Oncoplastic reduction mammaplasty, an effective and safe method of breast conservation

doi:10.1016/j.amjsurg.2018.02.024

The American Journal of Surgery

Volume 215, Issue 5, May 2018, Pages 910-915

https://doi.org/10.1016/j.amjsurg.2018.02.024 Get rights and content

Highlights

•
Oncoplastic surgery expands the indications for breast conservation.
•
Oncoplastic surgery can be offered to patients despite presence of comorbidities.
•
Reduction mammaplasty has excellent cosmetic and oncologic outcomes.
•
Surgical breast oncologists can effectively perform reduction mammaplasties.

Abstract

INTRODUCTION

Oncoplastic breast conserving surgery (BCS) can enhance both cosmetic and oncologic breast cancer outcomes. This study evaluates the outcomes and complications associated with oncoplastic reduction mammaplasty performed by surgical breast oncologists.

METHODS

A single institution retrospective chart review of patients undergoing oncoplastic reduction mammaplasty by a surgical breast oncologist for the treatment of breast cancer.

RESULTS

Seventy-one patients were identified. The average patient age was 59.6 years (range 37–77 years). Average lesion span was 31.4 mm (range 3–166 mm). Six (8.5%) patients required additional surgery to obtain adequate margins. One (1.4%) patient developed recurrent disease during the follow-up interval. No major surgical complications were observed.

CONCLUSION

Oncoplastic reduction mammaplasty is associated with low rates of re-excision and complications and can be safely and effectively performed by appropriately trained surgical breast oncologists.

Introduction

Breast conserving therapy (BCT) comprises partial mastectomy, axillary staging, and adjuvant systemic and radiation therapy. Seminal randomized studies have shown equivalent disease-free and overall survival with low risk of local recurrence that is comparable to mastectomy. As a result, BCT has become standard of care for the treatment of early stage breast cancer.1, 2, 3, 4

Successful BCT requires wide local resection with the goal of attaining adequate oncologic margins, which can compromise breast cosmesis and functionality. In fact, studies have shown that up to 40% of patients undergoing BCT have poor cosmetic outcomes.⁵ Additionally, recent studies have suggested that up to 40% of patients with breast cancer have macromastia, which is associated with increased rates of poor cosmetic outcomes attributed to increased rates of asymmetry, tissue retraction, and radiation changes.⁶

Oncoplastic surgery, which incorporates plastic surgical approaches at the time of partial mastectomy, has emerged as an alternative approach to breast conserving surgery.⁷ Because these tissue rearrangement techniques allow for larger resections, oncoplastic surgery has expanded the indications for breast conservation, allowing many patients with large or multifocal cancers who may have traditionally been advised to undergo mastectomy to consider BCT.7, 8, 9 Larger tissue resections also allow for wider margins; as a result, oncoplastic surgery has been shown to reduce rates of inadequate surgical margins, which results in fewer re-excisions and mastectomies compared to traditional partial mastectomy.10, 11, 12 Adjuvant therapies can then be initiated more expeditiously by avoiding additional operations.¹³ Given the multitude of benefits, interest in oncoplastic surgery has increased over the course of the last decade.14, 15, 16

The panoply of oncoplastic techniques ranges from simple volume redistribution techniques, including radial ellipse and mastopexy, to more advanced tissue rearrangement schemes such as reduction mammaplasty and contralateral procedures for symmetry.¹⁷ The more advanced techniques frequently require a multidisciplinary approach wherein a surgical breast oncologist resects the cancer and a plastic surgeon performs the tissue rearrangement component of the operation.¹⁸ Because oncoplastic surgery involves tissue rearrangement and may also include procedures on the contralateral breast for symmetry, there is concern that oncoplastic surgery may expose patients to additional surgical risks and complications. It has also been suggested the oncoplastic surgery may impair the accuracy of adjuvant radiation therapy targeting by making the localization of the tumor bed more challenging.¹³

Despite the ability to perform large resections, inadequate margins may still be found on final pathology. Critics of oncoplastic surgery raise concerns about the ability to accurately perform re-excision after oncoplastic surgery since traditionally tissue rearrangement and complex closure is typically performed by a plastic surgeon after cancer resection. As a result, there is rising interest among surgical breast oncologists to seek additional training in order to perform not only the cancer resection, but also the reconstruction to improve both oncologic and cosmetic outcomes.

