Extreme Oncoplasty

Introduction

The surgical management of breast cancer has seen a paradigm shift from radical ablation to maximum conservation. The Halstedian radical mastectomy of the late 1800s gradually evolved by 1975 to spare muscle, lymph nodes, skin, and ultimately manifested in the modern-day nipple–areola sparing mastectomy. The 1970s and 1980s brought forth prospective randomized trials supporting breast conserving therapy for tumors ≤5 cm as a viable alternative to mastectomy. Breast conserving therapy was widely adopted and evolved from quadrantectomies requiring wide margins to localized wire-directed excisions requiring merely no ink on tumor. These advances in breast conservation allowed a cosmetic benefit to the patient without sacrificing oncologic care. Unfortunately, many patients were left with post-lumpectomy deformities that compromised the aesthetic goal of the operation. The advent of oncoplastic surgery was led by the awareness of these post-lumpectomy deformities and gradual acceptance of the concept that optimal oncologic care and breast cosmesis are not mutually exclusive. As a result, post-lumpectomy deformities were not deemed an inevitable or unavoidable outcome and proactive measures to reduce their incidence were encouraged. Oncoplastic surgery further advanced breast conservation to allow larger and larger resections, while still maintaining the aesthetic appearance of the breast.

Modern medical therapies, with improved hormonal and chemotherapy, new techniques and protocols in radiation oncology, and a better understanding of the biology of breast cancer, have improved overall and breast cancer specific survival. Naturally, local recurrence rates have improved after both mastectomy and breast conservation. Recent prospective randomized trials have demonstrated local recurrence rates less than 1.5% at 5 years for patients randomized to excision plus whole breast radiotherapy. However, prospective randomized trials studying breast conservation were only conducted for tumors ≤5 cm. Consequently, women with tumors >5 cm, or those with multicentric or multifocal disease, are often denied breast conservation and are relegated to mastectomy with adjuvant radiotherapy.

Oncoplastic surgery presents an opportunity to re-examine this paradigm. A successful aesthetic result after oncoplastic surgery largely depends on a favorable tumor-to-breast volume ratio and the application of appropriate tissue rearranging maneuvers. One of the simplest scenarios is a small tumor in the lower pole of a large breast that is easily addressed with a standard Wise pattern or vertical pattern mammaplasty. However, when tumors are in unfavorable locations, are close to the overlying skin, or involve the skin, these standard techniques can be modified to still allow an oncoplastic reconstruction, albeit with nontraditional scar patterns. Gradually, we have evolved to push the limits of these techniques and apply to them to patients with less favorable tumor:breast volume ratios. With experience, it becomes apparent that even patients with >5 cm tumors, or those with multifocal or multicentric disease, can potentially have breast conservation while still achieving excellent cosmetic outcomes. It is particularly tempting when comparing this reconstructive approach to a post-mastectomy reconstruction. Patients with large or locally advanced tumors typically require post-mastectomy radiotherapy. Implant-based reconstruction with radiotherapy is fraught with poor results and higher complication rates. Autologous reconstruction avoids this issue but often requires multiple procedures and long recovery periods. With current data reporting low local recurrence rates, the impetus for defaulting to mastectomy is fading. Although it is unlikely that randomized prospective data will be gathered to support breast conservation for >5 cm tumors, there is clear interest in this concept, as evidenced by a growing body of literature dedicated to this topic.

At our institution, oncoplastic reconstruction is offered to all patients whenever technically feasible. Extreme oncoplasty is the term applied to a specialized concept for a breast conserving operation, using oncoplastic techniques, in a patient who, in most physicians’ opinions, requires a mastectomy. Extreme oncoplasty applies to breast conservation using a reduction mammaplasty technique in patients with larger lesions, with the goal of clear surgical margins, while maintaining or improving the cosmetic outcome. These lesions are generally large, >5 cm, multifocal, or multicentric tumors. They may be locally advanced, and many will have positive lymph nodes. Most of these patients will require radiation therapy, even if they are treated with mastectomy.

Oncoplastic reconstruction generally yields a cosmetic result superior to a mastectomy with immediate reconstruction and radiation therapy. There is less operative and postoperative morbidity with extreme oncoplasty, fewer surgeries required, and finally, radiation therapy is far kinder to breast conservation than to mastectomy with reconstruction.

Patient Selection

The ideal patient for extreme oncoplasty is a woman with a large breast, who desires a smaller breast, who desires breast conservation, and has disease limited to a single quadrant, with limited comorbidities. Naturally, not all patients meet every one of the criteria, and many decisions are made on a case-by-case basis. Neoadjuvant chemotherapy is often utilized to downstage a patient and convert from obligatory mastectomy to potential breast conservation. The overriding theme is that if a method of reconstruction with a volume-displacing technique is possible, regardless of the aforementioned criteria, then the patient is a candidate. The value of extreme oncoplasty is in its ability to condense surgical therapy. The patient will undergo the ablative surgery, immediate reconstruction, and immediate contralateral breast surgery within a 3-hour outpatient operation. The recovery is usually rapid, similar to the recovery process of a reduction mammaplasty, and there are no additional reconstructive procedures necessary. Although most patients are treated with volume displacement oncoplasty, occasionally a volume replacement technique involving local fasciocutaneous flaps (e.g., LICAP) may be utilized. Regional or distant tissue transfer techniques for oncoplastic reconstruction are usually not utilized, given the uncertainty of margin status at the time of reconstruction. Delayed partial breast reconstruction with autologous methods is another option; however, these patients may be better suited for mastectomy if they are considering this significant investment in reconstruction.