Breast-conserving Techniques Research Articles

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

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. 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. 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%. 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.

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

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. 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. Across 15 centres, 507 patients with median age (54 years, IQR; 48-62), body mass index (25.4kg/m2, IQR; 22.5-29), tumour size (26mm, IQR; 18-35), and specimen weight (62g, 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%). 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.

A clinical perspective on oncoplastic breast conserving surgery.

Breast conserving surgery (BCS) plus radiation treatment is the favored alternative for mastectomy in patients with breast cancer. To allow for breast conservation in patients with large invasive tumors and poor response to neoadjuvant systemic treatment (NST) or patients with extensive ductal carcinoma in situ (DCIS), oncoplastic breast conserving surgery (OPBCS) techniques are introduced. OPBCS allows for breast conservation in a selective group of breast cancer patients who initially would have been treated with mastectomy due to the unfavorable tumor-to-breast ratio. With OPBCS, the oncological tumor excision is combined with plastic surgical breast conservation techniques without compromising oncological safety and maintaining aesthetic outcomes by preserving the shape of the breast. OPBCS should however not be applied to all breast cancer patients and the selection of patients who benefit from OPBCS and the timing of OPBCS are best discussed in a multidisciplinary team (MDT). Caution is required in patients with higher risk of positive margins [e.g., multifocal breast cancer, invasive lobular carcinoma (ILC), larger tumors and DCIS]. In these patients, delayed OPBCS is recommended to facilitate re-excision and maintain excellent breast conserving rates. Despite proven benefits in selected patients, the increase in the adoption of OPBCS is relatively low. This article provides a clinical perspective on OPBCS.

The outcome of Grisotti flap oncoplastic technique in central breast cancer: case series

Breast cancer patients with centrally located cancer always receive mastectomy or the combination of central excision and primary closure. With the development of modern oncoplastic breast-conserving technique, a variety of techniques are available to deal with centrally located breast cancers (CLBCs). Among these techniques, Grisotti flap technique is special, because it is easy to handle and only causes minor injury by using a local rotational dermoglandular flap to fill the defect of central part. In our study, we performed grisotti flap on seven patients with CLBCs and one patient with Paget’s disease. We found that performing Grisotti flap technique is safe oncologically with satisfactory aesthetic outcome for patients with CLBCs. However, further long term study on larger number of patients is needed to assess the long-term outcome of this surgical procedure in terms of survival.

Worth the trip? The effect of hospital clinic closures for patients undergoing scheduled surgery

Recent decades' hospital closures and consolidations have been rationalized with reference to arguments of efficiency and quality returns to scale and scope. However, closures are met with public outcry from patients living in areas affected by such closures if accompanying increases in travel time are not offset by a higher quality of care. It is broadly established that increases in patients’ travel time to acute care lower the probability of survival, but in non-acute and scheduled care we lack knowledge about the quality of care that patients living in closure-affected areas receive.In the non-acute setting of scheduled breast cancer surgery, this study examines how hospital clinic closures affect the quality of care that closure-affected patients receive. The effects are identified using closures of breast cancer clinics in Denmark from 2000 to 2011, during which time the number of clinics was more than halved. Using event study designs on population-wide Danish register data from 1996 to 2014, this study examine changes in surgical outcomes for 9790 patients living in municipalities where the nearest clinic has been closed. The results show that closures have reduced the number of hospitalization days and shifted surgical procedures to state-of-the-art breast-conserving techniques without generating adverse health effects and without causing crowding in non-closing clinics. An examination of the mechanisms suggests that added volume returns at non-closing clinics were of less importance than simply reallocating patients to higher-quality clinics.Closures of clinics performing scheduled surgery may be an effective policy instrument if the goal is to reduce variation in the delivery of hospital care. Increased access to state-of-the-art care may counterbalance patients’ concerns of losing their local clinic. However, if the clinics to be closed are small compared to non-closing clinics then there is no potential for added economies of scale or scope in non-closing clinics.

An Innovative Breast-Conserving Oncoplastic Technique for Treating Small to Medium Volume Breasts With a Tumor in the Lower Quadrant: The Folding Flap Technique.

