DISSERTATION PRINCIPAL INVESTIGATOR: Dr Vijay Kumar Sharma 1st year DNB Surgical Oncology HCG Hospital GUIDE: Dr Mahesh Bandimegal Consultant Surgical Oncology

TITLE A Study of Complications and Cosmetic Outcome After Oncoplasty Techniques In Breast Cancer

INTRODUCTION Oncoplastic surgery combines the latest plastic surgery techniques with breast surgical oncology. When a large lumpectomy is required that will leave the breast distorted, the remaining tissue is sculpted to realign the nipple and areola and restore a natural appearance to the breast shape. Conservative surgery has become a well-established alternative to mastectomy in the treatment of breast cancer. However, in case of larger lesions or small-size breasts, the removal of adequate volumes of breast tissue to achieve tumor-free margins and reduce the risk of local relapse may compromise the cosmetic outcome, causing unpleasant results. In order to address this issue, new surgical techniques, so-called oncoplastic techniques, have been introduced in recent years to optimize the efficacy of conservative surgery both in terms of local control and cosmetic results. 3

Surgical planning should include the breast volume, tumor location, the extent of glandular tissue resected, and chiefly addressing individual reconstructive requirements, enabling each patient to receive an individual “custom-made” reconstruction.

 The reasoning behind oncoplastic breast surgery is twofold: to ensure that patients are treated with radical cancer surgery and to achieve the best possible cosmetic and resilient result, including a naturally shaped breast with acceptable symmetry. Oncoplastic breast surgery involves partial breast reconstruction and, if indicated, contralateral surgery all in one surgical procedure.

As a breast cancer treatment, oncoplastic breast surgery is expected to be similar to conventional breast-conserving surgery with regards to resection margins, locoregional recurrence and metastatic disease. Cancer surveillance after partial breast reconstruction seems not to be impaired.

Oncoplastic breast surgery is the application of surgical techniques from conventional breast-conserving surgery as well as plastic and reconstructive surgery, resulting in an improved aesthetic outcome for breast cancer patients. Thus, oncoplastic breast surgery may reduce the number of overall breast cancer patients undergoing a mastectomy.

Previous studies have shown that, compared with mastectomy, breast-conserving surgery has less of an impact on a patient’s body image, as well as psychosocial and social aspects of life. By providing a better aesthetic outcome than tumour resection alone, oncoplastic breast surgery may also improve quality of life for breast cancer patients after surgical treatment.

AIM To assess patient’s level of satisfaction after oncoplasty techniques. To study complications of oncoplasty techniques.

MATERIALS AND METHODS Study sites: Health Care Global hospital, Banglore Banglore Institute Of Oncology, Banglore Study Design: Observational Correlation Study Sample Size: 50

Inclusion Criteria: Patient diagnosed with primary breast cancer by mammography and biopsy. Exclusion Criteria: Patients for whom radiation therapy was contraindicated. Patients with multicentric tumors. Patients with extensive DCIS. Patients with disseminated systemic disease.

PREOPERATIVE PROTOCOL- Breast volume Tumor volume Mammography findings Histopathology Lymph node status Harmone receptor status Neoadjuvant chemotherapy

Intraoperative protocol Frozen section Type of oncoplasty technique: - Lumpectomy with round block technique - Central lumpectomy with a skin-glandular flap -Lumpectomy with reduction mastoplasty -Lumpectomy with batwing mastopexy - Radial segmental lumpectomy - Mini LD flap Drain

POST OPERATIVE PROTOCOL: Complications – fat necrosis, fibrosis, hypertrophic scarring Questionnaire on patients’ satisfaction Category Questions Cosmetic satisfaction 1. How do you feel when you look yourself undressed on in the mirror? 2. How do you feel when you look yourself dressed in the mirror? 3. How does your breast look with a brassiere? 4. How comfortable are you with a brassiere? 5. Do you feel natural with breast?  

Satisfaction of operative method 1. Are you satisfied with the result of the surgery? 2. Does the result coincide with the expectation before surgery? 3. If you were to have a surgery again, would you take the same procedure? Femininity 1. I am attractive. 2. I am emotionally stable. 3. I am generally confident. 4. I feel feminine after dressed. 5. I can accept the changes of the body after the surgery. Side effects 1. Do you have pain on your operated breast? 2. Do you have cramps around the breasts? 3. Are there any limitations on moving your arm? 4. Are there any pains on the shoulder or arm? Preference of operative method: contour vs. scar length 1. Is it acceptable that scar is obvious when the breast shape is satisfactory? 2. Is it acceptable that breast shape is unsatisfac- tory when the scar is barely visible  

REVIEW OF LITERATURE 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. Breast-conservation therapy with lumpectomy is a valuable component of breast cancer treatment, with an equivalent survival outcome to that of mastectomy1,2. Olivotto et al.3 and Mills et al.4 have documented that excision of a volume of parenchyma greater than 70cm3 in medium-size breasts often leads to unsatisfactory aesthetic results.

