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Expanding the role of breast conservation surgery by immediate volume replacement with the latissimus dorsi flap
Abstract
Many women with early breast cancer are treated with Mastectomy, instead of Breast Conservation Surgery (BCS), for fear of suboptimal tumor removal or cosmetic failure due to volume and shape loss. These women can be satisfactorily treated by BCS and immediate volume replacement. Synchronous breast augmentation by the autologous Latissimus Dorsi (LD) Muscle or Myocutaneous Flaps in the treatment of relatively large and/or retroareolar breast tumors was investigated in this study held at the National Cancer Institute of Cairo University and at the Aswan Cancer Center.
Between October 2000 and March 2003, 29 patients with histologically proven breast cancer were treated by BCS and immediate volume replacement with LD muscle or myocutaneous flaps. Patients' age ranged from 32 to 57 years. Tumors' size ranged from 28 to 69mm. Axillary dissections revealed positive lymph glands in 58.6% of cases. Tumor location was in the central quadrant in 45%, in the upper quadrants in 41% and in the lower quadrants in 14% of cases. The LD myocutaneous flap was used in 21 cases while, in the remaining 8 cases, only the LD muscle was needed.
The median size of the lumpectomy specimen was 219cm3. The safety margins obtained ranged between 9 and 28mm. The mean combined operating time was 238 minutes. The mean blood loss was 320ml and no patient required blood transfusion. The median hospital stay was 5 days. Persistent seroma in the back occurred in 52% of patients, requiring a median of 5 weekly aspirations. No sepsis or flap viability problems were encountered. Cosmetic results were satisfactory in 69% of patients. Only 17% showed some asymmetry in size, 7% some discrepancy in skin color and 7% a mild difference in Nipple Areola Complex (NAC) level.
Mastectomy can be avoided in a large number of women with small breast/tumor ratio or retroareolar tumors. Immediate volume replacement with LD flap can extend the role of BCS to these patients. This can be achieved without compromising the adequacy of resection, with minimal morbidity, very satisfactory cosmetic results, no need for prosthesis or contra lateral mammaplasty and no effect on postoperative clinical or radiological follow-up.
... However, its utilization in Africa is minimal even in early cases, and this is despite reports from many multinational clinical trials confirming equivalent survivals with breast-conserving surgery and mastectomy. 8,10,12 In many LMICs, mastectomy is still the most performed surgical intervention. The key drivers for mastectomies include late clinical presentation, limited availability of radiotherapy facilities, paucity of skilled plastic surgeons, and patient's preference. ...
... In eight of the 16 studies that reported oncoplastic breast surgery (OPBS) procedures, with a total of 764 patients, latissimus dorsi myocutaneous flap was specified as one of the techniques used, with a total of 112 (15%) patients receiving this procedure. 12,16,18,19,21,32,33 Only one study documented the Wise pattern mastopexy surgery, which was performed on 136 (18%) patients. 15 The level 1 oncoplastic surgery approach was performed on 91 (12%) patients, making it the third most prevalent procedure that was mentioned in the review. ...
... Only 26 studies met the criteria to be included in the systematic review; four of those studies were abstracts only, but they nevertheless contained essential data for inclusion. 8,12,36,37 Eighty-five percent of these studies were published within the past 10 years, with a significant number appearing in the past year alone. This indicates a growing trend toward breast-conserving surgery in Africa in comparison with previous years. ...
PURPOSE
Breast cancer is the most frequently diagnosed cancer in women worldwide. Surgery is a major treatment modality for breast cancer, and over the years, breast-conserving surgeries with breast radiation have shown similar outcomes with mastectomy. Not much is known about the frequency and outcome of breast-conserving surgery in Africa. This systematic review provides a comprehensive summary of the evidence evaluating cosmetic and oncologic outcomes after oncoplastic breast-conserving surgery (OBCS) for breast cancer in African women.
METHODS
This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases were systematically searched for studies on African women undergoing OBCS. The oncologic and cosmetic outcomes, as well as the localization and reconstruction techniques, were evaluated. Descriptive statistics were used to summarize the frequency and proportions of the extracted variables.
RESULTS
The literature search yielded 266 articles but only 26 of these were included in the review. Majority of the studies were from Egypt and South Africa. These studies collectively evaluated 1,896 patients with a mean age of 48.2 years and a mean follow-up period of 36.9 months. The most common histopathology was T2 (71.4%) invasive ductal carcinoma. Hook wire localization was the most common technique used for nonpalpable lesions in 85.3% of patients. Of the studies reporting oncoplastic technique, the latissimus dorsi volume replacement technique was the most reported (15%). Most patients were satisfied with their cosmetic outcome. Seroma was the most common postoperative complication (44.6%). Among studies that reported oncologic outcome data, the crude overall survival and disease-free survival were 93.1% and 89.4%, respectively.
