Aesthetic outcomes of various oncoplastic surgeries in breast cancer A Single institute experience

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49 Int J Res Med. 2015; 4(4);49-55 e ISSN:2320-2742 p ISSN: 2320-2734

Aesthetic outcomes of various oncoplastic surgeries in breast

cancer A Single institute experience

Mohit Sharma1*, Mahesh Patel 2, Vinod Dhakad3, Nayan Gupta3, Abhinav Deshpande3, Ruchit Kansaria3.

1

Assistant Professor, 2 Associate Professor, 3 Resident Doctor Department of Surgical Oncology Gujarat Cancer And Research Institute, Ahmedabad

INTRODUCTION

Breast-conservation therapy with lumpectomy is a valuable component of breast cancer treatment, with an equivalent survival outcome to that of mastectomy1,2. In addition to physical preservation, women who undergo breast conservation have a better view of their body image, are more comfortable with nudity and breast caressing, and might have less adverse physical sequelae from asymmetry, chest wall adhesions,and numbness associated

with mastectomy. 3,4 However, for breast conservation to be effective,surgeons need to remove cancers completely with an adequate surgical

*Corresponding Author

Dr. Mohit Sharma

Assistant Professor, Department of Surgical Oncology, G.C.R.I.

Email: mohitsharma1012@rediffmail.com Mobile no: 09275065875

margin width and maintain the breast’s shape and appearance.5 The undertaking of both goals together in the same operation can be challenging, depending on the tumour location and relative size in the breast . If a lesion is large or located in a region that is too difficult to excise without the risk of cosmetic deformity, special approaches to resection should be considered. The value of full-thickness excision with breast-flap mastopexy closure is intuitively apparent.The term oncoplastic surgery is used differently depending on the specialty in which it is

being referred.6-10 In plastic surgery, the term typically refers to large partial mastectomy combined with a volume replacement technique of partial breast-myo cutaneous flap reconstruction using the latissimus dorsi or transrectus abdominus muscle In the present study 41 cases of breast cancer underwent oncoplastic surgery using volume

ORIGINAL ARTICLE

ABSTRACT

Breast cancer is a major public health problem for women throughout the world. In the United States, breast cancer remains the most frequent cancer in women and the second most frequent cause of cancer death. In India it is the most common cancer in urban settings and second only to cancer of cervix in rural India. The treatment of patients with cancer has progressively become multidisciplinary. Multimodality therapy has reached new dimensions especially in breast cancer, where it has duplicated the results of age old mastectomy while at the same time avoiding physical and psychological mutilation.Surgery is still the backbone of curative treatment for breast cancer. There has been a gradual change from mutilating surgeries like radical mastectomy to more conservative surgeries with equal overall survival. Breast conservation treatment is defined as the excision of the primary breast tumor and adjacent breast tissue (breast -conserving surgery), usually followed by irradiation. Breast--conserving surgery also is commonly referred to as lumpectomy, partial mastectomy, and segmental mastectomy. Oncoplastic surgery refers to several surgical techniques by which segments of malignant breast tissue are removed to achieve wide surgical margins while the remaining glandular tissue is transposed to achieve the best possible cosmetic outcome. In the present study 41 females having breast cancer underwent breast cancer surgery at Gujarat Cancer And Reaserch Institute from 2011 to 2014.Surgery involved both volume displacement and volume replacement techniques of breast reconstruction.All the surgeries were done by cancer surgeon without help of plastic surgeon.Aesthetic outcomes were measured with help of various parameters and a scoring system was developed.

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50 Int J Res Med. 2015; 4(4);49-55 e ISSN:2320-2742 p ISSN: 2320-2734 displacement and volume replacement

techniques. Latissimus dorsi flap(L.D. flap) and Transverse rectus abdominis myocutaneous flap(TRAM flap) were used in volume replacement techniques. Aesthetic outcomes were measured by using various parameters at different time intervels.

MATERIAL AND METHODS

This study includes a total of 41 patients who underwent Oncoplastic breast conservative treatment, followed by radiotherapy and postoperative chemotherapy in TheGujarat Cancer And Research Institute Ahmedabad, from 2011 to 2014.

