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Role ofBreast Anthropometry
https://t.me/medicina_free
inOncoplasty andReconstruction
PraveenRoyalMokkapati, ManojGowda,
andS.V.S.Deo
10
10.1 Introduction
Breast cancer is the leading cancer among women
globally and has replaced cancer cervix as the
number one cancer in India. Surgical treatment for
breast cancer has witnessed a paradigm shift globally from a predominantly mastectomy based
approach to an approach based on breast conservation, oncoplasty, and reconstruction. Breast anthropometry including size, shape, ptosis, and nipple
areola complex (NAC) anatomy plays an important
role in surgical decision making and outcomes.
Study of anthropometric data of breast cancer
patients from different regions of the world helps
evolve individualized surgical decision making
guidelines in view of anthropometric variations.
10.2 The Magnitude ofBreast
Cancer andIts Impact
onWomen
In 2012, there have been 1,671,000 recorded
cases of breast cancer worldwide with 145,000
being recorded in India. This has led to 522,000
P. R. Mokkapati (*)
Surgical Oncologist, Health Care Global,
Vijayawada, India
M. Gowda · S. V. S. Deo
Department of Surgical Oncology, AIIMS,
New Delhi, India
deaths worldwide and 70,000 deaths in India [1].
The management of breast cancer uses different
modalities like surgery, chemotherapy, hormonal
therapy, and radiotherapy in various permutations and combinations. The surgical part of the
management can broadly be divided into breast
conservation surgery with or without oncoplasty
and mastectomy with or without reconstruction.
Although the human breast biologically has no
more purpose after lactation, it has immense
social and psychological implications which are
evident in the major categories of surgical
options. Whether a breast conservation or mastectomy is done, proper reconstruction and cosmetic results are paramount.
The female body image is very much inuenced by the breast in the modern era. The psychosocial impact caused by its loss following
mastectomy is signicant. With the advent of
BREAST-Q score and a holistic approach toward
breast cancer, many studies such as those that
have been done by Eltahir et al., Andrzejczak
etal., and Chao etal. demonstrated the difference
in perception of body image, psychosocial and
sexual well-being after only mastectomy vs mastectomy with reconstruction [2–4].
Yip etal. did a study on how important was
the breast volume symmetry to overall patient
satisfaction and found that “process of breast
reconstruction,” i.e. the amount of information
given to the patient about the postoperative outcomes led to more patient satisfaction than the
© 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_10
71
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P. R. Mokkapati et al.
actual result of the surgery although it did add
value to it [5]. Snell etal. observed the result of
clarifying the expectation of patients undergoing
breast reconstruction and how it affected patient
satisfaction [6]. This is what is being called “realistic expectations.” However, it is difcult to even
reach realistic expectations when there is no
information on what a normal breast is. To the
best of our knowledge, there have been no
reported studies on breast anthropometry in
Indian women. Most of the available implants are
designed based on Western counterparts.
Sinno et al. [7] did a study on postoperative
patient satisfaction in patients who received unilateral vs bilateral reconstruction. Patients with
bilateral reconstruction rated higher in their satisfaction with symmetry and aesthetics without
clothes with a signicant P value. Several methods of breast measurements were used to evaluate the aesthetics of a breast which can be used
for preoperative planning as well as postoperative outcome assessment [8–16].
10.4 Natural Shape Methods
They estimate the breast volume by using the
natural breast contour and include 3D modeling, thermoplastic casting, and water displacement techniques. They use different methods to
replicate the natural shape of the breast. In 3D
modeling and thermoplastic casting, a mold of
the breast in its natural form is made. This is
followed with the estimation of volume held by
these casts. In water displacement technique,
the person is made to position her breasts in a
prone position in a water container and the
amount of water displaced by them is taken to
be the volume of breast. The problem with
these methods is that they are cumbersome and
assume the posterior border of breast to be a at
plane. In addition, water displacement is very
uncomfortable and is difcult to maintain the
posture required and the posterior wall is
dened by plane of the opening of water
container.
10.3 Breast Anthropometry
Methods
Breast anthropometry includes the description of
breast mainly in terms of its
• Dimensions and volume which include vari-
ous radii and relative position of the nipple
with various landmarks.
