A feasibility study assessing quantitative indocyanine green angiographic predictors of reconstructive complications following nipple-sparing mastectomy

Introduction

Immediate post-mastectomy breast reconstruction offers benefits; however, complications can compromise outcomes. Intraoperative indocyanine green fluorescence angiography (ICGFA) may mitigate perfusion-related complications (PRC); however, its interpretation remains subjective. Here, we examine and develop methods for ICGFA quantification, including machine learning (ML) algorithms for predicting complications.

Methods

ICGFA video recordings of flap perfusion from a previous study of patients undergoing nipple-sparing mastectomy (NSM) with either immediate or staged immediate (delayed by a week due to perfusion insufficiency) reconstructions were analysed. Fluorescence intensity time series data were extracted, and perfusion parameters were interrogated for overall/regional associations with postoperative PRC. A naïve Bayes ML model was subsequently trained on a balanced data subset to predict PRC from the extracted meta-data.

Results

The analysable video dataset of 157 ICGFA featured females (average age 48 years) having oncological/risk-reducing NSM with either immediate (n=90) or staged immediate (n=26) reconstruction. For those delayed, peak brightness at initial ICGFA was lower (p<0.001) and significantly improved (both quicker-onset and brighter p=0.001) one week later. The overall PRC rate in reconstructed patients (n=116) was 11.2%, with such patients demonstrating significantly dimmer (overall, p=0.018, centrally, p=0.03, and medially, p=0.04) and slower-onset (p=0.039) fluorescent peaks with shallower slopes (p=0.012) than uncomplicated patients with ICGFA. Importantly, such relevant parameters were converted into a whole field of view heatmap potentially suitable for intraoperative display. ML predicted PRC with 84.6% sensitivity and 76.9% specificity.

Conclusion

Whole breast quantitative ICGFA assessment reveals statistical associations with PRC that are potentially exploitable via ML.

Practice of Tumor Bed Boost in Patients after Oncoplastic Breast-Conserving Surgery

The practice of boost to the tumor bed after treatment with oncoplastic breast-conserving surgery (BCS) remains variable. Using a survey, the present study evaluated the current practice of tumor bed boost administered in women after oncoplastic BCS. Actively practicing radiation oncologists across India were sent a questionnaire on the practice of adjuvant whole-breast radiotherapy and tumor bed boost after oncoplastic BCS via email and encouraged to participate. Of the 54 radiation oncologists who participated, most (98.1%) used a linear accelerator for radiotherapy. Hypofractionation was preferred by 59.26%, standard fractionation by 7.41%, and the remaining selected the fractionation strategy based on various patient factors. In addition, 83.33% participants reported that they always planned tumor boost, 51.85% preferred photons for the boost, and 75.93% administered sequential boost. The most common dose for the boost was 12.5 Gy in five fractions (40.74%). Most participants (77.78%) revealed that they used a combination of methods for identifying the tumor bed. With respect to clip placement, most surgeons (96%) at the participants' centers placed ≥ 4 clips at the tumor site, with both the base and margins being preferred by surgeons (81.48%) for placement. Finally, 12.96% participants revealed that the surgeons always involved them during surgical planning, whereas 7.4% participants reported that they always included the surgeons during radiotherapy planning, suggesting that radiation oncologists and oncoplastic surgeons do not involve each other during surgical and radiotherapy planning, possibly leading to suboptimal treatment. This may be attributed to the absence of guidelines regarding boost practices after oncoplastic BCS.

The King is in the altogether: Radiation therapy after oncoplastic breast surgery

Breast cancer is the most common malignancy, and the majority of the patients are diagnosed at an early disease stage. Breast conservation is the preferred locoregional approach, and oncoplastic breast conservation surgery is becoming more popular. This narrative review aims to discuss the challenges and uncertainties in target volume definition for postoperative radiation after these procedures, to improve radiation therapy decisions and encourage multidisciplinary.

