Journal of the Egyptian National Cancer Institute (2012) 24, 9196

Cairo University

Journal of the Egyptian National Cancer Institute

www.nci.cu.adu.eg www.sciencedirect.com

ORIGINAL ARTICLE

Pedicled dermoglandular ap reconstruction following breast conserving surgery

M. Khafagy, I. Fakhr *, A. Hamed, O. Youssef
Surgical Oncology Department, National Cancer Institute (NCI), Cairo University, Egypt Received 5 February 2012; accepted 1 May 2012 Available online 31 May 2012

KEYWORDS Dermoglandular ap; Breast cancer; Central defects; Oncoplastic surgery

Abstract Breast conserving therapy is the gold standard treatment of early breast cancer. However, a balance between good cosmetic outcome and limiting the risk of locoregional recurrence remains the key of success. The aim of this work was to evaluate the outcome of partial breast reconstruction using pedicled dermo-glandular ap from the upper outer quadrant, for central quadrantectomy BCS. Patients & methods: Thirty patients underwent wide excision of carcinoma of retroareolar or periareolar regions of the breast, from July 2008 to August 2011. Excisions included the nipple/areola complex down to the pectoralis fascia with a wide safety margin, and complete axillary dissection. Breast reconstruction was done by means of pedicled dermoglandular ap. Results: Mean age of patients was 51.86 years (range from 30 to 70 years). Tumor size ranged from 1 to 4.2 cm. Postoperative pathological results came out with 21 (70.0%) patients mean (range) of the tumor safety margin 2.01 (0.52.8). Seventeen (56.7%) patients had positive axillary lymph nodes. All patients received postoperative radiation therapy to the breast, while 17/30 (56.67%) and 6/30 (20%) received endocrine therapy or adjuvant chemotherapy, respectively, and only 7/ 30 (23.34%) patients received both therapies. During a median follow-up period of 24 months, neither local nor distant metastasis, were detected. The postoperative cosmetic result was excellent in 80% patients, good in 13.3% patients, acceptable in 6.7% with no poor result. Conclusion: Following central quadrantectomy BCS for small centrally located breast cancer, a pedicled dermoglandular ap from the upper outer quadrant is a good reconstructive option.
2012 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V. All rights reserved.

Introduction
* Corresponding author. Address: 6 Sahaba Sq., Mosadaq St., Dokki, Giza, Egypt. Tel.:+20 1001720671. E-mail address: ibrahimfakhr@gmail.com (I. Fakhr). Peer review under responsibility of the National Cancer Institute, Cairo University.

Production and hosting by Elsevier

Breast conserving therapy is the gold standard treatment of early breast cancer. However, a balance between good cosmetic outcome and limiting the risk of locoregional recurrence remains the key to success. Oncoplasty has been developed in the last 15 years as a new surgical approach and incorporates plastic surgical techniques in breast oncological surgery. This has generated much enthusiasm around the world, among both, breast and plastic surgeons,

1110-0362 2012 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jnci.2012.05.001

92 and in the UK, where formal oncoplasty training has been developed [1]. Oncoplastic breast-conservation surgery combines oncologic principles with plastic surgical techniques, but it is much more than a combination of two disciplines; it is a philosophy that requires vision, passion, knowledge of anatomy, and appreciation and understanding of esthetics, symmetry, and breast function [2]. There are two fundamentally different approaches: (1) volume-replacement procedures, which combine resection with immediate reconstruction by using local aps (glandular, fasciocutaneous, and latissimus dorsi mini-aps), and (2) volumedisplacement procedures, which combine resection with a variety of different breast reduction and reshaping techniques, according to the location of the tumor [3]. Aim The aim of this work was to evaluate the outcome of partial breast reconstruction using pedicled dermo-glandular ap from the upper outer quadrant, for upper half and central quadrantectomy BCS. Patients & methods During the period from July 2008 to August 2011, 30 patients with breast carcinoma were treated with oncoplastic surgery. Preoperatively all patients underwent physical examination of both breasts and axillae as well as bilateral mammograms and ultrasonography of both breasts. Histopathological diagnosis of cancer was made prior to surgery using core or ne needle biopsy. The planned procedure was discussed with patients, and their approval was documented. Surgery Tumors present at the retroareolar region, or encroaching on it, underwent central quadrantectomy including excision of the nipple/areola complex (NAC) down to the pectoralis fascia (Figs. 1 and 2). Following surgical excision, the breast specimen was orientated with sutures by the surgeon to retain orientation (Fig. 3). Surgical margins were determined by macroscopic and histologic examination of frozen sections of the breast specimens in the operating room. An adequate safety margin of at
Figure 3 Figure 2

M. Khafagy et al.

Preoperative planning (right upper quadrant).

