Research Article
Clinical Experiences for Oncoplastic Breast Surgery Improve a Cosmetic Outcome and Reduce Postoperative Complications
Yuko Kijima1,2,3*, Munetsugu Hirata3, Yoshiaki Shinden3, Toshiaki Utsumi1, Zenichi Morise2 and Shoji Natsugoe3
1Department of Breast Surgery, Fujita Health University, Japan
2Department of Digestive Surgery, Fujita Health University, Japan
3Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Japan
*Corresponding author: Yuko Kijima, Department of Breast Surgery, Fujita Health University, School of Medicine, 1-98, Dengakugakubo, Kutsukakecho, Toyoake, Aichi 470- 1192, Japan
Published: 09 Oct, 2018
Cite this article as: Kijima Y, Hirata M, Shinden Y,
Utsumi T, Morise Z, Natsugoe S.
Clinical Experiences for Oncoplastic
Breast Surgery Improve a Cosmetic
Outcome and Reduce Postoperative
Complications. Clin Surg. 2018; 3:
2145.
Abstract
Purpose: We evaluate perioperative and cosmetic results of Oncoplastic Breast Surgery (OBS) for
the Japanese patients with ptotic breasts according to time after introduction of this method. The
study aims to investigate the effect of experience for new surgical technique in breast surgery.
Methods: From March 2006 to December 2014, we performed OBS with volume displacement,
combining partial mastectomy with reduction mammoplasty, for consecutive 57 patients with
ptotic breasts in Kagoshima University Hospital. They were diagnosed having with early breast
cancer indicated for partial mastectomy and did not receive any preoperative systemic therapy. Out
of 57 patients, forty patients received volume displacement surgery on contralateral healthy breasts
immediately. We retrospectively analyzed their perioperative results, postoperative complications,
and cosmetic results according to time after we started OBS; early phase and late one.
Results: On both phases, patient's age, menopausal status, body mass index, systemic disease,
smoking, tumor location, axillary operation and operation type of OBS, there were no significant
difference. Operation period and plastic period were significantly shorter in late phase than in early
one (<0.05), while there were no significant differences in intraoperative bleeding, weight of resected
breast tissue, pathological margins in both phases. A rate of vascular disorder of nipple-areola were
fewer in late phase (<0.05), while there were no significant differences between two phases in rates of
fat necrosis, hyper plastic disorder of the scar. On cosmetic evaluation, it was improved in late phase
that percentages of excellent-good case on both phases were 85% and 100%, respectively.
Conclusion: The techniques of OBS with volume displacement were improved perioperative,
postoperative and cosmetic results after clinical experience in one institution.
Keywords: Breast cancer; Oncoplastic breast surgery; Ptotic breast; Volume displacement; Breast reduction
Introduction
Oncoplastic Breast Surgery (OBS) combining partial mastectomy with reduction mammoplasty and recentralization of Nipple–Areola Complex (NAC) for early breast cancer is widely practiced. We have introduced OBS for Japanese patient and revealed that it is suitable approach both in oncological and cosmetic reasons for Asian female whose breasts are not so large compared to Western female. It is necessary for us to report focusing in operation results, postoperative complication and cosmetic results by phase after introduction of OBS in one institution. We would like to retrospectively clarify whether there is technical acquisition for new approach and clinical experience influences the results of OBS.
Patients and Methods
Fifty-seven consecutive Japanese patients were diagnosed with early breast cancer in ptotic breasts
between March 2006 and December 2014 and underwent OBS combining partial mastectomy with
reduction mammoplasty and re-centralization of nipple-areola without any neoadjuvant systemic
therapy. Of these patients, forty patients underwent contralateral operation for symmetrical results.
Indications for oncoplastic surgery combining partial mastectomy
with reduction mammoplasty were as follows: (1) ptotic (the
nipple level was beneath the inframammary line) or large breasts;
(2) without any severe systemic disease; and (3) informed consent
being obtained preoperatively after an explanation of the surgical
procedures. We divided them into two groups retrospectively, early
phased: from March 2006 to July 2011, and late phase: from August
2011 to December 2014. There are twenty patients in each group.
During that period, two experienced surgeons were in charge in
operations. None of them received preoperative systemic chemo- or
endocrine therapy. The mean age of patients was 64.0 years (range:
47-76) and 64 .0 years (range: 42-73), and two and three patients
were premenopausal in early phase group and late one, respectively.