A Clinical Analysis of Prognosis and Patient-Reported Outcomes of Oncoplastic Breast-Conserving Surgery for Early Breast Cancer: A Retrospective Cohort Study

PURPOSE

Approximately 25-30% of patients suffer from breast deformity and/or asymmetry after conventional breast-conserving surgery (CBCS). Generally, it is thought that oncoplastic breast-conserving surgery (OBCS) results in an improved cosmetic result; however, studies comparing the prognosis and aesthetic outcomes of CBCS and OBCS in early breast cancer (EBC) are inadequate.

METHODS

A total of 143 patients were included in this retrospective cohort study; 53 underwent OBCS and 90 underwent CBCS. The resected weight, complications, esthetic results, patient satisfaction, and recurrence rate were compared between the groups. Patient-reported outcomes (PRO) were assessed by the BREAST-Q questionnaire.

RESULTS

The mean age of the patients in OBCS group was 43.8 years. This was younger than that in CBCS group (49.1 years, p < 0.001). Postoperative complications (11.3% vs. 8.9%, p = 0.64) and re-excision (5.7% vs. 6.7%, p > 0.99) rates were similar. The OBCS group had higher breast satisfaction and psychosocial well-being than the CBCS group (75 vs. 63, p < 0.001 and 84 vs. 77, p = 0.05); however, sexual well-being (56 vs. 66, p = 0.05) and physical well-being (65 vs. 76, p < 0.001) were worse in OBCS. After 42.3 (range: 12.6-69.2)-month median follow-up, no difference in event-free survival (EFS) was demonstrated between the groups (p = 0.13).

CONCLUSION

Although OBCS has the better aesthetic outcomes and identical oncological safety in comparison with CBCS, the sexual and physical well-being in OBCS are not improved for Asian patients. Hence, choosing an appropriate procedure may be more important for the typically small to moderate-sized breasts characteristic of Asian females unlike Westerners.

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 .

Modern Approaches to Oncoplastic Surgical Treatment

Partial breast reconstruction using oncoplastic techniques is performed at the time of lumpectomy and includes volume replacement techniques such as flaps and volume displacement techniques such as reduction and mastopexy. These techniques are used to preserve breast shape, contour, size, symmetry, inframammary fold position, and position of the nipple-areolar complex. Newer techniques such as auto-augmentation flaps and perforator flaps continue to broaden options and newer radiation therapy protocols will hopefully reduce side effects. Options for the oncoplastic approach now include higher risk patients as there is a larger repository of data on the safety and efficacy of this technique.

Adverse Outcome of Two-Staged Breast Reconstruction: More Than One Culprit

BACKGROUND

Two-stage prosthetic breast reconstruction with initial insertion of a tissue expander followed by change-over to an implant after a period of inflation has become a well-established option in breast reconstruction. Our aim was to analyze the feasibility of two-stage breast reconstruction in our center by following the surgical technique, number of complications and associated risk factors.

PATIENTS AND METHODS

We studied 91 patients who underwent skin sparring mastectomy and tissue expander placement in our surgical unit, between January 2017 and December 2021. Axillary surgery was performed in all patients. We collected data on age, smoker status, breast size, comorbidities, tumor characteristics, neoadjuvant treatment and surgical intervention details.

RESULTS

Skin necrosis (12.08%) and seroma (16.48%) were the most common complications. 7.69% of the patients required reintervention. Patients underwent delayed reconstruction after more than 6 months in 69.7% of the cases, while the overall reconstruction rate was 86.08%. Smoker status, an increased body mass index, comorbidities, neoadjuvant treatment, type of incision and location of the implant were the main factors that led to adverse outcomes.

CONCLUSIONS

Tissue expanders are a viable option for reconstruction; however, we observed a higher incidence of skin complications in smokers and in cases where periareolar incision was used.

Aesthetic monitoring-based assessment of oncological safety of oncoplastic management of breast cancer: a multi-center research study

BACKGROUND

Oncoplastic Breast surgeries (OBS) in breast cancer have evolved to preserve the cancerous breast rather than its amputation to improve postoperative cosmetic results. The lack of evidence to support the oncological safety and benefits of OBS is questionable. In this study, we evaluate various aspects of oncoplastic surgeries with a focused monitoring of aesthetic results and oncological safety.

