Extreme oncoplasty: breast conservation for patients who need mastectomy

Abstract

Extreme oncoplasty is a breast conserving operation, using oncoplastic techniques, in a patient who, in most physicians' opinions, requires a mastectomy. These are generally large, greater than 5 cm multifocal or multicentric tumors. Many will have positive lymph nodes. Most will require radiation therapy, even if treated with mastectomy. Sixty-six consecutive patients with multifocal, multicentric, or locally advanced tumors that spanned more than 50 mm were studied (extreme cases). All patients underwent excision and oncoplastic reconstruction using a standard or split wise pattern reduction and immediate contralateral surgery for symmetry. All received postexcisional standard whole breast radiation therapy with a boost to the tumor bed. The extreme cases were compared with 245 consecutive patients with unifocal or multifocal tumors that spanned 50 mm or less (standard cases). All extreme patients were advised to have a mastectomy; all sought a breast conserving second opinion. Diagnostic evaluation included digital mammography, ultrasound, MRI, and PET-CT (if invasive). Standard cases did extremely well. No ink on tumor was achieved 96% of the time among 245 patients. The median tumor size was 21 mm (mean 23 mm). Margins equal or greater than 1 mm were achieved in 88.6% of patients. Seventeen (6.9%) standard patients underwent re-excision to achieve wider margins and only one patient (0.4%) was converted to mastectomy. With 24 months of median follow-up, three patients (1.2%) experienced local recurrence. For extreme cases, no ink on tumor was achieved 83.3% of the time, which is comparable to published positive margin rates after standard lumpectomy. The median tumor size was 62 mm (mean 77 mm). Margins equal or greater than 1 mm were achieved in 54.5% of patients. Six (9.1%) extreme patients underwent re-excision to achieve wider margins and four patients (6.1%) were converted to mastectomy. With a follow-up of 24 months, one patient (1.5%) experienced a local recurrence. Extreme oncoplasty is a promising new concept. It allows successful breast conservation in selected patients with greater than 5 cm multifocal/multicentric tumors. It may be useful in patients with locally advanced tumors following neo-adjuvant chemotherapy. From a quality of life point of view, it is a better option than the combination of mastectomy, reconstruction, and radiation therapy. Long-term data on recurrence and survival are not available, using this approach. Based on historical data, it is expected the local recurrence will be somewhat higher but that there will be little or no impact on survival.

Keywords: avoiding mastectomy; breast conservation for large tumors; extreme oncoplasty; multifocal/multicentric breast tumors; oncoplastic breast conservation.

Figure 1

(Left) 65-year old with multiple left breast masses spanning 9 cm discovered on screening mammography, but best seen on MRI (Right).

Figure 2

(Left) Marked for a standard left reduction excision with contralateral right reduction for symmetry. (Right) Four bracketing guide wires are in place. A large segment of overlying skin will be removed with underlying breast to include pectoral fascia.

Figure 3

(Left) A 412-gram specimen was removed. The approximate position of the nipple is marked. (Right) Specimen radiograph show four suspicious areas. Final pathology revealed nine foci of invasion. The largest was 12 mm. There was extensive low-grade DCIS spanning 90 mm. All margins greater than 10 mm. Three sentinel lymph nodes were negative.

Figure 4

Preop (Left) and 4 years postop (Right). She received chemotherapy and whole breast radiation therapy. There is minimal skin hyperpigmentation on the left and mild breast shrinkage secondary to radiation therapy. There is no evidence of local or distant recurrence.

Figure 5

48-year old with multiple abnormalities detected on screening. Mammogram shows multicentric lesions spanning 81 mm. Biopsy revealed two foci of invasive lobular carcinoma and one focus of atypical ductal hyperplasia.

Figure 6

(Left) Two bracketing guide wires have been placed around each lesion. (Right) The patient has been marked for a split reduction excision. The inner black line shows skin that will be removed over the tumors. The outer yellow line shows amount of tissue that will be removed.

Figure 7

(Left) 202-gram specimen. (Right) Specimen radiograph. Final pathology revealed two foci of invasive lobular carcinoma spanning 42 mm. With ADH, the entire span was 81 mm. Closest margin was 5 mm. There were two negative sentinel lymph nodes.

Figure 8

(Left) Preop. (Right) 6 months Postop (3 months post-radiation therapy).

Figure 9

(Left) 42-year old with 6 cm palpable left breast mass and palpable left axillary nodes. Skin thickening present. (Right) Mammogram shows large left breast lesion and suspicious left axillary lymph nodes. Core biopsy reveals high-grade invasive ductal carcinoma (SBR 9/9). ER/PR negative, HER2 amplified. Ki67 = 80%. She was treated with neo-adjuvant Herceptin-based chemotherapy.

Figure 10

(Left) Preneo-adjuvant chemotherapy MRI confirms extensive left breast lesion. (Right) Postneo-adjuvant chemotherapy MRI shows near complete resolution.

Figure 11

(Left) She has been marked for a split reduction excision. (Right) Lateral view shows a large triangle of skin and underlying breast tissue that will be removed as part of the split reduction.

Figure 12

(Left) 298-gram specimen. (Right) Specimen radiograph. Microclip marking the lesion is central along with microcalcifications. Final pathology revealed no residual invasive breast cancer. There were a few small scattered foci of residual DCIS. Lymph nodes were negative.

Figure 13

(Left) Preop. (Right) she is 2 years postop and postradiation therapy. MRI and recent PET-CT negative.