Apart from these
• Shape
• Ptosis
• Mammographic density are other parameters
that aid in properly describing breast anthro-
pometry to aid in surgical planning.
Breast volume measurement has been done in
a number of ways. They have been classied into
1. Natural shape methods
2. Stereological methods
3. Geometrical methods
4. Mathematical modeling methods [8]
10.5 Stereological Methods
They use a 2D imaging technique like CT-scan
or MRI images that are taken with equally
spaced slices and then summate them to give the
breast volume [8, 10, 14]. Even ultrasound of
the breast can be used but it carries the problem
of breast compression when the procedure is
performed. They are one of the most accurate
methods of measuring breast volume because of
the exact estimation of the posterior wall. The
disadvantages are that they have to be done in a
supine position and give only the volume of the
breast and not much details of shape of breast in
its most socially functional position. CT scans
carry additional risk of radiation exposure. MRI
also takes a great deal of time. They are very
expensive equipment and logistically serve better for other indications. Having said that, CT
scans of chest are done as a part of staging of
locally advanced breast cancer and MRI breasts
for various decision making dilemmas in early
breast cancer. The scans obtained might serve
the additional purpose of measuring the breast
volume.
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10.6 Geometrical Methods
These methods approximate the shape of breast
to a cone or hemisphere or a half ellipsoid and
use geometric equations to calculate the breast
volume [9, 10, 18, 19]. These formulae are very
simple and easy to use. The necessary dimensions are obtained by simple tape or ruler measurements and substituted in these formulae to
give the volume based on the shape of breast
assumed. However, like natural displacement
methods, they also dene the posterior wall as a
at plane. And unlike them, they are less cumbersome and easier to do. Examples of these
methods are using the Grossmann Rounder cast
which shapes the breast into a cone and volume
of the cone can be obtained from a reading on
the cast. Linear equations like the Qiao et al.
[17] formula also assume the breast to be a cone
to give the breast volume. Breast volume calculated using formula given by Qiao etal. is as
follows:
Breast volume = 1/3 × 3.14 × MP2 ×
(MR+LR+IR– MP) in cubic cm
where MP is mammary projection
LR is lateral radius
MR is medial radius
IR is nipple inframammary fold length
10.7 Mathematical Models
They use formulae derived from polynomial
regression to calculate the breast volume [8]. The
gold standard of measuring breast volume is by
water displacement technique using mastectomy
specimens so that the problem of posterior wall is
eliminated. Studies have been done to measure
cadaveric breast volume or invivo breast with
carefully performed water displacement methods. Retrospectively, a formula is devised using
polynomial regression to estimate breast volume.
An example of this is the Sigurdson’s formula
[18]. The problem with this method is that very
complicated formulae are obtained and they
operate only within the constraints of the cohorts
originally used to devise them. Sigurdson’s formula is given by
Breast volume (cc) = 35.5(PP) + 37.7(FP) – 1305
where PP refers to the circumference of the base
of breast
and FP refers to the vertical length from the
inframammary fold to the projection of its midpoint on the anterior surface of the breast.
This formula was associated with an adjusted
R2 of 0.89, suggesting that 89 percent of volume
variability was accounted for by this model. The
formula can be applied to only breast volume
ranging from 500 to 2400 cc (ideally within 1
standard deviation of mean volume observed in
the study with a range from 877cc to 1756 cc).
The formula would not be suitable for breasts
that lack ptosis because key landmarks are based
on the inframammary fold. Furthermore, projection of this fold anteriorly onto the breast can be
difcult to evaluate accurately, particularly in
women with thick breast bases. A 1-cm difference in the location of this point, for example,
would result in a 38-cc change in volume.
