The Role of Oncoplastic Surgical Techniques in Management of Breast Cancer
Doaa Ahmed Hasan Moussa;
Abstract
Breast cancer is the most common neoplasm in women accounting for about 26% of all cancer cases diagnosed annually. It is over all the second leading cause of cancer death. However breast cancer is the leading cause of cancer death in women below 65 years.
Early diagnosis can partially be achieved through rapid access referral, accurate triple assessment and multidisciplinary management of potential breast cancer patients.All patients presenting with breast symptoms should undergo triple assessment, this involves history taking and examination, followed by breast imaging and pathological assessment.
Diagnostic investigations for breast cancer may be: Non-Invasive as mammography, Xeromammography, screen film mammography, digital mammography, ultrasonography, positrone emission tomography and magnetic resonance imaging or Invasive as ductography, fine needle aspiration cytology, scintimammography , core/vacuum assisted biopsy excisional biopsy and frozen section.
Once a diagnosis of early breast cancer has been established, surgical treatment needs to proceed, with either breast conservation or mastectomy. The possibility of axillary metastatic involvement should also be addressed. Once the surgical treatment is complete, patients should be referred to radiation oncologists and medical oncologists to finalize planning of definitive adjuvant therapy if appropriate.
Breast conservation involves resection of the primary breast cancer with a margin of normal appearing breast tissue, adjuvant radiation therapy, and assessment of regional lymph node status.
The termwide local excisionrefers to removal of the tumor with a margin of surrounding breast tissue (approximately 1–3 cm. Quadrantectomy is a form of wide local excision in which a wide segment (a ‘quadrant’) of tissue is resected that includes 2–3 cm of surrounding breast tissue together with skin and pectoral fascia.
There are no statistically significant differences in the survival rate or in the incidence of the development of new cancers between women treated with mastectomy and those treated with breast conservation therapy.
In addition to being equivalent to mastectomy in terms of oncologic safety.BCT appear to offer advantages over mastectomy with regard to quality of life and aesthetic outcomes. BCT allows for preservation of breast shape and skin as well as preservation of sensation and provides an overall psychological advantage associated with breast preservation.
Breast-conserving surgery combined with radiation is now well established as the preferred local-regional treatment for a majority of patients with early stage breast cancers.
Oncoplastic surgery defines the appropriate adequate surgery to extirpate a cancer in the breast combined with partial or total reconstruction as well as immediate or delayed reconstruction with access to a full range of techniques to correct excision defects.
Contraindications for oncoplastic surgery are generally defined by contraindications for BCT. These include multicentric disease, inflammatory carcinoma, and progressive disease after neoadjuvant therapy and patients’ wishes.
The techniques that are currently used for the reconstruction of the partial mastectomy defect are based on two different concepts: volume displacement and volume replacement.
Volume displacement procedures include Local glandular or dermoglandular flaps are mobilized and transposed into the resection defect. This leads to a net loss in breast volume and the potential need for a simultaneous contralateral reduction to achieve symmetry. The resection of the tumor can be combined with a range of mammoplasty techniques including Inferior pedicle techniques, Superior pedicle techniques, S-shape oblique reduction mammoplasty, Batwing technique, Round block techniques and Grisotti flaps.
Oncoplastic techniques may be used during any kind of breast conserving surgery for breast cancer. However, with regards to breast reduction techniques there are several indications and contraindications.
The breast volume excised plays a central role for breast cosmesis after BCT. In patients with an expected volume reduction of more than 10%, surgeons should think about the use of oncoplastic surgery as cosmetic outcome may significantly be impaired. Cosmetic results after breast conserving surgery of breast cancer in the medial, central or lower quadrant yields worse results compared with other locations. In patients with a mild to severe ptosis, even with smaller breasts, oncoplastic techniques by using breast lifting methods may be of advantage for the general cosmesis by lifting the nipple in the right place and keeping the scar around the areola. Although simple lumpectomy in macromastia patients may reach good cosmetic results, breast reduction of both sides improves symptoms such as back and shoulder pain and may thus improve the quality of life. Moreover, the homogeneity of radiation dose distribution may be altered in large breast, thus breast reduction may improve adjuvant radiotherapy effects.
