A clinical perspective on oncoplastic breast conserving surgery

Abstract

Breast conserving surgery (BCS) plus radiation treatment is the favored alternative for mastectomy in patients with breast cancer. To allow for breast conservation in patients with large invasive tumors and poor response to neoadjuvant systemic treatment (NST) or patients with extensive ductal carcinoma in situ (DCIS), oncoplastic breast conserving surgery (OPBCS) techniques are introduced. OPBCS allows for breast conservation in a selective group of breast cancer patients who initially would have been treated with mastectomy due to the unfavorable tumor-to-breast ratio. With OPBCS, the oncological tumor excision is combined with plastic surgical breast conservation techniques without compromising oncological safety and maintaining aesthetic outcomes by preserving the shape of the breast. OPBCS should however not be applied to all breast cancer patients and the selection of patients who benefit from OPBCS and the timing of OPBCS are best discussed in a multidisciplinary team (MDT). Caution is required in patients with higher risk of positive margins [e.g., multifocal breast cancer, invasive lobular carcinoma (ILC), larger tumors and DCIS]. In these patients, delayed OPBCS is recommended to facilitate re-excision and maintain excellent breast conserving rates. Despite proven benefits in selected patients, the increase in the adoption of OPBCS is relatively low. This article provides a clinical perspective on OPBCS.

Keywords: Breast cancer; breast conserving surgery (BCS); breast reconstruction; oncoplastic breast conserving surgery (OPBCS).

Figure 1

Patient A with usage of OPBCS. A 69-year-old patient, with a screen detected right-sided cT1N0M0, invasive lobular carcinoma with extensive DCIS (A: mammography). She underwent primary OPBCS (volume displacement) using a reduction technique following the Wise-pattern (B: per-operative, C: postoperative). OPBCS, oncoplastic breast conserving surgery; DCIS, ductal carcinoma in situ.

Figure 2

Patient B with usage of OPBCS. A 51-year-old patient, with a left-sided breast tumor: stage cT2mN1M0, HR-positive/HER2-negative of no special type with extensive DCIS. Imaging was performed before (A) and after (B) four cycles of doxorubicine and cyclofosfamide combined with 12 times paclitaxel, showing a radiological complete response. She underwent OPBCS (volume replacement) by use of TDAP flap technique due to extensive DCIS in the left breast (C). OPBCS, oncoplastic breast conserving surgery; HR, hormone receptor; HER2, human epidermal growth factor receptor 2; DCIS, ductal carcinoma in situ; TDAP, thoracodorsal artery perforator.

Figure 3

Two-step approach of OPBCS. OPBCS* = level 2 oncoplastic surgery using either volume displacement or volume replacement techniques. OPBCS, oncoplastic breast conserving surgery; DCIS, ductal carcinoma in situ; s-BCS, standard breast conserving surgery.