Evaluation of the Surgical Outcomes of Breast Oncoplastic Techniques Carried Out by a General Surgical Oncologist

Background With recent advances in different breast cancer treatment modalities, breast conservation surgery (BCS) has gained popularity and has become the mainstay for the treatment of early breast cancer. The model of dedicated breast surgeons working in breast units is standard in some but not all countries. We have aimed to define surgical outcomes of oncoplastic breast surgery carried out by one general surgical oncologist. Patients and methods We have conducted a prospective non-randomised case series analysis to assess the oncologic and aesthetic outcome of tissue displacement oncoplastic breast techniques in managing unifocal early-stage breast cancer from January 2019 to January 2020. One surgical oncologist with 23 years of surgical oncology experience carried out all operations. Results We have included 50 female patients treated with variant oncoplastic volume displacement techniques. We have used the round block technique in 20%, the batwing technique in 18%, lateral mammoplasty in 20%, and medial mammoplasty in 2%. We have also carried out wise pattern therapeutic mammoplasty with inferior pedicle in 20% (10 patients), and vertical mammoplasty with superior pedicle in 20% (10 patients). While 8% of our patients had Clavien-Dindo system grade I Immediate complications, including the surgical site infection and postoperative seroma and haematoma, 2% of patients had grade II complications in the form of partial areola and nipple complex necrosis leading to delayed wound healing requiring secondary suturing. No delayed complications or mortalities were recorded. Eight per cent of patients required re-excision to clear margins, 74% had excellent results, 24% had good results, and 2% had fair results. In addition, 64% were very satisfied with their results, 32% were satisfied, while 4% were not satisfied with aesthetic results. Conclusion Based on our limited number of patients, we have found that tissue displacement oncoplastic techniques carried out by a general surgical oncologist are safe and reliable in providing satisfactory oncological outcomes with a low risk of delaying adjuvant therapy and acceptable aesthetic outcomes.


Introduction
Breast cancer is one of the most common cancers worldwide and the most common cancer in females, equating to age-standardised incidence rates (ASIRs) of 19.7 breast cancer cases per 100,000 premenopausal women and 152.6 cases per 100,000 postmenopausal women [1]. It is also considered the most common type of cancer among Egyptian women. It accounts for about 38.8% of total malignancies among Egyptian women; it is also one of the leading causes of female mortalities [2].
With surgical innovation, breast conservation therapy (BCT) has gained popularity and has become the primary treatment modality for early breast cancer. It has been proven to have almost equal survival rates and acceptable recurrence rates for early-stage breast cancer treated with breast conservation surgery (BCS) followed by radiotherapy compared to total mastectomy alone [3].
Breast-conserving oncoplastic techniques are divided into volume displacement and volume replacement techniques: the first is constituted by rotational mammoplasty techniques (glandular rotation mammoplasty, dermoglandular rotation mammoplasty, and tumour adapted mastopexy), the latter by latissimus dorsi flap and lateral thoracic advancement flap [2].
Several studies have demonstrated an increased risk of breast deformity, poor aesthetic outcomes, and patients' satisfaction associated with resection of more than 20% of the breast volume [4]. On the contrary, other studies have reported better outcomes using oncoplastic resection techniques, including favourable aesthetic outcomes and patients' satisfaction, and clear tumour resection margins [5]. In recognition of the recent advances and evidence-based changes in breast cancer management, the European Society of Breast Cancer Specialists (Eusoma) has defined a breast centre (or unit) as the place where breast cancer is diagnosed and treated. It also has to provide all the services necessary, including prevention genetics assessment, treatment of the primary breast cancer as well as metastatic disease, with supportive and palliative care and survivorship, and psychosocial support. Furthermore, to gain recognition, a breast centre must have sufficient capacity to manage at least 150 newly diagnosed breast cancer cases per year [6].
Unfortunately, this is not feasible in all countries especially developing countries where breast cancer is still managed by general surgical oncologists yet with very good outcomes. Since the model of dedicated breast surgeons working in breast units is common in some but not all countries, we have aimed to define surgical outcomes of oncoplastic breast surgery carried out by one general surgical oncologist.

Study setting
This study was conducted in Aswan University Hospital, Aswan, Egypt.

Ethical considerations
We have obtained the Ethical Committee approval before conducting the study.

