Indications and Patient Selection for Oncoplastic Breast Surgery

Introduction

The newly diagnosed breast cancer patient and her interdisciplinary treatment team must address both the local control (breast) and systemic control (body) issues to minimize the risk of recurrence. From a surgical perspective, the fundamental goals are to remove the tumor with an adequate margin of normal tissue while optimizing the long-term aesthetic outcomes for the patient. The technical decision then becomes whether to proceed with breast conservation therapy (lumpectomy and radiation) or a mastectomy with or without reconstruction. With the pioneering work of the National Surgical Adjuvant Breast and Bowel Project (NSABP), Umberto Veronesi, MD, and others in the 1970s, breast conservation therapy (BCT) has been well established as oncologically safe, offering similar local control rates and equivalent long-term survival rates compared with non-nipple-sparing mastectomy. More recently, nipple-sparing mastectomy (NSM) has been demonstrated to be a third alternative for patients requiring or requesting removal of the breast parenchyma while preserving the skin envelope and nipple–areolar complex (NAC). Breast-conserving lumpectomy and radiation therapy must then be evaluated as an alternative to both nipple-sparing and non-NSM with reconstruction.

The benefits of breast conservation over mastectomy are well established. Clinical outcome studies with 20-year follow-up have demonstrated that breast conservation is equivalent to mastectomy in terms of overall survival. In addition, preservation of the natural breast confers a significant psychological advantage for many women diagnosed with breast cancer. In most cases, preservation of the NAC is possible; therefore, the natural breast elements remain, and the majority of women are happy with the final breast appearance. With the advent of oncoplastic techniques, breast conservation can be expanded to include wider margins of resection and achieve local recurrence rates that are similar to mastectomy. As the reconstructive options have expanded, so has the prevalence of oncoplastic surgery.

There are several differences between traditional breast conservation and oncoplastic surgery. With traditional lumpectomy, the skin is opened directly over the localized lesion. The tumor is then removed, oriented, and sent for pathological evaluation. The skin is closed without attempts to close the internal cavity. For small tumors (either ductal carcinoma in situ [DCIS] or invasive breast cancer), this approach is adequate. Unfortunately, up to 40–45% of patients can be found to have positive margins requiring re-operation to achieve negative margins. Historically, 30% of patients undergoing lumpectomy and subsequent radiation therapy surveyed were found to be dissatisfied with their cosmetic outcome. Cosmetic defects included deformity of the overall shape of the breast, volume loss, changes in the shape and location of the nipple, and Snoopy deformities of the NAC after a transverse incision in the lower central breast. The challenge thus becomes extending the indications for lumpectomy while minimizing the risk of positive margins to optimize the cosmetic results after not only the surgical lumpectomy but also radiation therapy.

In the 1990s, Werner Audretsch, Christian Gabka, and Heinz Bohmert applied reduction mammoplasty and mastopexy concepts to expand the number of patients who are candidates for breast conservation as “oncoplastic surgery.” The term oncoplastic breast surgery is a Greek-derived word that literally means “molding of tumor”; however, in its present context it refers to excision of the tumor (onco) and reconstruction and shaping of the breast (plastic). This often requires a team approach between the oncologic and reconstructive surgeon. Today, the spectrum of oncoplastic surgery includes four basic techniques including:

• 1.

  Local tissue mobilization and rearrangement

• 2.

  Reduction pattern mammoplasty

• 3.

  Skin and nipple rearrangement

• 4.

  Volume replacement

This chapter will discuss the aspects of the tumor characteristics, patient’s anatomy, medical comorbidities, treatment-related issues, psychosexual concerns, and possible complications that affect the indications and patient selection for oncoplastic breast surgery over NSM and non-NSM.

