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SECTION III Oncoplastic Breast Surgery – Outcomes
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174
been found to reduce the eects of acute dermatitis.
102
Grade
1 or 2 CTCAE dermatitis may be treated with petroleumbased emollients. More severe cases may be managed with
silver sulfadiazine cream. Breast pain is commonly reported
in about 20–30% of women, although it may not be associated with radiation.
103
Patients and physicians tend to rate breast cosmesis
after BCT good to excellent in 75–80%.
104
Fat necrosis
is present in 1–4% of patients undergoing BCT, although
TABLE
Onset and Dose Threshold of Acute Radiation
20.6
Dermatitis
Reaction Type Onset Dose Threshold (Gy)
Erythema 7–10 days 6
Dry desquamation 3–4 weeks 20
Moist desquamation 4+ weeks 30
Ulceration 5+ weeks >40
99
it is up to 10–30% in women undergoing IORT. Moderate to severe breast brosis is more common in patients
who receive increased radiation in WBI through a boost
(30.4% vs 15.0%) and manifests weeks to years following
treatment. A radiation boost often increases the incidence
of breast brosis (5.2% vs 1.8%).68 Animal studies seem
to indicate that fat grafting improves the quality of irradiated skin, with histological evidence of repair in a treated
105
group.
Khouri etal described using external expansion
of the radiated breast to expand the parenchymal space
and improve the vascularity before performing autologous
fat grafting.
105a
is will allow for placement of higher fat
volumes when compared with patients who underwent
BCT on average 7 years after treatment.
106
Further study
needs to be done on autologous fat grafting therapeutics
in the setting of BCT.
Summary
e demonstration of safety and ecacy following RT in
the management of breast cancer has revolutionized treatment options and made breast conservation and oncoplastic therapy possible. Recent advancement in APBI
techniques has been designed with the expressed purpose
to limit the amount of radiation exposure to normal tissues. Renement of technique may provide improved
cosmesis and decrease radiation impact to normal tissue;
trials are currently underway, and patient recruitment is
progressing. Future studies should rene the criteria for
BCT as certain subgroups seem to benet more than others. In addition, patient-reported outcome measures, such
as the BreastQ, should be routinely utilized to quantify
the eect on quality of life and psychosocial well-being
among dierent treatment types. e role of plastic surgery is becoming increasing appreciated as we bridge the
gap between treatment of disease and treatment of the
patient as a whole.
• Fig. . The acute toxicity of radiation at two weeks demonstrating
dermatitis and desquamation.
TABLE
Common Terminology Criteria for Adverse Events (CTCAE) by the National Cancer Institute Classication
20.7
of Acute Dermatitis (v5.0)
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
Faint erythema, dry
desquamation
100
Moderate to brisk erythema,
patch moist desquamation confined to skin folds
and creases, moderate
edema
Moist desquamation in areas
other than skin folds and
creases, bleeding induced
by minor trauma or abrasion
Life-threatening conse-
quences, skin necrosis or
ulceration of full thickness
dermis, spontaneous bleeding from involved site, skin
graft indicated
Death
CHAPTER 20 Radiation Therapy Considerations and Oncoplastic Breast Surgery
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175
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104. Frassica DA, Bajaj GK, Tsangaris TN. Treatment of complications after breast-conservation therapy. Oncology (Williston
Park). 2003;17(8):1118–1128; discussion 1131–1116, 1141.
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105. Garza RM, Paik KJ, Chung MT, etal. Studies in fat grafting: Part III. Fat grafting irradiated tissue--improved skin
quality and decreased fat graft retention. Plast Reconstr Surg.
2014;134(2):249–257.
105a. Khouri RK, Rigotti G, Khouri RK Jr, etal. Tissue-engineered
breast reconstruction with Brava-assisted fat grafting: a 7-year,
488-patient, multicenter experience. Plast Reconstr Surg. 2015;
135(3):643–58.
106. Mirzabeigi MN, Lanni M, Chang CS, et al. Treating breast
conservation therapy defects with brava and fat grafting:
technique, outcomes, and safety prole. Plast Reconstr Surg.
2017;140(3):372e–381e.
