Original Article
Assessment of cosmetic outcome of oncoplastic breast conservation surgery in women with early breast cancer: A prospective cohort study Adimulam G, Challa VR, Dhar A, Chumber S, Seenu V, Srivastava A Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India Correspondence to: Dr. Anurag Srivastava, E-mail: [email protected]
Abstract
BACKGROUND: The aim of this study was to assess the cosmetic outcome of patients undergoing oncoplastic breast conserving surgery in Indian population. MATERIALS AND METHODS: A prospective cohort of 35 patients who were eligible for breast conservation surgery was included in
the study from year 2007 to 2009. Patients with central quadrant tumors were excluded from the study. A double ‑ blind cosmetic assessment was done by a plastic surgeon and a senior nurse not involved in the management of patients. Moreover, self‑assessment was carried out by the patient regarding the satisfaction of surgery, comfort with brasserie, social and sexual life after oncoplastic surgery. RESULTS: In this study, 35 patients underwent oncoplastic breast conservation surgery by various techniques. The cosmetic outcome scores of the surgeon and nurse were analyzed for inter rater agreement using inter‑class Correlation Coefficients. There was a good association between them. The risk factors for poor cosmetic outcome was studied by univariate analysis and significant correlation was obtained with age, volume of breast tissue excised and estimated percentage of breast volume excised (P 4 cm, two or more tumors involving more than one quadrant, patients with previous breast irradiation, patients with a previous history of surgery on the same breast and tumors involving central quadrant were excluded from the study. All patients included in the study underwent sonomammogram of both breasts. Patients with suspicious axillary nodes were subjected to ultrasound guided Fine needle aspiration cytology (FNAC). All patients whose FNAC was reported as positive for nodal metastasis underwent full axillary dissection without sentinel lymph node biopsy (SLNB). Patients were assessed by the operating surgeons and radiation oncologist preoperatively and pre‑operative counseling done in the departmental Breast Cancer clinic. Preoperative estimated breast volume was measured in lying down position with arm above the head and a small pillow below the ipsilateral shoulder. The device used was Grossman and Rounder method. In this method a transparent plastic sheet is molded into the shape of the breast, and the reading over the edge of sheet gives the approximate breast volume in milliliters [Figure 1a and b]. For patients with clinically and sonographically negative axilla, SLNB was performed by combined technique using Tc‑99m sulfur colloid and Isosulphane blue dye. Blue and/or hot nodes and any palpable nodes were removed and sent for frozen section. Full axillary lymph node dissection (ALND) was carried out in those patients showing metastasis in the sentinel node. The tumor was excised with 2 cm margin all around the tumor. In large tumors this amounted to quadrantectomy. The tumor was approached through a curvilinear elliptical incision in the upper half of the breast and a radial incision Indian Journal of Cancer | January–March 2014 | Volume 51 | Issue 1
Adimulam, et al.: Oncoplastic breast surgery‑cosmetic outcome
in the lower half. In case of tumors located near the axilla, we approached the lesion as well as axillary nodes through a single incision placed along the natural axillary skin crease. The oncoplastic technique varied depending on the location of tumor, size of the breast and volume of the breast tissue excised. After removing the tumor, the volume and weight of the specimen measured immediately. Volume of the excised specimen was measured using water displacement method. The specimen was cut open to assess tumor size and width of margins. In the follow‑up, patients were seen jointly by the multidisciplinary team to plan the adjuvant therapy and thereafter patients were seen 3 monthly in the breast clinic. Cosmetic assessment was performed 6 months after surgery. The cosmetic assessment was carried out by a single lady nurse and a plastic surgeon who were not involved in patient management. Cosmetic score was assessed individually using the predetermined criteria. The seven criteria included were shape with brasserie, shape without brasserie, symmetry to the opposite breast, mobility, condition of inframammary fold, consistency and overall appearance. Patients were also given a questionnaire for the subjective assessment of satisfaction after surgery. The four criteria used were satisfaction after surgery, comfort with brasserie, social and sexual life after BCS. The Statistical software namely SAS 9.2, SPSS 15.0, Stata 10.1, MedCalc 9.0.1, Systat 12.0 and R environment version 2.11.1 were used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables, etc., The degree of agreement between plastic surgeon and nurse in assessing cosmesis was assessed using inter‑class correlation (ICC). Various factors affecting cosmetic outcome and margin status were correlated with surgeon’s total cosmetic score. Status of pathological margin (positive vs. negative) was analyzed in terms of tumor size, age, neoadjuvant chemotherapy. For continuous variables, Mann‑Whitney U test was used and for categorical variables, Fisher’s exact test was applied.