CONCLUSION
This systematic review revealed that the outcome of OBCS in African women compares with that in developed countries.
... Thirty-one papers were included in this assessment. 11,14,[16][17][18][19][20][22][23][24][25][26][27][29][30][31][33][34][35][36][37][38][39][40][41][42][43][45][46][47][48] A total of 1,729 patients were included, with a mean follow-up of 40.8 months (6-125 months). Locoregional and distant recurrence was 2.5% (0-8.1%) and 3.1% (0-14.6%) ...
... 37,44 There were also institutions that did not employ routine adjuvant radiotherapy, 26,27,41 hence there is a considerable discrepancy in its use, ranging from 33.3% to 100%, with more recent studies tending towards 100%. 11,[18][19][20]23,25,33,34,38,39,48 Overall complications ranged from 0% to 65.7%, with a mean of 21.1%. Complications described were divided into minor (I-II) and major (III-IV) as per the Clavien-Dindo classification: 17.1% (0-52%) and 5.6% (0-13.7%), ...
Introduction:
Oncoplastic breast conserving surgery allows higher volume excision to achieve oncological safety with minimal aesthetic compromise. The primary outcome of this study was to assess the oncological safety in the setting of volume replacement oncoplastic breast conserving surgery. The secondary objective was to assess cosmetic outcome.
Methods:
A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to explore the oncological safety of oncoplastic breast conserving surgery, with particular focus on volume replacement. Resection margin rates, re-excision rates, conversion to mastectomy rates, local and distant disease recurrence, volume replacement techniques, cosmetic outcomes and patient-reported outcome measures were assessed.
Findings:
The search criteria identified 155 articles, of which 40 met the inclusion criteria. These studies included 2,497 patients with a mean age of 47.8 years (range 38.4-59.6 years), a body mass index of 24.3kg/m2 (22.1-28.0kg/m2), with a mean follow-up of 37.1 months (6-125 months). A variety of volume replacement techniques were used, most commonly latissimus dorsi and chest wall perforator flaps. Whole mean pathological tumour size was 29.7mm (17-65mm) and mean specimen weight was 123.6g (46.5-220g). Mean re-excision rate was 7.2% and completion mastectomy rate was 2.3%. Locoregional and distant recurrence rate was 2.5% (0-8.1%) and 3.1% (0-14.6%), respectively. There were a variety of patient-reported outcome measures employed, with overall good to excellent outcomes.
Conclusions:
This review demonstrates that volume replacement oncoplastic breast conserving surgery is a safe option in terms of re-excision, completion mastectomy rates, and local and distant recurrence. Available patient-related outcome measures and cosmetic assessment tend towards better outcomes compared with wide local excision and mastectomy. However, data are significantly limited, with a paucity of high-level evidence, and it is therefore necessary to be cautious regarding the strength and interpretation of data in this review. Further prospective studies are required on this subject.
... Hernanz et al. reported a satisfactory cosmoses in (65%) of cases after a long follow-up period of 54 months [14]. Moreover, Naguib reported a 69% satisfactory cosmetic outcome in a series of 29 patients, after a follow-up ranging from 3 to 36 months [15]. Being a single stage operation (at the time of breast resection and axillary dissection), as described by Raja et al, Rains bury and Paramanathan, and Noguchi et al., LD mini-flap is more time saving and hence a cost effective [16]- [18]. ...
... We had (53.3%) of our patients who required weekly aspiration by a mean of 4 weeks. Similar results in a study by Naguib who reported seroma in (52%) of his patients that disappeared after a mean of five weeks of aspirations [15]. Throughout a regular follow-up visits, the presence of the LD flap did not limit the efficacy of clinical or radiological evaluation in any patient. ...
Introduction: Nowadays the more accepted surgical option for treating early breast cancer is breast conserving surgery. The main challenge in this type of surgery is to get free safety margins without need of second surgical operation, so many breast surgeons have started to depend on intraoperative frozen sections to ensure free safety margins. Aim of work: To assess our policy that we prefer to depend on intraoperative frozen section analysis to get free safety margin in breast conserving surgery from the 1st surgery, and its oncologic outcome. Patients and Methods: This is a retrospective study conducted in Oncology Center—Mansoura University (OCMU), where the data of 219 patients with breast cancer, who were managed by breast conserving surgery with intraoperative frozen section analysis of the safety margins, was analyzed. Results: The intraoperative frozen section analysis of safety margin was negative from the start in 183 (83.6%) patients, while it was positive in 36 patients (16.4%). Intraoperative decision of margin re-excision was applied for 29 patients (13.2%) in order to reach negative margin, modified radical mastectomy was offered for 4 patients (1.8%), while nipple sparing mastectomy with immediate breast reconstruction using latissimus dorsi flap was offered for 3 patients (1.4%). The postoperative paraffin results were typical with intraoperative frozen section analysis results in 216 patients (98.6%) and different results were obtained in only 3 patients (1.4%) who were managed by modified radical mastectomy in a second operation. Only 4 patients had local recurrence (1.8%) during the period of follow-up duration which was ranged from 1 to 86 months with mean ± SD (22.3 ± 14.1). Conclusion: The intraoperative frozen section analysis of safety margins in breast conserving surgery has very high-rate typical results with the paraffin section analysis and it is very helpful in decreasing the rate of second surgical operation in cases of infiltrated margins. It should be used routinely in all cases of breast conserving surgery.
