This action might not be possible to undo. Are you sure you want to continue?
Oncoplastic surgery for breast cancer based on tumour location and a quadrant-per-quadrant atlas
K. B. Clough1 , T. Ihrai1,2 , S. Oden1 , G. Kaufman1 , E. Massey1 and C. Nos1
1 The Paris Breast Centre – L’Institut du Sein, Paris, and 2 Breast Cancer Unit, Centre Antoine Lacassagne, Nice, France Correspondence to: Dr K. B. Clough, The Paris Breast Centre – L’Institut du Sein, 7 Avenue Bugeaud, 75116 Paris, France (e-mail: email@example.com)
Background: The majority of published techniques for oncoplastic surgery rely on an inverted-T
mammoplasty, independent of tumour location. These techniques, although useful, cannot be adapted to all situations. A quadrant-per-quadrant atlas of mammoplasty techniques for large breast cancers was developed in order to offer breast surgeons a technique dependent on tumour location, which reduces the risk of postoperative complications and delay to adjuvant therapy. Methods: From 2005 to 2010, a series of eligible women with breast cancer were treated by quadrantspeciﬁc oncoplastic techniques. All complications and any delay to adjuvant treatment were recorded prospectively, along with local and distant cancer recurrences. Cosmetic outcome was evaluated using a ﬁve-point scale. Results: A total of 175 patients were analysed. The median tumour size, after histological examination, was 25 (range 4–90) mm. Twenty-three patients (13·1 per cent) had involved margins. Seventeen of these patients were treated by mastectomy and three had a re-excision. Complications occurred in 13 patients (7·4 per cent), which led to a delay to adjuvant treatment in three (1·7 per cent). After a median follow-up of 49 (range 23–96) months, three patients had developed a local recurrence. The mean score after cosmetic evaluation was 4·6 of 5. Conclusion: A quadrant-per-quadrant approach to oncoplastic techniques for breast cancer was developed that tailors the mammoplasty for each tumour location. This panel of techniques should be a useful guide for breast surgeons, and extends the possibilities for breast conservation for large or poorly limited cancers, with a low complication rate and good cosmetic results.
Paper accepted 11 June 2012 Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.8877
For decades women with breast cancer were offered two surgical options: small lesions were treated with lumpectomy and radiotherapy (breast-conserving therapy, BCT), and large tumours by mastectomy. Oncoplastic surgery emerged as an additional surgical strategy 20 years ago1,2 . The objective was to allow oncologically safe breast conservation, by performing a wide excision for large or poorly located tumours, while limiting the risk of postoperative deformities. Most publications suggest that there is a major risk of deformity after standard BCT when more than 20 per cent of the breast volume is excised3 . In this setting, simple reshaping methods are not appropriate and more complex techniques are required, hence the growing use of oncoplastic surgery.
2012 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd
The plastic surgery techniques transferred to the ﬁeld of breast cancer were initially based on inverted-T mammoplasty1,2 . They were designed for central or lowerpole cancers and are not well adapted to all tumour locations. However, the majority of breast surgeons performing oncoplastic surgery still use inverted-T mammoplasty techniques, irrespective of tumour location. A wide excision in the inner or outer quadrants of the breast can require complex reshaping. Filling of the excision cavity relies on a glandular ﬂap and is not easily achieved with an inverted-T mammoplasty. A quadrant-per-quadrant atlas was designed by developing different mammoplasty techniques based on a direct approach to the tumour4 . The incision is integrated into a speciﬁc mammoplasty resection pattern, which is different for each quadrant of the breast. This approach avoids the
British Journal of Surgery 2012; 99: 1389–1395
Some patients may have had multiple reasons for oncoplastic surgery. smoking.bjs. Oden. Nos use of long glandular ﬂaps to ﬁll in large excision cavities. The breast reshaping is then performed by a mammoplasty technique with skin excision and nipple–areola recentralization.co. B. 1 Quadrant-per-quadrant atlas of oncoplastic techniques for breast cancer 2012 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd www. level 2 techniques are those required when the surgeon anticipates a breast volume resection of more than 20 per cent. All patients had been discussed previously by a multidisciplinary team to deﬁne the optimal treatment. 1)4 . Contralateral surgery for breast symmetry was considered at the initial assessment and offered to patients undergoing a large-volume resection that might result in a size discrepancy. Each location Upper quadrant junction: inferior pedicle mammoplasty Upper inner quadrant: round block or batwing technique Upper outer quadrant: lateral mammoplasty Lower inner quadrant: V mammoplasty Lower outer quadrant: J mammoplasty Lower quadrant junction: superior pedicle mammoplasty Fig. Kaufman. S. G.uk British Journal of Surgery 2012. T. The strategy was applied to a consecutive series of women with breast cancer who required mammoplasty. Clough. 