Oncoplastic Techniques Allow Extensive Resections for Breast-Conserving Therapy of Breast Carcinomas :

To determine whether preoperative doxorubicin and cyclophosphamide (AC) permits more lumpectomies to be performed and decreases the incidence of positive nodes in women with primary breast cancer. Women (n = 1,523) were randomized to National Surgical Adjuvant Breast and Bowel Project (NSABP) B-18; 759 eligible patients received postoperative AC and 747, preoperative AC. The clinical size of breast and axillary tumors was determined before each of four cycles of AC and before surgery. Tumor response to preoperative therapy was clinically complete (cCR), partial (cPR), stable (cSD), or progressive disease (cPD). Tissue from patients with a cCR was evaluated for a pathologic complete response (pCR). Breast tumor size was reduced in 80% of patients after preoperative therapy; 36% had a cCR. Tumor size and clinical nodal status were independent predictors of cCR. Twenty-six percent of women with a cCR had a pCR. Clinical nodal response occurred in 89% of node-positive patients: 73% had a cCR and 44% of those had a pCR. There was a 37% increase in the incidence of pathologically negative nodes. Before randomization, lumpectomy was proposed for 86% of women with tumors or = 5.1 cm. Clinical tumor size and nodal status influenced the physician's decision. Overall, 12% more lumpectomies were performed in the preoperative group; in women with tumors > or = 5.1 cm, there was a 175% increase. Preoperative therapy reduced the size of most breast tumors and decreased the incidence of positive nodes. The greatest increase in lumpectomy after preoperative therapy occurred in women with tumors > or = 5 cm, since women with tumors less than 5 cm were already lumpectomy candidates. Preoperative therapy should be considered for the initial management of breast tumors judged too large for lumpectomy.

In 1993, findings from a National Surgical Adjuvant Breast and Bowel Project (NSABP) trial to evaluate the worth of radiation therapy after lumpectomy concluded that the combination was more beneficial than lumpectomy alone for localized intraductal carcinoma-in-situ (DCIS). This report extends those findings. Women (N = 818) with localized DCIS were randomly assigned to lumpectomy or lumpectomy plus radiation (50 Gy). Tissue was removed so that resected specimen margins were histologically tumor-free. Mean follow-up time was 90 months (range, 67 to 130). Size and method of tumor detection were determined by central clinical, mammographic, and pathologic assessment. Life-table estimates of event-free survival and survival, average annual rates of occurrence for specific events, relative risks for event-specific end points, and cumulative probability of specific events comprising event-free survival are presented. The benefit of lumpectomy plus radiation was virtually unchanged between 5 and 8 years of follow-up and was due to a reduction in invasive and noninvasive ipsilateral breast tumors (IBTs). Incidence of locoregional and distant events remained similar in both treatment groups; deaths were only infrequently related to breast cancer. Incidence of noninvasive IBT was reduced from 13.4% to 8.2% (P = .007), and of invasive IBT, from 13.4% to 3.9% (P < .0001). All cohorts benefited from radiation regardless of clinical or mammographic tumor characteristics. Through 8 years of follow-up, our findings continue to indicate that lumpectomy plus radiation is more beneficial than lumpectomy alone for women with localized, mammographically detected DCIS. When evaluated according to the mammographic characteristics of their DCIS, all groups benefited from radiation.

After conservative treatment for breast cancer, 20% to 30% of patients have a residual deformity that sometimes requires surgical correction. Thirty-five of these patients were operated between 1990 and 1995 at the Institut Curie. The authors classify these sequelae into three types: type I, asymmetrical breasts with no deformity of the treated breast; type II, deformity of the treated breast, compatible with partial reconstruction and breast conservation; and type III, major deformity of the breast, requires mastectomy. Fourteen patients had a type I deformity; all but 1 patient were treated with mammaplasty. Seventy-one percent underwent unilateral surgery contralateral to the irradiated breast; 80% had a satisfactory cosmetic result (good or very good). Seventeen patients had a type II deformity. They were treated by various techniques (implant, mammaplasty, latissimus dorsi flap, or transverse rectus abdominis musculocutaneous flap). Only 43.8% of patients in this group had a late satisfactory cosmetic result. Four patients had a type III deformity. They were treated with mastectomy and immediate reconstruction using a musculocutaneous flap. All 4 patients had a very good cosmetic result. This classification is a valuable guide for technique selection. For type I deformities, surgery to the irradiated breast should be avoided when possible. Type II deformities raise the most difficult therapeutic problems. Because they are mainly postoperative, optimal treatment should be preventive--by performing immediate remodeling of the treated breast before radiotherapy. This pleads for integration of plastic surgical techniques at the time of the original lumpectomy, thus reducing the need for delayed reconstructive surgery.