Patients with over 25 of body mass index were 15 and 8 in both
groups, statistically much more in early phase than that of late phase
(P<0.05). Out of 20 patients in both groups, seven and twelve patients
were free from medication due to systemic disease. One patient in
early phase group is a smoker. Six patients in both groups received
medication for hypertension, diabetes mellitus and psychological
disorder, respectively (Table 1). Assessment of resected specimens of
breast cancer and stage classification was carried out in accordance
with the TNM Classification of Malignant Tumours 6th edition [1].
Tumor location
Five and 10 lesions located on upper area (upper, upper inner,
and upper outer area) in early and late phase, respectively. In the
same manner, 13 and 7 lesions located on lower area, and 2 and 3
lesions located on the central area, respectively (Table 1).
Selection of OBS
Kind of OBS was selected mainly depend on the tumor location,
tumor size and the excessive skin and gland depend on patient's
breast size and shape by one surgeon (Y.K).
Patients had a consultation with the breast surgeon at least twice
and more to conduct the type of operation, and the procedure. They
have been also explained different surgical options to the patient,
e.g., other oncoplastic surgical techniques such as immediate volume
displacement using a free graft or local flap [2,3]. On two days before
surgery the resection area was drawn together with a surgical margin
of at least 2.0 cm with the patient in a supine position. We carried out
the method to experience for the first time in reference to a literature
[4-6].
Informed consents
All patients signed informed consent to participate in the study.
Pathological examination
Two or three pieces of surgical margins were examined to
confirm being negative for cancer involvement intraoperatively. For
pathological diagnosis, all pieces of permanent sections cut by every 5
mm were examined postoperatively.
SLN biopsy and axillary lymphadenectomy
SLN biopsy using the RI and dye method was performed in
patients with clinically diagnosed as node-negative. SLNs were
biopsied and examined histologically during surgery. If SLN was
positive for metastasis, axillary lymphadenectomy was planned.
Cosmetic assessment
A digital camera with a resolution of 14.1 megapixels was used
with a blue panel as the background. Photographs were taken in four
positions with the patient standing on floor marks: facing the camera
with their arms down, facing the camera with their arms up, from the
left side with their arms up, and from the right side with their arms up.
Images were recorded, printed out and then cosmetically measured
and evaluated by two parsons (Y.K and M.H) independently.
Cosmetic assessment after breast-conserving therapy reported
by Sawai’s group supported the Japanese Breast Cancer Society [7].
This assessment contains eight items: 1. breast size, 2. breast shape, 3.
wound scar, 4. softness of the breast, 5. shape and size of nipple-areola,
6. color of nipple-areola, 7. level of nipple (difference of distance from
suprasternal notch in bilateral nipples), and 8. Lowest point of the
breast (difference of bilateral breasts). The cosmetology was evaluated
as excellent when the total score was 12 points, good when it was 9 to
11, fair when it was 5 to 8 and poor when it was 0 to 4.
Statistical analysis
Statistical significance was analyzed by the chi square test and t
test.
Table 1
Table 2
Table 3
Results
OBS using partial mastectomy with reduction
mammoplasty
Reduction types of surgery selected in this study were shown
in Table 2. Periareolar mammoplasty [8-9], lateral mammoplasty,
J-mammoplasty [10], L-mammoplasty, Horizontal mammoplasty
[11], vertical scar mammoplasty [11], inverted-T mammoplasty
[12,13], and amputation and NA grafting [14,15] were selected
due to tumor location, degree of breast ptosis, and necessity of
nipple resection because of ductal spreading. We experienced the
operation procedure and learned perioperative results each case, so
we sometimes chose another kind of OBS even if both of tumor side
factor and a host side factor were same.
Axillary operation
Axillary lymph nodes were dissected in 4 and 1 patients in both
phases. Remnant 16 and 19 patients were performed sentinel lymph
node biopsy (Table 2).
Pathological diagnosis
All of them were diagnosed with ductal carcinoma of the breasts.
Three patients in early phase were having with ductal carcinoma in situ.
All of patients, surgical margins were free from cancer involvement
which were larger than 2 mm. Average of pathological horizontal
margins were 14.1 mm and 13.6 mm, respectively (Table 3). No
one needed delayed operation due to positive margin. Pathological
examinations were added to the contralateral healthy breast tissue.
No unexpected cancer was detected from any healthy breast.
