- Email: [email protected]
UK survey of partial mastectomy and reconstruction
ARTICLE IN PRESS The Breast (2007) 16, 637–645
THE BREAST www.elsevier.com/locate/breast
ORIGINAL ARTICLE
UK survey of partial mastectomy and reconstruction R.M. Rainsbury, N. Paramanathan Oncoplastic Breast Unit, Royal Hampshire County Hospital, Winchester, Hampshire, UK Received 29 January 2007; received in revised form 8 May 2007; accepted 24 May 2007
KEYWORDS Partial mastectomy and reconstruction; Immediate reconstruction; Volume replacement; Volume displacement
Summary Background: Partial mastectomy and reconstruction can extend the role of breastconserving surgery, but the frequency of this type of surgery is unknown. Materials and methods: A UK survey was performed to determine the frequency, indications, techniques and outcomes of partial mastectomy and reconstruction. Results: Seventy-one of 180 (39%) respondents offered partial mastectomy and reconstruction. Reasons for not offering partial mastectomy and reconstruction included lack of experience (61%), uncertain indications (33%), uncertain benefits (45%) and concerns about oncological safety (22%). Immediate reconstruction was performed by 50% of respondents and perioperative margin analysis was uncommon. Respondents performed volume displacement or volume replacement or both approaches (23%, 18% and 59%). Complications included fat necrosis (68%), haematoma formation (55%), positive margins (46%), infection (41%) and flap loss or poor cosmetic outcome (10%). Conclusions: Partial mastectomy and reconstruction is becoming popular in the UK as an alternative to full mastectomy. Safe introduction of this approach in clinical practice will require a clearer understanding of technique selection, safety and clinical outcomes. & 2007 Elsevier Ltd. All rights reserved.
Introduction Several prospective randomised controlled trials have shown that the survival of women with early breast cancer treated by breast-conserving surgery Corresponding author.
E-mail address: [email protected] (R.M. Rainsbury).
(BCS) and radiotherapy, or by mastectomy, is the same.1–3 Local recurrence following BCS is related to a number of clinical and pathological variables. The margin of clearance is a strong predictor of local recurrence and recent data suggest that survival is affected adversely in 25% of patients who develop local recurrence.4 Quadrantectomy enables very wide local tumour excision, and
0960-9776/$ - see front matter & 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2007.05.009
ARTICLE IN PRESS 638
Methods An anonymised questionnaire was sent to 437 members of the Association of Breast Surgeons at the British Association of Surgical Oncology in June 2005. The questionnaire was structured to establish:
the number of new breast cancers treated per unit,
the proportion of respondents currently practising PMR, their training and level of experience, the reasons for avoiding PMR, the timing of the procedures, the use and outcome of intra-operative margin analysis, the techniques employed for reconstruction and the criteria used for the selection of patients, such as the size and site of tumours, the type and frequency of complications encountered after PMR (see sample questionnaire, Appendix 1).
Results Frequency of PMR One hundred and eighty of 437 questionnaires were returned (41%). The majority (60%) of respondents worked on high volume units (44 new cancers per week), with only few (8%) working on units managing o100 new cases per annum. PMR was offered to selected patients by 71 (39%) of all respondents, and the frequency with which PMR was offered was directly related to the workload of the unit (Fig. 1). PMR caseloads of o5, 5–10 and 410 per annum were reported by 55%, 19% and 26% of surgeons performing VR, and 36%, 30% and 34% of surgeons performing VD, respectively. Lack of experience (61%), uncertainty about benefits (45%), uncertainty about indications (33%) and oncological risks (22%) were cited by 109 respondents not offering PMR.
120
Number of respondents
single centre studies have reported low rates of local recurrence,5–7 but quadrantectomy carries the highest risk of cosmetic deformity. Partial mastectomy and reconstruction (PMR) has been developed to extend the role of BCS, while avoiding an unacceptable cosmetic result. For the purpose of this study, partial mastectomy was defined in the questionnaire as resection of 20–50% of breast volume (Appendix 1). This definition was informed by the poor cosmetic outcomes reported following the resection of 420% of breast volume8,9—a clinical setting where most surgeons would recommend total mastectomy in preference to BCS. Two fundamentally different approaches to reconstruction of the partial mastectomy resection defect have been established. Firstly, volume replacement (VR), when the resection defect is reconstructed by replacing the volume of tissue removed with a similar volume of autologous tissue from an extramammary site—usually latissimus dorsi. This approach restores the breast volume and avoids the need for contralateral surgery to achieve symmetry. Noguchi et al.10 first described PMR and VR using a myosubcutaneous flap of latissimus dorsi to reconstruct quadrantectomy defects in 1990. These were one-stage procedures using frozen section margin analysis to confirm complete local excision. Secondly, volume displacement (VD), when the resection defect is reconstructed using one of a range of local flaps within the breast, which are mobilised and advanced into the defect. This approach leads to a loss in breast volume, and contralateral surgery is usually required to restore symmetry. A number of conventional mammoplasty techniques have been adapted to allow reconstruction of resection defects with parenchymal flaps using a variety of different approaches.11–13 The broad range of oncological and reconstructive skills required for PMR, coupled with recent data confirming the oncological safety of this approach,14–16 is influencing the rate of integration of these procedures into clinical practice. This study was carried out to establish the current use of PMR in the treatment of breast cancer in the UK.
R.M. Rainsbury, N. Paramanathan
100 new cancers treated by unit/year
80
PM & R offered
60 40 20 0 >200
150200
10050-99 149 Cases per year
<50
Figure 1 Frequency of PMR in relation to unit workload.
ARTICLE IN PRESS UK survey of partial mastectomy and reconstruction
639
Acquiring skills in PMR
Timing and techniques Immediate reconstruction of the resection defect is carried out ‘usually or always’ by 50% of respondents and ‘sometimes’ by 38%. One-third of these surgeons carry out an intra-operative evaluation of margins using frozen section analysis, and report a correlation with the paraffin section result in 80% of cases. Positive ‘paraffin’ section margins after PMR had been encountered by three times as many surgeons not performing intra-operative margin analysis, compared with those using frozen section techniques (Fig. 3). Frozen section analysis is used more frequently by those performing 410 cases per annum (410 cases versus o10 cases per annum, 24% versus 4%). Most respondents (59%) use both VR and VD for PMR, but VD (e.g., Grisotti flap, central excision, superior and inferior pedicle therapeutic reduction mammoplasty) or VR (e.g., latissimus dorsi miniflap, lateral adipose tissue flap) is used exclusively by 23% and 18% of respondents, respectively. Positive margins in patients undergoing immediate reconstruction of the resection defect are managed most commonly by re-excision of the cavity wall (47%), followed by mastectomy
80 Structured Training Respondents %
60
40
20
0 <2000 >2000 Year commenced PMR
Figure 2 Proportion of respondents performing PMR who had attended structured training courses (%).
Positive margin 60% Respondents %
Surgeons performing PMR are either self-taught (38%), have learnt from colleagues (45%) or have attended structured training courses (52%). The proportion of those receiving structured training in PMR more than tripled in the group of respondents who began to carry out these procedures after 2000 (Fig. 2).
