Oncoplastic Breast in Brazil

Background:Oncoplastic breast reconstruction addresses lumpectomy or partial mastectomy defects after breast conserving surgery. A large subset of breast cancer patients may be candidates for oncoplastic partial breast reconstruction, but are likely underserved in the United States due to multiple factors. In this article, the authors provide an understanding of current trends in the literature and an overview of key areas for improvement in the delivery of breast cancer surgical care.Methods:A literature search of peer-reviewed articles relating to oncoplastic breast reconstruction was performed. In addition, current US laws relating to breast reconstruction, and communication and content from key surgical societies were reviewed. Key areas of improvement were identified after qualitative review of all sources.Results:Thirty-four relevant resources were included. There is a large potential population need for oncoplastic breast reconstruction, but no current accurate estimate of patients undergoing this type of reconstruction. There are a multitude of definitions and algorithms attempting to define and organize oncoplastic breast surgery. Legislative initiatives could be improved to prevent coverage gaps. Coding and billing for oncoplastic surgery is not standardized, which complicates both clinical implementation and research efforts. Collaboration between national societies is needed.Conclusions:Oncoplastic partial breast reconstruction is an important part of the total package of care that can be offered to the breast cancer patient. Improvements in legislation, coding, and billing, and unification of national society communications and initiatives can lead to better surgical outcomes for the breast cancer patient.

Oncoplastic breast reconstruction improves cosmetic outcomes when compared to standard breast conservation therapy alone. The authors studied whether tailoring a breast reduction to a cancer resection affects complication rates by comparing (1) outcomes between oncoplastic and benign macromastia patients and (2) complication rates between the cancer side and the symmetrizing side of an oncoplastic reduction. A retrospective chart review was performed on female patients who underwent either oncoplastic or benign breast reduction over 9 years by a single surgeon. Patient demographics, intraoperative data, and postoperative outcomes were gathered from the electronic medical record. Chi-square and t tests were performed when appropriate to determine significance. Of the 211 patients included in the study, 62 (29.4 percent) underwent oncoplastic breast reduction and 149 (70.6 percent) underwent breast reduction for benign macromastia. Total resection weight was greater in the benign group (p = 0.00). There was a higher rate of loss of nipple sensation in the oncoplastic group (p = 0.005) but no differences in any other complication. There was a higher complication rate in the oncologic breast when compared to the symmetrizing breast within the oncoplastic cohort (p = 0.039), but no differences in the rates of individual complications. Although the loss of nipple sensation was increased in patients undergoing oncoplastic breast reduction, all other outcomes were not significantly different between the two groups. The authors' findings indicate that oncoplastic breast reduction can be performed with a safety profile similar to that of a standard breast reduction. Therapeutic, III.

Oncoplastic surgery – Standard of care

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.

Background High fidelity simulation models for surgical procedural training has not been available for complex oncoplastic breast cancer operations until recently when a mastopexy model was developed.1 As its utility as an effective wider teaching tool(as opposed to a single procedure workshop trainer) has not been established yet, it was decided to explore this. Methodology Four mastopexy models were dissected and assessed by faculty and students of the Masters Degree in Oncoplastic Breast Surgery at the Royal College of Surgeons, all of whom are practising breast surgeons. Modifications requested were: higher fidelity skin to increase the difficulty of de-epithelisation to a realistic level, decreasing breast size from 2 L to a more average 1.2 L and insertion of a tumour in the upper outer quadrant. A batch of 16 models were produced to these specifications and mounted on PVC fascia boards (which doubled as whiteboards).These were employed at a further Masters study day for technical training in oncoplastic breast conservation procedures including breast reduction surgery, and verbal and questionnaire feedback sought. Results There were no problems with batch producing the breasts or adding the modifications. Teachers feedback: “the faculty were very impressed with the models, and would like to use them at an international training workshop later this year”. The students gave constructive feedback and this was reflected in the questionnaire Likert scales. Issues identified and potential refinements are tabulated below. Conclusions High fidelity breast surgery practical training was partially achieved with the availability of a high-fidelity breast model. Future refinements to optimise surgical training using these models can be summarised as increasing the time available for practising procedures and utilising larger breast models to facilitate level 2 oncoplastic procedures such as breast reduction, in addition to re-creating the chest wall anatomy to facilitate pre-operative mark-up of the specimens. Reference Johann Willers, Ricardo Bonomi, Fabio Rapisarda, Dibendu Betal. Development of a high fidelity oncoplastic breast simulation model. BMJ STEL 2015;1(Suppl 2):A39