... Another problematic area is when skin excision is required if the tumour is close to the skin or nipple-areola complex (NAC). Traditionally, the latissimus dorsi (LD) flap with skin has been the workhorse flap for this [3]. However, LD flap has its own morbidity associated with muscle harvests like seroma, donor site wound problems, and some difficulty in exercise with the ipsilateral arm for at least some time [4,5]; hence, musclesparing options like chest wall perforator flaps (CWPFs) hold potential for use in these situations. ...
Among 145 chest wall perforator flaps (CWPFs) performed at City Hospital, Birmingham (September 2017-February 2022), 11 were for novel indications, four were for whole breast reconstructions, two were for implant salvage procedures, three were CWPFs with skin paddle to replace excised skin/nipple-areola complex, and two were for upper inner quadrant tumours.
Tumour characteristics and post-operative complications were noted. Patient-reported outcomes measures (PROMs) were measured using a questionnaire adapted from the National Mastectomy and Breast Reconstruction Audit (NMBRA) study.
Among 11 patients, nine (81.81%) did not develop any complications. Ten patients responded to PROMs (median follow-up of eight months). The PROMs assessment showed that all patients (100%) were satisfied with the post-operative breast appearance. Of the patients, 90% (9/10) felt the results of their surgery to be good, very good, or excellent. Of the patients, 70% (7/10) said that they have no/little persistent pain. None of the patients had difficulty carrying out normal activities.
Thus, the applications of CWPFs could be extended for whole breast reconstruction, implant salvage procedures, where skin paddle is needed, and for upper inner quadrant tumours.
... The use of volume displacement OBCS has been well established. Similarly, several volume replacement techniques have also been well established, such as the latissimus dorsi (LD) myocutaneous flap [3][4][5] and the LD myosubcutaneous flap or LD mini (LDm) flap. [6][7][8] Variations of pedicled flaps based on the intercostal artery perforators and thoracodorsal artery perforators (TDAPs) have been described and shown to be reliable in immediate BCS reconstruction. ...
INTRODUCTION
Oncoplastic breast conservation surgery (OBCS) combines the principles of surgical oncology and plastic surgery. OBCS has now become a growing option for the treatment of breast cancer and forms a part of breast-conserving therapy (BCT). We sought to investigate and report our experience in two breast units in Glasgow (Victoria Infirmary and Western Infirmary) on volume replacement OBCS.
MATERIALS AND METHODS
Details of patients treated with volume replacement OBCS were identified from a prospectively recorded database from November 2010 to October 2015. The clinical records included in the oncoplastic dataset were analyzed for demographics, tumor, treatment characteristics, and recurrences. The data were analyzed for follow-up to determine the pattern and timing of recurrence up to April 2016. The primary outcome of this study was tumor-free margin resection rates, and the secondary outcomes were locoregional and distant recurrence rates as these correlate with the overall oncological safety of volume replacement oncoplastic breast surgery (OPBS).
RESULTS
A total of 30 volume replacement oncoplastic breast conservation procedures have been carried out in this time period. The mean age of the former group was 51 years. Twice as many patients presented symptomatically than had tumors detected on screening. The mean preoperative tumor size on radiology was 25.4 mm. Patients underwent 13 thoracoepigastric flaps, 5 lateral intercostal artery perforator (LICAP) flaps, 2 thoracodorsal artery perforator (TDAP) flaps, 1 lateral thoracic artery perforator (LTAP) flap, 1 crescent flap volume replacement surgery, and 8 matrix rotations. Two patients had neoadjuvant chemotherapy. Fourteen patients had adjuvant chemotherapy, and all patients were treated with adjuvant radiotherapy. Twenty-two patients were treated with hormonal therapy and four patients were treated with Herceptin. The rate of incomplete excision was 10%. Median follow-up time was 48.5 months. Only one regional recurrence was detected. Eight patients encountered some form of complication.