METHODS

This was a multi-center observational study focused on the statistics of data collected from cases who underwent oncoplastic surgeries from the cohort of breast cancer candidates at Mansoura University Hospitals/Egypt and King Faisal Medical Complex/KSA from January 2015 to June 2018. All data were analyzed carefully using SPSS v-26.

RESULTS

Eighty cases who underwent different oncoplastic surgeries were included and reviewed for the aesthetic outcome and oncological safety. The recurrence rate was found to be 2.5%. The breast impact treatment scale assessment method was used to analyze the aesthetic outcomes, and average scores were accepted in 90% of patients.

CONCLUSIONS

The oncoplastic breast surgeries are feasible and they had a high rate of oncological safety with the maintenance of good aesthetic outcomes and patient satisfaction.

Lateral intercostal artery perforator (LICAP) flap for breast volume augmentation: Applications for oncoplastic and massive weight loss surgery

Background

Lateral intercostal artery perforator (LICAP) flap for breast volume augmentation provides the benefits of addressing axillary tissue excess and avoiding intramuscular dissection. Previous experience with the LICAP flap in patients with prior breast conservation therapy (BCT) has led to the development of an extended version for massive weight loss (MWL) patients as well.

Methods

A retrospective review of all cases of LICAP flaps was performed by a single surgeon. Data were subsequently extracted and analyzed including patient demographics, indication and timing of volume augmentation, complications, and follow-up length.

Results

From 2016 to 2020, 12 patients underwent 16 LICAP flaps for volume augmentation. Indications for volume augmentation included deficits from prior oncologic surgery (ten patients) and loss of volume due to MWL (two patients). The average BMI was 29.9 kg/m². Among the oncologic group, eight patients had delayed reconstruction, while two were immediate. Nine patients underwent radiation prior to volume augmentation. Eight of the 14 patients simultaneously received fat grafting. There were 4 cases of delayed wound healing that improved with local wound care. There were no statistically significant differences in complication rates between the oncologic and MWL groups. The average length of follow-up was 11.4 months.

Conclusions

This study supports that the application of the LICAP flap can be effectively broadened from the oncologic population to the MWL population. If needed, extending the flap provides an option to simultaneously address excess axillary and back tissue.

Oncoplastic breast surgery: A guide to good practice

Oncoplastic Breast Surgery has become standard of care in the management of Breast Cancer patients. These guidelines written by an Expert Advisory Group; convened by the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), are designed to provide all members of the breast cancer multidisciplinary team (MDT) with guidance on the best breast surgical oncoplastic and reconstructive practice at each stage of a patient's journey, based on current evidence. It is hoped they will also be of benefit to the wide range of professionals and service commissioners who are involved in this area of clinical practice.

Breast MRI in DCIS size estimation, breast-conserving surgery and oncoplastic breast surgery

The impact of MRI on improving surgical outcomes in DCIS is debated. Here, we explore the utility of MRI in the investigation and management of DCIS in three key areas. Firstly, we highlight that MRI is likely to be a more accurate predictor of actual tumour size than conventional imaging. Secondly, we examine mastectomy rates and reoperation rates across the literature and suggest that surgical outcomes do not differ between pre-operative MRI and conventional imaging groups, despite improved size estimation on MRI. Finally, we examine the rapidly developing field of oncoplastic breast surgery and highlight a paucity of data in determining the usefulness of pre-operative MRI in this field, despite this being an oncologically safe alternative with improved patient outcomes and satisfaction.

Significantly reducing implant loss rates in immediate implant-based breast reconstruction: A protocol and completed audit of quality assurance

INTRODUCTION

Immediate implant-based breast reconstruction (IBR) rates have increased considerably with the advent of acellular dermal matrices. Implant loss is a significant complication and is costly to patients and the NHS. National Mastectomy and Breast Reconstruction Audit and Implant-Based Breast Reconstruction Audit data have demonstrated national implant loss rate of 9% at 3 months. National Oncoplastic Guidelines for Best Practice cite a < 5% target. We aimed to reduce implant loss by introducing a protocol with pre-, intra- and post-operative interventions.