2 Mammoplasty techniques Selection of technique was based on tumour location using the quadrant-per-quadrant atlas (Fig. Risk factors for complications such as fatty breasts. 99: 1389–1395 . Patient selection was based on preoperative clinical and radiological evaluation of the ratio between the planned excision volume and the breast volume.1390 K. as these ﬂaps might induce fat and glandular necrosis and lead to complications that could delay adjuvant treatment. Massey and C. In the present classiﬁcation of oncoplastic techniques (Table 1)4 . obesity or diabetes were recorded prospectively for each patient. Ihrai. Methods Women with breast cancer treated at the Paris Breast Centre by level 2 oncoplastic surgery techniques from 2005 to Table 1 Oncoplastic surgery levels of the breast Oncoplastic surgery level 1 Description Less than 20% of breast volume excised No skin excison required No mammoplasty required Anticipation of 20–50% breast volume excision Excision of excess skin required to reshape breast Based on mammoplasty techniques 2010 were included in the study. E.
2. at the centre of the new breast mound. in order to maintain good vascularization. Outcome analysis In all patients the cavity was clipped to enable postoperative localization of the original tumour bed. A more medial incision follows a similar pattern. poor.bjs. the individual techniques are described. fair. A round block technique6 is a suitable alternative to the inferior pedicle.co. 99: 1389–1395 . The parenchymal excision follows the skin pattern in the shape of a J for the right breast and a reversed J for the left breast. As for all lower-pole excisions. The retroareolar gland is then detached from the NAC. with its base located in the submammary fold and apex at the border of the areola. this technique does not allow the excision of more than 20 per cent of breast volume. Starting in the upper pole of the left breast and working clockwise. The procedure involves excising a pyramidal section of gland. except for the most commonly used inverted-T mammoplasty. at 4-month intervals for 5 years and then twice yearly for a further 5 years. Tumours of the upper outer quadrant: 1 to 3 o’clock A lateral mammoplasty technique7 is used. via an inverted-T incision5 . the NAC is carried on a deepithelialized superior pedicle. is the most appropriate method.Oncoplastic surgery for breast cancer 1391 is served by a speciﬁc mammoplasty. from the resection site to the anterior axillary line to allow adequate rotation of the remaining gland into the defect. This lateral mammoplasty results in a long radial scar over the original tumour site with a periareolar extension. with two oblique incisions from the nipple–areola complex (NAC) towards the axilla. 4. but the incision starts at the mediolateral edge of the de-epithelialized periareolar area. without detaching it from the skin. and then extends downwards to the inframammary crease. bad. lateral and medial) can be mobilized into the excision cavity to achieve an equitable redistribution of the remaining breast volume. A large portion of the upper outer quadrant can be removed by a direct approach. inverted-T techniques are better suited to lower-pole tumours located immediately beneath the skin resection of the Wise pattern. However. excising the skin overlying the tumour. good. All complications and any delay to adjuvant treatment were recorded prospectively. Tumours of the lower outer quadrant: 3 to 5 o’clock The J mammoplasty. similar to a quadrantectomy. Nominal values were compared using the χ2 test. The parenchymal excision roughly follows the skin excision. The lower inner quadrant V mammoplasty is more suitable for breast tumours at this location. A periareolar crescent of skin is de-epithelialized to allow NAC centralization. originally described by Elbaz8 for breast reduction. Tumours of the upper pole: 11 to 1 o’clock An inferior pedicle mammoplasty. The lower pole of the breast is entirely undermined from the pectoralis muscle and transferred medially to ﬁll the defect. The NAC is displaced medially in its optimal position. and www. A round block mammoplasty is also suitable for tumours at this location. as described previously9 . and the three glandular ﬂaps (central. Tumours of the upper inner quadrant: 9 to 11 o’clock The batwing technique for tumours in the upper inner quadrant was ﬁrst described by Anderson and colleagues10 . Statistical analysis Continuous variables data are presented as median (range). 