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Oncoplastic reshaping in breast-conserving surgery in a peripheral hospital. The Novi Ligure “San Giacomo” hospital experience Ann. Ital. Chir., 84, 4, 2013 389 Ann. Ital. Chir., 2013 84: 389-394 pii: S0003469X13019829 Pervenuto in Redazione Maggio 2012. Accettato per la pubblicazione Luglio 2012. Correspondence to: Pier Carlo Rassu, Viale Aurelio Saffi 60/7, 15067, Novi Ligure (Alessandria), Italy (e-mail: [email protected]) Pier Carlo Rassu*, Alberto Serventi*, Eliana Giaminardi*, Maria Maurizia Bocchio*, Ilaria Ferrero*, Giuseppe Colombo**, Vittorio Ruvolo***, Paolo Tava*** *Chirurgia Generale, Ospedale “San Giacomo”, Novi Ligure, Alessandria, Italy **Centre of Plastic Surgery Koru, Novi Ligure, Alessandria, Italy ***Direttore del Dipartimento di Chirurgia Tortona-Novi Ligure, (Primario SC Chirurgia Generale), Ospedale “San Giacomo” di Novi Ligure e Ospedale Civile “SS Antonio e Margherita di Tortona”, Alessandria, Italy Oncoplastic reshaping in breast-conserving surgery in a peripheral hospital. The Novi Ligure “San Giacomo” hospital experience AIM: To confirm that oncoplastic approach to cancer is a fundamental part of modern breast conserving surgery also in a suburban hospital. MATERIAL OF STUDY: The Authors used oncoplastic techniques in 60 cases including 45 first level and 15 second level procedures: they show some cases of conservative surgery and breast reshaping with upper, medial and lower pedicle. DISCUSSION: Screening programs are able to identify early breast cancer; the breast conserving surgery with oncoplastic glandular reshaping should be an established custom to ensure oncological safety with the best cosmetic result. CONCLUSIONS: The oncoplastic approach to breast cancer should be the theoretical and practical knowledge of the breast surgeon. Today in fact the breast surgeon must be a “vertical surgeon” in order to treat cancer completely, interfaced with a multidisciplinary team to ensure a personalized treatment for each patient. In this presentation the Authors want to focus on oncoplastic surgery in a medium flow suburban hospital. KEY WORDS: Breast conserving surgery, Oncoplastic breast surgery, Screening Introduction Oncoplastic breast surgery is by definition a destructive operation that must be strictly radical and that is often associated with common reconstructive plastic surgery techniques, aimed at ensuring the maximum oncological result and the best possible aesthetic outcome. Applying oncoplastic techniques, though, adds additional time to the breast resection surgery, which is no longer the “fresh- man’s task” but has become a complex surgery in terms of preoperative drawing, intra-operative set-up and final conditioning in order to get an aesthetically pleasing result 1 . Patients and Methods 185 breast surgeries were performed between January 2008 and April 2012 at the San Giorgio hospital of Novi Ligure; in 60 cases oncoplastic surgery techniques were applied, of which 45 were first level and 15 sec- ond level. Here are reported only a few examples of first

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Page 1: Oncoplastic reshaping in breast-conserving surgery … · Oncoplastic reshaping in breast-conserving surgery in a peripheral hospital. The Novi Ligure “San Giacomo” hospital experience

Oncoplastic reshaping in breast-conserving surgery in a peripheral hospital.The Novi Ligure “San Giacomo” hospital experience

Ann. Ital. Chir., 84, 4, 2013 389

Ann. Ital. Chir., 2013 84: 389-394pii: S0003469X13019829

Pervenuto in Redazione Maggio 2012. Accettato per la pubblicazioneLuglio 2012.Correspondence to: Pier Carlo Rassu, Viale Aurelio Saffi 60/7, 15067,Novi Ligure (Alessandria), Italy (e-mail: [email protected])

Pier Carlo Rassu*, Alberto Serventi*, Eliana Giaminardi*, Maria Maurizia Bocchio*, Ilaria Ferrero*, Giuseppe Colombo**, Vittorio Ruvolo***, Paolo Tava***

*Chirurgia Generale, Ospedale “San Giacomo”, Novi Ligure, Alessandria, Italy**Centre of Plastic Surgery Koru, Novi Ligure, Alessandria, Italy***Direttore del Dipartimento di Chirurgia Tortona-Novi Ligure, (Primario SC Chirurgia Generale), Ospedale “San Giacomo” di NoviLigure e Ospedale Civile “SS Antonio e Margherita di Tortona”, Alessandria, Italy

Oncoplastic reshaping in breast-conserving surgery in a peripheral hospital. The Novi Ligure “San Giacomo” hospital experience

