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S. V. S. Deo et al.

Fig. 3.1 Planning of incisions for breast conservation surgery for tumors in different locations of the breast

Fig. 3.2 Part of skin close or adherent to tumor is included in the incision

a Circumareolar/Langer’s lines b Resting Skin Tension lines c Radial (inferior quadrant)

Infra-mammary

3 Principles ofPlanning Incisions forBreast Oncoplasty andReconstruction

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mmary, peri-areolar, and axillary location (Fig.3.5) [4]. The incision may be placed directly overlying the tumor or away from tumor with tunneling for tumor access (indirect approach). Axillary surgery can be done using the same incision for upper outer quadrant and axillary tail tumors; otherwise, a separate incision placed behind anterior axillary fold should be used for axillary surgery.

Preoperatively anthropometric assessment of the patient and breast should be done. The shape of breast, degree of ptosis, NAC size and position, and tumor location should be documented in sitting as well as standing position. The measurements and incision on the skin should be marked

preoperatively and modications should be made, if required, by assessing them in sitting and standing position. Preoperative photographs in sitting and standing position should be taken for documentation, after due consent. This will help in planning the reconstruction options and also will be helpful in dealing with medicolegal issues in future, if any.

Intraoperatively, the patient should be adequately exposed (i.e. including the contralateral breast) and should be positioned in semi- reclining position and have a symmetrical arm positioning. The markings and measurements should be rechecked intraoperatively (Fig.3.6).

Trans-axillary

Fig. 3.3 Previous surgical scar included in the denitive surgical planning

Fig. 3.4 Planning of incisions in relation to Langer’s lines

Peri-areolar

Fig. 3.5 Anatomical locations where surgical scars can be hidden

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Fig. 3.6 Positioning of the patient, measurements and markings of breast for complex breast surgeries

3.2 Incision Planning forMastectomy

Non-skin sparing mastectomy (NSSM), skin sparing mastectomy (SSM), skin reducing mastectomy (SRM), nipple–areola sparing mastectomy (NASM) are the four types of mastectomies

S. V. S. Deo et al.

commonly performed. Elliptical incision including NAC (except for NASM) and surrounding skin can be utilized by placing transversely or with an upward angle toward axilla. Transverse incision is preferred in large breasted women, while a sigmoid or modied wise pattern incision is recommended for the small breasted women. Incisions should not cross normal anatomical boundaries of the breast such as clavicle, inframammary crease, sternal border, and the axillary fold.

Flaps should not be raised beyond inframammary crease, unless required. The infra- mammary crease should be marked preoperatively. Uninvolved skin should be preserved if delayed or secondary reconstruction is planned.

Inframammary crease or lateral mammary incisions may be used in cases of skin sparing or NAC sparing mastectomy in patients with small sized breast (Fig. 3.7) [5]. Other incisions that may be used for NASM or SSM are peri-areolar, trans-areolar, trans-areolar and trans-nipple, lateral mammary crease, italic “S” (Fig.3.8) [6].

3 Principles ofPlanning Incisions forBreast Oncoplasty andReconstruction

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Fig. 3.7 Nipple sparing mastectomy using an inframammary incision with implant reconstruction in a case of multicentric breast cancer

Fig. 3.8 Various incisions and approaches for skin sparing and nipple–areola sparing mastectomy

3.3 Conclusion

Judicious planning of incisions is extremely important to achieve good cosmetic outcomes in breast oncoplasty. It requires familiarity with anatomy, oncologic principles, and plastic surgical techniques. The incision planning should be individualized and should be tailored to patient, tumor, and treatment needs. It should aim at balancing oncologic and cosmetic outcomes.

References

1. Moufarrège R, Dionyssopoulos A, Aymeric A,

Sauvageau J. Is there a relation between mamma-

plasties incisions and the nal shape of the breast?

Ann Chir Plast Esthet. 2010;55:111–34. https://doi.

org/10.1016/j.anplas.2009.04.006.

2. Mitchell SD. A step-by-step oncoplastic breast con-

servation surgical atlas of reproducible dissection

techniques and anatomically ideal incision placement.

