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      Extreme Oncoplasty: Breast Conservation in Patients with Large, Multifocal, and Multicentric Breast Cancer

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          Abstract

          Introduction

          Extreme Oncoplastic Breast Conservation Surgery (EOBCS) is offered in selected patients with multifocal or multicentric breast cancer (MFMC). Recent evidence has suggested that EOBCS may be a valuable resource for patients with MFMC who may avoid the risk associated with mastectomy in favour of the benefits of breast conservation without risking their oncological outcomes. Our study examined the practice of EOBCS in two regional breast units in Glasgow, United Kingdom.

          Materials and Methods

          A prospectively collected database of 50 patients treated with EOBC in two breast units in Glasgow between 2007 and 2018 were evaluated, and clinical outcomes were observed.

          Results

          Fifty patients (median age 55) underwent EOBCS, of which 43 (86%) had invasive disease. Median tumour size was 55mm (50–90) and multifocal disease was identified in 22 (44%) patients. Nine patients (18%) were found to have positive margins and underwent a second procedure, with 6 (12%) proceeding to mastectomy. Five-year disease free survival rate was 91.5%, while cancer-specific survival was 95.7%.

          Conclusion

          EOBCS is oncologically safe in short-term follow-up. Large scale studies are required to confirm these preliminary results, in order to offer EOBCS as a valid option to patients with advanced or multifocal breast cancer.

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          Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer.

          Umberto Veronesi, Natale Cascinelli, Luigi Mariani … (2002)
          We conducted 20 years of follow-up of women enrolled in a randomized trial to compare the efficacy of radical (Halsted) mastectomy with that of breast-conserving surgery. From 1973 to 1980, 701 women with breast cancers measuring no more than 2 cm in diameter were randomly assigned to undergo radical mastectomy (349 patients) or breast-conserving surgery (quadrantectomy) followed by radiotherapy to the ipsilateral mammary tissue (352 patients). After 1976, patients in both groups who had positive axillary nodes also received adjuvant chemotherapy with cyclophosphamide, methotrexate, and fluorouracil. Thirty women in the group that underwent breast-conserving therapy had a recurrence of tumor in the same breast, whereas eight women in the radical-mastectomy group had local recurrences (P<0.001). The crude cumulative incidence of these events was 8.8 percent and 2.3 percent, respectively, after 20 years. In contrast, there was no significant difference between the two groups in the rates of contralateral-breast carcinomas, distant metastases, or second primary cancers. After a median follow-up of 20 years, the rate of death from all causes was 41.7 percent in the group that underwent breast-conserving surgery and 41.2 percent in the radical-mastectomy group (P=1.0). The respective rates of death from breast cancer were 26.1 percent and 24.3 percent (P=0.8). The long-term survival rate among women who undergo breast-conserving surgery is the same as that among women who undergo radical mastectomy. Breast-conserving surgery is therefore the treatment of choice for women with relatively small breast cancers. Copyright 2002 Massachusetts Medical Society
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            Sensitivity of MRI versus mammography for detecting foci of multifocal, multicentric breast cancer in Fatty and dense breasts using the whole-breast pathologic examination as a gold standard.

            Francesco Sardanelli, Pietro Panizza, Alfonso Fausto … (2004)
            Our aim was to compare the effectiveness of mammography and MRI in the detection of multifocal, multicentric breast cancer. Ninety patients with planned mastectomies (nine bilateral) underwent mammography and dynamic gadolinium-enhanced MRI. Off-site reviewers aware of the entry criterion (planned mastectomy) evaluated both examinations for the presence of malignant foci, recording the density pattern on mammography. The gold standard was pathologic examination of the whole excised breast (slice thickness, 5 mm). Of 99 breasts, pathologic findings revealed 52 unifocal, 29 multifocal, and 18 multicentric cancers for a total of 188 malignant foci (158 invasive and 30 in situ). Overall sensitivity was 66% (124/188) for mammography and 81% (152/188) for MRI (p 0.05, not significant), respectively. Mammography and MRI missed 64 and 36 malignant foci, respectively, with median diameters of 8 and 5 mm (p = 0.033) and an invasive-noninvasive ratio of 2.4:1 (45:19) and 1.0:1 (18:18) (p = 0.043), respectively. The overall positive predictive value (PPV) was 76% (124/164) for mammography and 68% (152/222) for MRI (not significant). In breasts with an almost entirely fatty pattern, sensitivity was 75% for mammography and 80% for MRI (not significant), and the PPV was 73% and 65% (not significant), respectively. In breasts with fibroglandular or dense pattern, the sensitivity was 60% and 81% (p < 0.001), and the PPV was 78% and 71% (not significant), respectively. MRI was more sensitive than mammography for the detection of multiple malignant foci in fibroglandular or dense breasts. Mammography missed larger and more invasive cancer foci than MRI. A relatively low PPV was a problem for both techniques.
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              Extreme Oncoplasty: Breast Conservation for Patients Who Need Mastectomy

