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22 Lipomodelling inBreast Surgery
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Extreme Oncoplasty inBreast
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Reconstruction
ChaitanyanandKoppiker, SnehaJoshi,
andSanketNagarkar
23
List of Abbreviations
ALN Axillary Lymph Node
BC Breast Cancer
BCS Breast Conservation Surgery
BCT Breast Conservation Therapy
CBE Clinical Breast Examination
DCIS Ductal Carcinoma in situ
EO Extreme Oncoplasty
IDC Invasive Ductal Cancer
LABC Locally advanced Breast Cancer
LOBC Locally operable Breast Cancer
LICAP Lateral Intercostal Artery Perforator
LVE Lymphovascular Embolization
MC Multicentric
MF Multifocal
MICAP Medial intercostal artery perforator
NACT Neo-adjuvant Chemotherapy
OBS Oncoplastic Breast Surgery
PROMS Patient Reported Outcome Measures
PASH Pseudo-angiomatous stromal
hyperplasia
QoL Quality of Life
RT Radiation Therapy
WLE Wide Local Excision
C. Koppiker (*)
Orchids Breast Health Centre, Prashanti Cancer Care
Mission, Pune, Maharashtra, India
S. Joshi · S. Nagarkar
Prashanti Cancer Care mission and CTCR,
Pune, Maharashtra, India
23.1 Extreme Oncoplasty
In the recent past, absolute and relative contraindications for conventional BCT have been well
reported. Several studies have now emerged
wherein these have been systematically challenged. Several authors have reported acceptable
oncological results with equivalent survival combined with much improved cosmetic results and
QoL with OBS [1, 2]. This has nally culminated
into the concept of extreme oncoplasty (EO)
where large, multicentric and multifocal tumours
as well as extensive DCIS have been effectively
treated with BCS.
Prof. Melvin Silverstein rst introduced the
concept of extended resections using oncoplastic
surgery and introduced the term Extreme
Oncoplasty. He had initially referred to it as radical conservation, however, the word radical was
an antithesis to the concept. He denes extreme
oncoplasty as “breast conservation for patients
whose tumors exceed the standards for breast
conservation, and who in most physicians’ opinions, need a mastectomy” [3, 4]. Extreme onco-
plasty patients are generally those with large
tumours, greater than 5cm, multifocal or multicentric tumours which are locally advanced with
nodal metastasis, recurrences in previously irradiated breasts. The EO technique allows resection of larger amount of breast tissue with safer
margins, and acceptable aesthetic results thereby
increasing breast conservation rates [5–7].
© 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_23
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Later in this chapter, we discuss seven extreme
oncoplasty cases from our clinic, out of which 6
are malignant scenarios, while one is a benign
breast condition.
23.2 Why Extreme Oncoplasty?
Mastectomy has been associated with several
severe sequelae such as body asymmetry, postural instability, depression, loss of self-esteem
and poor QoL [8, 9] Several reports have indicated that BCS has comparable local recurrence
rates and oncological outcomes with mastectomy
even in larger tumours and MF/MC disease as
discussed in the earlier sections [10]. Thus, it is
conceivable that EO, which provides all advantages of BCT as well as better aesthetic outcomes
will offer multiple advantages over mastectomy.
For patients with large tumour and MC/MF
disease, the surgical choice of EO looks very
promising. Compared to mastectomy with immediate reconstruction and RT, Oncoplastic reconstruction generally yields superior cosmetic
results. With low rates of post-operative morbidity followed by satisfactory RT techniques, EO is
becoming popular amongst the breast oncoplasty
community [11, 12]. EO-based oncoplastic surgery has the potential to extend the scope of BCS
to include contra-indicated scenarios such as
MC/MF tumours, large tumours and post-NACT
residual DCIS [13].
Therefore, to summarize, EO yields better
QoL, better survival and overall aesthetic outcomes as compared to the treatment regimen of
mastectomy followed by breast reconstruction
and RT. Furthermore, since some patients may
insist on BCT over mastectomy, such options
need to be considered. EO is a single operation
resulting in less pain and less morbidity, with the
organ being more sensate and functional.
Cosmetic results are always better, sometimes
even improved as compared to the earlier form,
leading to a better body image. This also results
in good satisfaction scores, to the extent that
some patients forget that they ever had BC.
