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• Fig. 17.2 Superficial nipple necrosis is a risk following periareolar
incisions.
• Fig. 17.3 Full thickness necrosis of the nipple–areolar complex is an
uncommon complication but can occur with wide undermining and
devascularization.
• Fig. 17.5 Cellulitis following oncoplastic surgery.
• Fig. 17.6 Hematoma extending beyond the breast borders is noted
following oncoplastic reduction mammaplasty.
• Fig. 17.4 Fat necrosis following oncoplastic reduction mammaplasty
is demonstrated on this computed tomography scan.
Postoperative antibiotics are considered in some patients
dependent upon native risk factors. Hematoma occurrence
is rare and usually preventable with good hemostasis following the ablative and reconstructive portions of the operation. Postoperative hematoma will usually require operative
evacuation, especially if the bleeding is active and associated
with severe swelling. A preoperative coagulation prole and
avoidance of aspirin products is recommended.
When assessing aesthetic outcomes and patient satisfaction, oncoplastic reduction techniques have been shown to
carry a signicant positive eect, thus again outweighing the
risk of complications in the majority of patients. Validated
patient satisfaction surveys administered to patients following these procedures have shown signicant improvements
in postoperative patient assessment (relative to preoperative)
with emotional health and acceptance of the patient’s own
body after surgery. Furthermore, comprehensive patient
CHAPTER 17 Complications of Oncoplastic Breast Surgery
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TABLE
Complication Rates Seen with Oncoplastic Breast Reduction, Based on Timing of the Procedure Relative
1 7.1
to Tumor Excision
Timing and Outcomes for Oncoplastic Reconstruction
Delayed
Overall Immediate
Patients 160 117 18 25
Complications 28.1% 20.5% 33.3% 60% 0.001
Infection 5% 3.4% 0 16% 0.019
Fat necrosis 1.9% 0.9% 0 8% 0.047
Mean satisfaction 69.8% 72.8% 68% 61.8% NS
Mean aesthetic outcome 62.5% 63.9% 54.6% 58.8% NS
Ergo FM, Losken A et.al. The use of reduction mammaplasty with BCT: an analysis of timing and outcomes. Plast Reconstr Surg 2015; 135:963e. NS, not significant.
immediate Delayed P-value
satisfaction surveys have not illustrated a decrease in postoperative self-assessment of any factors related to the breasts
by patients, including physical appearance, emotional wellbeing, condence, and sexuality.
ere is also been a clear benet from the standpoint of
complication reduction to performing immediate oncoplastic reduction at the time of partial mastectomy. Large series
have shown that patients undergoing immediate oncoplastic
reduction for reconstruction exhibit an approximately 20%
overall complication rate. When the oncoplastic reduction
is delayed, oftentimes until after adjuvant radiation treatment has been completed, the complication rate rises to
the 60% range (Table 17.1).8 e largest dierences seen
in specic complications when comparing immediate versus
delayed oncoplastic reduction are seen with infection rates
(3% vs 16%), fat necrosis (0.9% vs 8%), and asymmetry of
the breasts (8.5% vs 24%).8 us, experience indicates that
there is a signicant benet to proceeding with immediate
oncoplastic reduction from the standpoint of complication/
morbidity reduction.
When reduction mammaplasty is requested follow-
• Fig. 17.7 Preoperative image of a woman with mammary hypertrophy
and previous right breast conservation treatment.
ing breast conservation, there are two schools of thought.
e rst is that reduction mammaplasty should be avoided
because the complication rate is so high, and a mastectomy
should thus be considered. e other is that it is acceptable to proceed with a reduction mammaplasty; however,
there are several tenants that must be considered. e rst
is patient selection. If the skin is severely damaged and
brotic, reduction should be avoided; however, if the skin
is relatively soft, then reduction can be considered. Undermining should be kept to a minimum to maintain adequate
perfusion. Wedge excision of the parenchyma using a sharp
scalpel rather than electrocautery is advised. Free nipple
graft should be considered. Although, this will not guaran-
elevation. Figs. 17.9–17.14 illustrate a patient following
oncoplastic reduction mammaplasty complicated by a positive margin on nal pathology.
It is important to remember that re-operations on a previously radiated breast are more prone to adverse events.
