Factors associated with unsatisfactory cosmetic results in oncoplastic surgery.

Introduction: Oncoplastic surgery (OS) has expanded the indications for breast-conserving surgery associated with an adequate aesthetic result. However, few studies have described the factors associated with unsatisfactory cosmetic outcomes from this surgical modality. Materials and methods: This is a cross-sectional prospective study that included patients undergoing breast-conserving surgery (BCS) with or without OS. The patients self-evaluated the cosmetic results of the breasts posttreatment and had them photographed. The photos were analyzed by BCCT.core. Individual and treatment factors (local and systemic) for all patients were evaluated. These factors were dichotomized according to the use of OS and to the cosmetic result (satisfactory and unsatisfactory). Categorical variables were tested for association with surgical outcome using the chi-square test while numerical variables using the Mann-Whitney U test. Variables with p <0,2 were selected for multivariate analysis. Results: Of the 300 patients evaluated, 72 (24,0%) underwent OS. According to the patient self-evaluations, an unsatisfactory cosmetic result from OS was significantly associated with younger age at diagnosis, higher body mass index (BMI) at the time of evaluation, larger tumor size and greater weight of the surgical specimen. According to the BCCT.core, only the laterality of the tumor (left) was significantly associated with an unsatisfactory cosmetic result. In logistic regression, considering OS as a control variable, the risk of an unsatisfactory outcome according to patient self-evaluation was related to the tumor ≥ T2 odds ratio (OR) 1,85 (1,027-3,34) and age at diagnosis < 40 [OR 5,0 (1,84-13,95)]. However, according to the software, the variables were associated with an increased risk of an unsatisfactory outcome were the time interval between surgery and evaluation [OR 1,27 (1,16-1,39)], the presence of lymphedema [OR 2,97 (1,36-6,46)], surgical wound infection [OR 3,6 (1,22-11,16)], tumor location on the left side [OR 3,06 (1,69-5,53)], overweight [OR 2,93 (1,48-5,8)] and obesity [OR 2,52 (1,2-5,31)]. Conclusion: There is no standard methodology for breast cosmesis evaluation, which influences the factors associated with unsatisfactory results. Younger patients and those with increased BMI, left breast cancer and extensive resections tend to present with unsatisfactory cosmetic results when OS is performed.

New criteria for breast symmetry evaluation after breast conserving surgery for cancer.

OBJECTIVE: to evaluate symmetry after breast-conserving surgery (BCS) for cancer. METHODS: a prospective study of patients undergoing BCS. These patients were photographed using the same criteria of evaluation. The references points used were the nipple height difference (NH), the nipple-manubrium distances (NM), nipple-sternum distances (NS) and the angle between the intramammary fold and the nipple (nipple angle; NA). ImageJ software was used. Three breast symmetry models were evaluated: excellent/others (model 1), excellent-good/others (model 2) and others/poor (model 3). The ROC curve was used to select acceptable criteria for the evaluation of symmetry. Decision tree model analysis was performed. RESULTS: a total of 274 women were evaluated. The BCCT.core result was excellent in 5.8% (16), good in 24.1% (66), fair in 46.4% (127) and poor in 23.7% (65). The difference in NH was associated with good breast area (0.837-0.846); acceptable differences were below 3.1 cm, while unacceptable values were greater than 6.4 cm. Differences in the NM were associated with average breast area (0.709-0.789); a difference in value of less than 4.5 cm was acceptable, while values greater than 6.3 cm were unacceptable. In the decision tree combined model, a good-excellent outcome for patients with differential (d) dNH = 1 (0 to 5.30 cm) and dNM ≠ 3 (<6.28 cm); and for a poor/poor result, values dNM = 3 (> 6.35). CONCLUSIONS: the results presented here are simple tools that can assist the surgeon for breast symmetry evaluation.

Oncoplastic Surgery: Does Patient and Medical Specialty Influences the Evaluation of Cosmetic Results?

BACKGROUND: Oncoplastic surgery (OS) has added plastic surgery concepts and techniques to the breast cancer surgery. However, reports of the impact of OS on cosmesis after breast-conserving surgery (BCS) are limited in the literature. PATIENTS AND METHODS: This cross-sectional prospective study included patients who underwent BCS. The patients self-evaluated the cosmetic outcome of the breasts and had them photographed. The photos were evaluated by BCCT.core software and by 6 breast surgeons (mastologists and plastic surgeons) using the Harvard, Garbay, and Fitoussi scales. Kappa and weighted kappa tests were used to analyze agreement for categorical variables; for continuous variables, the interclass correlation index and the chi-square test to analyze the association between the OS and the symmetrization. RESULTS: A total of 300 patients were evaluated: 228 (76.0%) underwent traditional BCS and 72 (24.0%) underwent OS, and of these, 37 (51.4%) underwent contralateral symmetrization surgery. In the evaluation of the cosmetic result, the correlation between patients and observers (BCCT.core and surgeons) was weak; between the 2 groups of surgeons, the correlation was moderate (Fitoussi scale) and excellent (Garbay scale). Plastic surgeons are more critical for evaluating cosmetic results; they considered it good or excellent in 30.0% whereas patients, mastologists, and BCCT.core results considered it so in 78.8%, 34.0%, and 30.0%, respectively. In terms of cosmesis, OS and symmetrization did not influence the results in this study with long follow-up. CONCLUSION: Patients' self-evaluation reported better cosmesis than surgeons' analyses. Plastic surgeons were the most critical. OS and symmetrization did not influence the results.