This unfavorable correlation explains why some surgeons have favored more limited resections, such as lumpectomy or tumorectomy (excision of the primary tumor with margins of normal breast tissue less than 1 cm) as opposed to the classical quadrantectomy proposed by Veronesi et al.5 (“a large resection of the quadrant harboring the primary carcinoma with at least 2 cm of normal tissue surrounding the tumor and including the removal en bloc of a large portion of overlying skin and the underlying fascia of the major pectoralis muscle”).

When designing an oncoplastic procedure, the following steps should be followed: careful planning of the skin incisions and parenchymal excisions, adequate reshaping of the gland after parenchymal excisions, repositioning of the nipple-areola complex (NAC) to the center of the breast mound, and correction of the contralateral breast for better symmetry. Depending on the location of the tumor within the breast, different oncoplastic techniques can be used.6,7

These new techniques, called “oncoplastic” techniques, may allow removal of larger amounts of breast tissue with safer margins without compromising the cosmetic outcome. Oncoplastic procedures are less technically demanding and time consuming than major reconstructive operations and usually require limited training to be properly performed by surgeons experienced in routine breast surgery. These procedures are usually performed in a single surgical access, and the patient leaves the operating room without major residual asymmetry or deformity. When designing an oncoplastic procedure, the following steps should be followed: careful planning of the skin incisions and parenchymal excisions, adequate reshaping of the gland after parenchymal excisions, repositioning of the nipple-areola complex (NAC) to the center of the breast mound, and correction of the contralateral breast for better symmetry. Depending on the location of the tumor within the breast, different oncoplastic techniques can be used.12,13

Standard lumpectomy resections During standard lumpectomy, surgeons generally make a small, cosmetically placed incision directly over the area to be removed. Batwing mastopexy The batwing mastopexy is a surgical approach that is most ideal for cancers located deep within or adjacent to the nipple-areolar complex but not directly connected with the area8. Two closely similar half-circle incisions are made with angled wings to each side of the areola. Radial-segmental lumpectomy (quadrantectomy) With radial-excision lumpectomy, overlying skin is removed with the full-thickness fibroglandular excision to avoid excessive redundant skin and postoperative skin-pectoral adherence deformities, which preserves breast shape and appearance.

Donut mastopexy lumpectomy As an alternative to radial-segmental lumpectomy, the donut mastopexy lumpectomy is a unique breast resection in which a tissue segment is removed through a periareolar incision9-11.   Mini latissimus dorsi flap Using mini LD flap is indicated if 20% to 70% of the breast volume is excised and the patient does not want to have mastectomy with reconstruction and wants to stay the same breast size without the need for contralateral breast symmetrization.

REFERENCES 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. Olivotto IA, Rose MA, Osteen RT, et al. Late cosmetic outcome after conservative surgery and radiotherapy: analysis of causes of cosmetic failure. Int J Radiat Oncol Biol Phys 1989;17:747–53. 4. Mills JM, Schultz DJ, Solin LJ. Preservation of cosmesis with low complication risk after conservative surgery and radiotherapy for ductal carcinoma in situ of the breast. Int J Radiat Oncol Biol Phys 1997;39:637–41. 5. Veronesi U, Volterrani F, Luini A, et al. Quadrantectomy versus lumpectomy for small size breast cancer. Eur J Cancer 1990;26:671–73.

6. Anderson B, Masetti R, Silverstein M 6. Anderson B, Masetti R, Silverstein M. Oncoplastic approaches to partial mastectomy: an overview of volume-displacement techniques. Lancet Oncol 2005;6:145–57. 7. Masetti R, Pirulli PG, Magno S, Franceschini G. Oncoplastic techniques in the conservative surgical treatment of breast cancer. Breast Cancer 2000;7:276–80. 8.Silverstein MJ. An argument against routine use of radiotherapy for ductal carcinoma in situ. Oncology (Huntingt) 2003; 17: 1511–33.

9. Masetti R, Pirulli PG, Magno S, et al 9.Masetti R, Pirulli PG, Magno S, et al. Oncoplastic techniques in the conservative surgical treatment of breast cancer. Breast Cancer 2000; 7: 276–80. 10.Amanti C, Moscaroli A, Lo Russo M, et al. Periareolar subcutaneous quadrantectomy: a new approach in breast cancer surgery. G Chir 2002; 23: 445–49. 11.Amanti C, Regolo L, Moscaroli A, et al. Total periareolar approach in breast-conserving surgery. Tumori 2003; 89 (suppl 4): 169–72.

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