Turning subjective into objective: the BCCT.core software for evaluation of cosmetic results in breast cancer conservative treatment

Twelve expert observers from nine different countries convened in a workshop to evaluate the validity of the Breast Cancer Conservative Treatment. Cosmetic results (BCCT.core) software, an objective method for the aesthetic evaluation of breast cancer conservative treatment. Experts were initially asked to subjectively classify the aesthetic results of 30 photographed cases submitted to breast cancer conservative treatment according to the four-point Harris scale. It was pre-established that if at least two-thirds [Cardoso MJ, Cardoso J, Santos AC, Barros H, Oliveira MC. Interobserver agreement and consensus over the esthetic evaluation of conservative treatment for breast cancer. Breast 2005] of participants provided the same classification this would be considered a consensual evaluation for that case. For cases where such agreement was not reached, consensus was obtained using a nominal group technique. Experts then individually performed objective evaluation of the same set of photographs using the BCCT.core software. This provides an automatic rating of aesthetic results, once scale and reference points in the photograph have been chosen. Agreement between observers, between each observer and the consensus, for computer evaluation obtained by the different participants and between software and consensus was calculated using multiple kappa (k) and weighted kappa (wk) statistics. In the subjective assessment, first-round consensus was achieved in 17 (57%) cases. Overall interobserver agreement was fair to moderate (k=0.40, wk=0.57). In the objective assessment there was a higher level of concordance between participants (k=0.86, wk=0.90). Agreement between software and consensus classification was fair (k=0.34, wk=0.53), but was higher in the 17 cases that reached first-round consensus (k=0.60, wk=0.73). Merging the two middle classes of the Harris scale, to form a three-point scale, led to an improvement of all non-weighted measures of agreement. These results show that the BCCT.core software provides consistent evaluation of cosmesis. It has the potential to become a gold standard method for assessment of breast cosmesis in clinical trials, as it can be used simultaneously by a panel of observers from different parts of the world to provide more reliable assessments than has been possible previously.     

Poor esthetic results after conservative treatment of breast cancer. Technics of partial breast reconstruction

A wide consensus exists today in favour of breast saving procedures for the surgical treatment of small breast cancers. The goal of conservative treatment is to preserve the shape of the breast and consequently to avoid the psychological consequences of the mutilation. In this respect, the final esthetic evaluation of conservative treatment is a major point to be considered after the oncological results. To evaluate these cosmetic results, 89 patients treated more than five years ago were analyzed on a standard picture protocol and rated according to a rigorous scale previously defined. In this group, 45% were rated as excellent, 34% as fair and 21% as poor. These results were compared to the cosmetic results of a second group of patients evaluated after the surgical stage of their conservative treatment in order to precise the morphological damage due to the surgical procedure. In the second group, 73% were rated as excellent, 20% as fair and 7% as poor. This study underlines the frequency of skin contractions (16%) and glandular defects (20%). Several rules are proposed to prevent such sequelae at the time of the tumorectomy. The difficulty of cosmetic improvement of the poor esthetic results is emphasized and the techniques of partial reconstructions are discussed in the light of our experience which includes 25 cases of partial reconstruction.     

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.     

Post-treatment sequelae after breast cancer conservative surgery

Thanks to the earlier detection of breast cancer, the advent of neoadjuvant therapy and the development of more effective surgical procedures reducing treatment sequelae, conservative treatment has dramatically expanded over the past 15 years. Several factors have recognized negative aesthetic consequences for breast cancer patients: being overweight, having voluminous or on the contrary, very small breasts, having a tumor located in the lower quadrant, having high breast-tumor: breast-volume ratio. Tissue injuries induced by radiotherapy and chemotherapy, such as shrinking, fibrosis or induration, maximize the deleterious impact of surgery. The results of conservative treatment also deteriorate with time: weight gain is common and may result in increased breast asymmetry. Patients undergoing conservative treatment may experience sequelae including various degrees of the following dimorphisms, all possibly responsible for minor or even major breast deformity: breast asymmetry, loss of the nipple/areola complex, scar shrinkage and skin impairment, irregular shape and position of the nipple and areola. Various sensory symptoms have also been reported following conservative treatment, with patients complaining of hypo- or dysesthesia or even suffering actual pain. Breast lymphedema is also a common incapacitating after-effect that is believed to be largely underdiagnosed in clinical practice. Finally, like mastectomy, conservative breast surgery may induce serious psychological distress in patients who suffer the loss of physical integrity, womanhood or sexual arousal. Clinicians must be aware of the radiological changes indicative of late cancer recurrence. There are four types of modifications as follows: increased breast density, architectural distortion at the surgical site and formation of scar, mammary fat necrosis, and occurrence of microcalcifications. The management of sequelae of conservative breast treatment must therefore involve a multidisciplinary approach; patients not only expect better cosmetic appearance, but also a focus on other treatment advances such as improvement of psychological and sensory outcome. The interpretation of radiological images is also an integral part of the management of these patients at significant risk of recurrence.     

