 26.4 months. Nine patients (1.3%) died from cancer recurrence.

CONCLUSION

OBS is a safe procedure with minor complications and good oncologic outcomes. These techniques can be applied to most patients who are candidates for breast-conserving surgery.

Patient-reported outcome after oncoplastic breast surgery compared with conventional breast-conserving surgery in breast cancer

INTRODUCTION

Oncoplastic breast surgery (OBS) has developed as an extension of breast-conserving surgery (BCS) in an effort to improve esthetic and functional outcome following surgery for breast cancer. The aim of the present study was to evaluate the possible benefits of OBS, as compared with BCS, with regard to health-related quality of life (HRQoL), using patient-reported outcome measures (PROMs).

PATIENTS AND METHODS

Patients treated with OBS (n = 200) and BCS (n = 1304) in the period 1 January 2008 to 31 December 2013 were identified in a research database and in the Danish Breast Cancer Cooperative Group (DBCG) registry. Data on patient, tumor, and treatment characteristics were retrieved from the DBCG registry. Patients were sent a survey including the Breast-Q™ BCT postoperative module and a study-specific questionnaire (SSQ) in 2016. A good outcome in the Breast-Q module was defined as above the median. OBS was compared to BCS using a logistic regression analysis, and then adjusted for potential confounders, yielding odds ratios (OR) with 95% confidence intervals.

RESULTS

There was a statistically significant better outcome considering the HRQoL domain "Psychosocial Well-being " for patients treated with OBS as compared with BCS (OR 2.15: 1.25-3.69). No statistically significant differences were found for the domains "Physical Well-being" (0.83: 0.50-1.39), "Satisfaction with Breast" (0.95: 0.57-1.59), or "Sexual Well-being" (1.42: 0.78-2.58).

CONCLUSION

The present study indicates better outcomes of HRQoL for breast cancer patients treated with OBS as compared to patients treated with BCS. There was no increase in physical discomfort among OBS patients despite more extensive surgery.

Correlation of Specimen/Breast Volume Ratio to Cosmetic Outcome After Breast Conserving Surgery

Breast conserving surgery (BCS) is currently the standard of care for early breast cancer. One of the key determinants for the line of treatment in breast cancer is the size of the tumor in relation to the breast size. The aim of this study is to determine the effect of the ratio of the excised specimen to breast volume on the cosmetic outcome after conventional BCS. This is a retrospective study conducted on female patients with early stage breast cancer who underwent BCT at National Cancer Institute, Cairo University. The study included 41 patients with stage I and II breast cancer. Breast volume was calculated using mammography, and ratio of the specimen to breast volume was determined. This ratio was correlated with the cosmetic outcome using the BCCT.core software. Thirty-six out of the 41 breast cancer patients completed the study. Favorable outcome (excellent + good) was detected in 52.7% of patients, while 47.3% had unfavorable outcome (fair + poor). Breast volume, tumor site, patients' age, and weight did not seem to alter the cosmetic result. The only statistically significant factors affecting the cosmetic outcome were the specimen volume and the ratio of the specimen to the normal breast volume (p = 0.006 and 0.019 respectively). In order to obtain a satisfactory cosmetic outcome after conventional BCS, the ratio of the excised specimen to breast volume has to be seriously considered.

The axillary flap in oncoplastic resection of breast cancers located in the upper-outer quadrants: a new surgical technique

Background

The combination of breast conserving surgery (BCS) with plastic surgery techniques has provided a useful surgical tool matching the radicality of the oncological excision with the preservation of breast cosmesis. Even though BCS represents a good option for surgical treatment of tumors located in these quadrants, wide excisions often necessitate breast reshaping in order to avoid nipple areola complex (NAC) displacement and skin retraction. We present a new surgical technique to repair upper-outer quadrants’ defects following breast cancer excision using dermo-glandular flaps and an axillary adipo-fascial flap.

Methods

During the period from January 2014 to December 2015, 168 patients with an upper-outer quadrant’s breast cancer have been treated in our Department. 83 women have been treated with the described oncoplastic technique and immediate contra-lateral symmetrisation and 85 women underwent standard BCS. We present surgical, oncological and cosmetic outcomes comparing our results with standard BCS.

Results

At a mean follow-up of 27 months loco-regional recurrences in the two groups were comparable. Short-term complication rates were comparable between the two groups. Re-intervention rates for positive margins were significantly higher in the standard BCS group. The overall satisfaction with cosmetic outcome both assessed by the patient and the surgeon was significantly higher in the oncoplastic group.

