Volume displacement onco-plastic surgery techniques for early stage primary breast cancer

Volume displacement onco-plastic surgery techniques for early stage primary breast cancer

Taha A Ismail,a MD; Mohamed A Hablus,a MD; Helmy A Shalaby,a MD;

Hisham I Elsebai,b MD

a) Department of General Surgery, Tanta University, Tanta, Egypt. b) Cancer National Institute, Cairo University, Cairo, Egypt.

Abstract

Background: Until recently, the breast surgery could provide only two options for patients with primary stage breast cancer, either modified radical mastectomy  or segmental excision followed by radiation, but the introduction of the onco-plastic surgery (OPS) techniques at the time of tumor excision  has delivered  a third pathway,  enabling  surgeons  to perform  major resections involving up to 50% of breast volume without causing deformity. Volume displacement techniques  are only possible in patients with medium to large breasts, whereas  replacement techniques are suited to small breasted women. The choice of method is determined by both the breast volume and the size of the surgical cavity for infill.

The aim of this study: Was to assess the outcome  of applying  volume displacement onco­ plastic surgery techniques for early stage primary breast cancer regarding resection margins of the tumor, rate of recu"ence and the aesthetic outcome.

Patients and methods: This retrospective study was ca"ied out on twenty-six female patients

with early stage primary breast carcinoma treated by volume displacement onco-plastic surgery techniques throughout the period from September 2008 to September 2010. Patients within the inclusion criteria were evaluated by clinical examination, mammography and biopsy. Follow up ranged from 6 months  to 2 years with a mean of 20 months.  Assessment  of the cosmetic outcome was an integral part.

Results:  Age of patients ranged from thirty to sixty-five  years with a mean of 47.7 years. Fourteen patients in the study (54%) had previous history of breast disease or had previous breast biopsy or operation for suspected  malignancy. Metastatic work up revealed no distant metastasis. By clinical examination, mammographic and ultrasonographic assessment, the pre­ operative  mass size in 77% of cases ranged from 2 to 5 em. One patient had a mass smaller than 1 cm(4%) and five patients had no masses (post-excision) (19%), most patients (73%) were in grade II category, five were grade III (19%) and two were grade I (8%). Racquet mammoplasty was done in 15 cases (57.4%), the round block  technique  in 7 cases (27%) and the Grisotti technique in 4 cases (15.6%). All our specimens showed adequatefree margins, and all our cases showed no recu"ence. One case (3.9%) in grade III category developed distant metastasis. The cosmetic outcome was satisfactory.

Conclusion: OPS allowed large-volume resections with free margins and fewer re-excisions and mastectomies than that reported with standard BCS.  Volume displacement represents the simplest option for partial breast reconstruction and is usually prefe"ed over techniques for volume replacement which involve more extensive surgery with harvesting of a myocutaneous or subcutaneous flap. The cosmetic  outcome  was satisfactory both for the surgeons, as the general rule, it is much easier to prevent than to co"ect deformity; and for the patients, as the tumor was excised without amputation  of their breasts and their body image was preserved.

Introduction:                                                         in women worldwide.I And according to the

The breast is the most common site of cancer            National  Cancer  Institute, breast  cancer

accounts for  about 35%  of the  total malignancies  among Egyptian  females.2

Until  recently, the breast  surgery could provide  only  two options  for patients with primary stage breast cancer, either modified radical  mastectomy or segmental excision followed by radiation, but the introduction of the onco-plastic surgery (OPS)   techniques at the time of tumor excision has delivered a third pathway, enabling surgeons to perform major resections involving up  to 50%  of  breast volume  without  causing  deformity .3

This can eliminate  the need for complex

delayed reconstruction of deformities after breast conserving surgery,  which  often  has poor results especially after radiotherapy. As a general rule it is much easier to prevent than to correct deformity.4

Preserving the  woman's self-image by keeping her breast with a normal look greatly improves  the patient adherence  to treatment and may also result in increased disease free survival, because of the  psychological repercussion  on  the   immune  system.5

