Factors determining esthetic outcome after breast cancer conservative treatment

The aim of this study was to evaluate the factors that determine esthetic outcome after breast cancer conservative treatment, based on a consensual classification obtained with an international consensus panel. Photographs were taken from 120 women submitted to conservative unilateral breast cancer surgery (with or without axillary surgery) and radiotherapy. The images were sent to a panel of observers from 13 different countries and consensus on the classification of esthetic result (recorded as excellent, good, fair or poor) was obtained in 113 cases by means of a Delphi method. For each patient, data were collected retrospectively regarding patient characteristics, tumor, and treatment factors. Univariate and multivariate analysis were used to evaluate the correlation between these factors and overall cosmetic results. On univariate analysis, younger and thinner patients as well as patients with lower body mass index (BMI) and premenopausal status obtained better cosmetic results. In the group of tumor- and treatment-related factors, larger removed specimens, clearly visible scars, the use of chemotherapy and longer follow-up period were associated with less satisfactory results. On multivariate analysis, only BMI and scar visibility maintained a significant association with cosmesis. BMI and scar visibility are the only factors significantly associated with cosmetic results of breast cancer conservative treatment, as evaluated by an international consensus panel.     

Prediction of cosmetic outcome following conservative breast surgery using breast volume measurements

This study was undertaken to examine the feasibility of breast volume estimation as a predictor of cosmetic outcome. We looked at the cosmetic result of conservative surgery related to the percentage of breast tissue removed. The breast tissue excised was calculated by comparing the breast volume, calculated from the mammogram, and the specimen volume. A total of 24 patients were recalled to a special clinic and were assessed for their cosmetic result by the clinician, independent observer and the patient. The assessment was based on a scale of 1 to 4 (poor to excellent). Our results show that if less than 20% of the breast was removed, all assessors felt that the cosmetic result was at least fair. If more than 20% of the breast was removed, the cosmetic score was poor as assessed by the clinician and independent observer. When excision of greater than 20% of breast tissue is anticipated, then a breast reconstruction procedure should be considered, if cosmetic outcome is to be enhanced.     

早期乳腺癌保乳手术术中放疗59例

目的 研究早期乳腺癌保乳手术术中放疗的可行性,评价术后并发症、乳房美容效果及肿瘤复发事件.方法 2007年6月至2010年12月,115例患者做保乳手术,59例(研究组)做术中放疗,同期有56例(对照组)术后做全乳放疗,在术后1个月评估切口愈合状况及并发症;术后1年比较两组乳房美容效果;术后随访肿瘤复发及死亡事件.结果 研究组切口愈合天数为13 ～22d,对照组为9 ～14d.研究组2例出现切口脂肪液化,16例有切口水肿,对照组未见切口脂肪液化、水肿;两组均未出现术后切口感染或血肿.术后1年乳房美容评价:研究组41例中优秀或好的有36例、一般或差的5例;对照组37例中优秀或好的有25例、一般或差的有12例(P=0.031).随访3～42个月(中位24个月),研究组局部复发2例(3.39％),其中1例(1.7％)死亡;对照组局部复发1例(1.8％),无死亡.结论 早期乳腺癌保乳手术术中放疗安全可靠、美容效果好、局部控制满意.     

Interobserver agreement and consensus over the esthetic evaluation of conservative treatment for breast cancer

Twenty-four experts from 13 different countries were asked to evaluate photographs taken of 60 women following conservative breast cancer treatment. The esthetic result of each case was classified as poor, fair, good or excellent. Agreement was evaluated using the kappa (k) and weighted kappa (wk) statistics, for all observers, male and female participants, those younger and older than 50 years, those seeing more than 250 cases a year, and those with previous publications in this area. Consensus was obtained by way of a modified Delphi approach, when more than 50% of participants provided the same classification. In a second round, consensual cases were disclosed and a revised opinion was asked in non-consensual ones. Agreement between all participants was fair (k=0.24, wk=0.37) and remained within the same range (k=0.20-0.31, wk=0.31-0.45) in the subgroups analyzed. First round consensus was obtained in 46 out of 60 cases (77%) and in the second round in 59 out of 60 cases (98%). Evaluation of the esthetic results of conservative treatment for breast cancer is only fairly reproducible when performed by experts working in different geographical areas. Consensus is obtainable if a relatively low threshold of agreement is considered acceptable.     

