Zhiqiang MA,Mengyuan CHEN,Haibin WU,Jianxin HE,Ruonan WANG,Wei GUO,Wensheng WANG

Department of Breast and Thyroid Plastic Surgery,First Affiliated Hospital of Henan University,Kaifeng,Henan 475000,China

ABSTRACT Objective To investigate the application of oncoplastic surgery in breast-conserving surgery.Methods We retrospectively analyzed the clinical data of 103 breast cancer patients who underwent breast-conserving surgery in the First Affiliated Hospital of Henan University.All the patients were female whose tumor volume-to-breast volume ratio was greater than 20%.Fifty-two patients were treated with oncoplastic breast-conversing surgery(observation group),and 51 patients were treated with traditional breast-conserving surgery(control group).The volume of resected tissue,subjective satisfaction with breast shape,objective score of breast shape,and follow-up were compared between the two groups.Results In the observation group,the weight of resected breast tissue was 64.2-172.1 g,with a median of 98.7 g.In the control group,the weight of resected breast tissue was 67.5-175.7 g,with a median of 102.3 g.After 12 months of follow-up,the subjective satisfaction rate and objective score of breast shape in the observation group were significantly better than those in the traditional breast-conserving surgery group (P ＜ 0.05).There was no recurrence,metastasis,or death in the two groups.There was no significant difference in postoperative complications between the two groups (P ＞ 0.05).Conclusion Oncoplastic breast-conserving surgery leads to better cosmetic results and a more satisfactory clinical results.

KEY WORDS Breast cancer; Oncoplastic surgery; Breast-conserving surgery

INTRODUCTION

The morbidity of breast cancer has increased in recent years.Domestic and international studies have confirmed that conservative surgery and modified radical mastectomy have similar outcomes.Moreover,conservative surgery can minimize the physical and mental trauma caused by surgery and ensure the same survival and local recurrence rates[1-3].Although oncoplastic breast-conversing surgery(OPBS) can greatly maintain the breast appearance,many patients with a strong desire to conserve their breast are recommended for mastectomy because of the large tumor size.At present,indications for extreme oncoplasty include patients who undergo the resection of ≥ 20% of breast glands,patients with larger tumors (T＞ 5 cm),and patients with multiple or multicenter lesions[4].This places higher demands on the surgeon.The clinical data of 103 patients who were postoperative OPBS or traditional breast-conserving surgery were collected and analyzed.

DATA AND METHODS

General Data

The data of 103 patients with breast cancer (all female;median age,46 years; age range,21 to 67 years)who were admitted to the First Affiliated Hospital of Henan University from January 2017 to June 2019 were collected.We included patients with preoperative pathology of tumor confirmed to be non-special invasive breast cancer,a single tumor,and a tumor volumeto-breast volume ratio of 20%-40%,according to theGuidelinesdeveloped by the Committee of Breast Cancer Society,Chinese Anti-Cancer Association (CACA)[5].The patients were divided into two groups based on their procedures:the observation group,with 52 patients who underwent oncoplastic breast-conversing surgery,and the control group,with 51 patients who underwent traditional breast-conserving surgery.There was no significant difference between the groups in terms of age,axillary lymph node status,tumor location,estrogen receptor expression status,HER2 gene status,KI-67 expression,and histological grade (P＞ 0.05).See Table 1 for details.

Surgical Method

The surgical method and surgical incision executed were based on the location of the breast tumor,the proportion of tumor-to-breast volume,the breast volume,and other factors.In the observation group,we used a doublering incision,V incision,tennis racket incision,Omega incision,and inverted T incision.The range of tumor resection included the tumor,1-cm peritumoral tissue,and deep fascia of the pectoralis major.After the biopsy results of the residual cavity confirmed that the frozen cut edge was negative,titanium clips were used to mark each cut edge,and volume displacement or volume replacement repair of the breast residual cavity was performed.

Volume displacement involved reshaping the free glandular tissue flap around the residual cavity and suturing the defect after rotation.On the other hand,volume replacement involved transposing the free latissimus dorsi muscle flap to the defect in the surgical residual cavity and suturing with breast tissue for patients with a large residual cavity.

The patients in the control group underwent an arc or radial incision on the surface of the tumor,and titanium clips were used to mark each cut edge after confirming that the frozen cut edge was negative for tumor.The range of tumor resection was the same as that in the observation group.

Table 1 General characteristicsof breast cancer patients

Preoperative and Postoperative Treatment of Axillary Lymph Nodes

Based on the preoperative physical examination and imaging,sentinel lymph node biopsy or axillary lymph node dissection were performed in accordance with theCACA Guideline[5].Axillary lymph node dissection was performed if the patient’s sentinel lymph node biopsy was positive,following intraoperative freezing of pathological results.The postoperative treatment schedule was established according to the pathological type,molecular classification,and surgical TNM staging.

Effectiveness Evaluation and Follow-Up

All patients were reviewed and registered for follow-up 12 months after the operation,which mainly focused on the survival rate,recurrence or metastasis,subjective satisfaction rate of patients,and objective score of breast cosmetic result.The subjective satisfaction rate of patients is a questionnaire that is divided into five levels:very satisfied,satisfied,general,dissatisfied,and very dissatisfied.The objective score of breast cosmetic result are based on breast symmetry,skin color change,nipple displacement distance,local depression degree,scar,skin elasticity as scoring index[6],and ≥ 21 scores for good beauty effect.The specific scoring indicators are shown in Table 2.