Specimen removed.

least 2 cm and a complete axillary lymph node dissection (ALND) including all 3 levels were ensured in all excisions. Breast reconstruction was done by dermoglandular ap from upper outer quadrant. The ap was mobilized to repair the defect (Fig. 4). All patients who had central defects underwent NAC reconstruction by means of tattooing and local ap, respectively (Fig. 5).

Figure 1

Preoperative planning (left lower quadrant).

Figure 4

Flap dissection and positioning.

Pedicled dermoglandular ap reconstruction following breast conserving surgery Early complications

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There were 3/30 (10.0%) complications which were fat necrosis (n = 2; 6.67%) and delayed wound healing (n = 1; 3.34%) and were all treated conservatively. Follow-up Two of the patients were lost to follow-up. Therefore the follow-up comprised 28 patients. During a median follow-up period of 24 months, neither local nor distant metastasis, were detected. Cosmetic result
Figure 5 One month postoperative.

Pathological analysis All specimens were oriented and subjected to histopathology examination including ER, PR and Her-2-neu. Margins were regarded as negative when permanent histological examination found no cancer cells within a distance of 2 mm from excised tissue surface. Follow-up Postoperative clinical follow-up was done at 3 months intervals and included palpation of the breast and axilla. Mammograms and ultrasonography were done according to the standard protocol. MRI was done when needed. Cosmetic outcome The postoperative aesthetic result was evaluated asking the patients to rate the postoperative cosmetic result and their degree of satisfaction compared to the preoperative breast using a 4-point scale (excellent, good, acceptable or poor). Objective assessment of the cosmetic result was done by three surgeons and was rated on a 4-point scale (excellent, good, acceptable or poor). Evaluation was based on 5 criteria, namely: breast symmetry, glandular tissue defects, position/distortion of NAC, scar quality and/or retraction. Results Median age of patients was 53 years (range from 30 to 70 years; mean: 51.86 years). The nal histological examination results of all resected masses are presented in Table 1. Adjuvant therapy All patients (100%) received postoperative radiation therapy to the breast with a boost to the tumor site. Adjuvant systemic therapy was based on primary tumor characteristics where, 6/ 30 (20%) and 17/30 (56.67%) received chemotherapy or endocrine therapy, respectively. Only 7/30 (23.34%) patients received both chemotherapy and endocrine therapy. Delay of postoperative radiation treatment of 1 month was seen in one patient and was due to secondary wound healing.

The postoperative cosmetic result evaluated by the patients was excellent in 24/30 patients (80%), good in 4/30 patients (13.3%), acceptable in 2/30 (6.7%) with no poor result. The postoperative cosmetic result as evaluated by 3 professional investigators on a 4 points scale was excellent in 22/30 patients (73.3%), good in 6/30 patients (20.0%), acceptable in 2/30 (6.6%) with also no poor result. Minor cosmetic problems were due to breast asymmetry and keloid scar. Discussion When excising breast cancer, the surgeon faces two opposing goals: clear margins versus an acceptable cosmetic result. From an oncologic point of view, the largest specimen possible should be removed in an attempt to achieve the widest possible margins. From a cosmetic point of view, a much smaller amount of tissue should be removed in order to achieve the best possible cosmetic result. The surgeon must walk a ne line as he/she tries to satisfy two masters [2]. Indeed, oncoplastic surgery represents a step forward in breast conservation, allowing us to treat tumors in problematic locations (for example in the lower quadrants), to avoid poor cosmetic results, asymmetry or unpleasant scarring in the upper quadrants, and to obtain wider excisions and tumor free margins [4]. The goals of oncoplastic breast conservation surgery include: (1) complete removal of the lesion, (2) clear margins, the larger the better, (3) good to excellent cosmetic result, and (4) operating one time to perform the denitive procedure [2]. Moreover, Oncoplastic techniques allow wide breast resection, wider than that performed with conventional BCS, [46] making it possible to expand the indications of BCS to include those patients who have an NAC response unsuitable for conventional BCS [7]. Oncoplastic surgery is safe, as no statistical differences in terms of local recurrence and disease-free survival are evidenced when comparing classic quadrantectomies and oncoplastic approaches [6,8]. It should be considered for those patients where adequate local excision will cause cosmetic deformity either due to the volume resected or the site of the tumor. Other indications include women considering a breast reduction in addition to excision [9]. Concerning central NAC involvement, it is clear that central lumpectomy without any reconstruction of the NAC will reduce the cosmetic outcome. Centrally located tumors account for 5 20% of breast cancer cases and have long been thought to be

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Table 1 Pathological results.
15 (50.0%) 15 (50.0%) 5 (16.7%) 1 (3.3%) 6 (20.0%) 3 (10.0%) 1 (3.3%) 2.2 (14.2) 2 (0.65) 2.01 (0.52.8) 2.1 (0.54) 21 (70.0%) 4 (13.3%) 2 (6.7%) 1 (3.3%) 1 (3.3%) 1 (3.3%) 4 (13.4%) 21 (70.0%) 5 (16.7%)