Conservative surgery and radiation therapy for early breast cancer. Long-term cosmetic results

To evaluate the cosmetic outcome of conservative surgery (CS) and radiation therapy (RT) for early-stage breast cancer and its stability over time, we reviewed the records of 593 patients treated from 1968 to 1981. The breast appearance was scored as "excellent," "good," "fair," or "poor". Median follow-up was 76 months (range, 37 to 186 months). Cosmetic results were generally excellent or good. The percents of excellent, good, fair, and poor results at three years were 65%, 25%, 7%, and 3%, respectively. Patients not receiving adjuvant chemotherapy were more likely than those receiving chemotherapy to have excellent scores at five years (71% vs 40%). Tumor size also influenced cosmetic outcome: 73% of patients with T1 tumors vs 55% with T2 tumors had excellent scores at five years. Our results were stable over time: of 36 patients assessable at seven years whose cosmetic scores were good or excellent at three years, 34 (94%) continued to have good or excellent scores, and only two (5%) deteriorated to fair. We conclude that the cosmetic results achieved with CS and RT are good to excellent in approximately 90% of patients and that these results remain stable for at least seven years.     

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

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.     

Cosmetic results after wire-guided biopsy of benign breast lesions

Background: There are surprisingly few reports about the cosmetic results of wire-guided biopsy of benign breast lesions as opposed to breast-conserving surgery and irradiation of early breast cancer (BCT).

Study Design: Twenty potential perioperative risk factors for adverse cosmetic results after wire-guided breast biopsy were prospectively evaluated in 101 patients undergoing the first single biopsy after suspicion of a malignant lesion that subsequently proved to be benign. The overall cosmetic result was evaluated by using 6 specific cosmetic indices individually scored 6 months after the breast biopsy.

Results: The overall cosmesis was excellent, good, fair, or poor in 48.5%, 26.7%, 12.9%, and 11.9% of cases, respectively. The corresponding figures according to appraisal by the patients were 22.8%, 58.4%, 17.8%, and 1.0%, respectively. Unsatisfactory (fair or poor) overall cosmetic results were related to excisions extending down to the fascia (p = 0.001) and postoperative complications (p = 0.018) in multivariate analysis. Notably, specimen volume had no significant impact on overall cosmesis, as opposed to cosmesis after BCT.

Conclusions: Cosmetic outcomes after wire-guided biopsy of benign breast lesions were excellent or good in at least 75% of cases. Excisions extending down to the pectoralis fascia and complications were associated with poor aesthetic outcomes.     

Central quadrantectomy with resection of the nipple-areola complex compared with mastectomy in patients with retroareolar breast cancer

Appropriate surgery in women with retroareolar breast cancer should allow resection of the cancer with wide free margins and an acceptable cosmetic result. The aim of this study was to compare breast conservation surgery (BCS) to mastectomy for treatment of retroareolar breast cancer. In a prospective nonrandomized study, 69 women with retroareolar breast cancers underwent either central quadrantectomy (n=33) with complete removal of the nipple-areola complex or mastectomy (n=36). Two of 33 (6%) patients scheduled for BCS had a secondary mastectomy and immediate reconstruction due to involved margins. After a median follow-up of 42 month (range 17-99 months) in the BCS group and 43 months (range 16-118 months) in the mastectomy group local and regional recurrences as well as systemic disease were comparable between both groups. The postoperative cosmetic result after BCS as evaluated by the patients was rated as excellent in 80% and good in 20% with no poor result. BCS followed by radiation therapy is a feasible alternative to mastectomy in patients with retroareolar breast cancer.     

Factors influencing cosmetic outcome of conservative surgery and radiotherapy for breast cancer

Increasing acceptance of conservative therapy for early breast cancer has made the cosmetic outcome of the treated breast an important endpoint for evaluation. A number of interrelated patient, tumor, and treatment factors will determine the ultimate cosmetic outcome. Attention to surgical and radiotherapeutic technique should lead to good to excellent overall cosmetic results in the majority of patients.     

Cosmetic results in 242 patients treated by conservative surgery for breast cancer.

