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11 Principles ofRadiotherapy inBreast Oncoplasty andReconstruction
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excisions and provides similar long-term outcome.
11.2.5 Implant Related Complications
Adjuvant radiation after breast conservation sur­gery improves disease control, even in the lower risk patients [26, 27], however it causes acute and chronic effect on the skin and subcutaneous tis­sue leading to breast edema, color change, telan­giectasia, brosis, etc. Early effects of whole breast radiation include skin thickening and edema of breast, fat necrosis, which subsequently leads to varying degrees of brosis. Quantum of radiation induced complications are contributed by radiation dose, radiation technique, and inher­ent patient tolerance/tissue response. EORTC boost trial [9, 10] reported 10-year rates of mod­erate to severe brosis of 28.1% vs. 13.2% and severe brosis of 4.4% vs. 1.6% in the boost arm without compromising cosmetic outcome. Agrawal etal. proposed a classication system for better understanding of the radiation induced changes after OPS. Accordingly, the aesthetic outcomes may be classied as (1) Type 1: Global effect which includes breast edema/swelling and shrinkage/retraction of breast; (2) Type 2: Skin effect: (a) Subcutaneous brosis, (b) discolor­ations and/or telangiectasia; (3) Type 3: Parenchymal effects: (a) Fat necrosis, (b) radia­tion induced malignancy (Table 11.1) [28].
11.2.5.1 Implant Related Complications: Reconstructed Breast [Zachary Brownlee]
A breast conservation may not be possible always because of advanced disease or unfa­vorable breast to tumor ratio, and patients are offered a mastectomy. After a mastectomy many patients undergo reconstruction surgery which poses unique challenge and multiplies the complexity for radiation therapy delivery and experience unique toxicities [29]. Jhaveri etal. looked into long-term complication rates in patients treated with post-mastectomy radi­ation (PMRT) after immediate reconstruction [30]. Nearly 25% patients experienced grade III/IV complications. The complications rate was as high as 33% for patients receiving tis­sue expanders but patients with autologous transplant did not experience such complica­tions. Corderio et al. reported significantly higher rate of capsular contracture [68% vs 40%, p = 0.025] for patients treated with immediate breast reconstruction followed by PMRT but without compromising long-term cosmesis [31]. A systematic review by Clemens reported poorer patient satisfaction with prosthetic breast implant and higher requirement of major corrective surgery. Superior cosmetic outcomes are achievable if delayed reconstructions are performed follow­ing PMRT as it reduces chances of fat necro­sis. The authors also reiterated that the
Table 11.1 Effect of radiation on breast tissue at different timeframe
Types of RT effects Anatomical Aesthetic unit affected Outcome
Global Edema
Fibrosis/retraction
Surface Skin discoloration
Subcutaneous induration Telangiectasia
Parenchymal Fat necrosis
Radiation induced second malignancy
Volume loss Upward displacement of NAC
Hyperpigmentation of skin Hypopigmentation of NAC Scar difference
Uneven surface Irregular texture
Asymmetry of size, shape, NAC
Asymmetry of color Size/shape Texture Risk of re-surgery
Increased imaging/biopsy rate Compromised aesthetic
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presence of flap, tissue expander, or implant does not adversely affect radiation delivery and disease control. Introduction of sophisti­cated implants and more precise radiation holds promise to reduce chances of complica­tion in such patients. The literature found higher patient satisfaction with autologous reconstruction compared with prosthetic based reconstruction, additionally cosmetic outcome favored a delayed reconstruction rather than immediate [32].
11.2.5.2 Implant Related Complications: Conserved Breast andAPBI
Target volume delineation for a partial breast irradiation is a challenge and always prone to error if adequate attention is not paid to it. Roth et al. performed retrospective analysis of 134 patients with low-risk breast cancer [Pulse dose rate of 50.4Gy or high-dose rate (HDR) of 32Gy over 4days] and found APBI feasible in low risk patients who undergo OPS.The authors reported mild breast brosis in 27, telangiectasia in 6, hyperpigmentation in 14 cases [33].
11.2.6 Newer Techniques ofRT
Radiation techniques in the last few years have witnessed a paradigm shift. Modern radiation techniques like forward planning IMRT help spare the skin which does not come in target vol­ume in both whole breast radiation or partial breast radiation. It helps signicantly to reduce dose to the skin and subsequent discoloration and telangiectasia. Respiratory gating techniques like deep inspirational breath hold (DIBH) help to reduce the dose to heart and reduce possibility of cardiac morbidity.
