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Overview ofCurriculum
https://t.me/medicina_free
andTraining forOncoplastic
Breast Surgery
Chintamani, RohanKhandelwal, andS.V.S.Deo
36
36.1 Introduction
With the increasing incidence of breast cancer
worldwide [1], quality care with improved outcomes is the need of the hour. Breast cancer management has also undergone remarkable changes
in the last couple of decades with multi-modality
approach becoming the norm across the world,
that has denitely lead to better patient related
outcomes. Along with other modalities, surgical
management has also evolved over time [2].
There is a paradigm shift in the surgical approach
for breast cancer management from radical mutilating surgeries to organ conservation approach
[3]. Apart from oncological goals the focus of
current era breast surgeons is on cosmetic outcomes and quality of life issues. This has also led
surgeons to enhance their knowledge and skill set
to deliver better results to patients leading to the
development of structured curriculum and training programmes in some countries [4, 5].
Oncoplastic surgery (OPS), a term coined by
the German surgeon Audretsch encompasses procedures to resect the tumour followed by imme-
Chintamani
VMMC, New Delhi, India
R. Khandelwal
CK Birla Hospital, Gurgaon, India
S. V. S. Deo (*)
Department of Surgical Oncology, BRAIRCH &NCI,
AIIMS, New Delhi, India
diate breast reconstruction by applying the
principles of cosmetic surgery [6]. The practice
of oncoplastic surgery, however, varies depending on the social, geographic, and economic factors of the region, country or the continent. In the
developed nations, OPS is primarily focused on
reconstruction following surgery for early breast
cancer whereas in developing countries it may
include repairing the surgical defect left behind
after resection of relatively larger tumours [7].
Despite being a relatively new concept, OPS
has attracted lot of attention from breast surgeons
for various reasons and an important one being
lack of breast dedicated and optimally trained
plastic surgeon at most centres. Additionally, the
lack of uniformity in the form of resources and
training across the world has put the onus on surgical oncologist / general surgeon to enhance
one’s skills in order to offer the best possible
ablative and reconstructive options to the patients
[8]. Multiple studies have demonstrated better
patient related outcomes for surgeons that are
focussed on breast surgery rather than the general
surgeons. Higher patient satisfaction scores have
also been reported when patient care is handled
by a breast focussed surgeon [9]. All these points
have sparked a keen interest in OPS training
across the world.
Different countries have different sets of doctors taking care of breast cancer. In most countries, it falls under the domain of surgical
oncologist / general surgeons whereas there are
© 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_36
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Chintamani et al.
countries where gynaecologists may be dealing
with breast cancer [10]. With increasing popularity and acceptance of OPS, breed of dedicated
full-time breast surgeons is emerging in recent
past. Training in OPS is usually not a part of the
curriculum during the basic surgical residency. A
curriculum for structured training of general or
onco-surgeons in the eld of OPS is mandatory
in order to achieve better oncological and cosmetic outcomes.
36.2 Classication ofOncoplastic
Procedures forTraining
Purposes
Although, there are multiple classications of
oncoplastic procedures, the one proposed by
Urban in 2010, pertains to a three tiers system
(Table36.1). This classication is useful in certifying breast surgeons at different levels of experience. According to this classication and in order
to clear this certication, the trainee not only
requires specic knowledge of plastic surgery but
also adequate knowledge of radiology, pathology, surgery, medical and radiation oncology
[11]. Another practical classication by Krishna
Clough, helps surgeon not only in identifying the
procedure to be planned for a particular patient
but also stepwise approach for surgeons to learn
OPS.The bilevel classication recommends that
if less than 20% of the breast volume is excised,
then a level 1 procedure is adequate and most of
these can be performed by any breast surgeon
without any formal training in plastic surgery. If
between 20% and 50% of the breast volume is
excised, then principles of mammoplasty need to
be utilized to carry out effective reconstruction.
To perform Level II surgeries, a surgeon requires
specialized training in OPS [12, 13].The authors
are also of the opinion that basic training in breast
surgery is a pre-requisite to learning advanced
oncoplastic breast surgeries.