Study design
We have conducted a prospective non randomised case series analysis including consecutive patients treated with BCS carried out by the same surgeon from January 2019 to January 2020. We have included female patients older than 18 who had palpable breast cancers treated with BCS for unifocal T1, T2 (≤ 4cm) breast cancer. We have excluded patients treated with primary chemotherapy, patients with local recurrence, metastatic disease, and patients who had previous reduction mammoplasty. Patients' demographics, tumour characteristics, and histological findings were included.
All patients had triple assessment including clinical breast examination followed by digital mammogram as well as bilateral breast and axillary ultrasound scan. In addition, magnetic Resonance Imaging (MRI) was carried out for a selective group of patients (mainly patients with invasive lobular carcinoma to rule out multifocal and bilateral disease), and a staging CT scan was carried out for patients with axillary metastasis.
One surgical oncologist with 23 years of surgical oncology experience (General surgery MD and MRCS) carried out all operations. Surgical techniques used included round block, batwing, lateral and medial mammoplasty, as well as wise pattern and vertical mammoplasty.
We assessed immediate complications up to 30 days postoperative and delayed complications up to one year postoperative and graded them according to the Clavien-Dindo system [7]. Six months after the end of the adjuvant radiotherapy, the aesthetic result was assessed by two independent surgical oncologists other than the operating surgeon, using a 5-point score ranging from 1 to 5 [8]. Also, patients were verbally asked if they were very satisfied, satisfied, or not satisfied with their aesthetic results.

Statistical methods
Collected data were organised and statistically analysed using SPSS software statistical computer version 22 (SPSS Inc., Chicago, IL, USA). For quantitative data, the mean, standard deviation (SD), and range were calculated. Qualitative data collected were presented as numbers and percentages.

Patient and tumour characteristics
We have included 50 female patients, the mean age was 52 years SD 7.4 years, 19 patients were premenopausal, and 31 were postmenopausal. The patient's BMI was 27.4 SD 3.7; Bra size was B cup in 4 patients (8%), C cup in 28 patients (56%), D cup in 17 (34%), and DD cup in one patient (2%). All patients included were patients who presented with palpable breast lesions. The tumour was located in the upper inner quadrant in 22% (11 patients), the upper outer quadrant in 46% (23 patients), the lower outer quadrant in 18% (nine patients), the lower inner quadrant in 10% (five patients), and in the retroareolar region in 4% (two patients) ( Table 1)
We have also carried out wise pattern therapeutic mammoplasty with inferior pedicle in 20% (10 patients), and vertical mammoplasty with superior pedicle in 20% (10 patients). Seventy-two per cent (36 patients) had blue dye directed sentinel lymph node biopsy (SLNB), 28% (14 patients) had axillary lymph node clearance (ALNC) at the same time of the breast procedure, while 24% (12 patients) had sentinel lymph node biopsy followed by axillary lymph node clearance due to macrometastasis ( Table 1). The mean operative time was 90 minutes SD 25.
Eight per cent (four patients) had Clavien-Dindo system grade I immediate complications, including that 2% (one patient) had surgical site infection which led to minor wound dehiscence, 4% (two patients) had postoperative haematoma treated conservatively, 2% (one patient) had seroma requiring bedside aspiration. In comparison, 2% (one patient) Clavien-Dindo system grade II complication in the form of partial areola and nipple complex necrosis leading to delayed wound healing due to wound dehiscence, which was later treated by secondary suturing, no delayed complications or mortalities were recorded ( Table 2) [7].

Surgical treatment
The mean postoperative specimen weight 73g SD 17

Follow up
All patients were assessed clinically two weeks, six months and 12 months after surgery. The mean follows up period was 15.5 months SD 5.1.

TABLE 3: Aesthetic assessment and patients' satisfaction
None of our patients had a local recurrence or metastatic disease, or breast-related mortalities.