5. The section is removed. Complete detachment of the retroareolar gland from the NAC enables mobilization of the central gland for volume redistribution. The NAC is then recentralized on a de-epithelialized superolateral pedicle. is suitable in this area. The cosmetic result was rated on a ﬁve-point scale (excellent. The cosmetic outcome was evaluated systematically by the surgeon during postoperative followup. Tumours of the lower inner quadrant: 7 to 9 o’clock The inverted-T mammoplasty may also be used in this location. is centralized into its optimal position after superomedial de-epithelialization. The NAC 2012 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd Tumours of the lower pole: 5 to 7 o’clock The inverted-T mammoplasty with a superior pedicle is the technique of choice for tumours of the lower pole. However. This J mammoplasty is similar to the lateral mammoplasty technique for upper outer quadrant cancers. The glandular ﬂaps are then sutured into the cavity. All patients were followed up regularly after surgery.uk British Journal of Surgery 2012. joining the ﬁrst incision in the inframammary crease. as well as local and distant cancer recurrences. 1)11 . including the skin attached to the gland down to the pectoralis fascia. Histological specimens were analysed with particular reference to involved surgical margins. rather than a ‘onetechnique-ﬁts-all’ inverted-T technique. but can be extended in any direction. The submammary fold is then incised. 3. Breast reshaping is performed by undermining the remaining lateral and central gland from the pectoralis major muscle. and photographs were reviewed by a panel of three observers.
and favourable histopathological prognostic factors and age. ordinal values with the Kruskal–Wallis test. Oden. during the initial oncoplastic surgery in 34 patients and as a secondary procedure in 13. E. Nos Table 2 Indications for level 2 oncoplastic techniques No. All complications were handled in the outpatient setting and no patient required reoperation.bjs. A superior pedicle mammoplasty was performed in 32 patients. Clough. The median weight of the resection specimen was 125 (17–680) g. The margins were involved with cancer in 23 patients (13·1 per cent). Thirty-eight patients had preoperative chemotherapy to downsize the tumour and allow breast conservation. Of the 23 patients with involved margins. The median age of the patients was 58 (31–80) years. Texas. or both in the form of chemotherapy and/or hormone therapy. S. The rate of involved margins was strongly associated with the histological subtype: nine (7·8 per cent) of 116 patients with invasive ductal carcinomas. Median tumour size at histological examination was 25 (4–90) mm: 30 mm for DCIS. A contralateral breast reduction was performed in 47 patients (26·9 per cent) for breast symmetry. the three remaining patients were not reoperated on as they had minor margin involvement. The median follow-up was 49 (23–96) months. 26 mm for invasive lobular carcinoma and 21 mm for invasive ductal carcinoma.co. One patient died from breast cancer. College Station. 17 were treated by mastectomy and three required a local re-excision. Statistical analysis was done using Stata version 10 (StataCorp LP. After multidisciplinary discussion. B. T.uk British Journal of Surgery 2012. Ihrai. Massey and C. All patients had postoperative breast irradiation. Other complications included haematoma and areola slough. P < 0·050 was considered statistically signiﬁcant. Results A total of 175 patients had level 2 oncoplastic surgery between 2005 and 2010. Tumours in the remaining two patients had rare histological subtypes (1 cystic adenoid carcinoma. of patients (n = 175) Tumour size Poor tumour limitation Involved margins after lumpectomy Neoadjuvant treatment Localization of tumour Breast asymmetry Multifocal cancer Skin retraction or skin invasion by cancer Other 94 (53·7) 35 (20·0) 23 (13·1) 39 (22·3) 43 (24·6) 9 (5·1) 27 (15·4) 34 (19·4) 7 (4·0) Values in parentheses are percentages. 2 V mammoplasty for a 40-mm carcinoma of the lower inner quadrant of the left breast 2012 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd www. One hundred and sixteen patients had invasive ductal carcinomas. 1 phyllodes). four developed an axillary recurrence and 11 presented with distant metastasis. The complications were predominantly infections (6 patients) and fat necrosis (5). Complications occurred in 13 patients (7·4 per cent).1392 K. The median preoperative clinical tumour size was 25 (10–80) mm. which led to a delay in adjuvant treatment in three (1·7 per cent). four (16 per cent) of 25 with invasive lobular carcinomas and ten (31 per cent) of 32 with DCIS had involved margins (P = 0·025). Indications for use of a level 2 technique are shown in Table 2. USA). Kaufman. Three patients (1·7 per cent) developed an ipsilateral breast recurrence. G. 99: 1389–1395 . Fig. 25 had invasive lobular carcinomas and 32 had ductal carcinoma in situ (DCIS). Thirty-eight patients with invasive carcinomas received neoadjuvant or adjuvant treatment. A higher rate of contralateral surgery was observed when the oncoplastic procedure relied on an inverted-T mammoplasty: 20 (48 per cent) of 42 versus 27 (20·3 per cent) of 133 patients for other techniques (P < 0·001).