Breast cancer is the most common noncutaneous malignancy amongst women. Lumpectomy with adjuvant radiation is a mainstay of surgical treatment. Oncoplastic breast reconstruction reduces the resultant breast deformity. Obesity is a risk factor for the development of complications after breast reconstruction. This study's purpose was to determine if oncoplastic breast reconstruction is a safe procedure in obese patients. A single institution retrospective chart review was performed on women undergoing oncoplastic breast reduction from 2009 to 2021. Patients were then divided into groups based on body mass index (BMI). A statistical analysis was performed comparing rates of complications and time to adjuvant therapy. An estimated 340 patients were identified with an average age of 56.2 years (140 with BMI <30 kg/m2, 87 with BMI 30-34.9 kg/m2, 62 with BMI 35-39.9 kg/m2, and 51 with BMI >40 kg/m2). There was a significant difference between the BMI greater than 40 kg per m2 and BMI less than 30 kg per m2 group in the number of returns to the operating room (P = 0.0096), major complications (P = 0.0002), and minor complications (P = 0.0051). Average time to adjuvant treatment was 47 days and there was no statistically significant difference between the groups (P = 0.1691). There was a significant difference in major and minor complications between the BMI groups; however, there was no delay in the time to adjuvant therapy. Therefore, we conclude that with appropriate counseling on surgical risks, oncoplastic breast reduction is an acceptable option for breast cancer patients after lumpectomy, regardless of BMI.

Background: Oncoplastic surgery has become an important part of the surgical repertoire to offer both oncologically safe and aesthetically pleasing results in patients with breast cancer. Data comparing oncoplastic and reconstructive breast surgeries are limited. This study aimed to assess patient-reported outcomes (PRO) in our cohort of oncoplastic and reconstructively operated patients. Methods: Patients who underwent oncoplastic surgery, including immediate reconstruction by a single surgeon, between 2010 and 2018 were contacted to participate in this study. In total, 157 patients fulfilled the inclusion criteria. 54 patient data sets were used for statistical evaluation. Body Image Scale (BIS) and BreastQ questionnaires were used to measure subjective PRO scores, and pictures were taken to objectively measure symmetry using the Breast Analyzing Tool (BAT). Patients were divided into three groups according to the Tübingen classification (group 1: Tübingen 3–4 (n = 16), group 2: Tübingen 5 (n = 26), group 3: Breast Reconstruction/Tübingen 6 (n = 12]). Results: The mean age was 53.5 for group 1, 51.4 for group 2 and 46.8 for group 3. The mean follow-up was 62.9 ± 35.82 months. BIS was significantly better in group 3 (3.92 ± 1.73) than in group 1 and 2 (7.69 ± 4.48 and 4.81 ± 3.41, p = 0.016). Symmetry measured using BAT showed only a trend favoring reconstruction (p = 0.12). The BreastQ item “Sexual well-being” was significantly better in oncoplastic breast reduction surgery (p = 0.036). Conclusion: BIS was better after reconstructive breast surgery than after oncoplastic surgery. Reconstructive breast surgery in experienced breast care units offers high patient satisfaction and a high quality of life.

Background:Oncoplastic breast surgery aims to maintain quality of life by pre-empting and mitigating against breast asymmetry while not compromising oncological effectiveness. This case series demonstrates the implementation of an effective oncoplastic surgical practice in a community hospital within Canada and shows low rates of perioperative complications as well as high levels of patient-reported outcome measures.Methods:A retrospective chart review of patients diagnosed with stage 0–3 breast cancer treated with level I and level II oncoplastic techniques by a single breast surgeon was undertaken. Patient, tumour, procedure, and outcome data were collected. Patient satisfaction was assessed with the Breast-Q questionnaire administered pre- and postoperatively.Results:Oncoplastic breast conservation surgery was performed on 340 patients over a 31-month period. The average size of breast lesions was 1.8 cm, with 96 patients having lesions 2–5 cm in size and 10 patients having tumours larger than 5 cm. Thirty (8.8%) patients experienced a complication requiring intervention. The positive margin rate was 9.4%, and the completion mastectomy rate was 4.7%. Breast Q scores increased across breast satisfaction, process of care, psychosocial, physical, and sexual satisfaction domains postoperatively.Conclusion:This case series demonstrates the feasibility of an oncoplastic breast surgery practice in a busy community hospital in Canada. This adds to the growing body of North American data on the clinical and oncological safety of these techniques and introduces the idea of collecting patient-reported outcome measures within a Canadian population. We hope that this enables these techniques to become the standard of care in North America.