乳腺癌保留乳房术后影响乳房形态的多因素分析

目的探讨乳腺癌保乳术后影响乳房形态的因素及提高保乳术后乳房美学效果的方法。方法由整形外科医师和患者分别对67例乳腺癌保乳术后的美学效果做出各自独立的评价，单因素分析采用Mann-Whitney U检验，而多因素分析则应用Logistic回归的方法。结果医师对保乳术后乳房形态的满意率为65．7％。单元素分析中，年龄（P=0．003）、体重指数（P=0．002）、绝经状况（P=0．002）、放疗剂量（P=0．022）、肿物位于外上象限时的切口数量（P=0．036）、切除次数（P=0．036）、纤维化（P=0．002）、手术方式（P=0．002）对保乳术后乳房形态具有明显的影响。多元素分析中，纤维化、手术方式、放疗剂量对术后乳房形态具有明显影响（P=0．009、0．001、0．019）。患者对保乳术后乳房形态的满意率为76．1％。单元素分析中，手术方式（P=0．001）和纤维化（P=0．045）对乳房形态影响明显，差异具有统计学意义。多元素分析中，手术方式对术后乳房形态影响明显（P=0．005）。结论患者和医师的满意率具有正相关性（R=0．701，P〈O．01）。在可能影响乳房美学的27项因素中，年龄、体重指数、绝经状况、放疗剂量、肿物位于外上象限时的切口数量、切除次数、纤维化、手术方式对术后乳房形态影响明显。     

Conservative oncoplastic surgery in breast cancer. Indications and limitations to its application

Conservative surgery is the technique of choice in the surgical treatment of women with breast cancer. The conflict between the extent of resection and the final cosmetic result can lead to asymmetries and deformities that are intensified after adjuvant treatment. The introduction of oncoplastic techniques in the conservative management of breast cancer have allowed the indication for breast conservation to be increased and have improved cosmetic results, increasing the technical alternatives available to general surgeons specialized in breast cancer. The present article aims to review the indications and limitations of these conservative oncoplastic techniques in the surgical management of women with breast cancer.     

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.     

Oncoplastic Breast-Conserving Surgery: Analysis of Quadrantectomy and Immediate Reconstruction with Latissimus Dorsi Flap

Background Oncoplastic breast-conserving surgery satisfies oncologic principles and improves cosmetic outcomes, even when an important breast volume excision is required. Methods We reviewed 28 patients suffering from breast cancer treated with quadrantectomy and immediate myocutaneous latissimus dorsi flap reconstruction. We evaluated the status of the surgical margins, early complications, and cosmetic outcome. Cosmetic assessment was carried out by a panel made up of three women and one man: a female member of an association against breast cancer, a female general practitioner, a female gynecologic resident, and a male breast-specialized surgeon. Results Free margins were obtained in all cases. There were 11 postoperative complications: 9 seromas at the donor site, 1 dehiscence of the back wound, and 1 minor partial flap skin necrosis. Chemotherapy and radiotherapy adjuvant treatment was not compromised. The cosmesis outcome was deemed to be good in 43.75% of the cases and satisfactory in 56.25%. The score for overall cosmesis outcome was 6.92 out of 10. Symmetry and the scar of the reconstructed breast were the most influential criteria in the quantitative assessment of overall cosmetic results. Conclusion Partial mastectomy (quadrantectomy) and immediate reconstruction with a myocutaneous latissimus dorsi flap allows extensive resection, which fits oncologic requirements, without serious morbidity and a good cosmetic outcome.     