Discussion
The European Institute of Oncology in Milan reported that patients who had oncoplastic breast surgery (OPBS) not only experience less level of anxiety but also feel more comfortable viewing their body image. A further evaluation has found a vast majority of women with nipple preservation have reduced mental and emotional stress, improved body image, and overall satisfaction with results of OPBS [9].
With increased pressures for medical care and the increasing number of patients requiring breast cancer treatment, some general surgeons are developing an interest in breast cancer management. Also, some surgical oncologists are dedicating more time to breast cancer than other cancer sites, yet the outcome of these practices is yet to be evaluated. In nearly all the literature available in relation to oncoplastic breast resections, operations were either carried out by breast surgeons or in most cases, surgeons' subspeciality were not mentioned, the fact which might have affected the outcome in many patients, that's why we have clearly stated the surgeon's experience and qualification.
Tumour size in relation to breast size has always dictated the feasibility of breast-conserving surgery. The average tumour size was 31mm in our cohort, with most of our patients with medium-sized breasts. Studies comparing BCS using oncoplastic techniques and standard wide local excision demonstrated that significantly larger tumours were excised using BCS oncoplastic techniques rather than those treated with a standard wide local excision [10,11].
While we have used intraoperative specimen x-ray to assess resection margins status, others have used different modalities. Intraoperative frozen section assessment was the most popular as it shows a sensitivity of 83% and accuracy of 96% compared with paraffin sections examination [5].
It is well recognized that there is no universal concept on the tumour free margin [12]. Our cohort considered radial margins less than 1mm as close margins for both invasive and non-invasive diseases, so 8% of patients required re-excision to clear margins.
No local recurrence or systemic metastasis was reported in this study. This might be attributed to the relatively small number of patients, in addition to the short time of follow-up.
Oncoplastic breast resections are associated with possible postoperative complications, including seroma, hematoma, surgical site infections, wound dehiscence and fat necrosis, and rarely areola and nipple necrosis. There is always a fear of delay of administration of adjuvant treatment essential for the optimal treatment of breast cancer due to postoperative complications. While Rose et al. reported delay of adjuvant treatment in 6% of their cases due to delayed wound healing [13], none of our patients experienced a delay in adjuvant treatment.
Adjuvant radiotherapy carries a small risk of affecting cosmetic outcomes due to breast tissue atrophy and fibrosis as well as skin oedema [3]; hence we evaluated our patients six months postoperatively to assess patients' satisfactions as well as the aesthetic outcome. Cracco et al. achieved satisfactory cosmetic results in about 75% of their cases [14], also Losken et al. reported a 90% satisfaction rate following breastconserving surgery using oncoplastic techniques followed by radiotherapy [3]. In our cohort, more than 90% of patients were satisfied with their outcome.
In most patients, minor breast difference is not an issue [10]. In contrast, breast asymmetry in shape and size can be a problem in other cases, especially in patients with the preoperative size difference and those requiring large resections. Only one patient (2.0%) required contralateral symmetrising reduction mammoplasty to achieve symmetry in our cohort.
It has been noted that there is a significant variation in several aspects of oncoplastic practice. Tsigonis et al. found in their cohort that when general surgeons were involved in breast cancer management, operative time was definitely prolonged, but patients' oncological outcomes were not affected [15]. In our cohort, operations were carried out by a surgical oncologist rather than a dedicated breast surgeon. Yet, aesthetic and oncological outcomes were not inferior to those carried out by breast surgeons.
As OPBS has become standard of care in the management of breast cancer patients; the Association of Breast Surgery (ABS) in the UK, the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), and the Oncoplastic Breast Consortium (OPBC) came up with recommendations and guidance on the best breast surgical oncoplastic and reconstructive practice at each stage of a patient's journey, to ensure unified practice as well as best patient's outcomes [16,17].

Limitations of our analysis
We have only included patients with palpable breast lesions as we do not have a well-established breast screening program yet. We did not assess breast density preoperatively which might have affected oncoplastic technique selection. Unfortunately, we did not have the resources for intraoperative frozen section assessment, to assess resection margins or nodal status, but we carried out intraoperative x-ray specimen assessment to assess resection margins.

Conclusions
Breast-conserving surgery using various oncoplastic techniques is now a well-established first treatment line for managing early breast cancer. Yet, patients' outcomes vary in relation to many factors, one of which is the operating surgeon.
Although operations were carried out by a general surgical oncologist rather than a dedicated breast surgeon in our cohort, we reported good cosmetic results and patients' satisfaction, low reoperation and postoperative complication rate, and no delay in adjuvant therapy. However, we suggest further studies with a larger sample size to develop robust data to reach the best patient-related outcomes possible.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Aswan University Hospital, Egypt issued approval 577/11/21. Dr. Ibrahim Elyayat who obtained Ethics Committee is happy to be contacted at ibrahimelzayat@med.aswu.edu.eg if needed. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.