Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_732_Библиотеки_им_академика_М_И_Перельмана
.pdf
CHAPTER 1 Introduction to Oncoplastic Breast Surgery
https://t.me/medicina_free
3
History of Oncoplasty
In an eort to reduce the incidence of local recurrence and
maintain natural breast contour, the concept of oncoplastic
surgery was introduced.
29,30
Oncoplastic surgery diers from
standard BCT in that the margin and volume of excision is
typically greater than that of lumpectomy or quadrantectomy. With BCT, an excision margin of 1–2 mm is usually sucient; whereas with oncoplastic surgery, excision
margins typically range from 1–2 cm and resection volumes
typically range from 100–200 cm3. e resultant deformity
is usually reconstructed immediately using volume replacement or displacement techniques; however, a staged immediate reconstruction can also be considered. Reconstructive
options include adjacent tissue rearrangement, reduction
mammaplasty, or distant aps. When symmetry is desired,
contralateral procedures can be performed immediately at
the time of partial breast reconstruction or on a delayed
basis and include reduction mammaplasty, mastopexy, or
augmentation. Breast conservation using oncoplastic techniques has resulted in survival and local recurrence rates that
are essentially equal to that of MRM.
31,32
e purpose of this introductory chapter is to review
the history of these oncoplastic procedures and several of
the landmark studies as well as highlight some of the surgeons that have made signicant contributions to oncoplastic surgery. As oncoplastic surgery gains acceptance
and popularity, an optimal and systematic approach to
management is becoming increasingly necessary. is
introductory chapter will review many of the relevant
vignettes of oncoplastic surgery, and the subsequent chapters will expand upon many of the principles, concepts,
and techniques.
Safety and Efficacy of Oncoplastic Surgery
e indications and patient selection criteria for oncoplastic
surgery is now well appreciated and accepted. Oncoplastic
surgeons should be aware of all aspects related to the indications, techniques, and recovery for women considering
partial mastectomy. Safety in oncoplastic surgery requires
an appreciation of tumor biology and an understanding
of what constitutes an appropriate margin. e process
begins by obtaining a diagnosis that can be accomplished
using various techniques that include ne-needle aspiration,
core needle biopsy, and excisional biopsy. e next step is
the excision. e importance of obtaining a clear margin
becomes evident when one considers that the relative risk
of developing a recurrence is 15-fold higher in patients in
whom the surgical margin was not clear of tumor.
positive margin can be related to the size of the primary
tumor (T3 > T2 > T1) and to histological subtype (lobular > ductal).33 Preoperative identication of these women
with inltrating lobular carcinoma who may be at higher
risk of a positive surgical margin can be sometimes made
via mammography based on the presence of architectural
distortion.
35
33,34
A
It is known that larger tumors have an increased likelihood of a positive margin; therefore, obtaining wider margins may decrease the likelihood of a positive margin. Kaur
etal demonstrated that, as resection margins increase, the
incidence of a positive margin is reduced, especially when
comparing oncoplastic resection to standard quadrantectomy.36 Mean resection volume in this study was 200 cm3
following oncoplastic resection and 117 cm3 following
quadrantectomy. Giacalone etal have demonstrated that,
following oncoplastic resection, glandular removal was
increased, histological margins were wider, and the need for
re-excision was decreased.37 In addition, there was a trend
toward fewer mastectomies following oncoplastic resection
(2/42, 4.8%) compared with standard lumpectomy (12/57,
21.1%). Additional studies and supportive data will be
reviewed in upcoming chapters.
Immediate Reconstruction of the Partial
Mastectomy Deformity
e techniques currently used for the reconstruction of
the partial mastectomy defect are based on two dierent
concepts: volume displacement and volume replacement.
Volume displacement procedures include local tissue rearrangement, reduction mammaplasty, and mastopexy. Volume replacement procedures include local and remote aps
from various regions of the body. ese techniques are usually applied independently; however, new strategies can utilize them simultaneously.
e indications for volume displacement and replacement are dierent and, various algorithms have been devised
to assist with the decision-making process.
38-40
In general,
women with smaller breasts with minimal ptosis were found
to be better candidates for volume replacement procedures
(e.g., local ap, latissimus dorsi, and lateral thoracic ap),
whereas, in women with larger and more ptotic breasts,
volume displacement procedures (e.g., adjacent tissue rearrangement, reduction mammaplasty, and mastopexy) are
usually performed. e simultaneous use of replacement
and displacement has recently been described for women
with small to moderate breast volume in which parenchymal rearrangement is combined with the use of a small
41-43
device.
e history of these techniques as they relate to
oncoplastic surgery will be further reviewed.
Volume Displacement with Reduction
Mammaplasty
Reduction mammaplasty as an oncoplastic modality has
been performed since the early 1980s.44 Over the years,
this has become the principal method by which oncoplastic reconstruction has been performed.
reported on their 14-year experience in 101 women who
were selected for oncoplastic resection because a standard
lumpectomy would have resulted in a signicant contour
45,46
Clough et al
SECTION I Oncoplastic Breast Surgery – Getting Started
https://t.me/medicina_free
4
abnormality.45 e primary technique utilized was an
inverted “T” with nipple–areolar complex based on a superior pedicle. A contralateral reduction mammaplasty for
symmetry was performed immediately in 83% of women
and secondarily in 17% of women. Mean tumor excision
weight was 222 grams. e 5-year local recurrence rate was
9.4%, the overall survival rate was 95.7%, and the metastasis-free survival rate was 82.8%. Cosmetic outcome was
satisfactory in 82% of women. It was demonstrated that
cosmetic outcome tended to deteriorate when radiotherapy
was delivered preoperatively compared with postoperatively.