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 treatment of the central breast cancer with nipple-areolar resection: an alternative oncoplastic technique

Conservative surgery with radiation therapy is the standard treatment for early-stage breast cancer. Nevertheless, the patients with subareolar breast cancer have been often excluded from breast-conserving surgery and treated with mastectomy because of the unacceptable cosmetic effect associated with the resection of the nipple-areola complex (NAC), as well as oncologic concerns about multicentricity or multifocality associated with these tumours. We show a conservative "oncoplastic technique" in which the resection of the central portion of the breast, including the NAC, can allow a wide excision of the tumour with uninvolved margins of resection and good cosmetic results.     

Better cosmetic results and comparable quality of life after skin-sparing mastectomy and immediate autologous breast reconstruction compared to breast conservative treatment.

Preoperative chemotherapy (PCT) can be used in large primary breast cancer to facilitate breast conservative surgery (BCS). Cosmetic results of BCS are influenced by the size of the residual tumour, relative to the size of the breast. After mastectomy, immediate breast reconstruction (IBR) with autologous tissue provides excellent cosmetic outcome and has proven to be safe in breast cancer patients. Besides improving overall and disease free survival, Quality of Life (QoL), body image and cosmetic outcome are also important issues after treatment for breast cancer.In this study, Health-Related-Quality of Life (HRQL) and body image were evaluated, in patients treated with PCT, followed by BCS, or skin-sparing mastectomy (SSM) and perforator-flap breast reconstruction. Additionally, clinical observers assessed cosmetic outcome.All participants were evaluated by the Medical Outcomes Study (MOS) 36-item Short Form Health Status Survey (SF-36, 36 items) and a study-specific questionnaire. An external panel evaluated standardised photographs of the breasts.For all patients, norm-based scores of physical and mental health state are comparable with the general population, except for vitality (VT) score, which is somewhat lower. No significant differences can be observed between both groups. The majority of the patients were satisfied with the appearance of their breasts.The cosmetic results, assessed by the clinical team, were significantly better for patients having IBR, compared to BCS. The mean score was 7.5/10 for IBR, versus 6.0/10 for BCS (p<0.0001).Breast conserving treatment or mastectomy with reconstruction may yield comparable results of QoL, but cosmetic outcome is better after SSM and perforator-flap reconstruction. Patients must be offered both options, and clinicians should stress that both are equally effective.     

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.     

Mamoplastia de reducción en la cirugía del cáncer de mama

Reduction mammaplasty techniques enable the breast cancer surgeon to provide an integral surgical treatment, thus significantly increasing and improving surgical options. These techniques are used to correct problems after the conservative treatment of type 1 breast cancer and to achieve symmetry between the breasts after mastectomy. They are also the basis of cosmetic reconstruction techniques in conservative oncoplastic surgery.     

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.     

Conservative surgery and radiotherapy of early breast cancer]

Radiation dose-effect relationship is reviewed. In conservative treatment of early breast cancer, necessity of radiation is discussed and surgery with radiotherapy technique in our hospital is presented. Our procedures consist of lumpectomy which is removal of 1 cm of normal tissue containing primary breast cancer and complete axillary dissection and postoperative radiotherapy of 46 Gy with 9 Gy of electron boost. Since November 1987, 51 patients treated by this procedure have shown a good local control and a satisfactory cosmetic results. We can conclude that the positive aspects of radiotherapy in the management of conservative therapy for early breast cancer are overwhelming.     

