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4
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Oncoplasty versus Mastectomy:
Decisions and Outcomes
MAURICE Y. NAHABEDIAN AND COSTANZA COCILOVO
Introduction
As reconstructive techniques have improved, patient expectations have evolved. From the simplest to the most complex resection, patients expect to be satised with their nal
esthetic result. Trying to decide on the operation that is best
for patients now involves not only understanding the tumor
biology but also patient preference and how to achieve the
best esthetic results. Patients can choose breast conservation
with or without oncoplastic reconstruction, and mastectomy with nipple sparing or without and with or without
reconstruction. e challenge is helping the patient choose
the optimal oncologic and cosmetic solution for them.
Understanding expectation is critical before operative intervention. For some women, it is important to preserve as much
of their natural breast as possible; whereas for others, achieving the lowest local recurrence risk is the driving force even
when the statistical benet is minimal. Some women hope to
end up with a smaller or larger breast. In all cases, the role of
the breast surgeon is to help patients understand their choices.
Safety of Oncoplastic Breast Surgery
Oncoplastic surgery is considered oncologically safe. A review
of outcomes demonstrated high rates of overall survival (95%)
and disease-free survival (90%) as well as low rates of local
recurrence (3.2%), positive margins (10.8%), and re-excisions
(6%).1 Equivalent survival rates are an accepted norm. A population study of early breast cancer in the Netherlands suggests
an improvement in overall survival in early stage breast cancer
compared with mastectomy, likely due to the added benet of
radiation.2 For years, we have recognized that shrinking the
tumor with neoadjuvant chemotherapy can allow a better cosmetic outcome and increase the chance of breast conservation.
Benefits of Oncoplastic Surgery
e benets of oncoplastic surgery have been demonstrated
throughout the literature. In a review from the MD Anderson
Cancer Center of 9861 patients with breast conservation
and oncoplastic reconstruction, it was demonstrated that
there was a lower rate of seroma formation (13.4 vs 18%,
p = 0.002) and a lower rate of positive margins (5.8 vs 8.3%,
p = 0.04).3 Although mastectomy rates have increased across
the country, the MD Anderson review demonstrated that
rates of breast conservation with oncoplastic reconstruction
have also increased. Patients choosing oncoplasty tend to be
older than patients choosing mastectomy; however, obesity
rates were similar. e majority of patients (75%) in the
study had a T1 or T2 tumor; however, patients who chose
oncoplastic reconstruction tended to have larger tumors,
and the majority of patients who had lymph node-positive
breast cancer and T4 tumors chose mastectomy.
e location and characteristics of the tumor are other
factors that can inuence choice. e quadrant the tumor
was located in did not inuence the choice of oncoplastic
reconstruction except when located in the lower outer quadrant, in which case slightly more women had breast conservation alone. Tumor characteristics were generally similar,
with a slight increase in HER-2 neu positive tumors choosing oncoplastic reconstruction, as did patients who underwent neoadjuvant chemotherapy. is may have to do with
the fact that their tumors were larger at diagnosis and so, in
the initial discussion on surgical options, the suggestion for
oncoplastic reconstruction was made.
Wound-related complications and surgical site infections
were lower in patients who underwent breast conservation
and oncoplastic reconstruction compared with mastectomy
and reconstruction. e seroma rate was lower with oncoplastic reconstruction compared with breast-conserving surgery alone. e hematoma rate was lower compared with
mastectomy, as was wound-related complications.
e goal of oncoplastic surgery is to improve the esthetic
outcome while performing an oncologically safe operation. A Brazilian study compared esthetic results using a
semiautomatic software device demonstrating improved
outcomes with oncoplastic surgery.4 In general, when surgeons evaluate esthetic outcomes, they are more favorable
3
23
SECTION I Oncoplastic Breast Surgery – Getting Started
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24
to oncoplastic resection than patients are. In a recent review
of observational studies that included 8659 patients, it was
demonstrated that patient satisfaction was increased after
oncoplastic surgery compared with breast-conserving surgery; however, the dierence was slight (89.5% vs 82.9%).
As the eld of oncoplastic surgery has evolved over the
past decade, many breast and plastic surgeons remember the
signicant contour deformities that occurred with breast
conservation alone. Managing patient expectations is an
important aspect for all surgical procedures of the breast
because patients will often compare their outcomes to their
original breasts or to ideal versions that they have seen in
images. We have found in our institution that, although
patients are initially surprised by the change, as time goes
on they are generally pleased. e patients who express the
greatest satisfaction are those with larger more ptotic breasts
who in essence have a lift and reduction with increased projection. Patients with smaller breasts who chose breast conservation because it is a simpler and less invasive operation
are often disappointed because of the attening and loss of
projection that can occur.
A Spanish review of 801 patients comparing oncoplastic reduction mammaplasty to tumorectomy alone demonstrated similar overall survival at 10 years.6 Patients
undergoing oncoplastic reconstruction were younger, had
larger tumors, and the tumor was most likely located in the
lower pole. Although the oncoplastic reduction mammaplasty cohort had a higher rate of tissue necrosis (2.5% vs
0.1%), both were low. In their experience, reduction mammaplasty using an inverted T pattern made up 17% of the
group. Adverse events related to this approach included an
increased risk of having a lower pole deformity as well as
delayed healing or tissue necrosis. Similar to other studies,
they demonstrated that ductal carcinoma in situ (DCIS),
invasive lobular cancer, and larger tumors were the most
likely causes of positive margins. e BreastQ questionnaire
was used and demonstrated that patient satisfaction ranged
from 70–83 out of 100 at the 1-year mark with regard to
psychosocial status as well as satisfaction of the breast in the
sexual sphere.
