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breast cancer and sentinel node metastasis. JAMA. 2017 Sep 12;318(10):918–26.

17. Donker M, van Tienhoven G, Straver ME, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 2014 Nov;15(12):1303–10.

18. Engel-Nitz NM, Becker L, Gerdes R, Hao Y. Cost of recurrence among patients with HR+/HER2metastatic breast cancer. J Clin Oncol. 2015 May 20;33(15_suppl):e11504–4.

19. About Us-WORLD CANCER CARE CHARITABLE SOCIETY [Internet]. [cited 2021 Jun 7]. Available from: https://www.worldcancercare.co.in/index- info-

gov- n- sch.html

20. He X-M, Zou D-H. The Association of Young age with local recurrence in women with early-stage breast cancer after breast-conserving therapy: a metaanalysis. Sci Rep. 2017 Sep 11;7(1):11058.

21. Morrow M. Rethinking the local therapy of breast cancer: integration of biology and anatomy. Ann Surg Oncol. 2015 Oct;22(10):3168–73.

22. Wapnir IL, Price KN, Anderson SJ, et al. Efcacy of chemotherapy for ER-negative and ER-positive isolated Locoregional recurrence of breast cancer: nal analysis of the CALOR trial. J Clin Oncol. 2018;36:1073–9.

23. Moran MS, Schnitt SJ, Giuliano AE, et al. SSOASTRO consensus guideline on margins for breastconserving surgery with whole breast irradiation in stage I and II invasive breast cancer. J Clin Oncol. 2014 May 10;32(14):1507–15.

24. Morrow M. Trends in reoperation after initial lumpectomy for breast cancer. JAMA Oncol. 2017 Oct;3(10):1352–7.

25. Wapnir IL, Khan A. Current strategies for the Management of Locoregional Breast Cancer Recurrence. Oncology. 2019 Jan 17;33(1):19–25.

26. Chen J-Y, Huang Y-J, Zhang L-L, etal. Comparison of Oncoplastic breast-conserving surgery and breastconserving surgery alone: a meta-analysis. J Breast Cancer. 2018 Sep;21(3):321–9.

27. Smith TE, Lee D, Turner BC, etal. True recurrence vs. new primary ipsilateral breast tumor relapse: an analysis of clinical and pathologic differences and their implications in natural history, prognoses, and therapeutic management. Int J Radiat Oncol Biol Phys. 2000;48:1281–9.

28. Guidelines Detail [Internet]. NCCN. [cited 2021 Jun 7]. Available from: https://www.nccn.org/guidelines/

guidelines- detail

29. Kurtz JM, Jacquemier J, Amalric R, etal. Is breast conservation after local recurrence feasible? Eur J Cancer. 1991;27:24–244.

30. Hannoun-Levi J-M, Ihrai T, Courdi A. Local treatment options for ipsilateral breast tumour recurrence. Cancer Treat Rev. 2013 Nov 1;39(7):737–41.

31. Burger AEE, Pain SJ, Peley G.Treatment of recurrent breast cancer following breast conserving surgery. Breast J. 2013;19(3):310–8.

32. Chen SL, Martinez SR. The survival impact of the choice of surgical procedure after ipsilateral breast cancer recurrence. Am J Surg. 2008 Oct 1;196(4):495–9.

33. Chadha M, Trobetta M, Boolbol S, Osborne MR.Managing a small recurrence in the previously irradiated breast. Oncology. 2009 Oct;23(11):933–40.

34. Nelson JJ, Disa JA. Breast reconstruction and radiation therapy: an update. Plast Reconstr Surg. 2017 Nov;140(5S Advances in Breast Reconstruction):60S–8S.

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37. Ha JH, Hong KY, Lee H-B, etal. Oncologic outcomes after immediate breast reconstruction following mastectomy: comparison of implant and ap using propensity score matching. BMC Cancer. 2020 Jan 30;20(1):78.