Conclusions

The proposed oncoplastic technique represents a safe and effective solution for reshaping that follows upper-outer breast cancer wide excision, achieving comparable complication rates, lower re-intervention rates for positive margins and better cosmetic results when compared with standard BCS.

Oncoplastic breast surgery combining partial mastectomy with immediate breast reshaping using multiple local flaps for a patient with slim body

Oncoplastic breast surgery (OBS), which combines the concepts of oncologic and plastic surgery, is becoming more common worldwide. We report the results of OBS in a Japanese patient with early breast cancer located on the outer lower quadrant area. We performed OBS combining partial mastectomy with immediate breast reshaping using multiple adipofascial cutaneous flaps and free dermal fat graft because she refused any other OBS. We selected three local flaps to repair the defect. Perioperative and postoperative complications were not seen. The cosmetic findings 3 years after surgery were not excellent, but the patient was satisfied with the results. OBS combining partial mastectomy with immediate breast reshaping using a combination of several flaps was successfully performed in a patient with early breast cancer.

Surgical excision and oncoplastic breast surgery in 32 patients with benign phyllodes tumors

Background

The purpose of this study was to assess the effectiveness and safety in patients with benign phyllodes after performing local excision and following with intra-operative breast flap reconstruction.

Methods

Patients (n = 32) with eligible breast cystosarcoma phyllodes underwent wide local excision followed by intra-operative breast flap reconstruction. Primary outcome measures included average operative time, length of in-hospital stay, postoperative recurrence, and intra-operative and postoperative complications.

Results

Thirty-two patients who underwent surgical excision and oncoplastic breast surgery were evaluated using the BCCT.core software. A satisfactory symmetrical breast shape was achieved. The average operative time was 56.3 ± 8.2 min. The average postoperative duration of hospitalization was 3.7 ± 1.2 days. While there was no breast disease recurred during the 1 to 8-year follow-up period.

Conclusions

Wide local excision accompanied by intra-operative breast flap reconstruction could be adopted for removing benign phyllodes tumors while retaining the basic shape of the breast.

Wide Local Excision Versus Oncoplastic Breast Surgery: Differences in Surgical Outcome for an Assumed Margin (0, 1, or 2 mm) Distance

INTRODUCTION

Oncoplastic breast surgery (OBS) can be applied in larger tumors or in patients with high tumor-to-breast ratio without compromising oncologic safety. Inherent larger excisions may increase the probability of clear margins. We compare postoperative outcomes between simple wide local excision (WLE) and OBS assuming 3 different margin distances.

PATIENTS AND METHODS

Single oncoplastic surgeon data between April 2014 and September 2016, including tumor and treatment details, for WLE or OBS were reviewed. Relative incidence of margin positivity at 3 assumed distinct margin distances (2, 1, and 0 mm) and reexcision rates were compared. Statistical comparisons were performed by the Student t and chi-square tests.

RESULTS

Available data from 201 patients revealed similar patient age and respective tumor phenotypes between 2 cohorts (166 WLE and 35 OBS). Though both the preoperative (30 vs. 16 mm, P < .001) and postoperative tumor (30 vs. 19 mm, P = .001) sizes were greater in the OBS group, margin positivity rates were significantly lower, at 1 mm (5.7% vs. 20.8%, P = .036). Though similar rates of reexcision were observed, completion mastectomies were required in 5.4% of WLE versus 0 OBS. Similar rates of margin positivity and reexcision were observed between mammoplasties and chest wall perforator flaps.

CONCLUSION

OBS is not inferior to standard WLE at providing a safe and clear oncologic margin regardless of margin distance (up to 2 mm) despite larger tumor size. The additional benefit of improved cosmesis, particularly in patients with larger tumor-to-breast ratio, offers a suitable and safe alternative, thus increasing patient choice and reducing the incidence of reexcision and completion mastectomy.

The usefulness of pedicled perforator flap in partial breast reconstruction after breast conserving surgery in Korean women

Background

The emergence of breast-conserving surgery combined with radiotherapy as the treatment of choice for early stage breast cancer has resulted in greater focus on oncoplastic breast surgery. The use of perforator flaps has particularly gained in reputation for its effectiveness in the reconstruction of partial breast defects in Korean women. Herein, we present our experience with the use of thoracodorsal artery perforator (TDAP) and lateral intercostal artery perforator (LICAP) flaps.