invertedT mammoplasty is not suitable for all tumour locations. The excision defect was ﬁlled with adjacent breast tissue. Although median follow-up in the present series is limited to 49 months. Despite a smaller volume. the shape and the form of the breast is preserved. Postoperative complications have a negative oncological impact by delaying adjuvant therapy. which all demonstrated that oncoplastic surgery is a safe procedure for breast cancer treatment. It conﬁrms the ﬁndings of the three main published series with long-term follow-up. the lumpectomy defect must be ﬁlled with a long dermoglandular ﬂap. and complication rates ranged from 16 to 24 per cent20 – 22 . this ﬂap is a major reconstructive option to be considered in the event of cancer recurrence after BCT and radiotherapy. and delayed wound healing. 2012 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd The observed local recurrence rate was 1·7 per cent. The rate of positive margins was strongly associated with the histological subtype. Most patients do not request. However. The latissimus dorsi miniﬂap is an alternative volume replacement technique12 – 14 . no cosmetic sequelae have been observed despite the use of breast irradiation. and allows wide excision with a low rate of involved margins9. and patients should be warned of this drawback. even though the median tumour size (25 mm) was larger than in most series of conservative surgery.17 – 19 .bjs. based on the experience of various mammoplasty techniques at the Paris Breast Centre.Oncoplastic surgery for breast cancer 1393 Cosmetic evaluation was available for 80 patients (45·7 per cent). All techniques of the quadrant-per-quadrant approach gave satisfactory cosmetic results. 2.co. Figs S1 and S2. leading to re-excision or mastectomy15 . the quadrant-per-quadrant oncoplastic approach appeared to be oncologically safe. BCT was rarely performed. Despite the large resection volume. The techniques used mainly involve direct incisions. allowing direct closure of the excision cavity followed by breast reshaping. which explains the low rate of delayed surgery for breast symmetry. regardless of location. a more accurate preoperative tumour size assessment by radiographic imaging would probably make the resection more precise and decrease the risk of re-excision for such lesions16 . www. respectively. The quadrant-per-quadrant approach is based on an en bloc resection of the tumour and overlying skin. Discussion Oncoplastic surgery offers an alternative to mastectomy for large or poorly located tumours. 99: 1389–1395 . Immediate contralateral breast reduction was proposed for patients with large resection volumes. A quadrant-per-quadrant atlas of oncoplastic techniques depending on the tumour location was developed. When re-excision was required. The complications observed in these studies could have been due to the use of inverted-T mammoplasty for all tumours. non-palpable and ill deﬁned lesions. Level 2 oncoplastic surgery should be reserved for patients who cannot be treated with more limited excisions. This can be explained by the greater tumour size of DCIS compared with invasive carcinoma. supporting information). To date. This compares favourably with other oncoplastic series in which inverted-T techniques were applied to all quadrants. The present surgical approach based on tumour location has some limitations. The higher rate of contralateral surgery for breast symmetry following the inverted-T mammoplasty compared with other techniques was due to the larger resection volumes. however. The present series reports an extension of oncoplastic procedures for tumours located in all quadrants of the breast. The mean cosmetic score was 4·6. Oncoplastic surgery cannot be a ‘one-technique-ﬁts-all’ solution. or