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Follow-Up andCosmetic Outcomes

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inBreast Oncoplasty

S.V.S.Deo, AshutoshMishra, ChitreshKumar, andArunGoyal

35.1 Introduction

Oncoplastic breast surgery (OBCS) has developed as an extension of breast-conserving surgery (BCS) to improve aesthetic and functional results without compromising oncological outcomes, factors that may be crucial to patient satisfaction and quality of life. However, fair to poor cosmetic outcomes following OBCS are still observed in up to 40% of patients [1].

An oncoplastic breast surgeon has a dual responsibility of maintaining the natural contour of the breast and removing the tumour with full oncological safety at the same time. At times maintaining the balance between the two is very difcult and leads to poor cosmesis or compromised oncological outcome.

35.2 Goals ofFollow-Up

The follow-up protocols for oncological outcome are similar to non-oncoplastic procedures and largely depend upon the stage of the tumour. But the evaluation of cosmesis is by enlarge a subjective method and a very challenging task. Patient’s satisfaction largely depends upon the patient’s educational status, age, race, surgical techniques, and adjuvant radiation techniques.

S. V. S. Deo (*) · A. Mishra Department of Surgical Oncology, DR BRA-IRCH, AIIMS, New Delhi, India

C. Kumar Department of Surgical Oncology, AIIMS, Bilaspur, India

A. Goyal Department of Surgical Oncology, Max Superspeciality Hospital, New Delhi, India

https://doi.org/10.1007/978-981-99-5536-7_35

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GoalsofFollow-up &

Survillence

S. V. S. Deo et al.

Diseaserelated

Earlydetection of

Recurrence

IBTR Chestwall

Screeningfor new

primaryinIpsilateral

or Contralateral

Breast

Regional Lymph

Nodes

1. Detection of Recurrence

Oncological safety is the rst and foremost goal of follow-up. Therefore early detection of local recurrence in the breast itself, on the chest wall, or in regional lymph nodes, should be the rst aim of treating physician. Breast cancer recurrence following conservative surgery and radiotherapy usually occurs during the rst 5years after treatment, with a peak incidence after 2 years [11–13]. The rate of local recurrence is 2% per year [13]. In a follow- up visit of breast oncoplasty patients, all protocols should be followed as they are being followed for any breast cancer patients. But obviously we can choose modalities as per breast surgery or OPS type.

35.2.1 Simple BCS

• Clinical examination

• Bilateral Mammogram

Cosmosis Related

Detectionof

treatmentrelated

side effect

Subjective Evaluation ObjectiveEvaluation

Psychosocial Support

Most of the recurrences can be detected by clinical examination and bilateral mammography. On mammography they usually appear as suspicious microcalcications or masses. PostOPS or breast reconstruction, loco-regional recurrence has been noticed in almost 2–3% cases. Most of the early recurrences develop at the junction of the ap with local breast tissue or within few centimetres of initial tumour site [2]. Isolated axillary nodal recurrences has been noticed in 1–3% cases after level II ALND [3]. Knowledge of the normal breast appearance after oncoplastic surgeries is necessary for accurate imaging interpretation to avoid unnecessary additional imaging and biopsies. Expected postreconstruction complications may also be seen, including uid collection, infection, fat necrosis, and lymphedema. Recognition of the posttherapeutic manifestations of breast cancer is important to avoid unnecessary work-up and minimize patient anxiety.

35.2.2 Complex Breast Oncoplasty

• Clinical examination

• Bilateral Mammogram or USG

• Digital Breast Tomosynthesis

• CE-MRI Breast

35.2.3 Mammography

In rst 6months to 1year after BCS, mammography usually shows skin thickness or oedema, post-operatives collected uids/seroma, scar, fat necrosis, and dystrophic calcication. However, these changes subside after 2 years. There are

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some recurrences related red ag signs like mass, microcalcications, progressive increase in skin thickness and breast density, scar enlargement, axillary recurrence or Paget’s disease. Careful discretion has to be made while discerning between these benign changes and concerning abnormal mammographic ndings and while prescribing biopsy for these changes [10].

