Abstract: Oncoplastic breast conservation surgery (OBCS) is increasingly becoming part of routine breast cancer surgical management. OBCS may be viewed as an extension of standard breast conservation surgery for resecting tumors of larger sizes without compromising on cosmetic outcome, or as an alternative to mastectomy. High quality evidence to support the oncological safety and benefits of OBCS is lacking. This review will focus on the best available level of evidence and address key issues regarding oncological safety in OBCS, such as tumor resection margins and re-excision rates, local recurrence and patient outcome, postoperative complications and adjuvant therapy delivery, and briefly discuss cosmetic outcome in OBCS. Comparative observational studies and systematic review report no poorer outcomes compared with standard breast conservation surgery. More evidence needs to be generated to support the oncological safety and improved aesthetic outcome. Prospective data collection will significantly contribute to the generation of stronger evidence.
Keywords: oncoplastic breast conservation surgery, oncological safety, cosmetic outcomes, therapeutic mammoplasty, recurrence, survival
INTRODUCTION – OBCS: Rationale, definition, Trends, and Evidence for Practice
Breast conservation treatment (BCT) defined as breast conservation surgery (BCS) with whole breast irradiation is the standard of care in the management of early breast cancer. The goal of BCT is tumor-free resection margins and good local control. An important secondary goal is a satisfactory cosmetic outcome as this is associated with both patient satisfaction and improved quality of life11Poor cosmetic outcomes can affect up to 40% of patients undergoing BCT.25 There are many factors influencing the ultimate cosmetic outcome, including host factors, adjuvant therapy administered, tumor location in breast; however, the percentage of breast volume excised is the single most important factor influencing cosmetic outcome.11 How the breast looks after treatment is important because of the correlation between cosmetic outcome and the patients’ anxiety and depression score, body image, sexuality and self-esteem.1
In the past decade, BCT has evolved to ensure both adequate oncological resection and good cosmetic outcome for patients with larger tumors. Increasing utilization of neoadjuvant therapy to enable tumor shrinkage and allow BCT is one strategy. Oncoplastic BCS (OBCS) with or without neoadjuvant therapy facilitates tumor excision with a wide margin of resection followed by immediate reconstruction of the defect (partial breast reconstruction), thus preserving a natural breast shape in woman and improving cosmetic outcome. Indications for OBCS include: anticipated poor cosmetic outcome with standard BCS (sBCS); large tumor in large breast; an alternative to mastectomy; or prevention of lymphedema, fibrosis and chronic pain that may be associated with irradiation in large-breasted woman.41 Additionally, as OBCS is increasingly being utilized as an alternative to mastectomy, with or without, immediate reconstruction, this approach may offer a lower complication rate compared with total mastectomy and reconstruction, particularly if radiotherapy is being given in the adjuvant setting.3,5,59 Potential benefits of this approach could be improved patient satisfaction, quality of life, as well as decreased health care costs compared with full breast reconstruction.67
OBCS is defined as level 1 and 2 techniques.9 Level 1 oncoplastic techniques does not require specialist plastic surgical techniques and is used to prevent deformities for tumors excisions that are <20% of the breast volume and includes simple reshaping without skin excision and may require nipple recentralizing. Level 2 oncoplastic techniques should be considered when major volume loss is anticipated and are classified as volume displacement and volume replacement techniques. The majority of OBCS level 2 techniques utilize volume displacement techniques, which comprises tumor excision followed by reshaping of the breast parenchyma as well as reduction of the breast skin envelope.9 This is commonly referred to as therapeutic mammoplasty, and is often accompanied by a reduction of the contralateral breast to improve symmetry. Volume replacement OBCS techniques include latissimus dorsi (LD) myocutaneous flap, and various other pedicled flaps based on the use of intercostal artery or thoracodorsal artery perforators or a thoracoepigastric flap. Level 2 OBCS has traditionally been regarded as requiring specialized training in plastic surgical techniques.