80%
40%
20%
0% performed
not performed
Use of frozen section analysis
Figure 3 Proportion of respondents (%) who had encountered positive margins following PMR according to the use of intra-operative frozen section margin analysis.
and immediate breast reconstruction (30%), mastectomy alone (16%) and radiotherapy boost (7%). Patients with positive margins after VR are managed most frequently by breast-conserving re-excision (62%), in contrast to VD patients with positive margins, who are managed most frequently by mastectomy (69%).
Tumour and resection details PMR is being carried out for tumours in all breast locations, but most frequently for those in the upper outer, lower outer and central parts of the breast (Fig. 4). PMR was considered most frequently when resecting up to 30% of breast volume (38% of respondents), with fewer using VR or VD for more extensive excisions resulting in o40%, o50% and 450% loss of breast volume (used by 27%, 11% and 9% of respondents, respectively). The extent of resection achieved during PMR was similar for surgeons reporting low- and high-volume workloads (Fig. 5). Reported complications included fat necrosis (encountered by 68% of respondents), haematoma formation (55%), positive margins on final histology (47%), infection (41%), local recurrence (16%) and flap loss (10%). Surgeons performing 410 PMR cases annually had greater experience of complications than those dealing with fewer cases (Fig. 6). The majority of respondents (64%) reported that the effects of irradiation following PMR are similar to those observed after routine BCS. More pronounced effects or less pronounced effects were reported by 10% and 26%, respectively.
ARTICLE IN PRESS 640
R.M. Rainsbury, N. Paramanathan
Discussion
56
93 80
51
86
Figure 4 Proportion of respondents (%) prepared to consider PMR according to tumour location.
50%
Respondents %
40%
>10 cases per annum <10 cases per annum
30%
20%
PMR: frequency and concerns
10%
0% <20%
<30% <40% <50% Resection volume
>50%
Figure 5 Proportion of respondents (%) considering PMR in relation to resection volume and unit workload.
80% >10 cases per annum <10 cases per annum 60% Respondents %
The introduction of a range of oncoplastic techniques into clinical practice is expanding the surgical options for the treatment of breast cancer. It is extending the role of BCS17 and is likely to reduce the need for mastectomy in an increasing number of patients. It allows ‘radical conservation’ of the breast in situations where complete resection without reconstruction results in extensive volume depletion and a poor cosmetic result. In spite of the rising popularity of PMR, there are little published data on case selection, technique selection or the clinical outcome of this type of surgery. As a result, there is little if any information available to help the clinician or the patient to make informed decisions about treatment options. This study is unique in providing new data about the current use of PMR in relation to three aspects of clinical practice in the UK: first, the frequency of these procedures and concerns about their use; second, the timing and outcomes of margin analysis; third, the procedures used and the perioperative details.
40%
20%
0% haematoma
fat infection positive local necrosis margin recurrence Complications experienced
Figure 6 Reported experience of complications after PMR according to workload.
As the questionnaire was returned by 180 consultant surgeons, the responses can reasonably be regarded as a reflection of current practice. The proportion offering PMR (39%) is higher than anticipated, given the relatively recent introduction of these techniques and the paucity of data about long-term outcomes. This may in part be a reflection of the UK National Institute of Clinical Excellence Guidelines recommending that breast reconstruction should be made available at the initial surgical operation18 and in part due to the inclusion of reconstructive procedures in the Subspecialty Curriculum for Breast Surgery. These and a number of other developments are increasing the provision of a range of reconstructive procedures in clinical practice. The proportion of respondents performing PMR in this survey is less than those performing skin sparing mastectomy (73%) in a recent survey of the technique.19 This variation is likely to reflect the extent of integration of these different oncoplastic techniques into clinical practice. Skin sparing mastectomy is a relatively wellestablished and straightforward adaptation of conventional mastectomy which demands few additional oncoplastic skills when performed without reconstruction. By contrast, PMR is a new approach which requires experience in a range of oncoplastic reconstructive and therapeutic
ARTICLE IN PRESS UK survey of partial mastectomy and reconstruction mammoplasty techniques—skills reported by the minority of respondents in the current survey. Overall, this survey has confirmed that most surgeons are acquiring these skills through selftuition or in-house training, but an increasing number of more recently trained respondents are developing skills through structured training courses and hospital training posts. Better structured training will in future improve understanding and skills—which have been identified by this survey as greater obstacles to the use of PMR than concerns about oncological safety. Reported rates of local recurrence following VD range between 0% and 5% (23–48 months mean follow up),14,20–22 and following VR range between 0% and 7% (22–72 months mean follow-up).23–26 Units offering PMR require a range of resources —equipment, instruments, trained staff and above all, theatre time. A small unit may have difficulty in finding the time, providing the resources and acquiring the necessary skills, when compared to a larger unit dealing with 44 new cases per week. The direct relationship between annual caseload and the frequency of PMR highlighted by the survey supports this suggestion, but in the future all surgeons with an interest in breast surgery will be expected to acquire these skills.27 As a result, those breast units which are unable to offer oncoplastic surgery including PMR are unlikely to gain the certification necessary for recognition as an accredited provider of breast services.
Timing and outcomes of margin analysis The proportion of respondents with experience in one-stage procedures is surprisingly high (88%), given that only one-third performed intra-operative margin analysis to confirm adequate clearance. Confidence in intra-operative analysis appears to increase with greater experience and use of PMR, suggesting a learning curve in the use of a technique which is rarely carried out during conventional BCS. The management of the positive margin after PMR is not unlike that following conventional BCS—either by resection or by mastectomy. This survey has identified an interesting difference in the management of positive margins according to the type of reconstruction. Patients undergoing VR are managed most commonly by re-excision, as opposed to patients undergoing VD, who are managed most commonly by mastectomy. This difference may be a reflection of the difficulties encountered when attempting to locate the site of a positive margin following VD. This is because of
641 the large surface area which comprises the ‘cavity wall’ created by a typical therapeutic mammoplasty. By contrast, locating the positive margin following VR is a more straightforward procedure. This involves flap displacement, re-excision of the relevant margin, followed by flap replacement. The 80% correlation reported between frozen section and paraffin section is difficult to interpret without details of the methods used for frozen section analysis. Evidence supporting the accuracy of frozen section is increasing with independent studies reporting the clinical utility of this approach,28–30 and the 3-fold reduction in margin positivity reported by respondents using frozen section in this survey adds to that evidence (Fig. 3).