EO Indications Very few reports describe the
application of the EO technique in BC management. Given that the indications for EOs are different, various approaches have been devised to
assist with the decision process [3, 5].
Based on the current understanding, EO can
be particularly applicable to patients with following characteristics [4].
(a) Large size (> 5 cms) or large tumour-to-
breast ratio.
(b) LOBC/LABCs post-NACT with limited/par-
tial response or large areas of residual
calcication.
(c) Extensive intraductal component (> 5cm).
(d) Extensive DCIS.
(e) Large areas with multifocal disease.
(f) Limited multicentric disease up to ve foci.
(g) Patients presenting with large and inappro-
priate scars post-excision biopsy.
(h) Patients with any of the above or more insist-
ing on BCT.
(i) Recurrent disease after previous BCS+RT.
Long-term data on recurrence and survival
associated with EO is as yet lacking. It is expected
that the local recurrence will be somewhat higher
but that there will be little or no impact on survival. Given the multi-modal needs for managing
BCs with EO, only focus on surgical skills is
insufcient. Good EO outcomes require practitioner’s ability and technical skill but also other
attributes such as dedication, multidisciplinary
decision-making skills and the repetitive performance of specic tasks [14].
23.3 Global Scenario
The rst experience with EO was documented by
Prof. Silverstein in his study including 66 patients
who were advised mastectomy by other physicians, but instead opted for BCT using various
OBS techniques. These were compared to a
cohort of 245 patients who were termed as stan-
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dard and received therapeutic mammoplasty.
Though they observed signicantly higher mean
weight and span in extreme cases, the margin
negativity was acceptable at 83% and the local
recurrence rate even at 24months was comparable at 2.5% (vs. 1.5% standard) . This study ushered in a promising new surgical avenue for
managing patients with advanced disease while
providing a possibility of better aesthetics and
QoL [4]. Following this introduction of EO by
Silverstein, various groups have elaborated and
developed different aspects of the surgery and
documented surgical outcomes.
In 2019, we reported our own experiences
with a cohort of 40 Indian BC patients who
underwent EO.We reported safety of the procedure along with good satisfaction scores through
the BREAST Q tool [15]. We detail this study in
the Relevance of EO in India section of the
chapter.
In 2019, Crown etal. published a study with 111
EO patients; stating recurrence rates, cosmetic
scores and post-surgery complications. They
reported a low 1.1% recurrence rate and 95% good
to excellent cosmetic scores, albeit high re-excision
rates and 16% post-surgery complications [16].
Furthermore, Nebril and colleagues collected data
of ~1000 patients (2003–2017) and selected 204
patients meeting inclusion criteria for comparison
between EO (n = 33) and non-EO procedures
(remaining). The review reported signicantly
greater satisfaction and QoL in EO cohort while
observing similar local recurrence rates in each
arm at 66 months, thus showing possible safe
application of EO surgery [17]. The most recent
EO investigation by Savioli etal. of 50 EO patients
showed margin positivity of 18% who underwent
re-excision with 12% proceeding towards mastectomy. Their complication rates were acceptable
and showed 5year survival of 97.5% [18].
23.4 EO Considerations
While performing EO, it has been recommended
that the modern oncoplastic surgeon should
always follow some specic and important steps
as described by Gianluca and colleagues [14].
(a) careful local staging of the disease with
ultrasonography, mammography and magnetic resonance before surgery;
(b) adequate radiological pre-operative study
with localization of tumour and/or
calcications;
(c) multidisciplinary discussion, in a dedicated
“surgery board”, to choose an oncoplastic
technique tailored to patient;
(d) intraoperative ultrasound to guide the
resection;
(e) intraoperative radiological and pathological
evaluation of the specimen for denition of
lesion and margins of resection;
(f) frozen sections should be obtained from a
portion of all six faces of the resected
specimen;
(g) systematic circumferential tumour cavity
shaving to have a backup to lumpectomy
margins;
(h) placement of clips within the excision cavity
as a “landmark” to dene the tumour bed and
guide adjuvant breast radiotherapy;
(i) accurate pathological assessment of the
specimen using macro-sections.
This multidisciplinary path facilitates keeping
the amount of healthy breast tissue excised as low
as possible while also achieving tumour-free
margins.
