Oncoplastic Breast-Conserving Surgery: Can We Reduce Rates of Mastectomy and Chemotherapy Use in Patients with Traditional Indications for Mastectomy?

INTRODUCTION: Traditional indications for mastectomy include multiple ipsilateral lesions and/or disease spanning ≥ 5 cm. Neoadjuvant chemotherapy increases breast conservation but does not improve survival. We hypothesized that oncoplastic breast-conserving surgery (OPS) may allow for breast conservation while providing full staging and tumor profiling information to guide systemic therapy decisions, thereby permitting more judicious chemotherapy use. METHODS: This was an observational cohort of patients with invasive breast cancer with multiple lesions and/or disease spanning ≥ 5 cm who underwent OPS from 2012 to 2018. Clinicopathologic features, mastectomy rate, chemotherapy use, and recurrence were evaluated. RESULTS: Overall, 100 patients were identified. Average disease span was 62.8 ± 20.1 mm, with an average of 2.9 lesions (range 1-13). 'No ink on tumor' was achieved at the index operation in 80 patients; 13 patients underwent completion mastectomy to achieve adequate margins. Eighty-one patients completed radiation therapy. Breast conservation was possible in 50/58 (86%) patients who did not receive chemotherapy. Forty-two patients received chemotherapy (8 neoadjuvant, 34 adjuvant), of whom 37 (88%) achieved breast conservation. Twenty-six patients with high-risk features received adjuvant chemotherapy. Oncotype DX testing demonstrated the need for chemotherapy in an additional eight patients. After a median follow-up of 40 months, four patients had a local recurrence, including two who declined radiation therapy. CONCLUSIONS: OPS can facilitate breast conservation in most patients with traditional indications for mastectomy. Additionally, OPS may reduce unnecessary chemotherapy, especially in patients who qualify for Oncotype DX testing. Further study evaluating long-term oncologic and cosmetic outcomes is warranted.

Evaluating Need for Additional Imaging and Biopsy After Oncoplastic Breast-Conserving Surgery.

INTRODUCTION: Breast-conserving therapy (BCT) using oncoplastic surgery (OPS) allows for larger resections and improved aesthetics though volume redistribution and tissue rearrangement. Data regarding the impact of OPS on surveillance imaging and need for additional biopsies are limited. METHODS: This observational cohort underwent BCT at a single institution from 2009 to 2018; standard breast-conserving surgery (BCS) was the predominant approach until OPS was introduced in 2012. Rates of imaging beyond standard diagnostic views, as well as rates of biopsy following both approaches, are reported. RESULTS: A total of 422 consecutive patients were identified. The OPS group comprised 205 patients and the BCS group included 217 patients. There was no difference in need for additional imaging between groups (BCS: 58 patients [26.7%] vs. OPS: 53 patients [25.9%]; p = 0.91). When additional imaging was required, it was on the ipsilateral side in 35 (60.3%) BCS patients compared with 24 (45.3%) OPS patients (p = 0.21). The need for biopsy was higher in the BCS group (BCS: 41 patients [18.9%] with 47 total biopsies vs. OPS: 20 patients [9.3%] with 22 total biopsies; p < 0.01). Benign findings on biopsy were similar between groups (BCS: 18 [38.3%] vs. OPS: 11 [50.0%]; p = 0.66). CONCLUSIONS: OPS was not associated with an increased need for additional imaging compared with BCS. Concern regarding challenges with follow-up imaging should not impact the decision to offer OPS. Further study and longer-term follow-up is warranted to understand the trends in need for additional imaging, biopsy, and additional procedures following OPS.

Extreme oncoplasty: Expanding indications for breast conservation.

INTRODUCTION: Presence of multiple lesions and/or tumor span ≥5 cm are traditional indications for mastectomy. Patient desire for breast conservation has increased the interest in extreme oncoplastic breast conserving surgery (EOBCS) to avoid mastectomy; however, perioperative outcomes in this population have not been well described. METHODS: This is an observational cohort of breast cancer patients with multiple lesions and disease span ≥5 cm who underwent EOBCS. Patient demographics, disease span, margin width, mastectomy and re-excision rates, and cosmesis were evaluated. RESULTS: One hundred-eleven patients underwent EOBCS between 2012 and 2017. Eighty-two patients presented with multifocal or multicentric disease with an average of 3.2 lesions per breast spanning 57.1 ±â€¯23.6 mm. Eighteen patients presented with unifocal tumors measuring an average of 67.6 mm (range 50-160 mm) on imaging. Eleven patients with an imaging size of <5 cm had a disease span ≥5 cm on final pathology. No tumor on ink occurred in 87 (78.3%) patients. Fifty-seven (51.4%) patients had additional surgery for inadequate margins. Fifteen (12.6%) patients elected to have mastectomy while 42 (37.8%) patients opted for re-excision. Good to excellent cosmetic results were reported in 95% of patients who ultimately achieved breast conservation. Recurrence rate was 1.1% in patients who completed EOBCS and adjuvant radiation therapy. CONCLUSION: EOBCS can allow for breast conservation in patients who are traditionally counseled to undergo mastectomy. Although the re-excision rate was significant, most patients ultimately achieved breast conservation with adequate margins. Further study is warranted to determine the long-term oncologic outcomes of this approach.