5
• Fig. 4.1 Preoperative image of a woman with right breast cancer and
mammary hypertrophy scheduled for oncoplastic reduction mammaplasty.
• Fig. 4.2 Preoperative marking using an inverted T pattern.
Radiation and Oncoplastic Surgery
e question often arises, does radiation therapy harm oncoplastic reconstruction? e majority of patients having breast
conservation will receive radiation unless they are elderly or
have a favorable in situ cancer. e indications for radiation have broadened over the years such that many patients
after mastectomy with one or two positive lymph nodes
will have radiation therapy in lieu of an axillary dissection.
Other indications for radiation therapy include having three
or more positive lymph nodes. In a recent systematic review
of oncoplastic surgery in the setting of breast conservation,
Yoon et al did not nd any increased local recurrence following whole breast radiation and boost given to patients
who had an oncoplastic reconstruction.7 In this review, the
benets of whole breast irradiation (WBI) and accelerated
partial breast irradiation (APBI) were reviewed. e general
consensus was that the data on APBI with breast conservation therapy (BCT) and oncoplastic surgery with WBI is still
early to make any meaningful comparisons. e study found
that 70–100% of patients reported good to excellent satisfaction. One of the limitations of APBI becomes evident in
the patient who has had oncoplastic tissue rearrangement;
the location of the actual tumor bed may be obscured, and
there may not be space to place and expand the catheter.
New emerging techniques that can accurately deliver APBI
externally may overcome the challenge of placing catheters in
this space. Given the safety and positive cosmetic results with
radiation and oncoplastic surgery, there may be an esthetic
advantage to oncoplasty over mastectomy. Figs. 4.1–4.3 illustrate a patient following oncoplastic reconstruction.
CHAPTER 4 Oncoplasty versus Mastectomy: Decisions and Outcomes
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• Fig. 4.3 Postoperative result following the oncoplastic reduction and
radiation therapy on the right as well as a reduction mammaplasty
demonstrating excellent volume and contour symmetry.
Further support of oncologic safety has been demonstrated in several studies. Piper etal in a systematic review
demonstrated that, even in patients who had a positive margin after the initial surgery and underwent a re-excision,
higher recurrence rates were not observed compared with
patients undergoing completion mastectomy.8 In another
review of 980 patients from the United Kingdom, Mansell
etal compared three cohorts of patients that included those
having oncoplastic breast-conserving surgery (OBCS), wide
local excision (WLE), or mastectomy with or without immediate reconstruction.9 It was demonstrated that 5-year local
recurrence rates were similar in all three groups (WLE 3.4%,
OBCS 2%, and mastectomy 2.6%). Distant recurrence rates
were higher after mastectomy (13.1%) and OBCS (7.5%)
compared with WLE (3.3%, p < 0.001). e potential benets of oncoplastic surgery include improved patient satisfaction and quality of life as well as decreased health care
costs compared with mastectomy with full reconstruction.
9
is then begs the question as to why women choose
mastectomy or bilateral mastectomy instead of OBCS?
Younger women in urban settings with private insurance
and planned reconstruction were more likely to choose
mastectomy and reconstruction.10 Interestingly there seems
to be no link to tumor grade or stage. In other countries,
however, the choices are dierent. In Western Australia, for
example, tumor size was the greatest determinant of mastectomy versus breast conservation.11 Women with T1 tumors
were most likely to choose breast conservation; however,
as tumor size increased beyond 2 cm, mastectomy became
the more preferred option. Women who chose mastectomy
tended to be older and live in a rural area and have positive
nodes. In another analysis of 11,654 patients maintained in a
National Surgical Quality Improvement Program (NSQIP)
database, 9571 underwent breast conservation surgery and
2074 underwent simple mastectomy with implant reconstruction.12 e study demonstrated that the simple mastectomy with implant group had signicantly higher total
complication (5.5% vs 2.1%), wound complications (2.8%
25
• Fig. 4.4 Preoperative image of a woman with right breast cancer
scheduled to have bilateral skin sparing mastectomy and two-stage
prosthetic reconstruction.
vs 1.4%), surgical site infection (1.9% vs 0.4%), and bleeding (0.2% vs 0.05%) rates compared with the breast conservation group.
So then how do we decide who should get breast conservation with oncoplastic surgery and who is a better candidate for mastectomy? Clough etal have dened this as a
level 1 resection in which <20% of the breast is removed.13
is is typically corrected with local tissue rearrangement.
A level 2 resection is dened as removal of 20–50% of
the breast volume that typically correlates with a resection
weight that exceeds 200 grams resulting in a signicant
deformity. ese are often corrected with volume displacement techniques such as reduction mammaplasty. ey
reported on 101 patients managed with oncoplastic techniques because standard breast conservation would have
resulted in poor esthetic outcomes. Mean weight of excised
breast on the tumor side was 222 grams. e actuarial 5-year
local recurrence rate was 9.4%, the overall survival rate was
95.7%, and the metastasis-free survival rate was 82.8%.
