Central Quadrantectomy Research Articles

230 A Comparative Study Between Central Quadrantectomy and Nipple Resection with Areola Preservation Versus Grisotti Flap Mammoplasty in Central Breast Lesions Extending to Nipple: A Randomized Clinical Trial

Abstract Aim To evaluate central quadrantectomy and nipple resection with areola preservation (CQ-NR-AP) as a new reconstructive oncoplastic technique Versus Grisotti flap mammoplasty (GFM) in central malignant tumours of the breast extending to the nipple, in terms of time procedures, breast symmetry, patient satisfaction, post-operative complications and local recurrence. Method The current study is a single-blind, prospective, randomized, controlled, single-center trial conducted from May 2018 to May 2023 in the breast surgical unit of Ain Shams University Hospitals, which included 40 patients presented with central breast lesions extending to the nipple including one-year follow-up postoperative. Results As regards the mean intra-operative time in minutes, in the group (I) was 80.1 with a standard deviation of ±13.9, and ingroup (II) was 138.9 with a standard deviation of ±14.02(p=0.001). The seroma was detected in zero cases in group (I) and 2(10%) cases in group II (p=0.487) and those two cases were managed by aspiration only. Regarding, the wound infection was found in one case (5%) in group (I) and 3(15%) cases in group II (p=0.605). Regarding patient satisfaction and breast symmetry was much better in the group (I) Conclusions Central quadrantectomy and nipple resection with areola preservation were determined to be safer, easier, and associated with a lower incidence of complications in one-year follow-up as compared to the Grisotti flap mammoplasty technique. In addition, better patient satisfaction is one of the most difficult accomplishments in the management of centrally located breast tumors.

Oncoplastic surgery for Paget's disease of the breast.

Paget's disease of the breast (PDB) is a rare nipple entity associated with multifocality. Due to its location, resection of the entire nipple-areolar complex is necessary. Historically central quadrantectomy and mastectomy have the surgical treatments of choice. The feasibility of oncoplastic breast surgery (OBS) for PDB is unknown. This was a retrospective study performed in a Brazilian oncological hospital. We evaluated the factors related to the performance of OBS in PDB. In addition, the impact of OBS on local recurrence and survival was analysed. Comparisons were made between groups using the chi-square test, Mann-Whitney U test, and Kaplan-Meier method. To assess the impact factor of the variables on the performance of OBS, logistic regression was performed. Eighty-five patients were evaluated. OBS was performed in 69.4% (n=59), and of these, 16 (27.2%) were symmetrized with contralateral surgery. Mastectomy without reconstruction was performed in 28.3% of the patients. The primary procedure performed was mastectomy with reconstruction (n=38; 44.7%), and the preferential technique for immediate reconstruction was skin-sparing mastectomy with prosthesis; for late reconstruction, the preferred technique was using the latissimus dorsi. Breast conserving-surgery was performed in 27.0% (n=23), primarily using the plug-flap technique (OBS). Age was associated with the use of OBS; as patients aged 40-49 exhibited a higher rate of OBS (p = 0.002; odds ratio 3.22). OBS did not influence local recurrence (p=1.000), overall survival (p=0.185), or cancer-specific survival (p=0.418). OBS improves options related to surgical treatment in PDB without affecting local recurrence or survival rates.

Centrally located breast carcinomas treated with central quadrantectomy and immediate nipple-areola reconstruction: a cohort study.

Mastectomy has often been cited as the favoured option for centrally located breast tumours because lumpectomies or quadrantectomies that remove the nipple-areola complex often result in poor cosmesis. Currently, breast-conserving treatment is a preferred treatment for centrally located breast tumours, but this approach requires oncoplastic breast technique to avoid aesthetic sequels. This article describes the use of breast reduction techniques with immediate nipple-areola complex reconstruction (utilised to treat breast cancer) for centrally sited breast tumours PATIENTS: Ten patients suffering from a centrally located breast carcinoma were treated at our breast unit over a period of 16 years (2006-2022). Oncologic and patient-reported outcomes were updated revising electronic reports and surveying with BREAST-Q module Breast conserving therapy (version 2, Spanish) postoperative scales. Excision margins were complete in all cases. There have been no postoperative complications, all patients are alive and no cases of recurrence after 84.8 months of mean follow-up. Patients score the domain satisfaction with breast: mean 61.7 (Standard deviation 12.5) out of 100. Breast reduction mammaplasty with immediate nipple-areola complex reconstruction allows surgeons to carry out a central quadrantectomy to treat centrally located breast carcinoma with good oncologic and cosmetic outcome.