10.8 3D Surface Imaging
3D surface imaging for breast anthropometry is a
relatively uncharted territory. Images are acquired
fast, in whatever position desired, can be repeatedly measured as a virtual breast can been
acquired [8, 13, 19–21]. Several techniques have
been described and the most commonly used
among them are stereophotogrammetry and laser
scanning. Two images are recorded from slightly
different angles and the coordinates are acquired
either manually or automatically by projecting a
pattern like a grid on the breast. These instruments require dedicated rooms and lighting to
provide consistent imaging. They also require
frequent calibration. Some of them require xed
rigs to help the patient maintain a position while
the image is being recorded. Newer generation
technology overcomes, to some extent, the need
for frequent recalibration and xed rigs. The
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P. R. Mokkapati et al.
images can be post processed to anticipate operative results. They can also be stored and used
postoperatively to compare outcomes. This property of storage of three- dimensional breast has a
huge advantage over other methods as innumerable measurements can be performed on the
breast repeatedly with no patient discomfort. Any
anthropometric measurement can be done retrospectively on the images and compare to any system of measurement. The instruments have a
very low risk of radiation and are less expensive
compared to CT-scan or MRI.A number of 3D
imaging technologies have been explored for this
purpose. Dedicated commercial systems are also
available like 3DMD torso, Axis three XT 400,
Caneld Vectra XT, Crisalix 3D mammo simulator [11, 20, 22]. A number of researchers have
also tried the Microsoft Xbox Kinect system [23,
24]. The instrument which has potential for being
used in India is the Faro freestyle 3D scanner. It
has a range of 0.5–3m with a maximum lateral
resolution of 0.2–1mm and depth resolution of
0.2mm [25]. It is a handheld scanner with a gyroscope that collects point cloud data from the subject from any position desired.
The human breast has a very dynamic shape
and so it has to be measured in the most natural
position. A number of linear anthropometric
measurements have been dened by Hall etal.,
Qiao et al., and Dilek et al. to characterize the
shape and size of the human breast. Qiao etal.
reported the results in Chinese women and Dilek
etal. reported them in Turkish women [17, 22].
They used simple anthropometric measures like
clavicle-nipple length, sternal notch-nipple
length, medial mammary radius, lateral mammary radius, etc.
Linear anthropometry uses simple, inexpensive, reproducible ways to document various
aspects of the human breast. The estimation of
breast volume using linear equations or formulae
developed by polynomial regression using these
parameters is also relatively simple and straightforward. The patient is also not subjected to any
kind of radiation exposure. They individually
help in noting postoperative changes also.
10.9 Breast Shape
Breast shape classication has conventionally
been done based on the one proposed by Martin
and Saller. They have classied it into bowl
shaped, hemispherical, conical, and dependent
shapes based on the radius and anterior projection of the breast.
• Bowl shaped—anterior projection is less than
radius
• Hemispherical—anterior projection is equal
to radius
• Conical—anterior projection is greater than
radius
• Dependent—nipple is pointing downwards
A new measurement system that has been
given by Eric Swanson is a more objective
method to measure the breast shape. However,
the system cannot be used with linear anthropometry. It requires photographs or 3D imaging
[16]. It describes the breast in terms of upper pole
and lower pole measures and their relative ratios.
10.10 Ptosis
Breast ptosis is also an important determinant of
reconstruction decisions. Renault’s classication
of ptosis is the most common type of classication used. It classies ptosis into grade 0,1,2,3
and pseudoptosis.
In grade 0, the nipple should be approximately
2 cm above the inframammary fold. In grade 1
(mild) ptosis, the nipple is at the level of the inframammary fold (or approximately 1cm below it).
In grade 2 (moderate) ptosis, the nipple is
approximately 1–3cm below the inframammary
fold.
In grade 3 (severe) ptosis, the nipple is approxi-
mately 3cm or more below the inframammary fold.
If the nipple is at a level higher than 3 cm
above the inframammary fold or the lower pole
of the breast is located much below the fold, the
placement is called pseudoptosis [26].
10 Role ofBreast Anthropometry inOncoplasty andReconstruction
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10.11 Mammographic Density
Apart from the measurement of the breast in various dimensions, its density is also an important
attribute and has been in most cases measured
with the help of a mammogram. The most widely
used method is using the BI-RADS system into
four categories based on amount of broglandular tissue, with the upper limits of each category
being 24%,49%,74%, and 100% [27, 28].
• ACR grade I: 0–24% broglandular tissue
• ACR grade II: 25–49% broglandular tissue
• ACR grade III: 50–74% broglandular tissue
• ACR grade IV: greater than 75% broglandular tissue
Dening the breast in terms of these anthropo-
metric measurements, volume and shape along
with 3D surface imaging aids will certainly help
acquire a baseline data in Indian cancer patients
which can help guide post-mastectomy reconstruction options and in improving the quality of
their life.