Cosmesis was favorable in 82% of cases. Preoperative radiotherapy resulted in worse cosmesis than when given postoperatively, which is not surprising.13 Performing a partial
mastectomy without reconstruction but with the intent of
delayed reconstruction rarely resulted in a good cosmetic
outcome. Achieving symmetry for optimal cosmesis usually
requires a contralateral symmetry technique. ey can result
in longer operating time and require specialized training in
oncoplastic technique. Figs. 4.4–4.8 illustrate a patient following mastectomy, prosthetic reconstruction, and radiation therapy.
e benet of oncoplastic WLE compared with standard
excision associated with breast conservation has been demonstrated by studies from the United Kingdom. Down etal
retrospectively reviewed tumor clearance and the need for
further margin excision following standard WLE (group A,
n = 121) and OBCS (group B, n = 37).14 ey found that,
compared with standard surgery, oncoplastic techniques can
SECTION I Oncoplastic Breast Surgery – Getting Started
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26
• Fig. 4.5 Intraoperative image demonstrating placement of a dual
plane tissue expander and acellular dermal matrix.
• Fig. 4.6 Postoperative image following right breast radiation therapy.
The skin on the right is more fibrotic than the skin on the left.
• Fig. 4.7 Intraoperative image at the time of exchange of the tissue
expanders for permanent implants as well as autologous fat grafting to
improve the contour and quality of the mastectomy skin flaps.
• Fig. 4.8 Postoperative image at 2-year follow-up with nipple–areolar
tattooing demonstrating good volume and contour symmetry.
be employed for significantly larger tumors (17.6 mm vs
23.9 mm, p = 0.002), higher mean specimen weights (58.1
grams vs 231.1 grams, p < 0.0001), higher specimen volumes (112.3 cm3 vs 484.5 cm3, p < 0.0001), wider clear
margins (6.1 mm vs 14.3 mm, p < 0.0001), and lower rates
of further surgery (28.9% vs 5.4%, p = 0.002) (down).
ere was no statistical increase in complication rates following oncoplastic surgery. Radiation is more easily given to
women with smaller breasts, so the reduction mammaplasty
adds that benet as well.
14
e group at MD Anderson published their recommendations for choosing mastectomy versus breast conservation
with oncoplastic repair.15 For women with an A or B cup
breast, mastectomy is usually the better choice because the
remaining breast tissue is usually inadequate for performing an oncoplastic repair using tissue rearrangement techniques. However, the use of a vascularized tissue ap such
as a latissimus dorsi can be considered to correct the deformity. For women with larger breasts with a C or D cup,
oncoplasty using a breast reduction technique is considered.
e inverted T pattern skin incision allows access to most
areas of the breast for resection while allowing the nipple–
areolar to maintain a blood supply via a dermoparenchymal
pedicle. ey also describe a modication that retains the
medial wedge of breast tissue that is usually discarded with
a standard inferior pedicle design. When a standard inferior
pedicle is impinged on by the tumor resection, the inferior
pedicle is extended medially (the least frequent location for
breast cancer) to increase the blood supply (intercostals and
internal mammary perforating blood vessels) and the volume of breast tissue available for repair. is medial wedge
can be used to repair the upper inner quadrant, which is
often challenging. Similarly for defects in the inferior medial
quadrant, a more lateral pedicle can be used. ey recommend reducing the contralateral breast after radiation for a
more precise match.
CHAPTER 4 Oncoplasty versus Mastectomy: Decisions and Outcomes
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Conclusions
Women diagnosed with breast cancer can choose partial or
total mastectomy and achieve esthetic outcomes. Despite no
survival advantage, some women will prefer mastectomy to
breast conservation with oncoplasty. At many institutions
throughout the United States, women with A and B cup
breasts often choose to have nipple-sparing mastectomy
and prosthetic reconstruction that generally confers excellent cosmetic results. As breast size increases, particularly
in relation to tumor size, these patients are excellent candidates for breast conservation with immediate oncoplastic
surgery. Aside from the cosmetic advantage, adding oncoplastic surgery decreases the risk of positive margins and
thus a second surgery compared with breast conservation
alone because a larger volume of breast parenchyma can be
resected. Skilled plastic surgeons are able to correct everlarger defects expanding the number of patients who are
able to have breast conservation. In patients with mammary
hypertrophy who desire nipple-sparing mastectomy rather
than breast conservation and oncoplasty, plastic surgeons
have a variety of mammaplasty techniques to reduce the
breast in a staged procedure so that the patient can have a
nipple-sparing mastectomy several months later. e ultimate goal for any patient with breast cancer is to deliver an
oncologically safe operation that is esthetically pleasing.
References
1. De La Cruz L, Blankenship SA, Chatterjee A, etal. Outcomes after
oncoplastic breast-conserving surgery in breast cancer patients:
a systematic literature review. Ann Surg Oncol. 2016;23(10):
3247–3258.
2. Van Maaren MC, de Munck ML, de Bock GH, etal. 10 year
survival after breast conserving surgery plus radiotherapy compared with mastectomy in early breast cancer in the Netherlands:
a population based study. Lancet Oncol. 2016;17(8):1158–
1170.