35.2.4 Digital Breast Tomosynthesis (DBT)

DBT is the tool that helps in the follow-up of complex oncoplastic procedures, where parenchymal tissue usually overlaps and an early detection of recurrence might be obscured in conventional mammography. As DBT provides multiple section with varied angles while conventional mammogram produces 2D images [4].

35.2.5 MRI

MRI breast is not the rst line radiological modality for breast cancer follow-ups and it is not recommended by guidelines until there is any clinical or radiological suspicion of recurrence [5]. However, MRI is being used by clinicians as a part of routine practice, considering it more sensitive than conventional imaging in differentiating between post-surgery tissue alteration and tumour recurrence with a high negative predictive value and a sensitivity of 90–100% and a specicity of 89–92%, subsequently prevents unwanted biopsies [6, 7].

The sensitivity of MRI is higher after 12–18months of breast surgery compared to that of mammography (35–40%) [8]. In premenopausal women, false positive rate can be reduced by advising investigation ideally on days 6–13 of the menstrual cycle [9].

• Residual tumour extent in women after lumpectomy with close or positive resected margins [9]

• Occult primary tumour on mammography

• Inltrating lobular cancer [9]

• Breast implants

• Hereditary breast cancer, BRCA mutation

MRI is unable to differentiate possible resid-

ual tumour until at least 12–18months after BCS as it is affected by the strong enhancement of resection margins in response to inammatory postoperative reactions [10].

35.2.7 Role ofSurgeon inFollow-Up

Surgeon plays a very crucial role in the followup of breast oncoplasty patients, as they are aware of preoperative, intraoperative ndings, and reconstruction done. Therefore, communication in between the patient, radiologist, and the referring surgeon should remain an integral part of the post-oncoplastic breast evaluation process. Imaging surveillance in reconstructed breasts always poses a challenge for radiologists.

35.2.8 Screening foraNew Primary

Breast Cancer, intheIpsilateral, or Contralateral Breast

Protocols are almost similar as they are for any other breast cancer patients, but one must be quite vigilant in patients with TNBC, Her2 Enriched, Hereditary or familial breast cancer. Patients with BRCA mutation or with lifetime risk of 20–25% should be screened by annual MRI.

35.2.6 MRI Indications

• Any clinical or radiological suspicion of recurrence in complex oncoplastic breast

35.2.9 Detection ofTreatmentRelated Side Eects

During patient’s follow-up visit, it is important to address their treatment-related issues and help

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S. V. S. Deo et al.

them to maintain the quality of life. These issues may be related to surgery, systemic therapy, and radiation therapy.

• Surgery may cause ipsilateral arm lymphedema, shoulder stiffness, etc. They can be improved by physiotherapy, lymphedema preventive measures.

• Systemic therapy may cause hair fall, skin changes, osteoporosis, menopause related issues, etc. They all can be dealt with gradual counselling and supportive measures.

• Radiation related side effects like radiation damage to the lung, skin burns, etc. should be addressed without delay.

• Psychosocial support.

atic or having any suspicious nding on clinical examination [14].

35.3 Cosmetic Assessment

35.3.1 Timing

The cosmetic outcome should be assessed 1month and 1 year after the surgery and all the domains in questionnaire should be compared with preoperative domains. In some studies, it has been advised to assess breast after 2years of surgery for better assessment as by that time sequalae’s are over [16].

35.3.2 Methods ofCosmetic

35.2.10 Current Guidelines

onBreast Cancer Follow-Up

Breast surgery is under evolution since the beginASCO [14], ESMO [15], NCCN have almost similar recommendation for breast cancer Follow-ups.