IORT in the era of oncoplasty [34]: Partial breast irradiation is a well-established concept for early stage favorable risk patients. A wide array of techniques including interstitial plastic tube implantations, different balloon-based implants (MammoSite, hybrid applicators-North American clear path, SAVI, Contura, etc.). External beam based partial breast irradiation techniques have also been established which pro­vides non-inferior outcome. Intraoperative radia­tion (either with 50 kv X ray or self-shielded electron beam) (Fig.11.2) also emerged as very
Fig. 11.2 These two are the most commonly used equipment for intraoperative radiotherapy, the Mobetron which is enabled with 6, 9, 12MeV electron energy and intrabeam emits 50KV X-ray
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convenient techniques which allow treatment during the same day of surgery and under direct visualizations.
In addition, IORT has additional advantages if incorporated with OPS as it allows easy delinea­tion of target volume. However, data from phase III data failed to establish non-inferiority. In recent years efforts are being made to eliminate radiation for very favorable risk patients but these trials found signicantly higher rate of local recurrence. Hence, point should be made that such IORT techniques may be worth using for early stage favorable risk patients, as it reduces duration of hospital stay, requirement of anesthesia.
References
1. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG)*. Effect of radiotherapy after breast con­serving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10 801 women in 17 randomised tri­als. Lancet. 2011;378:1707–16.
2. Fisher ER, Anderson S, Redmond C, Fisher B. Ipsilateral breast tumor recurrence and survival following lumpectomy and irradiation: pathological ndings from NSABP protocol B-06. Semin Surg Oncol. 1992;8:161–6.
3. Kurtz JM, Amalric R, Brandone H, Ayme Y, Jacquemier J, Pietra JC, et al. Local recurrence after breast-conserving surgery and radiotherapy. Frequency, time course, and prognosis. Cancer. 1989;63:1912–7.
4. Correa C, Harris EE, Leonardi MC, Smith BD, Taghian AG, Thompson AM, etal. Accelerated partial breast irradiation: executive summary for the update of an ASTRO evidence-based consensus statement. Pract Radiat Oncol. 2017 Mar–Apr;7(2):73–9.
5. Strnad V, Major T, Polgar C, Lotter M, Guinot JL, Gutierrez-Miguelez C, etal. ESTRO-ACROP guide­line: interstitial multi-catheter breast brachytherapy as accelerated partial breast irradiation alone or as boost – GEC-ESTRO breast cancer working group practical recommendations. Radiother Oncol. 2018 Sep;128(3):411–20.
6. Vicini FA, Cecchini RS, White JR, Arthur DW, Julian TB, Rabinovitch RA, etal. Long-term primary results of accelerated partial breast irradiation after breast­conserving surgery for early-stage breast cancer: a randomised, phase 3, equivalence trial. Lancet. 2019 Dec 14;394(10215):2155–64.
7. Shaitelman SF, Jeruss JS, Pusic AL. Oncoplastic surgery in the management of breast cancer. J Clin Oncol. 2020 Jul 10;38(20):2246–53.
8. American Society of Plastic Surgeons: 2018 Plastic Surgery Statistics Report 2018. https://www.plas-
ticsurgery.org/documents/News/Statistics/2018/ plasticsurgery- statistics- full- report- 2018.pdf
9. Bartelink H, Maingon P, Poortmans P, Weltens C, Fourquet A, Jager J, etal. European Organisation for Research and Treatment of Cancer radiation oncol­ogy and breast cancer groups. Whole-breast irradia­tion with or without a boost for patients treated with breast-conserving surgery for early breast cancer: 20-year follow-up of a randomised phase 3 trial. Lancet Oncol. 2015 Jan;16(1):47–56.
10. Vrieling C, van Werkhoven E, Maingon P, Poortmans P, Weltens C, Fourquet A, etal. European Organisation for Research and Treatment of Cancer, radiation oncology and breast cancer groups. Prognostic fac­tors for local control in breast cancer after long-term follow-up in the EORTC boost vs no boost trial: a randomized clinical trial. JAMA Oncol. 2017 Jan 1;3(1):42–8.