3. Carter SA, Lyons GR, Kuerer HM, etal. Operative and oncologic outcomes in 9861 patients with operable breast cancer:
single institution analysis of breast conservation with oncoplastic
reconstruction. Ann Surg Oncol. 2016;23(10):3190–3198.
4. Santos G, Urban C, Edelweiss MI, etal. Long-term comparison
aesthetical outcomes after oncoplastic surgery and lumpectomy
in breast cancer patients. Ann Surg Oncol. 2015;22(8):2500–
2509.
5. Losken A, Dugal CS, Styblo TM, Carlson GW. A metaanalysis
comparing breast conserving therapy alone to oncoplastic technique. Ann Plast Surg. 2014;72(2):145–149.
6. Acea-Nebril B, Garcia-Novoa A, Builes-Ramirez S, etal. e role
of oncoplastic breast reduction in the conservative management
of breast cancer: complications, survival and quality of life. J Surg
Oncol. 2017;115(6):679–686.
7. Yoon JJ, Green WR, Kim S, etal. Oncoplastic breast surgery in
the setting of breast conserving therapy: a systemic review. Adv
Radiat Oncol. 2016;1:201–215.
8. Piper ML, Esserman LJ, Sbitany H, Peled AW. Outcomes following oncoplastic reduction mammoplasty: a systemic review.
Ann Plast Surg. 2016;76(3):222–226.
9. Mansell J, Weiler-Mitho E, Stallard S, Doughty JC, Mallon E,
Romics L. Oncoplastic breast conservation surgery is oncologically safe when compared to wide local excision and mastectomy.
Breast. 2017;32:179–185.
10. Bhat S, Orucevic A, Woody C, Heidel R, Bell J. Evolving trends
and inuencing factors in mastectomy decisions. Am Surg.
2017;83(3):233–238.
11. Martin M, Meyricke R, O’Neill T, Roberts S. Mastectomy or
breast conserving surgery? Factors aecting type of surgical
treatment for breast cancer- a classication tree approach. BMC
Cancer. 2006;6:98. https://doi.org/10.1186/1471-2407-6-98.
http://www.biomedcentral.com/1471-2407/6/98.
12. Pyfer B, Chatterjee A, Chen L, et al. Early outcomes in breast
conservation surgery versus mastectomy with implant reconstruction: a NSQIP analysis of 11,645 patients. Ann Surg Oncol.
2016;23:92–98.
13. Clough K, Lewis J, Couturaud B, Fitoussi A, Nos C, Falcou MC.
Oncoplastic techniques allow extensive resections for breast conserving therapy of breast carcinomas. Ann Surg. 2003;237(1):
26–34.
14. Down S, Jha PK, Burger A, Hussien M. Oncological advantages
of oncoplastic breast conserving surgery in treatment of early
breast cancer. Breast J. 2013;19(1):56–63.
15. Kronowitz SJ, Kuerer HM, Buchholz TA, Valero V, Hunt K.
A management algorithm and practical oncoplastic surgical techniques for repairing partial mastectomy defect. Plast. Reconstr.
Surg. 2008;122:1631–1647.
5
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Breast Surgeons and Oncoplastic
Surgery
JULIANN MARIE REILAND
Breast surgeons utilizing oncoplastic techniques is commonplace in the United Kingdom, Europe, and parts of South
America. In Canada and the United States, the adoption
of oncoplastic surgery by breast surgeons has been slow to
advance. Many factors play a role in the slow adoption, but
education and training are most likely the greatest obstacles
breast surgeons face. Breast surgery has evolved into its own
specialty, and breast surgeons have widened their scope of
practice to embrace and integrate aspects of other specialties
to better care for the cancer patient. Oncoplastic techniques
should be an essential addition to that scope of practice.
e treatment of breast cancer is a rapidly changing and
dynamic eld. e breast surgeon is the “rst responder” to
the crisis of a woman with a new breast cancer diagnosis.
e breast surgeon explains the disease to the patient and
partners with her to develop the best treatment plan based
on multiple variables. Each woman has unique physical, biological, and emotional variables that must be factored into
that plan. e patient with breast cancer has the best results
when her care involves a multidisciplinary approach with
all specialties involved in her treatment.1 As rst responder,
the breast surgeon has knowledge of the basic aspects of the
specialties involved and navigates the patient to the other
specialists when their expertise is required. In an eort to
expedite the patient’s care, the breast surgeon has adopted
aspects of radiology, genetics, and integrative medicine into
their practice.
A newly diagnosed breast cancer patient will likely
undergo multiple tests both before and after her diagnosis.
Breast surgeons read mammograms daily and perform ultrasounds both in the clinic and in the operating room to better facilitate the treatment of their patient. Advanced breast
imaging such as 3D mammography, magnetic resonance
imaging, and ultrasound have improved the evaluation
and diagnosis of breast cancer. Innovations such as contrast
enhanced digital mammography2 and automated breast
ultrasound3 are being recognized as new tools in advanced
imaging. It is the breast surgeon who determines which
tests are needed to obtain the best information regarding
treatments. Many breast surgeons are certied to perform
ultrasound and stereotactic core biopsies in the diagnosis
of breast disease. Breast surgeons and radiologists work
together to bridge specialties to facilitate the evaluation and
surveillance of the woman with breast cancer.
With the new diagnosis comes the question of “why me?”