• History and Physical Examination- Every

3–6 months for the rst 3 years, every 6–12 months for the next 2 years, then annually

• Mammography- Every 12 months; Post

BCS -1year after the initial mammogram and at least 6months after completion of RT; thereafter, yearly [14]

• Intensive follow-up- Not recommended

• Bone Mineral Density- On Aromatase

Inhibitors or Secondary Ovarian failure

• Gynaecological Assessment- every

12months if patient is on tamoxifen

Prescription of routine blood investigations (CBCs, KFT, LFT), X-ray Chest, bone scans, USG abdomen, CT scan, Whole body PET scan, MRI, or tumour markers (Serum CEA, CA 15-3, and CA 27.29) are not the part of routine breast cancer follow-up until unless patient is symptom-

ning of last century, where it started from Halstedian Radical mastectomy till currently undergoing Oncoplastic Breast Conservative Surgeries (OBCS). Therefore, measuring patientreported outcomes has become enormously substantial in cosmetic and reconstructive breast surgery. Despite the fact that factors inuencing cosmetic outcome have been under evaluation for last four decades and that various subjective and objective evaluation techniques have been studied, still consensus has not been reached on optimal approaches to cosmetic evaluation and the development of comparable scoring methods.

1. Patient-Reported Outcome Measures

Assessment

(PROMs) / Subjective Evaluation Methods

• Patient Self-Evaluation

• Panel Evaluation Patient self-evaluation methods are quite

popular because of the main role of patient’s subjective experience in the process of assessing health-related quality of life (HRQoL). However, patient self-evaluation has some prominent issues that they must depend on multiple factors

35 Follow-Up andCosmetic Outcomes inBreast Oncoplasty

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Table 35.1 Harvard scale (4-point Likert scale) [28]

Category Observations Excellent Treated breast nearly identical to untreated breast Good Treated breast slightly different from untreated breast Fair Treated breast clearly different from untreated breast but not seriously

distorted

Poor Treated breast seriously distorted

287

that are not quantiable like socio-economic status, age, etc. and consistent reporting of better scores by patients than by professionals.

Panel evaluation remains the most common and accepted approach to the subjective evaluation of cosmetic results, and the approach also takes breast asymmetry, scars, and skin changes into account [17, 18]. Using photographs of the breasts, panel evaluation rates a range of aspects and generally uses the so-called 4-point Likert or Harvard scale, with classication of overall cosmetic outcome as excellent, good, fair, or poor [19].

Considering the differences in the opinion of observers, a panel should have professionals and nonprofessionals from various backgrounds, with minimum of ve members. Despite the frequent use of panels for OBCS, the interobserver reliability of different panel constitutions and the validity of such panel evaluations remains ambiguous (Table35.1) [20].

35.4 PROMs: Questionnaires

35.4.1 Breast-Q [21]

It is being used to study the impact and effectiveness of breast surgery from the patient’s perspec-

tive. The conceptual framework included six domains and three modules.

Domains:

1. Satisfaction with breasts

2. Satisfaction with overall outcome

3. Psychosocial well-being

4. Sexual well-being

5. Physical well-being

6. Satisfaction with care

Considering the wide spectrum of breast aesthetic surgeries, BREAST-Q incorporates six modules (augmentation, reduction, breast cancer), each with a preoperative and postoperative version. The Breast Cancer module (comprised of 4 of the 6 modules) is created to provide an opportunity to clinicians and researchers to design their own version of the questionnaire to suit their needs [22].

1. Augmentation Module.

2. Reduction Module.

3. Breast Cancer. (a) Mastectomy Module. (b) Reconstruction Module. (c) Breast Reconstruction Expectations

Module.

(d) Breast-Conserving Therapy Module.

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35.4.2 Breast-Q Conceptual Framework

S. V. S. Deo et al.

Breast-Q data are transformed into scores according to the guidelines for the Breast-Q postoperative module. Higher scores are suggestive of more favourable outcomes.

35.4.3 The BREAST-Q BCT Module

This Breast-Q module is specially designed for breast conservative surgeries. In studies, It has been proved to be an accepted, reliable, and valid questionnaire for the assessment of HRQOL, experience of care and patient satisfaction after BCT in breast cancer patients. It can be recommended as a possible standard PROM for individual clinical assessment, quality assessment, and future trials [23].