There are three elements that are important in the identification of patients  who  would benefit from the OPS, namely, the excised volume (an average of IOOOg can be excised compared to 80g in breast conserving surgery), the tumor location and lastly the glandular density.6-8

Resection  defects  on oncoplastic surgery can be reconstructed by either volume replacement (Improving volume from elsewhere to replace  the amount  of tissue removed especially in small sized breasts) or volume displacement (recruiting and transposing local dermoglandular flaps into the resection site).9

Volume displacement  techniques are only possible in patients with  medium  to  large breasts, whereas replacement techniques are suited to small breasted  women. The choice of method  is determined by both the breast volume and the size of the surgical cavity for infili.lO

The common aim of volume displacement is to utilize the remaining breast tissue to fill the defect  resulting  from extirpation of the tumour. As previously discussed,  resections which lead to loss of>10-200/o ofbreast volume

are likely to incur significant cosmetic detriment and to demand some form of 'infill' to create an acceptable cosmetic outcome in the longer term. Displacement techniques re-shape the breast through advancement, rotation or transposition of existing parenchyma and skin with  a resultant decrease in overall  breast volume.lO

Aim of the work:

The aim of this study was to assess the outcome of applying volume  displacement onco-plastic surgery techniques for early stage primary breast  cancer  regarding resection margins of the tumor, rate of recurrence and the aesthetic outcome.

Patients and methods:

This retrospective study was carried out on twenty-six female patients  with early stage primary breast carcinoma admitted and had volume displacement onco-plastic breast surgery at the National  Cancer Institute  (17 cases) and Tanta University Hospital (9 cases) throughout the period from September  2008 to September 2010.

Exclusion criteria are

1- Advanced stages.

2- Multi-centricity.

3-No  tumor-free  margins  obtained.

4- Inflammatory breast cancer.

5- Unfavorable tumor to breast size ratio that results in an inferior cosmoses.

6-Patients had  a contraindication to radiotherapy.

7- No changes or progression after neo-adjuvant therapy.

8- Patients  who had serious co-morbidities.

9-  Small sized  breast where  the  volume replacement techniques are  preferred.

Pre-operative evaluation:

All Patients had triple assessment including:

1-Thorough clinical examination: A) Local for asymmetry,  enlargement, skin dimpling, skinpuckering, peau d'orange, skin nodules or ulceration, assessment  of breast lump: its texture, mobility, fixation to the skin, underlying muscles or chest wall, nipple retraction,  axillary lymph node palpation for number  & mobility. B) General  for distant  metastasis  including  chest

examination, abdominal examination, for hepatomegaly or ascites, pelvic examination for hard deposits or Krukenberg 's tumor.

2-Radiological evaluation: All patients  had soft        tissue   mammography  and complementary ultrasonography of the breast.

3-Pathological evaluation: All patients had fine

needle aspiration cytnlogy and /or incisional or   Tru-cut  biopsy  from  the   mass. In addition, metastatic work up in the form

of bone scan, abdomino-pelvic ultrasound, chest X-ray & when needed MRI evaluation, complete blood picture and liver functions were done.

Required preoperative laboratory investigations were  done  to  all  patients.

Neo-adjuvant therapy  was given  to four patients preoperatively for  down-staging.

Intra-operative frozen section assessment was done to evaluate the resection margins of the excised specimens.

Axillary dissection through separate incision

or from the same incision was done in all cases.

Post- operative excision biopsy specimens were sent for definitive pathological examination, for assessing  tumor type, size, grade,  safety  margins, in-situ component, hormone receptor status and axillary lymph nodes status, malignant metastasis and invasion or rupture.

Post-operative treatment: Regular antibiotics and   analgesia  were given  to  patients.

Operative techniques:

1-Lateral  (racquet)  mammo-plasty:

A large portion of the upper outer quadrant can be excised by direct  incision  over  the tumor, from the nipple-areola complex (NAC) towards the axilla, similar to quadrantectomy. After wide excision the re-shaping is performed by mobilizing lateral and central glands into the cavity and suturing them together. Central gland advancement  is accomplished through NAC undermining, complete detachment of retro-areolar gland from the NAC for maximal mobility  of the central gland for volume re­ distribution. Once the defect is eliminated, the NAC is placed in its optimal position, at the center of  the   new   breast mound. This mammoplasty results  in a long radial  scar.