Understanding and identifying risk factors for the occurrence of an initial or second breast cancer have also advanced
signicantly. ere has been an explosion of information
regarding genetic defects that increase a woman’s lifetime
risk from 25–80%.4 e understanding of genetics is crucial in the ability to counsel the patient as to her options
for treatment. Breast surgeons have adopted this knowledge
into their practice and have been recognized as appropriate
providers to counsel patients in genetics and genetic testing5
and share these responsibilities with geneticists when they
are available.
When a woman is diagnosed, one of her rst reactions
is to have surgery yesterday. However, tumor biology of a
woman’s breast cancer is often the driver of the order in
which she will be treated. Biologically aggressive tumors
such as estrogen and progesterone negative, HER-2 neu
positive (Luminal B), and triple negative tumors are now
recommended for treatment with neoadjuvant chemotherapy. With genomic sequencing, determining the precise
treatment for each individual cancer is evolving. e ability to eectively downstage tumors gives women with later
stage breast cancers more options in their surgical treatment.
Now, more than ever, the breast surgeon must be aware of
the nuances of tumor biology and identify the patient who
needs referral to medical oncology. e breast surgeon must
also impress upon the patient who is so anxious to have
surgery rst, the importance of neoadjuvant chemotherapy,
when appropriate, to her total care.
Radiation therapy after partial mastectomy is an important component of breast conservation therapy. With the
acceptance of varying modalities and time courses of radiation therapy, a 6-week course of daily whole breast radiation is being replaced by shortened whole breast radiation
28
CHAPTER 5 Breast Surgeons and Oncoplastic Surgery
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29
courses or better partial breast radiation options. Today a
woman can potentially have her breast cancer surgery and
her entire radiation therapy dose performed together in
1 day, with many other options oering shortened courses
of radiation from 2–21 days.6 e breast surgeon evaluates
the patient for the possible options of partial breast or whole
breast radiation and works closely with the radiation oncologist to determine patient selection and the intraoperative
placement of the radiation delivery system, as appropriate.
After the acute crisis of a breast cancer diagnosis and
treatment, the patient begins the process of putting her life
back together and understanding her “new normal.” e
breast surgeon again is a part of this process. Many breast
surgeons participate in monitoring the patient between 2–5
years after her cancer diagnosis.
7,8
In the United States,
most women are diagnosed with early stage disease. ese
women will have 98% survival.9 Survivorship becomes an
important part of the treatment plan for every woman with
breast cancer. Breast surgeons determine appropriate imaging needed for each patient in surveillance. ey counsel
women on lifestyle changes such as diet and exercise that are
known to aect recurrence rates. ey are knowledgeable in
survivorship options from integrative medicine to psychological counseling, and refer the patient to these services to
help the survivor thrive in her posttreatment life.
10-12
As a vital participant of so many advances in the multidisciplinary aspects of breast cancer, one would expect
the breast surgeon to also be adept in the use of the multiple surgical options available today when a woman desires
breast conservation. Sadly, this does not appear to be the
case. If oncoplastic surgery has gained wide acceptance in
Europe, the United Kingdom, and parts of South America,
why are breast surgeons in the United States and Canada
signicantly behind in adopting these techniques?
A common model for oncoplastic repair in the United
States and Canada is the two-surgeon approach. e breast
surgeon removes the breast cancer and the plastic surgeon
reconstructs the breast defect. One survey investigated current practices and polled members of both the American
Society of Plastic Surgeons (ASPS) and the American Society of Breast Surgeons (ASBrS). is survey reported 50%
of plastic surgeons believed they were not involved in reconstruction after partial mastectomy because breast surgeons
did not refer patients to the plastic surgeon.13 Another
survey polling ASBrS members showed 63% of breast surgeons refer patients to a plastic surgeon for a breast reduction with their cancer surgery when a reduction would
be indicated.14 Only half of the breast surgeons surveyed
routinely discuss oncoplastic procedures during the initial
breast cancer surgical consultation, whereas 29% sometimes do and 20% never discuss such procedures.14 From
the patient perspective, a recent Canadian report surveying
women with breast conservation regarding their options for
reconstruction indicated only 1.6% were referred to plastic surgery before surgery, but a full 30% would have seen
a plastic surgeon if it were oered.15 It is apparent from
these surveys that a disconnect is occurring between plastic
and breast surgeons. Failure to adopt oncoplastic surgical
techniques in the United States and Canada could in part
be due to the breast surgeons’ lack of knowledge of these
techniques. When surveyed regarding the desire to learn
oncoplastic techniques, 99% of breast surgeons indicated
an interest in learning the techniques with 77% being
extremely interested.14 Seventy percent of polled breast surgeons believed adoption of oncoplastic techniques would
be dependent upon training breast surgeons in those techniques, and 52% thought increasing awareness for breast
surgeons using oncoplastic techniques as they work with
plastic surgeons would improve adoption of oncoplastic
surgery techniques.
13
e simplistic denition of oncoplastic surgery is the best
oncologic surgery with the best cosmetic result. Another
clarifying denition: “oncoplastic surgery is surgery that is
considerate to what we leave women to live with for the rest
of their lives and should be an integral part of treatment for
all women with breast cancer.”16 Why would any surgeon
not consider this for every patient? Which patient deserves
less than the best aesthetic result?
