Neoplasms

Skin and Connective Tissue Diseases

All Conditions

Breast Neoplasms

therapeutic oncoplastic surgeries in cases of breast cancer

therapeutic mammoplasty

abdelradi amdelsalam, proffessor

mostapha thabet, professor

negmeldeen abulnaga, assistant lecturer

the purpose of this study was to examine the impact of therapeutic mammoplasty on the delivery of adjuvant chemotherapy

One out of every eight women will be diagnosed with breast cancer in her lifetime, making it the most common cancer in women. Over the last decades the survival rate has increased slowly, which is currently estimated to be 85 % in developed countries. However, with an estimated annual number of breast cancer deaths of 537,000 worldwide, breast cancer still is the most important cause of death by cancer among women. Despite advances in different treatment modalities, about 45 % of all breast cancer patients still undergoes a mastectomy for adequate local control. The resulting loss of a breast may have a negative effect on body image, sexuality, and sense of femininity. (8) Oncoplastic breast techniques are being increasingly employed to allow breast conservation whilst maintaining a quality aesthetic outcome. Therapeutic mammoplasty (TM) describes multiple breast-conserving techniques1 which remove the breast tumour in combination with adjuvant radiotherapy (1). TM is available to women with early stage breast cancer with larger or ptotic breasts who would benefit from a reduction mammoplasty technique in addition to tumour removal. The use of TM is increasing worldwide, with the potential to deliver benefits both oncologically, in terms of increased tumour free margin width, and with an associated superior long-term aesthetic outcome. Despite increasing enthusiasm for the techniques there is limited data on long-term oncological safety or effects upon delivery of adjuvant treatments.TM techniques can enable a larger volume of tissue to be resected with the tumour6 enabling patients to have breast-conserving surgery for larger tumours. Just as the role of TM is expanding, adjuvant chemotherapy is increasingly being used in women with early stage breast cancer and if delivered in a timely fashion after the primary resection, decreases recurrence and improves overall survival (3). However, TM is associated with higher complication rates than traditional breast-conserving methods and one barrier to TM is the concern that post-operative complications may lead to a delay in initiation of chemotherapy or even omission. There is increasing evidence that immediate breast reconstruction has an effect on adjuvant chemotherapy delivery. Three recent series involving over 4000 patients suggest that immediate breast reconstruction does lead to a significant delay in the delivery of adjuvant chemotherapy (2). However, the clinical significance of this delay has not been established. On the contrary, a recent study performed by Doughty et al. compared 95 patients undergoing immediate breast reconstruction following mastectomy with cohorts having breast-conserving surgery and simple mastectomy with no reconstruction, in which no delay to commencement of adjuvant chemotherapy was noted. The majority of case series on TM do not comment on the timing of adjuvant treatments. When they are reported, studies vary between no delays to adjuvant treatment through to five studies reporting delays in between 1.9%9 and 6% of patients (8).

female patient underwent therapeutic mammoplasty

the Effect of Therapeutic Mammoplasty on the Start of Adjuvant Chemotherapy

Therapeutic Mammoplasty Doesn't Delay Adjuvant Therapy for Breast Cancer Patients

noting the date of the operation and whether or not it delays the start of adjuvant chemotherapy due to any complications

Assiut University

resident at general surgery department

The intervention (post pilot study) is to systematically record the effect of routine use of acoustic as well as color imaging doppler during mammoplasty for breast cancer (for both the therapeutic and symmetrising breast reduction).

Use of Acoustic and color imaging doppler during surgery for breast cancer

Peter A Barry, MPhil, FRACS

Breast cancer surgery can often be carried out as part of a breast reduction procedure known as 'therapeutic mammoplasty'. Where a woman has a breast with adequate volume, even larger cancers can be removed in an aesthetically acceptable way with re-shaping of the breast (often reduction and lift) incorporated into the cancer removal. An expectation and desire for most women is that the nipple and areola (known as the 'nipple-areolar complex' or NAC) is not only preserved, but re-positioned (usually lifted) to re-balance the overall aesthetic result.

In moving the NAC, the surgeon must ensure an adequate blood supply is maintained to preserve nourishment of the NAC tissue otherwise it can die (necrose) resulting in its removal. The tissue carrying the blood supply is known as a 'pedicle' and is fashioned by the surgeon for each patient during surgery.

We know as surgeons, that in most areas of anatomy of the human body there are variations in the pattern of blood vessels. The NAC blood supply is no exception. Yet for each individual patient, the only way to safely know these anatomical patterns is to map them before or during surgery.

A surgical tool utilising an aspect of ultrasound (known as doppler) is often used to locate visually (or by hearing) blood flow from blood vessels in operations where such knowledge is critical to the success of the procedure (for example DIEP-based breast reconstruction or chest wall perforator flaps).

We would like to evaluate the effectiveness of the routine use of doppler for NAC preservation during mammoplasty procedures to see if it gives the consultant surgeon and/or trainee a greater degree of confidence when shaping the NAC pedicle to preserve its blood supply.