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Principles ofRadiotherapy
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inBreast Oncoplasty
andReconstruction
DayaNandSharma andSupriyaMallick
11
Radiotherapy, by means of double stranded DNA
damage (mainly) plays a pivotal role in treatment
of most of the solid tumors. Radiation is often
employed as denitive treatment option or in
sequence with surgery (adjuvant or neo- adjuvant).
Modern radiation is delivered either by linear
accelerator, which accelerates electrons and produces photon beam and electron beam of varying
energies or a brachytherapy machine which uses
radioactive sources (Ir
tion to a precisely dened lesion. Last two
decades witnessed a paradigm shift as breast conservation surgery (BCS) followed by radiation,
coined as breast conservation therapy (BCT),
gained popularity and became standard of care in
the management if early breast cancer. BCT
allowed patients to avoid mastectomy without
compromising long term disease control and survival. Initially entire breast used to be irradiated
(whole breast irradiation) [1]. Subsequently, it
was realized that most of the patients after a conservation surgery predominantly recur within the
same quadrant which introduced the concept of
irradiating the quadrant at risk of recurrence and
was popularized as partial breast irradiation [2,
3]. Interestingly, after BCS conventional radia-
tion takes nearly 5–7weeks’ time to complete the
treatment, which can easily be performed in one
D. N. Sharma (*) · S. Mallick
Department of Radiotherapy, All India Institute of
Medical Sciences, New Delhi, India
192
or Co60) to deliver radia-
go (intraoperative) or in 1 weeks (interstitial
brachytherapy/balloon-based applicators/photons) and hence was termed as accelerated partial
breast irradiation (APBI). Professional organizations have laid down suitability criteria for performing APBI.All such guidelines come down to
the fact that early breast cancer (max size 3cm,
N0, no NACT), favorable histology (margin negative, hormone positive, Her2neu- negative) in
elderly patients (age 50 or higher) are suitable for
APBI and have been established in randomized
trials [4–6]. Over the last two decades, there has
been a paradigm shift in surgical management of
breast cancer, with increased incorporation of
oncoplastic procedures into breast oncologic procedures [7]. Oncoplastic surgery is aimed at
excising the tumor with wide surgical margins to
deliver better cosmetic outcome. Cosmesis is the
most important yard stick to judge a quality of
breast cancer surgery after sound oncologic
clearance which is mitigated by combining plastic surgical approach with oncological surgical
approach. This holds immense potential to
increase the rate of breast-conserving surgery
which is clearly highlighted as American Society
of Plastic Surgeons (ASPS) reported a 29%
increase in reconstructive surgeries in the year
2018, compared to 2000. Interestingly, nearly
80% of these were implant based, and remaining
required both a tissue expander and implant [8].
Radiation technique and understanding of radiobiology have witnessed similar change in the
© 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_11
77
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D. N. Sharma and S. Mallick
mentioned time frame. Modern day radiation
delivers precise radiation to the precisely delineated target and improves disease control with
minimal normal tissue toxicity. In contrast to previous fractionation schedules advent of newer
safe protracted treatment course has improved
compliance to treatment by several folds.
Introduction of motion management during radiation has helped to reduce cardiac and lung dose
and complications secondary to it. It is obvious
that the interplay of oncoplasty and radiation
oncology treatment planning and outcomes is
complex. Oncoplastic surgeries on the basis of
breast size, size, and location of the tumor can be
broadly classied as volume displacement and
volume- replacement surgery. Transposition of
dermo- glandular tissue/ap in the defect is
known as volume displacement, whereas in
volume- replacement technique autologous tissues replace the volume loss.