Eligibility Criteria

1. Biopsy proven breast cancer.

2. Early breast cancer

Evaluation All patients underwent a complete history and physical examination. This was followed by mammosonogram, sonogram of abdomen and pelvis , X-ray of chest and trucut biopsy from the mass. If biopsy was done outside our institute a review of the slides was done by our pathologists. The surgery performed was a wide local excision with a level I and II axillary nodal clearance. Reconstruction was done using simple closure ,oncoplastic volume displacement and volume replacement techniques post lumpectomy in the same sitting. All the patients were treated with post operative radiotherapy. Adjuvant chemotherapy and hormonal therapy were given as indicated. Postoperatively patients were followed up with 6 monthly clinical examination and mammogram. Followup clinical examination included assessment of cosmesis

OBSERVATION

This is a non randomized study of 41 patients who underwent breast conservative treatment in our institute. Table 1 : Age Range Distribution

Fidure 1 : Age Distribution

The most common age group was 30-40 years followed by 41-50 years.

FIGURE 2 : Menopausal Status

25(61%) patients were premenopausal and 16 (39%) were postmenoposal.

SIDE

FIGURE 3 : SIDE

Left sided tumours 21 were more common than right sided cancers in this study. Quadrant Involved

0 5 10 15 20

30-40 41-50 51-60 61-70

Number of Cases

Number of Cases

61% 39%

MENOPAUSAL STATUS

Premenopausal Postmenopausal

19.4 19.6 19.8 20 20.2 20.4 20.6 20.8 21 21.2

RIGHT LEFT

BREAST SIDE INVOLVED

BREAST SIDE …

Age (years) Number of cases

30-40 16

41-50 13

51-60 6

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51 Int J Res Med. 2015; 4(4);49-55 e ISSN:2320-2742 p ISSN: 2320-2734 Figure 4 : Quadrant Involved

The most commonly involved quadrant was upper outer quadrant (56%).

Clinical T Stage:

Figure 5 : Clinical T Stage

The most common T stage was T2 (59%) followed by T1 and T3. No T4 cases were included in the study.

Clinical Nodal Stage

Figure 6 : Clinical N Stage

The findings of mammogram was similar

to the clinical findings in most of cases.

The ultrasound of the abdomen and pelvis

and X-ray did not detect any metastasis in

any patients. Neoadjuvant

Chemotherapy Only one patient received

neoadjuvant chemotherapy and had good

response. She underwent breast

conservative surgery thereafter. Surgery

All the patients underwent BCS which

includes lumpectomy with atleast a 1 cm

margin (including those who had

undergone previous lumpectomy – scar

revision was done) along with a level 1

and 2 axillary lymph nodal clearance by

either the same or different incision. Five

patients underwent MRM followed by

TRAM FLAP reconstruction. Only BCS

was done in 16(39%), BCS with

Latissimus Dorsi myocutaneous flap was

done in 14(34%) oncoplastic

reconstruction was done in 6 patients.

Sentinal lymph node biopsy was done in 2

patients.

0 20 40

UPPER … LOWER … UPPER …

QUADRANT

QUADRANT

0 5 10 15 20 25

T1 T2 T3

T STAGE

T STAGE

63% 37%

CLINICAL NODAL

STAGE

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52 Int J Res Med. 2015; 4(4);49-55 e ISSN:2320-2742 p ISSN: 2320-2734 Figure 7 : Type Of Reconstruction Done

Complications Seven patients (17%) developed minimal wound infection which resolved with antibiotics and conservative management. Final Histopathology The final histopathology was infiltrative ductal carcinoma in all the cases. The final staging was done using the AJCC TNM staging system.

PTNM STAGING

TABLE 2 : TNM STAGING

Ajcc Staging

The most common stage was stage IIA followed by stage IA Margin Status A gross margin of atleast 1cm was aimed at during surgery. The presence of tumour at the margin was considered positive. A frozen section of margin was done in all the cases. The margins were negative in all

the patients on frozen sections. No patients required re-excision. Adjuvant Chemotherapy All the patients received adjuvant chemotherapy. Anthracyclines and Taxens were main component of chemotherapy regimen. No grave adverse events were recorded during chemotherapy. Adjuvant Radiotherapy All the patients were planned to receive radiotherapy in the form of 50Gy in 25# over 5 weeks by external beam radiotherapy followed by boost of 10-15 Gy. Few of the patients among study group are under radiotherapy treatment during follow up and complete assessment of cosmesis is difficult. Hormonal Therapy 17 patients among the study group were ER negative and rest of the hormonal receptor positive patients were started on hormonal therapy as per their menopausal status. Cosmesis All the patients had a photograph taken of their breast post operatively during follow up visits. Cosmesis following breast conservative surgery was decided with regards to the following parameters.