Micap flap as an alternative to the Grisotti Flap for the reconstruction of the areola after central quadrantectomy – preliminary experience

Introduction: The Grisotti Flap is an excellent oncoplastic option for patients with retro-areolar cancer, whereas a short nipple areolar complex (NAC) to inferior mammary fold (IMF) distance pose a challenge to the surgeon due to lack of skin that can be transposed with the rotational flap.

A new oncoplastic technique for removal of centrally located malignant tumors and reconstruction by a local dermo-glandular flap in conservative breast surgery.

To evaluate the local dermo-glandular flap as a new reconstructive oncoplastic technique after removal of central malignant tumors of the breast, in terms of patient satisfaction and local recurrence. This study included 60 females with centrally located breast cancer who underwent central quadrantectomy and local dermo-glandular flap with either sentinel lymph node biopsy or axillary clearance. The mean age of the patients was 49.68 ± 8.52 years. The duration of the operation ranged from 68-105 minutes, with a mean of 79.77 ± 9.41 minutes. Local recurrence was observed in three patients (5.00%) with no distant metastasis. Forty-seven patients (78.33%) reported satisfaction after the operation. Ugly scarring and the existence of tissue defects were the main factors affecting patient satisfaction. Correction of these complications increased overall satisfaction to 88.33%. For small- and medium-sized breasts, the use of a local dermo-glandular flap for the management of centrally located malignant tumors seems to be a simple and easy technique with good oncological outcomes and acceptable few minor complications. This technique offers an immediate reconstruction of a new areola with fewer scars that will be hidden later after areola tattooing. Most of the patients reported satisfaction three months after areola reconstruction.

Multidisciplinary management of breast cancer in a 103 years old patient: The ultimate “primum non nocere” challenge

Multidisciplinary management of breast cancer in a 103 years old patient: the ultimate “primum non nocere” surgical challenge.Breast cancer in older individuals is increasingly encountered in clinical practice as the mean age of the world population increases. Underestimation of life expectancy and fitness for therapy might result in age-related undertreatment. We report the case of a 103 years old woman affected by breast cancer. Multidisciplinary team work proved to be once again fundamental in the decision making process leading to the surgical operation of right breast central quadrantectomy performed in loco-regional anesthesia. To date, as far as we know, this is the oldest patient surgically treated for breast cancer.

A Novel Technique for Single-stage Reconstruction of Nipple-Areola Complex following Central Lumpectomy.

SummarySeveral oncoplastic techniques have been proposed for subareolar breast cancer, some of which may require contralateral operation for symmetry, or more than one operation for delayed reconstruction of the nipple-areola complex (NAC). We herein developed a simple and effective oncoplastic approach following central quadrantectomy, aiming to achieve the following: (1) preservation of breast shape and contour for patients who are not accepting of a notably smaller breast or bilateral operation; (2) single procedure with advantages of single anesthetic and the ability to reconstruct a breast that has not yet been affected by radiation; (3) no autologous grafts with disadvantage of an extra donor site; (4) creation of natural neo-NAC with only incision within the region of the areola complex; and (5) maintaining long-term nipple projection. In this technique, the medial and lateral peri-areolar flap was advanced and rotated to restore partial neo-NAC, and to fill the defect after central tumor and NAC resection. The whole neo-NAC margin was created using the “round block” technique. Additionally, the nipple reconstruction was performed at the mitten of the neo-areola area using the C-V nipple flaps with an internal strut of rolled dermal grafts harvested from excised skin during the round block procedures. Lastly, a purse-string suture is placed in the outer skin margin for control of areola diameter and project. Six patients with central tumors of the breast were treated in this easily achieved approach. Patient satisfaction was noted as high, and the cosmetic results were evaluated as good to excellent.

Evaluation of central quadrantectomy with immediate nipple–areola complex reconstruction for centrally located malignant breast lesions