Oncoplastic breast surgery (OBS) is a form of breast conservation surgery (BCS) that involves a partial mastectomy followed by immediate volume displacement or volume replacement surgical techniques. To date, there are few studies evaluating OBS in older patients. Therefore, we sought to determine if outcomes differed between patients 65 years and older versus younger patients who underwent oncoplastic surgical procedures. A retrospective chart review was performed for all oncoplastic breast operations within a single health system from 2015 to 2021. Patients were stratified by age, with patients 65 years and older (OBS65+) identified and then matched with younger patients (OBS <65) based on BMI. Primary outcomes were positive margin rates and overall complication rates; secondary outcomes were locoregional recurrence (LR), distant recurrence (DR), disease-free survival (DFS), overall survival (OS), and long-term breast asymmetry. A total of 217 patients underwent OBS over the 6-year period, with 22% being OBS65+. Preoperatively, older patients experienced higher American Anesthesia (ASA) scores, Charlson Co-morbidity index (CCI) scores, and higher rates of diabetes mellitus, hypertension, and grade 3 breast ptosis. Despite this, no significant differences were found between primary or secondary outcomes compared to younger patients undergoing the same procedures. Oncoplastic breast reconstruction is a safe option in patients 65 years and older, with overall similar recurrence rates, positive margin rates, and survival when compared to younger patients. Although the older cohort of patients had greater preoperative risk, there was no difference in overall surgical complication rates or outcomes. Supporting the argument that all oncoplastic breast reconstruction techniques should be offered to eligible patients, irrespective of age.

PurposeSome studies have indicated age-specific differences in quality of life (QoL) among breast cancer (BC) patients. The aim of this study was to compare patient-reported outcomes after conventional and oncoplastic breast surgery in two distinct age groups.MethodsPatients who underwent oncoplastic and conventional breast surgery for stage I-III BC, between 6/2011–3/2019, were identified from a prospectively maintained database. QoL was prospectively evaluated using the Breast-Q questionnaire. Comparisons were made between women < 60 and ≥ 60 years.ResultsOne hundred thirty-three patients were included. Seventy-three of them were ≥ 60 years old. 15 (20.5%) of them received a round-block technique (RB) / oncoplastic breast-conserving surgeries (OBCS), 10 (13.7%) underwent nipple-sparing mastectomies (NSM) with deep inferior epigastric perforator flap (DIEP) reconstruction, 23 (31.5%) underwent conventional breast-conserving surgeries (CBCS), and 25 (34.2%) received total mastectomy (TM). Sixty patients were younger than 60 years, 15 (25%) thereof received RB/OBCS, 22 (36.7%) NSM/DIEP, 17 (28.3%) CBCS, and 6 (10%) TM. Physical well-being chest and psychosocial well-being scores were significantly higher in older women compared to younger patients (88.05 vs 75.10; p < 0.001 and 90.46 vs 80.71; p = 0.002, respectively). In multivariate linear regression, longer time intervals had a significantly positive effect on the scales Physical Well-being Chest (p = 0.014) and Satisfaction with Breasts (p = 0.004). No significant results were found concerning different types of surgery.ConclusionOur findings indicate that age does have a relevant impact on postoperative QoL. Patient counseling should include age-related considerations, however, age itself cannot be regarded as a contraindication for oncoplastic surgery.