1. breast quadrant with respect to the opposite side

2. nipple symmetry 3. contour maintenance 4. skin pigmentation 5. skin thickening

6. post operative scar healing 7. scar orientation

0 2 4 6 8 10 12 14 16

BCS BCS + LD FLAP TRAM FLAP BCS + ONCOPLASTIC

SURGERY

TYPE OF RECONSTRUCTION

TYPE OF RECONSTRUCTION

AJCC STAGE

IA IIA IIB IIIA

PTNM Number

PT1N0M0 6

PT1N1M0 5

PT2N0M0 10

PT2N1M0 13

PT3N1M0 4

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53 Int J Res Med. 2015; 4(4);49-55 e ISSN:2320-2742 p ISSN: 2320-2734 8. tender spots

9. heaviness felt

10. patient’s subjective opinion each point was given 0 or 1 point.

The final grade was decided as excellent 9-10 good 6-8 fair 3-5 poor 0-2

Figure 8: Cosmesis

Five patients had excellent cosmesis, two with no re-construction, one with oncoplastic re-construction and two with LD FLAP reconstruction. 25 patients had good cosmesis and 11 fair cosmesis. No patient had poor cosmesis. Final assessment of cosmesis requires prolonged follow up. Few of the patients in present study were under radiotherapy treatment hence final assessment of cosmesis was difficult to ascertain in these patients. Follow Up All patients underwent regular follow up at 3 month intervals in the first year and then biannually. Assessment was done during adjuvant chemotherapy and radiotherapy treatment. A complete history and physical examination was done on each visit. No patient in study group developed local recurrence or distant metastasis.

Figure : Cosmetic Outcomes After Breast Conservative Surgery Using Various Methods

Breast Reconstruction using TRAM flap

Breast Reconstruction using simple primary closer technique

Breast Reconstruction using volume displacement oncoplastic surgery

Breast Reconstruction using Latissimus Dorsi flap

DISCUSSION

Patients characteristics Age: The median age of the study population in current study is 38 years. Most of the patients were in 30-40 years age group followed by 40-50 years group. Selection bias, with younger women opting for conservation is also a factor. Tumour size: Most of patients who underwent breast conservation surgery are of T2 size. No patient with T4 status was included in this

0 10 20 30

A

xi

s

T

it

le

COSMESIS

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54 Int J Res Med. 2015; 4(4);49-55 e ISSN:2320-2742 p ISSN: 2320-2734 study. 11 patients had history of

lumpectomy, where margine status was not known. Majority of patients were of early breast cancer with young age. Receptor Status: Most tumor in this study were ER/PR receptor positive. Treatment Modalities Surgical procedure: Wide local excision with a targeted 1 cm gross margin along, with axillary dissection was done. Two patients underwent sentinel lymph node biopsy. Surgical procedure for reconstruction was decided on the basis of tumor breast ratio, previous surgical procedure and location of tumour. Simple breast conservation surgery was done where tumour size was small in comparison to breast volume. Breast reconstruction with oncoplastic volume displacement surgery was done in six cases, where simple primary closure of defect was not giving good cosmesis. Most of the defects were reconstructed using volume replacement techniques (LD flap and TRAM flap). In five cases TRAM flap was used for breast reconstruction, as defect size was very and symmetry with available and majority of patients were not willing to undergo second surgical

procedure. Radiotherapy: External Beam Radiotherapy 50Gy over 25 fractions with a tumour bed boost 10-15Gy was employed. Few patients in study group are still under radiotherapy treatment and final cosmesis is yet to be decided. Adjuvant