Procedures used and perioperative details This survey has shown that PMR is used most frequently for tumours in the outer quadrants and central parts of the breast, when compared with other locations. This may be related to the relative frequency of tumours in these locations, as well as the perceived difficulty of reconstructing defects in the medial quadrants of the breast, particularly when using VD. The problems encountered in reconstructing defects in the upper inner quadrant of the breast led Grisotti to define this area as ‘no man’s land,13 because of the failure of VD techniques to prevent deformity in this zone. Good cosmetic outcomes following reconstruction of this quadrant have recently been reported using modified parenchymal flaps during VD31 and using myosubcutaneous LD flaps during VR.32 The majority of respondents considered PMR when resecting 420% of the breast volume. This is in keeping with the findings of others8,9 that the risk of a poor cosmetic outcome escalates when attempting BCS without reconstruction for tumours requiring excision of 20% or more of the breast parenchyma. The deformity which results is most marked when resecting tumours in the upper inner quadrant13 and lower quadrants of the breast.11 A significant minority of surgeons have extended the use of PMR to include tumours necessitating a resection of up to 50% (11% of respondents) or more than 50% (8% of respondents) of the breast, but the extent of resection reported in this survey was independent of annual workload (Fig. 5). This is somewhat surprising, as the harvesting and modelling of larger flaps requires significant experience to achieve competence. Therapeutic reduction mammoplasty (VD) typically involves more extensive resection of breast parenchyma, as resection is integrated into the reduction procedure, in
ARTICLE IN PRESS 642 contrast to VR techniques.14,24 VD techniques are therefore most appropriate for patients with medium to large-sized breasts. Modification of the LD miniflap to harvest a layer of fat deep to Scarpa’s fascia33 and to harvest a flap carrying a skin island helps to increase the volume of the flap during VR, enabling reconstruction of defects resulting from resection of 50% or more of the breast parenchyma. Typically, this approach is most appropriate for women with small- or mediumsized breasts, who are not good candidates for a VD procedure, which will result in a further reduction of the size of the breast. Other VR techniques such as the subaxillary dermocutaneous fat flap34 and the lateral adipose tissue flap35 are more appropriate when replacing less extensive defects following the resection of smaller volumes of breast parenchyma. The range of complications encountered by respondents is typical of procedures which involve mobilisation of myocutaneous, myosubcutaneous and parenchymal flaps. Unsurprisingly, respondents with a higher workload reported more experience of complications (Fig. 6), but it was not possible to establish any relationship between workload and complication rates in this survey. The high proportion of respondents reporting experience of fat necrosis and the small proportion reporting experience of flap loss serves to highlight the added risks of PMR when compared with conventional BCS and the need for careful technique and case selection. The overwhelming majority (90%) of respondents report similar or superior outcomes following PMR and radiotherapy when compared with BCS and radiotherapy. This is of particular interest, as mastectomy and immediate reconstruction is an established treatment option for a group of patients who may also be considered for PMR. Nevertheless, up to 20% of those patients treated by mastectomy and immediate reconstruction will undergo adjuvant chest wall irradiation, with the attendant high risk of poor cosmetic outcome, regardless of the technique used for reconstruction.36 The favourable outcomes reported by respondents following PMR and radiotherapy are noteworthy in this context and require further prospective evaluation. This figure must be interpreted with particular caution, as respondents were asked to report on their personal experience, rather than providing a more objective evaluation based on their findings from prospective studies incorporating standardised methods of assessment of cosmetic outcome. Longer-term clinical outcomes comparing PMR with mastectomy and immediate reconstruction in patients requiring
R.M. Rainsbury, N. Paramanathan Table 1 Factors influencing the choice of technique for breast-conserving reconstruction.
Breast size Tumour position Scars Theatre time Complications Timing
Volume replacement
Volume displacement
Small or medium Any site
Medium or large
Breast and back 2–3 h Donor site, flap loss Immediate or delayed
Central or lower pole Bilateral breast 1–2 h (per side) Flap ischaemia, fat necrosis Immediate4delayed
adjuvant radiotherapy will help to inform patient and technique selection in the future.
Choice of technique Although this survey has established the use of PMR in the UK today, the surgeon and patient need to consider a number of factors when selecting the most suitable approach (Table 1). The choice of technique depends on a range of features, including breast size, tumour position, timing of surgery and patient expectation. VR techniques can preserve the shape and size of the breast, avoiding contralateral surgery to achieve symmetry. But they are complex procedures associated with donor site and flap morbidity. On the other hand, VD surgery is limited to the breast and although donor site problems are avoided, ischaemia of dermoglandular pedicles may delay healing and distort the result. Moreover, contralateral surgery is usually required to restore symmetry.
Conclusion PMR is becoming an established alternative to BCS and mastectomy in the UK. It is carried out more frequently by larger breast units, typically as a onestage procedure when resecting 20% or more of the breast parenchyma. The lack of a clear consensus regarding case and technique selection, and timing and margin analysis demands careful prospective data collection, backed up by structured training if the full potential of these new techniques is to be realised.
ARTICLE IN PRESS UK survey of partial mastectomy and reconstruction
643
Appendix 1
UK training post (e.g. oncoplastic fellowship) & Overseas training fellowship & From a colleague & Self-taught & Other (please state) &
UK Survey of partial mastectomy and reconstruction
General Questionnaire (1)
How many new breast cancers are treated by your Unit every year? o50 & 50–99 & 100–149 & 150–200 & 4200 &
(6)
When performing partial mastectomy, do you combine the procedure with immediate reconstruction? Always & Usually & Sometimes & Never &
(2)
Does your Unit offer partial mastectomyy with reconstruction of the resection defect as an alternative to total mastectomy 7 reconstruction in selected patients? Yes & No &
(7)
(3)
If your Unit does not offer partial mastectomy with reconstruction, kindly confirm your reasons and return the questionnaire Uncertain indications & Uncertain benefits & Oncological risks & Surgical risks & Limited or no experience & Other (please state) &
If you combine resection with immediate reconstruction of the defect, do you perform peroperative margin analysis with frozen section or cytological evaluation? Always & Usually & Sometimes & Never & Frozen section & Cytological evaluation &
(8)
If you perform peroperative margin analysis, how closely do the results correlate with the final histopathological analysis? 100% correlation & About 90% correlation & About 80% correlation & About 70% correlation & o70% correlation &
(9)
How do you manage a patient following partial mastectomy and immediate reconstruction who is found to have positive margins on subsequent histopathological analysis? Re-excise the positive margin & Perform a mastectomy without reconstruction & Perform a mastectomy with reconstruction & Standard breast irradiation & Standard breast irradiation + boost to index quadrant & Other (please state) &
(10)
Which of the following types of partial reconstruction do you perform? Volume replacement (e.g. LD miniflap, adipose tissue flap) &
y
Resection of 20–50% of breast volume, combined with volume replacement or volume displacement. If your Unit does carry out partial mastectomy and reconstruction, kindly answer questions 4–17 before returning the questionnaire (4)
When did you start to perform partial mastectomy and reconstruction on your Unit? 2004 & 2003 & 2002 & 2001 & 2000 & prior to 2000 &
(5)
How did you learn to perform these procedures? Structured course (e.g. RCS) &
ARTICLE IN PRESS 644
R.M. Rainsbury, N. Paramanathan
Volume displacement (e.g. Grisotti flap, central excision superior/inferior pedicle reduction mammoplasty) & (11)
How many volume replacement procedures do you carry out annually? None & o5 & 5–10 & 410 &
(12)
How many volume displacement procedures do you carry out annually? None & o5 & 5–10 & 410 &
(13)
In which of the following situations would you consider performing partial mastectomy and reconstruction? Up to 20% volume loss & Up to 30% volume loss & Up to 40% volume loss & Up to 50% volume loss & Over 50% volume loss & Other (please state) &
(14)
For which of the following tumour sites would you consider carrying out partial mastectomy and reconstruction? UOQ & LOQ & UIQ & LIQ & Central/subareolar &
(15)
In your experience, are the adverse effects of adjuvant breast irradiation More pronounced & The same & Less pronounced & following partial mastectomy and reconstruction than following breastconserving surgery alone?
