Volume displacement techniques and therapeutic mammoplasty: the Nottingham experience.

Introduction

Oncoplastic surgery aims to provide optimum effectiveness of surgical treatment for breast cancer with minimum effect on quality of life. It can offer improved aesthetic results from surgery and even enhance body image.

Women who undergo breast-conserving surgery for cancer have much to benefit from oncoplastic techniques. It is already known that approximately 25-30% of such women are dissatisfied with cosmetic results of their surgery. Those most likely to have a poor result are those with a large percentage volume of excision [1]. Volumes greater than 10% of total breast volume for medial lesions and 20% for lateral lesions are likely to result in an unsatisfactory aesthetic outcome. Centrally placed cancers that require excision of the nipple are often left with obvious asymmetry and distortion. As overall survival following breast cancer treatment improves, many women will be expected to live a long time with the cosmetic consequences of breast cancer surgery. Improving cosmetic outcomes should be one of the main aims of breast cancer surgery.

For very small excision volumes (for cancers <10 mm), very simple excision with accurate narrow margins, a well-placed scar and minimal disruption of surrounding breast tissue is usually the procedure of choice. For large cancers or small lesions in very small breasts, the two basic categories of oncoplastic breast-conserving surgery are volume replacement and volume displacement. The latter, which will be discussed in this review, can be further categorised into subcutaneous and/or subglandular undermining, and therapeutic mammoplasty.

Subcutaneous and/or subglandular undermining

The first category of volume-displacement surgery is suitable for any small excision volume (<10% medial, <20% lateral). Therapeutic mammoplasty, a volume replacement procedure or mastectomy should be considered for all other cases. The first stage of planning breast-conserving surgery is to consider the following questions:

* Is it necessary to excise skin overlying the cancer?

* What tissue is going to fill the defect?

* Where should the incision be?

* Is a bilateral breast reduction or mastopexy helpful?

In theory, it should only be necessary to excise overlying skin if a clear margin of normal tissue cannot easily be excised over the superficial margin of the cancer. In the elderly patient with thin skin and a fatty breast, skin excision overlying the cancer can minimise the need for parenchymal mobilisation and may be a safer approach.

In most cases, the tissue either side of the defect will be mobilised to fill it. In general terms, for dependent parts of the breast (particularly lower /mid lateral, lower medial) mobilised superior tissue will 'fall' into the defect and in upper parts of the breast or centrally below the nipple, lateral and medial tissue will be mobilised and stitched into the defect (Figure 1).

Sub-glandular or subcutaneous undermining alone can be extensive. Performing both requires a greater degree of planning and care. The pitfalls here are fat necrosis, lumpiness and subsequent distortion after radiotherapy. In practice, it depends on the quality of breast tissue. Very fatty breast tissue should be very carefully mobilised.

Skin incisions are usually based on lines of tension. These need to be marked pre-operatively with the patient standing. Any small cancer (<1 cm) can have a small overlying incision. For larger incisions, scars may be sited away from the cancer. A simple plan is shown in Figure 1.

[FIGURE 1 OMITTED]

Therapeutic mammoplasty

'Simple' parenchymal mobilisations work well for small excision volumes. However, certain areas of the breast are less forgiving of these techniques. These are mainly the lower pole and medial parts of the breast. In addition, medial excisions larger than 10% of breast volume and lateral excisions larger than 20% are less likely to be associated with a satisfactory outcome [1]. In such situations, a mammoplasty should be considered. Mammoplasty is also the procedure of choice for any woman with existing morbidity due to large breast size. This reduces the effects of radiotherapy on large breasts and has quality-of-life benefits.