Background Breast cancer, according to National Cancer Institute, is the commonest cancer in women in Egypt, representing ∼39% of total malignancies among Egyptian women. It is a leading cause of mortality among them as well. Objective To cure patients with preservation of breast tissue as much as possible with satisfactory physical and psychological outcome. This goal has led to the introduction of a new scope of surgery into our clinical practice called oncoplastic breast surgery, with the advantage of combining oncological safety and satisfactory cosmetic outcome. Patients and methods This prospective study was conducted on patients with centrally located breast tumors at the General Surgery Department at Ain Shams University Hospitals starting from November 2017. Approval of the Ethical Committee and written informed consent from all participants were obtained. Results Our study included 30 patients who underwent central quadrantectomy with immediate reconstruction of the nipple–areola complex (NAC) for retroareolar breast cancer. Patients’ mean age was 44.1±7.51 years (30–62 years). Of 30 patients, five (16.6%) had a positive family history of mammary cancer, four (13.3%) patients were diabetic, four (13.3%) patients were hypertensive, 20 (66.6%) patients received neoadjuvant chemotherapy. The mean lesional size was 1.32±0.56 cm (0.5–2.5 cm). Operation timing was longer in inferior pedicle mammoplasty, being 2.60±0.47 h, than Grisotti mastopexy, being 1.67±0.56 h. Contralateral surgery was higher in inferior pedicle (10/15) than Grisotti mastopexy (2/15). The overall percentage of complications was 26.7%. Overall, 93.3% in Grisotti mastopexy group had good to excellent outcomes compared with 80% with good to excellent outcomes in inferior pedicle mastopexy. High cosmetic outcome was obtained thanks to the presence and shape of the breasts relatively to the esthetic outcome of modified radical mastectomy. Conclusion Central quadrantectomy with immediate NAC reconstruction is a good choice for patients with centrally located malignant lesions involving the NAC. These patients are no longer abutted from breast conservative surgery. Moreover, they are offered immediate reconstruction, resulting in lower rates of reoperations and recurrence and also better cosmetic appearance and higher levels of satisfaction.

Squamous cell carcinoma of the breast: case report

Introduction: Primary squamous cell carcinoma of the breast (SCCB) is a rare malignant neoplasm, confirmed when at least 90% of the cells are of the squamous type. It represents about 1% of all cases of breast carcinomas. The literature has few reports on the subject, showing that SCCB has no specific radiological features. Objective: To report a case of SCCB diagnosed at the Instituto do Câncer Doutor Arnaldo Vieira de Carvalho. Method: We conducted a review of medical records, photographic records, and a literature review. Result: An 82-year-old woman had a small breast lesion in 2016, but for fear, she hid it until the end of 2018. In the beginning, the lesion was treated with topical corticosteroids and monitored at a community health clinic. After worsening, she was referred to a specialized service. Upon physical examination, the lesion was firm, exophytic, friable, and non-nodular, with fibroelastic axillary lymph nodes of up to 1.5 cm. The mammography from October 2018 was classified as BI-RADS® 2 and the breast ultrasound as BI-RADS® 3, showing only skin lesion. Incisional biopsy revealed SCCB with immunohistochemistry positive for cytokeratin-14 and protein p63 and negative for hormone receptors (HR) and HER2 expression. She underwent central quadrantectomy with axillary lymph node dissection in April 2019, confirming SCCB and without lymph node involvement (0/14). After 5 months, the patient showed lesions suggestive of herpes zoster, confirmed by serology. Without improvement with acyclovir, a new biopsy was performed, which confirmed local recurrence. In December, she started radiotherapy, but the lesion progressed to necrosis, papules, and extended to the dorsum, accompanied by intense pain. Chemotherapy with cisplatin 30 mg/m² weekly was proposed, with partial response. Conclusion: SCCB at diagnosis has >4 cm, and 50% of them have associated cysts. Usually, it has a high grade and is negative for HR and HER2 expression. Mammographic images do not have specific features, explaining the large lesions during screening. The literature review revealed that 70% of SCCB patients do not have lymph node involvement, but due to its unpredictable spread, lymph node dissection might be conducted for staging. It is considered an aggressive disease with an uncertain prognosis, and the data available is not enough to provide options to prevent recurrence. SCCB is rare, has a poor prognosis, and surgery is the most accepted initial treatment. In the case of recurrence, the treatment of choice is radiotherapy associated with cisplatin-based chemotherapy and anti-PD-L1 immunotherapy (cemiplimab), which was recently approved by the Food and Drug Administration (FDA).

Inferior dermoglandular flap for central quadrantectomy in non-ptosis breast cancer patients

The central located tumors has been reported to have nipple areola complex (NAC) involvement, most of the time NAC resection is also required to achieve good oncologic outcome. The tumor in this location used to be one of the indication for mastectomy. Clinical trials have proved that breast conservative surgery in centrally located tumor is similar to those who undergo mastectomy. However, in this particular situation, lumpectomy alone with simple closure may cause the deformities of the breast. This highlights the concepts of ‘immediate partial reconstruction’ during the breast conservative surgery to be able to prevent the poor cosmetic sequelae. In this study, we describe the surgical technique used in retroareolar breast cancer in non ptotic breast. The patient underwent central quadrantectomy with sentinel lymph node biopsy. Reshaping the breast by using the vertical skin pattern technique with inferior dermoglandular flap is required to fill the defect after removing central volume of the breast from breast conservative surgery (BCS). Inferior dermoglandular flap shows good outcome in non-ptotic breast with retroareolar tumor. However, a major disadvantage of our technique is the high-riding of the new NAC location. A simple and effective technique of the inferior dermoglandular flap is presented, in combination with the vertical skin pattern. This combined method allows correction of the central located tumor and parenchyma defect after BCS in all cases with acceptable results.