AIM: To confirm that oncoplastic approach to cancer is a fundamental part of modern breast conserving surgery also ina suburban hospital.MATERIAL OF STUDY: The Authors used oncoplastic techniques in 60 cases including 45 first level and 15 second levelprocedures: they show some cases of conservative surgery and breast reshaping with upper, medial and lower pedicle.DISCUSSION: Screening programs are able to identify early breast cancer; the breast conserving surgery with oncoplasticglandular reshaping should be an established custom to ensure oncological safety with the best cosmetic result.CONCLUSIONS: The oncoplastic approach to breast cancer should be the theoretical and practical knowledge of the breastsurgeon. Today in fact the breast surgeon must be a “vertical surgeon” in order to treat cancer completely, interfacedwith a multidisciplinary team to ensure a personalized treatment for each patient. In this presentation the Authors wantto focus on oncoplastic surgery in a medium flow suburban hospital.

KEY WORDS: Breast conserving surgery, Oncoplastic breast surgery, Screening

Introduction

Oncoplastic breast surgery is by definition a destructiveoperation that must be strictly radical and that is oftenassociated with common reconstructive plastic surgerytechniques, aimed at ensuring the maximum oncological

result and the best possible aesthetic outcome. Applyingoncoplastic techniques, though, adds additional time tothe breast resection surgery, which is no longer the “fresh-man’s task” but has become a complex surgery in termsof preoperative drawing, intra-operative set-up and finalconditioning in order to get an aesthetically pleasingresult1.

Patients and Methods

185 breast surgeries were performed between January2008 and April 2012 at the San Giorgio hospital ofNovi Ligure; in 60 cases oncoplastic surgery techniqueswere applied, of which 45 were first level and 15 sec-ond level. Here are reported only a few examples of first

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and second level oncoplastic reshaping, performed afterbreast-conserving surgery at the General Surgery Unit inNovi Ligure.

CASE 1

39 year-old patient with bilateral mastodynia and pal-pable mass in Q1-Q2 of the left breast and Q3 of theright breast. Mammography, ultrasound and magneticresonance were negative for focal nodule lesions, buthighlighted areas of inhomogeneous structure; the patientunderwent ultrasound-guided core biopsy in the areaswith most irregularity. The micro-histological examina-tion highlighted atypical duct hyperplasia (DIN 1 b)diagnosis with high mitosis rate, Ki67 15%, negative

ER/PgR. The intervention included a broad resection atthe convergence of the upper left quadrants and lowerexternal quadrant of the right breast and, given the fair-ly high degree of ptosis, the designed access was roundblock (Figg. 1, 2).

CASE 2

54 year-old patient suffering from severe fibrocystic dys-plasia with subversion of the gland structure. The mam-mography was negative for micro-calcifications but didnot clarify the lump situations because of the very denseappearance of the gland. Ultrasound and magnetic res-

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390 Ann. Ital. Chir., 84, 4, 2013

Fig. 1: Preoperative “round block” drawing for wide excision in the junc-tion of the upper quadrants of the left breast and for the same excisionin the lower outer quadrant of the right breast.

Fig. 2: Cosmetic outcome after 30 days from the surgery with good sym-metry and shape of the breasts.

Fig. 3: Preoperative drawing for nipple sparing mastectomy with “italicS” incision.

Fig. 4: Intraoperative detail of compositive mesh stitched to the pec-toralis major muscle and to the serratus anterior in order to cover thebreast implant.

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onance confirmed the ubiquitous distribution of simplecysts with maximum diameter of 6 cm and allowed toidentify a solid lesion featuring suspect characteristics(BiRADS U4). The ultrasound-guided suction needleresulted in yet another diagnostic suspicion (C4 accord-ing to the European guidelines). The measure of choicewas to perform core biopsy. In order to obtain a betteracoustic window and, most importantly, reach the nod-ule easily, cystocenthesis was in order. The micro-histol-ogy examination result confirmed the malignancy (B5b).The staging process was completed with axillary ultra-sound and cytology test on a suspect lymph node (pos-itive search of epithelial cells). The gland structure didnot allow to perform quadrantectomy and 1st leveloncoplastic remodelling, therefore the approach consist-ed of nipple-sparing mastectomy2 and immediate recon-struction with implant and contralateral adjustment (pic-ture 3). NAC dissection was performed by means of the“hydro-dissection” technique, recently described by Folli3,while the reconstruction (310 g implant) included thecreation of a sub-muscular pocket with full sparing ofthe distal insertion of the pectoralis major muscle. Thetissue gap between the lateral margin of the pectoralismajor and that of the serratus anterior muscle, whichwould have left the implant in direct contact with sub-cutaneous tissue, was filled with composite mesh (pic-ture 4). Contralateral adjustment took place by meansof augmentative mastoplasty (dual plane technique) andinsertion of 140 gr sub-muscular implant (Fig. 5).