BackgroundHere, we describe an innovative oncoplastic technique for small to medium volume breasts with a tumor in the lower quadrant and this technique could provide sufficient tissue to avoid visible defects after tumor removal and help reshape the natural shape of the breast.MethodsA detailed procedure for the folding flap technique is described step by step. Then, the results of a retrospective analysis of patients treated using this technique, including complications and disease recurrence rate, between January 2017 and November 2021 are reported. Aesthetic outcomes were evaluated on a 5-point scale proposed by the Paris Breast Center.ResultsA total of 52 patients underwent surgery with the folding flap technique, The average operation time was 98.4 min (range, 75–120 min), and the mean bleeding volume was 56.5 mL (range, 20–100 mL). A margin-positive result was confirmed in 1 patient who underwent re-excision. Short-term postoperative complications were observed in 7 patients, including 4 with fat liquefaction, 2 with seroma, and 1 with skin redness and swelling. No flap necrosis was observed. The median follow-up time was 28.6 months (range, 9–58 months), and 2 patients experienced local recurrence. The mean aesthetic score was 4.7 points, with 36 patients scoring 5 points and 26 patients scoring 4 points, respectively.ConclusionsThe folding flap technique, as an innovative and favorable oncoplastic technique for treating small- to medium-volume breasts with a tumor in the lower quadrant, could retain sufficient tissue to fill the residual cavity after the operation while improving the aesthetic outcome of the breast.

Breast-conserving surgery as a viable alternative to radical mastectomy

Breast cancer represents a large proportion of cancers that affect women and it is a major public health concern. For many years radical mastectomy was considered to be the only surgical procedure with curative potential for breast cancer. Radical mastectomy has a major negative impact on the quality of life. In order to avoid the complete removal of the breast, breast-conserving surgical techniques have been developed. During breast-conserving surgical procedures only the tumor is removed along with the surrounding breast tissue within the oncologic safety margin. Based on specialty literature we will summarize the surgical technique and explain the indications and contraindications of breast-conserving surgery for breast cancer along with the risk factors for disease recurrence.

Modified Grisotti flap technique in centrally located breast cancer: case report

Traditionally, breast cancer patients with centrally located mass always receive mastectomy or the combination of central excision and primary closure. With the development of modern oncoplastic breast-conserving techniques, these patients can conserve their breast, and achieve satisfactory cosmetic outcome as well as clear margin. A variety of techniques are available to deal with centrally located breast cancers (CLBCs). Among these techniques, Grisotti flap technique is special, because it is easy to handle, and only causes minor injury by using a local rotational dermoglandular flap to fill the defection of central part. However, in our clinical practice, we find a lot of women in south China have special properties. Such as short distance from inframammary liner to the nipple, long distance from midclavicular to the nipple, and large breast diameter. Simply apply the Grisotti flap technique to those patients is not very suitable that drive us to modify this technique to suit our patients. We adopt the idea that use pedicled skin flap with skin island to replace the central defection to modify Grisotti flap technique. And applied this technique to two patients. We find modified Grisotti flap technique for Paget's disease or CLBC had good cosmetic results as well as safety in suitable patients. In the future, we can use superior pedicle with skin island for ptotic breasts, and lateral pedicle is suitable for patients without large and ptotic breasts.

Analysis of the scope of surgical breast cancer treatment in countries with the low associated mortality-to-incidence ratio (review)

The worldwide implementation of «breakthrough» surgical approaches such as breast-conserving techniques, the development of mammoplasty, as well as new guidelines for performing biopsy of sentinel lymph nodes incentivized the transition to a higher level of quality in breast cancer care. This review summarizes the modern tendencies in audits of main breast cancer surgical treatments based on last experience of few countries demonstrating the low breast cancer mortality and high incidence (lowest breast cancer mortality-to-incidence ratio).

A Novel Breast-Conserving Surgical Technique in the Management of Phyllodes Tumours of the Breast.