a
b
c
d
Figure 1: (a) Grossman Rounder device. (b) Measurement of breast volume using Grossman Rounder device. (c) Inframammary fold oncoplasty for lower half tumors of breast. (d)Lateral axillary crease incision for lateral half tumors
Indian Journal of Cancer | January–March 2014 | Volume 51 | Issue 1
Results A total of 35 patients of early breast cancer were recruited. The results were obtained with a minimum follow‑up period of 6 months. Four patients received neoadjuvant chemotherapy three cycles of FEC regimen, i.e., 5‑Fluorouracil, Epirubicin, Cyclophosphamide as they had clinical tumor size of 4 cm with smaller breasts. The mean age of the patients was 46.94 years ± 10.45 (Range: 35‑59 years). The mean clinical size of the tumor was 2.84 cm ± 0.8 cm (Range: 1.4‑4 cm). Of 35 patients, 23 had tumor located in the upper outer quadrant (UOQ), 4 in the upper inner quadrant (UIQ), 5 in the lower inner quadrant (LIQ) and 3 in the lower outer quadrant (LOQ). The type of oncoplastic procedure was based on the location of tumor, percentage of breast volume excised and the need for ALND/SLNB [Figures 1 and 2]. Type of oncoplasty techniques performed are listed in Table 1. Volume of excised specimen was in the range of 210‑380 ml. Mean volume was 293 ml. The mean estimated percentage of breast volume excised (EPBVE) was 26.6% (Range: 20‑32%). A second surgery was performed in five patients (14.3%). Three had positive margins, one patient developed a hematoma on the postoperative day 6 that needed surgical evacuation. One patient developed radiation induced non‑healing ulcer after 6 months of surgery. Of the three patients with positive margins, margin revision was performed in two patients and mastectomy was performed in one patient. During the mean follow‑up period of 28 months (Range: 6 months‑48 months), none of the patient developed recurrence. Simple mastectomy was performed for the patient with radiation induced non‑healing ulcer [Figure 3e]. Status of pathological margin (positive vs. negative) were analyzed in terms of tumor volume excised, age and neoadjuvant chemotherapy. None of these factors analyzed had a significant effect on pathological margin. Whole breast
a
b
c
d
Figure 2: Oncoplasty techniques. (a and b) Technique of superior pedicle based dermoglandular oncoplasty performed for lower half tumors. (c and d) Cosmetic result following dough-nut mastopexy for tumors close to nipple areola complex
59
Adimulam, et al.: Oncoplastic breast surgery‑cosmetic outcome
irradiation (50 Gy, 25 fractions) followed by the boost to the tumor bed (16 Gy, 8 fractions) were given in 33 patients. Two patients received accelerated partial breast irradiation through interstitial brachytherapy ports [Figure 3d]. Thirty two patients received adjuvant chemotherapy. Twenty patients who were Estrogen/Progesterone positive received hormonal therapy.
good or excellent results. Total cosmetic scores given by a plastic surgeon and nurse were analyzed for inter‑rater agreement using ICC. There was outstanding agreement between the two observers (ICC value: 0.8946). Since there was outstanding inter‑rater agreement between the surgeon and nurse regarding cosmetic outcome, we tried to analyze the factors affecting this outcome, using univariate analysis. Analysis was performed to find out the correlation between the cosmetic score provided by the surgeon and various factors such as age of the patient, tumor size, site of tumor, volume of specimen removed, breast volume, ALND and axillary radiotherapy. Continuous variables, i.e., age, tumor size, breast volume, volume of specimen, percentage of breast volume excised were analyzed using Pearson Correlation. Categorical variables, i.e., site of tumor, ALND, axillary radiotherapy were analyzed using student t‑test. Since the majority of tumors in our study were in UOQ, we compared this site of tumor with other sites combined (i.e., UIQ + LOQ + LIQ). The results