Subject Areas: Clinical Trials, Epidemiology, Global Health, Gynecology & Obstetrics, Oncology, Public Health, Surgery & Surgical Specialties, Women’s Health
1. Introduction
The oncoplastic surgery’s purpose is the integration of the neo-breast in the body image; it allows the tumor’s exeresis while leaving the breast with normal curve thanks to a glandular reshaping [1] . However, it leads to volume reduction, source of asymmetry comparing to the other breast. Gestures of symmetrization (immediate or postponed) can be realized to improve the comfort if the patient wishes so.
Through this study, we aimed to estimate our experience about oncoplastic surgery and we wished to discuss practical questions: about the oncoplastic surgery’s indications, about the carcinologic results, and about the morbidity.
2. Patients and Methods
From January 1st, 2011 till January 31st, 2014, we studied retrospectively all the patients admitted in the national center of burnt and plastic surgery in the U.H. IBN-ROCHD of Casablanca, treated by oncoplastic surgery.
The studied parameters concerned the operated population’s characteristics, the tumors, the surgical techniques, the post-operating morbidity, the resumption’s rates of positive margins, the node analysis’ results, and the carcinological follow-up.
The statistical analysis of all the files’ information was recorded in a Microsoft Excel file allowing the data analysis.
3. Results:
3.1. Population’s characteristics
From January 2011 till January, 2014, 48 patients were treated by oncoplastic surgery. All the patients had an average age of 44 years old (extremes: 22 - 68). The tumor’s circumstances of discovery were clinical in 67% of the cases and infra clinical in 33% of the cases.
3.2. Tumors’ characteristics
The tumors’ distribution in the quadrants of the breast found out mainly lower and external tumors (figure 1).
The radiological tumoral average size was of 20.4 mm (extremes: 0 - 73 mm), while the oncoplastic surgery was suggested, for an average of 20.2 mm (extremes: 5 - 52 mm).
The anatomopathology was underlined in 97 % of the cases in preoperative (table 1).
Tumors were unifocal in 83.3% of the cases, bifocal in 14.6 % of the cases, in these cases; tumors were in the same quadrant. We note one case of multifocal micro calcifications limited to a quadrant of the breast dealing with a ductal carcinoma in situ.
3.3. Surgery techniques
We estimated our various techniques according to the glandular exeresis spot (table 2).
3.4. Surgical results
On the 48 oncoplastic surgery, the rate of resumption for positive margins sites was 14.5%. All the patients having a tumorectomy patch with positive margins had a surgical resumption by total mastectomy (MT). The anatomopathological analysis of there sumpted pieces found out infiltrating ductal carcinomas in seven cases.
The average duration of hospitalization was 3.5 days (extremes from 0 to 7 days). We had six post-operating complications: that is a rate of 12.5% of morbidity. As complication, we faced hematoma in three cases, an abscess in 1 case. A surgical resumption was necessary for 2 cases in front of the areola mamma enecrosis (nipple necrosis).
3.5. Oncological results
Over an average follow-up of 22 months, without histological distinction, the local recurrence rate was 13%. The 5-year survival could not be calculated due to the lack of the study’s retrospect.
4. Discussion
In 1990, German W. Audretstsch Düsseldorf called oncoplastic surgery all surgical techniques, which combine a
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Figure 1. Distribution of tumor-quadrant diagram according to Mc Culey [2] .
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Table 1. Tumors characteristic’s in our series (n = 48).
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Table 2. Used operating techniques (n = 48).
breast cancer conservative treatment to breast plastic surgery techniques [3] . It allows in some difficult circumstances to avoid performing a complete mastectomy when a simple conservative treatment will bring aesthetically unsatisfactory results. Apart from inflammatory cancers, multifocal cancers depend on total mastectomy [4] . All the other circumstances can potentially be indications for oncoplastic treatment. As long advocated by Clough, some tumor sites, such as lower quadrant or the central region, are excellent indications to avoid difficult sequelae to repair [5] . An indication of more accessory oncoplastic techniques is the gigantomastia, embarrassing for the patient’s comfort, but it may increase the morbidity of radiotherapy, especially in the practice of overprinting (boost) [2] - [6] . In our series, the oncoplastic treatment was made mainly for large tumors (majority of P T2). Our data concerned patients at risk of significant glandular distortion as far as tumor’s volume is concerned over the inadequate breast volume, or the tumor’s relatively unfavorable localization (Figure 2).
The importance of healthy borders is correlated with the decrease of local recurrence [7] - [10] .
In retrospective series, the rate of unhealthy sites varies from 8% to 18.9% of the cases [2] [11] - [13] for on- coplastic surgery, while the rate of unhealthy sites varies between 15% and 20% for the standard conservative surgery. Our rate of positive margins after oncoplastic treatment (14.5%) seems comparable to the published series on oncoplastic surgery and those on conventional conservative treatments as well (table 3).
It has been suggested to reduce the rate of positive margins, to make borders’ extemporaneous evaluation [14] . In the series of Olsen et al., extemporaneous evaluation, and per-operative resections helped to reduce the rate of secondary excision. This extemporaneous evaluation is the problem of feasibility. Returns to unhealthy margins were made by mastectomy in our series. The evaluation, as accurate as possible of the extension of the initial lesion (MRI), the caution regarding oncoplastic indications while the tumor is badly limited, and the quota of exclusively in situ or associated tumors, should limit the RBNS rate and the risk of secondary resumption.
The morbidity would be between 15% and 30% [15] - [17] , a little bit higher than the conventional conservative surgery is, estimated at approximately 10% [12] [16] [18] . In addition, main complications underlined in the literature after oncoplasty are healing disorders, abscesses, hematomas, cases of partial or complete nipple necrosis. In our series, the complication rate was 12.5%. The average hospital stay was 3.5 days, less than in the study of Staub (5.2 days), or of Giacolone (4 days). These complications may require further surgery in less than 5% of the cases, mainly in case of hematoma, nipple pain [17] [19] - [22] . In our study, the rate of reoperation was 4.1% and was mainly for nipple necrosis.
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Figure 2. A 43-year-old woman with a palpable tumor at the upper medial quadrant of her right breast. An oncoplastic resection of 300 g was performed. Histology showed a ductal carcinoma and axillary lymph node status was 4/14. Immediate postoperative outcome is presented.
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Table 3. Literature’s results in the retrospective studies on oncoplasty.
5. Conclusion
For twenty years, the limits of conservative treatment have not ceased to be pushed in order to reduce the number of radical mastectomies, improve the surgical borders quality and reduce the aesthetic sequelae after radiotherapy treatment. Oncoplastic techniques help to avoid a mastectomy where simple conservative treatment is not doable. Our study shows that these techniques have convincing results as far as morbidity, resumption rates for unhealthy borders and oncological results are concerned.