Despite advances in oncoplastic breast-conserving techniques, very large phyllodes tumours (PT) may still be recommended for mastectomy. We report a novel 2-staged breast-conserving technique that enables smaller excisional volumes whilst maintaining safe oncological excision. Stage-1 is a capsular dissection via a posterior glandular approach without sacrifice of native breast volume. Stage-2 is a delayed localised resection of the seroma cavity providing a circumferential "margin". Two cases are presented. This novel technique preserves the breast, optimises cosmesis and is a safe approach to the surgical management of large PT.

The Adoption of Oncoplastic Surgery Using Breast Reduction or Mastopexy Techniques in an Academic Breast Cancer Center Program Can Increase Breast Conservation Rates.

Interest in oncoplastic surgery (OPS), a form of breast conservation surgery (BCS), has grown in the United States over the last decade. Oncoplastic surgery allows for the removal of larger tumors without compromising esthetic outcome or oncologic safety. One of the quality measures on which breast cancer centers in the United States are evaluated is rate of BCS. The purpose of this study was to investigate whether the adoption of OPS increases BCS rates and decreases mastectomy rates at the institutional level. Clinicopathologic data were retrospectively collected for breast cancer patients in a single institution database. Rates of BCS vs mastectomy and partial mastectomy versus OPS were measured between 2012 and 2018 to capture 3 years before and 3 years after the hiring of an oncoplastic surgeon in 2015 with subsequent practice adoption of oncoplastic techniques. We compared the 2 periods using χ and Fisher exact test for categorical variables. Rates of breast conservation and mastectomy were further stratified by tumor stage. Four hundred sixty-eight patients underwent breast cancer surgery at Tufts Medical Center between 2012 and 2018.Patients who underwent surgery between 2012-2015 and 2016-2018 were similar in terms of age, histological type, tumor size, receipt of neoadjuvant therapy, receptor status, and Charlson Comorbidity Index. There was a statistically significant (P < 0.0001) increase in BCS rate after 2015 attributable to the practice adoption of OPS. The proportion of patients who were recommended reexcision did not significantly increase with the introduction of OPS suggesting an appropriate and safe patient selection process for patients undergoing these breast conservation techniques. When stratified by T stage (tumor size), rates of mastectomy for T2 tumors (greater than 2 cm but less than 5 cm) decreased precipitously after 2015 and BCS increased proportionately. The rate of BCS for T1 tumors also increased but less drastically. The adoption of OPS in an academic breast cancer center can result in significantly higher rates of BCS, particularly for those with larger tumors (T2). Academic breast cancer centers should strongly consider incorporating OPS to their treatment paradigm to provide patients with the option to avoid mastectomy.

An Oncoplastic Surgery Primer: Common Indications, Techniques, and Complications in Level 1 and 2 Volume Displacement Oncoplastic Surgery.

Oncoplastic surgery is a form of breast-conservation surgery that involves volume displacement and replacement techniques for optimal aesthetic results after oncologic resection with partial mastectomy. With growing emphasis on breast conservation, oncoplastic surgery is becoming a critical component in the approach to breast cancer in appropriately selected patients. Thus, it is paramount that surgeons are informed about oncoplastic surgery and its use in breast cancer treatment. This primer aims to provide key information regarding oncoplastic surgery. To accomplish this, we used supportive evidence from the literature, combined with clinical experience. The primer uses the American Society of Breast Surgeon's consensus definition and classification system for oncoplastic surgery, focusing on level 1 and 2 volume displacement techniques. We outline procedures within these categories, review common indications, and provide a guide to approaching tumors based on their quadrant position. The paper also describes complications specific to these procedures, as well as their management. Understanding these concepts will allow surgeons to assist patients in making informed decisions using these breast-conservation techniques.

Oncoplastic breast surgery and radiotherapy-Adverse aesthetic outcomes, proposed classification of aesthetic components, and causality attribution.