are given in Table 2. The overall rate of immediate complications in our study was 14.2% (5/35). Three patients developed wound infection, one patient developed hematoma and one patient developed flap necrosis. Three patients who developed wound infection were managed with a course of antibiotics and it did not affect the final cosmesis. Four patients developed arm edema (11.4%). Self‑assessment by the patient was assessed by a questionnaire, of which 12 out of 25 women (48%) were extremely satisfied with surgery, 12 (48%) women were moderately satisfied and one woman (4%) was not satisfied. Fourteen out of 25 women (56%) reported that they were comfortable with brasserie. Ten women (40%) were comfortable with minor adjustments. One woman (4%) told that she was uncomfortable with brasserie. None of them reported that they need a pad to mask the cosmetic deformity. Majority, 84% (21/25) of women felt that their social life was not affected by the surgery. Three women (12%) expressed that their social life was improved with surgery; where as
Cosmetic outcome could be assessed in 25 patients (2 patients who underwent mastectomy and 8 patients who underwent BCS were lost to follow‑up were excluded). It was assessed by seven variables (shape with bra, shape without bra, symmetry, mobility, consistency, appearance of infra mammary fold and overall appearance.) The final score (range: 7 to 26) was the sum of individual scores for the seven variables. The cosmetic outcome was assessed by a plastic surgeon and a nurse independently, using the same seven criteria. The score obtained was categorized into four outcomes as poor (≤15), fair (16‑18), good (19‑22) and excellent (23‑26). Total score given by surgeon was in the range of 8‑25. Average score was 18.8. Total score given by nurse was in the range of 11‑26. Average score was 20.12. Both of them had 12% of patients with poor cosmetic outcome and the rest of the patients had fair, Table 1: Type of oncoplasty procedure performed Oncoplasty procedure
Number of patients (%)
Curvilinear incision with breast parenchymal advancement flap (Figure 3c) Lateral axillary crease oncoplasty (Figure 1d) Round block/donut mastopexy (Figure 2c and d) Radial segmental oncoplasty (Figure 3a and b) Dermoglandular oncoplasty (Figure 2a and b) Inframammary fold oncoplasty (Figure 1c) Parallelogram incision over the lump Mini latissimus dorsi flap Rotation oncoplasty
17 (48.5)
Total
35 (100)
2 (5.7) 1 (2.9) 2 (5.7) 4 (11.4) 3 (8.6) 4 (11.4) 1 (2.9) 1 (2.9)
a
c
b
d
e
Figure 3: (a and b) Radial segmentectomy for Upper quadrant tumor and axillary dissection performed through the same incision. (c) Curvilinear incision with breast advancement flap for the upper half tumors. (d) Accelerated partial breast irradiation by Brachytherapy. (e) Radiation induced non-healing ulcer with intense fibrosis and poor cosmesis
60
Indian Journal of Cancer | January–March 2014 | Volume 51 | Issue 1
Adimulam, et al.: Oncoplastic breast surgery‑cosmetic outcome
Table 2: Univariate analysis between surgeon’s total cosmetic score and other variables P value#
Variable
Test applied
Age Size of tumor Estimated breast volume Volume of specimen EPBVE Site of tumor ALND
Pearson correlation Pearson correlation Pearson correlation
0.024 0.392 0.371
Comment Significant Not significant Not significant
Pearson correlation
0.019
Significant
Pearson correlation Student t test Student t test
0.017 0.107 0.775
Significant Not significant Not significant
Axillary RT
Student t test
0.608
Not significant
P value showing the significance of the variable in the cosmetic outcome. EPBVE=Estimated percentage of breast volume excised; ALND=Axillary lymph node dissection; RT=Radiotherapy #
1 woman (4%) reported deterioration in surgery. Seventeen women (68%) felt that was not affected after surgery, whereas 8 reported that their sexual life detoriorated
social life after their sexual life women (32%) after surgery.