M. Khafagy et al. results compared with other locations [18,19]. Regarding the in collete in the upper ner quadrant, scar formation and loss of de part are hardly tolerated by women. In the lower quadrant, the defect is easily visible compared to the other side. However, in the upper lateral quadrant, the gravity of the breast parenchyma may stretch the skin over the defect and may improve cosmoses without using a local oncoplastic technique [20]. Several authors reported on advantages of oncoplastic surgery. These include the increase of resection volume, [2123] leading to larger resection-free margins [2426] which may have an impact on oncologic outcome. However, to date, no prospective randomized or retrospective trial comparing lumpectomy and oncoplastic surgery has been performed to demonstrate a difference in local recurrence-free survival. Results of prospective and retrospective analyses suggest that there is no benet for resection-free margins of >2 mm compared with <2 mm; [27] thus, there is only little evidence that oncoplastic surgery may in fact improve oncologic results. However, the possibility of increased resection volume plays a central role in raising the rate of BCT [20]. All published studies report a low number of complications most of them minor complications [24,28]. Beside the prolongation of operative time, oncoplastic techniques may increase local morbidities [2931]. Skin necrosis and wound dehiscence are the most often reported complications after oncoplastic surgery. Obese patients, smokers, and patients with diabetes bear an increased risk to develop local complications [29]. In our study we reported only 6.67% of fat necrosis, and one case 3.34% wound dehiscence. An interesting nding of our study, as well as others [23], was that we observed no seroma in the breast which due to avoidance of any dead space in the breast may be partially responsible for the good cosmetic results. These are much better results than those reported by other studies [30] which may be partly explained by the fact that NAC was excised in most of our cases, a common site of complication. Moreover, we detected no tumor recurrence in our study, which contraindicates other studies [3235] who reported up to 10% locoregional recurrence over 5 years follow up. This nding may be explained by the fact that we operated on rather small tumors (median 2.0 cm), and we had a rather short duration of follow up (2 years). The cosmetic outcome is a major factor for the patients undergoing breast conservation treatment. Following breast conservation surgery up to 70% of patients reveal moderate and 30% major sequelae and an initial good cosmetic result may deteriorate with years [36,37]. The postoperative cosmetic result was graded as excellent by 80% of our patients. This was slightly superior to the cosmetic result graded by independent observers, contrary to the ndings detected by other studies [38,39], where trained observers gave better scores. This contradiction may not necessarily be based on objective criteria but due to the fact that breast cancer patients have an initial fear of losing their breast. However, we felt, as other authors also concluded [40,41], that the 4-points score provided sufcient reliability to be used routinely. Conclusions Following central quadrantectomy BCS for small centrally located breast cancer, a pedicled dermoglandular ap from the upper outer quadrant is a good reconstructive option. Regarding oncological safety we need further studies with

Tumor location (quadrant) Central Peri-areolar: Upper outer Upper inner Lower outer Lower inner Multifocal Tumor size: (cm) Mean (range) Median (SD) Tumor safety margin: (cm) Mean (Range) Median (SD) Tumor histology: IDC ILC Mixed IDC & ILC Tubular ca Papillary ca Multifocal ca Histological grade Well dierentiated Moderately dierentiated Poorly dierentiated Lymph node status: Total No. of dissected LNs: Mean (Range) Median (SD) Node positive 63 Positive LNs >3 Positive LNs Node negative Capsular inltration Lymphatic embolisation Angioinvasion Estrogen receptor status: Positive status Negative status Progesterone receptor status: Positive status Negative status Her-2-neu receptor status: Positive status Negative status

22.9 (1538) 25 (12.45) 17 (56.7%) 7 (23.3%) 10 (33.4%) 13 (43.3%) 6 (20.0%) 2 (6.7%) 2 (6.7%) 16 (53.3%) 14 (46.7%) 15 (50.0%) 15 (50.0%) 19 (63.3%) 11 (36.7%)

associated with a higher incidence of multicentricity and multifocality [10,11]. However, other more recent reports have failed to substantiate a specic correlation between location of the tumor and multicentricity [12,13]. For this reason, they represent an important challenge for breast surgeons, as they have been classically treated with a mastectomy, and until few years ago only 7% of central breast cancers were treated with conservative surgery [8]. A direct comparison between central quadrantectomy and mastectomy has seldom been studied, and no signicant differences in terms of local failure and overall survival have been reported [1417]. Cosmetic results after breast-conserving surgery for breast cancer in the medial, central, or lower quadrant yields worse

Pedicled dermoglandular ap reconstruction following breast conserving surgery larger series of patients and longer follow-up to better evaluate its safety. References
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