(16)
An increasing number of patients who are unsuitable for breast-conserving surgery are treated by total mastectomy and reconstruction. What proportion of these patients are offered partial mastectomy and reconstruction on your Unit? None & o10% & Around 20% &
Around 30% Around 50% 450% & (17)
& &
Which of the following complications have you encountered following partial mastectomy and reconstruction? Haematoma & Fat necrosis & Infection & Positive margins on definitive histology & Local recurrence & Other (please state) &
References 1. Fisher B, Redmond C, Poisson R, et al. Eight year results of a randomised clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1994;320:822–8. 2. Veronesi U, Banfi A, Del Vecchio M, et al. Comparison of Halsted mastectomy with quadrantectomy, axillary dissection, and radiotherapy in early breast cancer: long-term results. Eur J Cancer Clin Oncol 1986; 22:1085–9. 3. Abrams J, Chen T, Giusti R. Survival after breast-sparing surgery versus mastectomy. J Natl Cancer Inst 1994;86: 1672–3. 4. Clark M, Collins R, Darby S, (EBCTCG), et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005;366: 2087–106. 5. Veronesi U, Volterrani F, Luini A, et al. Quadrantectomy versus lumpectomy for small size breast cancer. Eur J Cancer 1990;26:671–3. 6. Fisher B. Lumpectomy versus quadrantectomy for breast conservation: a critical appraisal. Eur J Cancer 1995;31A: 1567–9. 7. Noh WC, Paik NS, Kim MS, et al. Ipsilateral breast tumour recurrence after breast-conserving therapy. A comparison of quadrantectomy versus lumpectomy at a single institution. World J Surg 2005;29:1001–6. 8. Bulstrode NW, Shrotria S. Prediction of cosmetic outcome following conservative breast surgery using breast volume measurements. Breast 2001;10:124–6. 9. Cochrane RA, Valasiadou P, Wilson ARM, Al-Ghazal SK, Macmillan RD. Cosmesis and satisfaction after breastconserving surgery correlates with the percentage of breast volume excised. Br J Surg 2003;90:1505–9. 10. Noguchi M, Taniya T, Miyazaki I, Saito Y. Immediate transposition of a latissimus dorsi muscle for correcting a postquadrantectomy breast deformity in Japanese patients. Int Surg 1990;75:166–70. 11. Clough KB, Nos C, Salmon RJ, Soussaline M, Durand JC. Conservative treatment of breast cancers by mammoplasty and irradiation: a new approach to lower quadrant tumours. Plast Reconstr Surg 1995;96:363–70.
ARTICLE IN PRESS UK survey of partial mastectomy and reconstruction 12. Bennelli L. A new periareolar mammaplasty: the ‘‘round block’’ technique. Aesthetic Plast Surg 1990;14:93–100. 13. Grisotti A. Immediate reconstruction after partial mastectomy. Oper Tech Plast Reconstr Surg 1994;1:1–12. 14. Clough KB, Lewis JS, Couturaud B, Fitoussi A, Nos C, Falcou MC. Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas. Ann Surg 2003;237:26–34. 15. Asgeirsson KS, Rasheed T, McCulley SJ, Macmillan RD. Oncological and cosmetic outcomes of oncoplastic breast conserving surgery. Eur J Surg Oncol 2005;31:817–23. 16. Spear SL, Pelletiere CV, Wolfe AJ, Tsangaris TN, Pennanen MF. Experience with reduction mammoplasty combined with breast conservation therapy in the treatment of breast cancer. Plast Reconstr Surg 2003;111:1102–9. 17. Raja MA, Straker VF, Rainsbury RM. Extending the role of breast-conserving surgery by immediate volume replacement. Br J Surg 1997;84:101–5. 18. National Institute for Clinical Excellence. Guidance on cancer services: improving outcomes in breast cancer. London: NICE; 2002. 19. Sotheran WJ, Rainsbury RM. Skin-sparing mastectomy in the UK—a review of current practice. Ann R Coll Surg Engl 2004;86:82–6. 20. Nos C, Fitoussi A, Bourgeois D, Fourquet A, Salmon RJ, Clough GB. Conservative treatment of lower pole breast cancers by bilateral mammoplasty and radiotherapy. Eur J Surg Oncol 1998;24:508–14. 21. Masetti R, Pirulli PG, Maqno S, Franceschino G, Chiesa F, Antinori A. Oncoplastic techniques in the conservative surgical treatment of breast cancer. Breast Cancer 2000;7:276–80. 22. Petit J, Rietjens M, Garusi C. Breast reconstructive techniques in cancer patients: which ones, when to apply, which immediate and long term risks? Crit Rev Oncol Hematol 2001;38:231–9. 23. Noguchi M, Minami M, Earashi M, et al. Oncologic and cosmetic outcome in patients with breast cancer treated with wide excision, transposition of adipose tissue with latissimus dorsi muscle, and axillary dissection followed by radiotherapy. Breast Cancer Res Treat 1995;35:163–71. 24. Rainsbury RM, Paramanathan N. Recent progress with breast-conserving volume replacement using latissimus
645
25.
26.
27.
28.
29.
30.
31.
32.
33. 34.
35.
36.
dorsi miniflaps in UK Patients. Breast Cancer 1998;5: 139–47. Nano MT, Gill PG, Kollias J, Bochuer MA. Breast volume replacement using the latissimus dorsi miniflap. ANZ J Surg 2004;74:98–104. Losken A, Schaefer TG, Carlson GW, Jones GE, Styble TM, Bostwick IIIrd J. Immediate endoscopic latissimus dorsi flap: risk or benefit in reconstructing partial mastectomy defects. Ann Plast Surg 2004;53:1–5. Cataliotti L, De Wolf C, Holland R, et al. Guidelines on the standards for the training of specialised health professionals dealing with breast cancer. Eur J Cancer 2007;43:660–5. Cendan JC, Coco D, Copeland IIIrd EM. Accuracy of intraoperative frozen-section analysis of breast cancer lumpectomy-bed margins. J Am Coll Surg 2005;201:194–8. Pinotti JA, Carvalho FM. Intraoperative pathological monitorization of surgical margins: a method to reduce recurrences after conservative treatment for breast cancer. Eur J Gynaecol Oncol 2002;23:11–6. Weber S, Storm FK, Stitt J, Mahvi DM. The role of frozen section analysis of margins during breast conservation surgery. Cancer 1997;3:273–7. McCulley S, Macmillan R. Planning the use of therapeutic mammoplasty—the Nottingham approach. Br J Plast Surg 2005;58:889–901. Gendy R, Able J, Rainsbury R. Impact of skin-sparing mastectomy with immediate reconstruction and breastsparing reconstruction with miniflaps on the outcomes of oncoplastic breast surgery. Br J Surg 2003;90:433–9. Rainsbury RM. Breast sparing reconstruction with latissimus dorsi miniflaps. Eur J Surg Oncol 2002;28:891–5. Chaturvedi S. Subaxillary dermocutaneous fat flap for reconstruction of the upper outer quadrant of the breast following conservation surgery. Br J Surg 2004;91:69–71. Ohuchi N, Harada Y, Ishida T, et al. Breast-conserving surgery for primary breast cancer. Immediate volume replacement using lateral tissue flap. Breast Cancer 1997; 4:135–41. Beharanwala KA, Dua RS, Ross GM, Ward A, A’Hern R, Gui GPH. The influence of radiotherapy on capsule formation and aesthetic outcome after immediate breast reconstruction using biodimensional anatomical expander implants. J Plast Reconstr Aesthet Surg 2006;59:1043–51.