Statistical Methods

The data were analyzed using SPSS 21.0 statistical software,and the measurement data were tested using theχ2test.The difference was statistically significant(P＜ 0.05).

Table 2 Objective score of breast cosmetic result

RESULTS

Operation and Short-Term Effects

In the observation group,52 patients underwent repair by volume displacement,and 13 patients by volume replacement.Of the patients who underwent volume displacement,11 underwent tennis racket incision,9 Omega incisions,12 double-ring incision,4 inverted T incisions,and 3 V incision.In the control group,we used radial incision in 37 patients and arc incision in 14 patients.The volume of excised breast tissue was 64.2-172.1 g(median,98.7 g) in the observation group and 67.5-175.7 g (median,102.3 g) in the control group.In the observation group,two patients had subcutaneous effusion,and one had delayed wound healing.In the control group,three patients had subcutaneous effusion,and one experienced delayed wound healing.We found no flap infection and necrosis in both groups and no between-group statistical difference in the postoperative complications (P＞ 0.05).The specific scoring indicators are shown in Table 3.

Table 3 Comparison of postoperative complications between groups [n (%)]

Follow-Up,Subjective Satisfaction,and Objective Score of Breast Cosmetic

There were no recurrences,metastases,or deaths in either group.On subjective satisfaction,43 patients in the observation group were very satisfied,8 were satisfied,1 was borderline,and 1 was not satisfied,resulting in a total satisfaction rate of 96.2% (51/53).In the control group,38 patients were very satisfied,3 were satisfied,8 were borderline,and 2 were not satisfied,achieving a total satisfaction rate of 80.4% (41/51).The satisfaction rate with regard to breast shape in the observation group was higher than that in the control group (P＜ 0.05).On the objective score of breast cosmetics,46 patients in the observation group had scores ＞ 21 and 34 in the control group,＞ 21,showing a significant difference (P＜ 0.05).See Table 4,Figure 1,and Figure 2.

Table 4 Objective score of breast cosmetic result

Fig.1 Oncoplastic breast-conversing surgery

Fig.2 Traditional breast-conserving surgery

CONCLUSION

With the advancement of medical technology,it is a common pursuit for physicians and patients to maintain the breast shape after surgery for breast cancer.The breast size of Asian women is smaller than that of European and American women and is mostly glandular.In order to obtain a safer margin,breast-conserving surgery removes a wider edge of the breast gland,which inevitably affects the appearance of the breast[7-8].After traditional breast-conserving surgery,the breast is often distorted,deformed,collapsed,and asymmetrical,which negatively affects the overall beauty of the breast[9-10]and harms the psychological state of patients to a certain degree.Currently,the most suitable population for ultimate oncoplastic surgery is mainly patients with more than 20% of the gland volume excised,large tumor volume(T ＞ 5 cm),and multi-focus or multicenter focus.Ultimate oncoplastic surgery can help maintain the cosmetic appearance of the postoperative breast shape,remold and protect it,and improve the patient's postoperative satisfaction.Studies have shown that the shape of the breast changes significantly[11-13]when the number of glands removed is ≥ 20% of the total size of the breast gland.It is necessary to choose different surgical methods based on the condition of individual patients.The volume displacement method can be used to achieve a small or moderate defect via tennis racket incision,Omega incision,double-ring incision,inverted T incision,J incision,and Bat wing incision.The free peripheral gland flap is displaced in ultimate oncoplastic surgery.The volume replacement method can be used to fill the residual cavity shape using the tissues surrounding the tumor.The flaps commonly include the latissimus dorsi muscle flap,thoracolumbar flap,and some perforator flap.Galactoplasty is suitable for patients with large or drooping breasts.

In recent years,free fat transplantation has become the main auxiliary technique for breast tumor plastic surgery[14-15].Fat transplantation can be used to correct local defects or deformities and improve the contour after breast-conserving surgery.In addition,fat transplantation can also increase the volume of autologous tissue flap and achieve better results combined with ultimate oncoplastic surgery.Thus,we should consider the breast gland tissue density and the effect of radiotherapy.If there is less glandular composition of the breast and more fat composition,we should avoid extensive subcutaneous dissociation and changes in breast shape to avoid fat necrosis and protect the blood supply to the tissues as much as possible during the surgery.Because most patients require postoperative radiotherapy,the surgery can also reduce its effect on breast shape[14,16-17].The patients’ objective satisfaction and objective score of breast cosmetic in the observation group is significantly better than that in the control group,with no recurrence,metastasis,or death after surgery nor significant difference in postoperative complications.With the improvement of plastic surgery,more patients with breast cancer will benefit.

FUNDING

This study received grant support from the Key Research and Development Promotion Projects in Henan Province(grant no.:202102310423)

ETHICS DECLARATIONS

Ethics Approval and Consent to Participate

This study received ethical approval from the ethics committee at the First Affiliated Hospital of Henan University.All participants provided written informed consent prior to enrolment in the study.

Consent for Publication

All the authors have consented for the publication.

Competing Interests

The authors declare that they have no competing interests.The authors state that the views expressed in the submitted article are their own and not the official position of the institution or funder.