11. Haviland JS, Owen JR, Dewar JA, Agrawal RK, Barrett J, Barrett-Lee PJ, etal. The UK standardisa­tion of breast radiotherapy (START) trials of radio­therapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol. 2013 Oct;14(11):1086–94.
12. Tse T, Knowles S, Bélec J, Caudrelier JM, Lock M, Brackstone M, Arnaout A. Consensus statement on tumour bed localization for radiation after oncoplastic breast surgery. Curr Oncol. 2020 Jun;27(3):e326–31.
13. Aldosary G, Caudrelier JM, Arnaout A, Chang L, Tse T, Foottit C, etal. Can we rely on surgical clips placed during oncoplastic breast surgery to accurately delin­eate the tumor bed for targeted breast radiotherapy? Breast Cancer Res Treat. 2021 Apr;186(2):343–52.
14. Strnad V, Krug D, Sedlmayer F, Piroth MD, Budach W, Baumann R, etal. Breast cancer expert panel of the German Society of Radiation Oncology (DEGRO). DEGRO practical guideline for partial-breast irradia­tion. Strahlenther Onkol. 2020 Sep;196(9):749–63.
15. Strnad V, Hannoun-Levi JM, Guinot JL, Lössl K, Kauer-Dorner D, Resch A, etal. Recommendations from GEC ESTRO breast cancer working group (I): target denition and target delineation for accelerated or boost partial breast irradiation using multicath­eter interstitial brachytherapy after breast conserv­ing closed cavity surgery. Radiother Oncol. 2015 Jun;115(3):342–8.
16. Huang J, Barbera L, Brouwers M, Browman G, Mackillop WJ.Does delay in starting treatment affect the outcomes of radiotherapy? A systematic review. J Clin Oncol. 2003;21(3):555–63.
17. Major T, Gutiérrez C, Guix B, van Limbergen E, Strnad V, Polgár C. Breast cancer working group of GEC-ESTRO.Recommendations from GEC ESTRO breast cancer working group (II): target denition and target delineation for accelerated or boost par­tial breast irradiation using multicatheter interstitial
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D. N. Sharma and S. Mallick
brachytherapy after breast conserving open cavity surgery. Radiother Oncol. 2016 Jan;118(1):199–204.
18. Buchholz TA, Austin-Seymour MM, Moe RE, Ellis GK, Livingston RB, Pelton JG, Grifn TW. Effect of delay in radiation in the combined modality treat­ment of breast cancer. Int J Radiat Oncol Biol Phys. 1993;6:23–35.
19. Benchalal M, Le Prisé E, de Lafontan B, Berton­Rigaud D, Belkacemi Y, Romestaing P, etal. Inuence of the time between surgery and radiotherapy on local recurrence in patients with lymph node-positive, early-stage, invasive breast carcinoma undergoing breast-conserving surgery: results of the French adju­vant study group. Cancer. 2005;104(2):240–50.
20. Hickey BE, Francis D, Lehman MH. Sequencing of chemotherapy and radiation therapy for early breast cancer. Cochrane Database Syst Rev. 2006;18(4):CD005212.
21. Correa C, Harris EE, Leonardi MC, Smith BD, Taghian AG, Thompson AM, etal. Accelerated partial breast irradiation: executive summary for the update of an ASTRO evidence-based consensus statement. Pract Radiat Oncol. 2017 Mar-Apr;7(2):73–9.
22. Haloua MH, Krekel NM, Winters HA, Rietveld DH, Meijer S, Bloemers FW, et al. A systematic review of oncoplastic breast-conserving surgery: current weaknesses and future prospects. Ann Surg. 2013;257:609–20.
23. Amabile MI, Mazouni C, Guimond C, Sarfati B, Leymarie N, Cloutier AS, etal. Factors predictive of re-excision after Oncoplastic breast-conserving sur­gery. Anticancer Res. 2015 Jul;35(7):4229–34.
24. Niinikoski L, Leidenius MHK, Vaara P, Voynov A, Heikkilä P, Mattson J, Meretoja TJ. Resection margins and local recurrences in breast cancer: comparison between conventional and oncoplastic breast conserving surgery. Eur J Surg Oncol. 2019 Jun;45(6):976–82.
25. Kim Y, Lee ES, Kang YJ, Lee H-B, Han J, Yoo T-K, et al. Oncological safety of oncoplastic breast conserving surgery-compare with conventional breast conserving surgery and total mastectomy. J Clin Oncol. 34(15_suppl) https://doi.org/10.1200/
JCO.2016.34.15_suppl.12531.