Outcome of different oncoplastic surgical (OPs) techniques for centrally located breast cancer (CLBC)

BackgroundOncoplastic breast surgery is a standard treatment of early breast cancer, offering a balance between good cosmetic outcome and limited risk of locoregional recurrence, by enabling proper resection margins. Aim of studyTo present multiple techniques of partial breast reconstruction following the resection of centrally located breast cancer (CLBC) resection. Patients and methodsFrom January 2011 to August 2014, 21 patients underwent central quadrantectomy for carcinoma of the central region of the breast. Excisions included the nipple/areola complex, in most of the cases, down to the pectoralis fascia with a wide safety margin, and proper axillary management. Oncoplastic approaches included latissimus dorsi flap, inferior pedicle flap, Melon slice, Grisotti and round block techniques. ResultsMean age of patients was 49.5±10.61years. Tumor size ranged from 1.5 to 4.5cm. Postoperative pathology revealed a tumor mean safety margin of 2.5±0.83cm, with positive axillary lymph nodes in 15 (75.0%) patients. Nineteen (95.0%) patients received postoperative breast radiotherapy, while 9/20 (45.0%) and 3/20 (15.0%) received adjuvant chemotherapy or hormonal therapy, respectively, and only 8/20 (40.0%) patients received both therapies. During a median follow-up period of 14.89months, neither local nor distant metastasis, were detected. The postoperative cosmetic result evaluated by the patients was excellent in 6/20 patients (30.0%), good in 11/20 patients (55.0%), fair in 3/20 (15.0%) with neither poor nor bad results, with an overall mean of 4.0±0.5 equivalent to 80% satisfaction. ConclusionMultiple oncoplastic breast surgery techniques can be used for the resection of CLBC with satisfying cosmetic outcomes.

Challenges in Diagnosis and Management of Paget's Disease of the Breast-a Retrospective Study.

Paget's disease of the breast is uncommon and patients may present with nipple discharge, eczema, plaque or nipple destruction with or without a lump. The aim of the present study was to evaluate the presentation, clinicopathological features and treatment given for patients presenting with Paget's disease of the breast. We performed a retrospective analysis of medical records of patients who were treated at our centre for Paget's disease of the breast from 2006-2011. Twenty patients were treated in this period. Twelve patients had associated lump and eight patients did not have a lump in the breast. Two patients did not have a lump or any detected abnormality in mammography. Multicentricity was present in five patients. Diagnosis of malignancy was made by fine-needle aspiration cytology for patients with palpable lump and nipple wedge biopsy for patients with no lump. Modified radical mastectomy was done in 10 patients: 2 patients underwent total mastectomy and sentinel lymph node biopsy and 8 patients underwent central quadrantectomy and sentinel lymph node biopsy. Eleven patients had invasive ductal carcinoma, one patient had ductal carcinoma in situ with foci of invasion and eight patients had ductal carcinoma in situ. Seven patients had lymph node metastases. Three patients had recurrence, one had local recurrence and two had distant recurrences. The mean follow up period was 28months (range 15-64months). Paget's disease of the breast is a rare entity and one needs imaging and biopsy to diagnose these patients as they have associated cancer. They can be considered for breast conservation surgery with good cosmetic and oncological results.

Breast conserving oncoplastic surgery in the treatment of centrally located malignant breast tumors

Central breast neoplasms account for 5 to 20% of breast cancer cases. For decades, they have been traditionally treated with mastectomy. The high incidence of involvement associated with these tumors necessitates nipple and areola resection. Oncoplastic surgical techniques, in well selected cases, enable the achievement of adequate cosmetic results following a radical central quadrantectomy along with the Nipple-Areola Complex. The present paper summarizes the indications, techniques and results of breast conserving surgeries of central breast tumors.