According to the volume replacement technique, when there is an insufficient volume of remaining breast tissue to perform a reconstruction, autologous tissues are imported and used as tissue flaps. These procedures can retain the volume and shape of the breast and avoid contralateral breast surgery. However, these techniques can be more complex and require a donor site and increased recovery time following autologous tissue harvesting.
Autologous methods of breast reconstruction rely on the use of vascularized tissue to create a naturally appearing breast. The long-lasting results of soft, viable tissue have provided a more permanent form of reconstruction without the risk of complications associated with implants. Autologous tissue reconstruction can be performed using various techniques including adipofascial flap, lateral thoracodorsal flap, thoracoepigastric flap, intercostals artery perforator flap, thoracodorsal artery perforator flap, latissimusdorsi flap, transverse rectus abdominis muscle flap and free flaps including free TRAM flap, free gluteal flap, deep inferior epigastric artery perforator flap and lateral transverse thigh flap.
The proper technique was primarily selected according to the excised volume of the breast based on the weight of the excised tumor and its margin of resection.
Latissimusdorsimyocutaneous flap for cases in which the resection mass was greater than 150 g, and for cases in which the resection mass was less than 150 g, lateral thoracodorsal flap, a thoracoepigastric flap, intercostal artery perforator (ICAP) flap and thoracodorsal artery perforator (TDAP) flap can be used.
The location of the tumor is an important factor involved in selecting the appropriate oncoplastic procedure.
The latissimusdorsimyocutaneous flap technique is commonly used for lateral and central defects, even for medial defects. The thoracodorsal perforator flap can be easily used for defects in the lateral and central regions of the breast. The lateral intercostals perforator flap is an alternative choice for lateral and inferior breast defects. The anterior intercostals artery perforator flap and the thoracoepigastric flap are appropriate for close defects that extend across the inferior or medial quadrants of the breast.
Early diagnosis can partially be achieved through rapid access referral, accurate triple assessment and multidisciplinary management of potential breast cancer patients.All patients presenting with breast symptoms should undergo triple assessment, this involves history taking and examination, followed by breast imaging and pathological assessment.
Diagnostic investigations for breast cancer may be: Non-Invasive as mammography, Xeromammography, screen film mammography, digital mammography, ultrasonography, positrone emission tomography and magnetic resonance imaging or Invasive as ductography, fine needle aspiration cytology, scintimammography , core/vacuum assisted biopsy excisional biopsy and frozen section.
Once a diagnosis of early breast cancer has been established, surgical treatment needs to proceed, with either breast conservation or mastectomy. The possibility of axillary metastatic involvement should also be addressed. Once the surgical treatment is complete, patients should be referred to radiation oncologists and medical oncologists to finalize planning of definitive adjuvant therapy if appropriate.
Breast conservation involves resection of the primary breast cancer with a margin of normal appearing breast tissue, adjuvant radiation therapy, and assessment of regional lymph node status.
The termwide local excisionrefers to removal of the tumor with a margin of surrounding breast tissue (approximately 1–3 cm. Quadrantectomy is a form of wide local excision in which a wide segment (a ‘quadrant’) of tissue is resected that includes 2–3 cm of surrounding breast tissue together with skin and pectoral fascia.
There are no statistically significant differences in the survival rate or in the incidence of the development of new cancers between women treated with mastectomy and those treated with breast conservation therapy.
In addition to being equivalent to mastectomy in terms of oncologic safety.BCT appear to offer advantages over mastectomy with regard to quality of life and aesthetic outcomes. BCT allows for preservation of breast shape and skin as well as preservation of sensation and provides an overall psychological advantage associated with breast preservation.
Breast-conserving surgery combined with radiation is now well established as the preferred local-regional treatment for a majority of patients with early stage breast cancers.