METHODS

Audit of IBR at a single oncoplastic breast unit was commenced and implant loss at 3 months was recorded (May 2012-July 2014). Patients were identified from a prospectively maintained database, and case notes were examined by identifying factors associated with implant loss. A team involving microbiology, theatre staff, infection control and surgeons was established. A novel, evidence-based intervention bundle, including more than 25 protocol changes, was introduced. Prospective re-audit of IBR (April 2015-December 2017) was completed following introduction of the new protocol and implant loss was recorded at 3 months.

RESULTS

The first retrospective audit of 77 reconstructions (54 patients) demonstrated 11 implant losses at 3 months (14%). Re-audit, post-intervention, comprised 129 reconstructions (106 patients) with no implant loss at 3 months. Fisher's exact analysis revealed statistically significant reduction in implant loss rate (P < 0.00001) following protocol introduction.

CONCLUSIONS

Implant loss rate following IBR can be reduced to an exceptionally low level, well below national targets, by adhering to this evidence-based intervention bundle. Our protocol could improve outcomes nationally.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Central round block repair of large breast resection defects: oncologic and aesthetic outcomes

Background

The central round block repair is a volume displacement technique to reconstruct large wide local excision (WLE) defects in breasts with moderate ptosis or hypertrophy. There are limited published data on the outcomes of this technique.

Methods

Data were collected prospectively for 57 consecutive patients and follow up information obtained from patient records. The volume of breast resection was estimated geometrically from mammography. Aesthetic outcomes were assessed from clinical measurements and panel review of patient photographs.

Results

The median age was 51 [22-86] years and follow-up 5 (1.9-8.4) years. The median specimen resection weight was 50 [25-361] g and tumour size 25 [10-75] mm. Estimated volume of breast excised was 17.8% (6-31%). In total, 12/57 patients had incomplete margins: five patients had re-excision to achieve clear margins and seven required mastectomy. Two patients had local recurrence during the follow-up period, five developed distant metastases. Aesthetic data were completed for 35/50 patients. Twelve (34%) had no measurable asymmetry and 31 (89%) had a nipple position within 2 cm of the original height. Only two patients requested symmetrising surgery.

Conclusions

Central round block reconstruction of large defects after WLE is a safe technique with good aesthetic outcomes. Contralateral symmetrising surgery is not usually required.

Effect of BioZorb® surgical marker placement on post-operative radiation boost target volume

Objective

BioZorb® is a tumor bed marker placed during partial mastectomy for targeted post-operative radiation. This study was designed to evaluate BioZorb® effect on radiation boost clinical target volume (CTV), planning target volume (PTV), median dose to ipsilateral lung (Gy), and heart irradiation in left-sided cancers.

Methods

Data was collected via a retrospective cohort study with two study arms: BioZorb® intra-operative placement versus no BioZorb® placement. Patients were stratified by BMI, age, tumor laterality and volume, and cancer stage. Mean, standard deviation, median, range of cubic centimeters of clinical and planning target volume, cardiac dose in left-sided cancers, ipsilateral lung dose, and volume of ipsilateral lung receiving 20 Gy were reported.

Results

Of 143 patients, median CTV (cm³) was 8.7 and 14.2 (P = 0.0048), median PTV (cm³) was 53.2 and 79.6 (P = 0.0010), median ipsilateral lung Gy was 7.53 and 6.74 (P = 0.0099) and volume (cc) of ipsilateral radiation lung at 20 Gy was 13.4 and 12 (P = 0.008), and median heart Gy in left-sided cancers was 2.01 and 2.21 (P = 0.9952) in BioZorb® and non-BioZorb® arms, respectively. Patients with BMIs of 25–30 had CTV medians of 7.8 and 11.1 in BioZorb® and non-BioZorb® arms, respectively (P = 0.0293).