Relevance of EO in India The BC scenario in
India is different given the variations in epidemiology, clinico-pathology as well as clinical management strategies. According to
WHO-GLOBOCAN data, BC is the most common cancer in India [19]. In 2020, 178,361 new
breast cancer cases (13.5% of all cancer cases)
and 90, 408 deaths (10.6% of all cancer-related
deaths) were reported in India [19]. Even though
women from all socio-economic strata are
affected, young (mid-forties), premenopausal
urban women appear to be at high risk. India
reports highest BC incidence-to-mortality ratio in
the world which is often attributed to late stage
(Stage II/III) diagnosis. Reports indicate high
prevalence of triple negative BCs in Indian BC
patients. Negligence in Indian women, resulting
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C. Koppiker et al.
in lack of awareness regarding disease symptoms, screening modalities, self-breast examination and/or routine mammographic screening
which ultimately results in costly delay in diagnosis and treatment [20].
Several reports indicate that majority of BCs
in India are diagnosed at an advanced stage (III or
IV) with large size (LABCs or LOBCs) [21]. Due
to advanced stage detection, MC/MF tumours are
commonly observed, contributing to highest
global BC incidence-to-mortality ratio. As a
result, total mastectomy is standard of care, rate
of BCS is low and NACT- guided clinical management protocols are most common. For breast
surgery, Mastectomy remains the most common
option in many Tiers II and III cities. BCT or
OBS options are offered only by few reputed tertiary cancer care centres in Tier I cities. A vast
majority of Indian population has no or limited
access to medical insurance. Furthermore, there
is a serious lack of awareness about OBS in the
medical fraternity as well as the society at large.
The cancer patient advocacy groups have not
been adequately sensitized to the issues pertinent
to patient rights and poor uptake of OBS in India
[22, 23].
With this background, the need for standard
OBS procedures based on EO for Indian BC
patients is even more pertinent. In our single
institutional study cohort of 40 Indian BC patients
who underwent EO, we have demonstrated the
safety and feasibility in MC/MF and large
tumours, both in de novo as well as post-NACT
scenarios. We observed no major post-operative
complications and a low rate of minor complications (7.7%). The PROMs in these patients indicate better acceptance of the EO procedure with
improvement in QoL.We also demonstrated the
feasibility of optimal RT technique - Simultaneous
Integrated Boost (SIB) to ensure satisfactory
oncological outcomes [15].
Based on our experiences, we propose that the
EO surgery has excellent applications for OBSbased clinical management in selective Indian
context to avoid unnecessary mastectomies and
offer BCT options without compromising oncological safety and improving aesthetic outcomes.
23.5 Clinical Management inEO
Surgery Our EO surgery technique encom-
passes excision of large volume of the breast dictated by the extent of tumour. Therapeutic
reduction mammoplasty (TRM) is performed
either by a wise pattern and/or vertical scar skin
pattern facilitates this. In some cases, the central
wedge excision with immediate nipple reconstruction (wise pattern) while in a few patients
nipple areolar grafting is performed [15]. After
tumour marking, localization and marking of the
perforator aps is performed by a handheld doppler pre-operative area. The decision for ap
selection depends on tumour site and donor area
availability of skin and subcutaneous tissue. After
the marking of tumour, the perforator is identied
with handheld Doppler in the same position as
that planned for surgery. The standard supine
position is maintained for LICAP, AICAP,
MICAP and LTAP aps.
EO and RT Conventionally, a RT plan encompasses a total dose of 45–50Gy in 25 daily fractions over 5 weeks followed by a boost of
10–16 Gy in 5–8 fractions. Nowadays, hypofractionated RT (dose >2Gy per fraction) delivered in fewer fractions over a shorter treatment
period is an alternative option (Bentzen et al.
2008). Additionally, in selective patients, particularly those <40years, a tumour bed boost delivered by an electron beam of specic energy after
whole breast irradiation (WBI) has been shown
to improve local control (Bartelink etal. 2007).