It is also important to recognize that patients undergoing
delayed oncoplastic reduction routinely report lower patient
satisfaction rates on validated surveys, compared with those
undergoing immediate oncoplastic reconstruction, with
regard to all categories of well-being. Blinded surgeon
assessment of outcomes illustrates similar improved subjective assessment for immediate reconstruction outcomes.
tee a complication-free operation, the complications can be
reduced. Figs. 17.7 and 17.8 illustrate a patient with severe
Local/Regional Flaps
mammary hypertrophy following right breast conservation
therapy. Following the reduction mammaplasty, distortion
of the inferolateral aspect of the breast was noted with arm
If there is insucient tissue for local tissue rearrangement
due to defect size or location, local or regional aps provide
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• Fig. 17.8 Postoperative image following reduction mammaplasty in a
previously radiated breast. The degree of soft tissue fibrosis is evident
with arm elevation.
• Fig. 17.11 The left excision/partial mastectomy has been performed
demonstrating a significant contour defect.
• Fig. 17.9 Preoperative image of a woman with left breast cancer
scheduled for oncoplastic reduction mammaplasty.
• Fig. 17.10 The preoperative marking before oncoplastic reduction
mammaplasty.
• Fig. 17.12 The oncoplastic reduction is complete but the margin is
positive on the left.
• Fig. 17.13 Following completion mastectomy and tissue expander
reconstruction.
• Fig. 17.14 Following exchange to a permanent implant and nipple–
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areolar reconstruction at 2-year follow-up.
viable options for reconstruction. Local aps from the subaxillary region are useful for moderate defects in the smaller
breast. More lateral defects may be reconstructed with a
transposition or rotational ap, moving skin and subcutaneous fat that is lateral to the breast, into defects in the
outer quadrants. e latissimus dorsi ap provides sucient
volume to correct almost any partial mastectomy defect, is
technically simple, and has relatively low morbidity. Because
of the dierent skin color and texture with this ap, it is better to replace an entire aesthetic unit during latissimus dorsi
reconstruction. However, this ap can still be performed if
no skin is missing by transferring the muscle and subcutaneous tissue alone. Another common rotational ap option
for oncoplastic reconstruction is the thoracodorsal artery
perforator (TDAP) ap.
e average reported complication rate for oncoplastic
ap reconstruction is in the 14% range.9 Some series have
reported higher rates with volume replacement and tissue
rotation, but the highest subset of complications in these
series tend to be related to ap donor site morbidity and
potential ap loss. With the oncoplastic latissimus ap,
overall reported complication rates are in the 35% range.
However, the majority (70%) of these complications relate
to ap donor site morbidity. Of these, seroma (20% range)
is the most commonly encountered complication.
ere are several techniques that are useful for the prevention and management of seroma following latissimus
dorsi ap reconstruction. e use of closed suction drains
is useful to remove excess uid and also to maintain a negative pressure environment. Quilting sutures are also recommended to decrease the potential dead space within the
harvest space. ese sutures can minimize shear forces that
tend to promote the lack of adherence.
e management of seroma is usually achieved by observation with occasional aspiration. Aspiration can be performed using a large bore needle and 60-mL syringe. A closed
suction drain can also be placed if the seroma is recurrent.
e use of talc or other adhesiogenic materials can also be
CHAPTER 17 Complications of Oncoplastic Breast Surgery
considered to create soft tissue adhesion and brosis. Surgical exploration and scarication of the seroma cavity is a last
resort and considered for refractory cases.
Oncologic Outcomes
Recurrence
With oncoplastic reconstruction, concern exists that local
tissue rearrangement may aect local recurrences and the
ability to detect them. However, numerous studies have
demonstrated that oncoplastic techniques have low local
recurrence rates when compared with breast conserving
therapy alone. Rietjens et al found that local recurrence
rates were low over long-term follow-up, with a 3% rate
at 5 years and no recurrences seen in those tumors smaller
than 2 cm.10 is is replicated in other large series, which
reported ranges of 1.5–2.5% local recurrence rates when
evaluating series of women undergoing bilateral reduction
mammaplasty.
In a prospective cohort study of patients with locally
advanced breast cancer undergoing oncoplastic surgery,
Bogusevicius etal reported a local/regional recurrence rate
of 10% at 86 months.11 However, these patients had larger
tumors and longer follow-up than the previously mentioned
studies. Additionally, excision of multifocal tumors within
the same quadrant has been shown to be oncologically safe
with the wide margins that can be taken with oncoplastic
procedures.
e one likely benet of oncoplastic reduction specically, and all oncoplastic reconstruction methods, is that the
reconstructive procedures allow for larger oncologic resections with wider margins. us, this likely results in a lower
recurrence rate compared with oncologic resection alone.