Introduction: Despite recommendations by breast cancer guidelines, that immediate breast reconstruction (IBR) should be offered to all breast cancer patients considered for mastectomy national IBR rates have been reported as low as 12% in Australia. We report our oncoplastic breast cancer unit experience on acceptance of IBR, where it is routinely offered for all the medical fit breast cancer patients. Methods: We retrospectively reviewed, prospectively collected data on IBR by 3 oncoplastic breast cancer surgeons from 1st of September 2014 to 31st of March 2016.Patients were considered to be unfit for IBR if they were American Society of Anasthesiologist (ASA) Score 4 or 5, have unstable psychiatric illness, inflammatory breast cancer or high metastatic cancer burden. All the patients who were fit for IBR were offered both prosthetic and autologous IBR options. Results: 137 patients underwent mastectomy operation, of whom 27 were considered unfit for IBR. Of the remaining 110 patients, 84 (76%) accepted IBR. Of the patients who had IBR 64 (76%) had single stage prosthetic, 15 (18%) two stage prosthetic and 5 (6%) autologous reconstructions. Those who accepted IBR were younger compared to those who didn't have IBR (median age: 47 yrs vs. 67 yrs, p&amp;lt;0.001), and were more likely to be in current relationship (78.57% vs. 61.54%, p=0.06). All the three surgeons had high IBR acceptance rates (70.45%, 71.43%, 84.44%) and patient insurance status did not influence IBR acceptance rate (public 57% vs. private 65%, p=0.47). The majority of patients (25 of 26) who did not accept IBR stated that breast reconstruction was not important for their body image. Conclusion: Our recent data shows, in Australia, when routinely offered to breast cancer patients who are fit for reconstructive surgery by oncoplastic breast cancer surgeons, IBR is highly accepted. Younger patients and those who are in current relationship, were more likely to accept IBR, whereas, individual perception of insignificance of breast reconstruction for the body image was the main determinant of not accepting IBR. Citation Format: Cheung DSM, Trinh L, Edirimanne S, Eslick G. Immediate breast reconstruction is highly accepted by breast cancer patients undergoing mastectomy when routinely offered- Recent experience of an Australian tertiary oncoplastic breast unit [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-08.

Oncoplastic breast surgery combines certain plastic surgery procedures with a breast cancer resection to minimize the cosmetic penalty. We compared current practices in breast surgery in Canada and the UK, looking at the classification of oncoplastic breast surgery, management of larger tumours that would otherwise mandate a mastectomy, and the breast surgeon’s role in immediate breast reconstruction. Reconstructive breast surgery has always fallen within the domain of the plastic surgeon, but surgical subspecialization and more focused fellowship training have meant that breast surgeons with the appropriate skillset can offer these procedures. This evolution of the breast surgeon has led to the birth of a new field of breast surgery known as oncoplastic and reconstructive breast surgery. Those tasked with developing surgical training programs in Canada must now decide whether to train breast surgeons in these techniques to improve long-term quality of life among Canadian patients with breast cancer.

Introduction: Majority of women diagnosed with breast cancers (BC) have self-detected large tumors (mean tumor size &amp;gt;4 cm). There are number of myths and misconceptions regarding safety of breast conservation surgery (BCS), which, coupled with the fear of re-operation for infiltrated margins lead to poor acceptance of BCS by Indian BC patients. Practice of oncoplastic breast surgery (OBS), neo-adjuvant chemotherapy (NACT) and intra-op frozen section (FS) margins assessment have helped us achieve safe, single stage breast conservation even for patients with large tumors. In this retrospective study, we evaluated the OBS techniques used in patients undergoing primary or post-NACT BCS and compared the outcomes in terms of ipsilateral breast tumor recurrence (IBTR) and overall survival (OS) between patient groups that underwent OBS-BCS, non-OBS BCS and mastectomy. Methods: Retrieving data from a prospectively maintained database, all patients treated for stages I-III BC between 2009 &amp; 2018 at a specialty breast surgery unit were reviewed. Patient demographics, TNM stage, pathology, OBS technique, margin re-excision, and outcomes in terms of IBTR and OS, were evaluated; and compared with non-OBS BCS and mastectomy patients. Results: Of 1884 (Median age 50 years, 59% post-menopausal, T3-18%, T4b-7%) who underwent curative breast surgery, 1424 (75%) underwent mastectomy. Rest 460 (24.4%) underwent BCS, of which 43% underwent OBS BCS. Fifty-two patients (26.6%) underwent post-NACT BCS, of which 27.5% had pathological complete response (pCR). OBS techniques used were volume displacement in 169 (86.4%) and volume replacement (mini LD/LD flap) in 29 (13.6%). The OBS techniques used constituted Level-1 OBS in 33% and level-2 OBS in 66%. Procedures performed included round block / modified Benelli-10.6%, batwing mastopexy- 6%, wise pattern reduction mammoplasty+contralateral symmetrization-4%, and other procedures-9.5% (medial mammoplasty, inverted T/vertical scar mastopexy, J or L mammoplasty, parallelogram excision, Z plasty). Intraop FS histology detected infiltrated margins in 11.6% of patients undergoing OBS-BCS, which were re-excised/ converted to mastectomy in the same sitting, thus avoiding a re-operation. In comparison, 17% patients who underwent non-OBS BCS had margin infiltration. Cosmetic outcomes and patient satisfaction were better in OBS BCS patients. Peri-op complications including partial nipple necrosis, skin necrosis, seroma, wound dehiscence and infection occurred in 17%. IBTR occurred in 4% of OBS-BCS patients, compared to 7% patients who underwent non-OBS BCS. Over 36 mo median follow-up, stagewise OS was similar in patient groups undergoing mastectomy, OBS BCS or non-OBS BCS. Conclusion: Employing OBS techniques has enabled us offer BCS for EBC and large or locally advanced BC. These techniques facilitate safe BCS of patients undergoing primary or post-NACT breast surgery, with relatively lower margin infiltration and local recurrence rates, comparable survival and higher patient satisfaction of their cosmetic outcomes, compared to patients undergoing mastectomy or conventional/ non-OBS BCS. Table: Types of oncoplastic procedures used in patients undergoing primary or post-NACT Oncoplastic breast surgical breast conservation surgeryNo.of patientsPercentageLevel I16181.3 %Level II(MiniLD/ LD/ Contralateral Symmetrisation)3718.6%Volume Displacement16985.3%Volume Replacement2913.6%Ipsilateral breast tumor recurrence84.02% Citation Format: Gaurav Agarwal, VC Ramya, Anjali Mishra, Gyan Chand, Sabaretnam Mayilvahanan, Vinita Agrawal, Narendra Krishnani, Namita Mohindra, Punita Lal. Oncoplastic breast conservation surgery for patients with large breast cancers undergoing primary or post-NACT breast conservation surgery is safe and effective [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-13-07.