Discussion Oncoplastic surgery according to Audretsch is tumor specific immediate reconstruction for breast conservation by using plastic techniques.[4,5] John Bostwick III described oncoplastic breast surgery for reconstruction after breast conservation or total mastectomy, immediate or delayed reconstruction, immediate repair for locally advanced breast cancers and recurrence. [5] Clough described two levels depending on the volume of breast tissue and the complexity of reconstruction procedure. [6] Urban had described three classes in order to improve the skills of surgical trainees based on the complexity of the procedure.[7‑9] Hoffmann developed a complex classification system where he described two type, six tier classification system with 12 main categories, 13 subcategories and 39 sub‑sub categories for oncoplastv breast surgery.[10] Various classifications were proposed to define when should a volume displacement technique to be used and when a volume replacement technique to be done. Selection criteria for volume displacement or volume replacement technique was based on the amount of breast tissue excised (100 cm 3 of breast tissue was removed. [19] In our study mean EPBVE was 26.6% and we found significant negative correlation between EPBVE and cosmesis. Recently a study by Niwinska et al., found quadrantectomy and brachytherapy were associated with poor cosmetic outcome when compared with tumorectomy and electrons.[20] In the present study, two patients received brachytherapy irradiation and both of them developed infection, though they didn’t have poor cosmetic outcome. Few studies showed that axillary lymph node radiotherapy was associated with poorer outcome, though in the present study it was not significant.[21,22] A systematic review of oncoplastic breast surgery was carried out by Franceschini et al., were they evaluated 11 studies on volume displacement techniques. This study showed that risk of margin involvement varied from 0% to 18.9%, risk of local recurrence from 0% to 13% and excellent‑good cosmetic result was obtained in 70% to 95% of patients.[11] In the present study, the incidence of immediate complications was 8.5% (3/35) with no local recurrence. In a study by Patterson et al., appearance of the treated breast was rated good to excellent by 94%, although 88% noted a difference of slight to moderate degree between treated and untreated breasts. [21] In the present study, none of the patients underwent mastopexy/ reduction mammoplasty to the contralateral breast though they had been counseled for a second surgery for better cosmesis. In our study, as analyzed by a plastic surgeon and nurse, 88% of patients had good to excellent outcomes and when objective assessment by patient satisfaction on cosmetic outcome was done 96% of patients had good to excellent results on satisfaction of the cosmesis. This 61
Adimulam, et al.: Oncoplastic breast surgery‑cosmetic outcome
satisfaction was not necessarily based on objective criteria defining esthetic parameters, but is strongly influenced by preservation of the breast as an original body part. Since the loss of breast would be considered as loss of feminity and a social stigma, mere preservation of breast provides high satisfaction. Conclusion
12. 13.
14.
Oncoplastic breast conservation surgery should be offered to all patients undergoing wide local excision of breast tumor. It involves simple techniques and most of the time breast advancement will suffice. Patient satisfaction with BCS and oncoplasty is very high.
15.
16.
References 1. Clough KB, Cuminet J, Fitoussi A, Nos C, Mosseri V. Cosmetic sequelae after conservative treatment for breast cancer: Classification and results of surgical correction. Ann Plast Surg 1998;41:471‑81. 2. D’Aniello C, Grimaldi L, Barbato A, Bosi B, Carli A. Cosmetic results in 242 patients treated by conservative surgery for breast cancer. Scand J Plast Reconstr Surg Hand Surg 1999;33:419‑22. 3. Lanitis S, Hadjiminas D. Oncoplastic surgery: Taking breast surgery to the next level. Hell J Surg 2012;84:92‑105. 4. Audretsch W. Space‑holding technic and immediate reconstruction of the female breast following subcutaneous and modified radical mastectomy. Arch Gynecol Obstet 1987;241 Suppl:S11‑9. 5. Rancati A, Gonzalez E, Dorr J, Angrigiani C. Oncoplastic surgery in the treatment of breast cancer. Ecancermedicalscience 2013;7:293. 6. Clough KB, Kaufman GJ, Nos C, Buccimazza I, Sarfati IM. Improving breast cancer surgery: A classification and quadrant per quadrant atlas for oncoplastic surgery. Ann Surg Oncol 2010;17:1375‑91. 7. Urban C, Lima R, Schunemann E, Spautz C, Rabinovich I, Anselmi K. Oncoplastic principles in breast conserving surgery. Breast 2011;20 Suppl 3:S92‑5. 8. Urban CA. Oncoplastic in a pre‑paradigm era: A Brazilian perspective in an American problem. Plast Reconstr Surg 2010;125:1839‑41;1841. 9. de Andrade Urban C. New classification for oncoplastic procedures in surgical practice. Breast 2008;17:321‑2. 10. Hoffmann J, Wallwiener D. Classifying breast cancer surgery: A novel, complexity‑based system for oncological, oncoplastic and reconstructive procedures, and proof of principle by analysis of 1225 operations in 1166 patients. BMC Cancer 2009;9:108. 11. Franceschini G, Terribile D, Magno S, Fabbri C, Accetta C, Di Leone A,