This study reports the oncologic and cosmetic outcomes for patients undergoing oncoplastic reduction mammaplasties performed by surgical breast oncologists.

Section snippets

Methods

Oncoplastic reduction mammaplasty performed by surgical breast oncologists is routinely offered to patients for treatment of breast cancer at Virginia Mason Medical Center in Seattle, WA. This study assesses the oncologic and cosmetic outcome of seventy-one consecutive patients who were treated by two surgical breast oncologists using this approach. The study was approved by the institutional review committee and met the guidelines of the responsible governmental agency. All patients undergoing

Results

Seventy-one patients underwent oncoplastic reduction mammaplasty (Table 2). The average patient age was 59.6 years (range 37–77) and the average BMI was 31.9 kg/m² (range 18–42). Thirty-five (49.3%) patients had BMIs greater than 30 and 23 (32.4%) patients had BMIs greater than 35. Nine patients had diabetes (12.6%). Three patients (4.2%) had genetic mutations including 1 with BRCA1, 1 with BRCA2, and 1 with CHEK2 mutations. Fourteen (19.7%) patients had smoked within a year of surgery.

Discussion

Overall, the oncologic outcomes associated with oncoplastic reduction mammaplasty were excellent. Rate of inadequate margins (9.8%) and need for mastectomy (2.8%) were low and consistent with recent studies despite having relatively large tumors (average 31.4 mm, ranging up to 166 mm).¹⁸ Inadequate margins were all for DCIS, the full extent of which is notoriously challenging to ascertain on preoperative imaging.²⁰ The patients who underwent re-excision had benign tissue on re-excision

Conclusions

Oncoplastic reduction mammaplasty has expanded the indications for BCT.7, 8, 9 This study demonstrates that oncoplastic reduction mammaplasty can be performed safely by appropriately-trained surgical breast oncologists with an acceptable complication profile and achieve excellent oncologic and cosmetic outcomes.

Conflicts of interest

The authors have no conflicts of interest.

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Cited by (20)