In Search of a Gold Standard Scoring System for the Subjective Evaluation of Cosmetic Outcomes Following Breast‐Conserving Therapy

The absence of a widely accepted method for aesthetic evaluation following breast‐conserving surgery for breast cancer limits the ability to evaluate cosmetic outcomes. In this study, two different panel scoring approaches were compared in an attempt to identify a gold standard scoring system for subjectively assessing cosmetic outcomes following breast‐conserving therapy. Standardized photographs of each participant were evaluated independently by twelve health care professionals involved in breast cancer diagnosis and treatment using the Danoff four‐point scale. Individual Danoff scores were combined using two methods, a random sample “three‐panel” score and an iterative “Delphi‐panel” score, in order to create a final cosmetic score for each patient. Agreement between these two aggregative approaches was assessed with a weighted kappa (wk) statistic. Patient and professional recruitment occurred at two separate tertiary care multi‐disciplinary breast health centers. Women with unilateral breast cancer who underwent breast‐conserving therapy (segmental mastectomy or lumpectomy and radiotherapy) and were at least 2 years after radiotherapy were asked to participate. Ninety‐seven women were evaluated. The Delphi approach required three rounds of evaluation to obtain greater than 50% agreement in all photographs. The wk statistic between scores generated from the “three‐panel” and “Delphi‐panel” approaches was 0.80 (95% CI: 0.71–0.89), thus demonstrating substantial agreement. Evaluation of cosmetic outcomes following breast‐conserving therapy using a “three‐panel” and “Delphi‐panel” score provide similar results, confirming the reliability of either approach for subjective evaluation. Simplicity of use and interpretation favors the “three‐panel” score. Future work should concentrate on the integration of the three‐panel score with objective and patient‐reported scales to generate a comprehensive cosmetic evaluation platform.     

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.     

110例乳腺癌保乳综合治疗的临床观察

目的探讨乳腺癌保乳手术的临床疗效。方法对我院2002年1月-2008年12月收治的110例乳腺癌保乳手术患者临床资料进行回顾性分析。结果110例患者术后均恢复良好,随访半年～6年,无一例死亡,无一例局部复发,出现肝及肺转移2例,保乳手术后患者美容效果满意率为83．6％。结论掌握乳腺癌患者保乳的手术指征结合术后的综合治疗,可降低乳腺癌保乳术后局部复发,并取得满意的美容效果。     

Predictors of breast asymmetry after breast-conserving operation for breast cancer

BACKGROUND: Although breast-conserving surgery is the standard of care for early-stage breast cancer, many women report breast asymmetry after this procedure. Risk factors for poor esthetic outcomes are not well understood. STUDY DESIGN: A self-administered survey was sent to patients who underwent lumpectomy (n = 898) at the University of Michigan Medical Center between January 2002 and May 2006 (n = 714, response rate = 79.5%). Breast asymmetry was assessed using items from the Breast Cancer Treatment and Outcomes Survey. Responses were summed to generate a score, and linear regression was used to generate adjusted breast asymmetry scores by patient-related factors (age, body mass index [BMI], tumor size, and tumor position in the breast) and treatment factors (reexcision lumpectomy, radiation therapy, and postoperative seroma). RESULTS: Patient-related risk factors for breast asymmetry included younger age (asymmetry score: 18.7 versus 16.2, p = 0.03), higher BMI (17.1 versus 19.2, p = 0.007), and larger tumors (16.7 versus 19.1, p = 0.01). Resection of superior medial tumors and inferior lateral tumors was also associated with substantially higher asymmetry. Treatment-related risk factors for asymmetry included reexcision lumpectomy (18.1 versus 16.9, p = 0.013), postoperative seroma (19.3 versus 17.2, p = 0.005), and radiation therapy (17.9 versus 15.0, p = 0.008). Increasing breast asymmetry score was associated with a higher odds of desiring breast reconstruction (odds ratio = 1.2, 95% CI, 1.13 to 1.30). CONCLUSIONS: Both patient- and treatment-related factors place women at risk for poor esthetic outcomes after breast-conserving surgery. Oncoplastic and reconstructive options should be considered for those at a higher risk for poor esthetic outcomes at the time of consultation.     

Conservative and esthetic surgery in cancer of the breast]

After a review of the studies justifying conservative surgery in the treatment of breast cancer, the author describes the possibilities of improving the results of this surgery either by the use of flaps or prostheses or (in the case of large breasts) by performing mammoplasties. The review of a series of 116 cases illustrates the range of possibilities of cosmetic surgery.