Any woman with either ptosis or with some laxity of the lower pole of the breast is potentially suitable for a mammoplasty. In its simplest form a mammoplasty will allow some skin excision that will create a smaller breast form, disguising the underlying parenchymal resection. A wide range of techniques can be used, most based on conventional mammoplasty techniques for breast reduction or mastopexy (Figure 2). The relatively simple principles previously described [2] form the basis of technique selection and planning. Essentially, the cancer is either excised within a standard breast reduction or not. If not, the tissue used to fill the wide local excision defect is either an extension of the 'primary' nipple--areola pedicle or is created via a 'secondary' pedicle. It is important that the technique used must be safe, in terms of the viability of any pedicle and the reliability of wound closure. Fat necrosis and wound problems are the pitfalls of injudicious surgical technique. Sometimes very simple methods such as wedge closure or melon-slice mammoplasty, both of which remove the nipple-areola, can create very 'safe' excision patterns with satisfactory cosmetic outcome [2] (Figure 2). Mammoplasty is usually bilateral with a standard symmetrisation technique. Unilateral mammoplasty does, however, have a role, particularly when the degree of shape adjustment is minor or in those situations where a woman does not perceive shape or size adjustment as a positive, but would accept and prefer it to mastectomy. In such situations, contralateral mammoplasty could be performed once clear margins have been obtained and treatment is complete.

[FIGURE 2 OMITTED]

Conventional breast conservation for the treatment of breast cancer has been shown to have equivalent survival outcomes compared with radical surgery [3-6]. In view of the increasing use of oncoplastic techniques, which may allow conservation operations for cancers that would traditionally have been treated by mastectomy, it is important that outcomes are audited and are as good if not better than conventional treatment.

Since our last review [7], several more groups have published their long-term data on patients with volume-displacement surgery. One of the earliest proponents of oncoplastic surgery, the Milan group, followed up 148 patients with bilateral reduction mammoplasty for a median of 74 months [8]. Complete resection of the cancer was possible in 91% of cases; the average size of resection was 22 mm (1-100 mm), and 21% of cases had multifocal disease. The average volume of resection was 198 g (20-2100 g). At 5 years, the local recurrence rate was 3%, and the rate of distant metastasis was 13%, which is comparable to that of standard breast-conserving surgery. Cosmetic outcome was not considered in this retrospective review [8]. Earlier, the same group had assessed the safety of oncoplastic surgery by studying 30 consecutive patients who had oncoplastic surgery and compared them with another 30 patients who had a standard quadrantectomy [9]. The mean volume of tissue excised in the oncoplastic group was 200.18 [cm.sup.3] (range, 36-594 [cm.sup.3]), compared to 117.55 [cm.sup.3] (range, 18-360 [cm.sup.3]) in the quadrantectomy group. Margins were negative in 25 out of 30 (83.3%) patients in the oncoplastic group compared to 17 out of 30 (56.7%) in the quadrantectomy group. This was confirmed by Giacalone et al. who showed that oncoplastic surgery allowed a greater volume of resection (190 [cm.sup.3] versus 99 [cm.sup.3]) [10]. However, although resection margins were clear in a greater number of patients who had oncoplastic surgery, this did not reach statistical significance.

Losken et al. described similar findings from another retrospective study [11]. A total of 63 women had wide excision, therapeutic mammoplasty with a contralateral symmetrisation procedure, although in eight patients (11%) this was performed as a two-staged procedure to confirm negative margins and 10 women had benign disease. The total resected volume was 762 g (36-2295 g). Six cancer patients (11%) had close/positive margins, with four requiring total mastectomy and two needing further re-excisions. There was a complication rate of 22% but no delay in adjuvant treatment. Follow-up was for an average of 3.25 years (range, 2 months to 11 years), with a local recurrence of 2% (1/49). None of the patients developed distant metastasis.

Conclusion

Although there have been several studies assessing the cosmetic outcomes following conservation or reconstruction surgery, no formal studies comparing the cosmetic outcomes in oncoplastic surgery to other surgical methods have yet been published.

To date, all data (mostly retrospective studies at present) show that oncoplastic surgical techniques are equivalent to standard surgical treatment, although long-term prospective data, as well as cosmetic outcome data are still lacking (see Table 1).