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et al. Update on oncoplastic breast surgery. Eur Rev Med Pharmacol Sci 2012;16:1530‑40. Kaur N, Petit JY, Rietjens M, Maffini F, Luini A, Gatti G, et al. Comparative study of surgical margins in oncoplastic surgery and quadrantectomy in breast cancer. Ann Surg Oncol 2005;12:539‑45. Giacalone PL, Roger P, Dubon O, El Gareh N, Rihaoui S, Taourel P, et al. Comparative study of the accuracy of breast resection in oncoplastic surgery and quadrantectomy in breast cancer. Ann Surg Oncol 2007;14:605‑14. Gray JR, McCormick B, Cox L, Yahalom J. Primary breast irradiation in large‑breasted or heavy women: Analysis of cosmetic outcome. Int J Radiat Oncol Biol Phys 1991;21:347‑54. Touboul E, Belkacemi Y, Lefranc JP, Uzan S, Ozsahin M, Korbas D, et al. Early breast cancer: Influence of type of boost (electrons vs iridium‑192 implant) on local control and cosmesis after conservative surgery and radiation therapy. Radiother Oncol 1995;34:105‑13. Steeves RA, Phromratanapongse P, Wolberg WH, Tormey DC. Cosmesis and local control after irradiation in women treated conservatively for breast cancer. Arch Surg 1989;124:1369‑73. Vrieling C, Collette L, Fourquet A, Hoogenraad WJ, Horiot JH, Jager JJ, et al. The influence of patient, tumor and treatment factors on the cosmetic results after breast‑conserving therapy in the EORTC ‘boost vs. no boost’ trial. EORTC Radiotherapy and breast cancer cooperative groups. Radiother Oncol 2000;55:219‑32. Cochrane RA, Valasiadou P, Wilson AR, Al‑Ghazal SK, Macmillan RD. Cosmesis and satisfaction after breast ‑ conser ving surger y correlates with the percentage of breast volume excised. Br J Surg 2003;90:1505‑9. Taylor ME, Perez CA, Halverson KJ, Kuske RR, Philpott GW, Garcia DM, et al. Factors influencing cosmetic results after conservation therapy for breast cancer. Int J Radiat Oncol Biol Phys 1995;31:753‑64. Niwinska A, Galecki J, Monika N, Hanna T. Risk factors of cosmetic outcome in early breast cancer patients after breast conserving therapy. Open Breast Cancer J 2009;1:18‑24. Borger JH, Kemperman H, Smitt HS, Hart A, van Dongen J, Lebesque J, et al. Dose and volume effects on fibrosis after breast conservation therapy. Int J Radiat Oncol Biol Phys 1994;30:1073‑81. Patterson MP, Pezner RD, Hill LR, Vora NL, Desai KR, Lipsett JA. Patient self‑evaluation of cosmetic outcome of breast‑preserving cancer treatment. Int J Radiat Oncol Biol Phys 1985;11:1849‑52. How to site this article: Adimulam G, Challa VR, Dhar A, Chumber S, Seenu V, Srivastava A. Assessment of cosmetic outcome of oncoplastic breast conservation surgery in women with early breast cancer: A prospective cohort study. Indian J Cancer 2014;51:58-62. Source of Support: Nil. Conflict of Interest: None declared.
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Assessment of cosmetic outcome of oncoplastic breast conservation surgery in women with early breast cancer: A prospective cohort study Adimulam G, Challa VR, Dhar A, Chumber S, Seenu V, Srivastava A Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India Correspondence to: Dr. Anurag Srivastava, E-mail: [email protected]
Abstract
BACKGROUND: The aim of this study was to assess the cosmetic outcome of patients undergoing oncoplastic breast conserving surgery in Indian population. MATERIALS AND METHODS: A prospective cohort of 35 patients who were eligible for breast conservation surgery was included in
the study from year 2007 to 2009. Patients with central quadrant tumors were excluded from the study. A double ‑ blind cosmetic assessment was done by a plastic surgeon and a senior nurse not involved in the management of patients. Moreover, self‑assessment was carried out by the patient regarding the satisfaction of surgery, comfort with brasserie, social and sexual life after oncoplastic surgery. RESULTS: In this study, 35 patients underwent oncoplastic breast conservation surgery by various techniques. The cosmetic outcome scores of the surgeon and nurse were analyzed for inter rater agreement using inter‑class Correlation Coefficients. There was a good association between them. The risk factors for poor cosmetic outcome was studied by univariate analysis and significant correlation was obtained with age, volume of breast tissue excised and estimated percentage of breast volume excised (P 4 cm, two or more tumors involving more than one quadrant, patients with previous breast irradiation, patients with a previous history of surgery on the same breast and tumors involving central quadrant were excluded from the study. All patients included in the study underwent sonomammogram of both breasts. Patients with suspicious axillary nodes were subjected to ultrasound guided Fine needle aspiration cytology (FNAC). All patients whose FNAC was reported as positive for nodal metastasis underwent full axillary dissection without sentinel lymph node biopsy (SLNB). Patients were assessed by the operating surgeons and radiation oncologist preoperatively and pre‑operative counseling done in the departmental Breast Cancer clinic. Preoperative estimated breast volume was measured in lying down position with arm above the head and a small pillow below the ipsilateral shoulder. The device used was Grossman and Rounder method. In this method a transparent plastic sheet is molded into the shape of the breast, and the reading over the edge of sheet gives the approximate breast volume in milliliters [Figure 1a and b]. For patients with clinically and sonographically negative axilla, SLNB was performed by combined technique using Tc‑99m sulfur colloid and Isosulphane blue dye. Blue and/or hot nodes and any palpable nodes were removed and sent for frozen section. Full axillary lymph node dissection (ALND) was carried out in those patients showing metastasis in the sentinel node. The tumor was excised with 2 cm margin all around the tumor. In large tumors this amounted to quadrantectomy. The tumor was approached through a curvilinear elliptical incision in the upper half of the breast and a radial incision Indian Journal of Cancer | January–March 2014 | Volume 51 | Issue 1