Adjuvant therapy
All patients of earlier 23 patients, except one, avoided
postoperative radiation therapy to the remnant gland due to our
institutional indication for radiation therapy at that time. All later
consecutive 17 patients received postoperative radiation therapy to
the remnant gland.
Results of surgical procedure
The total operative period, including the waiting period for the
results of the pathological examination of several surgical margins and
SLN, ranged between 112 and 289 mins, with the mean period being
174 mins in early phase. In late phase, it ranged between 96 mins to
216 minutes with the mean period being 148 mins. It was significantly
shorted in pate phase (P<0.05, Table 4). The mean plastic period was
88 minutes (ranged 40 mins to 230 mins) and 84 minutes (ranged
50 mins to 129 mins), respectively. Bleeding were 43 g (ranged 0 g
to 230 g) and 28 g (5 g to 65 g), respectively. The amount of resected
breast tissue was 173 g (ranged 39 g to 350 g) and 160 g (ranged 56
g to 668 g), respectively. No one received delayed operation due to
cancer involvement of surgical margin after permanent pathological
examination.
Postoperative complications and cosmetic outcomes
Postoperative complications were shown in Table 5. Vascular
disorder of NAC was observed in 6 and 1 patients, respectively
(p<0.05). One of them whose disorder was most severe was shown in
Figure 1. All of them were epithelialized completely in several weeks.
Fat necrosis was shown in one patient in late phase. Hyperplastic
disorder was shown in three and one patients, respectively (Figure2).
Cosmetic outcome was shown in Table 5. In early phase, sixteen
patients (80%) was evaluated as excellent and good by cosmetic
assessment, while all twenty ones were evaluated as excellent-good in
late phase (P<0.05). On three patients in early phase cosmetic results
were evaluated as poor-fair. On one patient whose lesion located on
upper-inner quadrant area, we selected horizontal-mammoplasty.
The shape and size of bilateral breasts were different, and the
position of nipple were not symmetrized (Figure 3). On two patients
whose tumor located on outer-lower quadrant area, we selected
J-mammoplasty. The breast size and shape were not kept symmetry.
On all patients of late phase, cosmetic results were evaluated as
excellent-good (Figure 4).
Postoperative oncological outcome
No patient experienced local recurrence, distant recurrence,
or cancer specific death. Only one patient passed away 59 months
postoperatively due to pancreatic cancer, good oncological and
cosmetic conditions were obtained in her breast.
Table 4
Table 5
Figure 1
Figure 1
Vascular disorder of nipple-areola. a) Postoperative 2 weeks. b)Postoperative 5 weeks. c) Postoperative 7 years.
Figure 2
Figure 2
Hypertrophic disorder, Lt Breast cancer, 62-years old, T2N0M0 stageiIA, Bp+Ax. a) Preoperative findings. b) J-mammoplasty was designed. c)
Postoperative 7 yeas findings.
Figure 3
Figure 3
Cosmetic result was evaluated as poor (Left breast cancer, 60-years old). a) Preoperative findings of ptotic breasts. b) Horizontal mammoplasty was
designed. c) Postoperative 7 yeas findings.
Figure 4
Figure 4
Cosmetic result was evaluated as excellent (Left breast cancer, 55-years old). a) Preoperative findings of ptotic breasts. b) Horizontal mammoplasty
was designed. c) Postoperative 4 yeas findings.
Discussion
The final cosmetic result of breast-conserving therapy is dependent
on many factors, including tumor size, tumor site, breast volume, the
extent of surgery, chemotherapy, radiotherapy, hormone therapy,
and age [16-19]. OBS which combines the concepts of oncologic and
plastic surgeries is becoming more common, especially in Western
countries [16,20-23]. There are currently many different OBS such as
the careful planning of skin and parenchymal excisions, reshaping of
the gland following parenchymal excisions, and repositioning of the
NAC to the center of the breast mound with or without corrections
to the contralateral breast in order to achieve better symmetry [18].
Different kinds of TMs based on tumor location have been reported
and established, and the concept of TM combining partial mastectomy
with a breast reduction technique has become more popular [4,5,24].
However, few studies have been conducted by Japanese institutions
[2,3,10,11,13,14,25,26]. It is not clear that clinical experiences for
new surgical technique affected the postoperative complications
and cosmetic results until now. So we evaluated our experience and
results of oncoplastic breast surgery combining with partial resection
and reduction type of surgery of the breasts.