21
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Patient Satisfaction and Outcomes
Following Oncoplastic Breast Surgery
TAMMY JU, CHRISTINE TEAL, AND BRIDGET A. OPPONG
Introduction
Breast Conservation
Increased compliance with breast cancer screening guidelines, as well as advancements in imaging technology, have
led to earlier detection of breast cancer. Currently, the
majority of breast cancers are diagnosed at earlier clinical
stages. is should eliminate the need for mastectomy in
a majority of cases as multiple randomized studies with
extensive follow-up have established that breast conservation therapy (BCT) confers equivalent local control and
survival as mastectomy, including the National Surgical
Adjuvant Breast and Bowel Project (NSABP) B-06 study.1
e oncologic safety of BCT, considered when the tumor
size-to-breast size ratio is favorable in selected patients, has
been well established. However, there continues to be an
increasing trend toward mastectomy. Recent studies show
persistently high mastectomy rates, even when women are
candidates for lumpectomy.2 Despite the extensive data
showing no survival advantage with mastectomy, this has
not dissuaded women from choosing mastectomy for both
treatment and prophylaxis.
e topic of contralateral prophylactic mastectomy has
added to the decision-making process fueling the increase in
mastectomy rates in patients with unilateral breast cancer.2
Hypotheses explaining why women opt for more extensive
surgery include fear and perceived risk in the contralateral
breast, optimal reconstruction outcomes, increase in genetic
testing and determination of risk prole, as well as the
use of breast magnetic resonance imaging (MRI) that can
detect smaller cancers. ere are record numbers of prophylactic mastectomies being performed in the United States.
Data show that mastectomy rates have increased in recent
years with high rates of risk-reducing surgery for high-risk
patients and those already diagnosed with breast cancer.3
Although there are general guidelines providing indications
for both bilateral prophylactic mastectomy and contralateral prophylactic mastectomy, when it should be advised
remains controversial. e factors associated with this
phenomenon are unclear and likely involve a complex interplay of patient and physician factors. As more women opt
for this type of surgical management in the high-risk and
cancer management settings, the question arises as to what
benchmark should surgeons utilize to advise their patients?
When deliberating over cancer treatment options, one
concern patients often voice is the potential asymmetry after
breast conservation surgery that can result in the removal
of a signicant fraction of total breast volume. In addition, breast asymmetry is compounded by the overall size
reduction that occurs after whole breast irradiation. Whole
breast radiotherapy after BCT can reduce the risk of local
recurrence as much as threefold compared with surgery
alone1 and, therefore, is a necessary component of breast
conservation. Many patients after an initial satisfactory
cosmetic result following breast conservation will develop
a progressive asymmetry over time, prompting the need for
additional surgery. is is usually a contralateral reduction
mammaplasty (Fig. 21.1). erefore, symmetrization procedures done at the time of lumpectomy can be an important
addition to BCT with the benet of optimizing long-term
cosmetic results and perhaps even discouraging unnecessary
mastectomies. As a consequence of the advancements in
oncoplastic surgery, especially among the west coast surgical oncology pioneers, oncoplastic procedures are becoming
more accepted and utilized.
Outcomes after Oncoplastic Surgery
Patient Outcomes
As oncoplastic techniques increase in popularity and utilization, evidence-based analyses of surgical outcomes will be
important to support further adoption. Although there is
not an overabundance of literature on oncoplastic breast surgical techniques, in recent years multiple studies have been
published. In the largest comprehensive literature review to
date on oncoplastic breast-conserving surgery (BCS), data
were extracted from 55 studies that collectively evaluated
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lumpectomy and radiation
• Fig. 21.1 Delayed contralateral reduction for asymmetry years after right lumpectomy and whole breast irradiation.
6011 patients.4 Wise pattern mastopexy was the most commonly utilized oncoplastic technique, performed in 35.4%
of patients, followed by the round block (14.8%) and latissimus dorsi volume replacement (9.5%) techniques. is
systematic review by Cruz etal is one of the few studies to
have short-term and long-term outcomes. Long-term data
revealed oncoplastic surgery to have high rates of overall and
disease-free survival and low local recurrence thereby conrming the oncologic safety of this procedure in patients
with T1–T2 invasive breast cancers.