The aim of this paper is to discuss and understand the interplay of surgical and radiotherapy (RT) techniques that potentially affect the aesthetic outcomes following breast conservation treatment. It reviews the reported cosmetic outcomes within the practice-changing RT trials incorporating varied fractionation regimes as well as sequence (before, during, or after surgery) over the past two decades. The paper importantly highlights an overall improvement in breast surgical techniques particularly oncoplastic breast conservation techniques due to dedicated and streamlined training of late. Hence, erstwhile complications or sequel of breast surgery and associated post-RT aesthetic concerns may not be of the same variety or magnitude that were noted in the past. Paper thus concludes by highlighting the paradigm shift in the breast surgical practice that will have a bearing on the accuracy of RT outcomes assessed (within or out with clinical trials) with implications as a potential research and outcomes assessment gap.

A step-by-step oncoplastic breast conservation surgical atlas of reproducible dissection techniques and anatomically ideal incision placement.

To develop an atlas for oncoplastic surgery (OPS) with template dissection techniques via anatomically ideal incisions for breast conservation surgery. The evolution of breast conservation techniques has evolved from placing an incision directly over the lesion to the incorporation of a thoughtful decision making process utilizing oncoplastic surgical (OPS) techniques to combining OPS with incision placement in anatomically advantageous sites. The high survival rates of breast cancer and effect of breast surgery on quality of life reinforce emphasis of optimal oncologic as well as aesthetic outcome. OPS results in greater patient satisfaction, fewer surgeries, and is oncologically safe. Today's breast surgeon is tasked with optimizing both oncologic and aesthetic outcomes. Presentation of reproducible dissection techniques and incision placement strategies to afford surgeons a step-by-step approach of OPS via anatomically ideal incisions in breast conservation surgery. Demonstration of reproducible techniques to facilitate the decision making process of optimal breast conservation surgery, eliminate knowledge gaps for surgeons, optimize outcome for individuals undergoing breast conservation surgery, and decrease disparity of care. Adoption of OPS techniques utilizing an anatomically ideal incision in breast conservation surgery is a feasible and reproducible practice for breast surgeons. Application of these techniques results in maintained optimal shape, size, and contour without the typical overlying skin envelope scars. OPS techniques performed under the skin envelope result in expected OPS oncologic and aesthetic outcomes with the addition of the resulting scar(s) in anatomically discrete position(s).

The TeaM (Therapeutic Mammaplasty) study: Protocol for a prospective multi-centre cohort study to evaluate the practice and outcomes of therapeutic mammaplasty

IntroductionWide local excision and adjuvant radiotherapy is the standard of care for early breast cancer. For large tumours, however, mastectomy is frequently recommended as conventional breast-conserving techniques often result in poor cosmetic outcomes. Therapeutic mammaplasty (TM) may extend the boundaries of breast-conserving surgery by combining breast reduction and mastopexy techniques with tumour excision, preserving a natural breast shape and avoiding the need for mastectomy. The prevalence of this operative option among surgeons in the UK and its success rate are unknown. The TeaM study is a multicentre prospective study that aims to investigate the practice and outcomes of TM. Methods and analysisBreast centres performing TM will be invited to participate through the research collaborative network and the professional associations. All patients undergoing TM between September 2016 and March 2017 will be included. Demographic, operative, oncological and complication data within 30-days of surgery will be collected. The primary outcome will be unplanned re-operation for complications. Secondary outcomes will include unplanned readmission, re-excision rates and time to adjuvant therapy. Prospective data on 500 patients from 50 centres are anticipated. Exploratory analyses will identify predictors for complications and inform the design of a definitive study. Ethics and disseminationResearch ethics approval is not required for this study. This has been confirmed by the on-line Health Research Authority decision tool. This study will provide novel information regarding the practice and outcomes of TM in the UK. This will inform decision-making for patients and surgeons and inform future research. Dissemination of the study protocol will be via the Mammary Fold Academic and Research Collaborative, the Reconstructive Surgery Trials Network and the professional associations, the Association of Breast Surgery and British Association of Plastic, Reconstructive and Aesthetic Surgeons. Results will be presented at relevant surgical conferences and published in peer-reviewed journals.