Accessory nipple reconstruction following a central quadrantectomy: a case report

Introductionnipple dichotomy (or intra-areolar polythelia) is a rare congenital malformation in which one or more supernumerary nipples are located within the same areola.A case of a woman undergoing a central quadrantectomy with a contralateral supernumerary nipple used for reconstruction is reported. No other report in the Literature, according to our search, has focused on reconstructive use of an accessory nipple after breast conserving surgery.Case presentationthe patient is a 73 year-old Caucasian woman, who two years earlier underwent a lower-outer left Quadrantectomy plus axillary sampling and radiation therapy for a 2,2 cm lobular carcinoma with no lymph node involvement.A routine follow-up assessment showed an important fibrotic change on the operated breast, just across the infra-mammary fold; at a breast Magnetic Resonance Imaging, a 1,5 cm area in retroareolar position, suspicious for local recurrence, was evident.An open biopsy was therefore performed, under local anaesthesia, including the nipple-areolar complex to realize a central Quadrantectomy with a Grisotti procedure; a congenital dichotomic nipple in the contralateral breast was then used to repair the defect through a "nipple-sharing" technique. The final histological examination reported a fibrotic mastopathy without atypias.Conclusionin this case, the "nipple-sharing" technique has allowed in the same time the correction of a rare congenital defect and provided the surgeon with a supernumerary nipple to be used in the immediate reconstruction after breast conserving surgery.

Central Quadrantectomy with Resection of the Nipple-Areola Complex Compared with Mastectomy in Patients with Retroareolar Breast Cancer

Appropriate surgery in women with retroareolar breast cancer should allow resection of the cancer with wide free margins and an acceptable cosmetic result. The aim of this study was to compare breast conservation surgery (BCS) to mastectomy for treatment of retroareolar breast cancer. In a prospective nonrandomized study, 69 women with retroareolar breast cancers underwent either central quadrantectomy (n=33) with complete removal of the nipple-areola complex or mastectomy (n=36). Two of 33 (6%) patients scheduled for BCS had a secondary mastectomy and immediate reconstruction due to involved margins. After a median follow-up of 42 month (range 17-99 months) in the BCS group and 43 months (range 16-118 months) in the mastectomy group local and regional recurrences as well as systemic disease were comparable between both groups. The postoperative cosmetic result after BCS as evaluated by the patients was rated as excellent in 80% and good in 20% with no poor result. BCS followed by radiation therapy is a feasible alternative to mastectomy in patients with retroareolar breast cancer.

Immediate Reconstruction of the Nipple/Areola Complex in Oncoplastic Surgery After Central Quadrantectomy

Oncoplastic surgery adds valuable techniques for breast-conservation therapy that allows for wide excisions and prevents breast deformities. However, no such technique has addressed loss of the nipple/areola complex (NAC) after central lumpectomy. We present a simple and effective technique for immediate reconstruction of the NAC after such loss due to tumorectomy. After central tumorectomy, a local tissue flap is created above the defect to restore the nipple. Then the neonipple is carried on a superior-based, dermoglandular pedicle to its new position, similar to breast reduction surgery. The operation is continued with resection of redundant tissue lateral to the pedicle for optimal breast shape. From the discarded breast tissue, a full-thickness skin graft is harvested and used to reconstruct the areola. The contralateral breast is treated with a usual mammaplasty and tailored to the specific needs of the opposite side. Nine patients with central tumors of the breast were treated in this fashion at our institution. In all patients, the aesthetic result was good to excellent. In 1 patient, there was delayed wound healing of the full-thickness skin graft for the areola, which healed by secondary intention. The presented technique is easily achieved and produced excellent results after breast-conservation surgery. It will expand the armamentarium of oncoplastic surgery to meet central defects with loss of the nipple/areola complex.

A CASE OF INVASIVE BREAST CANCER LOCALIZED AT THE NIPPLE

We experienced an extremely rare case of invasive breast cancer localized at the nipple. A 47-year-old woman was seen at the hospital because of a swelling and eczematoid change of the right nipple. We found a 3.5cm tumor of the nipple but no mass at the subareolar area. This lesion was diagnosed as invasive breast cancer localized at the nipple. Breast conservative surgery (Bp (2cm)+Ax) with nipple-areolar-complex involved, so-called central quadrantectomy, was performed. Microscopically the tumor showed the finding of papillotubular carcinoma and occupied her nipple completely with a little intraductal component spreading into the underlying mammary gland. One of five axillary lymph nodes dissected showed metastasis. Postoperatively she was treated with radiation therapy to the intact breast to at a dose of 55Gy. In future a nipple-areolar plastical surgery will be expected. There are only three case reports about invasice ductal carcinoma of the nipple, of which modified radical mastectomy in two and partial mastectomy in one were performed. In this paper we discuss the indication of breast conservative surgery for the breast cancer located in the central area.