Limitations of EO Majority of the reports
assessing EO are small cohort studies and may
have patients’ selection bias with a trend favouring BCT for MC/MF.Additionally, these studies
may have included patients with better prognostic indicators [18]. In India, one of the major
limitations to EO is the acceptance of the procedure amongst women. Mastectomy is the
accepted gold standard across the country and it
may be difcult for most centres to practice EO
in India. Large scale studies such as the MIAMI
study with long-term follow-up are essential to
assess the safety of EO surgery [24]. Future stud-
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ies must be carried out with multicentric, prospective, randomized approach with an emphasis
on inclusion of PROMs. Such an approach will
evaluate oncological outcomes as well as cosmetic scores and will assist in informed decisionmaking. Such long-term studies for EO are
necessary given the potential of EO as the most
suitable surgical choice for the management of
advanced BCs. Furthermore, due variability in
the study design, differences in classication and
denitions between multifocal versus multicentric cancers and dissimilarities in reporting outcome measures has prevented EO from becoming
standard of care.
Summary and Conclusions
EO is increas-
ingly becoming a commonly used OBS technique for special situations that involve BC
patients with large, MC/MF tumours and postNACT residual large DCIS. Careful surgical
decision-making algorithms followed by multidisciplinary clinical management of
EO-operated cases will be key to ensuring optimal post-surgery outcomes and aesthetic results.
This technique may prove to be particularly
applicable in developing countries such as India
in which advance staged BC with MC/MF
tumours are common. To provide the benets of
this OBS technique to many more BC patients,
it will be important to train the next generation
of oncoplastic breast surgeons. Going forward,
optimally designed randomized clinical studies
to conclusively prove the safety and efcacy of
EO surgery are needed.
23.6 Case Discussion
23.6.1 Case 1: EO forCase ofMC/MF
Tumours
ai
di
(a) Pre-op marking (bi) and (bii) Mammogram showing
the lesions (marked in yellow) (c) Excision planning for
Therapeutic Mammoplasty (di) and (dii) Intraoperative-
aii
dii e f
A 38-year-old female patient was diagnosed with
multiple left breast lumps during CBE. On
Radiology, MF lumps along with multiple satel-
b c
Skin with NAC removed (Excision volume:
19 cm × 15 cm × 4 cm, 1348 cc) (e
(4months) (f) Post-operative (2years)
lite nodules were noted in the lower quadrant as
well as retroaeriolar region with skin thickening
over the central quadrant. Biopsy from both the
) Post- operative
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C. Koppiker et al.
lesions (6 o’clock and inframammary fold)
revealed multifocal IDC Grade II, ER-80%,
PR-60% Positive, HER2 Negative status. NACT
was administered as fourcycles of FEC 3-weekly.
Post-NACT mammogram shows reduction in
skin thickening at NAC with retroaeriolar prominence and two tumours in lower quadrant measuring 1.1×0.8cm and 1.7×1.7cm, respectively.
Patient underwent central quadrant excision
along with complete lower quadrant within the
wise pattern (EO) along with and right symmetri-
a
d
bi bii c
e
sation reduction mammoplasty. HPE revealed
multicentric IDC Grade II with foci of comedo
type DCIS, the largest tumour size as
2.5×1.5×1cm with closest margin 0.5cm from
base. ALN status: 8/13, LVE Positive, clinical
staging pT2N2M0. Patient received adjuvant
chemotherapy (ninecycles of weekly Paclitaxel)
followed by RT.
23.6.2 Case 2: EO forExtensive DCIS
f
gh i
(a) Pre-operative Markings (bi) and (bii) Mammogram
showing the lesion (c) Biopsy of calcication with clip
insertion (d) Excision planning for Left Therapeutic
Mammoplasty axillary clearance and right breast symme-
A 40-years-old female reported with a complaint
of lump in left breast since 3weeks. On radiological examination, tumour was identied in
UOQ measuring approximately 2 cm × 1.3 cm
with extensive calcications involving most of
the UOQ extending to 8–9 cms. Stereotactic
trisation mammoplasty. (e
volume: 14× 10.5×4.7 cm; 657 cc) (h) Post-operative
(after 3months) (i) Post-operative
- g) Intraoperative (Excision
Biopsy indicated DCIS comedocarcinoma of
grade III with ER-90%, PR- 0%, HER2 + ve,
positive status. Patient underwent wide excision
after wire placement with left therapeutic mammoplasty (EO) along with right breast reduction
mammoplasty with symmetrisation. Post-surgical
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histopathology report indicated extensive IDC
Grade II with extensive DCIS (grade II) seen
over 9cm, Ki67 (20%), tumour size (the largest
tumour size 2.5×2×2cm with maximum invasive component of 0.3cm), closest anterior margin 1.5cm from invasive tumour and DCIS is 0.5.