Breast diseases
2023, DiSaia and Creasman Clinical Gynecologic Oncology
The breast is a hormone sensitive gland that develops during adolescence. Diseases of the breast comprise a spectrum of disorders ranging from benign to malignant. Breast cancer remains the most common malignancy among American women, comprising 15.2% of incident cancer cases in the United States. The American Cancer Society estimates that approximately 281,550 incident cases of invasive breast cancer in females in addition to approximately 48,000 incident cases of ductal carcinoma in situ will be diagnosed in 2021. Approximately 43,600 women are expected to die from breast cancer, making breast cancer the second leading cause of cancer-related death after lung cancer. The lifetime risk among women of developing breast cancer is 12.5% (1 in 8); the lifetime risk of dying from breast cancer is 3.6% (1 in 28). Recent advances in screening and systemic therapies have been credited with improved disease-free and overall survival. This decline is thought to be secondary to the increased use of mammographic screening with early detection of breast cancer and the use of effective adjuvant therapies. This chapter presents an overview of breast cancer screening, diagnosis, and treatment of benign and malignant conditions of the breast. Some of the many factors that have led to improved disease-specific survival include early screening and improvement in adjuvant therapies, as well as decreased rates of hormone replacement therapy as a result of the Women’s Health Initiative reports.
The no-vertical scar technique for oncoplastic breast reconstruction
2023, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
The Wise pattern, based on the inferior pedicle, is another common oncoplastic method.10-12,17 While the peri‑areolar, vertical, and inframammary fold (IMF) scars allow for versatility in tissue resection and re-arrangement, the Wise pattern is prone to wound breakdown at the “T-point”.10-19 A free nipple graft may be necessary for very large-breasted, ptotic patients.
Oncoplastic reconstruction can optimize breast conserving therapy. Nipple loss is a concern in patients with significant ptosis and breast hypertrophy particularly with pedicle undermining during tumor resection. The modified Robertson technique (No-Vertical Scar reduction) has been previously described for breast reduction in large, ptotic patients using a wide, bell-shaped inferior pedicle with only inframammary fold and peri‑areolar incisions. The purpose of this study was to evaluate the No-Vertical Scar (NVS) technique applied to oncoplastic reconstruction.
Women undergoing oncoplastic breast reduction using a NVS, Wise, or Vertical method were assessed. Predictive variables included patient demographics, comorbidities, and sternal notch to nipple (SNN) distance. Outcome variables were delayed wound healing, surgical site infection, seroma, fat necrosis, nipple necrosis, use of a free nipple graft, and time between surgery and adjuvant radiation.
Fifty patients met inclusion criteria using NVS (N = 15), Wise (N = 16), and Vertical (N = 19) methods. The NVS group had a significantly higher BMI (p=.009), greater sternal notch to nipple distance (p=<0.001) and increased resection volume (p=<0.001) as compared to Wise and Vertical groups. There was no significant difference in complications (p=.25). No nipple necrosis occurred, and no free nipple grafts were required.
The NVS approach is a useful technique for oncoplastic reconstruction in select patients with macromastia and severe Grade II or Grade III ptosis. The wide, bell-shaped pedicle is versatile for obliterating a lumpectomy cavity and optimizing nipple perfusion if pedicle undermining occurs during resection.
Comparing costs of standard Breast-Conserving Surgery to Oncoplastic Breast-Conserving Surgery and Mastectomy with Immediate two-stage Implant-Based Breast Reconstruction
2022, Journal of Plastic, Reconstructive and Aesthetic Surgery
Conventional breast-conserving surgery (C-BCS) has equal oncological outcomes and superior cosmetic and patient-reported outcomes compared to mastectomy with immediate two-stage implant-based breast reconstruction (M-IBR). Oncoplastic breast-conserving surgery (OP-BCS) is increasingly being used, as it often has better cosmetic results and it enables larger tumour resection. However, OP-BCS and M-IBR compared to C-BCS lengthens operative time and might lead to more complications and consequently to additional costs. Therefore, this study aimed to compare costs and complication rates of C-BCS, OP-BCS and M-IBR.
This single-centre, retrospective cohort study, calculated costs for all patients who had undergone breast cancer surgery between January 2014 and December 2016. Patient-, tumour- and surgery-related data of C-BCS, OP-BCS and M-IBR patients were retrieved by medical record review. Treatment costs were calculated using hospital financial data. Differences in costs and complications were analysed.
A total of 220 patients were included: 74 patients in the C-BCS, 78 in the OP-BCS and 68 in the M-IBR group. From most expensive to least expensive, differences in total costs were found between C-BCS vs. OP-BCS and C-BCS vs. M-IBR (p=<0.01 and p=0.04, respectively). Costs of OP-BCS and M-IBR were comparable. Complication rates were 5.5% for C-BCS, followed by 17% for OP-BCS, and 34% for M-IBR (p<0.01).
Considering total treatment costs, OP-BCS was financially non-inferior to M-IBR, whereas complication rates were higher following M-IBR. Therefore, when considering other benefits of OP-BCS, such as higher patient-reported outcomes and similar oncological outcomes, a shift from M-IBR to BCS using oncoplastic techniques seems justified.
Comparative study of surgical and oncological outcomes in oncoplastic versus non oncoplastic breast-conserving surgery for breast cancer treatment
2021, JPRAS Open
Citation Excerpt :
Some authors found delays in the commencement of adjuvant treatment in 1.9% and 4.6% of patients who underwent oncoplastic surgery.12,31 Known factors such as diabetes, smoking, and the presence of comorbidities were significantly associated with the occurrence of early major complications, as demonstrated in previous studies, which shows that adequate patient selection is the first step to prevent major complications.2 The surgical margin is a determinant prognostic factor in the local control of the disease.15,16,32,33