Breast Cancer Res Treat. 2017;165:505–16. https://

doi.org/10.1007/s10549- 017- 4344- z.

https://t.me/medicina_free

S. V. S. Deo et al.

3. Skaria AM. Incision lines on the female breast. DRM. 2020;236:248–50. https://doi.

org/10.1159/000505541.

4. Seki H, Sakurai T, Maeda Y, et al. Utility of the periareolar incision technique for breast reconstructive surgery in patients with breast cancer. Surg Today. 2020;50:1008–15. https://doi.org/10.1007/

s00595- 020- 01975- y.

5. Daar DA, Abdou SA, Rosario L, et al. Is there a preferred incision location for nipple-sparing mas-

tectomy? A systematic review and meta-analysis. Plast Reconstr Surg. 2019;143:906e–19e. https://doi.

org/10.1097/PRS.0000000000005502.

6. Rawlani V, Fiuk J, Johnson SA, et al. The effect of incision choice on outcomes of nipple-sparing mastectomy reconstruction. Can J Plast Surg. 2011;19:129–

33. https://doi.org/10.1177/229255031101900410.

Oncologic Principles ofBreast

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Conservation andOncoplastic Breast Surgery

DillipKumarMuduly andMadhabanandaKar

4.1 Introduction

Breast conservation surgery (BCS) refers to resection of the tumor with a three-dimensional grossly free margin, along with the preservation of cosmesis. The term breast conservation therapy (BCT) is interchangeably used with BCS; however, BCT means incorporating locoregional radiotherapy and BCS.BCS require good surgical skills and experience and quality BCS is of paramount importance for any successful oncoplastic breast surgical procedure.

4.2 Clinical Evaluation andStaging

The patients with early breast cancer present with a breast lump or may be detected on a screening method. Triple assessment is mandatory in all patients, including clinical examination, imaging of breast (ultrasound and/or mammogram), and a tissue diagnosis (core-cut biopsy). A guided corecut biopsy always gives better results. In addition to histopathology; immunohistochemistry for Estrogen Receptor (ER), Progesterone Receptor (PR), and Her2neu are done in all patients, particularly those planned for neoadjuvant chemo-

D. K. Muduly (*) · M. Kar Department of Surgical Oncology, All India Institute of Medical Sciences, Bhubaneswar, India

therapy. Staging is performed clinically using AJCC/TNM staging method. For clinical stage I and II, no further metastatic staging investigations are required. For clinical stage III and IV, we need to perform CECT Chest, abdomen, and pelvis with Bone scan/PET scan alone as staging investigation [1].

4.3 Local Imaging

All patients undergo a bilateral mammogram at the time of presentation. Digital mammography is preferred to analog mammography, particularly for women with dense breasts. The mammogram will tell if there is any lesion, whether the lesion is solitary/multiple, the size and location of the lesion, whether unilateral or bilateral, and the ACR density category. Information on the mammogram helps in deciding whether BCS is feasible or not. The ACR density category is one of the factors in deciding the type of oncoplastic surgery to be planned.

Ultrasound of the breast is usually performed to conrm the results of a mammogram. The USG of the breast would help inlocalizing and characterizing any lesion, site, size, and the number of lesions, distance from the skin, pectoral fascia, and nipple-areolar margin. Ultrasound is also used to guide a biopsy and may be used intra-operatively to localize and guide an adequate resection margin. The USG of the axilla is

https://doi.org/10.1007/978-981-99-5536-7_4

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D. K. Muduly and M. Kar

performed in all patients with early breast cancer to see for any suspicious nodes before planning for a sentinel node biopsy.

Although highly sensitive, magnetic resonance imaging (MRI) of the breast is not performed routinely due to its low specicity. However, MRI may be performed in addition to mammogram and ultrasound in; (a) unknown primary with an axillary nodal metastasis where clinical examination and conventional imaging has failed to detect the primary lesion [2, 3], (b) There remains a high suspicion for malignancy and US and needle biopsy have not made a diagnosis [4], (c) The patient has lobular cancer, and wide local excision is being considered, (d) The examination or initial imaging suggests there may be multi-focal disease, (e) there is discordance regarding tumor size between the clinical examination and initial imaging or the size of the tumor cannot be reliably assessed clinically or on imaging (this typically includes inltrating tumors, most notably lobular carcinomas, and when the tumor is occult on initial imaging modalities). (f) The patient has silicone implants. (g) MRI guided biopsy of a lesion not visible on mammography or ultrasound.