36.3 Current Status ofOPS
Training Across theWorld
Table 36.1 Three tiers system classications of breast
oncoplastic procedures
Class-1 Class-2 Class-3
Monolateral
breast
reconstruction
techniques such
as aesthetic skin
incisions,
deepithelization
of the areolar
margins,
glandular
mobilization and
reshaping
techniques, purse
string sutures for
central quadrant
reconstruction,
immediate breast
reconstruction
with temporary
expanders. These
basic oncoplastic
techniques do not
require specic
plastic surgical
training.
Bilateral
procedures:
Immediate and
delayed breast
reconstruction
with implants,
lipolling, breast
augmentation,
breast reduction,
mastopexy,
Grisotti ap,
nipple and areola
reconstruction.
Here it is
necessary a
specic plastic
skill to do a good
symmetrization.
Mono or
bilateral
more
complex
procedures
involving
autologous
aps
(pedicled or
free aps),
or
combination
of
techniques.
In terms of basic training, not many differences
have been observed in various countries. As mentioned earlier, it is usually surgeons– general surgeons, breast surgeons, plastic surgeons,
onco-surgeons and sometimes gynaecologists
who deal with the surgical management of breast
cancer. Studies have demonstrated that majority
of these surgeons are not exposed to OPS during
their surgical residency or post-graduate training.
Specialized courses and fellowships are therefore
required to train surgeons in this eld [8, 10, 14].
.Many countries have formally started OPS training modules in the last decade. United Kingdom
has been the forerunner in the eld of OPS and
since 2002, formal OPS training has been incorporated in the curriculum. Trainees from both
general surgery and plastic surgery background
are accepted for limited OPS training spots, making it a highly competitive fellowship [15].
Brazil was one of the rst countries to establish a training oncoplastic breast centre. A
21module course was outlined, which consisted
of theoretical and practical knowledge being
36 Overview ofCurriculum andTraining forOncoplastic Breast Surgery
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293
imparted to surgeons over 1 weekend per month.
Analysis of the module revealed it to be effective
in training surgeons in OPS.At the beginning of
the course, only three quarters of the surgeons
were able to perform level-1 OPS) and none of
them were capable of performing level-2 and
level-3 procedures. A feedback conducted at the
conclusion of the course revealed all surgeons
were capable of performing at least level-2 procedures [16].
In France, obstetrics and gynaecology trainees
can opt for 1year of OPS training after completing 3years of experience in gynaecology, breast
surgical oncology or plastic surgery [12, 13].
Although breast surgical oncology training in the
USA was formalized in 2003, a survey of the
early graduates demonstrated that only 53% felt
well prepared to perform oncoplastic breast surgery. This has led to increasing number of breast
fellowship programmes in the USA with specic
focus on OPS training [17, 18].Canada has also
successfully implemented a 1-year training fellowship in OPS with the aim that graduating fellows can independently perform level-1 and 2
OPS, in addition to implant based reconstructions [8].
OPS is a relatively new concept in low- and
middle-income countries (LMIC) like India.
There is a shortage of trained general surgeons,
surgical oncologists, and plastic surgeons.
However, the awareness and interest among surgeons regarding OPS is increasing. In certain
LMICs like India dedicated breast surgery society (Association of Breast Surgeons of India) was
established to improve breast health care. These
societies in collaboration with other international
scientic associations are playing a signicant
role in propagating OPS training among surgeons
dealing with surgery. Because of the scarcity of
well-trained breast focussed plastic surgeons
across the LMICs the authors feel that it is most
feasible if well-trained oncoplastic surgeons perform both the resection and reconstruction of
breast cancer patient or in other words justify the
“one surgeon– dual role” concept. This arrange-
ment would not only be more cost effective for
the patient but would also ensure better delivery
of care as well. To address this issue, senior oncoplastic surgeons from India and UK have created
a structured training programme for budding
oncoplastic surgeons [www.breastoncoplasty.
org]. This programme aspires to provide the nec-
essary theoretical and practical knowledge of
OPS to trainees through a mix of online and
ofine training methods [19, 20].