Most large cohort series assessing oncoplastic reduction
mammaplasty patients report local recurrence rates in the
8% range at 10 years, and an overall long-term survival rate
in the 83% range. Although the link between larger resection margins and lower recurrence rates in the breast has
never been clearly established, there is a likely positive relationship. is accounts for the consistent ndings in most
reports of 5-year recurrences of 3.4% range for lumpectomy
in all patients relative to 2% range reported for oncoplastic
patients.
Positive Margins
Although oncoplastic techniques allow for wider resections,
the tissue rearrangement performed in reconstruction may
complicate management of positive margins. Positive margins have been reported in wide ranges, between 2.7–22%,
and have been associated with higher stage, positive nodes,
positive lymphovascular invasion, use of neoadjuvant chemotherapy, larger initial T stage, positive estrogen receptor,
and younger age. Many oncoplastic techniques utilize dermoglandular aps, which transposes tissue from one area of
the breast to another.7 If a second surgical stage is needed
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TABLE
for presence of disease at the edges of the specimen, this can
become challenging due to the displacement of the glandular tissue from the previous surgery, thereby making further
excision very dicult.
these patients undergo completion mastectomy. Additionally, because most mammaplasty techniques rely on a unipedicle or bipedicle technique, subsequent need for surgery
risks pedicle compromise, thereby restricting future thera-
Reported Rates of Positive Margins and Need for Follow-up Completion Mastectomy from Multiple Series
17.2
when Performing Tumor Excision with Immediate Oncoplastic Breast Surgery
Resection Margin Involvement and Reoperation Rates Following Oncoplastic Reconstruction
Author Year OBCS # OBCS + margin OBCS re-excision Mastectomy conversion
Crown 2015 387 18% 18% 15%
Mansell 2015 119 13.4% 1.6% 11.9%
DeLorenzi 2016 454 2.9% 0 15.4%
Chauhan 2016 33 0 0 0
Carter 2016 1177 4.8% NR NR
OBCS, Oncoplastic breast conservation surgery.
Carter SA, etal. Ann Surg Oncol 2016; 23(10):3190–3198; Chauhan, etal. Indian J Surg Oncol 2016; 7(4):413–419; DeLorenzi Eur J Surg Oncol 2016; 42(1):71–77;
Mansell J, etal. Breast 2017; 32:179–185; Crown A, etal. Ann Surg Oncol 2015; 22:3363–3368.
rates have ranged from 5–15% (Table 17.2). ese low rates
have been demonstrated despite including patients with
tumors greater than 4 cm preoperatively.
When assessing oncoplastic reduction techniques spe-
Although re-excision is possible in such cases, more often
cically, multivariate regression models have found certain
tumor characteristics to be predictive of need for completion mastectomy. ese include estrogen receptor (ER)positive status, BMI over 30, and specimen weights greater
than 1000 grams at time of resection.
peutic options.
Intraoperative frozen section has been evaluated as a
Delay of Adjuvant Therapy
means to combat positive margins with oncoplastic reconstruction as well. When frozen section has been assessed as a
diagnostic technique to evaluate margins in patients undergoing latissimus dorsi mini-aps with partial mastectomy,
approximately 30% of patients had positive frozen sections.
ese sections illustrated a sensitivity of 83% and accuracy
of 96% when compared with paran sections. Overall,
local recurrence rate ranges around 0.9% with a median
follow-up of more than 40 months when frozen section is
used at time of oncoplastic reconstruction.
Caruso etal evaluated the utility of intraoperative frozen
section in patients undergoing therapeutic mammaplasty.
ey found that 8/52 patients (3 false positives, 5 true positives) had positive frozen sections with a sensitivity of 83%
and accuracy of 94%. Based on their ndings, they advocated for intraoperative assessment of margins as a means of
improving local control in a single stage, thereby reducing
the need for secondary re-excisions or mastectomies (none
in their study).12 Figs. 17.9–17.14 illustrate a patient following oncoplastic reduction mammaplasty who had a positive margin who then underwent a completion mastectomy
and reconstruction.
When assessing complications related to oncoplastic reconstruction, the nal factor that must be considered is delay
of adjuvant oncologic treatment due to postoperative morbidity. Hillberg etal assessed a large series of patients undergoing immediate oncoplastic reconstruction at the time of
partial mastectomy.13 is series included patients undergoing both oncoplastic reduction mammaplasty, as well as
local/regional rotational aps for volume replacement and
defect reconstruction.
e overall complication rate reported was 37.5% with
10% of patients requiring antibiotic treatment and 6.6%
requiring a corrective operation. Of all the complications
experienced, approximately 80% occurred before planned
adjuvant radiation treatment. As a result, 8.2% of all
patients in this series experienced a delay in the planned
start of radiation therapy. us, although overall complication rates in these can be high, approximately 10% of
patients experiencing a complication will undergo a delay in
adjuvant treatment. ose patient characteristics that predict complications leading to adjuvant treatment delay are
greater patient age, greater patient BMI, and larger lumpectomy resection weights.