Oncological and Surgical Outcome after Oncoplastic Breast Surgery

Background : Oncoplastic surgery combines breast-conserving treatment and plastic surgery techniques. The aim of the study was to identify breast and tumor-related characteristics that contribute to the rate of complications and recurrence.Material & Methods : This retrospective study included 72 patients with a median follow-up of 32 months. For each patient, a comprehensive set of data was collected, including epidemiology, tumor characteristics, preoperative information, detailed pathology reports, radiotherapy treatment and type of surgical technique. The rate of complications, recurrence and survival were studied.Results : Complete tumor removal was performed with clear margins in all patients but in 25 of them margins were less than 2 mm. One patient had local recurrence and another developed distant metastases. The study showed that the size of the margin was not predictive of recurrence as long as not positive; the greater the resection volume, the larger the excision margin. The resection size was the only factor influencing complications and no specific tumor-related factor significantly increased the complication rate. Surgical complications did not delay the initiation of chemotherapy and radiotherapy.Conclusion : This is the first oncoplastic study where both tumor and breast characteristics were analyzed using the most recent criteria of the literature. Oncoplastic surgery can be considered as oncologically safe. The resection size was the sole significant risk factor for postoperative complications. Complications after oncoplastic breast surgery did not differ neoadjuvant therapy. Long-term event-free survival was excellent (96% at 7 years).

Targeted oncoplastic breast surgery (TOBS) – classification of breast-conserving techniques

Targeted oncoplastic breast surgery (TOBS) – classification of breast-conserving techniques

Advanced locoregional therapies in breast.

Advanced locoregional therapies continue to advance the treatment of breast cancer. These techniques are geared towards optimizing oncologic and aesthetic outcome as well as decreasing and treating morbidity. We present a selection of specialized locoregional therapies dedicated to the optimization of breast cancer treatment. Locoregional therapies for breast cancer are presented to address breast conservation techniques, lipofilling techniques, reconstruction techniques for nipple-sparing mastectomy, re-irradiating the breast, axillary reverse mapping, and vascularized lymph node transfer. We present a synopsis of identified breast locoregional therapies targeted to address optimal oncologic and aesthetic outcome as well as decrease and treat morbidity.

Breast conservation therapy without capsular contracture in young augmented women using interstitial brachytherapy.

PurposeTo describe a breast-conserving technique using interstitial brachytherapy after lumpectomy and axillary nodal sampling in selected women who are diagnosed with breast cancer in the presence of augmentation mammoplasty.Material and methodsOver the past 20 years, we have developed and improved a technique of “pinch view” image-guided catheter insertion that avoids implant puncture. Selection criteria include: 1) women of any age with either subpectoral or retroglandular, augmentation implants (silicone or saline) who were diagnosed with stages Tis, T1, T2, N0, or N1 breast cancer; 2) any pathologic subtype of malignant breast cancer was accepted; 3) microscopic tumor extent ≤ 3 cm; 4) axillary node negative or metastasis to 1 to 3 nodes without extracapsular extension; and 5) surgical margins clear by the NSABP “no ink on tumor” definition. More than 250 women have been successfully treated. Patients were treated with high dose rate Iridium-192 brachytherapy to 34 Gy in 10 or 32 Gy in 8 twice daily fractions. The target volume was the surgical cavity edge with 1.5 to 2 cm margin using 3-D treatment planning systems.ResultsThe implant technique as currently employed is described. There have been no implant ruptures, and the Planning Treatment Volume (PTV-eval) exhibited at least 90% coverage by the 90% isodose line in the vast majority of cases. Dose Homogeneity Index exceeded 70% in most cases. The maximum skin dose was below the prescription dose in every case. Other than some patients with pre-existing capsular contracture, less than 5% experience new capsular contracture after interstitial brachytherapy.ConclusionsA technique of reliable and reproducible accelerated partial breast irradiation is described that minimizes the risk of capsular contracture by avoiding circumferential dose to the foreign body in the breast.

Vertical scar therapeutic mammaplasty - a future direction for oncoplastic breast conservation

Introduction: Vertical Scar Therapeutic Mammaplasty (VSTM) has been advocated as an alternative treatment option for breast cancer in comparison to conventional breast conserving surgery (BCS) and other oncoplastic breast conservation techniques. However, there is a paucity of published data on VSTM that evaluates the oncological outcomes. A study was performed comparing re-excision rates of VSTM with published rates for conventional BCS.