THE BREAST www.elsevier.com/locate/breast
ORIGINAL ARTICLE
UK survey of partial mastectomy and reconstruction R.M. Rainsbury, N. Paramanathan Oncoplastic Breast Unit, Royal Hampshire County Hospital, Winchester, Hampshire, UK Received 29 January 2007; received in revised form 8 May 2007; accepted 24 May 2007
KEYWORDS Partial mastectomy and reconstruction; Immediate reconstruction; Volume replacement; Volume displacement
Summary Background: Partial mastectomy and reconstruction can extend the role of breastconserving surgery, but the frequency of this type of surgery is unknown. Materials and methods: A UK survey was performed to determine the frequency, indications, techniques and outcomes of partial mastectomy and reconstruction. Results: Seventy-one of 180 (39%) respondents offered partial mastectomy and reconstruction. Reasons for not offering partial mastectomy and reconstruction included lack of experience (61%), uncertain indications (33%), uncertain benefits (45%) and concerns about oncological safety (22%). Immediate reconstruction was performed by 50% of respondents and perioperative margin analysis was uncommon. Respondents performed volume displacement or volume replacement or both approaches (23%, 18% and 59%). Complications included fat necrosis (68%), haematoma formation (55%), positive margins (46%), infection (41%) and flap loss or poor cosmetic outcome (10%). Conclusions: Partial mastectomy and reconstruction is becoming popular in the UK as an alternative to full mastectomy. Safe introduction of this approach in clinical practice will require a clearer understanding of technique selection, safety and clinical outcomes. & 2007 Elsevier Ltd. All rights reserved.
Introduction Several prospective randomised controlled trials have shown that the survival of women with early breast cancer treated by breast-conserving surgery Corresponding author.
E-mail address: [email protected] (R.M. Rainsbury).
(BCS) and radiotherapy, or by mastectomy, is the same.1–3 Local recurrence following BCS is related to a number of clinical and pathological variables. The margin of clearance is a strong predictor of local recurrence and recent data suggest that survival is affected adversely in 25% of patients who develop local recurrence.4 Quadrantectomy enables very wide local tumour excision, and
0960-9776/$ - see front matter & 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2007.05.009
ARTICLE IN PRESS 638
Methods An anonymised questionnaire was sent to 437 members of the Association of Breast Surgeons at the British Association of Surgical Oncology in June 2005. The questionnaire was structured to establish:
the number of new breast cancers treated per unit,
the proportion of respondents currently practising PMR, their training and level of experience, the reasons for avoiding PMR, the timing of the procedures, the use and outcome of intra-operative margin analysis, the techniques employed for reconstruction and the criteria used for the selection of patients, such as the size and site of tumours, the type and frequency of complications encountered after PMR (see sample questionnaire, Appendix 1).
Results Frequency of PMR One hundred and eighty of 437 questionnaires were returned (41%). The majority (60%) of respondents worked on high volume units (44 new cancers per week), with only few (8%) working on units managing o100 new cases per annum. PMR was offered to selected patients by 71 (39%) of all respondents, and the frequency with which PMR was offered was directly related to the workload of the unit (Fig. 1). PMR caseloads of o5, 5–10 and 410 per annum were reported by 55%, 19% and 26% of surgeons performing VR, and 36%, 30% and 34% of surgeons performing VD, respectively. Lack of experience (61%), uncertainty about benefits (45%), uncertainty about indications (33%) and oncological risks (22%) were cited by 109 respondents not offering PMR.
120
Number of respondents
single centre studies have reported low rates of local recurrence,5–7 but quadrantectomy carries the highest risk of cosmetic deformity. Partial mastectomy and reconstruction (PMR) has been developed to extend the role of BCS, while avoiding an unacceptable cosmetic result. For the purpose of this study, partial mastectomy was defined in the questionnaire as resection of 20–50% of breast volume (Appendix 1). This definition was informed by the poor cosmetic outcomes reported following the resection of 420% of breast volume8,9—a clinical setting where most surgeons would recommend total mastectomy in preference to BCS. Two fundamentally different approaches to reconstruction of the partial mastectomy resection defect have been established. Firstly, volume replacement (VR), when the resection defect is reconstructed by replacing the volume of tissue removed with a similar volume of autologous tissue from an extramammary site—usually latissimus dorsi. This approach restores the breast volume and avoids the need for contralateral surgery to achieve symmetry. Noguchi et al.10 first described PMR and VR using a myosubcutaneous flap of latissimus dorsi to reconstruct quadrantectomy defects in 1990. These were one-stage procedures using frozen section margin analysis to confirm complete local excision. Secondly, volume displacement (VD), when the resection defect is reconstructed using one of a range of local flaps within the breast, which are mobilised and advanced into the defect. This approach leads to a loss in breast volume, and contralateral surgery is usually required to restore symmetry. A number of conventional mammoplasty techniques have been adapted to allow reconstruction of resection defects with parenchymal flaps using a variety of different approaches.11–13 The broad range of oncological and reconstructive skills required for PMR, coupled with recent data confirming the oncological safety of this approach,14–16 is influencing the rate of integration of these procedures into clinical practice. This study was carried out to establish the current use of PMR in the treatment of breast cancer in the UK.
R.M. Rainsbury, N. Paramanathan
100 new cancers treated by unit/year
80
PM & R offered
60 40 20 0 >200
150200
10050-99 149 Cases per year
<50
Figure 1 Frequency of PMR in relation to unit workload.
ARTICLE IN PRESS UK survey of partial mastectomy and reconstruction
639
Acquiring skills in PMR
Timing and techniques Immediate reconstruction of the resection defect is carried out ‘usually or always’ by 50% of respondents and ‘sometimes’ by 38%. One-third of these surgeons carry out an intra-operative evaluation of margins using frozen section analysis, and report a correlation with the paraffin section result in 80% of cases. Positive ‘paraffin’ section margins after PMR had been encountered by three times as many surgeons not performing intra-operative margin analysis, compared with those using frozen section techniques (Fig. 3). Frozen section analysis is used more frequently by those performing 410 cases per annum (410 cases versus o10 cases per annum, 24% versus 4%). Most respondents (59%) use both VR and VD for PMR, but VD (e.g., Grisotti flap, central excision, superior and inferior pedicle therapeutic reduction mammoplasty) or VR (e.g., latissimus dorsi miniflap, lateral adipose tissue flap) is used exclusively by 23% and 18% of respondents, respectively. Positive margins in patients undergoing immediate reconstruction of the resection defect are managed most commonly by re-excision of the cavity wall (47%), followed by mastectomy
80 Structured Training Respondents %
60
40
20
0 <2000 >2000 Year commenced PMR
Figure 2 Proportion of respondents performing PMR who had attended structured training courses (%).
Positive margin 60% Respondents %
Surgeons performing PMR are either self-taught (38%), have learnt from colleagues (45%) or have attended structured training courses (52%). The proportion of those receiving structured training in PMR more than tripled in the group of respondents who began to carry out these procedures after 2000 (Fig. 2).
80%
40%
20%
0% performed
not performed
Use of frozen section analysis
Figure 3 Proportion of respondents (%) who had encountered positive margins following PMR according to the use of intra-operative frozen section margin analysis.
and immediate breast reconstruction (30%), mastectomy alone (16%) and radiotherapy boost (7%). Patients with positive margins after VR are managed most frequently by breast-conserving re-excision (62%), in contrast to VD patients with positive margins, who are managed most frequently by mastectomy (69%).
