Oncoplastic Breast Surgery

The mention of breast cancer can be seen in the ancient literature. This disease afflicting women was considered to be a curse and was approached with nihilistic attitude. One can read about the horrific treatments women suffering from breast cancers had to endure. In the 19^th century, however, the clinicians started approaching this health issue scientifically. Many surgeons in the west performed various surgical procedures on women suffering from breast cancer and published their results. Unfortunately, in that era, women were diagnosed in advanced stages of the disease and the surgical management invariably failed to improve patients’ survival. Sir William Halsted from Johns Hopkin’s Institute published his results of performing radical mastectomy in his seminal paper in 1890. Halsted’s radical mastectomy procedure was the first ever systematic surgical approach based on the prevailing understanding of breast cancer at that time. The surgeons of that time were so enamoured by the success of radical mastectomy that for nearly a decade after it was the only surgical treatment for all stages of breast cancer. However, due to extensive nature of the surgical procedure, the survivors experienced significant morbidity. Gradually the awareness about the disease increased and as a result the stage at presentation improved. It was realised that not all patients need radical mastectomy. In the mid twentieth century, various techniques of modified radical mastectomy were adopted into the clinical practice. Breast cancer surgery further evolved in the last two decades of twentieth century. As a result of further awareness about the disease, adoption of population based breast cancer screening programs in the western countries, the stage of presentation further improved.  It was soon realised that patients with early breast cancer can be safely managed with wide local excision of the lump and radiotherapy. Addition of radiotherapy to wide lumpectomy / quadrantectomy was then defined as breast conservation therapy (BCT). The advocates of the patients also demanded better quality of life approach to management of the disease. Oncological safety of BCT was established after the results of six landmark trials were published. As a result, breast conservation surgery became the procedure of choice for early breast cancer before the turn of twentieth century. To begin with there were very rigid indications for BCT. Tumours more than 3 cm, and tumours located in central or medial quadrant were considered to be contraindications for BCT. The basic two goals of BCT are oncological safety and better cosmetic outcome of the breast conservation surgery. However, patients with large tumours and small breasts needing more than 20% of volume resection during lumpectomy tend to have unacceptable cosmetic deformity after conventional breast conservation surgery. Excision of even a small volume of breast tissue from upper inner and lower quadrants of breasts causes significant defects.

A woman’s breasts symbolise motherhood, feminity and define her sexuality. Loss of a breast or having a deformed breast after breast cancer surgery has a significant impact on psycho-sexual well-being of a woman. In last few decades, our knowledge about breast cancer biology has improved. There has been a paradigm shift in the therapeutic options for the management of breast cancer. As a result of current multimodality approach, the prognosis of breast cancer has become much better. With the improvement in survival quality of life issues have come into sharp focus. The need of treating a patient in a holistic manner was acutely felt. That has led to the birth of Oncoplastic breast surgical techniques (OPBCS).

Oncoplastic surgery is an amalgamation of the principles of oncological surgery with the techniques of Aesthetic and Reconstructive surgery to restore shape, size, contour and symmetry of the breasts at the end of breast cancer surgery. It refers to resection of the tumour (either partial or total mastectomy) and immediate reconstruction of the defect using plastic surgical techniques (local parenchymal/muscle flaps or free flaps). OPBCS includes excision of the cancer with adequately wide free margins to achieve loco regional control immediate remodelling of the defect to improve the cosmetic result.

Based on the volume of tissue resection as well as the complexity of the surgery, Oncoplastic breast surgeries can be classified into, Level 1 and level 2 techniques needed when the resection volume is up to 20% and more than 20% (20-50%) respectively. These techniques can also be classified into two broad categories as volume replacement and volume displacement techniques. In addition to reconstruction of partial mastectomy defects, the Oncoplastic surgery also includes immediate or delayed breast reconstruction in patients who have undergone total mastectomy. Breast reconstruction can be done using silicone implants as well as autologous tissue flaps. Oncoplastic surgery also includes contralateral symmetrisation and reconstruction of the nipple -areola complex (NAC), when needed Immediate and late reconstruction after mastectomy.

Indications of oncoplastic breast surgery:

1. Unfavourable breast: tumour ratio
2. Central, medial, lower pole tumours
3. Large ptotic breasts
4. Partial / no response to neoadjuvant chemotherapy
5. Deformities due to previous BCS
6. DCIS occupying a large area (may be a quadrant) of the breast
7. Total mastectomy with immediate / delayed reconstruction

Contraindications:

1. Inflammatory breast cancer
2. Multicentric carcinoma (relative)
3. Previous chest wall radiotherapy (relative)

Oncoplastic techniques are being used for over 20 years now. Although, there no randomized trials, multiple large series published so far, have reported oncological safety of these techniques. Publications of patient reported outcome measures (PROMs) have also proved a significant improvement in physical, social and sexual well-being of breast cancer patients who have undergone Oncoplastic breast surgery. Compared to conventional BCS, OPBCS needs longer operation duration, can have slightly higher risk of complications, needs training and can be costly. However, these specialised techniques have become an integral part of a breast cancer surgery in today’s times.

Dr. Vaishali Zamre
Sr. Consultant & Chief of Breast Surgical Oncology (Unit – 2)