Oncoplastic surgery defines the appropriate adequate surgery to extirpate a cancer in the breast combined with partial or total reconstruction as well as immediate or delayed reconstruction with access to a full range of techniques to correct excision defects.
Contraindications for oncoplastic surgery are generally defined by contraindications for BCT. These include multicentric disease, inflammatory carcinoma, and progressive disease after neoadjuvant therapy and patients’ wishes.
The techniques that are currently used for the reconstruction of the partial mastectomy defect are based on two different concepts: volume displacement and volume replacement.
Volume displacement procedures include Local glandular or dermoglandular flaps are mobilized and transposed into the resection defect. This leads to a net loss in breast volume and the potential need for a simultaneous contralateral reduction to achieve symmetry. The resection of the tumor can be combined with a range of mammoplasty techniques including Inferior pedicle techniques, Superior pedicle techniques, S-shape oblique reduction mammoplasty, Batwing technique, Round block techniques and Grisotti flaps.
Oncoplastic techniques may be used during any kind of breast conserving surgery for breast cancer. However, with regards to breast reduction techniques there are several indications and contraindications.
The breast volume excised plays a central role for breast cosmesis after BCT. In patients with an expected volume reduction of more than 10%, surgeons should think about the use of oncoplastic surgery as cosmetic outcome may significantly be impaired. Cosmetic results after breast conserving surgery of breast cancer in the medial, central or lower quadrant yields worse results compared with other locations. In patients with a mild to severe ptosis, even with smaller breasts, oncoplastic techniques by using breast lifting methods may be of advantage for the general cosmesis by lifting the nipple in the right place and keeping the scar around the areola. Although simple lumpectomy in macromastia patients may reach good cosmetic results, breast reduction of both sides improves symptoms such as back and shoulder pain and may thus improve the quality of life. Moreover, the homogeneity of radiation dose distribution may be altered in large breast, thus breast reduction may improve adjuvant radiotherapy effects.
According to the volume replacement technique, when there is an insufficient volume of remaining breast tissue to perform a reconstruction, autologous tissues are imported and used as tissue flaps. These procedures can retain the volume and shape of the breast and avoid contralateral breast surgery. However, these techniques can be more complex and require a donor site and increased recovery time following autologous tissue harvesting.
Autologous methods of breast reconstruction rely on the use of vascularized tissue to create a naturally appearing breast. The long-lasting results of soft, viable tissue have provided a more permanent form of reconstruction without the risk of complications associated with implants. Autologous tissue reconstruction can be performed using various techniques including adipofascial flap, lateral thoracodorsal flap, thoracoepigastric flap, intercostals artery perforator flap, thoracodorsal artery perforator flap, latissimusdorsi flap, transverse rectus abdominis muscle flap and free flaps including free TRAM flap, free gluteal flap, deep inferior epigastric artery perforator flap and lateral transverse thigh flap.
The proper technique was primarily selected according to the excised volume of the breast based on the weight of the excised tumor and its margin of resection.
Latissimusdorsimyocutaneous flap for cases in which the resection mass was greater than 150 g, and for cases in which the resection mass was less than 150 g, lateral thoracodorsal flap, a thoracoepigastric flap, intercostal artery perforator (ICAP) flap and thoracodorsal artery perforator (TDAP) flap can be used.
The location of the tumor is an important factor involved in selecting the appropriate oncoplastic procedure.
The latissimusdorsimyocutaneous flap technique is commonly used for lateral and central defects, even for medial defects. The thoracodorsal perforator flap can be easily used for defects in the lateral and central regions of the breast. The lateral intercostals perforator flap is an alternative choice for lateral and inferior breast defects. The anterior intercostals artery perforator flap and the thoracoepigastric flap are appropriate for close defects that extend across the inferior or medial quadrants of the breast.
Other data
| Title | The Role of Oncoplastic Surgical Techniques in Management of Breast Cancer | Other Titles | دور تقنيـــات جراحــــة الاورام التجمــيليــة فــــي عـــلاج سرطـــــــان الثــــــدي | Authors | Doaa Ahmed Hasan Moussa | Issue Date | 2014 |
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