Of the short-term outcomes, margin status is one of
the most important measures of success, and 11 studies
reported specic margins for 1455 patients. Among these
patients, 143 (9.8%) were classied as having positive margins, of which 113 (7.8%) had tumor on ink. Other shortterm data reported included postoperative complications,
including liponecrosis, skin necrosis, hematoma, seroma,
delayed wound healing, nipple necrosis, and/or infection,
which occurred in 14.3% of patients. Specically, complication rates from oncoplastic BCS in this study, including liponecrosis (3.3%), skin necrosis (0.5%), hematoma
(2.5%), seroma (1.0%), delayed wound healing (2.2%),
nipple necrosis (0.4%), and/or infection (1.9%), closely
reected those found in a previous study that further demonstrated no statistically signicant dierence in the incidence of these issues among women undergoing oncoplastic
and non-oncoplastic lumpectomies. However, Tenofsky
et al found a higher incidence of non-healing wounds in
the oncoplastic group compared with the non-oncoplastic
group (8.6 vs 1.2%; p = 0.042).5 It is important to note that
this did not prolong time to radiation within the oncoplastic group. erefore, oncoplastic reconstruction at the time
of BCS does not appear to signicantly increase the risk of
postoperative complications that would delay initiation of
adjuvant therapy.
Cosmetic Outcomes and Patient Satisfaction
In the systematic review by Cruz etal, 25 studies also evaluated cosmetic outcomes in 1962 patients. e vast majority
reported positive results with oncoplastic surgery achieving
excellent, good, fair, or poor outcomes in 55.2%, 31.0%,
9.4%, and 4.4% of patients, respectively.4 When it comes to
the literature, however, there are limited studies investigating patient-reported satisfaction and outcomes after oncoplastic surgery. Furthermore, it has been shown that there is
a lack of consistent and validated measures by which these
patient outcomes are reported.6 e majority of the studies
are from Europe or South America and do not include the
U.S. population. In addition, within these studies, heterogeneity exists in the denition of oncoplastic or breast conservation surgery along with their comparison group (if one
is included). Overall, recent studies show positive patientreported satisfaction with aesthetic results,7 breast appearance,8 improvement in functional return to work/activity9
and overall satisfaction
gery compared with standard lumpectomy/mastectomy.
e majority of this data is collected from questionnaires
in the postoperative period to assess patient-reported satisfaction and outcomes. For example, a study in the UK
by Chand et al compared therapeutic mammoplasty (oncoplastic breast conservation surgery [OBCS]) to a latissimus
dorsi miniap and gave patients the BreastQ questionnaire
to assess satisfaction.8 Patients who underwent OBCS felt
their breasts had a more natural feel, were better in terms
of size, less likely to report neck pain, and reported higher
overall satisfaction. Interestingly, this was one of the few
studies that asked about emotional/sexual well-being and
found that there was no dierence between groups, suggesting anxiety about a cancer diagnosis and treatment inuences emotional well-being more than the type of surgery
performed.
8
6,8
after undergoing oncoplastic sur-
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Some studies cite specic patient populations that OBCS
may have the most benet in, such as patients with macromastia.9 Kelsall etal performed a study from the UK comparing OBCS to mastectomy with immediate reconstruction.
When unmatched, body image scale, breast appearance, and
return to work/function were better in the OBCS group.
However, when matched to case controls, women with
larger breasts reported better body image scores and selfrated breast appearance, which was not seen in women with
smaller breasts. Even when patients required postoperative
radiation, patients in the OBCS cohort reported better
body image scores compared with those with mastectomy/
immediate reconstruction.9 Somewhat contradictory to
this, a study in 2017 by Ojala etal compared aesthetic and
functional outcomes 3 years after surgery and found that,
overall, patients in the conventional group had better selfreported aesthetic outcomes than the oncoplastic resection
group10 using two types of questionnaires. Of note, they
found larger tumors and tumor multifocality were predictors
of poor aesthetic outcomes. However, this cohort study was
limited by only a small percentage undergoing oncoplastic
surgery (n = 86: 23%) compared with conventional surgery
(n = 293: 77%). Nonetheless, conventional resection may
be better for certain patients. Another study in 2015 out of
Brazil by Santos etal actually examined aesthetic outcomes
of oncoplastic versus lumpectomy patients evaluated by a
software system, specialists, and patients. Although the software and specialists reported signicantly better aesthetic
outcomes in the oncoplastic group, patients did not.