require. In the present series. The complication rate in this study was low and only 1·7 per cent of the patients had their postoperative treatment delayed. Oncoplastic techniques avoid breast deformities. the local recurrence rate was 9·4 per cent at a median follow-up of 48 months9 . Difﬁculties in performing level 2 oncoplastic techniques constitute a limitation to the implementation of the quadrant-perquadrant atlas.uk British Journal of Surgery 2012. because the volume of the remaining breast would not allow further resection without major deformity. However. they are much longer than usual lumpectomy scars. These scars are rarely conspicuous because they become less visible after radiotherapy. Although ideally suited for tumours located in the lower pole. further surgery for cosmesis. with a risk of glandular necrosis owing to insufﬁcient blood supply. For tumours not located in the lower pole. The cosmetic scores were 5 (very good) and 4 (good) in 68 patients (85 per cent) (Fig. One of the major concerns about BCT is the rate of involved margins (20–40 per cent). and this tissue should therefore be conserved whenever possible. This avoids extensive subcutaneous undermining and always allows reshaping of the breast using the appropriate mammoplasty. training in these techniques can be acquired gradually in dedicated units. but also by the fact that DCIS and invasive lobular carcinomas are. In a previously published series of 101 patients who had inverted-T mammoplasty for large lower-pole tumours with a median size of 32 mm. only 13·1 per cent of patients had involved margins.
2 Clough KB.1394 K. Aesthetic Plast Surg 1990. de Vries J. 20: 101–111. Oncoplastic approaches to partial mastectomy: an overview of volume-displacement techniques. Silverstein MJ. Plast Reconstr Surg 1977. Fama F. A reduction mammplasty with the areola–nipple based on an inferior dermal pedicle. based on a speciﬁc mammoplasty technique for each tumour location. Plast Reconstr Surg 2005. Munhoz AM. 14 15 16 17 18 19 20 21 22 Falcou MC. Durand JC. 117: 1091–1103. Rainsbury RM. de Jong JS. Rainsbury RM. Reyal F. Falcou MC. Ann Surg Oncol 2005. Clough. Sarfati I. 12: 539–545. G. Gemperli R. Practical guidelines for repair of partial mastectomy defects using the breast reduction technique in patients undergoing breast conservation therapy. Critical analysis of reduction mammaplasty techniques in combination with conservative breast surgery for early breast cancer treatment. Kaufman. 16: 387–395. Garusi C et al. 96: 1141–1146. Nat Clin Pract Oncol 2007. Ann Surg 2003. Buccimazza I. Breast Cancer 1998. 206: 1045–1050. Soussaline M. Mazzarol G. 120: 1755–1768. 107: 1702–1709. Curnier A.bjs. 237: 26–34. [Mammoplasty combined with irradiation: conservative treatment of breast cancer localized in the lower quadrant. Sturtz GP. Couturaud B. Br J Surg 2009. T. 4: 657–664. Paramanathan N. Couturaud B. References 1 Clough KB. 99: 1389–1395 . Salmon RJ. Higgs GM. Rey PC. 35: 117–122. Petit JY. Fitoussi AD. Arruda EG. Disclosure 12 13 The authors declare no conﬂict of interest. Montag E. Maisonneuve P. Bart J. Ensor JE et al. Fitoussi AD. Plast Reconstr Surg 2006. Masetti R.] Ann Chir Plast Esthet 1990. Plast Reconstr Surg 1995. Plast Reconstr Surg 2001. Luini A. Surgery insight: oncoplastic breastconserving reconstruction – indications. Prospective evaluation of late cosmetic results following breast reconstruction: I. Berry M. 17: 1375–1391. Ihrai. A new periareolar mammaplasty: the ‘round block’ technique. S. Nos C. Mortellaro VE. 8 Elbaz JS. Hunt KK. Implant reconstruction. O’Donoghue JM. Arruda EG. 96: 363–370. Fitoussi AD. 5 Robbins T. Macmillan RD. Nos C. Plast Reconstr Surg 2010. Obtaining adequate surgical margins in breast-conserving therapy for patients with early-stage breast cancer: current modalities and future directions. Falcou MC. Long-term oncological results of breast conservative treatment with oncoplastic surgery. Oden. Fitoussi A. Salmon RJ. Breast 2007. choices and outcomes. Buchholz TA. Nos C. Soussaline M. van Dam GM. Massey and C. Recent progress with breast-conserving volume replacement using latissimus dorsi miniﬂaps in UK patients. 