Need for Completion Mastectomy
Conclusion
Although large long-term follow-up studies are lacking for
oncoplastic breast surgery, published studies have described
low rates of need for completion mastectomy. Reported
Oncoplastic breast reconstruction can be performed through
a number of techniques, all of which serve to minimize
CHAPTER 17 Complications of Oncoplastic Breast Surgery
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aesthetic deformities and improve patient satisfaction following breast conservation. Although these techniques are
powerful in their ability to improve overall outcomes, the
complication rates must be taken into account when counseling patients. In general, the addition of an oncoplastic
technique will increase the complication rate, relative to
oncologic resection alone, due to the larger amount of surgery. However, in the majority of cases, this risk is justied
given the vastly improved appearance and patient satisfaction encountered with the reconstructed conserved breast.
Surgeons must always consider performing these procedures
in the immediate setting, as a delay of the oncoplastic reconstruction, oftentimes after adjuvant radiation therapy, will
signicantly increase associated complication rates.
References
1. Fisher B, Anderson S, Bryant J, etal. Twenty-year follow-up of a
randomized trial comparing total mastectomy, lumpectomy, and
lumpectomy plus irradiation for the treatment of invasive breast
cancer. N Engl J Med. 2002;347:1233–1241.
2. Losken A, Dugal CS, Styblo TM, Carlson GW. A meta-analysis
comparing breast conservation therapy alone to the oncoplastic
technique. Ann Plast Surg. 2014;72:145–149.
3. Piper M, Peled AW, Sbitany H. Oncoplastic breast surgery: current strategies. Gland Surg. 2015;4(2):154–163.
4. Warren Peled A, Sbitany H, Foster RD, Esserman LJ. Oncoplastic mammoplasty as a strategy for reducing reconstructive
complications associated with postmastectomy radiation therapy.
Breast J. 2014;20:302–307.
5. Chang EI, Warren Peled A, Foster RD, etal. Evaluating the feasibility of extended partial mastectomy and immediate reduction
mammoplasty reconstruction as an alternative to mastectomy.
Ann Surg. 2012;255:1151–1157.
6. Kronowitz SJ, Feledy JA, Hunt KK, etal. Determining the optimal approach to breast reconstruction after partial mastectomy.
Plast Reconstr Surg. 2006;117:1–11.
7. Losken A, Hart AM, Broecker JS, Styblo TM, Carlson GW.
Oncoplastic breast reduction technique and outcomes: an evolution over 20 years. Plast Reconstr Surg. 2017;139(4):824e–833e.
8. Egro FM, Pinell-White X, Hart AM, Losken A. e use of reduction mammaplasty with breast conservation therapy: an analysis of
timing and outcomes. Plast Reconstr Surg. 2015;135(6):963e–971e.
9. Losken A, Hart AM, Chatterjee A. Updated evidence on the
oncoplastic approach to breast conservation therapy. Plast Recon-
str Surg. 2017;140:14S–22S. 5S Advances in Breast Reconstruction.
10. Rietjens M, Urban CA, Rey PC, et al. Long-term oncological
results of breast conservative treatment with oncoplastic surgery.
Breast. 2007;16(4):387–395.
11. Bogusevicius A, Cepuliene D, Sepetauskiene E. e integrated
evaluation of the results of oncoplastic surgery for locally
advanced breast cancer. Breast J. 2014;20(1):53–60.
12. Caruso F, Ferrara M, Castiglione G, etal. erapeutic mammaplasties: full local control of breast cancer in one surgical stage
with frozen section. Eur J Surg Oncol. 2011;37(10):871–875.
13. Hillberg NS, Meesters-Caberg MAJ, Beugels J, Winkens B, Vissers YLJ, van Mulken TJM. Delay of adjuvant radiotherapy due to
postoperative complications after oncoplastic breast conserving
surgery. Breast. 2018;39:110–116.