In this retrospective study, it is revealed that total operation
period and plastic period of late phase became shorter, postoperative
complication became less, and cosmetic results became better than
those of early phase. It seems that we did improve oncoplastic breast
surgery according to not only learning of the operation technique but
also the adequate selection of the reduction mammoplasty.
In this study, we examined contralateral breast tissue whether
being detected unexpected cancer or not. In Munhz’s series, it was
detected in the opposite breast in 2.8% of patients. Although the
diagnosis of occult cancer is not a reason to perform opposite breast
reduction, this procedure may be advantageous for high-risk patients
and particularly for those who have already had breast cancer [27].
It is difficult to explain the discrepancy of our results and Munhoz’s
report, but the incidence of breast cancer of Japanese patients were
not so far from that of other countries, so the advantages by removing
the contralateral breast tissue at the time of breast conserving surgery
might be coming important on the Japanese patients as well as
Western ones.
Patient satisfaction is very important in the management of breast
cancer [28]. In another series of out study, in which OBS combining
partial mastectomy and free nipple areola grafting technique for
patients with ptotic breast, 60% of patients noted that they were happy
with the aesthetic results obtained, 40% were satisfied, and no one
was dissatisfied. Eighty percent of patients considered the aesthetic
appearance of their breasts to have been improved by surgery, which
we regard as satisfactory [15]. We need to assess not only cosmetic
evaluations, but also the satisfaction of patients with those newly
introduced surgeries in Japan.
We are aware of some problems resolved in this study. The cost of
opposite breast surgery is currently not covered by the national health
insurance system. We showed the results of OBS with contralateral
breast surgery to achieve good symmetric results under the approval
of the Ethical Review Board of our university hospital. If opposite
breast surgery for good symmetry immediately at the time of cancer
surgery is accepted by the national insurance system, many patients
will have more choices and get better oncological control easily, and
better cosmetic improvements will be achieved. In near future, it will
be necessary to establish a system performed at an appropriate value.
Immediate bilateral operation might to be appropriate for patients,
due to reduction of expected cancer on the contralateral healthy
breast.
It remains that there is a possibility to perform an additional
resection or mastectomy even after contra lateral symmetry
established if pathological margins are positive or local recurrence
appear. We select OBS under enough understanding about those
limitations.
Conclusion
The newly introduced OBS for Japanese patients have been well performed and experience progressed in both of safety and cosmesis. This is expected to become more popular as a treatment in Japan.
References
- Sobin LH, Wittekind C. TNM: classification of malignant tumours. 6th edn. New York: Wiley-Liss. 2002.
- Kijima Y, Yoshinaka H, Hirata M, Shinden Y, Ishigami S, Nakajo A, et al. Oncoplastic breast surgery using spindle shaped-partial mastectomy for early breast cancer in the upper quadrant area. MPS. 2013;3(2):57-64.
- Kijima Y, Yoshinaka H, Hirata M, Nakajo A, Arima H, Okumura H, et al. Oncoplastic breast surgery combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap for Paget's disease. Surg Today. 2014;44(9):1783-8.
- 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(5):1375-91.
- Berry MG, Fitoussi AD, Curnier A, Couturaud B, Salmon RJ. Oncoplastic breast surgery: a review and systematic approach. J Plast Reconstr Aesthet Surg. 2010;63(8):1233-43.
- 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.
- Japanese Breast Cancer Society. Cosmetic assessment after breast conserving surgery. The 12th annual meeting of the Japanese Breast Cancer Society. 2004; pp107-9.
- Kijima Y, Yoshinaka H, Hirata M, Nakajo A, Arima H, Ishigami S, et al. Oncoplastic breast surgery combining periareolar mammoplasty with volume displacement using a crescent-shaped cutaneous flap for early breast cancer in the upper quadrant. Surg Today. 2013;43(8):946-53.
- Kijima Y, Yoshinaka H, Hirata M, Mizoguchi T, Ishigami S, Nakajo A, et al. Oncoplastic surgery in Japanese patients with breast cancer close to the areola: partial mastectomy using periareolar mammoplasty: a case report. Case Rep Surg. 2011;2011:121985.
- Kijima Y, Yoshinaka H, Ishigami S, Hirata M, Kaneko K, Mizoguchi T, et al. Oncoplastic surgery for Japanese patients with ptotic breasts. Breast Cancer. 2011;18(4):273-81.