Tumour and resection details PMR is being carried out for tumours in all breast locations, but most frequently for those in the upper outer, lower outer and central parts of the breast (Fig. 4). PMR was considered most frequently when resecting up to 30% of breast volume (38% of respondents), with fewer using VR or VD for more extensive excisions resulting in o40%, o50% and 450% loss of breast volume (used by 27%, 11% and 9% of respondents, respectively). The extent of resection achieved during PMR was similar for surgeons reporting low- and high-volume workloads (Fig. 5). Reported complications included fat necrosis (encountered by 68% of respondents), haematoma formation (55%), positive margins on final histology (47%), infection (41%), local recurrence (16%) and flap loss (10%). Surgeons performing 410 PMR cases annually had greater experience of complications than those dealing with fewer cases (Fig. 6). The majority of respondents (64%) reported that the effects of irradiation following PMR are similar to those observed after routine BCS. More pronounced effects or less pronounced effects were reported by 10% and 26%, respectively.
ARTICLE IN PRESS 640
R.M. Rainsbury, N. Paramanathan
Discussion
56
93 80
51
86
Figure 4 Proportion of respondents (%) prepared to consider PMR according to tumour location.
50%
Respondents %
40%
>10 cases per annum <10 cases per annum
30%
20%
PMR: frequency and concerns
10%
0% <20%
<30% <40% <50% Resection volume
>50%
Figure 5 Proportion of respondents (%) considering PMR in relation to resection volume and unit workload.
80% >10 cases per annum <10 cases per annum 60% Respondents %
The introduction of a range of oncoplastic techniques into clinical practice is expanding the surgical options for the treatment of breast cancer. It is extending the role of BCS17 and is likely to reduce the need for mastectomy in an increasing number of patients. It allows ‘radical conservation’ of the breast in situations where complete resection without reconstruction results in extensive volume depletion and a poor cosmetic result. In spite of the rising popularity of PMR, there are little published data on case selection, technique selection or the clinical outcome of this type of surgery. As a result, there is little if any information available to help the clinician or the patient to make informed decisions about treatment options. This study is unique in providing new data about the current use of PMR in relation to three aspects of clinical practice in the UK: first, the frequency of these procedures and concerns about their use; second, the timing and outcomes of margin analysis; third, the procedures used and the perioperative details.
40%
20%
0% haematoma
fat infection positive local necrosis margin recurrence Complications experienced
Figure 6 Reported experience of complications after PMR according to workload.
As the questionnaire was returned by 180 consultant surgeons, the responses can reasonably be regarded as a reflection of current practice. The proportion offering PMR (39%) is higher than anticipated, given the relatively recent introduction of these techniques and the paucity of data about long-term outcomes. This may in part be a reflection of the UK National Institute of Clinical Excellence Guidelines recommending that breast reconstruction should be made available at the initial surgical operation18 and in part due to the inclusion of reconstructive procedures in the Subspecialty Curriculum for Breast Surgery. These and a number of other developments are increasing the provision of a range of reconstructive procedures in clinical practice. The proportion of respondents performing PMR in this survey is less than those performing skin sparing mastectomy (73%) in a recent survey of the technique.19 This variation is likely to reflect the extent of integration of these different oncoplastic techniques into clinical practice. Skin sparing mastectomy is a relatively wellestablished and straightforward adaptation of conventional mastectomy which demands few additional oncoplastic skills when performed without reconstruction. By contrast, PMR is a new approach which requires experience in a range of oncoplastic reconstructive and therapeutic
ARTICLE IN PRESS UK survey of partial mastectomy and reconstruction mammoplasty techniques—skills reported by the minority of respondents in the current survey. Overall, this survey has confirmed that most surgeons are acquiring these skills through selftuition or in-house training, but an increasing number of more recently trained respondents are developing skills through structured training courses and hospital training posts. Better structured training will in future improve understanding and skills—which have been identified by this survey as greater obstacles to the use of PMR than concerns about oncological safety. Reported rates of local recurrence following VD range between 0% and 5% (23–48 months mean follow up),14,20–22 and following VR range between 0% and 7% (22–72 months mean follow-up).23–26 Units offering PMR require a range of resources —equipment, instruments, trained staff and above all, theatre time. A small unit may have difficulty in finding the time, providing the resources and acquiring the necessary skills, when compared to a larger unit dealing with 44 new cases per week. The direct relationship between annual caseload and the frequency of PMR highlighted by the survey supports this suggestion, but in the future all surgeons with an interest in breast surgery will be expected to acquire these skills.27 As a result, those breast units which are unable to offer oncoplastic surgery including PMR are unlikely to gain the certification necessary for recognition as an accredited provider of breast services.
Timing and outcomes of margin analysis The proportion of respondents with experience in one-stage procedures is surprisingly high (88%), given that only one-third performed intra-operative margin analysis to confirm adequate clearance. Confidence in intra-operative analysis appears to increase with greater experience and use of PMR, suggesting a learning curve in the use of a technique which is rarely carried out during conventional BCS. The management of the positive margin after PMR is not unlike that following conventional BCS—either by resection or by mastectomy. This survey has identified an interesting difference in the management of positive margins according to the type of reconstruction. Patients undergoing VR are managed most commonly by re-excision, as opposed to patients undergoing VD, who are managed most commonly by mastectomy. This difference may be a reflection of the difficulties encountered when attempting to locate the site of a positive margin following VD. This is because of
641 the large surface area which comprises the ‘cavity wall’ created by a typical therapeutic mammoplasty. By contrast, locating the positive margin following VR is a more straightforward procedure. This involves flap displacement, re-excision of the relevant margin, followed by flap replacement. The 80% correlation reported between frozen section and paraffin section is difficult to interpret without details of the methods used for frozen section analysis. Evidence supporting the accuracy of frozen section is increasing with independent studies reporting the clinical utility of this approach,28–30 and the 3-fold reduction in margin positivity reported by respondents using frozen section in this survey adds to that evidence (Fig. 3).