Clinical staging pT1aNsnM0. Patient received
a
d
b c
e
Herceptin and hormonal therapy followed by
RT.The patient is alive and well at 5years.
23.6.3 Case 3: EO forClinically Large
Residual Tumour After NACT
f
(a) Pre-op with Large Fungating Tumour (b) 4cycles of
NACT (c) Post-completion of NACT + Pre-Operative
Markings (d) Planning of excision along with the extended
medial pedicle carrying skin for reconstruction of defect.
A 68-year-old female presented with a large fungating tumour mass with ulceration. USG showed
metastatic right axillary lymph node. Biopsy
revealed IDC Grade III.ER/PR/HER2 –Negative,
Ki 67(60%). CT Thorax indicated large illdened heterogeneous mass lesion in Right
Breast measuring 7.6×7.3×8.1cm with nipple
(e) Right therapeutic mammoplasty, WLE with extended
medial pedicle for skin cover, axillary clearance and left
breast symmetrisation (Excision volume 5×5×1.5 cm,
4.5×2cm; 37.5cc and 9cc) (f) 4-year follow-up
retraction. NACT (AC 4 cycles followed by
Paclitaxel 12 weekly) was administered. Right
Therapeutic Mammoplasty (EO)+Right Axillary
Clearance + Left Reduction Mammoplasty was
performed. HPR indicated no residual tumour, all
margins were unremarkable. ALN status: 00/16,
RT was administered.
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23.6.4 Case 4: EO forPost-NACT
Large Residual Calcication
C. Koppiker et al.
a
d
bi bii c
e
g h
(a) Pre-operative markings (bi) and (bii) Pre- operative
mammogram (c) Excision planning for Therapeutic
Mammoplasty (d) Specimen mammogram with wire
marking (e) Intraoperative (Excision volume
fi fIi
12.5×11.5×4cm and wire localized lesion- 8×7×3cm;
575cc and 168cc) (e) Intra-operative excision (f) Postoperative mammogram (g
(h) Post-operative (4years)
) Post- operative (immediate)
A 45-year-old female patient presented with a
left breast lump which on mammography was
seen in UIQ measuring 4.5×1.8×2.4cm with
mild nipple retraction. Additionally, grouped heterogenous microcalcication was noted anteromedial to the primary lesion measuring 3.3cm.
Trucut Biopsy report showed IDC Grade II,
ER-40%, PR-60%, HER2 report Positive (3+)
and FNAC Node negative. Patient received only
four cycles of NACT due to side effects. PostNACT residual lesion measured
3.14×2.26×1.23cm with calcications distant
from the lesions. Patient underwent Left
Therapeutic mammoplasty with SNB (Extreme
Oncoplasty) and Right Reduction Mammoplasty.
HPE report showed IDC Grade II with scattered
areas of DCIS, Dimensions of largest focus of
invasion was 2.2×1×1cm. SLN status negative,
margins were free from tumour (0.5cm closest
margin), clinical staging pT2N0M0. Post-surgery
treatment regimen included Herceptin and
Hormonal therapy followed by RT.The patient is
doing well after 4.5years.
ef
bc
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23.6.5 Case 5: EO forLOBC Case
withPerforator Flaps
a
d
g h i
175
(a) Pre-operative (b) Mammography; arrows depict pleomorphic microcalcication in UOQ (c) pre-op marking
for planning LICAP ap (d) Pictorial representation of
A 42-year female patient presented with a large
lump in UOQ right breast tumour with extensive
calcication over 5cms. The extent of the mass
was clearly seen on the USG.Biopsy indicated
IDC Grade II, ER -90%. PR-90%. HER
2-Negative. Ki67 (14%). OBS-EO was per-
surgical plan (e) Intraoperative Specimen Mammogram
(Excision volume: 9 × 6 × 4 cm; 216 cc) (f-h) Postoperative immediate (i) Post-operative (3years)
formed with BCS with LICAP ap and Sentinel
node biopsy. Post- surgery HPE revealed IDC
Grade II with foci of DCIS in surrounding tumour
(largest tumour size was 5.5×3.5×3cm) with
LVE.SLN status: 0/2, clinical staging pT3N0.
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