As far as curriculum is concerned any oncoplasty training programme or fellowship should
encompass the following domains including
anatomy, pathology, imaging, multidisciplinary
treatment approach, oncologic and plastic surgical components. Majority of countries running
OPS fellowships have adopted a 1-year training
policy. It has been observed that prociency in
both level I and II can be obtained by trainees
over a 1-year period. The authors also feel that a
1 to 2year dedicated training period (depending
on the case load at the training facility) is sufcient for a candidate with a basic post-graduation/
residency training in general surgery/surgical
oncology backgrounds. In recent past exclusive
breast surgery training programmes (MCh Breast
surgery/Breast and endocrine surgery) are also
being initiated in some countries.
36.4 Conclusion
In the ever evolving eld of breast cancer management, oncoplastic breast surgery is fast
assuming a pivotal role. OPS not only helps in
providing better quality of life outcomes to
patients but also helps in effective utilization of
surgical resources at places where the availability
of a trained and breast focussed plastic surgeon is
a concern.
A holistic OPS training module of adequate
duration should be implemented to train surgeons
with basic training in breast surgery. As the perceptions of breast cancer patients to surgery vary
from one geography to the other, it is better if an
OPS trainee gets some international exposure
post the completion of the fellowship.
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Chintamani et al.
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Workow andSurgeons Check List
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forOncoplastic Breast Surgery
andReconstruction
S.V.S.Deo, S.ManojGowda, andNaveenKumar
37
• History:
– Symptoms: Lump/Skin changes/ Nipple
discharge
– Duration of symptoms
– Family history of cancer/Genetic/heredity
predisposition
– Personal history– Marital status/Children/
Menopausal status
– Socioeconomic factors and family setup
– Patient preferences/desires/expectations
• Clinical Examination:
– Breast anthropometry:
Breast cup size/volume
Ptosis grade
Clavicle to nipple length
Suprasternal notch to nipple length
Nipple to IMF length
– NAC
Areola diameter
Nipple diameter
Nipple projection
– Tumour factors:
Size of tumour
Location of tumour
Number: Unicentric/Multicenteric
Axilla status: N0/N+
S. V. S. Deo (*)
Department of Surgical Oncology, AIIMS and NCI,
New Delhi, India
S. ManojGowda · N. Kumar
Department of Surgical Oncology, AIIMS,
New Delhi, India
• Imaging:
– Mammography:
Tumour size
Tumour location
Number
Breast density (ACR grading)
– Ultrasound
– MRI
• Biopsy Report Evaluation
– Histology -Type/Grade
– Molecular subtype- ER/PR/Her2/Ki67
• Surgical Planning: MDT
– Surgeons provisional Plan
– Patient counselling
– Patients desire regarding surgical
procedure
– Final Plan:
Surgery for Primary:
• BCS/Mastectomy-MRM/RM/SSM/
NASM/SRM
• Incision– Primary/Axilla
• Closure and Reconstruction:
– Primary Closure
– Type I Oncoplasty
– Type II Oncoplasty
– Reconstruction– Implant / Autol-
ogous Flap
– ADM/Mesh
Surgery for Axilla:
• SLNB
– Blue dye
– Tc99 Radiocolloid
© 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_37
295
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– Indocyanine green
– Dual technique
• ALND
– Complications anticipated
– Backup plan in case of intraoperative nd-
ings/complications
• Documentation:
– MDT- Treatment plan
– Consent for surgery and for photographic
documentation
– Photographic documentation: Preoperative
pictures, intra-operative pictures and early
late post-operative pictures.
• Intra operative check list:
– Position of the patient
– Painting and draping
– Photographic documentation: Before inci-
sion and after closure
– Intra-operative events/complications
– Any change in plan
– Implants– Follow devise regulations
– ADM/mesh
– Assessment of vascularity of ap
– Drain policy
• Postoperative Care, MDT planning, and
Follow-up
– Wound care and Dressings
– Breast support in post-operative period
– Antibiotic policy
– Drain removal policy
– Early postoperative follow-up plan, wound
care, and suture removal
– Physiotherapy
– Histopathology report review
– Oncology MDT– Adjuvant treatment plan
– Clinical assessment and Imaging protocol
– Long-term cosmetic and oncological
assessment
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