To suggest oncoplastic techniques are merely specic
procedures would do the eld of oncoplastic surgery a
great injustice. Instead, oncoplastic surgery begins as an
embraced philosophy as the surgeon collaborates with
other surgeons in the care of the patient. e ability to
evaluate a woman’s breast and consider all the possible surgical approaches for the removal of cancer and restoring
the appearance of both breasts is mentored and developed
through sharing these techniques. e spectrum of options
from basic to advanced will require skill sets of both breast
and plastic surgeons. As the breast surgeon discovers the
benets of the basic oncoplastic techniques, the surgeon
will also understand the importance of partnering with
plastic surgeons to rely on their expertise for appropriate
patient treatment.
Training breast surgeons to perform basic principles
in oncoplastic surgery will be the start to ensure the best
aesthetic result for every woman undergoing breast cancer
surgery.
Hidden Incisions
Unfortunately, with wired-, wireless-, and ultrasoundguided localization of tumors, breast surgeons have become
accustomed to placing incisions over the cancer or wire and
dissecting directly down to the lesion. However, any breast
surgeon could easily make an incision at the nipple–areolar
complex (NAC), the inframammary fold (IMF), or axilla
and develop a plane of dissection in the supercial breast to
either reach the lesion found on ultrasound or wireless localization or intercept the guidewire as it traverses the skin and
breast tissue to reach the lesion. is approach uses the same
techniques of dissection in the anterior mammary fascia for
a skin-sparing or nipple-sparing mastectomy. Although this
may take more time initially, the benets to the patient in
these hidden incision techniques will be invaluable.
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Volume Displacement Techniques
Involving Local Tissue Rearrangement
Closure of the defect produced by the lumpectomy cavity
is a skill only 60% of breast surgeons reported performing
routinely.14 For decades, surgeons have been taught to leave
the lumpectomy cavity intact and allow it to ll in with
seroma. is caused a normal-appearing breast for the rst
few weeks as the cavity remained full of uid. Long-term
aesthetic sequela of leaving a large uid-lled space in the
breast cancer patient cannot be understated. e seroma that
lls the space generally absorbs before whole breast radiation, and the skin begins to sink into the defect. Radiation
will only cement this process and cause disguring results,
requiring time and extensive surgery to correct. Oncoplastic
surgery lls in the lumpectomy defect with local tissue and,
in the process, restores the full breast mound, which results
in better cosmesis.17 In certain volume displacement operations (level 1 volume displacement oncoplastic surgery),18
the breast surgeon has the technical ability to repair this
lumpectomy defect. e development of glandular aps,
and dissection of the breast from the skin fold in the anterior mammary fascia and o the pectoralis muscle in the
posterior are techniques used daily in the performance of
any mastectomy. For a basic partial mastectomy using oncoplastic techniques, this dissection can be done for at least the
quadrant of the breast with the lesion. e dissection in this
plane is best when it extends beyond the lesion to the edge
of the glandular tissue. e defect is closed by either advancing or rotating the glandular aps into the empty space to
close the defect.
creates a dimple or pulls at the NAC, extending the dissection of the supercial breast from the skin envelope easily
corrects dimple or pucker in the skin.
ese two steps can dramatically improve the cosmetic
result for any woman who requires breast surgery for benign
or malignant disease. ey are well within the skill set of the
breast surgeon.
17-19
If the skin is tethered to the breast and
Volume Displacement Techniques
Involving a Reduction in the Skin Envelope
In the patient with a larger breast lesion, consideration
must rst be given to tumor biology and determining if the
patient would be better suited for neoadjuvant chemotherapy.20 Today all surgeons need to understand any woman
with triple negative or HER-2 neu positive breast cancer
needs a medical oncology evaluation before any surgery.
Neoadjuvant chemotherapy has been used to downstage
breast cancers, enabling a woman to pursue breast conservation safely without decreased survival.
In early stage breast cancer and due to downstaging of
later stage breast cancer with neoadjuvant chemotherapy,
the use of volume displacement techniques becomes more
straightforward. In addition to approaching the tumor
from the hidden incisions and developing advancement
21
or rotational aps, decreasing the breast skin envelope to
accommodate larger resections of breast is needed. Fitoussi’s
graph of oncoplastic surgical approaches to breast cancer was
developed when removal of skin was required in the patient
with a lesion greater than 20% breast volume.22 With neoadjuvant chemotherapy, the skin above the lesion is safely
preserved, and either the donut, the vertical mammaplasty,
or wise pattern skin incisions can be easily utilized for the
majority of cases while still maintaining the best oncologic
surgical principles. e term therapeutic mammaplasty23 has
also been used to describe the technique of removing the
breast lesion with adequate margins, reshaping the breast
mound, and reducing the breast skin envelope using the
wise pattern skin reduction. In most circumstances, an
inferior, superomedial, or superior pedicle can be used and
modied for autoaugmentation techniques.
performing these operations need training in plastic surgery
techniques to ensure safety and optimal outcomes.
24-27
Surgeons
Contralateral Equalization for Symmetry
For the woman whose bra size is B–DD and does not desire
breast reduction, careful consideration must be given to the
contralateral breast to maintain symmetry. When an oncoplastic repair of the aected breast changes the position of
the NAC, failure to perform a symmetry procedure will signicantly aect the aesthetic result. Today when queried,
only 50% of breast surgeons referred patients to plastic
surgeons for evaluation for symmetrization.14 A surgeon
trained in plastic surgery techniques will be able to safely
provide the simple skin reduction or minor mammaplasty
for equalization. e patient may consider this an improvement from the appearance of her breasts preoperatively and
add to factors that improve her quality of life.