New criteria for breast symmetry evaluation after breast conserving surgery for cancer / Novos critérios para avaliação da simetria da mama após cirurgia conservadora de câncer

ABSTRACT Objective: to evaluate symmetry after breast-conserving surgery (BCS) for cancer. Methods: a prospective study of patients undergoing BCS. These patients were photographed using the same criteria of evaluation. The references points used were the nipple height difference (NH), the nipple-manubrium distances (NM), nipple-sternum distances (NS) and the angle between the intramammary fold and the nipple (nipple angle; NA). ImageJ software was used. Three breast symmetry models were evaluated: excellent/others (model 1), excellent-good/others (model 2) and others/poor (model 3). The ROC curve was used to select acceptable criteria for the evaluation of symmetry. Decision tree model analysis was performed. Results: a total of 274 women were evaluated. The BCCT.core result was excellent in 5.8% (16), good in 24.1% (66), fair in 46.4% (127) and poor in 23.7% (65). The difference in NH was associated with good breast area (0.837-0.846); acceptable differences were below 3.1 cm, while unacceptable values were greater than 6.4 cm. Differences in the NM were associated with average breast area (0.709-0.789); a difference in value of less than 4.5 cm was acceptable, while values greater than 6.3 cm were unacceptable. In the decision tree combined model, a good-excellent outcome for patients with differential (d) dNH = 1 (0 to 5.30 cm) and dNM ≠ 3 (<6.28 cm); and for a poor/poor result, values dNM = 3 (> 6.35). Conclusions: the results presented here are simple tools that can assist the surgeon for breast symmetry evaluation.

RESUMO Objetivo: avaliar simetria após a cirurgia conservadora da mama (CCM) para câncer. Métodos: estudo prospectivo de pacientes submetidos à CCM, as quais foram fotografadas segundo os mesmos critérios de avaliação. Os pontos de referência utilizados foram a diferença de altura do mamilo (AM), a distância mamilo-manúbrio (MM), a distância mamilo-esterno (ME) e o ângulo entre o sulco intramamário e o mamilo (ângulo mamilo; AnM). Foi usado o programa ImageJ. Avaliamos três modelos de simetria mamária: excelente/outros (modelo 1), excelente-bom/outros (modelo 2) e outros/ruim (modelo 3). Aplicamos a curva ROC para selecionar os critérios aceitáveis para a avaliação da simetria. Realizamos análise com o modelo de árvore de decisão. Resultados: foram avaliadas 274 mulheres. Os resultados do BCCT.core foram excelentes em 5,8% (16), bons em 24,1% (66), regulares em 46,4% (127) e ruins em 23,7% (65). A diferença de AM (dAM) foi associada a boa área mamária (0,837-0,846); diferenças aceitáveis foram inferiores a 3,1 cm, enquanto os valores inaceitáveis foram superiores a 6,4 cm. As diferenças MM (dMM) foram associadas à área regular das mamas (0,709-0,789); diferença de valor inferior a 4,5 cm foi aceitável, enquanto valores superiores a 6,3 cm foram inaceitáveis. O modelo combinado de árvore de decisão demonstrou resultado bom-excelente para pacientes com diferencial (d) dAM = 1 (0 a 5,30 cm) e dMM ≠ 3 (< 6,28 cm), e resultado ruim/ruim com dMM = 3 (> 6,35 cm). Conclusões: os resultados aqui apresentados são ferramentas simples que podem auxiliar o cirurgião na avaliação da simetria mamária.

Breast cancer screening in developing countries.

Developing countries have limited healthcare resources and use different strategies to diagnose breast cancer. Most of the population depends on the public healthcare system, which affects the diagnosis of the tumor. Thus, the indicators observed in developed countries cannot be directly compared with those observed in developing countries because the healthcare infrastructures in developing countries are deficient. The aim of this study was to evaluate breast cancer screening strategies and indicators in developing countries. A systematic review and the Population, Intervention, Comparison, Outcomes, Timing, and Setting methodology were performed to identify possible indicators of presentation at diagnosis and the methodologies used in developing countries. We searched PubMed for the terms "Breast Cancer" or "Breast Cancer Screening" and "Developing Country" or "Developing Countries". In all, 1,149 articles were identified. Of these articles, 45 full articles were selected, which allowed us to identify indicators related to epidemiology, diagnostic intervention (diagnostic strategy, diagnostic infrastructure, percentage of women undergoing mammography), quality of intervention (presentation of symptoms at diagnosis, time to diagnosis, early stage disease), comparisons (trend curves, subpopulations at risk) and survival among different countries. The identification of these indicators will improve the reporting of methodologies used in developing countries and will allow us to evaluate improvements in public health related to breast cancer.

Breast cancer screening in developing countries

Developing countries have limited healthcare resources and use different strategies to diagnose breast cancer. Most of the population depends on the public healthcare system, which affects the diagnosis of the tumor. Thus, the indicators observed in developed countries cannot be directly compared with those observed in developing countries because the healthcare infrastructures in developing countries are deficient. The aim of this study was to evaluate breast cancer screening strategies and indicators in developing countries. A systematic review and the Population, Intervention, Comparison, Outcomes, Timing, and Setting methodology were performed to identify possible indicators of presentation at diagnosis and the methodologies used in developing countries. We searched PubMed for the terms “Breast Cancer” or “Breast Cancer Screening” and “Developing Country” or “Developing Countries”. In all, 1,149 articles were identified. Of these articles, 45 full articles were selected, which allowed us to identify indicators related to epidemiology, diagnostic intervention (diagnostic strategy, diagnostic infrastructure, percentage of women undergoing mammography), quality of intervention (presentation of symptoms at diagnosis, time to diagnosis, early stage disease), comparisons (trend curves, subpopulations at risk) and survival among different countries. The identification of these indicators will improve the reporting of methodologies used in developing countries and will allow us to evaluate improvements in public health related to breast cancer.