Procedures used and perioperative details This survey has shown that PMR is used most frequently for tumours in the outer quadrants and central parts of the breast, when compared with other locations. This may be related to the relative frequency of tumours in these locations, as well as the perceived difficulty of reconstructing defects in the medial quadrants of the breast, particularly when using VD. The problems encountered in reconstructing defects in the upper inner quadrant of the breast led Grisotti to define this area as ‘no man’s land,13 because of the failure of VD techniques to prevent deformity in this zone. Good cosmetic outcomes following reconstruction of this quadrant have recently been reported using modified parenchymal flaps during VD31 and using myosubcutaneous LD flaps during VR.32 The majority of respondents considered PMR when resecting 420% of the breast volume. This is in keeping with the findings of others8,9 that the risk of a poor cosmetic outcome escalates when attempting BCS without reconstruction for tumours requiring excision of 20% or more of the breast parenchyma. The deformity which results is most marked when resecting tumours in the upper inner quadrant13 and lower quadrants of the breast.11 A significant minority of surgeons have extended the use of PMR to include tumours necessitating a resection of up to 50% (11% of respondents) or more than 50% (8% of respondents) of the breast, but the extent of resection reported in this survey was independent of annual workload (Fig. 5). This is somewhat surprising, as the harvesting and modelling of larger flaps requires significant experience to achieve competence. Therapeutic reduction mammoplasty (VD) typically involves more extensive resection of breast parenchyma, as resection is integrated into the reduction procedure, in
ARTICLE IN PRESS 642 contrast to VR techniques.14,24 VD techniques are therefore most appropriate for patients with medium to large-sized breasts. Modification of the LD miniflap to harvest a layer of fat deep to Scarpa’s fascia33 and to harvest a flap carrying a skin island helps to increase the volume of the flap during VR, enabling reconstruction of defects resulting from resection of 50% or more of the breast parenchyma. Typically, this approach is most appropriate for women with small- or mediumsized breasts, who are not good candidates for a VD procedure, which will result in a further reduction of the size of the breast. Other VR techniques such as the subaxillary dermocutaneous fat flap34 and the lateral adipose tissue flap35 are more appropriate when replacing less extensive defects following the resection of smaller volumes of breast parenchyma. The range of complications encountered by respondents is typical of procedures which involve mobilisation of myocutaneous, myosubcutaneous and parenchymal flaps. Unsurprisingly, respondents with a higher workload reported more experience of complications (Fig. 6), but it was not possible to establish any relationship between workload and complication rates in this survey. The high proportion of respondents reporting experience of fat necrosis and the small proportion reporting experience of flap loss serves to highlight the added risks of PMR when compared with conventional BCS and the need for careful technique and case selection. The overwhelming majority (90%) of respondents report similar or superior outcomes following PMR and radiotherapy when compared with BCS and radiotherapy. This is of particular interest, as mastectomy and immediate reconstruction is an established treatment option for a group of patients who may also be considered for PMR. Nevertheless, up to 20% of those patients treated by mastectomy and immediate reconstruction will undergo adjuvant chest wall irradiation, with the attendant high risk of poor cosmetic outcome, regardless of the technique used for reconstruction.36 The favourable outcomes reported by respondents following PMR and radiotherapy are noteworthy in this context and require further prospective evaluation. This figure must be interpreted with particular caution, as respondents were asked to report on their personal experience, rather than providing a more objective evaluation based on their findings from prospective studies incorporating standardised methods of assessment of cosmetic outcome. Longer-term clinical outcomes comparing PMR with mastectomy and immediate reconstruction in patients requiring
R.M. Rainsbury, N. Paramanathan Table 1 Factors influencing the choice of technique for breast-conserving reconstruction.
Breast size Tumour position Scars Theatre time Complications Timing
Volume replacement
Volume displacement
Small or medium Any site
Medium or large
Breast and back 2–3 h Donor site, flap loss Immediate or delayed
Central or lower pole Bilateral breast 1–2 h (per side) Flap ischaemia, fat necrosis Immediate4delayed
adjuvant radiotherapy will help to inform patient and technique selection in the future.
Choice of technique Although this survey has established the use of PMR in the UK today, the surgeon and patient need to consider a number of factors when selecting the most suitable approach (Table 1). The choice of technique depends on a range of features, including breast size, tumour position, timing of surgery and patient expectation. VR techniques can preserve the shape and size of the breast, avoiding contralateral surgery to achieve symmetry. But they are complex procedures associated with donor site and flap morbidity. On the other hand, VD surgery is limited to the breast and although donor site problems are avoided, ischaemia of dermoglandular pedicles may delay healing and distort the result. Moreover, contralateral surgery is usually required to restore symmetry.
Conclusion PMR is becoming an established alternative to BCS and mastectomy in the UK. It is carried out more frequently by larger breast units, typically as a onestage procedure when resecting 20% or more of the breast parenchyma. The lack of a clear consensus regarding case and technique selection, and timing and margin analysis demands careful prospective data collection, backed up by structured training if the full potential of these new techniques is to be realised.
ARTICLE IN PRESS UK survey of partial mastectomy and reconstruction
643
Appendix 1
UK training post (e.g. oncoplastic fellowship) & Overseas training fellowship & From a colleague & Self-taught & Other (please state) &
UK Survey of partial mastectomy and reconstruction
General Questionnaire (1)
How many new breast cancers are treated by your Unit every year? o50 & 50–99 & 100–149 & 150–200 & 4200 &
(6)
When performing partial mastectomy, do you combine the procedure with immediate reconstruction? Always & Usually & Sometimes & Never &
(2)
Does your Unit offer partial mastectomyy with reconstruction of the resection defect as an alternative to total mastectomy 7 reconstruction in selected patients? Yes & No &
(7)
(3)
If your Unit does not offer partial mastectomy with reconstruction, kindly confirm your reasons and return the questionnaire Uncertain indications & Uncertain benefits & Oncological risks & Surgical risks & Limited or no experience & Other (please state) &
If you combine resection with immediate reconstruction of the defect, do you perform peroperative margin analysis with frozen section or cytological evaluation? Always & Usually & Sometimes & Never & Frozen section & Cytological evaluation &
(8)
If you perform peroperative margin analysis, how closely do the results correlate with the final histopathological analysis? 100% correlation & About 90% correlation & About 80% correlation & About 70% correlation & o70% correlation &
(9)
How do you manage a patient following partial mastectomy and immediate reconstruction who is found to have positive margins on subsequent histopathological analysis? Re-excise the positive margin & Perform a mastectomy without reconstruction & Perform a mastectomy with reconstruction & Standard breast irradiation & Standard breast irradiation + boost to index quadrant & Other (please state) &
(10)
Which of the following types of partial reconstruction do you perform? Volume replacement (e.g. LD miniflap, adipose tissue flap) &
y
Resection of 20–50% of breast volume, combined with volume replacement or volume displacement. If your Unit does carry out partial mastectomy and reconstruction, kindly answer questions 4–17 before returning the questionnaire (4)
When did you start to perform partial mastectomy and reconstruction on your Unit? 2004 & 2003 & 2002 & 2001 & 2000 & prior to 2000 &
(5)
How did you learn to perform these procedures? Structured course (e.g. RCS) &
ARTICLE IN PRESS 644
R.M. Rainsbury, N. Paramanathan
Volume displacement (e.g. Grisotti flap, central excision superior/inferior pedicle reduction mammoplasty) & (11)
How many volume replacement procedures do you carry out annually? None & o5 & 5–10 & 410 &
(12)
How many volume displacement procedures do you carry out annually? None & o5 & 5–10 & 410 &
(13)
In which of the following situations would you consider performing partial mastectomy and reconstruction? Up to 20% volume loss & Up to 30% volume loss & Up to 40% volume loss & Up to 50% volume loss & Over 50% volume loss & Other (please state) &
(14)
For which of the following tumour sites would you consider carrying out partial mastectomy and reconstruction? UOQ & LOQ & UIQ & LIQ & Central/subareolar &
(15)
In your experience, are the adverse effects of adjuvant breast irradiation More pronounced & The same & Less pronounced & following partial mastectomy and reconstruction than following breastconserving surgery alone?