Spear et al have reported on their 6-year multidisciplinary experience combining wide excision of tumor
with immediate bilateral reduction mammaplasty.47 All
women had mammary hypertrophy with a mean excision volume of 1085 grams per breast. Follow-up ranged
from 1–6 years with a mean of 24 months. Complications
included fat necrosis (n = 3), nipple hypopigmentation
(n = 2), hematoma, and complex scar. Patient satisfaction
was scored on a visual analog scale that ranged from 1–4
with a mean score of 3.3. A panel of independent observers also graded the outcomes and scored the pre-radiation
outcome as a 2.9 and the post-radiation outcome as 3.03.
No woman developed a local recurrence, although one
woman died of metastatic disease. e principal conclusions from this study were that partial mastectomy
followed by oncoplastic and contralateral reduction mammaplasty was oncologically safe and avoided the asymmetry that was typically observed following BCT alone or
following total mastectomy with immediate total breast
reconstruction.
Losken etal have reported on their 10-year experience
utilizing reduction mammaplasty in the setting of oncoplastic surgery.
39,48
A total of 20 women were included
in this review. Mean tumor size was 1.5 mm, and the
mean weight of the tumor specimen was 288 grams. e
excised surgical margins were negative in 80%. e most
common reduction technique was a superomedial or
inferior pedicle. Postoperative abnormal mammograms
were noted in eight women (40%), all of whom underwent additional biopsy. No woman was noted to have a
recurrence with a mean follow-up of 23 months. Breast
aesthetics and patient satisfaction were acceptable in all
women.
ese studies and others have demonstrated the utility
of reduction mammaplasty in the setting of oncoplastic surgery. It is important to note that no two oncoplastic reduction procedures are the same and that oncoplastic reductions
are dierent from standard breast reductions. Parenchymal
displacement may take the form of a ap of vascularized
parenchyma or as parenchymal rotation advancement. If
there is doubt about obtaining a clear margin at the time of
the primary excision, a staged immediate reconstruction can
be performed following margin conrmation. Figs. 1.1–1.2
illustrate a patient before and after oncoplastic reduction
mammaplasty.
• Fig. 1.1 Preoperative marking of a woman with mammary hypertro-
phy and left breast cancer in preparation for left oncoplasty and right
reduction mammaplasty.
• Fig. 1.2 Postoperative image at 1 year following left breast radiation
therapy demonstrating good volume, contour, and symmetry.
Volume Displacement with Adjacent Tissue
Rearrangement
Adjacent tissue rearrangement is the most common method
by which the partial mastectomy defect is reconstructed.
ese techniques rarely require a two-team approach, as the
ablative surgeon is usually able to use these techniques and
close these defects. Adjacent tissue rearrangement is indicated when the partial deformity extends to the chest wall
and there is sucient adjacent tissue to close the defect and
maintain a natural contour. Volume displacement is performed but without the need to create parenchymal aps.
Volume replacement is usually not necessary because there
is sucient local tissue. e primary goal of adjacent tissue rearrangement is to avoid the contour deformity that is
sometimes seen with traditional breast conservation. With
this method of oncoplastic reconstruction, the excision is
usually extended to the chest wall, and the adjacent paren-
https://t.me/medicina_free
chyma is undermined and mobilized to permit the closure
of small or large deformities without creating a contour
abnormality.
Specic parenchymal rearrangement procedures include
batwing mastopexy, radial segment quadrantectomy, donut
mastopexy, and reduction mastopexy. Veronesi etal introduced the concept of segmental parenchymal wide excision including the overlying skin.49 is allowed for the
quadrantectomy approach that was instrumental in establishing the feasibility of BCT. ese operations were generally performed using a radial approach for tumors that were
laterally based. An alternative to the radial approach was the
periareolar approach initially described by Amanti etal.50
is permitted excisions that resulted in less conspicuous
scars. With the introduction of the periareolar subcutaneous quadrantectomy, also known as the periareolar donut
mastopexy, incisions could be created circumferentially
around the nipple–areolar complex and remain relatively
inconspicuous. Anderson et al. introduced various concepts
that include skin incisions using a parallelogram pattern and
batwing mastopexy.44 ese parallelogram incisions allowed
for wider excision margins while maintaining the natural
contour of the breast. e batwing mastopexy is an extension of this concept and is used primarily for centrally situated tumors near the nipple–areolar complex. Clough et al
introduced the technique of reduction mastopexy lumpectomy.45 is technique has been especially useful for tumors
situated near the lower pole of the breast. Standard lumpectomy of these tumors would often result in an inferiorly
displaced nipple–areolar complex.
Volume Replacement with Local and
Remote Flaps
Local and remote aps for volume replacement are most
useful for defects in which volume displacement procedures
would not be adequate due to small breast volume or due
to extensive resection. e selection of a local or remote ap
will depend upon the abilities of the reconstructive surgeon
and the location of the defect. Flaps can be musculocutaneous and perforator-based and can be transferred on a vascularized pedicle or as a free tissue transfer. Many of these
options will be reviewed in the subsequent chapters. What is
provided in this chapter is a brief overview of the techniques
and their origins.
e most common ap for immediate reconstruction
following partial mastectomy has been the latissimus dorsi
musculocutaneous ap.
deformities of the superior, lateral, and inferior aspects
of the breasts. ere are several methods by which the
latissimus dorsi ap can be harvested. e traditional
technique involves making a posterolateral thoracic incision, whereas more modern techniques utilize an endo-
53,56
scope.