In addition, we evaluate the training potential of patients undergoing symmetrising breast reduction, whereby the tissue removed is first mapped using acoustic doppler as for the NAC above.

Despite breast cancer being one of the most frequent affecting women worldwide, it is also one of the most curable. Its multimodality treatment is based on surgery, radiotherapy and systemic therapy.

Breast conservation has evolved thanks to the utilization of mammoplasty techniques to achieve better aesthetic results - known collectively as 'oncoplastic' when applied to cancer surgery.

The key considerations in oncoplastic surgery are: tumour characteristics (extent, location) and reconstituting the aesthetically acceptable breast shape as well as nipple-areola complex (NAC) preservation. The former is vital to achieve clear resection margins to optimise local control. Planning is aided by imaging with ultrasound, mammography and often MRI. NAC preservation is a priority and expectation of patients and surgeons alike developed in the field of aesthetic breast surgery by plastic surgeons.

The attachment of any structure to the body by its nourishing blood supply (arteries and veins) is known as a 'pedicle'. The anatomy of the pedicle and its preservation is key to preservation of the NAC which has a well understood blood supply albeit with variations across patients and well-described patterns (ref). To preserve the NAC as part of a cancer resection and aesthetic breast re-shaping, a pedicle must be fashioned and the NAC successfully re-positioned to restore the aesthetic balance of the newly shaped (and often lifted) breast.

The aim of this study is to determine if by use of doppler (acoustic or colour flow modalities) to map the blood vessels supplying the NAC (for each individual patient), surgeons and trainees can construct a safe pedicle with greater confidence and ease, reducing the concern about diminishing its blood supply which could lead to NAC necrosis and loss. We would like to study the nipple blood supply as it pertains to each patient before surgery using acoustic doppler (AD) and colour doppler imaging (CDI). Each modality has its strengths and weaknesses and this evaluation aims to assess the contribution of each.

The most challenging part of therapeutic mammoplasty is the pre-operative planning. The surgeon must consider (1) localization of the tumour location and extent, (2) re-shaping of the remaining breast parenchyma and (3) placement of the vascularized the NAC and pedicle.

Several studies have been done regarding NAC vascularization and its variation between not only each person, but also each side (right versus left). Most studies were on cadavers3, MRI 4or CT angiography5. On the other hand, Seitz et al6 pointed out the predominancy of the NAC vascularization based on preoperative MRI in the breast without cancer. Specifically, they split all 56 breasts into 5 categories: type I medial, type II lateral, type III central, type IV inferior, and type V mixed. Moreover, they highlighted that the majority of NACs were supplied mostly by medial vessels. Basaran et al7 evaluated sixteen patients with severe gigantomastia and they marked the vessel locations before surgery by using Doppler ultrasonography.

Given the variation between people and their breasts, in this SE we would like to map preoperatively the NAC vascularization to understand if it could assist the surgeon's plan or even enable them to modify the NAC pedicle design. The mapping will be done by both CDI and AC. We will use both techniques to understand if there will be any difference in their accuracy and to determine if 1 modality alone will suffice.

Whilst both methods (acoustic and colour flow doppler) are used selectively in cases by some surgeons, this SE will specifically if routine use incorporated into the procedure will systematically facilitate pedicle design. The doppler carries no risk to the patient and is considered a tool to facilitate surgery rather than an intervention beyond standard of care.

Specifically, acoustic doppler (AC) - is a hand-held device, easy to use intra-operatively which gives an audible signal in real-time to enable marking of the exact location of a blood vessel at a given point (or along a specified line) within the tissue / under the skin.

Colour doppler imaging (CDI) will additionally give visual information which includes the calibre and depth of the vessel and enables the entire course of the vessel and any connections to be mapped relatively easily.

In reality, when the design and shaping of the NAC pedicle is undertaken during the operation, ideal placement / movement of this structure may be restricted by the surrounding tissue attachments which the surgeon may be fearful of dividing in case a critical artery is divided in the process (compromising the NAC perfusion). Knowing the exact location of the artery will give the surgeon confidence in knowing how far such tissue mobilisation can be safely undertaken.

Some therapeutic mammoplasties also involve creation of a 'secondary pedicle' which consists of breast tissue - again mobilised on a pedicle which must be moved within the breast to fill a defect created by the cancer resection. A secondary aim of this SE will be to map the principle arteries which supply that tissue as well.

In summary, this SE aims to establish the benefits of an ad-hoc practice by careful documentation of consecutive cases prospectively during surgery for mammoplasty where NAC or secondary pedicle mobilisation is required.

Mapping Arterial Perforators Within the Breast During Mammoplasty

Mapping Arterial Perforators of the Nipple Areolar Complex and the Horizontal Septum During Mammoplasty

Any amount (as witnessed clinically) of full-thickness necrosis of the nipple-areolar complex of either breast in patients who have undergone breast reduction (for cancer - on the cancer side or matching reduction side)

Royal Marsden NHS Foundation Trust

Behaviors and Mental Disorders

Breast Diseases

Skin Diseases

Quality of Life

All patients with clinical-instrumental diagnosis of breast cancer, candidates for conservative oncoplastic surgery who give informed consent to the study, will be included in the study.