CASE 3

51 year-old patient, palpable right retro-alveolar node,NAC deformation and nipple retraction. Mammography,ultrasound and magnetic resonance described a neoplasmwith maximum diameter of 2 cm and the involvementof the homo-lateral axillary lymph nodes (BiRADS

R5/U5); the FNAC performed both on the breast neo-plasm and on the suspect lymph node in axillary con-firmed the malignancy (C5). The suggested surgery wascentral quadrantectomy, 2nd level upper pedicle oncoplas-tic reshaping with inverted T scar, dermo-glandular infe-rior flap prosthesis, immediate reconstruction of the nip-ple-areola complex with dermal local flaps, axillary dis-section and contralateral adjustment (Figg. 6, 7).

CASE 4

78 year-old patient with an history of right breast upperquadrantectomy with sentinel lymph node biopsy 5 yearsbefore. Over the latest examinations a distortion appearedwith microcalcifications (BiRADS R5) in left Q1. Anultrasound-guided core biopsy was performed in the dis-

Ann. Ital. Chir., 84, 4, 2013 391

Oncoplastic reshaping in breast-conserving surgery in a peripheral hospital: the Novi Ligure “San Giacomo” hospital experience

Fig. 5: Cosmetic outcome after 20 days from the surgery.

Fig. 6: Preoperative drawing for lumpectomy of the central quadrant: 2nd

level oncoplastic reshaping with superior pedicle flap, dermo-glandularinferior flap prosthesis and nipple-areola complex reconstruction.

Fig. 7: Cosmetic outcome after 30 days from the surgery.

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tortive area, showing high-degree DCIS. Following theprevious surgery on the right breast, performed in anoth-er centre, the patient showed clear breast asymmetry. Thesurgery included a large excision of the outer left quad-rant with subsequent 1st level oncoplastic reshaping, cen-tralization of nipple-areola complex and sentinel lymphnode biopsy (Figg. 8, 9).

CASE 5

61 year-old patient with palpable node at the conver-gence of the upper quadrants: ultrasound and mam-mography confirmed the presence of a 2 cm node(BiRADS R5/U5) and cytology highlighted a malignantneoplasm diagnosis (C5). The patient did not ask for

contralateral adjustment, hence we offered lumpectomy ofthe junction of the upper quadrants with 2nd level oncoplas-tic reshaping with inferior pedicle flap (Figg. 10, 11).

Discussion

The surgical treatment of breast carcinoma is based ona glandular resection which must comply with an onco-logical limit – which has not been well and completelyidentified yet – of at least 1 cm from the apparent edgeof the neoplasm at surgery and higher than 2 mm athistology in case of infiltrating neoplasm 4 and at sen-tinel lymph node biopsy for staging purposes. The sen-tinel lymph node micro-metastasis response is no longera necessary indication for axillary dissection, which will

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392 Ann. Ital. Chir., 84, 4, 2013

Fig. 8: Preoperative planning for lumpectomy of the outer left quadrantin clear breast asymmetry.

Fig. 9: 1st level of oncoplastic reshaping with centralization of nipple-areola complex and good final symmetry of the breasts.

Fig. 10: Preoperative drawing for lumpectomy of the junction of theupper quadrants of the left breast: 2nd level oncoplastic reshaping withinferior pedicle flap.

Fig. 11: Cosmetic outcome after 30 days from the surgery with a goodsymmetry and shape of the breasts.