2-Round block (Benelli) technique:

The Round block mammoplasty utilizes a periareolar incision and was originally described by Benelli. The procedure starts by making two concentric periareolar incisions, followed by de-epithelialization of the inverting skin. The outer edge of de-epithelialization is incised and the entire skin  envelope is undermined in a similar manner to performing a mastectomy. The NAC remains vascularized by its posterior glandular base. Wide excision of the  tumor and  surrounding tissue is performed from the subcutaneous plane down

1D the pectnralis muscle. The medial and lateral glandular flaps  are  then  mobilized of  the pectoralis muscle and sutured together. The periareolar  incisions are then approximated, resulting  only  in   a  periareolar  scar.

3 -Grisotti technique:.

Preoperative drawings: With the patients in the sitting or standing position, skin markings are done.

A circle  outlining  the areola is drawn. A

smaller circle is then drawn marking the new nipple-areola complex to be created adjacent to the native areola. Next, the submammary fold is marked.

Excision of the NAC included in the pattern

of central  quadrantectomy. The excision is extended down  to  the  pectoralis fascia.

De-epithelialization of the flap except for

a  skin  island which is preserved for reconstruction of the areola. Then the medial and inferior margins  of the flap  are incised down to the fascia and the flap is advanced and rotated 1D fill the defect.

Suction drains, and wound closure are then

performed in all techniques.

Post-operative radiotherapy: Was offered to all patients,  and according  to tumor type and nodal status, chemotherapy and hormonal therapy were given.

Follow up: All patients were followed up monthly for 3 months, three monthly  for the first year, then yearly thereafter.

Follow up ranged from 6 months to 2 years with a mean of 20 months.

All patients were  evaluated on visit  by,

clinical examination, sono-mamography and metastatic work-up.  Also assessment of the cosmetic outcome was  an  integral part.

Study design:

This is a retrospective study on twenty-six females with early stage cancer breast operated on by volume displacement techniques OPS. Data were collected, tabulated and then analyzed  using  SPSS®  computer software

version 16.0. Firstly, numerical variables were examined for normality then were presented as median, mean ± standard  deviation  (SD). On the other hand categorical variables were presented as number of cases.

a-  Pre-operative drawing.

b-  Peri-areolar and  radial lateral incision over the tumor.

c- De-epithelialization of the inverting skin.

d- Excision of the tumor down to  the   pectoralis  muscle.

e- The cavity  left  after wide     f- Closure  of the defect  and local resection  of the tumor.                                                     NAC positioning on top of the

breast mound.

g- At the end of the operation.     h- After 1 week.

i- After 1 year.

Figure (1): Racquet mammoplasty.

Ain-Shams J Surg 2012; 5(3):657..-668

a- Two concentric periareolar incisions.

d-  Closure  of  the   defect.

b- De-epithelialization of the inverting skin.

e- After I month.

c- Excision of the tumor with good safety margin.

f- After 1 year

Figure (2): Round block technique.

a- Pre-operative skin marking.

b-  Excision of  the  central tumor with NAC.

c-  The  new  nipple-areola complex  to   be   created.

Ain-Shams J Surg 2012; 5(3):657-668                                                                                                                                                                                                            I I

d- Positioning of the new NAC.     e-At the end of the procedure.    f-After 1 month. This case was diabetic and  had  wound infection.

Figure (3): Grisotti technique.

Results:

The results were tabulated as follow:

Table (1): The demographic data and clinical presentation.

Table (2): Operative results.

Table (3): Tumor mass size.

Table (4): Relation between grade and prognosis.

Table (5): Early post-operative complications.

Table (6): Cosmetic outcome (according to the surgeons).

According to patients, they were satisfied by the result  that their breasts were not amputated  (by their expression), preserving their body image with complete tumor removal.

