Minimising surgical treatment of early breast cancer

Introduction

Breast-sparing oncoplastic procedures (BSOP) offer a radical new alternative to mastectomy and conventional breast-conserving surgery in early breast cancer treatment. Wider clearance reduces local recurrence, with a direct impact on long-term survival [1]. Loss of volume is the leading cause of breast deformity, especially for central, medial and inferior tumours [2]. BSOP require the simultaneous deployment of oncological and reconstructive skills, and the emergence of oncoplastic surgeons is increasing the availability of these procedures in clinical practice [3].

Indications

BSOP are most appropriate when resecting 20% to 50% of the breast volume [4], when the likelihood of major deformity escalates [2]. New assessment tools enable direct calculation of the volume loss [2], and this approach is proving a useful alternative to total mastectomy and immediate reconstruction in patients requiring postmastectomy radiotherapy [5]. These techniques allow extremely wide local excision while minimising the sensory and structural disturbance following total mastectomy [6]. The techniques avoid the sequelae of implant-based procedures and enjoy the benefits of autologous reconstruction.

Choice of technique

BSOP encompass two fundamentally different approaches. Firstly, volume displacement techniques, which transpose local breast flaps into the resection defect and are most suitable for medium to large, ptotic breasts. Secondly, volume replacement techniques, which transpose autologous tissues from extramammary sites, and are most suitable for women with small to medium-sized breasts who wish to avoid volume loss. Both techniques adapt conventional methods of breast reduction or reconstruction to avoid the need for mastectomy, and a variety of volume displacement and volume replacement techniques have been described [7].

Outcomes

For volume displacement, 11 retrospective studies involving 433 patients have reported local recurrence rates of 0% to 7% and cosmetic failure rates of 0% to 18% at a median follow-up of 21 to 54 months. For volume replacement, seven studies involving 189 patients have reported local recurrence rates of 0% to 5% and cosmetic failure rates of 0% to 9%, with a median follow-up of 24 to 53 months [7]. The clinical utility of BSOP awaits further assessment and the wider availability of oncoplastic skills [8].