Methods

This study included 33 patients who underwent breast reconstruction using TDAP or LICAP flaps at our hospital from January 2011 to December 2014. Data from patient medical records, and patient satisfaction surveys, which were conducted 12 months postoperatively, were retrospectively evaluated.

Results

TDAP and LICAP flap-based reconstructions were performed in 14 and 19 patients, respectively. Five patients developed complications that required additional intervention. Overall patient satisfaction was observed to be excellent in 15 (46%) patients, and good in 12 (36%).

Conclusions

Based on our experience, oncoplastic breast surgery using TDAP or LICAP flap is an effective remodeling technique for small-to-moderate breast defects in Korean women with smaller breasts.

Training oncoplastic breast surgeons: the Canadian fellowship experience

BACKGROUND

Oncoplastic breast surgery combines traditional oncologic breast conservation with plastic surgery techniques to achieve improved aesthetic and quality-of-life outcomes without sacrificing oncologic safety. Clinical uptake and training remain limited in the Canadian surgical system. In the present article, we detail the current state of oncoplastic surgery (ops) training in Canada, the United States, and worldwide, as well as the experience of a Canadian clinical fellow in ops.

METHODS

The clinical fellow undertook a 9-month audit of breast surgical cases. All cases performed during the fellow's ops fellowship were included. The fellowship ran from October 2015 to June 2016.

RESULTS

During the 9 months of the fellowship, 67 mastectomies were completed (30 simple, 17 modified radical, 12 skin-sparing, and 8 nipple-sparing). The fellow participated in 13 breast reconstructions. Of 126 lumpectomies completed, 79 incorporated oncoplastic techniques.

CONCLUSIONS

The experience of the most recent ops clinical fellow suggests that Canadian ops training is feasible and achievable. Commentary on the current state of Canadian ops training suggests areas for improvement. Oncoplastic surgery is an important skill for breast surgical oncologists, and access to training should be improved for Canadian surgeons.

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.

The Main Topics at the Oncoplastic Breast Surgery Course and Expert Panel

The Oncoplastic and Reconstructive Breast Surgery course was held in Izmir by the Izmir Breast Diseases Federation in collaboration with the Breast Diseases Federation of Turkey. The techniques of oncoplasty, the application details and experience in this subject were shared. In this text, the main topics and outcomes are briefly summarised. These evaluations can be considered highly valuable on both local and regional scales.

Oncoplastic Breast Surgery: What, When and for Whom?

Oncoplastic surgery is integral to all breast cancer surgeries. The use of an aesthetic approach to breast conservation or mastectomy greatly enhances the range of options that can be offered to women with breast cancer and facilitates better outomes from it. It should be the standard of care. However, a structured approach to selecting appropriate techniques is essential, and although many operative procedures are reported, this article sets out to describe a set of principles and an algorithm by which the what, when and for whom for oncoplastic surgery can be defined.

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.

Versatility of therapeutic reduction mammoplasty in oncoplastic breast conserving surgery

Oncoplastic breast conserving surgery is the gold standard approach for the surgical treatment of early breast cancer. There is a well defined technique named “therapeutic mammoplasty” which is characterized for using a reduction mammaplasty technique to treat breast cancer conservatively. In our current practice, “therapeutic mammoplasty” or therapeutic reduction mammaplasty is our favorite oncoplastic breast conserving approach which it used in almost half of our patients. This technique is very versatile allows us the resection of tumors located in all breast quadrants of patients with moderate-to large-sized breasts. We describe a series of 57 patients who were treated using a therapeutic reduction mammaplasty. All surgical procedures were carried out by one comprehensive breast surgeon who planned and designed the surgery performing both oncologic and reconstructive procedures. Surgical margins were insufficient in eight patients (14%). Nine patients (15.8%) had a complication in early postoperative period and in one of them adjuvant radiotherapy was delayed four months due to a wound dehiscence. The rate of synchronous contralateral symmetrization was 31.6%. Our conclusion is that reduction mammaplasty is a useful and safe skill to treat breast cancer conservatively playing a very important role therefore it must be situated in the priority of learning objectives.