Discussion:

The aim of the local treatment of breast cancer is to achieve long term loco-regional control with minimal morbidity.

With advances made in radiotherapy breast conserving surgery  had become  established with equivalent survival rates to mastectomy.ll

Preserving the breast as much as possible and  satisfying the  patient physically and psychologically is one of the goals of modern breast cancer surgery, if it does not preclude onco-logical rules.12,13

Onco-plastic surgery (OPS) is defined as tumor  excision with  wide safety margin followed by immediate  reconstruction  based on pre-operative designing with  any of the mammoplasty techniques to prevent local deformity.9

The aim of this study is to determine whether

oncoplastic breast  surgery ensures  a better outcomeregarding sound  tumor  excision satisfactory cosmetic appearance and  low recurrence rates.

By clinical  examinationmammographic and ultrasonographic assessmenpre-operative mass size in 77% of cases ranged from 2 to 5 emone patient had a mass smaller than 1 em (4%) and five patients had no masses (post­ excision) (19%). Most patients (73%) were in grade II categoryfive were grade III (19%) and two were gradeI (8%).

Thuspre-operative assessment of patients showed that they were candidates  for breast conservation rather than mastectomythe two options were discussed with patients and after consent takingpatients had  oncoplastic surgery.

The mean age of our cases was 47.7 years. This is the same as the mean age of cases in the study by Kaur et al. In a comparative study conducted by Giacalone et al, the mean age of patients undergoing oncoplastic  surgery was

51.3  years  and  that  of  patients who  had quadrantectomy was 58.5 yearsindicating that younger age groups are more concerned about the cosmetic outcome.

Age of patients ranged from thirty to sixty­

five years with a mean of 47.7 years.Fourteen patients inthe study (54%) had previous history of breast disease or had previous breast biopsy or operation for  suspected malignancy metastatic work up revealed no distant metastasis.

The  upper outer quadrant was  the commonest site  (38.4%). This  location is considered the most favorable site for major resections without deformity in breast conserving therapy, in contrast to other zones of high risk of deformity such as the upper and the lower poles where "a birds beak" deformity is classically seen on excision of tumors in the lower pole of the breast.8

Patients with central retro-areolar tumors constitute from 5-20% of breast cancer and were considered for mastectomy until recently because of the risk of tumor multicentricity and the poor cosmetic outcome.14

Volume displacement represents the simplest option for partial breast reconstruction and is usually preferred  over techniques  for

volume  replacement which  involve more extensive surgery with  harvesting of a myocutaneous or subcutaneous flap. These flaps cannot subsequently be used for whole­ breast reconstruction should the patient develop

local  recurrence and require  mastectomy.1o

In our study, racquet  mammoplasty was done  inlS cases  (57.4%), the  round  block technique  in 7 cases (27%) and the Grisotti technique in 4 cases (15.6%).

According to the post-operative histopathology reports, specimen sizes ranged from  90cc to SSOccwith  a mean  value  of

247cc, with tumor sizes ranging from 0.7cm to Scm with a mean of2.75cm. This is more than those of Kaur et al, in their study: the mean volume was 200.18cc  while the mean volume of quadrantectomy group in the same studywas 117.5cc.7

Also in the study conducted by Giacalone et al, the mean volume of tissue resected by oncoplastic techniques and by quadrantectomy was 234cc and 114cc respectively.These results show that the amount of breast tissue excised during oncoplastic surgery is higher than that excised  during  standard quadrantectomy.15

Margin width correlate with the volume of the breast specimen; Vicini  et al concluded that  the  risk  of recurrence was  directly correlated with the volume  of the glandular specimen.They found that patients with smaller excised volumes (<60cm3) had higher rates of local  recurrence than patients  with excised volumes  of more than 60cm3. This is more pronounced  as tumor size increased. The 5- and 10- year local recurrence rate decreased as the specimen volume to tumor volume ratio increased.16

So OPS allowed  large-volume resections with free margins and fewer re-excisions and mastectomies than that obtained with standard BCS.