11
ere is currently a large prospective trial occurring in
the Netherlands comparing women who undergo BCS to
evaluate cosmetic outcome, patient satisfaction, and quality of life based on the lumpectomy technique; however,
it has not been completed.12 is will be one of a limited
number of prospective trials investigating the utilization
and outcomes of oncoplastic techniques compared with
standard lumpectomy. Further, the investigators have
a goal to use the data to create a clinical decision model
to guide the use of oncoplastic techniques in the future
(Table 21.1).
Current Practices
Surgical management discussions for newly diagnosed
breast cancer have moved beyond just the standard
lumpectomy or mastectomy. Oncoplastic techniques are
now frequently added with the benet of increasing cosmesis while permitting the breast surgeon to also excise a
larger specimen, likely reducing the risk of margin positivity. Adding this oncoplastic option can be done in a primary, immediate, or delayed fashion. Most commonly, the
oncoplastic portion is performed in conjunction with the
initial lumpectomy. Although some breast or general surgeons may utilize these techniques themselves, the majority, in our area, work in conjunction with plastic surgeons
who perform tissue rearrangements in the ipsilateral breast
with contralateral symmetrization. Our plastic surgeons
commonly do reductions and/or mastopexies as their
most common procedures, which is similar to approaches
reported in the literature.
Delayed or Two-Stage Oncoplastic Surgery
A decision the surgical oncologist faces when contemplating adding oncoplastic techniques is timing (i.e., whether
to perform the lumpectomy and plastic surgery component
in the same operation or separate the two in a delayed fashion). A major factor is the breast surgeon’s condence in
the ability to extirpate the tumor and obtain clear margins.
Specic cases at risk for positive margins typically include
patients who do not have a discrete or focal tumor, or who
have discordance in the extent of disease estimations based
on conicting mammographic, ultrasound, or breast MRI
measurements. is subset also tends to include those with
DCIS or an extensive intraductal component and invasive lobular histology. If based on the measures discussed,
there is a higher than average risk of inadequate margin
and consequently a need for possible re-excision, consideration should be given to delaying the plastic surgery
component when utilizing an oncoplastic approach. is
allows another attempt to attain clear margins, instead of
committing the patient to mastectomy due to the diculties of re-excisions after rearrangement of the breast tissues.
Although re-excision in general may be less accurate due
to postoperative changes, it is much more complicated by
the tissue rearrangements performed during reductions or
mastopexy. For patients in whom there is such a concern,
delaying the plastic surgery portion of the case is the optimal decision.
Included in this category are those who have undergone
neoadjuvant chemotherapy. Although there is geographic
and institutional variation, neoadjuvant chemotherapy
is used in approximately one-quarter of new diagnoses.
With data demonstrating improvement in long-term
outcome with this approach in certain subgroups, such
as HER-2 positive subtypes, more patients will be oered
neoadjuvant chemotherapy. Another strategy is the use
of neoadjuvant chemotherapy to downstage the axilla in
the hopes of avoiding axillary lymph node dissections that
have the inherent risk of chronic lymphedema. Posttreatment breast MRI is the most common modality utilized
to assess treatment response and residual disease. e postchemotherapy imaging compared with pretreatment baseline can guide surgical decision making; however, MRI can
often give an inaccurate estimation of the extent of disease. erefore, a delayed approach is frequently helpful in
this population to conserve the breast and/or avoid mastectomy. Once margins are evaluated and conrmed free
of tumor, the patient can have their oncoplastic procedure
with the plastic surgeon 1–2 weeks later. Furthermore, for
women with moderate to severe mammary hypertrophy,
oncoplastic techniques will allow the breast surgeon to
remove a larger segment of the breast that will reduce risk
of a positive margin (Fig. 21.2).