3 Bulstrode NW. 11 Clough KB. 116: 741–752. [Technic of mammoplasty by a J cicatrix.] Ann Chir Plast 1975. 59: 64–67. Strom EA. Br J Plast Surg 2005.co. Hochwald SN. Conservative treatment of breast cancers by mammaplasty and irradiation: a new approach to lower quadrant tumors. Oncoplastic breast surgery for cancer: analysis of 540 consecutive cases [outcomes article]. Grobmyer SR. Nos This study has conﬁrmed that the techniques outlined in the quadrant-per-quadrant atlas of oncoplastic surgery techniques for breast cancer. beneﬁts. 14: 93–100. Ann Surg Oncol 2009. Pleijhuis RG. Kaur N. Lewis JS. with good cosmetic results. Comparative study of surgical margins in oncoplastic surgery and quadrantectomy in breast cancer. Oncoplastic surgery techniques extend the possibilities of breast conservation for patients with large or poorly limited cancers. McCulley SJ. B. Lancet Oncol 2005. Aldrighi C. Kuerer HM. 125: 454–462. Breast 2001.uk British Journal of Surgery 2012. Improving breast cancer surgery: a classiﬁcation and quadrant per quadrant atlas for oncoplastic surgery. Ann Surg Oncol 2010. 2012 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd www. 58: 902–907. Rietjens M. Marshall J. Therapeutic mammaplasty – analysis of 50 consecutive cases. 6 Benelli L. Urban CA. 4 Clough KB. Aldrighi JM et al. Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas. 9 Clough KB. Salmon RJ. Mafﬁni F. Kaufman GJ. 7 Ballester M. Campana F. Nos C. Fels KW. 5: 139–147. are associated with a low reoperation rate and a low risk of delay to adjuvant therapy. Aldrighi C et al. Kronowitz SJ. 16: 2717–2730. E. Graaﬂand M. Outcome analysis of breast-conservation surgery and immediate latissimus dorsi ﬂap reconstruction in patients with T1 to T2 breast cancer. 10: 124–126. Mendenhall NP et al. Lateral mammoplasty reconstruction after surgery for breast cancer. Is there a role for routine use of MRI in selection of patients for breast-conserving cancer therapy? J Am Coll Surg 2008. 6: 145–157. 10 Anderson BO. Rietjens M. Plast Reconstr Surg 2007. Shrotria S. Munhoz AM. Montag E. Berry MG. Gatti G et al. Couturaud B et al. Prediction of cosmetic outcome following conservative breast surgery using breast volume measurements.
bjs. 99: 1389–1395 .com) Snapshots in Surgery: to view submission guidelines. Any queries (other than missing material) should be directed to the corresponding author for the article. submit your snapshot and view the archive. Snapshot Quiz Snapshot Quiz 12/17 Question: What is this condition and why is appendicectomy the best course of management? The answer to the above question is found on page 1405 of this issue of BJS. Bowness JS. S1 J mammoplasty for a carcinoma located in the lower outer quadrant (Word document) Fig.co. Whiston hospital. Merseyside. S2 Lateral mammoplasty for a 35-mm carcinoma of the upper outer quadrant of the left breast (Word document) Please note: John Wiley & Sons Ltd is not responsible for the functionality of any supporting materials supplied by the authors. Prescot.uk British Journal of Surgery 2012.Oncoplastic surgery for breast cancer 1395 Supporting information Additional supporting information may be found in the online version of this article: Fig.bjs. Davies PSE: Department of General Surgery. please visit www.co.uk 2012 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd www. L35 5DR (e-mail: jsbowness@gmail.