18
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Local Recurrence and Reconstructive
Options Following Oncoplastic Breast
Surgery
RACHEL ROLPH AND JIAN FARHADI
e management of recurrent breast cancer is a multidisciplinary challenge. Clinical and radiological follow-up of
patients following breast cancer treatment aims to detect
early locoregional and distant metastasis. Local breast recurrence represents the reappearance of cancer and can occur
at or near the site of excision following breast-conserving
surgery (BCS) or in the soft tissues of the anterior chest wall
or skin ap following mastectomy. In the case of oncoplastic
surgery, the majority of local recurrence appears at the initial site where the resection was performed.
e clinical presentation of a patient with a local recurrence may vary and includes a new lump or rmness within
the operated breast, nipple inversion or discharge, as well
as skin changes, for example, erythema, rash, rm nodules,
oedema, tethering, or thickening of scar tissue (Figs. 18.1 and
18.2). Dierential diagnoses include postoperative brosis,
fat necrosis, suture granulomas, benign breast disease, and
post-radiotherapy skin changes. Persistent edema and erythematous skin overlying the operated breast should raise the
suspicion of inammatory recurrent breast cancer and warrants punch biopsy; however, this can be dicult to dierentiate from mastitis and post-radiotherapy skin changes. Even
rarer is cutaneous metastasis “en cuirasse” located on thoracic
and abdominal walls characterized by inltrated, hard, and
sclerodermiform plaques.
Mammography is the mainstay of surveillance imaging
following BCS detecting 8–50% of ipsilateral recurrences,
whereas ultrasound and magnetic resonance imaging remain
supplementary surveillance modalities.2 Mammographic
appearances of ipsilateral recurrence include new nondystrophic microcalcications, a new mass compared with
baseline mammogram, increased architectural distortion or
opacity, and an increase in skin thickening after posttreatment changes have subsided.3 Not all local recurrences will
be associated with mammographic change, and a normal
mammogram does not exclude local recurrence. Stereotactic
1
and core biopsies histologically conrm the diagnosis of local
recurrence.
Local recurrence rates following surgery vary widely in
the literature due to dierences in patient cohort selection,
extent of surgery, and use of adjuvant therapies. e incidence of local recurrence after BCS and radiotherapy ranges
from 10–22% at 10 years and, after mastectomy, ranges
from 5–15% at 10 years.
is 3–4 years for BCS and 2–3 years for mastectomy.3 Breast
recurrence is a predictor of distant metastasis and decreased
survival. A meta-analysis by the Early Breast Cancer Trialists’ Collaborative Group demonstrated a negative eect of a
local recurrence on survival.7 In 5–15% of cases, local recurrence is associated with concomitant regional and distant
metastasis; therefore, computed tomography and positron
emission tomography staging is considered for all patients
with conrmed local recurrence.
• Fig. 18.1 Local recurrence following right breast oncoplasty demon-
strating ulcerated nodules along the medial perimeter of the breast.
4-6
e median time to recurrence
6,8
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CHAPTER 18 Local Recurrence and Reconstructive Options Following Oncoplastic Breast Surgery
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• Fig. 18.2 Local recurrence following right mastectomy demonstrating
nodularity in the subcutaneous tissues around the mastectomy scar.
e a etiology of local recurrence remains unclear; however,
theories include incomplete excision of the primary tumor,
unrecognized multifocal disease, entrapment of tumor cells
within obstructive lymphatics, and local implantation of systemic circulating cells.9 In the context of local recurrence alone,
excision surgery and adjuvant therapies have curative intent.
For patients presenting with local recurrence and distant metastasis, a multidisciplinary approach will be required to assess the
need for palliative resection of the local recurrence as an adjunct
to systemic treatment.
Determinants of Local Recurrence
e importance of negative margins in BCS cannot be overstated, and positive margins are a risk factor for increased
local recurrence. Positive margins according to the joint
guidelines of the American Society of Breast Surgeons/
Society of Surgical Oncology/American Society of Radiation Oncology constitute “ink on tumor” for invasive breast
cancer and less than 2 mm margins for ductal carcinoma in
situ.10 Current UK guidelines from the Association of Breast
Surgery consensus dene positive margins as 1 mm for both
invasive and ductal carcinoma in situ.11 A systematic review
on oncologic reporting in BCS highlighted variation in the
frequency of margin involvement (0–36%) and local recurrence rates of 0–10.8%.12 Positive margins (ink on invasive
or ductal carcinoma in situ) are associated with a twofold
increase in the risk of ipsilateral recurrence compared with
negative margins.13 More widely clear margins than no ink
on tumor do not signicantly decrease the rate of recurrence
compared with no ink on tumor even in high-risk groups
with unfavorable biology.13 Local recurrence is inuenced
more by tumor biology and therapy than surgical margin.14
Young age at diagnosis (less than 40 years) is a signicant
risk factor for local recurrence at 5 years with a relative risk
of 2.21 (95% CI 1.62–3.02).
15,16
Body mass index gain following BCS is also signicantly associated with higher rates
of recurrence.