CONCLUSION
This study continues to show the relative oncological safety of volume replacement oncoplastic conservations as an option for reconstruction in breast cancer patients. Further research is urgently needed to build robust evidence supporting the long-term oncological safety.
When breast cancer is located centrally, behind the nipple-areolar complex, mastectomy is commonly employed as the surgical strategy due to risk of deformity associated with resection of the central mound of the breast. If breast conservation is attempted without glandular reshaping, the contour of the breast is altered and often blunted resulting in loss of glandular projection. The Grisotti mammoplasty uses a local parenchymal-cutaneous flap to refill the central volume loss preserving an intact sensate breast with an idealized shape. This approach is best used in women with a moderate degree of ptosis who do not desire significant alteration in the size and shape of their breast. Given the approach uses a local advancement flap, attention to isolating perforator vessels is unnecessary. Completion of nipple reconstruction can be achieved with tattooing or a nipple reconstruction, the latter usually in a delayed fashion to allow for neovascularization of the recipient graft site. Contralateral symmetrization can be performed with a J-mammoplasty synchronously or after the completion of adjuvant radiotherapy.
In this chapter we describe the background to the use of volume replacement flaps after breast-conserving surgery. We consider patient selection, surgical technique including planning and patient positioning, incision placement and operative technique and also describe the literature on oncological and cosmetic outcome and complications. The literature in this area is sparse, and more work is needed to confirm the relevant place of the different types of flap and to directly compare objective outcome and patient satisfaction with the alternative, namely, mastectomy and immediate breast reconstruction.
We describe the background to the use of distant volume replacement flaps after breast-conserving surgery. We consider patient selection, surgical technique, (including planning and patient positioning), incision placement and operative technique and also describe the literature on oncological and cosmetic outcomes and complications. The literature in this area is rather sparse and more work is needed to confirm the relevant place of the different types of flap and to directly compare objective outcome and patient satisfaction with the alternative, namely mastectomy and immediate breast reconstruction.
Oncoplastic surgery consists a new approach for extending breast conserving surgery possibilities This manuscript aimed to systematically review data on the oncological outcome of oncoplastic breast surgery. Electronic databases were searched with the appropriate search term up to and including April 2013. Inclusion criteria: full publications including at least 10 patients and providing evidence on at least one of the following outcomes: margin involvement, local recurrence, metastatic disease, death number. Forty studies including 2,830 patients, met inclusion criteria; twenty one studies investigated volume displacement techniques; fifteen studies investigated volume replacement techniques; four studies presented data on various oncoplastic techniques. Study quality was low. The majority of studies were observational studies. The length of follow-up was relatively short, with only two studies reporting a median duration longer than 60 months. Only seven studies including more than 100 patients. There was great variation in the frequency of margin involvement ranging between 0% and 36% of patients. Local recurrence was observed in 0%-10.8% of patients. Distant metastasis was observed in 0-18.9% of patients. In conclusion, long term oncological outcome of oncoplastic surgery for breast cancer is not adequately investigated. Further research efforts should focus on Level I evidence on oncological outcome of oncoplastic surgery.
Conventional indications for mastectomy (MX) reflect circumstances where breast conserving therapy (BCT) could compromise oncological or cosmetic outcome. MX continues to be recommended for the majority of women with multiple lesions within the same breast. In this article, we review the oncological safety and aesthetic considerations of BCT in the context of multifocal (MF) or multicentric (MC) breast cancer. Literature review facilitated by Medline and PubMed databases. Published studies have reported divergent results regarding the oncological adequacy of BCT in the management of MF or MC disease. Earlier studies demonstrated high rates of local recurrence (LR) for BCT. More recent series have found BCT to be comparable to MX in terms of LR, distant failure, disease free and overall survival. Few studies have adequately evaluated cosmetic outcomes following BCT for MF or MC breast cancer. Contemporary oncoplastic techniques have extended the clinical utility of BCT and are of particular relevance to breast conservation in the context of MF or MC lesions. Appropriate case selection, preoperative oncological and aesthetic planning, satisfactory clearance of the surgical margins and adjuvant radiotherapy are of paramount importance. In the absence of level-1 guidance concerning the management of women with MF or MC disease, each case requires discussion with regard to tumor and patient related factors in the context of the multidisciplinary team. In selected patients with MF or MC disease, BCT is oncologically safe and cosmetically acceptable. Uniformity of practice and the establishment of a standard of care will require an evidence-base from prospective studies.