Type 1 procedures generally involve a unilateral approach, able to guarantee good resective quality, without a significant alteration of the volume with respect to the contralateral breast.

Post-surgical histopathological data and any associated postsurgical complications will be collected through the compilation of a database.

Aesthetic and functional post-surgical results related to the quality of life, as data perceived by the surgeon and by the patient, will be collected through the administration of a questionnaire.

All patients with clinical-instrumental diagnosis of breast cancer, candidates for conservative oncoplastic surgery who give informed consent to the study, will be included in the study.

Type 2 procedures (therapeutic mammoplasty), offer a greater resective potential, but generally require the use of contralateral surgery to obtain symmetry, simultaneous or delayed.

Post-surgical histopathological data and any associated postsurgical complications will be collected through the compilation of a database.

Aesthetic and functional post-surgical results related to the quality of life, as data perceived by the surgeon and by the patient, will be collected through the administration of a questionnaire.

Control and review of pathological parameters (oncological radicality resection volume, locoregional extension / TNM / multifocality and tumor biological profile).

Study and recording of post-surgical clinical and pathological data of patients diagnosed with breast cancer undergoing unilateral or bilateral conservative oncoplastic surgery.

Control and review of post-surgical complications (dehiscence, liponecrosis, infection, seroma, hematoma, fibrosis, scar hypertrophy).

Study and recording of any associated post-surgical complications (of patients diagnosed with breast cancer undergoing unilateral or bilateral conservative oncoplastic surgery.

Control and review of technical analysis by the surgeon, and of psychosocial well-being, physical discomfort, adverse effects of radiotherapy by the patient collected through the administration of a questionnaire.

Study and recording of aesthetic and functional post-surgical results related to the quality of life, as data perceived by the surgeon (technical analysis), and by the patient.

Paolo Orsaria, MD, PhD;

Policlinico Universitario Campus Bio-Medico

Paolo O MD. PhD; [porsaria]

Paolo Orsaria, Surgeon;

Evaluation of quality of life after conservative oncoplastic surgery in patients with breast cancer

The aim of the study is the evaluation of the oncological, aesthetic and functional results after conservative oncoplastic breast surgery using unilateral or bilateral remodeling techniques in a prospective sample of 250 patients.

Endpoints:

* evaluation of post-surgical histopathological data with a selective focus on the achievement of oncological radicality in relation to the surgical technique ( resection volume, locoregional extension / TNM / multifocality and tumor biological profile) and any major , minor, delayed associated complications (dehiscence, liponecrosis, infection, seroma, hematoma, fibrosis, scar hypertrophy).This data will be collected through the compilation of a database by the health personnel.
* evaluation of aesthetic and functional results related to the quality of life after oncoplastic conservative surgery (unilateral or bilateral), as data perceived by the surgeon (technical analysis), and by the patient (psychosocial well-being, physical discomfort, adverse effects of radiotherapy). This data will be collected through the administration of a questionnaire whose data will be entered into the database by the healthcare personnel.

Quality of Life After Conservative Oncoplastic Surgery in Breast Cancer Patients (IRONY: lIfe afteR ONcoplastic surgerY)

IRONY: lIfe afteR ONcoplastic surgerY

focus on the achievement of oncological radicality in relation to the surgical technique (yes or no).

focus on the resection volume in relation to the surgical technique (cm3).

focus on the locoregional extension (TNM staging criteria, American Joint Committee on Cancer, 8th edition)

focus on the tumor biological profile ( luminal A, luminal B HER2-, luminal B HER2+, HER2+, triple-negative).

focus on any major , minor, delayed associated complications (dehiscence, liponecrosis, infection, seroma, hematoma, fibrosis, scar hypertrophy).

focus on data perceived by the surgeon (technical analysis) through a questionnaire with scores ranging from 1 to 3.

focus on data perceived by the patient (psychosocial well-being, physical discomfort, adverse effects of radiotherapy).

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
the Effect of Therapeutic Mammoplasty on the Start of Adjuvant Chemotherapy	NCT05920070	Effect of Thera...	therapeutic mam...	25 Years - 65 Years	Assiut University
Mapping Arterial Perforators Within the Breast During Mammoplasty	NCT06347952	Breast Cancer	Use of Acoustic...	18 Years -	Royal Marsden NHS Foundation Trust
Quality of Life After Conservative Oncoplastic Surgery in Breast Cancer Patients (IRONY: lIfe afteR ONcoplastic surgerY)	NCT05842148	Breast Cancer	Study and recor... Study and recor... Study and recor...	18 Years - 85 Years	Campus Bio-Medico University
the Effect of Therapeutic Mammoplasty on the Start of Adjuvant Chemotherapy	NCT05920070	Effect of Thera...	therapeutic mam...	25 Years - 65 Years	Assiut University

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