17
Pan etal performed a meta-analysis of the results of 88 trials
involving 62,923 women with estrogen receptor (ER)-positive
breast cancer who were disease-free after 5 years of scheduled
endocrine therapy.18 e risk of disease recurrence, both locally
and distant, was strongly correlated with the original TMN classication (tumour, node, metastasis) status and tumor grade.
During the study period from 5–20 years, the absolute risk of
local recurrence with T1N0 ER positive breast cancer or a contralateral breast cancer were low grade 17%, moderate grade
22%, and high grade 26%. Tumor grade and size are signicant
predictors of recurrence after adjustment to other variables.
19,20
Breast tumors can be divided into subtypes based on
molecular proling, particularly those diering in proliferation.21 Measurement of the level of activation of the proliferation pathway is via Ki-67 expression. Ki-67 is a nuclear
protein associated with cellular proliferation. Immuno-staining can assess the percentage of breast cancer cells expressing
Ki67 (<14%; >14%). Molecular subtypes of breast cancer
include luminal A (ER-positive or progesterone receptor
[PR]-positive and Ki-67 < 14%); luminal B (ER- or PR-positive and Ki-67 ≥ 14%); luminal human epidermal growth
factor receptor 2 (HER2) (ER- or PR-positive and HER2positive); HER2-enriched (ER-negative, PR-negative, and
HER2-positive); and basal-like (ER-, PR-, and HER2negative, triple negative). Luminal B, HER2 positive, and
triple negative subtypes all show signicant increased risk
for both local recurrence and distant recurrence following
BCS.22 Five-year local recurrence rates following BCS and
radiotherapy for each subtype have been reported: 0.8% for
luminal A, 2.3% for luminal B, 1.1% for luminal HER2,
10.8% for HER2-enriched, and 6.7% for triple-negative
disease.23 Similarly, after mastectomy, patients with luminal
A tumors had the lowest rates of local recurrence, 8% at 10
years.24 Gene expression proling by microarray analysis is
being used to identify gene expression proles that can predict local recurrence. Although still being rened, researchers
have been able to identify subgroups of patients at increased
risk of developing local recurrence following BCS.
25,26
Indications and Techniques for Second
Oncoplastic Breast Surgery
e standard treatment recommended for ipsilateral recurrence following BCS is salvage mastectomy with radiotherapy
to the chest wall if not already administered previously.27 e
management plan following salvage surgery is formulated in a
multidisciplinary approach to determine the benets of radiotherapy, endocrine, and chemotherapy on a case-by-case basis
with the aim to reduce secondary recurrence and distant metastasis. e adjuvant treatment strategy will take into account the
biology of the original tumor, time to recurrence, patient TN
status, age, previous adjuvant treatments, and comorbidities.
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Patients presenting with ipsilateral recurrence in the
tumor bed may decline salvage mastectomy and seek alternative treatment options. For this small subgroup of patients,
repeat breast-conserving surgery (rBCS) with or without
additional radiotherapy may be considered. Patients with
inammatory breast cancer, small volume breasts, multicentric or multifocal recurrence, skin involvement, or poor
tumor biology (e.g., high grade, triple negative, HER2-positive) are not candidates for this approach. Patient choice
would be the main determining factor to consider a second
conservative surgery and is not to be oered routinely. e
evidence base supporting rBCS is limited and therefore cannot currently be recommended over mastectomy.28 Small
unifocal recurrence in a large volume breast, a long interval
to recurrence, and amenable tumor location would be factors enabling rBCS to be technically feasible. Cosmesis in
the re-operated breast may be compromised in rBCS due
to reduced pliability of the breast parenchyma, signicant
volume disparity between breasts, and post-radiotherapy
changes to the skin envelope. ere are no published level
1 studies comparing salvage mastectomy versus rBCS ±
radiotherapy for patients with ipsilateral breast recurrence.
Low incidence of recurrence and heterogeneity of the recurrence population, for example, timing to recurrence, tumor
staging and biology, means recruitment, and design of a
large-scale study comparing the two treatments, proves difcult. Two phase II prospective trials investigating the use of
partial breast re-irradiation following rBCS are in progress
(https://clinicaltrials.gov).