The surgery of breast cancer has changed lately in favour of breast conserving treatment, the main purpose of which is to provide good cosmetic results together with radical resection of the tumour. In this paper we describe the cosmetic results obtained in 242 patients treated by conservative surgery (226 quadrantectomies, 93%, and 16 lumpectomies, 7%) for low risk breast cancer. Several of these resections were combined with plastic surgical techniques for residual breast reshaping. The technique chosen depended on the site of tumour, width of resection, and breast volume. The cosmetic assessment was made by the patient and the physician. Our data suggest that better cosmetic results may be obtained when plastic surgical procedures are combined with conservative surgery for breast cancer.     

Conservative surgery and radiation in the treatment of early (stages I and II) breast cancer. Long-term results

Multiple nonrandomized series as well as prospective randomized trials have demonstrated that the long-term results of conservative surgery and appropriate radiation are equal to those of mastectomy for the treatment of early breast cancer. Moderate doses of radiation combined with surgical excision result in optimal local-regional control, good to excellent cosmetic results in the majority of patients and minimal complications. The long-term potential carcinogenic effects of radiation have not materialized in the clinical setting and the incidence of contralateral breast cancer and second non-breast malignancy is comparable to that reported after mastectomy. Based on this data, conservative surgery and radiation continues to represent a valid alternative to mastectomy for the treatment of early breast cancer.     

Plastic surgery and conservative treatment of breast cancer. Indications and results]

After conservative treatment for breast cancer, 75% of patients have good cosmetic results, but 20 to 25% of patients have a fair or a bad result. The tumor itself is responsible for some of these bad results (tumor volume, location in the inferior quadrants of the breast) but more often, failures are related to surgery and/or radiotherapy. Some patients will then ask for reconstructive surgery. It should always be preceded by a careful examination of the breast, both with an oncologic and a reconstructive approach. The techniques used are numerous, ranging from simple reexcision of the lumpectomy scar to mastectomy with immediate TRAM flap reconstruction. We believe that plastic surgery techniques should be used as soon as the initial lumpectomy, as they help to fill in the defect. In the case of a tumor located in the inferior quadrants, bad cosmetic results are twice as frequent as in the upper quadrants: we treated 16 of these patients with immediate bilateral breast reduction, reshaping the breast at the same time as the lumpectomy, and achieving symmetry of the contralateral breast. This technique did not interfere with radiotherapy or chemotherapy. When radiotherapy followed surgery, cosmetic results were good. Local and distant recurrences were not modified by the adjunction of a breast reduction to the lumpectomy. In 49 cases, we also proposed a bilateral breast reduction for larger tumors (T > 3 cm, bifocal cancer). 4-year local recurrence rate was less than 10%: this technique could help to extend the indications for conservative treatment for breast cancer. More cases and longer follow-up are necessary.     

Superior-medial dermoglandular pedicle reduction mammaplasty for immediate conservative breast surgery reconstruction: technical aspects and outcome

BACKGROUND: Reduction mammaplasty procedures and especially the superior-medial dermoglandular pedicle (SMDP) technique are frequently used for esthetic objectives; however, few reports have been available regarding its application following conservative breast surgery reconstruction. The purpose of this study is to analyze the feasibility of the technique and describe the surgical planning and its outcome following oncologic surgery. METHODS: Thirty-nine patients underwent immediate bilateral SMDP breast reconstructions. Mean time of follow-up was 20 months. SMDP was indicated to reconstruct inferior breast defects in patients with enough remaining breast tissue. Reconstructed (RB) and opposite (OB) breast complications were evaluated and information on esthetic result and patient satisfaction was collected. RESULTS: Tumors (51.2%) measured 2 cm or less (T1) and 66.6% were located in the lower outer quadrants. Mean change in nipple position was 12.5 cm. Immediate RB complications occurred in 8 patients (20.5%), with skin necrosis in 3 (7.6%), infection in 2 (5.1%), dehiscence in 2 (5.1%), and partial areola necrosis in 1 (2.5%) patient. Late complications were observed in 7.6%. All late complications were observed after adjuvant radiotherapy. The cosmetic result was considered to be good or very good in 84.6%, and the majority of patients were either very satisfied or satisfied. All complications were treated by conservative approach. CONCLUSION: SMDP is a reliable technique and should be given primary consideration in cases of lower quadrant reconstruction. The success of the procedure depends on patient selection, coordinated planning, and careful intraoperative management.     