- Kijima Y, Yoshinaka H, Hirata M, Mizoguchi T, Ishigami S, Nakajo A, et al. Oncoplastic surgery in a Japanese patient with breast cancer in the lower inner quadrant area: partial mastectomy using horizontal reduction mammoplasty. Breast Cancer. 2014;21(3):375-8.
- Kijima Y, Yoshinaka H, Hirata M, Mizoguchi T, Ishigami S, Nakajo A, et al. Oncoplastic Surgery for Japanese patients with breast cancer of the lower pole. Surg Today. 2011:41(10):1461-5.
- Kijima Y, Yoshinaka H, Funasako Y, Natsugoe S, Aikou T. Oncoplastic surgery after mammary reduction and mastopexy for bilateral breast cancer lesions: Report of a case. Surg Today. 2008;38(4):335-9.
- Kijima Y, Yoshinaka H, Hirata M, Mizoguchi T, Ishigami S, Arima H, et al. Oncoplastic surgery combining partial mastectomy with breast reconstruction using a free nipple-areola graft for ductal carcinoma in situ in a ptotic breast: report of a case. Surg Today. 2011:41(3):390-5.
- Kijima Y, Yoshinaka H, Hirata M, Shinden Y, Nakajo A, Arima H, et al. Therapeutic mammoplasty combining partial mastectomy with nipple-areola grafting for patients with early breast cancer: a case series. Surg Today. 2016;46(10):1187-95.
- 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(5):471-81.
- Bostwick J, 3rd, Paletta C, Hartrampf C. Conservative treatment for breast cancer. Complications requiring reconstructive surgery. Ann Surg. 1986;203(5):481-90.][Petit JY RM. Deformities following tumorectomy and partial mastectomy. In: plastic and reconstructive surgery of the breast. Noon B, editor. Philadelphia: Marcel Decker 1991.
- Clough KB, Nos C, Salmon RJ, Soussaline M, Durand JC. Conservative treatment of breast cancers by mammaplasty and irradiation: a new approach to lower quadrant tumors. Plast Reconstr Surg. 1995;96(2):363-70.
- Noguchi M, Saito Y, Mizukami Y, Nonomura A, Ohta N, Koyasaki N, et al. Breast deformity, its correction, and assessment of breast conserving surgery. Breast Cancer Res Treat. 1991;18(2):111-8.
- Audretsch W, Rezai M, Kolotas C, Zamboglou N, Schnabel T, Bojar H. Onco-plastic surgery: "target" volume reduction (BCT-mastopexy), lumpectomy reconstruction (BCT-reconstruction) and flap-supported operability in breast cancer. Proceeding 2nd European Congress on Senology. Proceeding 2nd European Congress on Senology. 1994;October 2-6:139-57.
- Audretsch W, Rezai M, Kolotas C, Zamboglou N, Schnabel T, H B. Perspect Plast Surg. Perspect Plast Surg. 1998;11:71-106.
- Bostwick J, 3rd, Paletta C, Hartrampf CR. Conservative treatment for breast cancer. Complications requiring reconstructive surgery. Ann Surg. 1986;203(5):481-90.
- Petit JY RM. Deformities following tumorectomy and partial mastectomy. In: plastic and reconstructive surgery of the breast. Noon B, editor. Philadelphia: Marcel Decker 1991.
- Masetti R, Pirulli PG, Magno S, Franceschini G, Chiesa F, Antinori A. Oncoplastic techniques in the conservative surgical treatment of breast cancer. Breast cancer. 2000;7(4):276-80.
- Zaha H, Hakazu O, Watanabe M, Higa M. Breast-conserving surgery using reduction mammoplasty. 2008;223:211-5.
- Kijima Y, Yoshinaka H, Shinden Y, Hirata M, Nakajo A, Arima H, et al. Oncoplastic breast surgery for centrally located breast cancer: a case series. Gland surgery. 2014;3(1):62-73.
- Munhoz AM, Aldrighi CM, Montag E, Arruda E, Brasil JA, Filassi JR, et al. Outcome analysis of immediate and delayed conservative breast surgery reconstruction with mastopexy and reduction mammaplasty techniques. Ann Plast Surg. 2011;67(3):220-5.
- Waljee JF, Hawley S, Alderman AK, Morrow M, Katz SJ. Patient satisfaction with treatment of breast cancer: does surgeon specialization matter? J Clin Oncol: An American Society of Clinical Oncology. 2007;25(24):3694-8.