In 141 mastectomy specimens, performed for invasive or noninvasive carcinomas, histopathologic study was performed to assess the extent of nipple-areola involvement by the tumor. In this study, patients were excluded if (1) the tumor was located beneath the areola; and (2) nipple and/or areola abnormalities were clinically present. Tumor involvement of the nipple and/or areola was found in 44 of 141 specimens (31%), with intraductal growth in 36 (82%) of 44, stromal invasion in 3 (7%), and ductal and stromal invasion in 5 (11%). Analysis of nipple-areolar involvement with consideration of the different variables indicates that it occurred in association with tumor size, tumor-areola distance, and histologic type. Such information provides clinically relevant guidelines in decision making for limited breast surgery.
We evaluated the oncologic and cosmetic outcome in patients with breast cancer treated with wide excision, transposition of adipose tissue with latissimus dorsi muscle (LDM), and axillary dissection followed by radiotherapy. In this study, a wide excision of breast tissue was performed to obtain tumor-free margins. The subsequent breast deformity was not corrected in six patients in the early phase of the study (Group 1), and in 16 patients in the late phase (Group 2) in which the breast deformity was not remarkable at the time of operation. Breast deformity was corrected by transposing adipose tissue with LDM on a vascular pedicle in the remaining 51 patients (Group 3). Five year survival was 100%. Two patients developed distant metastases. None were found to have local recurrence. Fifty percent of the Group 1 patients, 69% of the Group 2 patients, and 67% of the Group 3 patients had an excellent or good cosmetic result. However, when the cosmetic results were evaluated in patients who underwent transposition and had small breasts, the results were excellent or good in 76%, compared to 38% in the patients who had reconstructions who had large breasts. The difference was statistically significant (p = 0.0309). Therefore, it was confirmed that wide excision and axillary dissection followed by breast radiation could provide adequate local control, but frequently resulted in breast deformity. However, transposition of adipose tissue may be useful to correct the breast deformity, especially in women with small breasts.
The authors have reviewed the results of their first 85 immediate reconstructive procedures following mastectomy for breast cancer. acceptable cosmetic results were obtained in most patients with no mortality or life-threatening morbidity. There were a number of problems related to the wounds and the prostheses, which decreased with increasing experience. There was a moderate increase in blood transfusion requirements, and a considerable increase in operating time. No detrimental effect on tumor behavior was observed when assessed as part of a case-control study. It is concluded that this approach is feasible and safe, and deserves further evaluation.
Twenty-five patients were evaluated, 13 who had immediate breast reconstruction and 12 who had delayed breast reconstruction for early breast cancer. Data were elicited about the psychological impact of the cancer, the mastectomy, and the reconstruction. Our results support the conclusion that immediate breast reconstruction is accompanied by a lower incidence of psychological morbidity postoperatively, and we recommend that immediate breast reconstruction be offered as an alternative to women with early breast cancer.
Breast conservation has become well-established in the treatment of early mammary carcinoma. However, a standardised treatment modality has not emerged. We have analysed the data from 1,973 patients treated in three consecutive randomised trials by four different radiosurgical procedures: Halsted mastectomy, quadrantectomy plus radiotherapy, lumpectomy plus radiotherapy, and quadrantectomy without radiotherapy, to compare the outcomes of these procedures in terms of local recurrence rate and overall survival. Eligibility criteria were similar in the three trials, and comparability between the four subgroups was excellent. Median follow-up for all patients was 82 months. The annual rates of local recurrence varied markedly according to the treatment. Patients treated with Halsted mastectomy and quadrantectomy plus radiotherapy had low annual rates of local recurrence (0.20 and 0.46, respectively) while both lumpectomy plus radiotherapy and quadrantectomy without radiotherapy had significantly higher rates (2.45 and 3.28, respectively). Patients under 45 years of age had a much higher incidence of local recurrences, while in women over 55 years local recurrences were much less frequent. Overall survival curves were identical in the four groups of patients, so that the three breast conserving radiosurgical procedures had the same survival rates as Halsted mastectomy. However, local recurrence rates were markedly influenced by the treatment method, patient age and specific histological features.
The objective of this study was to define and evaluate mammographic changes in patients treated with breast-conserving therapy and a new reconstructive technique that uses autologous tissue from a latissimus dorsi musculosubcutaneous flap.
Of 20 patients who underwent either immediate or delayed endoscopic latissimus dorsi muscle flap reconstruction after lumpectomy, 13 also had postsurgery mammograms available for review. Radiographic findings assessed included skin thickening, density or radiolucency at the reconstruction site, density around the flap, fat necrosis, calcifications, and the presence of surgical clips.
Mammograms for three patients (23%) revealed thickening that we believed was attributable to radiation therapy. No patient had increased density in the flap itself; all flaps were relatively radiolucent centrally (13/13; 100%). Mammograms revealed density around the rim of the flap in four patients (31%). This density was most likely secondary to latissimus dorsi muscle fibers and did not limit radiographic evaluation. One patient had calcifications, probably secondary to fat necrosis. No oil cysts were seen. In the majority of patients (11/13; 85%), surgical clips were visible.