Indications

Oncoplasty enables the breast surgery team to excise more breast tissue, widening the margin of clearance between the tumor and the normal parenchyma. In addition, natural breast appearance is more likely to be achieved, although the volume will be less. These benefits have expanded the number of patients eligible for breast conservation. Many women who are treated with oncoplastic breast conservation surgery would otherwise have needed a mastectomy and/or have had a poor aesthetic result. Fundamentally, the indications for oncoplastic breast surgery are the same as those for breast conservation surgery. Patients should be considered for BCT if they have an adequate tumor-to-breast volume ratio to establish negative margins and are candidates for radiation therapy . All patients undergoing breast-conserving surgery (lumpectomy, partial segmental mastectomy, quadrantectomy, and tylectomy) should be assessed for their oncoplastic needs. The most common indications for oncoplastic breast surgery are tumor size (37%), poor tumor location (22%), oncocosmetic (1%), multifocality (10%), skin retraction (9%), positive margins after previous surgery (5%), and other reasons (5%).

It is also important to identify patients who are not candidates for breast conservation. Historically, absolute contraindications to BCT include (1) patients with a high probability of recurrence due to multicentric disease or the inability to obtain clear margins; (2) patients who are currently pregnant; (3) those with active collagen vascular disease, such as active lupus and scleroderma ; and (4) those with a history of prior breast irradiation either related to prior breast cancer or Hodgkin’s disease. Soft contraindications include (1) patients with a high probability of subsequent breast cancers including those with BRCA1/2 mutations, PTEN, etc.; (2) tumors that directly involve the NAC; and (3) patients with high tumor-to-breast ratios.

The increasing use of neoadjuvant chemotherapy has increased the number of patients eligible for breast-conserving surgery and oncoplastic tissue rearrangement. This is, in part, predicated on the invasive tumor molecular subtype. Neoadjuvant dual HER2 blockade with trastuzumab and pertuzumab in combination with cytotoxic chemotherapy for patients with HER2+ amplification results in a high pathology complete response (pCR) (16.8–66.2%) . Patients with ER+/HER2- cancers have lower pCR rates (7.0–16%), and those with triple negative tumors have 33–35% chances of achieving a pCR ; 40–70% overall will achieve a partial response.

Patient Selection

Comprehensive preoperative evaluation is necessary to determine patients appropriate for oncoplasty and the necessary type of reconstruction. The surgical team should obtain the patient’s history of any prior breast surgery, chest radiation, and infections. Risks factors for wound complications such as diabetes mellitus, active smoking, cardiovascular conditions, history of Ehlers-Danlos, coagulopathies, poor nutrition, and obesity should be noted. Patients with a history of chronic pain, fibromyalgia, and opioid dependence should also be assessed to coordinate optimal care with their primary care provider.

It is also important to understand the patient’s psychosexual concerns and feelings about her breast. Loss of nipple–areolar and breast sensation may be important to patients undergoing breast surgery in terms of quality of life and satisfaction. Patients undergoing skin-sparing mastectomy and NSM can have considerable loss in skin and nipple sensation. Many patients complain of loss of sexual arousal with breast or nipple stimulation after mastectomy. As such, fear of loss of nipple sensation may be an important consideration for oncoplastic tissue rearrangement. Very little data are currently available about the risks of nipple sensation loss after oncoplastic breast surgery and radiation. Concerns about nipple viability, postoperative nipple positioning, fears about the risk of recurrence, and risks of needing additional surgery should be ascertained along with the patient’s history of anxiety. Lastly, patients’ concerns about foreign body implantation and complications, including the remote risk of implant-associated anaplastic large-cell lymphoma, should be addressed.

On physical exam, the surgeon should clinically evaluate the patient’s breast and chest anatomy for breast symmetry, prior scars, bra size, and degrees of ptosis. Enlarged lymph nodes should be assessed for possible regional disease. Patients who have had prior breast conservation and radiation therapy are generally not good candidates for oncoplastic surgery. Diagnostic mammogram, ultrasound, and breast magnetic resonance imaging (MRI) should be strongly considered to precisely identify the location and extent of the breast tumor. Patients undergoing neoadjuvant chemotherapy should undergo another preoperative MRI to assess the extent of the residual tumor and rule out the possibility of disease progression. This will confirm that breast conservation and oncoplastic tissue rearrangement is still possible.

Tumor Characteristics