Therapy: Anthracyclin based

chemotherapy was the main stay of treatment and hormonal manipulation was added as indicated. Assessment of cosmesis There is no standard way to measure cosmesis, hence a scoring system based on various parameters was used to ascess cosmesis. Proper assessment of cosmesis is difficult, it requires prolonged follow up. As changed occurs in reconstructed breast after radiotherapy which takes longer duration to subside. A more liberal use of reconstruction procedure was probably required for better cosmesis. There is also requirement of a standard method to measure cosmesis. Oncoplastic volume displacement techniques require special attention. When tumour size is large, better cosmetic results can be achieved by reducing the opposite

volume. Patient must be educated enough to understand the procedure as multiple surgeries may be required for better cosmetic results. In present study oncoplastic volume displacement techniques were not used in most of cases as it requires special plastic surgery assistance and majority of reconstructions were done by operating surgeon himself. In comparison to western world average breast size is smaller in Indian women and they present in advanced stages of disease hence most of them are not suitable for oncoplastic volume displacement reconstruction procedures. CONCLUSION

Breast conserving therapy is a more resource intensive treatment as compared to mastectomy and its outcome depends critically on quality of therapy.

• Cosmetic outcome are not up to the mark, more liberal use of reconstructive procedure is needed. It is better to involve reconstructive surgeon for better aesthetic outcome. • Breast conserving therapy is oncologycally safe and its outcome is not inferior to mastectomy. Hence all the patients with early breast cancer have to be counseled regarding this treatment option.

• Proper counseling regarding prolonged treatment period is essential to reduce the radiotherapy dropout rates.

• Conservation of patient with locally advanced breast cancer at presentation is feasible provided they are adequately down stage with neoadjuvant chemotherapy. As locally advanced breast cancer( LABC) forms the major mode of presentation in our population it requires a special focus. • Judicious case selection, establishment of a scientific treatment protocol, a rigrous adherence to the same and a dedicated team approach are essential to achieve better results. • A standard method to measure

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55 Int J Res Med. 2015; 4(4);49-55 e ISSN:2320-2742 p ISSN: 2320-2734 BIBLIOGRAPHY:

1. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002; 347: 1233–41. 2. Veronesi U, Cascinelli N, Mariani L, et

al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002; 347: 1227–32. 3. Schover LR. Sexuality and body image

in younger women with breast cancer. J Natl Cancer Inst Monogr 1994: 177– 82.

4. Schrenk P. Surgical and plastic reconstructive therapy of breast carcinoma. Wien Med Wochenschr 2000; 150: 63–71.

5. Masetti R, Pirulli PG, Magno S, et al. Oncoplastic techniques in the conservative surgical treatment of breast cancer. Breast Cancer 2000; 7: 276–80.

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Figure

FIGURE 3 : SIDE Left sided tumours 21 were more common

FIGURE 3 :

SIDE Left sided tumours 21 were more common p.2
FIGURE  2 : Menopausal Status 25(61%) patients were premenopausal and

FIGURE 2 :

Menopausal Status 25(61%) patients were premenopausal and p.2
Figure 4 : Quadrant Involved

Figure 4 :

Quadrant Involved p.3
Figure 5 : Clinical T Stage The most common T stage was T2 (59%) followed by T1 and T3

Figure 5 :

Clinical T Stage The most common T stage was T2 (59%) followed by T1 and T3 p.3
Figure 6 : Clinical N Stage

Figure 6 :

Clinical N Stage p.3
TABLE 2 : TNM STAGING

TABLE 2 :

TNM STAGING p.4
Figure 7 : Type Of Reconstruction Done

Figure 7 :

Type Of Reconstruction Done p.4
Figure 8: Cosmesis  Five patients had excellent cosmesis, two with no re-construction, one with oncoplastic re-construction and two with LD FLAP reconstruction

Figure 8:

Cosmesis Five patients had excellent cosmesis, two with no re-construction, one with oncoplastic re-construction and two with LD FLAP reconstruction p.5
Figure 8: Cosmesis  Five patients had excellent cosmesis, two

Figure 8:

Cosmesis Five patients had excellent cosmesis, two p.5
Figure : Cosmetic Outcomes After Breast Conservative Surgery Using Various Methods

Figure :

Cosmetic Outcomes After Breast Conservative Surgery Using Various Methods p.5

References

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