Moving Forward: Training Breast Surgeons
Breast surgeons and plastic surgeons have diering opinions
on how to increase the adoption of oncoplastic surgery in
the United States. Both surgeon groups agreed that increasing awareness of the oncoplastic team approach would be
helpful. However, 67% of breast surgeons believed training breast surgeons in oncoplastic techniques would facilitate the adoption of those techniques, whereas only 28%
of plastic surgeons believed this to be true.13 When revisiting the practice patterns of breast and plastic surgeons discussed earlier, perhaps the breast surgeons do not refer their
patients to plastic surgeons for reconstruction because they
are not aware of the options available.
Oncoplastic breast surgery needs to be a concept that is
ingrained in the surgeon during general surgery residency
training. Teaching basic surgical planning and the importance of hidden incisions for long-term cosmesis in general
surgery residency will be an important step in ensuring all
women with either benign or malignant breast disease have
a surgeon who has been taught to integrate aesthetic results
in their surgical planning.
CHAPTER 5 Breast Surgeons and Oncoplastic Surgery
https://t.me/medicina_free
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Basic oncoplastic surgery training is not standardized in
breast fellowships. ere are currently no requirements for a
set of oncoplastic surgical techniques performed by the fellow
while in training. Depending upon the experience in oncoplastic techniques by the breast surgery faculty and the plastic surgery faculty’s attitude toward training breast surgeons’
oncoplastic techniques, the training provided by fellowships
can be either sparse or robust. Although there are no surveys
asking graduating fellows about their comfort with performing
basic oncoplastic techniques independently, 28% of practicing
breast surgeons reported learning oncoplastic techniques in fellowship training.14 Coordination with the American Society
of Breast Surgeons and the Surgical Society of Oncology to
develop a minimum set of basic oncoplastic techniques mastered by a graduating fellow could be one step to increasing
adoption of oncoplastic techniques. Plastic surgery departments that embrace the breast fellow and train them in basic
oncoplastic techniques rather than relegate them to holding
retractors will help develop a better collegiality among the two
specialties and foster the team approach that is vital in our system. e culture of the two specialties working together in fellowship training will encourage coordination in practice of the
breast/plastic surgeon team for the patient requiring advanced
oncoplastic (level 2 volume displacement procedures).
17
Today the practicing breast surgeon has an increasing
number of options for oncoplastic training in the United
States. ere are both industry-sponsored and academic
courses that provide multiple learning opportunities. e
obstacles in obtaining the training include the cost of training in both the course and time away from practice. e
surgeon capable of integrating oncoplastic techniques into
the practice philosophically and technically will self-select
by taking courses to expand their knowledge and skills.
Basic oncoplastic surgical techniques as the new standard
of care for all women undergoing breast surgery will improve
the quality of breast surgery across the board. Breast surgeons
will be expected to provide the best aesthetic results possible
by both their patients and referring colleagues. If the breast
surgeon is unable to master the basic skills, they will need
to partner with plastic surgery on a regular basis to provide optimum results. Failure to do so may result in loss of
referrals and losing that patient population in their practice.
e breast surgeon who does have the skills to safely master basic oncoplastic techniques with good aesthetic results
will develop stronger referrals and build their practice. at
surgeon will also be aware of the importance in partnering
with plastic surgeons to ensure that more patients requiring breast reduction techniques and volume replacement
techniques (intercostal perforator aps, thoracodorsal artery
perforator aps, implants, etc.) are appropriately managed
by the team approach. Finally, as a long-term future possibility, for those breast and plastic surgeons who wish to
concentrate their entire practice on the treatment of breast
cancer and reconstructive eorts, the United States may join
Europe and the United Kingdom in eorts to develop oncoplastic fellowship programs that train surgeons in all aspects
of oncologic and reconstructive eorts.
In the end, it must always be about the patient. If
every woman with breast cancer deserves the best oncologic and cosmetic result, then every surgeon operating
on a breast cancer patient needs to have the knowledge
and understanding to oer the best results whether it is
delivered by one surgeon or a team of surgeons. Leadership from plastic, breast, and general surgery societies
need to come together to develop a plan to safely train
breast and general surgeons in basic oncoplastic surgery
and establish a standard for implementing the breast/
plastic surgery team.
References
1. El Saghir NS, Keating NL, Carlson RW, Khoury KE, Fallow-
eld L. Tumor boards: optimizing the structure and improving
eciency of multidisciplinary management of patients with
cancer worldwide. Am Soc Clin Oncol Educ Book. 2014:e461–
e466.
2. Ali-Mucheru M, Pockaj B, Patel B, Pizzitola V, Wasif N, Stucky
CC, etal. Contrast-enhanced digital mammography in the surgical management of breast cancer. Ann Surg Oncol. 2016;23(suppl
5):649–655.
3. Brem RF, Lenihan MJ, Lieberman J, Torrente J. Screening breast
ultrasound: past, present, and future. AJR Am J Roentgenol.
2015;204(2):234–240.