e use of secondary repeat breast conservation surgery
for local recurrence was rst described by Kurtz etal in a
retrospective analysis of 52 patients.29 Wide local excision
alone was performed for stage I–II breast cancer patients for
small, slow-growing, ipsilateral recurrence. ey reported
no signicant dierences between mastectomy and rBCS
for 10-year overall survival (54% and 64%, respectively). A
higher rate of secondary recurrence was however observed
in the rBCS without re-irradiation (38% vs 25%). Since
then, the majority of published studies on this topic are
small retrospective, non-randomized cohort studies.28 ey
are subject to selection bias and poor study quality. Patients
receiving rBCS are more often to have better prognostic
characteristics compared with those treated with mastectomy (e.g., size, multifocality, aggressive tumor biology). A
recent retrospective cohort study by Kolben etal has reported
data supporting the use of rBCS in selected patients.30 Of
170 patients, 34.1% of women underwent secondary BCS,
whereas 65.9% were treated by salvage mastectomy. Fiveyear ipsilateral recurrence-free rate after secondary BCS was
77.6% (Standard Deviation (SD) ± 6.1%) and 75.0% (SD
± 4.5%) for patients after mastectomy. Five-year diseasefree survival was 57.3% (SD ± 8.2%), and 61.9% (SD ±
5.5%); 5-year overall survival was 84.7% (SD ± 5.8%), and
72.6% (SD ± 5.1%), respectively. Ishitobi etal reported a
20% local recurrence rate following rBCS alone.31 Survival
rates following rBCS compared with salvage mastectomy
are conicting. Alpert etal reported a 64.5% survival rate
at 10 years with no signicant dierence between salvage
mastectomy and rBCS observed in 271 patients undergoing rBCS or mastectomy for recurrence (55% vs 45%).32
Yoshida et al reported no signicant dierence in overall
survival between the two surgical approaches after adjustment for clinical and tumor characteristics.33 In contrast,
Chen etal observed signicantly better survival rates at 5
years following salvage mastectomy when compared with
rBCS (78% vs 67%, p = 0.003).
34
Kurtz et al reported risk factors associated with secondary recurrence following rBCS alone.35 rough multivariate
analysis, the group reported that the disease-free interval to
recurrence and resection margins signicantly inuence local
control following rBCS. Five-year local control was 92% for
recurrences occurring after 5 years versus 49% for shorter intervals, and 73% for negative margins versus 36% for positive or
indeterminate margins. e authors concluded that wide excision represents an alternative to mastectomy in salvage treatment for selected patients with mobile tumors, 2 cm or smaller
in diameter, and no signs of rapid growth.35 Prior adjuvant systemic therapy, skin or muscle inltration, and lymphovascular
inltration in the breast recurrence are additional risk factors
for shorter disease-free survival following rBCS.
30
Re-irradiation following rBCS is an emerging concept in
the treatment of recurrence, although it remains in an experimental phase. Repeat irradiation to the resected breast cavity
following rBCS is a technique applied to reduce secondary
local recurrences rst reported in the 1990s.36 Ishitobi etal
reported 5-year second recurrence survival rates are improved
with post-rBCS radiotherapy; radiotherapy after initial surgery, radiotherapy after salvage surgery, and no radiotherapy
were 78.0%, 93.5%, and 52.7%, respectively.31 ere is no
consensus regarding the optimal treatment for patients who
have previously had BCS with irradiation. e normal tissue tolerance does not permit a second full-dose course of
radiotherapy to the entire breast after a second BCS. Reirradiation to the entire breast is poorly tolerated due to poor
cosmetic outcome and high toxicity rates.37 New modes of
delivering focal radiotherapy to the breast have raised the possibility of localized radiation therapy for women post-rBCS.
Accelerated partial breast irradiation (APBI) is proposed as
an alternative to whole breast re-irradiation. APBI limits irradiation to the target area post-wide local excision plus 1–2
cm margin of tissue in a shorter time period while delivering
equivalent doses to whole breast irradiation.37 A number of
techniques are reported including multicatheter interstitial
brachytherapy (IB), balloon catheter brachytherapy, intraoperative radiation therapy (IORT), and external beam irradiation (EBI). A recent Cochrane review summarizing evidence
for partial breast irradiation (PBI) and APBI for treatment
of primary breast cancer versus whole breast radiotherapy
highlighted the limitations of the data currently available in
this eld. e authors reported cosmetic outcomes and late
eects were worse with PBI/APBI, but less skin toxicity was
noted.38 Local recurrence was increased with PBI/APBI (the
dierence was small) with no evidence of detriment in other
oncologic outcomes.