With the endoscopic technique, the muscle is
accessed through the breast and axillary incision without
51-56
is ap is indicated for
CHAPTER 1 Introduction to Oncoplastic Breast Surgery
• Fig. 1.3 A lower pole defect is demonstrated following partial mas-
tectomy.
the need to incise or excise remote skin. Kat etal have
reviewed their 3-year experience in 30 women who had
oncoplastic surgery using the latissimus dorsi musculocutaneous ap.52 Flap survival was 100%, and all patients
were pleased with aesthetic outcomes. Losken etal have
reviewed their 5-year experience using the latissimus dorsi
muscle ap harvested endoscopically in 39 women.53
Donor site morbidities occurred in 12 women (31%) and
included a seroma in 7 women as well as skin necrosis,
lymphedema, dehiscence, hypertrophic scarring, and a
persistent sinus tract.
Harvesting the latissimus dorsi as a mini-ap is advantageous because the size of the ap can be tailored to t
the size of the defect.
54,55
e LD mini-ap is generally
harvested through an extended anterolateral breast incision that is used for the resection as well. Rainsbury has
demonstrated that this ap extends the role of BCT and
oncoplastic surgery; enables reconstruction for a deformity
involving 20–30% of the breast; can be used for central,
upper inner, and upper outer quadrant tumors; and can
be performed immediately or on a delayed basis.55 Gendy
etal have used the latissimus dorsi mini-ap for oncoplasty
in 89 women and compared outcomes with immediate
breast reconstruction following total skin-sparing mastectomy.54 Findings were favorable for the oncoplastic techniques with regard to postoperative complications (8% vs
14%), further surgical interventions (12% vs 79%), nipple sensory loss (2% vs 98%), restricted activities (54%
vs 73%), and cosmetic outcome (visual analog score: 83.5
vs 72). Figs. 1.3–1.6 illustrate a patient following partial
breast reconstruction with a latissimus dorsi musculocutaneous ap.
5
SECTION I Oncoplastic Breast Surgery – Getting Started
https://t.me/medicina_free
6
• Fig. 1.4 A latissimus dorsi musculocutaneous flap is harvested in
preparation for delayed reconstruction.
Perforator aps for partial breast reconstruction include
the thoracodorsal artery perforator (TDAP) ap, the lateral
thoracic ap, and the intercostal perforator ap.
57-60
e
TDAP is an adipocutaneous ap in which the latissimus
dorsi muscle is totally spared. e vascularity of the ap is
derived from the perforating branches of the thoracodorsal
artery and vein. e lateral thoracic ap is a fasciocutaneous
ap that is perfused via the lateral thoracic, axillary, or thoracodorsal artery and vein. e intercostal perforator ap is
perfused via a perforating intercostal artery and vein that is
based along the inferior aspect of the anterior axillary line.
ese aps are usually transferred on a vascularized pedicle
but may be transferred as a free tissue transfer as well.
Clinical experience with these aps has been encouraging. Levine et al have provided an algorithm for perforator ap utilization.57 e rst choice is the TDAP ap,
followed by the lateral thoracic ap, and nally the intercostal perforator ap. e decision is based on the quality
of the vessels during the operative procedure. Munhoz etal
have used the lateral thoracic ap in 34 women for partial
breast reconstruction.59 Complications included partial ap
necrosis in three (8.8%), fat necrosis in two (5.8%), and
infection in one (2.9%). Donor-site complications included
a seroma in ve women (14.7%) and wound dehiscence in
three (8.8%). Patient satisfaction was achieved in 88% of
women with a mean follow-up period of 23 months.
• Fig. 1.5 The latissimus dorsi flap is inset into the defect.
• Fig. 1.6 Postoperative follow-up demonstrating restoration of vol-
ume, contour, and symmetry.
Combining Volume Displacement and
Replacement
A relatively recent innovation in the oncoplastic armamentarium is to combine volume displacement and replacement
simultaneously.
women with smaller breasts who desire oncoplasty but seek
an alternative to the classical volume replacement techniques
described. Alternatives to the use of mini-aps or perforator
aps can include the use of devices, namely implants, but also
resorbable materials that are available as three-dimensional
constructs that have been used for radiation imaging.
e biplanar oncoplasty was initially described by
Nahabedian et al. and Miraliakbari et al, and incorporates
the use of breast implants or tissue expanders placed under
the pectoralis major muscle as well as parenchymal rearrangement that occurs above the pectoralis major muscle, hence, the name biplanar oncoplasty.
prosthetic devices such as breast implants in the setting of
oncoplasty and radiation therapy has historically resulted in
higher complication rates such as capsular contracture, premature removal, and decreased patient satisfaction. However, the increased use of prosthetic devices coupled with
the use of acellular dermal matrices in the setting of radiation therapy has reduced the incidence of capsular contracture and made the biplanar technique more feasible. Barnea
etal will discuss this operation in greater detail in one of the
later chapters. Figs. 1.7–1.10 illustrate a patient following
simultaneous volume displacement and replacement using
a prosthetic device.
41-43
is technique is primarily indicated in
41-42
e use of
• Fig. 1.7 Preoperative image of a patient with multifocal breast cancer
https://t.me/medicina_free
scheduled for partial mastectomy.