As regard resection margins, all specimens

in our research showed free resection margins with an average of 2.5cm, the least resection margin obtained was 0.4cm as the deep margin in a patient with invasive  ductal carcinoma, grade II, who  received post-operative radiotherapy and hormonal therapy  and has close follow up, and yet, no recurrence detected The largest resection margin was 1Ocm as the

deep margin in an excised upper outer quadrant tumor.

All our specimens  showed adequate  free

margins, and  all our  cases showed no recurrence, but this also might be due to the relatively  short time of follow up. One case (3.9%) in grade III category developed distant metastasis; histologic grade III has the highest frequency of distant metastasis. This reflects the fact that a higher  grade means  a higher risk; that is a tumor with more abnormal looking cells tends to grow and spread more quickly.

Clough et al reported a local recurrence rate of9.4% with a mean follow up of3.8 years.17

Raja et al reported a local recurrence rate of 3% with a mean follow  up of 5 years.IS Most authors define a positive margin  as less than lmm and a close margin as less than

2mm  of  normal breast  tissue  between the resection margin and the next cancer cell.I9-21

Post-operative pathological assessment showed that variable histological types could be handled using OPS; that 68% of cases had invasive ductal  carcinoma, 8%  had mixed ductal-lobular carcinoma and 4% had tubular carcmoma.

Five patients had associated carcinoma in situ, four of them with ductal carcinoma in situ (DCIS), and one of them lobular carcinoma in situ  (LCIS).  No  recurrences were  detected among patients with associated carcinoma in situ, with free resection margins, the smallest being  5mm    and   the    largest  4.5cm.

Five cases had multiple tumors (multifocal) and  were  successfully managed without recurrences except for one case that had distant metastasis in the form of malignant  pleural effusion  as described earlier, but no breast local recurrence.

These results are in agreement with that of

the study done by Staub et al., that oncoplastic techniques allow for excision  of multifocal tumors located in the same quadrant without oncological compromise.22

Wound infection  occurred in  6  cases (23.4%) three of them were diabetics, seroma in one case (3.9%) and minimal skin slough in one case (3.9%).

Ghon et al; 2008 stated that, there are less

simple excision of tumour compared with a more  complex oncoplastic procedure with parenchymal undermining  and transposition. There is a higher chance of wound infection and fat necrosis in patients who smoke, are obese (body mass index >30), have large breasts or  are  diabetics, and  these potential complications and  their  effect on  further oncological treatment should be fully discussed with the patient.lO

The  cosmetic appearance was  scored according to both  the surgeon and  patient satisfaction as follows:from the surgeon's point of view: 17 patients were scored as excellent,

8 as good, 1 as fair, taking into account the preservation of the normal breast shape in spite of the large volume of resection obtained with wider free resection margins.

As mentioned above, resection volumes of

90 to 550cc could  be obtained without compromise of the cosmetic outcome as stated by the operating surgeons with  wider  free margins.  Also, the ability  to conservatively excise tumors from less favorable  locations, such as the upper inner quadrants  or central retroareolar area of the breast, which  often create a  major risk  for  deformity, made oncoplastic surgery a favorable substitute for breast conserving surgery.

According to patients, they were satisfied by  the  result  that  their  breasts were  not amputated  (by their expression), preserving their body image with complete tumor removal.

Patient decision may  be  motivated by different factors including preservation of the breast, cosmetic results, operative morbidity, treatment  duration  and   convenience.23

Conclusion and recommendations:

OPS allowed large-volume resections with free margins and fewer  re-excisions and mastectomies than that reported with standard BCS.

Volume displacement represents  the simplest option for partial breast reconstruction and is usually preferred  over techniques for volume  replacement which  involve more extensive surgery with  harvesting of a myocutaneous  or   subcutaneous flap.

much   easier to  prevent than   to  correct deformity;  and for the patientsas the tumor was excised without amputation of their breasts and   their  body image was   preserved.

Large number of patients and longer follow­ up period are required for better assessment of this promising technique.

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