4.4 Patient Selection forBreast

Conservation Surgery

All patients with early breast cancers without absolute contra-indications can be offered breast conservation as choice of treatment. Patients with EBC who are unt for upfront BCS due to large tumor size or adverse tumor versus breast ratio can be offered NACT to downstage the disease and facilitate BCS.

4.4.1 Absolute Contra-indications

forBCT

4.4.1.1 Contra-indication at

Presentation

If the patient is in the rst trimester of pregnancy at presentation, she should be treated with mas-

tectomy. If she presents in the second or third trimester, she can be managed with BCS followed by adjuvant chemotherapy or NACT followed by surgery. Adjuvant RT can be administered postpartum.

4.4.1.2 Contra-indication Based onPast-history

History of prior irradiation to the chest wall.

4.4.1.3 Contra-indication onClinical Examination

If on examination, multicentric disease is there with two or more lumps, and they cannot be resected without compromising cosmesis.

4.4.1.4 Contra-indication onInvestigation

Diffuse appearing malignant microcalcication on the mammogram.

4.4.1.5 Contra-indication Detected On-table During Surgery (Frozen)/Post-Surgery (Paran Sections)

Persistent margin positive (cavity shave) after reresection of a positive margin.

4.4.2 Relative Contra-indications toBCT

4.4.2.1 Connective Tissue Diseases

Some of the patients with connective tissue disorders tolerate poorly to radiotherapy. Patients with Scleroderma, Sjogren’s Syndrome have higher complications due to skin fragility. Systemic Lupus erythematosus and rheumatoid arthritis patients also have an increased risk of skin toxicity. In recent studies, there was no significant difference in the incidence of acute or late complications. However, there was a higher incidence of radiation complications in patients with scleroderma. No fatal complication were noted in any of the patients [5].

4 Oncologic Principles ofBreast Conservation andOncoplastic Breast Surgery

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4.4.2.2 Tumor Breast Ratio

This is dened as tumor size relative to breast size and is an essential factor in selecting patients for BCT.A large tumor in a small breast is a relative contra-indication since an adequate resection would signicantly alter cosmetic alteration. However, now-a-days, these patients may undergo BCT with oncoplastic techniques/NACT followed by BCT with/without oncoplasty.

4.4.2.3 Pendulous Breast

A pendulous breast was previously a contraindication for BCT due to difculty in reproducibility of radiation dose homogeneity. However, these patients are no longer a contra-indication if the dose homogeneity can be ensured.

4.4.3 Factors No Longer Contraindication toBCT

4.4.3.1 Age

Older age is no longer a contra-indication for surgery. In contrary, they have a lower risk of recurrence, and they should be offered with BCT if there is no other contra-indication.

4.4.3.2 Tumor Location

Although the patients with a medial tumor are challenging to reconstruct, they are not contraindications for BCT. With oncoplastic surgery, these patients are increasingly taken up for breast conservation.

4.4.3.3 Invasive Lobular Carcinoma

If resected up to negative margins, it’s not a contra- indication. The presence of classic LCIS at the resection margin does not increase the recurrence rates and does not bear a clinical signicance and does not need a re-resection of the margin.

4.4.3.4 Extensive Intraductal Component (EIC)

Extensive intraductal component (EIC) means presence of >25% volume of DCIS component present in the resected lumpectomy specimen, in a patient with invasive tumor. The EIC does not

apply to a tumor that is pure DCIS. The EICpositive cancers with negative resection margins do not have an increased risk of ipsilateral recurrence following BCT [6].

4.4.3.5 Family History ofBreast Cancer

Patients with family history of breast cancer are not contra-indication for BCT. However, they should be informed that, they have a higher risk of increased second primary cancers [7].

4.4.3.6 Lymph Node Positivity

Presence of positive lymph node is a marker for poor prognosis with increased distant recurrence and not a contra-indication for BCT.Node positive patients undergoing mastectomy or BCT have similar outcomes.