CHAPTER 1 Introduction to Oncoplastic Breast Surgery
• Fig. 1.9 One-week follow-up in which the defect was reconstructed
with a biplanar technique consisting of tissue rearrangement and
placement of a 180mL subpectoral silicone gel implant.
7
• Fig. 1.8 The 201-gram specimen is excised.
A second option that incorporates volume displacement
and replacement simultaneously utilizes an entirely dierent
prosthetic device called BioZorb®.
61,62
is is an implantable, resorbable, three-dimensional coil that is used to mark
the site of tumor extirpation for radiation therapy localization. Its other benet is that it can behave like a ller material to act as a volume replacement device. e dierence
between this approach and the biplanar approach is that the
volume replacement and displacement occur above the pectoralis major muscle. Following insertion of the BioZorb®
device at the base of the partial mastectomy defect, parenchymal rearrangement occurs to cover the device followed
by skin closure. Contour and volume abnormalities can be
minimized. Nahabedian will review this technique in a subsequent chapter.
Conclusion
is introductory chapter was prepared to review the history of oncoplastic surgery and to provide a framework for
• Fig. 1.10 One-year follow-up demonstrating good volume, contour,
and symmetry.
the remaining chapters. All of the principles, concepts, and
specic techniques will be discussed in greater detail in the
forthcoming chapters.
References
1. Halsted WS. e results of radical operations for the cure of
breast carcinoma. Ann Surg. 1894;20:497.
2. Madden JL. Modied radical mastectomy. Surg Gynecol Obstet.
1965;121:1221–3120.
3. Donegan WL, Sugarbaker ED, Handley RS, Watson FR. e
management of primary operable breast cancer. A comparison
of time-mortality factors after standard, extended, and modied
radical mastectomy. Proc Natl Cancer Conf. 1970;6:135–143.
SECTION I Oncoplastic Breast Surgery – Getting Started
https://t.me/medicina_free
8
4. Scanlon EF, Caprini JA. Modied radical mastectomy. Cancer.
1975;35:710–713.
5. McWhirter R. e value of simple mastectomy and radiotherapy
in the treatment of cancer of the breast. Br J Radiol. 1948;21:599–
610.
6. Toth BA, Lappert P. Modied skin incisions for mastectomy:
the need for plastic surgical input in preoperative planning. Plast
Reconstr Surg. 1991;87:1048–1053.
7. Singletary SE. Skin-sparing mastectomy with immediate breast
reconstruction: the M.D. Anderson Cancer Center experience.
Ann Surg Oncol. 1996;3:411–416.
8. Slavin S, Schnitt SJ, Duda R, etal. Skin-sparing mastectomy and
immediate reconstruction: oncologic risks and aesthetic results in
patients with early-stage breast cancer. 102:49–62.
9. Noguchi M, Katev N, Myazaki I. Diagnosis of axillary lymph
node metastases in patients with breast cancer. Breast Cancer Res
Treat. 1996;40:283–293.
10. O’Hea BJ, Hill AD, El Shirbini AM, etal. Sentinel lymph
node biopsy in breast cancer: initial experience at Memorial
Sloan-Kettering Cancer Center. J Am Coll Surg. 1998;186:
423–427.
11. VerHeyden CN. Nipple-sparing total mastectomy of large breasts:
the role of tissue expansion. Plast Reconstr Surg. 1998;101:1494–
1500.
12. Nahabedian MY, Tsangaris TN. Breast reconstruction following subcutaneous mastectomy for cancer: a critical appraisal of
the nipple-areolar complex. Plast Reconstr Surg 2006;117:1083–
1090.
13. Crowe JP, Kim JA, Yetman R, et al. Nipple-sparing mastectomy
technique and results of 54 procedures. Arch Surg. 2004;139:
148–150.
14. Cense HA, Rutgers EJ, Lopes Cardozo M, Van Lanschot JJB.
Nipple-sparing mastectomy in breast cancer: a viable option?
EJSO. 2001;27:521526.
15. Sacchini V, Pinotti JA, Barros A, etal. Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical
problem? J Am Coll Surg. 2006;203:704–714.
16. Longacre JJ. e use of local pedicle aps for reconstruction of
the breast after total or subtotal extirpation of the mammary
gland and for correction of distortion and atrophy of the breast
due to excessive scar. Plast Reconstr Surg. 1953;11:380.
17. Snyderman RK, Guthrie RH. Reconstruction of the female breast
following radical mastectomy. Plast Reconstr Surg. 1971;47:465.
18. Arnold PG, Hartrampf CA, Jurkiewicz MJ. One-stage reconstruction of the breast, using the transposed greater omentum.
Case report. Plast Reconstr Surg. 1976;57:520–522.
19. Schneider WJ, Hill Jr HL, Brown RG. Latissimus dorsi myocutaneous ap for breast reconstruction. Br J Plast Surg. 1977;30:
277.
20. Hartrampf CR, Schean M, Black PW. Breast reconstruction with
a transverse abdominal island ap. Plast Reconstr Surg. 1982;69:
216–225.
21. Argenta LC. Reconstruction of the breast by tissue expansion.
Clin Plast Surg. 1984;11:257–264.
22. Grotting JC, Urist MM, Maddox WA, Vasconez LO. Conventional TRAM ap versus free microsurgical TRAM ap for
immediate breast reconstruction. Plast Reconstr Surg. 1989;83:
828–841.
23. Allen RJ, Treece P. Deep inferior epigastric perforator ap for
breast reconstruction. Ann Plast Surg. 1994;32:32–38.
