Neo-Adjuvant chemotherapy and its affects to the axilla-Can we safely downgrade axillary surgery to mirror the approach in the breast.

The use of neo-adjuvant chemotherapy (NACT) to downgrade surgery in the breast from mastectomy to breast-conserving surgery is well-established. In certain patients, the use of adjuvant axillary radiotherapy can be safe and effective in place of axillary node clearance. What remains less clear are the alternative surgical options to the axilla following NACT. The aim of this study was to examine the effects of NACT in the axilla and whether downgrading axillary node clearance to axillary conserving surgery to mirror the approach in the breast may be a viable and safe practice. Patients undergoing neo-adjuvant chemotherapy were identified over a seven-year period between 2010 and 2017. Surgical plans were compared with pre- and post-chemotherapy. Histological information at the time of diagnosis was compared to surgical excision specimens. 349 patients were included for analysis, and 264 had axillary status documented at diagnosis. The average patient age was 51 years, and Grade 3, ER-positive, and Her2-negative cancers made the biggest histological subgroups. Complete pathological response (CPR) was seen in the breast in 27% of cases. 19% of patients requiring mastectomy had their surgery downgraded. Following NACT, axillary CPR was seen in 42% of patients and residual axillary nodal burden was limited to four nodes in 73% of patients. Axillary conserving surgery may be a safe alternative surgical approach in the downstaged axilla following neo-adjuvant chemotherapy. Advances in perioperative identification of suspicious nodes may be needed to facilitate progress.

Positive Margins After Oncoplastic Surgery for Breast Cancer.

BACKGROUND: Oncoplastic techniques applied to breast-conserving surgery (BCS) allow large-volume resections without compromising cosmetic results. Level II oncoplastic techniques are based on mammoplasties. When required, they allow resection of more than 20 % of the breast volume; however, a subgroup of these patients will still have positive margins. The clinical management of positive margins after level II oncoplastic surgery (OPS) is a challenge. METHODS: All patients who had undergone level II oncoplastic techniques at The Paris Breast Center between 2004 and 2013 were reviewed. The choice of the optimal mammoplasty technique was based on the tumor location and the 'quadrant per quadrant atlas'. RESULTS: A total of 277 level II oncoplastic techniques were performed on 272 patients. The mean tumor size was 26 mm (range 2-160 mm), with a mean resected weight of 175 g (range 50-1540 g). The rate of positive margins was 11.9 %. Risk factors for positive margins identified in univariate analysis were histologic subgroup, tumor size, T stage and grade. In multivariate analysis, only patients with invasive lobular carcinoma had a significantly higher risk of positive margins. A second operation was required in 33 cases, and a third operation was required in three cases because of positive margins. Final breast conservation rate was 91 %. CONCLUSIONS: Level II OPS results in a low positive margin rate despite large tumor size. Patients with involved margins can be offered a second BCS if the remaining volume allows this.

Level 2 oncoplastic surgery for lower inner quadrant breast cancers: the LIQ-V mammoplasty.

BACKGROUND: Oncoplastic surgical techniques offer an option of breast conserving surgery for larger tumors with the use of glandular reshaping to prevent postoperative deformity. A technique for the excision of lower inner quadrant tumors via a V incision is described, the lower-inner quadrant-V (LIQ-V) mammoplasty, and the results of a pilot study are reported. METHODS: Retrospective collection of pre- and postoperative data was collected from patients undergoing a LIQ-V mammoplasty for a LIQ tumor. RESULTS: Twenty-two patients were operated on between 2004 and 2011 at a mean age of 58 years. The mean follow-up was 55 months. The mean resection weight was 101 g for tumors ranging in size from 4 to 31 mm. The margins were clear in 95% of cases. There was one case of local recurrence and metastatic disease. The cosmetic outcome was judged as excellent in 68% of cases, and no patient required further ipsilateral or contralateral symmetrizing surgery. DISCUSSION: The deformity often associated with tumors of the LIQ is adequately addressed by this new technique. It has a complication rate comparable to other mammoplasty series and a high rate of clear resection margins. Many oncoplastic surgery techniques are based on inverted T mammoplasty, but these are not suited for all tumor locations. The LIQ-V mammoplasty is an adaptation of the standard techniques that best suit the LIQ. It is oncologically safe and provides disease-free margins, and although the resection volumes are large, the cosmetic outcome is not compromised.

Oncoplastic technique for the elimination of the lateral "dog ear" during mastectomy.

Following a mastectomy, both the cosmetic and functional results can be impaired by the presence of a lateral "dog ear." This is a particular problem in women with a large body habitus giving an increased amount of adipose tissue lateral to the breast. The standard approaches to this operation of horizontal or oblique incisions often results in an uncomfortable, unsightly lateral "dog ear". We describe a modification to the standard mastectomy incision that allows extensive excision of the lateral adipose tissue, re-draping the skin over the chest wall, thus eliminating the "dog ear." The mastectomy is performed through two oblique incisions originating in the axillary skin crease encompassing the nipple areolar complex, followed by extensive lateral fat excision. A distance of 2-3 cm is kept between the superior limit of the two incisions. At closure the lateral skin flap is advanced superiomedially on the chest wall without tension. This simple and reproducible technique improves cosmesis and patient satisfaction following modified radical mastectomy by eliminating the lateral "dog ear."