4.4.4 Principles ofNeoadjuvant Chemotherapy Followed byBCT

Patients with early breast cancer unsuitable for BCT due to large tumor size may be planned for NACT followed by BCS. The NACT increases the BCT rate; however, it does not impact recurrence or survival. However, all patients receiving NACT should have undergone a core-cut biopsy with the evaluation of ER, PR, and Her2neu status before chemotherapy. Those with negative hormone receptors and Her2neu negative tumors show the highest response rate. Those with hormone receptor-positive and HER2 negative are less likely to respond to NACT or become eligible for BCT.Meticulous clinical and radiological evaluation by the treating surgeon, precise documentation of clinical ndings, metal marker placement in the tumor prior to NACT are essential prerequisites for NACT - BCS protocols. Post-chemotherapy assessment includes clinical and radiological evaluation. Wire-guided localization or any other localization method should be used to target tumor bed with metal marker. Volume of excision should be as per post-NACT residual tumor burden. Specimen mammography should be performed to conrm excision of target lesion.

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4.5 Surgical Principles

The incision should be planned according to the tumor location and breast anatomy. No excessive tunneling should be performed. During resection care is taken to take adequate grossly normal margin (usually 1cm) around the tumor. There are different techniques to ensure a gross margin of 1 cm around the tumor. The most common technique used by the surgeons is Palpation Guided Resection for palpable lesions. The surgeon palpates the lesion after raising the aps when required, and the nger placed on the tumor margin helps ensure a 1cm gross normal tissue margin (Fig. 4.1). The USG can be used (Ultrasound-Guided Resection), particularly in non-palpable or indistinct lesions, to localize and accurately ensure margins (Fig.4.2). Other techniques used for non-palpable lesions are wire-

D. K. Muduly and M. Kar

Fig. 4.2 Ultrasound-Guided Resection

Fig. 4.1 Finger Guided Resection with gross normal margin. (Art: Dr. Dipin)

4 Oncologic Principles ofBreast Conservation andOncoplastic Breast Surgery

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guided resection, radio-guided occult lesion localization (ROLL), radioactive iodine (I-125) seed localization (RSL), and cryo-assisted localization (CAL) techniques.

4.5.1 Breast Conservation Surgery– Margin Status

There are two types of margins described. One is the lumpectomy margin, which can be assessed by the following methods. After resection, the surgeon can assess the lumpectomy margin by pal- pating the resected lumpectomy specimen for any gross margin positivity. The surgeon takes sec- tions on the resected primary specimen along different margins (Fig. 4.3). Ultrasound of the lumpectomy specimen may be performed to ensure the adequacy of gross margin (Fig.4.4). The specimen may be sent for specimen mam- mogram to see for adequacy of margins, particularly in non-palpable lesions (Fig.4.5). The other is, taking margin specimen separately from the resected cavity, also called cavity shave margins (Fig.4.6). If available, many centers perform frozen section biopsy or imprint cytology of the lumpectomy or cavity shave margins, which gives an accurate intra-operative microscopic margin status and reduces the positive margin rate and

Fig. 4.4 Intra-operative margin assessment by ultrasound. (Post-resection)

rate of re-resection. Two randomized trials have shown cavity shave margin reduces the margin positive rate by 50%. We at our institute routinely perform cavity shave margins intra- operatively and perform frozen section biopsy. Any positive margin is immediately subjected to further reresection/mastectomy based on circumstances [8,

9].

Different newer, lesser invasive, and faster technologies have been described that accurately predict the microscopic margin status; however, they are costly and unavailable at many centers, e.g., MarginProbe, which uses spectroscopy, and Lumicell, which uses uorescent imaging as the principle.

Microscopic margin status is the most crucial factor in BCT, and the currently microscopic positive margin is dened as “ink-on-tumor”. A negative microscopic margin is dened as “no ink on tumor” [10] (Table4.1).

Fig. 4.3 Cut-section of the specimen to assess the gross margin

4.5.2 Metal Marker Placement

ontheResection Cavity

After resection, meticulous hemostasis must be obtained. Metallic titanium clips are placed on the margins before closure to help the radiation oncologist identify the cavity for tumor boost. Routinely a clip is placed in each medial, lateral, superior, inferior, and deep margins of the resection cavity (Fig.4.7).

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