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remain a passage, no longer compulsory, only in case ofmacro-metastases5. It is therefore crucial to accuratelyplan the surgical operation by means of ultrasound axil-lary examination, as well as fine needle aspiration cytol-ogy or core biopsy of the suspect lymph node 6,7.Oncoplastic surgery results from the need to performoncologically correct surgery operations while sparing theaesthetic of the patient. It is a known fact that remov-ing a portion higher than 20% of the whole breast vol-ume is a predictive factor of poor aesthetic outcome 8,9.Oncoplastic surgery is comprised of two levels of inter-vention: the first level consists of the creation andarrangement of skin and gland flaps upon underminingthe skin envelope along the avascular plane of the fas-cia superficialis and from the pre-pectoral one in orderto conceal the resection defect and, if necessary, centringthe NAC. The second level is typical of reconstructivesurgery and leverages, in case of mid-large breasts, thevolume displacement techniques, that is, the creation ofupper, mid, lower and lateral pedicle flaps 10. The vol-ume replacement techniques are more complex andrequire the creation of muscular flaps from the rectusabdominis or latissimus dorsi. Last, there are some tech-niques that include corrections, such as the reconstruc-tion of the NAC by means of local dermal flaps. Duringthe latest European Breast Cancer Conference held inVienna a decision was made to rank oncoplastic tech-niques into four levels: – 1st level: reshaping with glandular flaps with/withoutcontralateral carried out by oncoplastic breast surgeon; – 2nd level: glandular reshaping by means of upper, mid,lower and lateral peduncle flaps, performed by theoncoplastic breast surgeon and without the support ofthe plastic surgeon;– 3rd level: “conservative mastectomies” (nipple sparing,skin sparing, skin reducing) and reconstruction withexpandable implant, performed jointly by the breast andplastic surgeons;– 4th level: complex mammary reconstruction with mus-cle and skin flaps that require the exclusive presence ofthe plastic surgeon.With screening, the number of early breast neoplasmdiagnoses increased, both in the intraductal (22%) aswell as invasive forms 11. “Voluntary screening” allowswomen to get to the breast examination with small-sizedlesion, hence surgery is mostly designed in terms of aquadrantectomy connected to sentinel lymph node biop-sy and 1st level oncoplastic remodelling. Planning thesurgical operation begins with the breast examinationwith axillary and breast ultrasound in order to later per-form the FNAC or CB of the lesion and the suspectlymph-nodes 12. In 24 hours is then possible to offerthe surgical approach and the most appropriate proce-dure for lymph node staging. If the ultrasound test ofthe axillary should be negative for suspect lymph nodes,a lymphoscintigraphy is performed (24 hours before) insearch of the sentinel lymph node.

In oncoplastic surgery the operation must be carefullyplanned in advance in the form of accurate incision linedrawings on the patient’s skin. As regards non-palpablelesions, these must be carefully identified; at our hospi-tal we routinely use the traditional marker wire withmetal hook placed the same morning of the surgery withultrasound or stereotactic guide. The BiRADS U5 nodes,R5 with C4 cytology and diameter lower than one cen-timetre, are not subject to frozen assay and are imme-diately sent to definitive histology. The only this request-ed of the pathologist is the macroscopic edge evaluation.The surgical sample is usually weighted and well ori-ented by means of clips. For full-blown lesion with C5cytology, the sentinel lymph node is sent to definitivehistology or, in case of uncertain pre-operative cytology,to intraoperative examination. In case of micro-metas-tases with good prognosis tumours in older patients(Ki67 < 20%, ER +, PgR +, HER2 -), the case is sub-ject to multi-disciplinary discussion and axillary lym-phectomy is not performed. Otherwise the patient willbe administered a traditional axillary dissection surgery,which in our centre is performed both with ultrasounddissector 13,14 and with a radiofrequency system 15,16. Thecases that were reported are just meant to provide a sim-ple example on how oncoplastic surgery techniques havebecome an indispensable tool in the armamentarium ofbreast surgeon, who must become “vertical surgeon”, thatis, capable of managing invasive diagnostics, oncologicalsurgery, basic reconstruction and, in most complex cas-es, must work side by side with the plastic surgeon spe-cialist 17. The patients operated at the San Giacomo hos-pital of Novi Ligure took the surgery plan well andshowed a high degree of satisfaction in terms of theresults accomplished.

Conclusions

The application of regional screening programmes forbreast carcinoma allowed to reach the early diagnosisgoal. Patient prognosis is directly correlated with thestage of the disease, hence the earlier the diagnosis thelonger the survival and the closer we get to “zero mor-tality”. In this view surgery plays a key role in local con-trol, though the need to rigorously comply with the rulesof oncological surgery must not collide with the respectfor women’s bodily image. Oncoplastic surgery allows toperform oncologically correct resections while attempt-ing to achieve the best possible aesthetic result.

Riassunto

L’approccio oncoplastico alla moderna chirurgia dellamammella deve costituire il bagaglio teorico-pratico delsenologo. Al giorno d’oggi infatti il senologo è un “chi-rurgo verticale” che deve gestire la malattia in modo

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completo, interfacciandosi con un team multidisciplina-re, al fine di garantire un trattamento personalizzato perogni singola paziente. In questa presentazione di casi cli-nici si vuole porre l’accento sulla chirurgia oncoplasticain un ospedale di periferia a medio flusso: vengono pre-sentati casi di ricostruzione mediante tecniche di primoe secondo livello con allestimento di lembi a pedunco-lo superiore, medio e inferiore. La chirurgia oncoplasti-ca della mammella permette di trattare la malattia tumo-rale in modo radicale cercando di ottenere il migliorerisultato estetico.