Conclusion

The BioZorb® arm showed statistically significant reductions in CTV and PTV but not ipsilateral lung or heart irradiation.

Oncoplastic breast conservation surgery is oncologically safe when compared to wide local excision and mastectomy

BACKGROUND

Support for the oncological safety of oncoplastic breast conservation surgery (OBCS) is mostly based on evidence comparing recurrence rates after OBCS to wide local excision (WLE). However, OBCS is often indicated for larger cancers and oncological results should also be compared to patients treated with mastectomy. In this study we compared recurrence and survival following OBCS, mastectomy and WLE.

METHODS

Patients treated with OBCS between 2009 and 2012 were identified from a prospectively maintained database. For comparison, consecutive patients treated with WLE or mastectomy with or without immediate reconstruction (Ms ± IR) over the same time period were identified. Histological variables of patients were compared using Fisher Exact or Chi squared tests, and recurrence and survival were compared using Kaplan-Meier and Cox regression survival analysis.

RESULTS

980 patients' data were analysed (OBCS: n = 104; WLE: n = 558; Ms ± IR: n = 318). Tumour size, grade, nodal status, ER, and PR expression of patients treated with OBCS were all significantly more adverse compared with patients treated with WLE (p < 0.001). These histological variables were similar in patients treated with Ms ± IR and OBCS. 5-year local recurrence rates were similar in all three groups (WLE: 3.4 per cent, OBCS: 2 per cent, Ms ± IR: 2.6 per cent; log rank = 0.973), while distant recurrence rates were higher after Ms ± IR and OBCS (Ms ± IR:13.1 per cent, OBCS:7.5 per cent, WLE:3.3 per cent; log rank: p < 0.001).

CONCLUSION

OBCS is oncologically safe in patients even when histological results are similar to patients treated with Ms ± IR.

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.

Imaging Results Following Oncoplastic and Standard Breast Conserving Surgery

BACKGROUND

Oncoplastic breast-conserving surgery (OBCS) requires more complex surgical techniques than standard wide local excision (WLE) and the postoperative complication rate may be higher. Since these can have an impact on postoperative imaging, we compared imaging and biopsy results after OBCS and WLE.

METHODS

Findings for patients undergoing OBCS (n = 83) or standard WLE (n = 128) were compared. Numbers, indications and outcomes of mammograms, breast ultrasounds, magnetic resonance imaging scans and biopsies done within 2 years after surgery were analysed.

RESULTS

OBCS was applied for more advanced malignancy. Significantly more patients required breast ultrasound after OBCS than WLE (20/71 vs. 17/116; p = 0.024). Breast Imaging Reporting and Data System (BI-RADS) category 3 or 4 ultrasound results were found only in patients with OBCS (6/29 vs. 0/19; p = 0.034). Significantly more biopsies were required after OBCS (9/71 vs. 3/116; p = 0.006). New lumps or lumpiness were the commonest indications, and pathology confirmed fat necrosis in the majority (7/12). The rate of fat necrosis after OBCS was 18% on clinical examination (13/71), 15% with ultrasound (11/71) and 7% confirmed on pathology (5/71).

CONCLUSION

Patients treated with OBCS require significantly more ultrasound scans and consequent biopsies than patients who underwent WLE. This is mainly due to fat necrosis developing after OBCS in the majority of cases.

Oncoplastic breast conserving surgery

Oncoplastic breast conserving surgery is a fundamental component of the repertoire for the management of breast cancer. It facilitates removal of large volumes of breast tissue, and can improve cosmetic outcomes and patient satisfaction whilst maintaining good oncological principles, reducing re-excision and mastectomy rates and assisting in adjuvant radiotherapy planning. We review the various techniques for oncoplastic breast conserving surgery that have emerged over recent years and describe their utilisation in excising tumours from various locations within the breast, and the pertinent patient specific factors that must be considered in technique selection. Finally complications and the evidence for the oncological safety specific to this type of surgery are discussed.