Principles of oncoplastic surgery in breast surgery

After a conservative treatment for breast cancer, 75% of patients end up with a good aesthetic result, i.e. little or no residual asymmetry and minor postradiotherapy after-effects. In 20 to 25% of cases, the conservative treatment leaves lasting after-effects associated with surgery and radiotherapy. Such aesthetic after-effects are difficult to treat and they require additional plastic surgery in 5 to 10% of cases. Oncoplastic surgery, which combines large lumpectomy and remodeling procedure involving different plastic surgery methods, improves these cosmetic results after a partial mastectomy and widens the scope for conservative treatment. Today, these techniques are well codified. They range from simple reshaping to more sophisticated techniques involving a concomitant controlateral-breast-symmetrisation procedure. These surgical options must be elaborated in detail with the patient and depend on the patient, the type of the tumor, its position, the ratio between the volume of the tumor and that of the breast and the overall care given by a multispecialist team. Plastic surgery is now an integral part of the treatment of breast cancer, hence the use of the word: oncoplastic surgery.     

Factors influencing cosmetic results after breast conserving management (Turkish experience)

We aimed to determine predictive factors affecting cosmetic results after breast conserving management in breast cancer. Data on 96 patients with 97 breast cancer cases, who had been admitted to Uluda? University M.A. Radiotherapy Center between October 1995 and December 1998 and managed with breast-conserving treatment, were analysed to determine the factors affecting cosmetic outcome. Possible factors affecting cosmesis were grouped as patient-related, tumor-related and treatment-related. Mann-Whitney U test was used in univariate analyses whereas logistic regression was used in multivariate analyses. Median follow-up time was 29.5 months ranging between 11 and 53 months and median age at admission was 50 (range 22-84). Cosmetic results were grouped in five categories; excellent; good; fair; poor and, very poor, using criteria, such as presence of fibrosis, telangiectasia, shape of breast, asymmetry, status of areola, pigmentation. Treated breasts were scored by the patients, three radiation oncologists and a breast surgeon independently. In the analysis performed using scores given by the patients, cases with scores 3 and above (unsatisfactory) were compared with cases with scores below 3 (satisfactory). Eighty-two patients (84%) considered cosmetic result as satisfactory (excellent/good) whereas 15 patients (16%) considered unsatisfactory (fair/poor/very poor). In univariate analysis using Mann-Whitney U test, type of surgery (P=0.0655) was the statistically significant factors affecting cosmetic results. In multivariate analysis using logistic regression, tumor quadrant (P=0.0060) and elapsed radiation therapy days (P=0.0090) were the most significant factors. Median values were taken into consideration for the scores given by the physicians and cases with scores 3 and above (unsatisfactory) were compared with cases with scores below 3 (satisfactory). Eighty-two cases were evaluated as satisfactory (84%) whereas 15 cases were unsatisfactory (16%). In this set of data, patient age (P=0.0144), menopausal status (P=0.0111), institution which surgery was performed (P=0.0045), type of surgery (P=0.0044), placement of metallic clips (P=0.0083) and skin fibrosis (P=0.038) were found to be significant in univariate analysis using Mann-Whitney U test. In multivariate analysis using logistic regression, institution where surgery took place (P=0.0015), menopausal status (P=0.0087) and telangiectasia (P=0.0657) were the most significant factors.     

Cosmesis with bilateral mammoreduction for conservative breast cancer treatment

Over 7 years, 57 women with breast cancer underwent lumpectomy and bilateral mammoreduction. Physical complaints about large or lax breast shape were the predominate rationale. Two patients were immediately lost to follow-up, 55 patients remained and were followed every 3 months for an average of 1.6 years. This is the largest series traceable by computer and literature search. Chart review and patient examination in this retrospective review were utilized as the basis for data within the article. Collated notes from patients' doctors were assessed, as well as documented patient responses to the procedure. Pictures without head/face for identifiers were taken of the patients. Chart data were collected by clinicians, but were reviewed blindly by a statistician. The overall control and cosmesis rates as well as alleviation of heavy breast problems were noted. Only 6% of women had fair to poor cosmetic results; the majority (82%) had excellent to good results. Women with very large breasts or markedly relaxed breast tissue of concern to the patients proved optimal candidates for lumpectomy of cancer and bilateral mammoreduction in the conservative treatment of these cancers. There was a significant reduction in the physical complaints of the patients as well. For women with very pendulous or extremely large breasts, lumpectomy and bilateral mammoreduction may prove to be the optimal course of action.     