This article provides an overview of the principles and techniques of oncoplastic and reconstructive breast surgery for patients with early-stage breast cancer. Oncoplastic breast surgery (OPBS) with partial breast reconstruction is a natural evolution in the application of breast conserving surgery and permits wide surgical resection of tumours that might otherwise mandate mastectomy and whole breast reconstruction. These reconstructive techniques must be optimally selected and integrated with ablative breast surgery together with non-surgical treatments such as radiotherapy and chemotherapy that may be variably sequenced with each other. A multidisciplinary approach with shared decision-making is essential to ensure optimal clinical and patient-reported outcomes that address oncological, aesthetic, functional and psychosocial domains. Future practice of OPBS must incorporate routine audit and comprehensive evaluation of outcomes.

Most of the approaches that were valid until recently in breast cancer surgery have undergone significant changes with rising awareness, increasing number of patients, and knowledge. It is important to repair the damage caused by surgical treatment performed in accordance with oncological principles and to obtain good cosmetic results. The quality-of-life indexes increase and body image is positively affected by the development of oncoplastic surgery and reconstruction techniques.The oncoplastic techniques are commonly used for the closure of glandular defects. Surgeons must pay attention to the breast volume, tumor location, the amount of breast tissue that would be removed, and the oncoplastic technique that may be required. Oncoplastic breast surgery allows wide local excision of the mass with good cosmetic results. In addition, a contralateral breast lift, breast augmentation or breast reduction may be required to accommodate the conceptually reconstructed breast. The use of oncoplastic breast surgery techniques results in lower mastectomy rates with equivalent local and long-term survival rates as compared with mastectomy and offers women the option of plastic and reconstructive interventions performed at the time of initial surgery. Mastectomy may be needed for large tumors, as breast-conserving surgery may not be possible or may not produce satisfactory cosmetic results. Breast reconstruction methods after mastectomy include autologous or implant-based breast reconstructions, which can be performed at the same time as the breast cancer surgery (immediate reconstruction) or at a later time (delayed reconstruction).Oncoplastic and reconstructive breast surgery minimizes the impact of breast cancer surgery and yields equivalent survival outcomes without psychological morbidity. With advanced techniques, better breast image than before can also be achieved. In this review, the technical details of oncoplastic breast surgery, surgical margin positivity management, reconstruction methods, radiation therapy given after reconstruction surgery, radiologic imaging modalities, and management of complications are discussed.