References

1. Margenthaler JA: Optimizing conservative breast surgery. J SurgOncol, 2011; 103(4):306-12.

2. Nava MB, Catanuto G, Pennati A, Garganese G, Spano A:Conservative mastectomies. Aesthetic Plast Surg, 2009; 33(5): 681-86.

3. Folli S, Curcio A, Buggi F, Mingozzi M, Lelli D, Barbieri C,Asioli S, Nava MB, Falcini F: Improved sub-areolar breast tissueremoval in nipple-sparing mastectomy using hydrodissection. Breast,2012; 21(2):190-93.

4. Sabel MS: Surgical considerations in early-stage breast cancer:Lessons learned and future directions. Semin Radiat Oncol, 2011;21(1):10-19.

5. Giuliano AE, Hunt KK, Ballman KV, Beitsch PD, WhitworthPW, Blumencranz PW, Leitch AM, Saha S, McCall LM, MorrowM: Axillary dissection vs no axillary dissection in women with inva-sive breast cancer and sentinel node metastasis: A randomized clinicaltrial. JAMA, 2011; 305(6):569-75.

6. Brancato B, Crocetti E, Bianchi S, Catarzi S, Risso GG,Bulgaresi P, Piscioli F, Scialpi M, Ciatto S, Houssami N: Accuracyof needle biopsy of breast lesions visible on ultrasound: Audit of fineneedle versus core needle biopsy in 3233 consecutive samplings withascertained outcomes. Breast, 2011; [Epub ahead of print].

7. O’Leary DP, O’Brien O, Relihan N, McCarthy J, Ryan M,Barry J, Kelly M, Redmond HP: Rapid on-site evaluation of axil-lary fine-needle aspiration cytology in breast cancer. Br J Surg, 2012;99(6):807-12.

8. Gainer SM, Lucci A: Oncoplastics: techniques for reconstructionof partial breast defects based on tumor location. J Surg Oncol, 2011;103:341-47.

9. Chan SWW, Lam SH, Polly SY: Cosmetic outcome and per-centage of breast volume excision in oncoplastic breast conserving surgery.World J Surg, 2010; 34:1447-452.

10. Clough KB, Kaufman GJ, Nos C, Buccimazza I, Sarfati IM:Improving breast cancer surgery: a classification and quadrant per quad-rant atlas for oncoplastic surgery. Ann Surg Oncol, 2010; 17:1375-391.

11. De Gelder R, Fracheboud J, Heijnsdijk EA, den Heeten G,Verbeek AL, Broeders MJ, Draisma G, de Koning HJ: Digital mam-mography screening: Weighing reduced mortality against increased over-diagnosis. Prev Med, 2011; 53(3):134-40.

12. Brancato B, Zappa M, Bricolo D, Catarzi S, Risso G, BonardiR, Cariaggi P, Bianchin A, Bricolo P, Rosselli Del Turco M,Cataliotti L, Bianchi S, Ciatto S: Role of ultrasound-guided fine need-le cytology of axillary lymph nodes in breast carcinoma staging. RadiolMed, 2004; 108(4):345-55.

13. Böhm D, Kubitza A, Lebrecht A, Schmidt M, Gerhold-Ay A,Battista M, Stewen K, Solbach C, Kölbl H: Prospective randomizedcomparison of conventional instruments and the Harmonic Focus(®)device in breast-conserving therapy for primary breast cancer. Eur JSurg Oncol, 2011; [Epub ahead of print].

14. Ostapoff KT, Euhus D, Xie XJ, Rao M, Moldrem A, Rao R:Axillary lymph node dissection for breast cancer utilizing HarmonicFocus®. World J Surg Oncol, 2011; 15(9)90.

15. Antonio M, Pietra T, Domenico L, Massimo D, Ignazio R,Antonio N, Luigi C: Does LigaSure reduce fluid drainage in axillarydissection? A randomized prospective clinical trial.Ecancermedicalscience, 2007; 1:61 Epub 2007.

16. Manouras A, Markogiannakis H, Genetzakis M, Filippakis GM,Lagoudianakis EE, Kafiri G, Filis K, Zografos GC: Modified radi-cal mastectomy with axillary dissection using the electrothermal bipo-lar vessel sealing system, Arch Surg, 2008; 143(6):575-80.

17. Colombo G, Dellacasa I, Ruvolo V, Ottonello M, Bormioli M,Meszaros P: Oncoplastic surgery for the treatment of breast cancer.Minerva Ginecol, 2009; 61(5):439-44.

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