              Melvin Silverstein, Nirav B. Savalia, Sadia Khan … (2015)
              Extreme oncoplasty is a breast conserving operation, using oncoplastic techniques, in a patient who, in most physicians' opinions, requires a mastectomy. These are generally large, greater than 5 cm multifocal or multicentric tumors. Many will have positive lymph nodes. Most will require radiation therapy, even if treated with mastectomy. Sixty-six consecutive patients with multifocal, multicentric, or locally advanced tumors that spanned more than 50 mm were studied (extreme cases). All patients underwent excision and oncoplastic reconstruction using a standard or split wise pattern reduction and immediate contralateral surgery for symmetry. All received postexcisional standard whole breast radiation therapy with a boost to the tumor bed. The extreme cases were compared with 245 consecutive patients with unifocal or multifocal tumors that spanned 50 mm or less (standard cases). All extreme patients were advised to have a mastectomy; all sought a breast conserving second opinion. Diagnostic evaluation included digital mammography, ultrasound, MRI, and PET-CT (if invasive). Standard cases did extremely well. No ink on tumor was achieved 96% of the time among 245 patients. The median tumor size was 21 mm (mean 23 mm). Margins equal or greater than 1 mm were achieved in 88.6% of patients. Seventeen (6.9%) standard patients underwent re-excision to achieve wider margins and only one patient (0.4%) was converted to mastectomy. With 24 months of median follow-up, three patients (1.2%) experienced local recurrence. For extreme cases, no ink on tumor was achieved 83.3% of the time, which is comparable to published positive margin rates after standard lumpectomy. The median tumor size was 62 mm (mean 77 mm). Margins equal or greater than 1 mm were achieved in 54.5% of patients. Six (9.1%) extreme patients underwent re-excision to achieve wider margins and four patients (6.1%) were converted to mastectomy. With a follow-up of 24 months, one patient (1.5%) experienced a local recurrence. Extreme oncoplasty is a promising new concept. It allows successful breast conservation in selected patients with greater than 5 cm multifocal/multicentric tumors. It may be useful in patients with locally advanced tumors following neo-adjuvant chemotherapy. From a quality of life point of view, it is a better option than the combination of mastectomy, reconstruction, and radiation therapy. Long-term data on recurrence and survival are not available, using this approach. Based on historical data, it is expected the local recurrence will be somewhat higher but that there will be little or no impact on survival.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Breast Cancer (Dove Med Press)
                Journal ID (iso-abbrev): Breast Cancer (Dove Med Press)
                Journal ID (publisher-id): bctt
                Journal ID (pmc): bctt
                Title: Breast Cancer : Targets and Therapy
                Publisher: Dove
                ISSN (Electronic): 1179-1314
                Publication date (Electronic): 25 May 2021
                Publication date Collection: 2021
                Volume: 13
                Pages: 353-359
                Affiliations
                [1 ]Academic Unit of Surgery, University of Glasgow, Glasgow Royal Infirmary , Glasgow, UK
                [2 ]Department of Breast Surgery, Forth Valley Royal Hospital , Larbert, UK
                [3 ]Department of Breast Surgery, Gartnavel General Hospital , Glasgow, UK
                [4 ]Canniesburn Department of Plastic Surgery, Glasgow Royal Infirmary , Glasgow, UK
                [5 ]Department of Breast Surgery, New Victoria Hospital , Glasgow, UK
                Author notes
                Correspondence: Francesca Savioli Email Francesca.savioli@glasgow.ac.uk
                [*]

                These authors contributed equally to this work

                Author information
                http://orcid.org/0000-0002-9905-998X
                Article
                Publisher ID: 296242
                DOI: 10.2147/BCTT.S296242
                PMC ID: 8164874
                PubMed ID: 34079367
                SO-VID: f16c17fd-2024-4dad-a5ef-ef8c2ae77058
                Copyright © © 2021 Savioli et al.
                License:

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                History
                Date received : 02 February 2021
                Date accepted : 22 April 2021
                Page count
                Figures: 0, Tables: 2, References: 33, Pages: 7
                Categories
                Subject: Original Research

                Keywords: extreme oncoplasty,therapeutic mammoplasty,breast conservation therapy,multifocal breast cancer,multicentric breast cancer
                Data availability:
                Keywords: extreme oncoplasty, therapeutic mammoplasty, breast conservation therapy, multifocal breast cancer, multicentric breast cancer

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