26. Chen JY, Huang YJ, Zhang LL, Yang CQ, Wang K. Comparison of Oncoplastic breast-conserving
surgery and breast-conserving surgery alone: a meta­analysis. J Breast Cancer. 2018 Sep;21(3):321–9.
27. Matuschek C, Bölke E, Haussmann J, etal. The ben­et of adjuvant radiotherapy after breast conserving surgery in older patients with low risk breast cancer­a meta-analysis of randomized trials. Radiat Oncol. 2017;12:60.
28. Agrawal A. Oncoplastic breast surgery and radiotherapy- adverse aesthetic outcomes, proposed classication of aesthetic components, and causality attribution. Breast J. 2019 Mar;25(2):207–18.
29. Brownlee Z, Garg R, Listo M, Zavitsanos P, Wazer DE, Huber KE.Late complications of radiation ther­apy for breast cancer: evolution in techniques and risk over time. Gland Surg. 2018 Aug;7(4):371–8.
30. Jhaveri JD, Rush SC, Kostroff K, Derisi D, Farber LA, Maurer VE, Bosworth JL.Clinical outcomes of postmastectomy radiation therapy after immediate breast reconstruction. Int J Radiat Oncol Biol Phys. 2008 Nov 1;72(3):859–65.
31. Cordeiro PG, McCarthy CM. A single surgeon’s 12-year experience with tissue expander/implant breast reconstruction: part I. a prospective analysis of early complications. Plast Reconstr Surg. 2006 Sep 15;118(4):825–31.
32. Hershenhouse KS, Bick K, Shauly O, Kondra K, Ye J, Gould DJ, etal. Systematic review and meta-analysis of immediate versus delayed autologous breast recon­struction in the setting of post-mastectomy adjuvant radiation therapy. J Plast Reconstr Aesthet Surg. 2021 May;74(5):931–44.
33. Roth AM, Kauer-Dorner D, Resch A, Schmid A, Thill M, Niehoff P, etal. Groupe Europeen de Curietherapie­European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) breast working group. Is oncoplastic surgery a contraindication for accelerated partial breast radiation using the interstitial multi­catheter brachytherapy method? Brachytherapy. 2014 Jul-Aug;13(4):394–9.
34. Crown A, Grumley JW.Association of Intraoperative Radiotherapy in the treatment of early-stage breast cancer with minor surgical site complications in Oncoplastic breast-conserving surgery. JAMA Surg. 2017 Dec 1;152(12):1180–2.
Preoperative Preparation forGood
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Oncoplastic Breast Surgery
O.CemYilmaz, SertacAtaGuler, andBahadirM.Gulluoglu
12
In oncoplastic breast surgery (OBS), the factors determining postoperative success are the ade­quate patient and technique selection, precise planning, systematic breast examination, and preoperative marking. Before the patient is taken to the operating room, likely adverse outcome and complications should be estimated and the decision-making process should be done with the patient’s active participation. The mainstay phi­losophy of OBS should be based on “Primum Non Nocere (First do not harm).” The potential of achieving a good-looking breast with OBS should not prevent the patient to receive adequate onco­logical treatment.
O. C. Yilmaz Istanbul Breast Center, Istanbul, Turkiye
SENATURK Senology Academy, Istanbul, Turkiye
S. A. Guler SENATURK Senology Academy, Istanbul, Turkiye
Department of Surgery, Breast & Endocrine Surgery Unit, Kocaeli University School of Medicine, Kocaeli, Turkiye
Medical Visual Documentation Unit, Kocaeli University Hospital, Kocaeli, Turkiye
B. M. Gulluoglu (*) SENATURK Senology Academy, Istanbul, Turkiye
Department of Surgery, Breast Surgery Unit, Marmara University School of Medicine, Istanbul, Turkiye
12.1 Factors forDecision-Making
Suitability for Radiotherapy (RT) to the Breast The presence of absolute contraindica-
tions for partial mastectomy is also an absolute contraindication for OBS. OBS should not be considered in the presence of skin disease or sys­temic diseases involving the skin as well as previ­ous history of receiving mantle RT to the chest-wall which would prevent the patient from receiving RT after surgery [1].
