Extreme oncoplastic conservation is a safe new alternative to mastectomy.

OBJECTIVES: Extreme oncoplastic breast conserving surgery (eOPBCS) allows breast conservation for tumours ≥ 50 mm, but long-term outcomes are unclear. We investigated early complications and the longer-term clinical and oncological outcomes following eOPBCS to assess the clinical utility and safety of this technique. MATERIALS AND METHODS: A prospectively collected database of all eOPBCS procedures (1993-2016) using LD miniflaps (LDm) and therapeutic mammoplasties (TM) was interrogated and cross-checked with hospital records to establish length of follow up (FU), clinical outcomes (complications, revisions), local recurrence (LR) and survival. RESULTS: Ninety eOPBCS procedures (62 LDm, 28 TM) performed for large tumours (mean 67 [50-177] mm) were identified, overall FU 80 (10-308) months (LDm 91 [13-308], TM 54 [10-120] months). Forty two per cent were node positive, and 2 were benign (benign cases excluded from LR and FU analysis). Eleven patients required surgery for involved excision margins (LDm 3 re-excisions and 2 mastectomies, TM 6 mastectomies). Surgery for complications and subsequent revision was required in 6% and 37% of LDm and 18% and 7% of TM patients, respectively. Seven patients developed LR (LDm 5 versus TM 2) giving a predicted 5 and 10 year LR rate of 1.1% and 16%. CONCLUSION: Long-term FU of this unique series has confirmed that eOPBCS is a safe procedure for patients with bulky tumours normally treated by mastectomy, without risking local control. TM patients experienced more early complications but LDm patients required more revisions over a more prolonged period of FU.

Patient-Reported Outcomes Are Better after Oncoplastic Breast Conservation than after Mastectomy and Autologous Reconstruction.

Oncoplastic breast-conserving surgery (OBCS) avoids mastectomy for larger tumors, but patient-reported outcomes are unknown. METHODS: The BREAST-Q questionnaire was distributed to 333 women following therapeutic mammaplasty or latissimus dorsi (LD) miniflap since 1991 [tumor diameter, 32.5 (5-100) mm). QScore software generated scores/100 for breast appearance, physical, emotional, and sexual wellbeing. Outcomes following therapeutic mammaplasty and LD miniflap were compared and qualitative data analyzed to identify common themes relating to satisfaction. RESULTS: One hundred fifty (45%) women responded [mammaplasty versus LD miniflap, 52% versus 42%; age, 52 (30-83) years; follow-up, 84 (4-281) months). Eighty-nine percent rated OBCS better than mastectomy, > 80% recommending it to others. Mean outcome scores for breast appearance, physical, and emotional wellbeing were high and persisted beyond 15 years. Therapeutic mammaplasty patients were significantly more satisfied than those undergoing LD miniflap with the shape (P < 0.05), the size (P < 0.005), and the natural feel of the treated breast (P = 0.01). They demonstrated similar scores for physical and emotional wellbeing and a lower score for sexual wellbeing than LD miniflap patients. More LD miniflap patients reported back/shoulder symptoms and were more likely to report upper back pain (P < 0.05), but very few (< 5%) were concerned about donor-site appearance. Overall satisfaction with surgical outcomes was high in both OBCS groups (82% "excellent/very good") but greatest after therapeutic mammaplasty (P < 0.005). CONCLUSIONS: Patients report long-lasting satisfaction after OBCS and outcomes that compare very favorably with those reported following mastectomy and immediate autologous reconstruction.

The Effect of the Timing of Radiotherapy on Clinical and Patient-Reported Outcomes After Latissimus Dorsi Breast Reconstruction: A 10-Year Study.

BACKGROUND: Breast reconstruction (BR) is considered to be adversely affected by radiotherapy (RT), particularly when an implant is used. The aim of this study was to compare clinical and patient-reported outcomes after expander-assisted latissimus dorsi breast reconstruction depending on the timing of RT. METHODS: Patients undergoing BR over a 10-year period (follow-up mean, 56 [14-134] months) were divided into 3 groups. Group 1, RT after mastectomy and BR, Group 2, RT before mastectomy and BR, and Group 3, RT after mastectomy but before BR. The primary endpoints were early and late surgical interventions. Validated questionnaires were circulated to all study patients and matched controls. RESULTS: Three hundred thirteen patients underwent 389 BRs. One hundred eighteen patients received RT, of which 65 had undergone expander-assisted latissimus dorsi breast reconstruction. Both use and timing of RT influenced clinical outcomes. Overall, use of RT resulted in a 3-fold increase in complications (P = 0.003). Postreconstruction RT resulted in more than double the number of complications compared with prereconstruction RT (P = 0.008) and delaying BR until after mastectomy and RT reduced complications to levels observed in control patients (P = nonsignificant). Complications were halved in patients undergoing autologous LD reconstruction (P = 0.0001). Patient-reported outcomes were similar for emotional well-being, satisfaction, and shoulder symptoms, although a nonsignificant increase in chronic breast symptoms was reported by the RT group. CONCLUSION: The timing and type of LD reconstruction chosen by patients receiving RT has a significant impact on the risk of subsequent complications and unplanned interventions but has little impact on longer term patient well-being or satisfaction.

Immediate latissimus dorsi miniflap volume replacement for partial mastectomy: use of intra-operative frozen sections to confirm negative margins.

BACKGROUND: Latissimus dorsi (LD) miniflap volume replacement is used for immediate reconstruction after partial mastectomy. This prospectively collected series was analyzed to evaluate the accuracy of intraoperative frozen sections. METHODS: After partial mastectomy, "bed biopsies" were submitted for intraoperative frozen-section analysis. If disease free, volume replacement was undertaken; if involved, targeted re-excisions were taken. Demographic, pathological, and outcome data were recorded. The proportion of breast excised was calculated. Local recurrences were recorded. RESULTS: One hundred ten partial mastectomies with LD miniflap volume replacement were completed. The median proportion of breast excised was 28% (maximum 72%); median weight 207 g. Frozen sections were positive in 33% of patients with a sensitivity of 83% and accuracy of 96% when compared with paraffin sections. Local recurrence occurred in one case. The median follow-up was 41.4 months. CONCLUSIONS: LD miniflap volume replacement extends the role of breast-conserving surgery. Frozen-section analysis of bed biopsies facilitates a single-stage procedure.