11.1 Challenges inPatients
Undergoing Oncoplasty:
Diculty inDelineating
Boost Volume
Tumor bed boost was found to reduce local disease recurrence across all age groups [9]. A
recent update from the EORTC boost trial highlighted reduction of local recurrence from 31 to
15% (HR, 0.37; 95% CI, 0.22–0.62; P<0.001)
in high-grade tumors in younger than 50 years
[10]. It is quite convincing that boost reduces
ipsilateral recurrence from 16.4% (no boost) to
12.0% up to 20years without any effect on sur-
vival [10]. Clips placed during surgery, seroma
cavity along with the radiological data from
mammogram serve as surrogate for delineating
the boost volume. Tissue mobilization in oncoplastic surgery poses a challenge in delineating
boost volume. In the era of conventional fractionation boost was associated with signicant
difference inlocal control across all age groups,
so patients who opt for conventional fractionation are at risk of erroneous boost volume delineation. Radiation practice started changing after
Whelan etal. and START group established noninferior results with 40Gy delivered in 3weeks
compared to 50Gy. Recently studies are looking
into extreme hypofractionation regimen.
However, the hypofractionation trials left the
boost to the discretion of the treating physicians
and a post-hoc analysis found no signicant
impact of boost after hypofractionation radiation
[11]. “FAST” trial in UK involving 300 patients
tested 30Gy in 5 fractions, 6Gy per fraction over
35 days (5 weeks) Vs 28.5Gy (5.7Gy/Fr) over
35days Vs 50Gy in 25 fractions. Two-year follow-up data of the above trial, cosmesis of the
breast signicantly affected. The UK-FAST
FORWARD and UK IMPORT HIGH are two
such trials randomized patients to 40 Gy in
15fractions over 3weeks to 26 and 27 Gy in 5
fractions delivered over a period of 1week. In a
recent publication the FAST FORWARD trial
published non-inferiority of the 26Gy arm. The
importance of boost was further reduced in the
FAST-FORWARD trial, but point should be
made that the patients included in FAST
FORWARD are relatively early risk patients (T3,
N0-1). However, this degree of tissue displacement in oncoplastic surgery poses a greater challenge to perform accelerated partial breast
irradiation (APBI). Efforts are being made to
bring homogeneity in practice so that delivery of
boost and performing APBI does not compromise outcome in the background of oncoplasty.
Canadian Locally Advanced Breast Cancer
National Consensus Group recently emphasized
that surgeon and radiation oncologists should be
working in close collaboration and speak “a
common language” and there should be homogenous documentation tumor size, location, defect
size, accurate description of the surgical procedure. They also emphasized surgical clips should
be placed intraoperatively at least one in each of
the cavity side walls, which may be helpful in
delineating the tumor bed [12]. However, reliability of surgical clips to delineate tumor bed is
often questioned because of potential chances of
clip migration, observer variability [13].
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79
11.2 Target Denition
andDelineation After
Oncoplastic Surgery
Accurate target volume delineation is critical for
successful implementation of APBI after an
oncoplastic surgery. Many guidelines have
addressed this issue [14]. According to the Breast
Cancer Working Group of the German Society
for Radiation Oncology (DEGRO) and GEC
ESTRO after a closed cavity surgery, mainstay of
target delineation is scar and surgical clips and
information from the imaging. The entire area of
surgical dissection comes under the term of
“whole surgical scar”. Imaging-correlated target
volume is delineated with the inputs from preoperative imaging which typically includes the size,
location of tumor. So, the estimated tumor bed
comprises the part of whole scar which corroborates with the image correlated target. A safety
margin, 20mm minus surgical margin is added to
the estimated target volume to create the clinical
target volume. In case of brachytherapy based
APBI CTV serves as PTV, but in external beam
based APBI additional 10mm margin is added to
CTV to generate planning target volume.
Intraparenchymal placement of clips prior to
rotation of glandular tissue is an important prerequisite for APBI in the setting of oncoplasty.
Additional 10- and 20-mm margin should be
added to the clinical target volume for such
patients, if being treated with brachytherapy or
teletherapy after an oncoplastic surgery
(Figs.11.1a, b) [15, 16].
11.2.1 GEC ESTRO Recommendation
[15, 16]
1. Perform a CT with marks on the scar.
2. Delineation of clips.
3. Delineation of surgical bed—whole surgical
scar (WS) inside breast.
4. Delineation of ImTV (imaging-correlated tar-
get volume).
5. Delineation of ETB (estimated tumor bed).
6. Delineation of CTV (clinical target volume).
7. Delineation of PTV (planning target
volume).