Loco-Regional Extension of the Breast Cancer Tumor location, tumor size, tumor mul-
tifocality, breast size, ptosis, and breast density are among the initial factors to be measured and assessed. These should be done both by clinical examination and imaging such as mammography (MMG), breast ultrasonography (US), and breast magnetic resonance imaging (MRI) where appro­priate. Then, according to these ndings the vol­ume of breast tissue required to be excised for margin-clear tumor removal is estimated. Here the tumor location is also important to under­stand the availability and extent of local tissue needed to close the cavity. So, anticipating the deformity after resection and postoperative desired bra cup size would give idea about which techniques to be used for OBS with what type of incision [2].
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. V. S. Deo (ed.), Breast Oncoplasty and Reconstruction,
https://doi.org/10.1007/978-981-99-5536-7_12
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Features of the Bilateral Breasts A thorough breast and regional examination and related mea­surements are essential for good cosmetic out­come after OBS.Breast cup size, breast density, supraclavicular notch to nipple distance, nipple to inframammary distance, breast base width and height, level of ptosis, skin quality, and breast asymmetry are assessed for selecting proper and suitable repair technique. Incisions for OBS should be customized according to the breast size, skin quality, level of ptosis and if there is any, location and extent of previous biopsy inci­sions apart from tumor location. Need for sym­metrization of contralateral breast should be considered and elaborated with the patient [3, 4].
Associated Diseases/Conditions In the presence of uncontrolled diabetes, chronic renal failure, and malnutrition that may prevent wound heal­ing, OBS may result with complicated wounds (i.e. delay in healing, surgical site infection) instead of providing benet to the patient. Therefore, detailed questioning of the patient for any systemic illness is advised. Malnutrition should be assessed before surgery. Ameliorating or controlling systemic diseases and restituting malnutrition have utmost importance to prevent those adverse outcomes if necessary, the patient can be nourished with nutritional supplements such as maltodextrin for carbohydrate loading and arginine which may facilitate wound healing and increase lean body mass. This supplementa­tion may be continued after the surgery as well when necessary [1, 5, 6].
patient’s adherence to the postoperative instruc­tions [1, 7].
History of Previous Breast Surgery and Scars If
the patient underwent a previous breast surgery, it is important to plan the incision and the type of the oncoplastic technique according to the previ­ous breast surgery and its remaining scar. In patients who underwent reduction mammoplasty prior to surgery, performing the new procedure through the previous incision would reduce com­plications and provide advantages in aesthetic planning. However, it is necessary to pay atten­tion to the blood supply of the nipple in these cases and the surgeon should be careful for the nipple loss risk [2].
History of Hypertrophic Scar Formation after any Previous Surgery The patient should be
informed about the possibility of hypertrophic scar and keloid development after OBS.In par­ticular, it is important to avoid incisions length­ening to the midline or near to the presternal region [3, 8].
History of Neoadjuvant Chemotherapy (NAC) In patients receiving NAC, preoperative
hemoglobin level and the patient’s weight loss before and after the medical treatment should be evaluated. Low hemoglobin levels may lead to tissue perfusion problems and tissue loss. Proper blood replacement should be considered when necessary. Also adequate prophylaxis for surgical site infection should be done [1, 9].
Smoking and Alcohol Intake Although it was reported that the complications decrease when the tobacco products were stopped 15–30 days before the operation, the risk of necrosis of nip­ple and skin is still very high especially in cases with long-term tobacco addiction. The patient should be informed about the unfavorable conse­quences, especially when techniques are used to release the nipple such as during free nipple transfers. In patients with alcohol and drug­addiction, it is necessary to assess whether the patient’s current mental state would compromise
12.2 Examination oftheBreasts
The rst point that should be remembered for OBS is that the oncological safety comes before cosmetic concerns. In OBS, the primary goal is to remove the tumor site with clear margins.
In order to evaluate the tumor site, the surgeon who will perform OBS should also have sufcient knowledge and experience in breast imaging such as MMG and breast US. Evaluation with MMG is the gold standard for planning the exci-
12 Preoperative Preparation forGood Oncoplastic Breast Surgery
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sion of microcalcication areas that cannot be assessed by breast US.In the presence of micro­calcications, preoperative evaluation and mark­ings should be performed together with an experienced radiologist. Preferably the surgeon should accompany the wire localization proce­dure performed by the radiologist.