Training the oncoplastic breast surgeon-current and future perspectives

Oncoplastic breast surgery has evolved to become a distinct subspecialty within the field of general surgery. The oncoplastic breast surgeon requires comprehensive knowledge and understanding of all aspects of breast oncology, in addition to technical proficiency in operative procedures to remodel and reconstruct the breast. This article describes current educational resources available for the training of oncoplastic breast surgeons both within the UK and internationally. A recent development is the online Master of Surgery degree in Oncoplastic Breast Surgery, based at the University of East Anglia in the UK. This innovative course combines delivery of clinical knowledge using interactive problem-based forum discussions with assessment of operative and decision making skills. The degree is facilitated and assessed by an expert specialist breast faculty, and requires students to achieve standards expected of a first year practising UK oncoplastic breast consultant. Future international developments using this blended educational model are discussed.

Current aspects of therapeutic reduction mammaplasty for immediate early breast cancer management: An update

Breast-conservation surgery (BCS) is established as a safe surgical treatment for most patients with early breast cancer. Recently, advances in oncoplastic techniques are capable of preserving the breast form and quality of life. Although most BCS defects can be managed with primary closure, the aesthetic outcome may be unpredictable. Among technical options, therapeutic reduction mammaplasty (TRM) remains a useful procedure since the BCS defect can be repaired and the preoperative appearance can be improved, resulting in more proportional breasts. As a consequence of rich breast tissue vascularization, the greater part of reduction techniques have based their planning on preserving the pedicle of the nipple-areola complex after tumor removal. Reliable circulation and improvement of a conical shape to the breast are commonly described in TRM reconstructions. With an immediate approach, the surgical process is smooth since both procedures can be carried out in one operative setting. Additionally, it permits wider excision of the tumor, with a superior mean volume of the specimen and potentially reduces the incidence of margin involvement. Regardless of the fact that there is no consensus concerning the best TRM technique, the criteria is determined by the surgeon’s experience, the extent/location of glandular tissue resection and the size of the defect in relation to the size of the remaining breast. The main advantages of the technique utilized should include reproducibility, low interference with the oncological treatment and long-term results. The success of the procedure depends on patient selection, coordinated planning and careful intra-operative management.

Quality of information reporting in studies of standard and oncoplastic breast-conserving surgery

The aim of this systematic review was to establish the completeness of reporting of key patient, tumour, treatment, and outcomes information in the randomized-controlled trials (RCTs) of standard breast-conserving surgery (sBCS) considered to be the 'gold-standard', and to compare this with the reporting of the same key criteria for all published studies of oncoplastic breast-conserving surgery (oBCS). Pubmed (1966 to 1st April 2013), Ovid MEDLINE (1966 to 1st April 2013), EMBASE (1980 to 1st April 2013), and the Cochrane Database of Systematic Reviews (Issue 4, 2013) were searched separately for the following terms: (i) 'oncoplastic AND breast AND surgery'; and (ii) 'therapeutic AND mammaplasty'. Only English language and full text articles were reviewed. Following a pilot evaluation of all studies, key reporting criteria were identified. 16 RCTs of sBCS (n = 11,767 patients) were included, and 53 studies met the inclusion criteria for oncoplastic BCS (n = 3236 patients), none of which were RCTs. No study reported all of the criteria identified, with a mean of 64% of key criteria (range, 55-75%) reported in studies of sBCS, and 54% of criteria (range, 10-85%) reported in studies of oBCS. It is therefore evident that there is much room for improvement in the quality of reporting is BCS studies. Standards are proposed to give future studies of BCS a framework for reporting key information and outcomes.

Surgical and oncological outcome after skin-sparing mastectomy and immediate breast reconstruction

INTRODUCTION

We present clinical outcomes after SSM in operable breast cancer especially in light of increased diagnoses of in situ disease after screening and increased usage of adjuvant aromatase inhibitors (AIs) in recent years.

PATIENTS AND METHODS

Case records of 81 patients who had SSM for cancer over 4 years (April 2006-July 2010) were reviewed.