Endoscopic latissimus dorsi muscle flap reconstruction, previously used only for mastectomy patients, is now being used for improved esthetic outcome in selected patients who desire breast conservation. Our results indicate that the mammographic findings are predictable. The most common findings are relative radiolucency centrally, with or without density from muscle fibers around the edges of the area of tissue transfer. The transplanted musculosubcutaneous flap does not interfere with mammographic evaluation.
Deformities following lumpectomy and radiation can provide reconstructive challenges for the plastic surgeon. With the increasing incidence of breast conservation therapy, these problems are likely to become more frequent in the future. The use of autologous tissue, particularly the latissimus dorsi, provides an excellent option for correcting these tissue deformities. We propose using an inverted latissimus with a deepithelialized skin paddle to correct these defects when there is no shortage of overlying skin. Additionally, this technique provides a softer texture to the entire radiated breast.
Reducing the psychological distress, which may result from the treatment of breast cancer is an important plastic surgical goal. Such distress occurs with both conservative surgery (CS) and total breast reconstruction (BR), as in the case of mastectomy. Immediate or delayed breast reconstructions are becoming increasingly common as their absolute contraindications are becoming less and less. For example, absolute contraindications to immediate breast reconstruction might only be limited to cases of locally advanced disease or inflammatory cancers. Today’s plastic surgeons are called upon to improve the cosmetic results of aggressive conservative treatment. Indications for breast-preserving surgery, restricted initially to very small tumors, unifocal tumors, are now being proposed for tumors up to 4 or 5 cm in diameter, bifocal tumors located in the same quadrant, and even for large tumors which have been reduced in size by several courses of neoadjuvant chemotherapy. In some cancer protocols, the size reestriction on tumors suitable for CS relates only to tumor size as it compares to total breast volume, the main criterion being the final expected cosmetic result. In all cases, the cosmetic outcome correlates to the size of the specimen removed — more precisely, to the size of the specimen compared to the size of the breast and the size of the tumor including the width of the free margins.
Does transecting the tendinous insertion of the latissimus dorsi on the humerus improve aesthetic results and avoid the displeasing bulge in the armpit that sometimes occurs when the latissimus dorsi is used for breast reconstruction? In a prospective study, 60 patients who were having breast cancer surgery and simultaneous breast reconstruction using the latissimus dorsi flap were randomized for cutting (n = 29) or leaving intact (n = 31) the tendinous muscle insertion on the humerus. The cosmetic outcome was evaluated by patients and surgeons 6 to 12 months postoperatively. Patients reported good cosmetic results in 29 of 31 cases with the humeral insertion left intact and in 26 of 29 cases when the tendon was cut (p = 0.59), as compared with 21 of 31 cases versus 25 of 29 cases (p = 0.091), according to the surgeon's evaluation. A lateral bulge was more frequently observed by the surgeons in the group with intact insertion (10 of 31 patients), as compared with the group with a transected humeral insertion (2 of 29 patients). Discomfort caused by this bulge was reported by 19 of 31 patients with intact insertion, but only 3 of 29 patients with the tendon cut (p < 0.0001). The additional transection of the tendon was not associated with any complications. The additional transection of the tendinous humeral insertion of the latissimus dorsi muscle improves aesthetic results and avoids a displeasing bulge in the axilla when the latissimus dorsi flap is used for breast reconstruction.
Breast conservation surgery is now widely accepted as the treatment of choice in early breast cancer. Randomised controlled trials have shown comparable recurrence and survival rates following breast conservation when compared to mastectomy, with the perceived advantage that it should leave a cosmetically acceptable result without reconstruction. It is our experience that an adequate local excision may result in a poor cosmetic result with distortion of the nipple position, especially in women with small breasts. Between January 1994 and July 1996, we have performed 30 procedures, combining a wide local excision and axillary lymph node clearance for breast cancer with immediate reconstruction of the defect with a latissimus dorsi musculocutaneous flap. All patients had postoperative radiotherapy to the residual breast and, where appropriate, to the axilla. Adjuvant hormonal therapy or chemotherapy was prescribed where indicated. Patient's ages ranged from 36 to 72 years. All tumours were in the lateral, superior or inferior quadrants. The mean combined operating time was 120 min. Two patients required postoperative blood transfusion. Mean hospital stay was 8 days. Histology confirmed tumour clearance in all cases and six patients had axillary lymph node metastases. There were two cases of minor wound infection and six cases of seroma at the donor site. We conclude that breast cancers are ideally treated by a multidisciplinary team and that an immediate latissimus dorsi musculocutaneous flap may correct the deformities often seen after breast conservation surgery.