In palpable lesions, both preoperative and intraoperative breast US increase the surgical success and reduce the re-excision rate [10, 11]. It is important to measure the size of the tumor at its correct localization. Preferably, this is done by a standard US device (with a linear probe using 9–12mHz frequency). For this exam, the patient lays on the examination table mimicking the position that she is given on the operation table at the theater. Patient’s ipsilateral arm is positioned at 90° abduction. By using breast US, the overall lobar anatomy of the breast is assessed. If the patient has received NAC, the presence and loca­tion of the tumor and/or previously located clips are assessed. The marking of the target area/ lesion is made on the breast skin perpendicular to the target area with a permanent marker pen. During this marking, the distance between the tumor and the skin is measured to decide whether
to excise the skin overlying the tumor or not. This step is done regardless of the planned excision technique. Then the standing position is given to the patient with both hands on the waists. From front, surgeon examines the breast and skin. Initial assessment is done to evaluate the symme­try of both breasts.
Then, in order to estimate the excess skin amount after resection, skin elasticity and pres­ence of excess skin are evaluated by the surgeon. This is done by gentle pinching of the breast skin between the surgeon’s dominant hand’s thumb and forenger. This assessment is done at medial, superior, and lateral parts of the breast (Figs.12.1 a, b, c). Pinch test also provides the width of the breast base for implant reconstructions.
Also, both breast US and manual physical examination are used to assess the density of the breast tissue. Then, by using tape measure, the distance between jugular notch and nipple/areola complex is measured at both breasts. This dis­tance is basically around 21 cm in an adult woman who gave birth and breastfed (Fig.12.2) [12].
While the patient is at standing position, the degree of ptosis is also measured and recorded.
a
c
Fig. 12.1 (a, b, c) Skin pinch testing at medial (a), superior (b), and lateral (c) aspects of the breast. (From the archives of Dr. S.Ata Guler)
b
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Fig. 12.2 Measuring the distance between jugular notch and nipple/areola complex. (From the archives of Dr. S.Ata Guler)
This is done by assessing the positional relation­ship of the nipple to the ipsilateral upper arm. Recording of measurements before OBS is essen­tial for both medical and legal requirements.
12.3 Shared Decision-Making
Every breast cancer patient may have different expectations from their treatments. Therefore, all the details about her cancer have to be discussed openly. This communication should include information about the disease stage, expected treatments such as surgery, RT and systemic treatments, expected benets from these individ­ually or in combination, availability of those
O. C. Yilmaz et al.
treatments, comparison of different treatment modalities, options among surgical treatments, and expected results from each of them [1]. When communicating with the patient, the efcacy (including redo surgery and local recurrence rates, disease specic, and overall survival), safety (adverse outcomes/complications), cost and quality-of-life issues (aesthetic outcome, patient satisfaction, etc.) should be discussed in detail for each type of treatment and technique. The surgeon bias should be eliminated as much as possible.
12.4 Preoperative Visual
Documentation
Medical photographic imaging of the breasts before OBS is another procedure which helps the surgeons to achieve better outcome after surgery. It is crucial for the post-surgical cosmetic result assessment during follow-up and auditing [13,
14]. It is recommended to take series of photo-
graphs of each breast which are taken from 3 views (anterior, 45° oblique and lateral) with hands-on-hips and hands-on-head positions sepa­rately, framing both breasts from sternal notch to the umbilical hole in each pose. With this, a nal set of 10-photograph series is composed for archiving (Fig.12.3). This set of photographs is used to compare to those similarly taken after surgery with regular intervals [15].
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Fig. 12.3 Preoperative standardized 10-image series of both breasts for outcome assessment. (From the archives of Dr. S.Ata Guler)
12.5 Marking
For facilitating the surgery and achieving an opti­mum result from the OBS, a detailed marking on the breast has to be done before the surgery pref­erably before coming to the theater. It is done according to the technique selected for the patient when the patient is at standing position. First, the tumor or, if multiple, tumors are marked on the breast skin reecting their actual diameters and
shape. Then, midline, inframammary, and lateral breast folds as well as bilaterally the breast meridians are marked. Planned new areola posi­tion, incisions, skin, and glandular resection areas with or without deepithelization and aps are marked clearly. Here, different colored mark­ers may be helpful to discriminate the areas to be resected and preserved areas between each other over the surgical eld.