References

[1.] Asgiersson K, Rasheed T, McCulley SJ and Macmillan RD. Oncological and cosmetic outcomes of oncoplastic breast-conserving surgery. Eur J Surg Oncol, 2005, 31, 817-823.

[2.] McCulley SJ and Macmillan RD. Planning and use of therapeutic mammaplasty--Nottingham approach. Br J Plast Surg, 2005, 58, 889-901.

[3.] Neff PT, Bear HD, Pierce CV et al. Long-term results of breast conservation therapy for breast cancer. Ann Surg, 1996, 223, 709-716.

[4.] Montague ED, Ames FC, Schell SR and Romsdahl MM. Conservation surgery and irradiation as an alternative to mastectomy in the treatment of clinically favorable breast cancer. Cancer, 1984, 54, 2668-2672.

[5.] Veronesi U, Luini A, Galimberti V and Zurrida S. Conservation approaches for the management of stage I/II carcinoma of the breast: Milan Cancer Institute trials. World J Surg, 1994, 18, 70-75.

[6.] Osborne MP, Ormiston N, Harmer CL et al. Breast conservation in the treatment of early breast cancer. A 20-year follow-up. Cancer, 1984, 53, 349-355.

[7.] Asgeirsson KS, Rasheed T, McCulley SJ and Macmillan RD. Oncological and cosmetic outcomes of oncoplastic breast conserving surgery. Eur J Surg Oncol, 2005, 31, 817-823.

[8.] Rietjens M, Urban CA, Rey PC et al. Long-term oncological results of breast conservative treatment with oncoplastic surgery. Breast, 2007, 16, 387-395.

[9.] Kaur N, Petit JY, Rietjens M et al. Comparative study of surgical margins in oncoplastic surgery and quadrantectomy in breast cancer. Ann Surg Oncol, 2005, 12, 539-545.

[10.] Giacalone PL, Roger P, Dubon O et al. Comparative study of the accuracy of breast resection in oncoplastic surgery and quadrantectomy in breast cancer. Ann Surg Oncol, 2007, 14, 605-614.

[11.] Losken A, Styblo TM, Carlson GW et al. Management algorithm and outcome evaluation of partial mastectomy defects treated using reduction or mastopexy techniques. Ann Plast Surg, 2007, 59, 235-242.

[12.] Caruso F, Catanuto G, De Meo L et al. Outcomes of bilateral mammoplasty for early stage breast cancer. Eur J Surg Oncol, 2007, Epub ahead of print.

[13.] Clough KB, Lewis JS, Couturaud B et al. Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas. Ann Surg, 2003, 237, 26-34.

[14.] Nos C, Fitoussi A, Bourgeois D et al. Conservative treatment of lower pole breast cancers by bilateral mammoplasty and radiotherapy. Eur J Surg Oncol, 1998, 24, 508-514.

[15.] Masetti R, Pirulli PG, Magno S et al. Oncoplastic techniques in the conservative surgical treatment of breast cancer. Breast Cancer, 2000, 7, 276-280.

R Douglas Macmillan, Ching W Chan and Stephen J McCulley

Oncoplastic Breast Service, Institute of Breast Surgery, City Hospital, Nottingham, UK

Correspondence to: R Douglas Macmillan, Oncoplastic Breast Service, Institute of Breast Surgery, City Hospital, Nottingham NG5 1PB, UK (email: [e-mail])

Table 1: Summary of studies with 50 or more patients
reporting local recurrence after volume-displacement
surgery.

Study             Number of     Mean      Involved      Local
                  patients    follow-up   margins    recurrences
                              (months)      (%)          (%)

Rietjens et al.      148         74          3.0         3.0
  2007 [8]
Losken et al.        53          40         11.0         2.0
  2007 [11]
Caruso et al.        63          68          0           1.6
  2007 [12]
Clough et al.        101         46         10.9         9.4
  2007 [13]
Nos et al.           50          48         10.0         7.0
  1998 [14]
Masetti et al.       56          23          NR           0
  2000 [15]

NR, not reported