24. Crile G, Esselstyn CB, Hermann RE, Hoerr SO. Partial mastectomy for carcinoma of the breast. Surg Gynecol Obstet. 1973;136:
929–933.
25. Crile G. Results of conservative treatment of breast cancer at ten
and 15 years. Ann Surg. 1975;181:26–30.
26. Montague E, Gutierrez AE, Barker JL, Tapley ND, Fletcher GH.
Conservation surgery and irradiation for the treatment of favorable breast cancer. Cancer. 1979;43:1058–1061.
27. 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.
28. Matory WE, Wertheimer M, Fitzgerald TJ. Aesthetic results following partial mastectomy and radiation therapy. Plast Reconstr
Surg. 1990;85:739–746.
29. Gabka CJ, Maiwald G, Baumeister RG. Expanding the indications spectrum for breast saving therapy of breast carcinoma by
oncoplastic operations. Langenbecks Arch Chir Suppl Kongressbd.
1997;114:1224–1227.
30. Masetti R, Pirulli PG, Magno S, etal. Oncoplastic techniques in
the conservative surgical treatment of breast cancer. Breast Can-
cer. 2000;7:276–280.
31. Rietjens M, Urban CA, Rey PC, et al. Long-term oncological
results of breast conservative treatment with oncoplastic surgery.
Breast. 2007;16:387–395.
32. Asgeirsson KS, Rasheed T, McCulley SJ, Macmillan RD. Oncological and cosmetic outcomes of oncoplastic breast conserving
surgery. Eur J Surg Oncol. 2005;31:817–823.
33. Chapgar AB, Martin RCG, Hagendoorn LJ, Chao C, McMasters
KM. Lumpectomy margins are aected by tumor size and histologic
subtype but not by biopsy technique. Am J Surg. 2004;188:399–402.
34. Schnitt SJ, Abner A, Gelman R, Connelly JL. e relationship
between microscopic margins of resection and the risk of local
recurrence in patients treated with breast conserving surgery and
radiation therapy. Cancer. 1994;74:1746–1751.
35. Moore MM, Borossa G, Imbrie JZ, etal. Association of inltrating lobular carcinoma with positive surgical margins after breastconservation therapy. Ann Surg. 2000;231:877–882.
36. Kaur N, Petit JY, Rietjens M, etal. Comparative study of surgical margins in oncoplastic surgery and quadrantectomy in breast
cancer. Ann Surg Oncol. 2005;12:1–7.
37. Giacalone PL, Roger P, Dubon O, El Gareh N, Daures JP, Laffargue F. Lumpectomy vs. oncoplastic surgery for breast-conserving therapy of cancer. A prospective study about 99 patients.
Annales de Chirurgie. 2006;131:256–261.
38. Kronowitz SJ, Feledy JA, Hunt KK. Determining the optimal
approach to breast reconstruction after partial mastectomy. Plast
Reconstr Surg. 2006;117:1–11.
39. Losken A, Styblo TM, Carlson GW, Jones GE, Amerson BJ.
Management algorithm and outcome evaluation of partial mastectomy defects treated using reduction or mastopexy techniques.
Ann Plast Surg. 2007;59:235–242.
40. Clough KB, Cuminet J, Fitoussi, etal. Cosmetic sequellae after
conservative treatment for breast cancer: classication and results
of surgical correction. Ann Plast Surg. 1998;41:471–481.
41. Nahabedian MY, Patel KM, Kaminsky AJ, Cocilovo C, Miraliakbari R. Biplanar oncoplastic surgery: a novel approach to breast
conservation for small and medium sized breasts. Plast Reconstr
Surg. 2013;132:1081–1084.
42. Kaminsky AJ, Patel KM, Cocilovo C, Nahabedian MY, Miralakbari R. e biplanar oncoplastic technique case series: a 2-year
review. Gland Surgery. 2015;4(3):257–262.
43. Barnea Y, Friedman O, Arad E, Barsuk D, Menes T, Zaretski A,
Leshem D, Gur E, Inbal A. An oncoplastic breast augmentation
technique for immediate partial breast reconstruction following
breast conservation. Plast Reconstr Surg. 2017;139:348e–357e.
CHAPTER 1 Introduction to Oncoplastic Breast Surgery
https://t.me/medicina_free
9
44. Anderson BO, Masetti R, Silverstein ML. Oncoplastic approaches
to the partial mastectomy: an overview of volume displacement
techniques. Lancet Oncol. 2005:145–157.
45. Clough KB, Lewis JS, Couturaud B, Fitoussi A, Nos C, Falcou MC. Oncoplastic techniques allow extensive resections
for breast-conserving therapy of breast carcinomas. Ann Surg.
2003;237:26–34.
46. Munhoz AM, Montag E, Arruda EG, etal. Critical analysis of
reduction mammaplasty techniques in combination with breast
conservation surgery for early breast cancer treatment. Plast
Reconstr Surg. 2006;117:1091–1103.
47. Spear SL, Pelletiere CV, Wolfe AJ, Tsangaris TN, Pennanen MF.
Experience with reduction mammaplasty combined with breast
conservation therapy in the management of breast cancer. Plast
Reconstr Surg. 2003;111:1102–1109, 2003.
48. Losken A, Elwood ET, Styblo TM, Bostwick J. e role of reduction mammaplasty in correcting partial mastectomy defects. Plast
Reconstr Surg. 2002;109:968–975.