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12.6 Conclusion
To achieve optimum outcome by means of onco­logical and aesthetic results after OBS, the sur­geon should consider all the factors related to the disease itself and the patient. Detailed history about the patient’s past, a thorough breast exami­nation, and a meticulous review of the breast imaging are the key factors for better outcome in patients. Detailed history should include patient’s general condition and associated diseases. Also, the surgeon should involve the patient into decision- making process which it is crucial to achieve the patient satisfaction after hearing her expectations from the treatment. Thorough breast examination should be done both for orientation for actual cancer topography in the breast and for assessing the physical features of both breasts. Joint evaluation of patient’s breast imaging with a radiologist would help surgeons to understand the extent of the disease more precisely. Herewith, multidisciplinary decision-making facilitates the selection of the most appropriate technique. Nevertheless, estimating the unfavorable out­come is the primary skill of a “good” oncoplastic surgeon. Therefore, meticulous diagnostic and glandular work-up, correcting underlying associated conditions, choosing the feasible sim­plest OBS technique meeting patient’s expecta­tions, and good planning/marking are among the most necessary steps for good oncoplastic breast surgery.
References
1. Gilmour A, Cutress R, Gandhi A et al. Oncoplastic breast surgery: a guide to good practice, EJSO, https://
doi.org/10.1016/j.ejso.2021.05.006.
2. Bulstrode NW, Shrotria S. Prediction of cosmetic outcome following conservative breast surgery using breast volume measurements. Breast. 2001;10:124–6.
3. Habibi M, Broderick KP, Sebai ME, Jacobs LK. Oncoplastic breast reconstruction: should all patients be considered? Surg Oncol Clin N Am. 2018;27:167–80.
4. Manseld L, Agrawal A, Cutress RI. Oncoplastic breast conserving surgery. Gland Surg. 2013;2:158–62.
5. Bilku DK, Dennison AR, Hall TC, Metcalfe MS, Garcea G. Role of preoperative carbohydrate load­ing: a systematic review. Ann R Coll Surg Engl. 2014;96:15e22.
6. Engelen MPKJ, Klimberg VS, Allasia A, Deutz NEP. Major surgery diminishes systemic arginine availability and suppresses nitric oxide response to feeding in patients with early stage breast cancer. Clin Nutr. 2018;37:1645–53.
7. Ilonzo N, Tsang A, Tsantes S, Estabrook A, Thu Ma AM. Breast reconstruction after mastectomy: a ten­year analysis of trends and immediate postoperative outcomes. Breast. 2017;32:7–12.
8. Kronowitz SJ, Kuerer HM, Buchholz TA, et al. A management algorithm and practical oncoplastic surgical techniques for repairing partial mastectomy defects. Plast Reconstr Surg. 2008;122:1631–47.
9. Gulluoglu BM, Guler SA, Ugurlu MU, Culha G. Efcacy of prophylactic antibiotic administra­tion for breast cancer surgery in overweight or obese patients: a randomized controlled trial. Ann Surg. 2013;257:34–43.
10. Karadeniz-Cakmak G, Emre AU, Tascilar O, Bahadir B, Ozkan S.Surgeon performed continuous intraop­erative ultrasound guidance decreases re- excisions and mastectomy rates in breast cancer. Breast. 2017;33:23–8.
11. Tasdoven I, Karadeniz Cakmak G, Emre AU, Engin H, Bahadir B, Bakkal HB, Gulluoglu MB.Intraoperative ultrasonography-guided surgery: an effective modal­ity for breast conversation after neo-adjuvant chemo­therapy. Breast J. 2020;26:1680–7.
12. Piper M, Peled AW, Sbitany H.Oncoplastic breast sur­gery: current strategies. Gland Surg. 2015;4:154–63.
13. Cardoso MJ, Cardoso JS, Vrieling C, et al. Recommendations for the aesthetic evaluation of breast cancer conservative treatment. Breast Cancer Res Treat. 2012;135:629–37.
14. Eadie C, Herd A, Stallard S. An investigation into digital imaging in assessing cosmetic outcome after breast surgery. J Audiov Media Med. 2000;23:12–6.
15. Guler SA, Demir O.The art of medical photography in breast surgery: clinical, intra-operative and speci­men photography, standards and recommendations. Chirurgia. 2021;116(Suppl):35–44.
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