Introduction

For most of the 20th century, mastectomy was the surgical treatment of choice for breast cancer. Mastectomy is a disfiguring operation. Umberto Veronesi introduced breast conservation in the 1970s and has shown with multiple long-term studies that breast-conserving surgery has overall similar survival to mastectomy with a higher local recurrence rate. The rationale for considering breast-conserving surgery followed by radiation therapy came from several studies conducted in the 1970s and 1980s. From 1973 to 1980, the Milan Cancer Institute recruited patients for a randomized study to compare radical mastectomy with breast-conserving surgery termed ‘quadrantectomy’. Quadrantectomy, as the name implies, involves removing a quarter of the breast. There were 701 patients enrolled in the study who had invasive breast cancers with a maximum diameter of 2 cm or less and no palpable axillary nodes. Of these, 352 were randomized to breast conservation. All patients had a complete axillary dissection and radiation if they underwent breast conservation. Results at 20 years showed overall and breast cancer specific survival rates were similar in the two groups. Local recurrences were higher in the group that received breast-conserving therapy. The Milan Trial II was designed to compare ‘tumorectomy’ with axillary dissection and radiation therapy to ‘quadrantectomy’ with axillary dissection and radiation. A tumorectomy in this study is defined as excision of the tumor with a 2 mm margin of healthy tissue around it. The overall survival rate was not different in the two groups but the local recurrence rate in the tumorectomy group (13.3%) was twice that of the quadrantectomy (5.3%) group. Local recurrence was highest in patients with an extensive intraductal component.

The challenge is how to select which patients are best served by breast conservation and how to achieve balance between the need for a proper oncologic operation with an acceptable cosmetic result. In Europe, quadrantectomy is often favored because of its lower local recurrence rate; however, a larger volume of breast tissue is removed. The goal is to find a way to preserve the symmetry, shape and contour of the breast, while allowing these more aggressive resections to widely clear margins. Oncoplastic surgery attempts to do this. Oncoplastic surgery is the concept of combining a plastic surgery procedure with breast-conserving surgery to achieve a more favorable final cosmetic result without compromising oncologic principles. It is a broad term that covers tissue rearrangement within the patient’s breast, the use of prosthetic devices to supplement tissue, or the creation of additional volume by adding a native tissue flap. Many questions then arise: Who needs these reconstructive techniques? Should they be performed with muscle flaps or tissue rearrangement? When should they be performed? Should they be performed at the time of the original surgery; in an immediate–delayed fashion 2–3 weeks after the original surgery, or after radiation therapy is complete? What happens to patients who have positive margins after their original surgery? The following sections will review these reconstructive options.

Muscle flap

Losken et al reported on their series of 39 patients who underwent lumpectomy or quadrantectomy with immediate latissimus reconstruction. The average follow-up was 3.7 years. Four patients with DCIS (ductal carcinoma in situ) and 5 with invasive carcinoma had positive or inadequate margins. Two DCIS patients underwent re-excision and confirmation of negative margins. Of the 5 patients with invasive cancer, 2 had re-excision to clear margins, and 1 had a re-excision to negative margins but had a local recurrence 2 years later and underwent a mastectomy ( Table 2.1 ).

The authors reported no interference in follow-up imaging or physical examination in the diagnosis of local recurrence due to the flap. Several patients required resection of the latissimus flap to achieve local control of the tumor because of positive margins or tumor recurrence, causing loss of a useful muscle flap and significant morbidity. Not including patients with known metastatic disease at the time of original surgery, 7 of 39 patients (18%) lost their flap. The authors concluded that it was oncologically safer to not perform immediate latissimus transposition into a fresh lumpectomy site given this rate of flap losses. The need to have clear margins when performing breast conservation is important; however, with immediate oncoplastic surgery the need is imperative. An immediate flap reconstruction is not advised without having clearly established negative margins.

Tissue rearrangement

One of the largest series of tissue rearrangement procedures was reported by Clough et al, at the Institut Curie between July 1985 and June 1999. There were 101 consecutive women with breast carcinoma who underwent wide lumpectomy with tissue remodeling and mammaplasty as well as a contralateral symmetry procedure. Patients with large tumors in whom a standard lumpectomy would have been deforming but in whom clear margins could be obtained with a larger resection were chosen. Eighty-nine women had an immediate contralateral procedure and 12 women had a delayed procedure. On the affected side, 11 patients had involved margins. Six patients had a mastectomy and 5 had a boost to the tumor bed with no re-excision of margins. 20% of patients had an early complication. These complications included hematoma, seroma, abscess, delayed wound healing, skin necrosis, and nipple–areolar necrosis. Four patients required reoperation and 4 patients with delayed wound healing had a delay in radiation treatment. Seven patients developed a local recurrence, 4 of which were in the same quadrant, for a rate of 9.4% ( Fig. 2.1 ).

At a median follow-up of 46 months, 13 patients developed distant metastases. 88% of patients had acceptable cosmetic results (rated as excellent, good, or fair). In patients with poor results the most frequently cited flaw is that the residual breast volume is too small. Results were worse in patients who had received preoperative chemotherapy, as these patients had larger volumes resected. The authors concluded that their results demonstrate the feasibility of performing large resections and using local tissue rearrangement to fill the deficit. Their survival rates are comparable to large trials. The median weight of tissue removed was 222 g. With this amount, it was feasible to follow standard treatment protocols and to reconstruct the breast in an acceptable fashion.

Role of surgical margins

These authors, as in most series, report a local recurrence rate and a rate of metastases but do not clarify how much overlap there is between these groups. We know that inadequate margins lead to higher local recurrence rates. Recurrence rates as high as 17% have been reported when local excision was incomplete. We do know if inadequate resections lead to a higher rate of distant metastases or if those 5 patients with inadequate margins, who received a boost rather than a mastectomy, had their cancer care compromised by the decision. The authors were aiming for 1 cm margins and report that many of their patients had a wider rim. These wider excisions are beneficial from the oncologic point of view as they decrease the risk of local recurrence. They are also important when patients undergo neoadjuvant chemotherapy, because even when there is a response the tumor may shrink in a multi­focal fashion and a large resection still needs to be performed.