Adimulam, et al.: Oncoplastic breast surgery‑cosmetic outcome
in the lower half. In case of tumors located near the axilla, we approached the lesion as well as axillary nodes through a single incision placed along the natural axillary skin crease. The oncoplastic technique varied depending on the location of tumor, size of the breast and volume of the breast tissue excised. After removing the tumor, the volume and weight of the specimen measured immediately. Volume of the excised specimen was measured using water displacement method. The specimen was cut open to assess tumor size and width of margins. In the follow‑up, patients were seen jointly by the multidisciplinary team to plan the adjuvant therapy and thereafter patients were seen 3 monthly in the breast clinic. Cosmetic assessment was performed 6 months after surgery. The cosmetic assessment was carried out by a single lady nurse and a plastic surgeon who were not involved in patient management. Cosmetic score was assessed individually using the predetermined criteria. The seven criteria included were shape with brasserie, shape without brasserie, symmetry to the opposite breast, mobility, condition of inframammary fold, consistency and overall appearance. Patients were also given a questionnaire for the subjective assessment of satisfaction after surgery. The four criteria used were satisfaction after surgery, comfort with brasserie, social and sexual life after BCS. The Statistical software namely SAS 9.2, SPSS 15.0, Stata 10.1, MedCalc 9.0.1, Systat 12.0 and R environment version 2.11.1 were used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables, etc., The degree of agreement between plastic surgeon and nurse in assessing cosmesis was assessed using inter‑class correlation (ICC). Various factors affecting cosmetic outcome and margin status were correlated with surgeon’s total cosmetic score. Status of pathological margin (positive vs. negative) was analyzed in terms of tumor size, age, neoadjuvant chemotherapy. For continuous variables, Mann‑Whitney U test was used and for categorical variables, Fisher’s exact test was applied.
a
b
c
d
Figure 1: (a) Grossman Rounder device. (b) Measurement of breast volume using Grossman Rounder device. (c) Inframammary fold oncoplasty for lower half tumors of breast. (d)Lateral axillary crease incision for lateral half tumors
Indian Journal of Cancer | January–March 2014 | Volume 51 | Issue 1
Results A total of 35 patients of early breast cancer were recruited. The results were obtained with a minimum follow‑up period of 6 months. Four patients received neoadjuvant chemotherapy three cycles of FEC regimen, i.e., 5‑Fluorouracil, Epirubicin, Cyclophosphamide as they had clinical tumor size of 4 cm with smaller breasts. The mean age of the patients was 46.94 years ± 10.45 (Range: 35‑59 years). The mean clinical size of the tumor was 2.84 cm ± 0.8 cm (Range: 1.4‑4 cm). Of 35 patients, 23 had tumor located in the upper outer quadrant (UOQ), 4 in the upper inner quadrant (UIQ), 5 in the lower inner quadrant (LIQ) and 3 in the lower outer quadrant (LOQ). The type of oncoplastic procedure was based on the location of tumor, percentage of breast volume excised and the need for ALND/SLNB [Figures 1 and 2]. Type of oncoplasty techniques performed are listed in Table 1. Volume of excised specimen was in the range of 210‑380 ml. Mean volume was 293 ml. The mean estimated percentage of breast volume excised (EPBVE) was 26.6% (Range: 20‑32%). A second surgery was performed in five patients (14.3%). Three had positive margins, one patient developed a hematoma on the postoperative day 6 that needed surgical evacuation. One patient developed radiation induced non‑healing ulcer after 6 months of surgery. Of the three patients with positive margins, margin revision was performed in two patients and mastectomy was performed in one patient. During the mean follow‑up period of 28 months (Range: 6 months‑48 months), none of the patient developed recurrence. Simple mastectomy was performed for the patient with radiation induced non‑healing ulcer [Figure 3e]. Status of pathological margin (positive vs. negative) were analyzed in terms of tumor volume excised, age and neoadjuvant chemotherapy. None of these factors analyzed had a significant effect on pathological margin. Whole breast
a
b
c
d
Figure 2: Oncoplasty techniques. (a and b) Technique of superior pedicle based dermoglandular oncoplasty performed for lower half tumors. (c and d) Cosmetic result following dough-nut mastopexy for tumors close to nipple areola complex
59
Adimulam, et al.: Oncoplastic breast surgery‑cosmetic outcome
irradiation (50 Gy, 25 fractions) followed by the boost to the tumor bed (16 Gy, 8 fractions) were given in 33 patients. Two patients received accelerated partial breast irradiation through interstitial brachytherapy ports [Figure 3d]. Thirty two patients received adjuvant chemotherapy. Twenty patients who were Estrogen/Progesterone positive received hormonal therapy.
