Oncoplasty versus Mastectomy: Decisions and Outcomes

Introduction

As reconstructive techniques have improved, patient expectations have evolved. From the simplest to the most complex resection, patients expect to be satisfied with their final esthetic result. Trying to decide on the operation that is best for patients now involves not only understanding the tumor biology but also patient preference and how to achieve the best esthetic results. Patients can choose breast conservation with or without oncoplastic reconstruction, and mastectomy with nipple sparing or without and with or without reconstruction. The challenge is helping the patient choose the optimal oncologic and cosmetic solution for them.

Understanding expectation is critical before operative intervention. For some women, it is important to preserve as much of their natural breast as possible; whereas for others, achieving the lowest local recurrence risk is the driving force even when the statistical benefit is minimal. Some women hope to end up with a smaller or larger breast. In all cases, the role of the breast surgeon is to help patients understand their choices.

Safety of Oncoplastic Breast Surgery

Oncoplastic surgery is considered oncologically safe. A review of outcomes demonstrated high rates of overall survival (95%) and disease-free survival (90%) as well as low rates of local recurrence (3.2%), positive margins (10.8%), and re-excisions (6%). Equivalent survival rates are an accepted norm. A population study of early breast cancer in the Netherlands suggests an improvement in overall survival in early stage breast cancer compared with mastectomy, likely due to the added benefit of radiation. For years, we have recognized that shrinking the tumor with neoadjuvant chemotherapy can allow a better cosmetic outcome and increase the chance of breast conservation.

Benefits of Oncoplastic Surgery

The benefits of oncoplastic surgery have been demonstrated throughout the literature. In a review from the MD Anderson Cancer Center of 9861 patients with breast conservation and oncoplastic reconstruction, it was demonstrated that there was a lower rate of seroma formation (13.4 vs 18%, p = 0.002) and a lower rate of positive margins (5.8 vs 8.3%, p = 0.04). Although mastectomy rates have increased across the country, the MD Anderson review demonstrated that rates of breast conservation with oncoplastic reconstruction have also increased. Patients choosing oncoplasty tend to be older than patients choosing mastectomy; however, obesity rates were similar. The majority of patients (75%) in the study had a T1 or T2 tumor; however, patients who chose oncoplastic reconstruction tended to have larger tumors, and the majority of patients who had lymph node-positive breast cancer and T4 tumors chose mastectomy.

The location and characteristics of the tumor are other factors that can influence choice. The quadrant the tumor was located in did not influence the choice of oncoplastic reconstruction except when located in the lower outer quadrant, in which case slightly more women had breast conservation alone. Tumor characteristics were generally similar, with a slight increase in HER-2 neu positive tumors choosing oncoplastic reconstruction, as did patients who underwent neoadjuvant chemotherapy. This may have to do with the fact that their tumors were larger at diagnosis and so, in the initial discussion on surgical options, the suggestion for oncoplastic reconstruction was made.

Wound-related complications and surgical site infections were lower in patients who underwent breast conservation and oncoplastic reconstruction compared with mastectomy and reconstruction. The seroma rate was lower with oncoplastic reconstruction compared with breast-conserving surgery alone. The hematoma rate was lower compared with mastectomy, as was wound-related complications.

The goal of oncoplastic surgery is to improve the esthetic outcome while performing an oncologically safe operation. A Brazilian study compared esthetic results using a semiautomatic software device demonstrating improved outcomes with oncoplastic surgery. In general, when surgeons evaluate esthetic outcomes, they are more favorable to oncoplastic resection than patients are. In a recent review of observational studies that included 8659 patients, it was demonstrated that patient satisfaction was increased after oncoplastic surgery compared with breast-conserving surgery; however, the difference was slight (89.5% vs 82.9%).

As the field of oncoplastic surgery has evolved over the past decade, many breast and plastic surgeons remember the significant contour deformities that occurred with breast conservation alone. Managing patient expectations is an important aspect for all surgical procedures of the breast because patients will often compare their outcomes to their original breasts or to ideal versions that they have seen in images. We have found in our institution that, although patients are initially surprised by the change, as time goes on they are generally pleased. The patients who express the greatest satisfaction are those with larger more ptotic breasts who in essence have a lift and reduction with increased projection. Patients with smaller breasts who chose breast conservation because it is a simpler and less invasive operation are often disappointed because of the flattening and loss of projection that can occur.

A Spanish review of 801 patients comparing oncoplastic reduction mammaplasty to tumorectomy alone demonstrated similar overall survival at 10 years. Patients undergoing oncoplastic reconstruction were younger, had larger tumors, and the tumor was most likely located in the lower pole. Although the oncoplastic reduction mammaplasty cohort had a higher rate of tissue necrosis (2.5% vs 0.1%), both were low. In their experience, reduction mammaplasty using an inverted T pattern made up 17% of the group. Adverse events related to this approach included an increased risk of having a lower pole deformity as well as delayed healing or tissue necrosis. Similar to other studies, they demonstrated that ductal carcinoma in situ (DCIS), invasive lobular cancer, and larger tumors were the most likely causes of positive margins. The BreastQ questionnaire was used and demonstrated that patient satisfaction ranged from 70–83 out of 100 at the 1-year mark with regard to psychosocial status as well as satisfaction of the breast in the sexual sphere.

Radiation and Oncoplastic Surgery

The question often arises, does radiation therapy harm oncoplastic reconstruction? The majority of patients having breast conservation will receive radiation unless they are elderly or have a favorable in situ cancer. The indications for radiation have broadened over the years such that many patients after mastectomy with one or two positive lymph nodes will have radiation therapy in lieu of an axillary dissection. Other indications for radiation therapy include having three or more positive lymph nodes. In a recent systematic review of oncoplastic surgery in the setting of breast conservation, Yoon et al did not find any increased local recurrence following whole breast radiation and boost given to patients who had an oncoplastic reconstruction. In this review, the benefits of whole breast irradiation (WBI) and accelerated partial breast irradiation (APBI) were reviewed. The general consensus was that the data on APBI with breast conservation therapy (BCT) and oncoplastic surgery with WBI is still early to make any meaningful comparisons. The study found that 70–100% of patients reported good to excellent satisfaction. One of the limitations of APBI becomes evident in the patient who has had oncoplastic tissue rearrangement; the location of the actual tumor bed may be obscured, and there may not be space to place and expand the catheter. New emerging techniques that can accurately deliver APBI externally may overcome the challenge of placing catheters in this space. Given the safety and positive cosmetic results with radiation and oncoplastic surgery, there may be an esthetic advantage to oncoplasty over mastectomy. Figs. 4.1–4.3 illustrate a patient following oncoplastic reconstruction.