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TABLE
Summary of Recent Studies for Patient-Reported Outcomes after Oncoplastic Breast Surgery
21.1
Sample
Author Year
Santos etal [10] 2015 Brazil Multicenter 122 - BCCT Software
Rezai etal [6] 2015 Germany Single-center cohort 558 - customized satisfac-
Ojala etal [9] 2017 Finland Single-center 379 - BCTOS
Chand etal [7] 2017 UK Single-center 150 -BreastQ question-
Kelsall etal [8] 2017 UK Single-center case
Catsman etal
[11]
2018 Netherlands Prospective single-
Country Type of Study
matched cohort
study
center cohort
study
Size
567 -BIS
TBD -expert panel
Satisfaction Tool
Used Results
- aesthetic specialists
- custom questionnaire
tion questionnaire
- custom questionnaire
naire
-Q-score
-custom questionnaire
-BCCT
-BreastQ and other
questionnaires
- BCCT/software and
specialists reported
improved aesthetic outcome with oncoplastics
- patients reported no difference
- 78% of patients with
BCS reported aesthetic
outcomes as “good” or
“very good”
- conventional resection may be better in
selected patients
- 89% of women rated
oncoplastic BCS better
than mastectomy
- more natural breast with
higher overall satisfaction compared with
latissimus flap
-Unmatched cases
favored oncoplastic
BCS over mastectomy
with IBR regarding
BIS, appearance, and
function
- Case matched showed
women with larger
breasts had better
appearance scores,
function, and return to
work
- TBD
BCCT, core software; BCS, breast-conserving surgery; BCTOS, Breast Cancer Treatment Outcome Scale Questionnaire; BIS, body image scale; BreastQ,
validated patient reported outcomes questionnaire following breast reconstruction; IBR, ; Q-score, software generating scores for breast appearance, physical,
emotional, and sexual well-being; TBD, To be determined.
Intraoperative Margin Assessment
During breast conservation surgery, margin assessment
in real time would be ideal. is can potentially save the
patient from having to undergo additional procedures,
such as re-excision or mastectomy. e economic and quality of life benets to the patient when additional surgery
is avoided cannot be overstated. As a consequence, there
has been sustained interest in dierent techniques that can
assess margins intraoperatively. Especially when an oncoplastic breast surgery is planned, it would be even more benecial to have denitive surgery in one operation. Dierent
intraoperative margin techniques have been trialed including frozen section analysis, touch prep, and a variety of new
devices including Dune. None of these have been widely
adopted given the limited data available and concerns about
histological accuracy. For example, during frozen section
analysis, the generally fatty breast tissue is dicult to x
for reliable analysis. At our institutions, therefore, it is not
generally performed.
Re-excision after Oncoplastic Breast Surgery
A potential device that can aid in re-excision if needed
after oncoplastic BCS is the BioZorb device. In 2013,
the BioZorb tissue marker was introduced as an implantable device that, when sutured into a lumpectomy cavity,
CHAPTER 21 Patient Satisfaction and Outcomes Following Oncoplastic Breast Surgery
Right Oncoplastic Breast Reconstruction
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Left Breast Reduction
183
A
Right Oncoplastic Breast Reconstruction
Left Breast Reduction
B
• Fig. 21.2 (A and B) Immediate oncoplastic breast conservation surgery (OCBS) following neoadjuvant
chemotherapy. Right oncoplastic breast reduction and left breast reduction. (Photos courtesy Drs. Elizabeth Feldman and Samir Rao.)
allows for postoperative, three-dimensional visualization
of the tumor removal site boundaries. Initial reports indicate that the bio-absorbable marker was readily identied on postoperative clinical imaging and that placement
reduced planned treatment/radiation BOOST volumes by
approximately 30–40%. e device’s trellis-type framework has also been shown to improve oncoplastic breast
reconstruction outcomes.13 is marker is sutured into the
lumpectomy bed providing a palpable guide in the immediate postoperative period. In the event that a re-excision is
indicated based on nal pathology, the device can provide
guidance to accurately locate the lumpectomy cavity even
after extensive tissue rearrangements. Consequently, the
surgeon can again attempt breast conservation, sparing the
patient an unwanted mastectomy. e device also replaces
the standard clips placed at the borders of the lumpectomy
cavity.
Conclusion
In summary, oncoplastic breast surgery has increased in
popularity but is still relatively new. erefore, the data
on the patient experience is overall limited, but the current studies denitely show promise. Utilization of oncoplastic techniques has increased patient satisfaction after
breast conservation in comparison to women who undergo
standard lumpectomy practices. erefore, it is important
that oncoplastic options are discussed at the time of initial
consultation so that they may optimally be performed at
the same time as lumpectomy to minimize delaying adjuvant treatment. Another crucial consideration is the oering of this approach before radiation therapy because the
patient’s options are limited after radiation has been completed. Patients who have an oncoplastic approach have
improved cosmesis and are generally more satised with
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