RESULTS

Eighty-one patients (median age, 51.7 years; range, 31.5-66.1 years) had 82 SSMs with immediate breast reconstruction (IBR) (59 implant-based; 23 latissimus dorsi flap). Median tumor size was 22 mm (range, 1-86 mm) including in situ disease, and tumor types were invasive (n = 48) and noninvasive (n = 34). Median clearance margin was 5 mm (range, 0-45 mm). Sentinel node was positive in 15 SSM (19.5%) excluding 5 in pure in situ disease. Median Nottingham prognostic index was 3.54 (range, 2.1-6.98), 84% were estrogen receptor-positive (pure in situ, 70.6%), and 8.5% were HER2-positive. Radiotherapy to breast was given to 17.1% of patients and 37.8% of patients received hormone therapy (tamoxifen, 24.4%; upfront AI, 4.9%; switch regime, 8.5% [ie, tamoxifen to exemestane at 2 years). Eight patients (9.6%) had infection/wound healing problems with loss of implant in 3 (3.6%). At median follow-up of 23.9 months (range, 9-64), there was 1 local with systemic (liver) and 1 SR only (brain and liver) after invasive disease with median disease-free survival of 24.4 months (range, 6.1-61.9).

CONCLUSIONS

Despite less use of AIs in our series, the local recurrence (2%) and SR (4%) rates were less than reported in the literature for invasive tumors. This suggests that SSM provides opportunity for enhanced esthetic outcome with IBR without compromise of the local oncological safety compared with conventional simple mastectomy.

Male mastectomy: an oncoplastic solution to improve aesthetic appearance

Mastectomy for breast cancer in men typically results in an unsatisfactory aesthetic appearance due to loss of the normal male chest contour. In this article we present two case studies and a new oncoplastic surgical technique that has given excellent aesthetic results for this challenging problem.

Oncoplastic Breast Surgery - Our Experiences in the Breast Clinic, IPGME&R, Kolkata

Oncoplastic breast surgery is the fusion of oncological and surgical principles to gain successful breast tumour excision with good cosmesis. It is an widely accepted and popular method in the western world. However, the picture is different in India. The major issues here, like late detection and advanced tumours, poor socio-economic status overriding quality of life issue and shortage of dedicated oncoplastic surgeons result in a poor acceptance and practice of oncoplastic breast surgery. This article explores the use of various oncoplastic techniques in clinical practice and discusses future directions in this emerging field in an Indian perspective. In our institute (breast care unit, I.P.G.M.E&R,Kolkata), we performed a retrospective study over a period of five years (2005-2009). It included a sample size of 30 patients with diagnosed breast cancer or Phylloides Tumor (PT). The study focused on the indications, type of oncoplastic procedure used, cosmetic outcome (shape / volume replacement, ptosis correction & chest wall coverage), complications faced and response to subsequent therapy. The indications, for which oncoplastic techniques were applied, were DCIS (2), LCIS (1), IDC (19) and phylloides tumor (8). Of the 30 patients, RAT was used in 8, LDMF (of various types and volume) was used in 16, pedicled TRAM flap was used in 3 and reduction mastopexy in 3.The procedural indications of reconstruction were total glandular replacement by TRAM flap, mini-LDMF to fill volume loss after BCS or wide local excision, rotation advancement technique for reshaping / symmetry maintenance after BCS or wide local excision, LDMF for chest wall coverage after MRM and reduction mastopexy after wide local excision. From patient's point of view the outcome of surgery was highly satisfactory (score 3 or more) in 19 out of 30 patients (63.33%). LDMF was the most commonly used (16 out of 30) oncoplastic procedure with least complication rates (0 out of 16). 4 out of 30 patients had complications related to the procedure. Chest wall coverage after MRM still forms the main indication of oncoplastic surgery in this country.

Optimizing results of breast cancer surgery: a 8 yrs' experience

Management of breast cancer in developing country, in contrast to Western countries, is challenging considering more number of advanced cases and poor understanding of the disease and its management by the population and even many physicians. We tried to look prospectively at our experience with breast cancers, trying to optimize the results given the wide- variety of cases we see.