good or excellent results. Total cosmetic scores given by a plastic surgeon and nurse were analyzed for inter‑rater agreement using ICC. There was outstanding agreement between the two observers (ICC value: 0.8946). Since there was outstanding inter‑rater agreement between the surgeon and nurse regarding cosmetic outcome, we tried to analyze the factors affecting this outcome, using univariate analysis. Analysis was performed to find out the correlation between the cosmetic score provided by the surgeon and various factors such as age of the patient, tumor size, site of tumor, volume of specimen removed, breast volume, ALND and axillary radiotherapy. Continuous variables, i.e., age, tumor size, breast volume, volume of specimen, percentage of breast volume excised were analyzed using Pearson Correlation. Categorical variables, i.e., site of tumor, ALND, axillary radiotherapy were analyzed using student t‑test. Since the majority of tumors in our study were in UOQ, we compared this site of tumor with other sites combined (i.e., UIQ + LOQ + LIQ). The results are given in Table 2. The overall rate of immediate complications in our study was 14.2% (5/35). Three patients developed wound infection, one patient developed hematoma and one patient developed flap necrosis. Three patients who developed wound infection were managed with a course of antibiotics and it did not affect the final cosmesis. Four patients developed arm edema (11.4%). Self‑assessment by the patient was assessed by a questionnaire, of which 12 out of 25 women (48%) were extremely satisfied with surgery, 12 (48%) women were moderately satisfied and one woman (4%) was not satisfied. Fourteen out of 25 women (56%) reported that they were comfortable with brasserie. Ten women (40%) were comfortable with minor adjustments. One woman (4%) told that she was uncomfortable with brasserie. None of them reported that they need a pad to mask the cosmetic deformity. Majority, 84% (21/25) of women felt that their social life was not affected by the surgery. Three women (12%) expressed that their social life was improved with surgery; where as
Cosmetic outcome could be assessed in 25 patients (2 patients who underwent mastectomy and 8 patients who underwent BCS were lost to follow‑up were excluded). It was assessed by seven variables (shape with bra, shape without bra, symmetry, mobility, consistency, appearance of infra mammary fold and overall appearance.) The final score (range: 7 to 26) was the sum of individual scores for the seven variables. The cosmetic outcome was assessed by a plastic surgeon and a nurse independently, using the same seven criteria. The score obtained was categorized into four outcomes as poor (≤15), fair (16‑18), good (19‑22) and excellent (23‑26). Total score given by surgeon was in the range of 8‑25. Average score was 18.8. Total score given by nurse was in the range of 11‑26. Average score was 20.12. Both of them had 12% of patients with poor cosmetic outcome and the rest of the patients had fair, Table 1: Type of oncoplasty procedure performed Oncoplasty procedure
Number of patients (%)
Curvilinear incision with breast parenchymal advancement flap (Figure 3c) Lateral axillary crease oncoplasty (Figure 1d) Round block/donut mastopexy (Figure 2c and d) Radial segmental oncoplasty (Figure 3a and b) Dermoglandular oncoplasty (Figure 2a and b) Inframammary fold oncoplasty (Figure 1c) Parallelogram incision over the lump Mini latissimus dorsi flap Rotation oncoplasty
17 (48.5)
Total
35 (100)
2 (5.7) 1 (2.9) 2 (5.7) 4 (11.4) 3 (8.6) 4 (11.4) 1 (2.9) 1 (2.9)
a
c
b
d
e
Figure 3: (a and b) Radial segmentectomy for Upper quadrant tumor and axillary dissection performed through the same incision. (c) Curvilinear incision with breast advancement flap for the upper half tumors. (d) Accelerated partial breast irradiation by Brachytherapy. (e) Radiation induced non-healing ulcer with intense fibrosis and poor cosmesis
60
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Table 2: Univariate analysis between surgeon’s total cosmetic score and other variables P value#
Variable
Test applied
Age Size of tumor Estimated breast volume Volume of specimen EPBVE Site of tumor ALND
Pearson correlation Pearson correlation Pearson correlation
0.024 0.392 0.371
Comment Significant Not significant Not significant