Background: Oncoplastic surgery has been increasingly used in breast cancer treatment and allows the performance of breast-conserving surgery in cases of larger tumors with unfavorable location or tumor-breast disproportion. Purpose: To compare surgical and oncological outcomes of patients undergoing oncoplastic and nononcoplastic breast-conserving surgery. Methods: Retrospective cohort study with convenience sampling of 866 patients who consecutively underwent breast-conserving surgery from 2011 to 2015. Results: The mean follow-up was 50.4 months. Nononcoplastic breast conservation surgery was performed on 768 (88.7%) patients and oncoplastic surgery on 98 (11.3%) patients. Patients in the oncoplastic group were younger (p<0.0001) and most were premenopausal (p<0.0001). Comorbidities such as diabetes (p=0.003) and hypertension (p=0.0001) were less frequent in this population. Invasive carcinoma >2 cm (p<0.0001), multifocality (p=0.004), ductal in situ carcinoma (p=0.0007), clinically positive axilla (p=0.004), and greater weight of surgical specimens (p<0.0001) were more frequent in the oncoplastic group. A second surgery for margin re-excision was more frequently performed in the nononcoplastic group (p=0.027). There was more scar dehiscence in the oncoplastic group (p<0.001), but there was no difference in early major complications (p=0.854), conversion to mastectomy (p=0.92), or local recurrence (p=0.889). Conclusion: Although used for the treatment of larger and multifocal tumors, surgical re-excisions were performed less often in the oncoplastic group, and there was no increase in conversion to mastectomy or local recurrence. In spite of the higher rate of overall complications in the oncoplastic group, major complications were similar in both groups.
Extreme oncoplasty: Expanding indications for breast conservation
2019, American Journal of Surgery
Citation Excerpt :
Patients had clinical follow up at 1–2 weeks post-surgery, every 6 months for two years, then annually. As described previously, the operating surgeon assigned cosmesis scores at the six-month follow-up using the Harvard Breast Cosmesis Scale.12,18 Surgical complications and interventions were identified through medical record review and the prospectively collected data contained in the Virginia Mason Multidisciplinary Breast Cancer Database.
Presence of multiple lesions and/or tumor span ≥5 cm are traditional indications for mastectomy. Patient desire for breast conservation has increased the interest in extreme oncoplastic breast conserving surgery (EOBCS) to avoid mastectomy; however, perioperative outcomes in this population have not been well described.
This is an observational cohort of breast cancer patients with multiple lesions and disease span ≥5 cm who underwent EOBCS. Patient demographics, disease span, margin width, mastectomy and re-excision rates, and cosmesis were evaluated.
One hundred-eleven patients underwent EOBCS between 2012 and 2017. Eighty-two patients presented with multifocal or multicentric disease with an average of 3.2 lesions per breast spanning 57.1 ± 23.6 mm. Eighteen patients presented with unifocal tumors measuring an average of 67.6 mm (range 50–160 mm) on imaging. Eleven patients with an imaging size of <5 cm had a disease span ≥5 cm on final pathology. No tumor on ink occurred in 87 (78.3%) patients. Fifty-seven (51.4%) patients had additional surgery for inadequate margins. Fifteen (12.6%) patients elected to have mastectomy while 42 (37.8%) patients opted for re-excision. Good to excellent cosmetic results were reported in 95% of patients who ultimately achieved breast conservation. Recurrence rate was 1.1% in patients who completed EOBCS and adjuvant radiation therapy.
EOBCS can allow for breast conservation in patients who are traditionally counseled to undergo mastectomy. Although the re-excision rate was significant, most patients ultimately achieved breast conservation with adequate margins. Further study is warranted to determine the long-term oncologic outcomes of this approach.
Optimise not compromise: The importance of a multidisciplinary breast cancer patient pathway in the era of oncoplastic and reconstructive surgery
2019, Critical Reviews in Oncology/Hematology
Citation Excerpt :
No significant difference in satisfaction rates for cosmetic outcome were seen (Palsdottir et al., 2018). Another small series assessing 71 patients who underwent OBS reported good or excellent cosmetic satisfaction scores in 90% of the 64 respondents (Crown et al., 2018). This is in contrast to data from a Dutch study where patients who had conventional BCS had higher scores for satisfactory cosmetic outcomes compared to OBS (Lansu et al., 2015).
Modern breast cancer care is a complex multidisciplinary undertaking in which the integrated function of multiple constituent parts is critical, and where changes to one therapeutic component may profoundly influence the delivery and outcomes of another. Oncoplastic and reconstructive breast surgery has evolved in the era of longer survival rates for women with breast cancer and aims to enhance oncological and cosmetic outcomes. However, concurrently there has been an expansion in the indications for post-mastectomy radiation therapy (Abdulkarim et al., 2011; Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), 2014; Poortmans et al., 2015; Wang et al., 2011), the recognition of several biologically distinct breast cancer subtypes (Perou et al., 2000; Sørlie et al., 2001, 2003; Cheang et al., 2008, 2009; Sotiriou et al., 2003; Millar et al., 2011; Blows et al., 2010; Schnitt, 2010; Haque et al., 2012; Dai et al., 2015) and the development of recommendations for prophylactic surgery for high-risk women, including BRCA-mutation carriers (James et al., 2006; Domchek et al., 2010). Primary systemic therapy is increasingly utilised yet has varying efficacy depending on tumour biology (Cortazar et al., 2014). In this paper we review the evidence which informs the multidisciplinary team opinion in the era of oncoplastic and reconstructive breast surgery. We aim to describe an optimal multidisciplinary approach which balances competing risks of multimodal therapies to optimise oncological and cosmetic outcomes.