38
CHAPTER 18 Local Recurrence and Reconstructive Options Following Oncoplastic Breast Surgery
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Studies applying this technology to recurrent breast
cancer treatment following rBCS are limited to small case
series, varying follow-up durations, and subject to selection bias. e majority of studies report results for rBCS
with brachytherapy for patients with small T0-2 recurrent
lesions, no metastasis, and negative resection margins with
late onset of recurrence (mean 70 months).39 Authors report
EBI with 45 Gy (1.8 Gy per fraction) to rBCS is generally well tolerated with low acute and late skin toxicities
and good local disease control.40 e prognostic factors for
favorable overall survival rates were younger age (p = 0.045),
lower T category (p = 0.019), and N0 category (p = 0.005).
Hannoun-Levi etal have reported promising results for
217 women treated with multicatheter brachytherapy following rBCS.41 Secondary local recurrence rates were 5.6%
(1.5–9.5) at 5 years and 7.2% (2.1–12.1) at 10 years. Overall survival rates for 5 and 10 years were 88.7% (83.1–94.8)
and 76.4% (66.9–87.3%), respectively, and report comparable results to salvage mastectomy. Similar overall survival
and disease-free survival rates have been reported in other
small case series.
42,43
Grade 1–2 toxicities are observed in
the majority of patients (skin atrophy, pigmentation, telangiectasia, slight induration, and loss of subcutaneous
42,44
fat).
Approximately 11% of women experience grade
3 or 4 toxicities (marked skin atrophy, gross telangiectasia,
ulceration, severe brosis, eld contracture, necrosis).
42,44
e most common side eect reported from IB is cutaneous and subcutaneous brosis (up to 60%) as a function of
dose and volume, which may considerably aect overall cosmetic outcome following secondary oncoplastic surgery due
to parenchymal tethering.
39,45,46
Factors aecting cosmesis
include the distance of the catheter or balloon from the skin,
the type of device used, the volume of residual breast tissue
after rBCS, and degree of initial breast asymmetry.47 Complications related to device include persistent breast pain,
a chronic abscess in the sinus tract of the balloon catheter,
and infections of the catheter tract requiring mastectomy
and antibiotics, respectively.48 Proponents of the technique
report stable cosmetic scores (from excellent to good) and
patient satisfaction in 60–80% of patients; however, most
studies did not use standardized evaluation schemes.
39,45,48
In 2007, Kraus-Tiefenbacher etal reported on the use of
IORT following rBCS.49 Fifteen patients were treated after
previous EB radiotherapy after ipsilateral breast recurrence.
At median follow-up, short, acute toxicity 26 months after
IORT was reported as mild with no grade 3–4 toxicities in
the group. Further high quality research is required to support rBCS with or without re-irradiation in routine clinical
practice.
BCS and radiotherapy, and data are limited to observational
studies. Decisions regarding reconstruction in this cohort
should be made within a multidisciplinary team with a
tailored individual approach. Options regarding the timing and types of reconstruction vary considerably among
surgeons, particularly in this context.
50,51
Authors emphasize the need for careful detailed assessment and discussion
with patients regarding their risk factors, disease extent,
reconstructive options, and personal preferences. Figs.
18.3 and 18.4 illustrate a patient diagnosed with left breast
cancer managed with oncoplasty who early on developed
a recurrence managed with mastectomy and device-based
reconstruction.
e majority of patients will have received radiotherapy
following their initial BCS. Histological analysis of the
eects of radiotherapy to breast tissue reveals considerable
architectural tissue change: epidermal hyperplasia, atrophy of dermal appendages, high density of dermal collagen
bers, and unidirectional alignment of dermal collagen
bers.52 In the context of prosthetic breast reconstruction,
these changes are strongly associated with complications
including diculty in expanding irradiated skin, grade 3
and 4 Baker capsular contracture (relative risk 3.75), and
expander/implant extrusion following prosthetic reconstruction.
prosthetic reconstruction in the irradiated breast is associ-
52-54
e presence of acellular dermal matrix with
ated with an increased complications rate with a 2.3-fold
greater chance of reoperation.
55
Systematic reviews on radiotherapy in the context of
post-mastectomy reconstruction report prosthetic reconstruction is associated with an increased reconstructive
failure rate and overall complication rate when compared
with autologous reconstruction.
56-59
Despite this, the frequency of immediate prosthetic-based reconstruction in the
setting of radiation therapy is increasing.60 e detrimental
eect of radiotherapy persists regardless of two-stage versus
one-stage prosthetic reconstruction and the timing of the
Reconstructive Options Following Salvage
Mastectomy for Recurrence
Despite international guidelines recommending salvage
mastectomy following recurrence, there are no level 1 studies to guide surgeons’ choice for reconstruction following
• Fig. 18.3 The patient developed a local recurrence following previ-
ous breast conserving surgery and was scheduled for left skin-sparing
mastectomy and tissue expander reconstruction.
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