The Breast-Q BCT preoperative module incorporates four subscales with 30 items. Scores are computed for each of the questionnaire domains. Scores are converted onto a scale of 0–100 according to the BREAST-Q protocol, with a higher value representing a more favourable outcome.

The BCT module must be analysed psychometrically and has been evaluated only in retrospective and cross-sectional studies so far. By using the Rasch measurement method, the BREAST-Q gains an advantage over most other PROMs [23].

35.5 EORTC Quality-of-Life Questionnaire [24, 25]

35.5.1 EORTC QLQ C30 & EORTC– BR23

In 1980, The European Organization for Research and Treatment of Cancer (EORTC) created a study group on quality of life, with an objective to develop a short instrument to assess health related quality of life in cancer patients mainly lung, oesophagus, and breast cancer.

The EORTC QLQ C30 and BR23 questionnaires are well-established PROMs. The general quality-of-life questionnaire is known as EORTC–C30. It is a multidimensional, selfadministered questionnaire that consists of 30 questions and assesses symptoms that occurred in the previous 2weeks. Answers are presented in a Likert scale: 1–4, i.e., not at all, a little, quite a bit, very much, respectively.

The QLQ-C30 has nine multi-item scales:

• ve functional scales (physical, role, cogni-

tive, emotional, and social);

• three symptom scales (fatigue, pain, and nau-

sea and vomiting); and

• a global health and quality-of-life scale.

Multiple single-item symptom measures are also the part of QLQ-C30.

35 Follow-Up andCosmetic Outcomes inBreast Oncoplasty

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35.5.2 EORTC– BR23

EORTC–BR 23 was developed by Sprangers etal. [27]. It is a specic module for breast cancer patients and must be used in combination with the EORTC–C30.

The EORTC questionnaire-BR 23 consists of 23 questions (questions 31 to 53), supplementing the general questionnaire. Its answers are also projected in a Likert scale. This questionnaire contains two scales, namely the functional scale and the symptom scale [26].

35.6 Objective Evaluation

Methods

35.6.1 BCCT.core

BCCT.core software is commonly used Objective Evaluation method for Oncoplastic Breast Conservative Surgery. The ultimate cosmetic objective of BCT is the attainment of two identical breasts. Considering this goal in the centre of process, these objective computerized evaluation methods assess and measure the breast asymmetry. This includes the breast cancer conservative treatment cosmetic results (BCCT.core) software, which provides an extensive set of automated measurements that incorporate a wide range of items that shows overall cosmetic and aesthetic outcome. Digitalized marking of the nipples, axillae, and sternum jugular notch help the software in automatic identication of the breast contour, and implements automated measurements including breast shape, volume, deformity, nipple position, scar visibility, and skin changes. Using this range of items and a 4-point scale, the results reect cosmetic issues that may arise following BCT and allow overall assessment of cosmetic outcome.

BCCT.core software usually provides fast and realistic reporting compared to panel evaluation. This standardized and computerized process helps in comparing the results of Oncoplastic breast conservative surgeries across the world. [28]

35.7 Summary

OBCS has now become the part of breast cancer routine surgical practice and most likely results in an improved cosmetic outcome. Follow-up of oncoplastic breast is challenging particularly in terms of oncological safety and aesthetic outcomes. In complex breast oncoplasty, oncoplastic surgeon along with radiologist plays a crucial role in early detection of recurrence or residual disease. For comprehensive and real time assessment of post-oncoplasty breast cosmesis, more objective cosmetic assessment tools or articial intelligence software’s are needed.

References

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2. Farras Roca JA, Dao TH, Lantieri L, Lepage C, Bosc R, Meyblum E, Pigneur F, Beaussart P, Assaf E, Totobenazara JL, etal. Ipsilateral breast cancer recurrence after deep inferior epigastric perforator (DIEP) ap reconstruction: incidence and radiological presentation. Diagn Interv Imaging. 2016;97:203–9.

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