61 Principles of Oncoplastic Breast Surgery and Patient Selection
Oncoplastic surgery has assumed its rightful place in breast cancer management, attempting to retain adequate breast shape in the face of breast conservation surgery and radiation therapy associated with it. This chapter outlines the principles governing its use and patient selection for the procedures involved.
Indications for oncoplastic surgery.
Benefits of oncoplastic surgery.
Planning and timing.
Management of positive margins.
Management of the opposite breast.
Key Teaching Points
Oncoplastic surgery should be considered in any woman considered at risk for breast deformity following lumpectomy and radiation.
Oncoplastic reduction reduces the risk of long-term complications in patients undergoing radiation.
Understanding breast flap blood supply is critical to understanding which procedure is required for a given defect.
Respecting breast blood supply ensures parenchymal flap survival.
Large defects in moderate-to-larger-breasted women are ideally suited to this approach.
The goals of breast conservation surgery in the management of breast cancer include prevention of local recurrence with maintenance of sufficient tissue to produce a favorable breast shape. The risk of local recurrence is closely related to the adequacy of excision; the wider the margins, the lower the risk of local recurrence. For breast conservation to be effective, breast shape often has to be compromised because of the extent of resection required for tumor clearance.
Although the initial surgical procedure may result in significant distortion of the breast, subsequent radiation therapy adds additional risk for deformity with a breast shape that deteriorates over time.
Although the dosing and long-term effects of radiation therapy are beyond the surgeon’s control, it is feasible to manipulate the ultimate shape of the breast after a lumpectomy. This may be achieved in select patients through immediate reconstruction of partial mastectomy defects. The value of this technique, which has been called oncoplastic breast conservation ther-apy (BCT), becomes intuitively apparent. Oncoplastic breast conservation is achieved either through volume displacement or volume replacement techniques, depending on tumor location and size, and breast shape and volume.
The word oncoplastic is derived from the Greek onkos (“tumor”) and plastikos (“to mold”). Drs. Werner Audretsch from Dusseldorf and Krishna Clough from Paris introduced the concept of oncoplastic surgery to broaden the indications for breast conservation therapy and minimize the incidence of poor aesthetic results. As defined by them, this approach for managing quadrantectomy defects combined partial mastectomy with initial reconstruction of the deformity for women with breast cancer. In a review of 10,607 breast cancer surgeries, the oncoplastic approach was the one procedure with the biggest increase of nearly fourfold from 2007 to 2014. There is some inconsistency in how the oncoplastic approach is offered in various parts of the world. In the United Kingdom, the interest in oncoplastic surgery has increased over the last 15 years with significantly more breast surgeons performing reduction techniques and latissimus dorsi flaps. Seventy-five percent of breast surgeons there have an interest in further oncoplastic training, while plastic surgeons interested in further oncoplastic training dropped from 62 to 27%. A survey in Canada demonstrated that surgeons who did predominantly breast were more likely to use the oncoplastic technique and involve plastic surgeons. Those not performing oncoplastic procedures cited a lack of training and access to plastic surgeons as significant barrier. A survey in the United States of both breast and plastic surgeons agreed that complex partial reconstructions were best performed using the team approach and that margin concerns were a major concern and aesthetic benefits were a major driving force in both groups.
Growth in the field of oncoplastic surgery is being driven by patient demand, along with the development of combined surgical techniques made possible through greater interaction between specialties. Patients are most effectively managed by a multidisciplinary team of breast surgeons, reconstructive surgeons, radiologists, radiation oncologists, pathologists, and surgical and medical oncologists. Communication among the team members is critical. When breast conservation surgery is performed by two teams, the ablative surgeon must understand breast aesthetics and the potential for a poor cosmetic result, and the reconstructive surgeon must understand the various options for achieving an optimal outcome.
61.1 Benefits of the Oncoplastic Approach
The oncoplastic approach represents a promising method for balancing the goals of breast conservation surgery in some patients—offering adequate margins of excision with acceptable cosmetic results. Oncoplastic surgery also permits better radiation dosimetry with less cosmetic deformity in patients with large breasts. In a study from the Royal Marsden group, Gray and colleagues clearly demonstrated that the larger the breast of a patient undergoing breast conservation therapy, the worse the aesthetic outcome.
Reducing the breast volume with standard or modified breast reduction techniques not only helps to eliminate initial deformity after lumpectomy but also allows the radiation oncologist to provide more even dosimetry with less severe long-term fibrosis or fat necrosis.
Oncoplastic surgery expands the indications for breast conservation allowing the resection of much larger tumors relative to breast size, tumors larger than 4 cm, locally advanced cancers, and prior neoadjuvant chemotherapy that would otherwise only be treated with mastectomy. One of the initial driving forces behind the oncoplastic technique was the aesthetic benefits. Partial reconstruction prior to radiation therapy will minimize the number of BCT deformities and improve breast shape. Compared to partial mastectomy alone, there is less deformity long term especially after radiation with regard to possible nipple eversion volume loss deformity and breast asymmetry. Compared to simple mastectomy with reconstruction, the oncoplastic approach preserves breast tissue and sensation and has lower complication rates and without potential donor site morbidity.
In addition to broadening the indications for BCT and minimizing the potential for a poor cosmetic result, the oncoplastic approach has further benefits. A reduced breast increases the efficiency of postoperative radiation therapy, and physical examination and breast imaging are potentially easier in smaller breasts. The relief of symptoms of macromastia has been well documented.
The use of this approach also allows additional sampling of the ipsilateral breast with a reduction in metachronous breast cancer occurrence by 33% and a diagnosis of synchronous breast cancer on the opposite side of around 4%. Further reduction of risk by performing reduction mammaplasty is still debated, although removal of additional breast tissue through reduction techniques makes theoretical sense in terms of risk reduction for breast cancer.
Clough and colleagues stated that oncoplastic techniques allow more extensive resections with greater likelihood of tumor clearance with widely negative margins. We have similarly demonstrated this in our series, where the average weight of the resection using oncoplastic breast conservation is more than 230 g, compared with institutional norms in the United States of about 40 to 50 g for lumpectomy with a nononcoplastic approach. This does not include the additional glandular excisions necessary to achieve symmetry with the contralateral breast. The ability to widely excise the breast parenchyma, often with a quadrantectomy, reduces the incidence of positive margins. Positive margin rate is significantly lower in oncoplastic patients.
Benefits of Oncoplastic Surgery
Avoids a breast conservation therapy (BCT) deformity.
Broadens the indications for BCT and avoids the necessity of mastectomy in certain patients.
Maintains shape and symmetry.
Maximizes resection to reduce local recurrence.
Improves radiation dosing for larger-breasted women.
Reduces complications associated with irradiating a large breast.
Potentially improves oncologic safety.