In case of oncoplastic surgery no recommendations can be given but in selected cases of limited rotational aps the CTV can be dened as
the sum of the clipped area (CA) and the distance
of 20mm minus the smallest surgical free margin
(SFM) dened by the pathologist (CTV=CA +
(20-SFM)). The PTV is dened as the
CTV+10mm.
a b
Fig. 11.1 (a) Representative diagram of target volume
delineation in case of APBI. Black dots: Clips, area
marked with red-clipped tumor bed, light blue line represents clinical target volume (CTV), which is an expansion
by 20mm-surgical free margin, outermost blue line: plan-
ning target volume (PTV) which is an expansion of CTV
by 10 mm. (b) Representative image of APBI showing
inclusion of clips and other target area covered by prescribed dose
80
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D. N. Sharma and S. Mallick
11.2.2 Optimal Type
ofReconstruction
intheSetting ofPlanned
Adjuvant Radiotherapy
Optimal type of reconstruction is yet to be established; however, it looks impractical to have a
randomized controlled trial to address the issue.
Prosthetic based breast implants were in use initially but increasing number of reports highlighted lesser patents satisfaction and relatively
higher complication rate. Autologous reconstruction results in better quality of life as well as
fewer complications and failures. Wide range of
autologous aps, in particular deep inferior epigastric perforator aps are considered superior to
transverse rectus abdominal muscle (TRAM)
pedicled aps and may be more suitable for
PMRT. Other options are latissimus dorsi and
muscle-sparing free TRAM aps.
11.2.3 What Is theOptimal Timing
ofReconstruction
intheSetting ofPlanned
Adjuvant Radiotherapy
Adjuvant radiation plays pivotal role in the management of breast cancer after a conservation surgery. The early breast cancer trialists’
collaborative group [EBCTCG], in a metaanalysis of 17 randomized trials comprising of
10,801 women treated with or without radiotherapy after a conservative surgery reported that
addition of radiation halves the rate at which the
disease recurs and reduces the breast cancer
death rate by about a sixth [9]. In a subsequently
analysis the EBCTCG group highlighted 5.4%
reduction in mortality when adjuvant postmastectomy radiation was added in node positive
patients [1]. Earlier small non-randomized trials
have evaluated and landed with contradictory
results. Huang etal. performed a pooled analysis
of 1927 patients and reported that 5-year local
recurrence rates in patients treated with RT before
chemotherapy (CT) was 6.0% vs. 16.0% in
patients treated with CT before RT [17]. Buchholz
et al. reported decrease in overall survival and
disease-free survival in patients who received
delayed RT (>6months post-surgery) due to a
prolonged CT administration [18]. Benchalal
et al. reported no increase in local recurrence
whether RT was delivered directly after lumpectomy, either after the third CT cycle or the sixth
CT cycle [19]. However, in multivariate analyses
patients with positive margins experienced
increased local recurrence rates. In a Cochrane
review of published trials Bellon etal. concluded
that sequence of administration does not impact
on local recurrence or overall survival as soon as
RT is administered within 7months after surgery
[20]. Most of the above-mentioned studies,
reporting impact on local recurrence with late RT
delivery in order to administer CT rst, do not
provide data on overall survival. In general, no
robust evidence suggests any impact on overall
survival. RT administration after CT does not
result in decreased survival in most of the studies;
however, RT should be administered within
7months after surgery.
11.2.4 Managing Margin Positivity
Over the last decade oncological safe margin for
breast cancer has evolved, and nowadays if inked
margin is free it is considered safe and optimum
as any margin positivity leads to higher rate of
local recurrence and merits revision. However, in
cases of APBI surgical margins should be negative by at least 2mm [21]. A systematic review
reported that patients undergoing OPS experience 3–13% close margins and nearly 10%
achieve positive margins. The authors concluded
that a larger volume of resection does not ensure
margin negative surgery always [22]. There are
reports of nearly 30% [23] margin positive rate
after OPS whereas neither margin positivity rate
and local recurrence varied either with conventional breast conservation and OPS in other published data [24, 25]. Amabile et al. reported
microcalcications, tumor multifocality, and
obesity as predictors of re-excision after
OPS.Chen etal. in a metanalysis of all available
data found BCS along with OPS safe over BCS
alone and the additional OPS decreases re-
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