To measure the cosmetic outcome of breast-conserving surgery and identify the factors which influence cosmesis.
A total of 254 patients with primary breast cancer treated by wide local excision, with or without radiotherapy, were subjectively assessed for cosmesis by a six-member panel using photographic evaluation and objectively by an independent observer using specific measurement.
Good to excellent cosmetic results were achieved in 184 (72%) patients on panel subjective assessment and 201 (79%) patients on objective assessment. Good correlation (P<0.001) and agreement were found between the panel's subjective photographic assessment and the objective assessment. The main factors found to affect cosmesis negatively were: medially located tumours; weight of specimen; re-excision procedures; radiotherapy; small breasts and longer scars.
These cosmetic results, combined with a low local recurrence rate following wide local excision, validate the operative method used.
BACKGROUND: Breast conserving treatment (BCT) is accepted as an appropriate therapy for most patients with stage I and stage II breast cancer. However, BCT is associated with a relatively high incidence of local recurrence, and aesthetically unacceptable results occur in some patients. A novel method of immediate volume replacement using autogenous tissue has been developed to strike a balance between adequate excision and cosmesis. We determined the oncological outcome inpatients with breast cancer treated with wide excision, immediate volume replacement with autogenous tissue, and axillary dissection followed by radiotherapy. METHODS: One hundred fifty-three patients with TIS, stage I, II, or III breast cancer underwent wide excision and axillary dissection. The surgical margin ofexcised breast tissue was examined histologically during surgery. If involved, the breast tissue adjacent to the primary site was excised. When the margin of re-excision was positive, patients underwent modified radical mastectomy with or without breast reconstruction. After wide excision, immediate volume replacementwith autogenous tissue was perform-ed, unless the deformity was corrected by undermining and conization of the residual breast tissue. Postoperatively, all patients received breast irradiation. RESULTS: Eighteen patients underwent modified radical mastectomy. The surgical margin was negative in 132 of the 135 patients who underwent BCT. The crude local recurrence rate was 0.7% (1/135). Estimated overall and disease-free 5-year survival rates were 96% and 94%, respectively. CONCLUSION: Wide excision with tumor-free margins and axillary dissection followed by breast irradiation provides adequate local control in many patients with breast cancer. Immediate breast volume replacement with autogenous tissue mayavoid some unpleasant cosmetic results associated with extensive local resection. Our technique eliminates the need for mastectomy in selected patients.
This paper describes a method of immediate breast reconstruction following conservative breast surgery. The technique is innovative in that axillary clearance, quadrantectomy and the harvest of the latissimus dorsi muscle are carried out through a small transverse axillary incision with no incision in the breast.
The authors performed immediate breast reconstruction on four patients using a sensate latissimus dorsi musculocutaneous flap accompanied by neurorrhaphy during the past 6 years. In the neurorrhaphy, the lateral cutaneous branch of the dorsal primary divisions of the seventh thoracic nerve, which controls the sensation of the myocutaneous flap, was anastomosed to the lateral cutaneous branch of the fourth intercostal nerve, which controls the sensation of the breast. The subjects consisted of four patients whose postoperative follow-up period was 14 to 29 months, with an average of 19.3 months. The control subjects consisted of 10 cases with a latissimus dorsi musculocutaneous flap whose sensory nerve had not been reconstructed (postoperative follow-up period, 15 to 49 months; average, 26.9 months). The sensory examination included tests of touch, pain, and temperature. The innervated musculocutaneous flap sensation showed gradual recovery at about 6 months after surgery and reached the value of the normal side after about 1 year. In the control subjects, the recovery was gradual after more than 1 year and reached the value of the normal side in only some of the control subjects. On the basis of these findings, the authors consider the present technique to be useful for the recovery of sensation in immediate breast reconstruction.
Breast conserving treatment (BCT) should provide similar quality of local control as mastectomy and avoid psychological distress due to mutilation. Randomized trials have demonstrated the value of conservative surgery for small tumors. Several publications have indicated the possibility of improving the cosmetic result when quadrantectomy is combined with plastic surgery. These papers focused on two techniques involving reduction mammaplasty and latissimus dorsi flap procedures. At the European Institute of Oncology (EIO) we use various plastic procedures to reshape the breast and to improve symmetry. The choice of these techniques depends on tumor size and location, as well as on breast volume.
In two years (1995 and 1996) 111 patients were treated at the EIO with quadrantectomy and concomitant plastic surgery. Preoperative tumor staging was as follows: T1 57.5%, T2 29%, T3 4.5%, Tis 8%, and sarcoma 1%. The tumor locations were upper quadrant 50%, lower quadrant 40%, and central quadrant 10%. The plastic surgery techniques used included local glandular flaps, areola transposition, mastopexy or classical reduction mastoplasty procedures, the round block technique, prosthesis insertion, and distal musculocutaneous flaps. Cosmetic evaluation on the basis of predefined cosmetic criteria was carried out on photographs after a mean follow-up of 21 months. In 48 cases the patients' own rating of breast cosmesis was asked.