Pearson correlation
0.019
Significant
Pearson correlation Student t test Student t test
0.017 0.107 0.775
Significant Not significant Not significant
Axillary RT
Student t test
0.608
Not significant
P value showing the significance of the variable in the cosmetic outcome. EPBVE=Estimated percentage of breast volume excised; ALND=Axillary lymph node dissection; RT=Radiotherapy #
1 woman (4%) reported deterioration in surgery. Seventeen women (68%) felt that was not affected after surgery, whereas 8 reported that their sexual life detoriorated
social life after their sexual life women (32%) after surgery.
Discussion Oncoplastic surgery according to Audretsch is tumor specific immediate reconstruction for breast conservation by using plastic techniques.[4,5] John Bostwick III described oncoplastic breast surgery for reconstruction after breast conservation or total mastectomy, immediate or delayed reconstruction, immediate repair for locally advanced breast cancers and recurrence. [5] Clough described two levels depending on the volume of breast tissue and the complexity of reconstruction procedure. [6] Urban had described three classes in order to improve the skills of surgical trainees based on the complexity of the procedure.[7‑9] Hoffmann developed a complex classification system where he described two type, six tier classification system with 12 main categories, 13 subcategories and 39 sub‑sub categories for oncoplastv breast surgery.[10] Various classifications were proposed to define when should a volume displacement technique to be used and when a volume replacement technique to be done. Selection criteria for volume displacement or volume replacement technique was based on the amount of breast tissue excised (100 cm 3 of breast tissue was removed. [19] In our study mean EPBVE was 26.6% and we found significant negative correlation between EPBVE and cosmesis. Recently a study by Niwinska et al., found quadrantectomy and brachytherapy were associated with poor cosmetic outcome when compared with tumorectomy and electrons.[20] In the present study, two patients received brachytherapy irradiation and both of them developed infection, though they didn’t have poor cosmetic outcome. Few studies showed that axillary lymph node radiotherapy was associated with poorer outcome, though in the present study it was not significant.[21,22] A systematic review of oncoplastic breast surgery was carried out by Franceschini et al., were they evaluated 11 studies on volume displacement techniques. This study showed that risk of margin involvement varied from 0% to 18.9%, risk of local recurrence from 0% to 13% and excellent‑good cosmetic result was obtained in 70% to 95% of patients.[11] In the present study, the incidence of immediate complications was 8.5% (3/35) with no local recurrence. In a study by Patterson et al., appearance of the treated breast was rated good to excellent by 94%, although 88% noted a difference of slight to moderate degree between treated and untreated breasts. [21] In the present study, none of the patients underwent mastopexy/ reduction mammoplasty to the contralateral breast though they had been counseled for a second surgery for better cosmesis. In our study, as analyzed by a plastic surgeon and nurse, 88% of patients had good to excellent outcomes and when objective assessment by patient satisfaction on cosmetic outcome was done 96% of patients had good to excellent results on satisfaction of the cosmesis. This 61
Adimulam, et al.: Oncoplastic breast surgery‑cosmetic outcome
satisfaction was not necessarily based on objective criteria defining esthetic parameters, but is strongly influenced by preservation of the breast as an original body part. Since the loss of breast would be considered as loss of feminity and a social stigma, mere preservation of breast provides high satisfaction. Conclusion
12. 13.
14.
Oncoplastic breast conservation surgery should be offered to all patients undergoing wide local excision of breast tumor. It involves simple techniques and most of the time breast advancement will suffice. Patient satisfaction with BCS and oncoplasty is very high.
15.
16.
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Indian Journal of Cancer | January–March 2014 | Volume 51 | Issue 1
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