Outcome of oncoplastic breast surgery in 90 prospective patients

Background

Oncoplastic breast surgery refers to a wide range of techniques with a parallel goal of safely removing all malignant breast tissue while achieving the best possible esthetic outcome. We report the results of our oncoplastic breast operations from 2005 to 2007.

Methods

Ninety selected breast cancer patients were treated with a variety of oncoplastic operations. The patients were prospectively monitored. Radiotherapy and systemic adjuvant treatment were given according to national guidelines.

Results

Fifteen patients had an immediate surgical complication, of which 8 required a reoperation. Eleven patients had an inadequate surgical margin and required a completion mastectomy. During a median follow-up of 26 months no local or regional recurrences were noticed. Three patients developed distant metastases.

Conclusions

Oncoplastic breast surgery offers tools for breast conservation in patients otherwise destined for mastectomy or poor esthetic outcome. Despite the high proportion of patients in this series with large-volume ductal carcinoma in situ (DCIS) or extensive intraductal component, the use of oncoplastic techniques achieved negative margins with acceptable cosmetic results in the majority (84%) of patients.     

Surgery of Cosmetic Sequelae After Breast‐Conserving Therapy

Abstract: Although a considerable number of patients have an unfair cosmetic result after breast‐conserving therapy, which correlates with poor psychosocial functioning, surprisingly, really only very few patients undergo surgical correction. The purpose of this article was to report our experience in the surgical treatment of such patients and analyze a special subgroup which required bilateral reduction mammaplasty because of associated symptomatic macromastia and their desire to reduce their breast size. From July 2000 to November 2008, some 23 patients consulted for unsatisfactory cosmetic outcome after breast‐conserving therapy, fourteen of them accepting the surgical treatment proposed and these were operated upon. We used the following techniques: reduction mammaplasty of the contralateral breast for symmetrization (9), bilateral reduction mammaplasty (4), one mammaplasty and augmentation of contra‐lateral breast and one myocutaneous dorsi flap for surgical correction of ipsilateral breast. One patient had serious complications, having partial necrosis of the areola, fat and breast skin necrosis, and needed reoperation for surgical removal of necrotic tissue. Some factors such as obesity and heavy smoking habits could explain this. We were able to evaluate cosmetic outcome in ten patients; late cosmetic outcome was good in seven patients, fair in two and poor in one. Despite the fact that most patients treated by breast‐conserving therapy are satisfied with the fact that they have retained their breasts and minimized an unfair cosmetic outcome, cosmetic evaluation should be introduced as a matter of routine.     

Conservative treatment in cancer of the breast

Conservative treatment combining breast saving surgical procedures and radiotherapy, is considered as the best treatment for small breast cancers. The purpose of the study is to define the most appropriate surgical technique in order to reach both the complete resection of the primary and the best cosmetic result. Terms corresponding to the type of resection will be define in order to facilitate the comparison between the different studies on tumorectomies for breast cancer. Technical problems will be analyzed in the light of our experience of the conservative treatment especially in what concerns the cosmetic results.     

Developmental breast asymmetry

Developmental breast asymmetry (DBA) can affect psychosocial well-being in the young female. Correction of breast asymmetry may present a reconstructive challenge, especially in tuberous breasts. Fifty-two cases of DBA treated between January 2002 and January 2006 were reviewed. Preoperative clinical assessment of the specific anatomical deformity, subsequent surgical treatment modalities, esthetic outcome, and patient's satisfaction were evaluated. Surgical modalities used in our series include augmentation mammaplasty with or without tissue expansion, parenchymal scoring, nipple areola complex reduction, glanduloplasty techniques, mastopexy and reduction mammaplasty. The mean age of DBA presentation was 21 years; 69% (36/52) patients had tuberous breasts, of which 67% (24/36) were unilateral and 33% (12/36) were bilateral deformities. Patients with tuberous breast deformity presented consistently under the age of 25 years. Esthetic outcome was rated "good" in 75% (39/52), and symmetry rated as "good" in 58% (30/52) by professional evaluation. Surgical treatment is tailored to the affected esthetic units of the individual breast. In our experience, symmetry is the hardest parameter to achieve, particularly in tuberous breasts. Operative treatment is of great value to the psychosocial well-being of the patient. A conceptual approach in the assessment and treatment of DBA is emphasized by this series.