49. Veronesi U, Luini A, Galimberti V, Zurrida S. Conservation
approaches for the management of stage I/II carcinoma of the
breast: Milan Cancer Institute trials. World J Surg. 1994;18:70–75.
50. Amanti C, Moscaroli A, Lo Russo M, etal. Periareolar subcutaneous quadrantectomy: a new approach in breast cancer surgery. G
Chir. 2002;23:445–449.
51. Noguchi M, Taniya T, Miyazaki I, Saito Y. Immediate transposition
of a latissimus dorsi muscle for correcting a postquadrantectomy
breast deformity in Japanese patients. Int Surg. 1990;75:166–170.
52. Kat CC, Darcy CM, O’Donoghue JM, Taylor AR, Regan PJ. e
use of the latissimus dorsi ap for the immediate correction of the
deformity resulting from breast conserving therapy. Brit J Plast
Surg. 1999;52:99–103.
53. Losken A, Schaefer TG, Carlson GW, Jones GE, Styblo TM,
Bostwick J. Immediate endoscopic latissimus dorsi ap. Ann Plast
Surg. 2004;53:1–5.
54. Gendy RK, Able JA, Rainsbury RM. Impact of skin sparing mastectomy with immediate reconstruction and breast sparing reconstruction with miniaps on the outcomes of oncoplastic breast
surgery. Br J Surg. 2003;90:433–439.
55. Rainsbury RM. Breast sparing reconstruction with latissimus
dorsi miniaps. EJSO. 2002;28:891–895.
56. Monticciolo DL, Ross D, Bostwick 3rd J, etal. Autologous breast
reconstruction with endoscopic latissimus dorsi musculosubcutaneous aps in patients choosing breast-conserving therapy: mammographic appearance. Am J Roentgenol. 1996;167:385–389.
57. Levine JL, Soueid NE, Allen RJ. Algorithm for autologous breast
reconstruction for partial mastectomy defects. Plast Reconstr Surg.
2005;116:762–767.
58. Holmstrom H, Lossing C. e lateral thoracodorsal ap in breast
reconstruction. Plast Reconstr Surg. 1986;577:933.
59. Munhoz A, Montag E, Arruda EG, et al. e role of the lateral thoracodorsal fasciocutaneous ap in immediate conservative breast surgery reconstruction. Plast Reconstr Surg.
2006;116:1699–1710.
60. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous ap without muscle. Plast Reconstr Surg. 1995;96:1608–
1614.
61. Harms S, Lebovic G, Kaufman CS, Cross M. Mammographic
imaging after partial breast reconstruction: impact of a bioabsorbable breast implant. J Clin Oncol. 2015;33(28):111.
62. Wiens N, Torp L, Wol B, et al. Eect of BioZorb® surgical
marker placement on post-operative radiation boost target volume. Int J Radiat Oncol. 2018;7:175–179.
2
https://t.me/medicina_free
Safety of Oncoplastic Breast
Reconstruction
PETER W. THOMPSON AND GRANT W. CARLSON
Introduction
Historically, early stage breast cancer has been treated with
either mastectomy or breast conservation therapy (local
tumor excision with adjuvant radiation therapy). Clinicopathologic characteristics such as tumor size and extent of
breast involvement determine patient suitability for one
approach or the other. Landmark prospective studies have
shown that these two approaches have equivalent diseasefree and overall survival.
Total mastectomy can be a cosmetically deforming and
psychologically taxing procedure. Breast reconstruction following mastectomy involves use of prosthetic techniques or
harvesting autologous tissue from distant sites to recreate a
breast mound. Breast conservation is therefore appealing in
its potential to preserve the native breast mound; however,
an acceptable cosmetic result is not guaranteed. Up to 40%
of patients who undergo breast conservation have had an
unacceptable cosmetic result.
Oncoplastic techniques utilize plastic surgical methods
of volume displacement and replacement to achieve the primary goal of negative surgical margins as well as the secondary goal of optimal aesthetic result and breast symmetry.
Oncoplastic breast conservation has become an increasingly
common technique compared with traditional breast conservation over the last 10 years by facilitating reconstruction after larger volume resections.3 Oncoplastic surgery has
greatly expanded the group of patients who may be candidates for breast conservation, and studies using validated
questionnaires have demonstrated excellent levels of patient
satisfaction.4 Concerns regarding the oncologic safety
of these techniques have increased, mirroring their rising
popularity. Safety data pertaining to oncoplastic breast surgery are limited by a lack of prospective data and long-term
follow-up.
When discussing reconstructive options with pati ents,
oncologic risks and benets should be reviewed. With
1
2
oncoplastic procedures, appropriate patient counseling requires attention to several important clinical questions:
• Do oncoplastic techniques aect the rate of positive
margins in breast conservation, and how should positive
margins be managed?
• Do oncoplastic techniques aect the rate of local recurrence, disease-free survival, and overall survival?
• Does oncoplastic surgery result in a higher incidence of
complications?
• Does oncoplastic surgery aect the delivery of radiation
or future surveillance of breast cancer?
In this chapter, the available data to answer these impor-
tant questions will be reviewed.