(16)
An increasing number of patients who are unsuitable for breast-conserving surgery are treated by total mastectomy and reconstruction. What proportion of these patients are offered partial mastectomy and reconstruction on your Unit? None & o10% & Around 20% &
Around 30% Around 50% 450% & (17)
& &
Which of the following complications have you encountered following partial mastectomy and reconstruction? Haematoma & Fat necrosis & Infection & Positive margins on definitive histology & Local recurrence & Other (please state) &
References 1. Fisher B, Redmond C, Poisson R, et al. Eight year results of a randomised clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1994;320:822–8. 2. Veronesi U, Banfi A, Del Vecchio M, et al. Comparison of Halsted mastectomy with quadrantectomy, axillary dissection, and radiotherapy in early breast cancer: long-term results. Eur J Cancer Clin Oncol 1986; 22:1085–9. 3. Abrams J, Chen T, Giusti R. Survival after breast-sparing surgery versus mastectomy. J Natl Cancer Inst 1994;86: 1672–3. 4. Clark M, Collins R, Darby S, (EBCTCG), et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005;366: 2087–106. 5. Veronesi U, Volterrani F, Luini A, et al. Quadrantectomy versus lumpectomy for small size breast cancer. Eur J Cancer 1990;26:671–3. 6. Fisher B. Lumpectomy versus quadrantectomy for breast conservation: a critical appraisal. Eur J Cancer 1995;31A: 1567–9. 7. Noh WC, Paik NS, Kim MS, et al. Ipsilateral breast tumour recurrence after breast-conserving therapy. A comparison of quadrantectomy versus lumpectomy at a single institution. World J Surg 2005;29:1001–6. 8. Bulstrode NW, Shrotria S. Prediction of cosmetic outcome following conservative breast surgery using breast volume measurements. Breast 2001;10:124–6. 9. Cochrane RA, Valasiadou P, Wilson ARM, Al-Ghazal SK, Macmillan RD. Cosmesis and satisfaction after breastconserving surgery correlates with the percentage of breast volume excised. Br J Surg 2003;90:1505–9. 10. Noguchi M, Taniya T, Miyazaki I, Saito Y. Immediate transposition of a latissimus dorsi muscle for correcting a postquadrantectomy breast deformity in Japanese patients. Int Surg 1990;75:166–70. 11. Clough KB, Nos C, Salmon RJ, Soussaline M, Durand JC. Conservative treatment of breast cancers by mammoplasty and irradiation: a new approach to lower quadrant tumours. Plast Reconstr Surg 1995;96:363–70.
ARTICLE IN PRESS UK survey of partial mastectomy and reconstruction 12. Bennelli L. A new periareolar mammaplasty: the ‘‘round block’’ technique. Aesthetic Plast Surg 1990;14:93–100. 13. Grisotti A. Immediate reconstruction after partial mastectomy. Oper Tech Plast Reconstr Surg 1994;1:1–12. 14. Clough KB, Lewis JS, Couturaud B, Fitoussi A, Nos C, Falcou MC. Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas. Ann Surg 2003;237:26–34. 15. Asgeirsson KS, Rasheed T, McCulley SJ, Macmillan RD. Oncological and cosmetic outcomes of oncoplastic breast conserving surgery. Eur J Surg Oncol 2005;31:817–23. 16. Spear SL, Pelletiere CV, Wolfe AJ, Tsangaris TN, Pennanen MF. Experience with reduction mammoplasty combined with breast conservation therapy in the treatment of breast cancer. Plast Reconstr Surg 2003;111:1102–9. 17. Raja MA, Straker VF, Rainsbury RM. Extending the role of breast-conserving surgery by immediate volume replacement. Br J Surg 1997;84:101–5. 18. National Institute for Clinical Excellence. Guidance on cancer services: improving outcomes in breast cancer. London: NICE; 2002. 19. Sotheran WJ, Rainsbury RM. Skin-sparing mastectomy in the UK—a review of current practice. Ann R Coll Surg Engl 2004;86:82–6. 20. Nos C, Fitoussi A, Bourgeois D, Fourquet A, Salmon RJ, Clough GB. Conservative treatment of lower pole breast cancers by bilateral mammoplasty and radiotherapy. Eur J Surg Oncol 1998;24:508–14. 21. Masetti R, Pirulli PG, Maqno S, Franceschino G, Chiesa F, Antinori A. Oncoplastic techniques in the conservative surgical treatment of breast cancer. Breast Cancer 2000;7:276–80. 22. Petit J, Rietjens M, Garusi C. Breast reconstructive techniques in cancer patients: which ones, when to apply, which immediate and long term risks? Crit Rev Oncol Hematol 2001;38:231–9. 23. Noguchi M, Minami M, Earashi M, et al. Oncologic and cosmetic outcome in patients with breast cancer treated with wide excision, transposition of adipose tissue with latissimus dorsi muscle, and axillary dissection followed by radiotherapy. Breast Cancer Res Treat 1995;35:163–71. 24. Rainsbury RM, Paramanathan N. Recent progress with breast-conserving volume replacement using latissimus
645
25.
26.
27.
28.
29.
30.
31.
32.
33. 34.
35.
36.
dorsi miniflaps in UK Patients. Breast Cancer 1998;5: 139–47. Nano MT, Gill PG, Kollias J, Bochuer MA. Breast volume replacement using the latissimus dorsi miniflap. ANZ J Surg 2004;74:98–104. Losken A, Schaefer TG, Carlson GW, Jones GE, Styble TM, Bostwick IIIrd J. Immediate endoscopic latissimus dorsi flap: risk or benefit in reconstructing partial mastectomy defects. Ann Plast Surg 2004;53:1–5. Cataliotti L, De Wolf C, Holland R, et al. Guidelines on the standards for the training of specialised health professionals dealing with breast cancer. Eur J Cancer 2007;43:660–5. Cendan JC, Coco D, Copeland IIIrd EM. Accuracy of intraoperative frozen-section analysis of breast cancer lumpectomy-bed margins. J Am Coll Surg 2005;201:194–8. Pinotti JA, Carvalho FM. Intraoperative pathological monitorization of surgical margins: a method to reduce recurrences after conservative treatment for breast cancer. Eur J Gynaecol Oncol 2002;23:11–6. Weber S, Storm FK, Stitt J, Mahvi DM. The role of frozen section analysis of margins during breast conservation surgery. Cancer 1997;3:273–7. McCulley S, Macmillan R. Planning the use of therapeutic mammoplasty—the Nottingham approach. Br J Plast Surg 2005;58:889–901. Gendy R, Able J, Rainsbury R. Impact of skin-sparing mastectomy with immediate reconstruction and breastsparing reconstruction with miniflaps on the outcomes of oncoplastic breast surgery. Br J Surg 2003;90:433–9. Rainsbury RM. Breast sparing reconstruction with latissimus dorsi miniflaps. Eur J Surg Oncol 2002;28:891–5. Chaturvedi S. Subaxillary dermocutaneous fat flap for reconstruction of the upper outer quadrant of the breast following conservation surgery. Br J Surg 2004;91:69–71. Ohuchi N, Harada Y, Ishida T, et al. Breast-conserving surgery for primary breast cancer. Immediate volume replacement using lateral tissue flap. Breast Cancer 1997; 4:135–41. Beharanwala KA, Dua RS, Ross GM, Ward A, A’Hern R, Gui GPH. The influence of radiotherapy on capsule formation and aesthetic outcome after immediate breast reconstruction using biodimensional anatomical expander implants. J Plast Reconstr Aesthet Surg 2006;59:1043–51.