The global results were good in 77.5%, fair in 17%, and poor in 5.5% of the patients. No statistical difference was observed between different tumor locations, although the percentage of good cosmetic results, which was similar in the upper and lower quadrantectomy groups, was slightly lower for centrally located tumors. With regard to the different techniques, we obtained 100% good results with the round block technique and the Grisotti flap, 87% good results with the inferior pedicle, 74% good results with the Lejour and superior pedicle techniques, 67% good results with the latissimus dorsi flap, and 58% good results with prosthetic implants. The outcome was less satisfactory when no contralateral mastoplasty was performed (14 of the 111 cases): 72% good, 14% fair, and 14% poor results. These differences were not statistically significant. The median weight of the specimens was 157 g, which is almost three-fold the usual weight in regular tumorectomies. Six carcinomas were found in contralateral breasts (4 DCIS and 2 infiltrating).
The double-team approach (plastic surgeons and oncologists) to BCT may improve the final cosmetic result following large tumor excisions. It can also extend the indications for breast preserving surgery. Moreover, it allows surgical and histological exploration of the contralateral breast when a surgical procedure for symmetry is required.
The use of the latissimus dorsi myocutaneous flap (LDMF) in reconstructive breast surgery is well documented. Few reports exist of its use in oncologic breast surgery. This series describes indications and complications of the LDMF in locally advanced cancer. The records of 83 patients were analysed for age and sex, menstrual status, stage, indication, margins of resection, chemotherapy, radiotherapy, complications, and survival. The indication was to cover defects caused by resection of locally advanced breast cancer (67 cases), recurrent breast cancer (13 cases), radiation damage (2 cases), and surgical complications (1 case). The mean age of the patients was 50.2 years; 52% were postmenopausal. The flaps had mean diameters of 32 by 14 cm. The donor site was skin grafted. Clear margins were achieved in 83%. At the LDMF insertion site, wound infection required drainage in 1 case; flap necrosis required reintervention in 7 cases. In 2 cases a second skin graft was done for the LDMF donor site. The proportions of wound infections and incomplete skin graft take were significantly greater in patients receiving preoperative cyclophosphamide/methotrexate/5-fluorouracil (CMF) versus cyclophosphamide/doxorubicin/5-fluorouracil (CAF) chemotherapy (p < 0.001 and p < 0.05, respectively). The late complication rate was 7.2%. The mean follow-up is 40.0 months. The complication rates for CMF versus CAF chemotherapy suggest an adverse effect of methotrexate, which warrants further investigation. The use of the LDMF made wide resection of locally advanced lesions and radionecrosis possible; major complications were rare. LDMF has its place in the armamentarium of the surgeon who regularly sees locally advanced breast cancer.
In the absence of medical contraindications, survival after undergoing breast-conserving therapy (BCT), mastectomy (M), and mastectomy with immediate reconstruction (MIR) is equal. The authors studied demographic factors to identify the variables that differed significantly among women making different surgical choices.
Women with ductal carcinoma in situ or clinical Stage I or II breast carcinoma with no contraindications for BCT or MIR who were treated between 1995 and 1998 were identified from a prospectively collected data base. Demographic and tumor factors were compared using the Fisher exact test.
There were 578 women with 586 tumors who did not have contraindications for BCT or MIR. Among this group, 85.2% of women chose BCT, 9.2% of women chose M, and 5.6% of women chose MIR. Women undergoing M alone were older and were more likely to have Stage II carcinoma compared with women undergoing BCT. Patients undergoing M or MIR were more likely to have had a prior breast biopsy compared with patients who chose BCT. Marital status and employment approached significance (P = 0.06); however, a family history of breast carcinoma was not a predictor of treatment choice.
The current findings suggest a need for patient education strategies that emphasize the lack of influence of age and prior breast biopsy on the use of BCT. Differences in demographic variables may reflect true variations in patient preference among groups, emphasizing the need to address the spectrum of treatment options with patients.
Volume loss following breast-conserving surgery (BCS) is the key reason for major local deformity and a bad cosmetic outcome. Latissimus dorsi miniflaps can be used to reconstruct central and upper quadrant resection defects, replacing the volume excised with autogenous tissue. Partial mastectomy, axillary dissection, flap harvest and reconstruction of the resection defect is performed as a one-stage procedure through a single lateral incision. This oncoplastic approach allows extensive local excision during BCS without cosmetic penalties in a group of patients normally treated by mastectomy.
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