Margins in Oncoplastic Surgery
e three goals of breast conservation therapy (BCT) are
to remove the primary tumor, decrease breast tumor recurrence, and optimize cosmesis. Positive margins have been
clearly shown to be a risk factor for local recurrence, but
until recently there was no consensus as to what constitutes
a “negative” margin. Based on a meta-analysis of 33 studies reporting on more than 32,000 patients, the Society
for Surgical Oncology and American Society of Radiation
Oncology released a joint guideline dening a negative
margin as “no ink on tumor.”5 ere was no evidence that
obtaining a wider margin, such as a threshold of >2 mm
or >5 mm, resulted in a lower rate of local recurrence. is
recommendation is important when considering an oncoplastic breast conservation procedure, which is often oered
to patients with larger tumors who might not be good candidates for standard breast conservation. In a meta-analysis
of more than 8500 patients published in 2014, Losken etal
compared the outcomes of patients who had undergone
standard breast conservation with patients who had undergone immediate breast reconstruction using oncoplastic
techniques. ey found that, despite overall signicantly
10
CHAPTER 2 Safety of Oncoplastic Breast Reconstruction
https://t.me/medicina_free
11
larger tumor size and lumpectomy specimen weight in the
oncoplastic group, the overall positive margin rate was signicantly lower in the oncoplastic group compared with
the standard breast conservation group (12% vs 21%).6 An
acceptably low positive margin rate following oncoplastic
breast conservation has been conrmed in multiple studies, ranging from 0–21% according to a recent systematic
review published by Piper etal.
7
One concern voiced by critics about oncoplastic breast
conservation techniques, which utilize volume displacement and parenchymal rearrangement to ll the empty
space created by tumor excision, is that the architecture
and orientation of the lumpectomy cavity becomes distorted. is has the potential to make identication and
re-excision of previous surgical margins more dicult, and
in these cases completion mastectomy may be necessary to
achieve negative surgical margins. Data from Piper etal
suggest that the overall rates of re-excision and completion mastectomy in patients undergoing oncoplastic breast
conservation are acceptably low (3.5% and 3.7%, respectively).7 Despite larger tumor size in patients undergoing
oncoplastic breast conservation, available data comparing
re-excision and completion mastectomy rates between
patients undergoing oncoplastic and standard breast conservation suggest that re-excision of positive margins is
less frequently required in the oncoplastic group, whereas
completion mastectomy is required at similar rates between
the two groups.
6,8,9
Piper etal suggest placement of clips in the cardinal
directions of the lumpectomy cavity to both facilitate reexcision in the setting of positive margins and to assist
with targeting of the radiation boost. e authors make
the argument that, because local tumor recurrence usually occurs in the previous lumpectomy site, marking
with clips also allows a second re-excision of breast tissue
rather than completion mastectomy in the setting of local
recurrence.
7
A good understanding of factors predictive of margin
positivity is necessary to properly counsel patients considering breast conservation versus total mastectomy, as a nding of positive margins after breast conservation will often
necessitate additional surgery. In a retrospective review by
Clough etal of 272 patients undergoing oncoplastic BCT,
the only factor predictive of margin positivity after multivariate analysis was invasive lobular tumor histology.10 A
retrospective review by Amabile etal looking at 129 patients
undergoing oncoplastic breast surgery further identied
obesity, tumor multifocality, and the presence of microcalcications on mammogram as predictive of the need for
re-excision.
11
In summary, oncoplastic breast conservation techniques
can be oered to patients with acceptable rates of margin
positivity compared with standard breast conservation;
however, proper patient selection is essential, as margin
positivity is one of the primary factors predictive of local
recurrence.
Local Recurrence, Distant Recurrence,
Disease-Free Survival, and Overall Survival
Following Oncoplastic Breast Conservation
e primary determinant of the safety and applicability
of any oncologic procedure is its eect on recurrence and
survival. As mentioned previously, the ecacy of BCT as a
treatment for early stage breast cancer has been established
by landmark studies demonstrating equivalent disease-free
and overall survival compared with mastectomy.1 As oncoplastic modications of standard breast conservation techniques have only become a mainstream treatment option in
the last 10–15 years, long-term follow-up data evaluating
safety and ecacy are less readily available. De La Cruz etal
performed a systematic review of 55 articles pertaining to
oncoplastic outcomes including 6011 patients with a mean
follow-up of 50.5 months. Most patients included in this
analysis had early-stage breast cancers with invasive ductal
histology. e authors analyzed recurrence and survival outcomes for three dierent follow-up intervals. Among 871
patients with the longest follow-up (at least 5 years), the
rates of overall survival, disease-free survival, local recurrence, and distant recurrence were 93.4%, 85.4%, 6%, and
11.9%, respectively.12 e authors noted that these rates
compare favorably with rates of local recurrence and overall
survival after standard breast conservation, suggesting that
long-term outcome is more dependent on patient factors
and tumor biology than on surgical technique. Given the
equivalent recurrence and survival outcomes with oncoplastic techniques, these procedures may be safely oered
to most women who might also be candidates for standard
breast conservation; the potential benet of improved cosmesis with oncoplastic surgery does not appear to compromise cancer recurrence and survival.
Complications Following Oncoplastic
Breast Reconstruction
Preoperative counseling of patients considering oncoplastic breast reconstruction must also include a discussion of
complications. Overall safety of the oncoplastic approach
can be considered in comparison to standard breast conservation, in comparison to bilateral breast reduction, or in
comparison to total mastectomy with reconstruction. All of
these analyses have been performed with a nding of favorable complication proles for oncoplastic reconstruction.
e overall complication rate of oncoplastic reconstruction
ranges from 14–16% in systematic review and meta-analysis of the literature.
vary depending on publication but include delayed wound
healing, fat necrosis, infection, nipple necrosis, seroma,
and hematoma; these complications vary in incidence from
<1–4%.
