Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas

Abstract

Objective: To assess the oncologic and cosmetic outcomes in women with breast carcinoma who were treated with breast-conserving therapy using oncoplastic techniques with concomitant symmetrization of the contralateral breast.

Summary background data: Although breast-conserving therapy is the standard form of treatment for invasive breast tumors up to 4 cm, in patients with large, ill-defined, or poorly situated tumors, cosmetic results can be poor and clear resection margins difficult to obtain. The integration of oncoplastic techniques with a concomitant contralateral symmetrization procedure is a novel surgical approach that allows wide excisions and prevents breast deformities.

Methods: This is a prospective study of 101 patients who were operated on for breast carcinoma between July 1985 and June 1999 at the Institut Curie. The procedure was proposed for patients in whom conservative treatment was possible on oncologic grounds but where a standard lumpectomy would have led to poor cosmesis. Standard institutional treatment protocols were followed. All patients received either pre- or postoperative radiotherapy. Seventeen patients received preoperative chemotherapy to downsize their tumors. Mean follow-up was 3.8 years. Results were analyzed statistically using Kaplan-Meier estimates.

Results: Mean weight of excised material on the tumor side was 222 g. The actuarial 5-year local recurrence rate was 9.4%, the overall survival rate was 95.7%, and the metastasis-free survival rate was 82.8%. Cosmesis was favorable in 82% of cases. Preoperative radiotherapy resulted in worse cosmesis than when given postoperatively.

Conclusions: The use of oncoplastic techniques and concomitant symmetrization of the contralateral breast allows extensive resections for conservative treatment of breast carcinoma and results in favorable oncologic and esthetic outcomes. This approach might be useful in extending the indications for conservative therapy.

Figure 1. Preoperative skin markings done in the upright position, showing tumor location and dotted line for skin incision.

Figure 10. A 43-year-old woman with a 3 × 3-cm palpable invasive ductal carcinoma. (A) Mammogram showed extensive microcalcifications in the lower pole of the left breast. (B) After excision of the tumor and microcalcifications as an en-bloc specimen with tissue excised for the remodeling procedure. (C) The remodeling procedure: apposition of medial and lateral glandular pillars. (D) The result at 6 years after radiotherapy to the left breast.

Figure 11. Typical breast deformity after breast-conserving surgery for a large tumor of the lower pole of the left breast.

Figure 2. The area surrounding the nipple–areolar complex de- epithelialized and the inframammary skin incision.

Figure 3. Undermining the breast off the pectoral fascia and palpation of the tumor.

Figure 4. Developing the superiorly based flap for the nipple–areolar complex.

Figure 5. Excised tissue consisting of en-bloc specimen of tumor with wide margin of normal tissue and tissue excised for mammoplasty.

Figure 6. The residual defect. Arrows indicate apposition of medial and lateral pillars of gland.

Figure 7. Reshaping the breast. Arrow indicates relocation of nipple–areolar complex to the de-epithelialized area.

Figure 8. Resultant scars on both breasts after the procedure.

Figure 9. A 52-year-old woman with extensive microcalcifications in the lower pole of the left breast. (A) Core biopsy shows DCIS. A wire has been inserted under radiologic control to localize the tumor. (B) Preoperative skin markings. Hatched area indicates location of microcalcifications. Bold lines indicate lines of skin incision. (C) Two-year postoperative result after receiving postoperative radiotherapy to the left breast.