4. Easton DF, Pharoah PD, Antoniou AC, Tischkowitz M, Tavtigian
SV, Nathanson KL, etal. Gene-panel sequencing and the prediction of breast-cancer risk. N Engl J Med. 2015;372(23):2243–
2257.
5. Kaufman CS. Yes, breast surgeons may provide breast cancer
genetic assessment and testing. Ann Surg Oncol. 2015;22(1):1–3.
6. Correa C, Harris EE, Leonardi MC, et al. Accelerated par-
tial breast irradiation: executive summary for the update of an
ASTRO evidence-based consensus statement. Pract Radiat Oncol.
2017;7(2):73–79.
7. Kantsiper M, McDonald EL, Geller G, Shockney L, Snyder C,
Wol AC. Transitioning to breast cancer survivorship: perspectives of patients, cancer specialists, and primary care providers.
J Gen Intern Med. 2009;24(Suppl 2):S459–S466.
8. Runowicz CD, Leach CR, Henry NL, Henry KS, Mackey HT,
Cowens-Alvarado RL, et al. American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care
guideline. J Clin Oncol. 2016;34(6):611–635.
9. 2008–2014 hscgshbh. SEER 18 2008-2014, All Races, Females
by SEER Summary Stage.
10. Dizon DS. Quality of life after breast cancer: survivorship and
sexuality. Breast J. 2009;15(5):500–504.
11. Falloweld L, Jenkins V. Psychosocial/survivorship issues in breast
cancer: are we doing better? J Natl Cancer Inst. 2015;107(1):335.
12. Bodai BI, Tuso P. Breast cancer survivorship: a comprehensive
review of long-term medical issues and lifestyle recommendations. Perm J. 2015;19(2):48–79.
13. Losken A, Kapadia S, Egro FM, Baecher KM, Styblo TM, Carl-
son GW. Current opinion on the oncoplastic approach in the
USA. Breast J. 2016;22(4):437–441.
14. Chatterjee A, Gass J, Burke MB, et al. Results from the Ameri-
can Society of Breast Surgeons oncoplastic surgery committee
2017 survey: current practice and future directions. Ann Surgical
Oncol. 2018. Accepted for publication.
SECTION I Oncoplastic Breast Surgery – Getting Started
https://t.me/medicina_free
32
15. Vrouwe SQ, Somogyi RB, Snell L, McMillan C, Vesprini D, Lipa
JE. Patient-reported outcomes following breast conservation therapy and barriers to referral for partial breast reconstruction. Plast
Reconstr Surg. 2018;141(1):1–9. therapy regardless of age. Ann
Surg Oncol. 2012;19(10):3246-3250.
16. Macmillan RD, McCulley SJ. Oncoplastic breast surgery: what,
when and for whom? Curr Breast Cancer Rep. 2016;8:112–117.
17. Clough KB, Kaufman GJ, Nos C, Buccimazza I, Sarfati IM.
Improving breast cancer surgery: a classication and quadrant
per quadrant atlas for oncoplastic surgery. Ann Surg Oncol. 17(5):
1375–1391.
18. Yang JD, Lee JW, Cho YK, Kim WW, Hwang SO, Jung JH,
etal. Surgical techniques for personalized oncoplastic surgery
in breast cancer patients with small- to moderate-sized breasts
(part 2): volume replacement. J Breast Cancer. 2012;15(1):
7–14.
19. Chen C-Y, Calhoun KE, Anderson BO. Oncoplastic techniques for
breast conservation surgery. Breast surgical techniques and interdisciplinary management. Springer; 2010:381–390.
20. Abdulkarim BS, Cuartero J, Hanson J, Deschenes J, Lesniak
D, Sabri S. Increased risk of locoregional recurrence for women
with T1-2N0 triple-negative breast cancer treated with modied
radical mastectomy without adjuvant radiation therapy compared with breast-conserving therapy. J Clin Oncol. 2011;29(21):
2852–2858.
21. Landercasper J, Bennie B, Parsons BM, Dietrich LL, Greenberg
CC, Wilke LG, etal. Fewer reoperations after lumpectomy for
breast cancer with neoadjuvant rather than adjuvant chemotherapy: a report from the national cancer database. Ann Surg Oncol.
2017;24(6):1507–1515.
22. Tan MP. Is there an ideal breast conservation rate for the treatment of breast cancer? Ann Surg Oncol. 2016;23(9):2825–2831.
23. Fitoussi A, Berry M, Couturaud B, Salmon R. Oncoplastic and
reconstructive surgery for breast cancer. e Institut Curie Experience: Springer Science & Business Media; 2009.
24. McCulley S, Macmillan R. Planning and use of therapeutic mammoplasty—Nottingham approach. Br J Plast Surg. 2005;58(7):
889–901.
25. Chatterjee A, Dayicioglu D, Khakpour N, Czerniecki BJ. Oncoplastic surgery: keeping it simple with 5 essential volume displacement techniques for breast conservation in a patient with
moderate- to large-sized breasts. Cancer Control. 2017;24(4).
1073274817729043.
26. Liang Y, Naber SP, Chatterjee A. Anatomic and terminological
description and processing of breast pathologic specimens from
oncoplastic large volume displacement surgeries. Modern Pathol-
ogy. 2018:1.
27. Losken A, Funderburk CD, Duggal C. e extended superomedial pedicle: advancing mammaplasty techniques. Modern Plast
Surg. 2013;3:20–27.
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