7,12
Complications requiring operative intervention
make up on average around 3% of all complications.
6,12
e most common complications
6,13
SECTION I Oncoplastic Breast Surgery – Getting Started
https://t.me/medicina_free
12
Compared with standard breast conservation with lum p ectomy, oncoplastic techniques may have a comparable or
slightly lower rate of complications. In a National Surgical
Quality Improvement Program (NSQIP) database analysis of nearly 76,000 patients undergoing BCT, the overall
30-day rate of complications in patients undergoing oncoplastic breast surgery was 1.7% compared with 1.9% in
patients undergoing standard breast conservation.14 In their
meta-analysis of oncoplastic breast reconstruction with an
average follow-up of 37 months, Losken etal found that the
overall rate of complications was 15.5% in the oncoplastic
group compared with 25.9% in the standard breast conservation group, albeit with a shorter follow-up period in
the oncoplastic group.6 Lower rates of seroma in oncoplastic reconstructions compared with standard breast conservation may be attributable to lling of the lumpectomy cavity
by displacement and rearrangement of the remaining breast
parenchyma in a way that obliterates the dead space.
3
Oncoplastic reconstruction also appears to have a lower
rate of complications compared with total mastectomy and
reconstruction. In their retrospective cohort study including more than 9800 patients with breast cancer, Carter etal
found that patients undergoing oncoplastic reconstruction
had a lower rate of hematoma, infection, and wound healing complications compared with patients who underwent
total mastectomy and reconstruction.3 Losken etal demonstrated that, in a population of breast cancer patients with
macromastia, patients who underwent total mastectomy
with reconstruction by either implant-based or autologous
methods had nearly twice the overall rate of complications
compared with patients who underwent oncoplastic reconstruction (22% vs 43%).15 is dierence is at least partially attributable to risks associated with implants as well
as donor-site complications, although in women with very
large breasts, the potential for seroma, hematoma, infection,
and contour deformities are greater when a reconstruction
must ll a larger mastectomy cavity.
e oncoplastic reconstruction approach often involves
a contralateral mastopexy or reduction for symmetry on
the non-cancer breast. In this instance, the nal result is
aesthetically similar to a bilateral reduction mammaplasty
performed for symptomatic macromastia. In a prospective
evaluation of patients undergoing bilateral breast reduction
either with or without breast cancer, the overall rate of complications was similar (18.8% for oncoplastic group, 18.3%
for breast reduction group). Seroma was the most common
complication in both groups at around 5–6%. Interestingly,
approximately 50% of the complications in the oncoplastic
group occurred in the non-cancer breast.16 From this, the
authors conclude that oncoplastic reconstruction with contralateral reduction has a safety prole similar to a standard
bilateral breast reduction.
Surgical complications immediately following oncoplastic
breast reconstruction can negatively aect oncologic outcome
by delaying the administration of adjuvant therapies. Data
directly analyzing timing of adjuvant therapies following
oncoplastic reconstruction are limited; most of the available
evidence, although lacking in detail, supports the claim that
complications following oncoplastic reconstruction have minimal eect on timing of delivery of adjuvant therapy.
6,13,16
In
contrast, one retrospective institutional review published by
Hillberg etal examined outcomes of 150 patients undergoing
oncoplastic breast reconstruction performed by a single surgeon; the authors reported that 8.2% of patients experienced
a delay in receiving adjuvant radiation due to a complication.
ese results may be aected by a higher than expected overall complication rate in this series (37.5%).17 Similarly, evidence that oncoplastic reconstruction delays administration
of adjuvant chemotherapy is lacking. A retrospective review
of 169 breast cancer patients performed by Khan etal demonstrated no dierence in time to initiation of adjuvant chemotherapy whether standard breast conservation, oncoplastic
breast conservation, mastectomy alone, or mastectomy with
immediate reconstruction was performed.
18
Appropriate patient selection for oncoplastic reconstruction includes identication of patients at increased risk
for postoperative complications. In their NSQIP database
analysis, Cil etal identied several factors that were independently associated with an increased risk of postoperative complication in the 30-day period.14 ese included
obesity, smoking, American Academy of Anesthesiologists
(ASA) category 3 or 4, diabetes, bleeding disorder, chronic
obstructive pulmonary disease (COPD), and a longer operative time. Of these, the presence of a bleeding disorder had
the highest association with postoperative complications
(odds ratio 1.8). Multiple other studies have identied elevated body mass index (BMI) as a risk factor for postoperative complications.
16
In summary, patients who undergo oncoplastic reconstruction have a favorable complication prole compared
with patients undergoing standard breast conservation or
other methods of reconstruction. Oncoplastic techniques
do not appear to negatively aect timing of radiation delivery. Appropriate technique and patient selection are crucial
to minimize postoperative morbidity.
Cancer Surveillance Following
Oncoplastic Reconstruction
Oncoplastic breast conservation techniques by denition
preserve the majority of the breast parenchyma; therefore,
ongoing mammographic surveillance of the remaining
breast tissue is crucially important to detect cancer recurrence. Critics of oncoplastic reconstruction have voiced
concerns that distortion of parenchymal architecture and
more extensive postsurgical changes compared with standard breast conservation may negatively aect the early
detection of local tumor recurrence. Oncoplastic breast
reconstruction combines time-tested techniques of standard breast conservation and breast reduction. e mammographic changes following these procedures are well
Соседние файлы в папке Библиотека им академика М.И. Перельмана