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Oncoplastic reduction mammaplasty, an effective and safe method of breast conservation

Highlights

Abstract

INTRODUCTION

METHODS

RESULTS

CONCLUSION

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Conflicts of interest

EJSO

Eur J Surg Oncol

Eur J Surg Oncol

J Plast Reconstr Aesthetic Surg

J Plast Reconstr Aesthetic Surg

J Plast Reconstr Aesthetic Surg

Clin Breast Canc

Five-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without radiation therapy in the treatment of breast cancer

N Engl J Med

Comparing radical mastectomy with quadrantectomy, axillary dissection and radiotherapy in patients with small cancers of the breast

N Engl J Med

Mastectomy versus breast conserving therapy in the treatment of stage I and II carcinoma of the breast: a randomized trial at the National Cancer Institute

J Clin Oncol

Randomized clinical trial to assess the value of breast-conserving therapy in stage I and II breast cancer, EORTC 10801 trial

Monogr Natl Cancer Inst

A systematic review of oncoplastic breast-conserving surgery: current weaknesses and future prospects

Ann Surg

Oncoplastic breast conservation surgery: the new paradigm

J Surg Oncol

Long-term results after oncoplastic surgery for breast cancer a 10-year follow-up

Ann Surg

Oncoplastic breast-conserving surgery reduces mastectomy and postoperative Re-excision rates

Ann Surg Oncol

Outcomes after oncoplastic breast-conserving surgery in breast cancer patients: a systematic literature review

Ann Surg Oncol

The benefits of margin control of the oncoplastic approach to breast conservation therapy (BCT)

Aesthetic Surg J