An example of lumpectomy for lower inner quadrant breast cancer with 1(st) level oncoplastic reconstruction by glandular splitting

Oncoplastic techniques extend the scope for breast conserving surgery by combining an extensive local excision with a simultaneous reconstruction of the defect to avoid local deformity. If less than 20% of the breast volume is excised a level I procedure is adequate and can be performed by breast surgeon without specific training in plastic surgery. For breast cancer is possible to fill the defect of the lower inner lumpectomy by splitting the upper inner quadrant. The Authors describe a novel technique in giant breast.

Oncoplastic surgery in breast conservation: a prospective evaluation of the patients, techniques, and oncologic outcomes

BACKGROUND

The oncologic efficacy of breast-conserving therapies has been established in recent decades. Oncoplastic breast surgery (OBS), as a leap forward in breast conservation, offers concomitant techniques of oncologic and plastic surgeries that grant better esthetic results. The outcomes of our oncoplastic surgeries from 2007 to 2012 are reported.

METHODS

A series of 258 cases with breast masses (18 benign and 240 carcinomas) were operated on by OBS techniques and prospectively followed. Neoadjuvant and adjuvant oncologic treatments were also delivered as indicated.

RESULTS

Free margins were obtained in 95% of cancer patients. During the 26 months of follow-up, local recurrence happened in 7 (2.9%) patients, of which 1 underwent oncologic therapies and 6 underwent completion mastectomy. Complications postponed adjuvant therapies in 3 (1.2%) patients. Postsurgically, metastases were diagnosed in 8 (3.3%) patients. Two patients (.8%) died of cancer.

CONCLUSIONS

Outcomes of OBS are oncologically acceptable with low frequencies of positive margins and recurrence, while cosmetic results are much improved by OBS.

Round block technique is a useful oncoplastic procedure for multicentric fibroadenomas

PURPOSE

Multicentric fibroadenomas, defined as multiple fibroadenomas located at different quadrants of the breast, occur in 10-20% of women with fibroadenoma. The surgical management of multicentric fibroadenomas may be troublesome for surgeons and patients. In this study, we report our preliminary experience using the "round block technique" in the management of women with multicentric fibroadenomas of the breast.

MATERIALS AND METHODS

Records of patients with breast diseases managed with the round block technique were searched for in the Changhua Christian Hospital oncoplastic breast surgery database. The patients' clinicopathologic characteristics, type of surgery, operation time, blood loss, and complications were recorded. The cosmetic outcome was evaluated by the patient and operating surgeon two months after the surgery.

RESULTS

Twenty patients with multicentric fibroadenomas managed by the round block technique comprised the current study cohort. The mean age of the subjects was 36.5 ± 10.4 years. Twelve (60%) patients had tumors on one side of the breast, and eight (40%) had bilateral breast lesions. The average number of tumors removed was 3.3 ± 1.2 (range 2-6) per breast, and mean tumor size was 2.2 ± 0.5 cm. Three (15%) patients developed mild ecchymosis of the breast undergoing operation, which resolved spontaneously. One (5%) patient had partial nipple ischemia/necrosis due to 2 tumors excised near the nipple-areolar complex. The aesthetic results were evaluated as good in 19 (95%) patients and fair in 1 (5%).

CONCLUSIONS

The round block technique is a useful oncoplastic procedure for the management of multicentric fibroadenomas excised at the same time.

Use of boost radiotherapy in oncoplastic breast-conserving surgery - a systematic review

BACKGROUND

The use of local boost radiotherapy to the tumour bed has been demonstrated in randomised-controlled trials to reduce local recurrence rates following breast-conserving surgery (BCS) and is the standard of care. Oncoplastic BCS techniques with parenchymal rearrangement present new challenges to the localisation of the tumour bed and therefore delivery of local boost radiotherapy. The aim of this review was to evaluate the reporting of boost radiotherapy in the oncoplastic BCS literature.

METHODS

Pubmed, Ovid MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched for studies reporting oncoplastic BCS using volume displacement techniques.

RESULTS

24 studies met the inclusion criteria (n = 1933 patients). Use of boost radiotherapy was reported in 11 studies, in 2 of which it was for the treatment of incomplete or close margins, and marking of the tumour bed was only reported in 8 studies. None of the studies reported the number of patients where the tumour bed could not be localised.

CONCLUSIONS

The use of local boost radiotherapy and tumour bed marking was not reported in the majority of studies of oncoplastic BCS. Future studies need to provide detailed information regarding the use of boost radiotherapy and difficulties determining the target volume so that current radiotherapy approaches can be reviewed and improved for these advanced techniques.