Oncoplasty as the Standard of Care in Breast Cancer Surgery

European Oncology & Haematology, 2014;10(1):43–7

Abstract:

Oncoplastic surgery is redefining breast cancer surgery today. Despite the lack of randomised clinical trials, current evidence suggests at least equivalent oncological outcomes, reduced re-excision rates and superior aesthetic results. This review outlines the arguments for the superiority of this new approach over the current standard of care and discusses some of the difficulties with regards to training and mentoring the next generation of surgeons.

Keywords: Oncoplastic surgery, breast-conserving treatment, breast cancer, breast reconstruction
Disclosure: Cicero Urban, Karina Furlan Anselmi, Flavia Kuroda and Jean-Claude Schwarz have no conflicts of interest to delare. No funding was received for the publicaton of this article.
Received: May 09, 2014 Accepted June 06, 2014 Citation European Oncology & Haematology, 2014;10(1):43–7
Correspondence: Cicero Urban, Rua Angelo Domingos Durigan 1240, Cs 1, 82020340, Curitiba, Brazil; E: cicerourban@hotmail.com

Over the last two decades, the field of oncoplastic surgery (OPS) has been established and continually refined, representing a major advance in breast cancer surgery. After establishing the safety of breast-conserving treatment (BCT) in the 1980s, there has been an increasing demand on the part of both patients and surgeons for better aesthetic outcomes and improved quality of life after breast cancer surgery. This demand led to the development of more sophisticated surgical techniques, combining principles in plastic surgery and surgical oncology to prevent the common deformities that previously occurred after standard BCT.

Although the benefits of OPS with respect to larger specimens, wider margins and improved cosmesis seem obvious, the lack of level 1 evidence comparing it to standard BCT has led to some controversy. Can a new surgical technique become the new standard of care without having the highest level of evidence in the literature? The introduction of sentinel node biopsy in the 1990s was quickly implemented into clinical practice, as it was clear how to compare it with the previous standard of axillary dissection in randomised trials. OPS, however, encompasses too many different techniques and variables to easily compare it with standard BCT in a well conducted randomised clinical trial. In fact, OPS is a new method and surgical philosophy, rather than a single technique, and a true surgical refinement of BCT.

So, the aim of this review is to revisit the history, concept, philosophy and results of OPS, and to discuss how the lack of specific training and mentoring in this field has led to significant barriers in its wider acceptance and utilisation for breast cancer surgery.

History, Concept And Philosophy
Historically it is difficult to define when, where and how the first time a mammoplasty technique was used in BCT with the aim of reducing deformities. There were a number of non-academic surgeons, in different countries, who were doing this kind of surgery sporadically, even before its appearance in the literature. The German surgeon Werner Audretsch originally coined OPS, and there is little doubt that its practice began in Europe, most probably in France, where it was formally introduced in a number of different oncological centres. Deformities due to BCT were even more frequent at that time, when wider margins (with a variation of 1 to 5 cm in some series) were considered crucial to local control of disease, resulting in larger resections. In addition, radiotherapy techniques were less refined, resulting in more adverse effects on aesthetic outcomes (see Figure 1). These poor outcomes led to pioneering work by plastic surgeons to introduce aesthetic techniques into BCT, most notably Jean-Yves Petit at Gustave-Roussy, Jean-Yves Bobin at Léon-Bérard and Michel Abbes at Lacassagne Center.1–6

But it was in the central quadrant of the breast where the collaboration between oncological surgeons and plastic surgeons was strongly established early on, as a real necessity in BCT. Here, it was not only to achieve a better aesthetic result, but also to avoid mastectomy, which was a frequent indication in these cases. In 1993 Galimberti, at the National Cancer Institute in Milan, published a series of 37 consecutive patients who underwent a central quadrantectomy with immediate breast reconstruction, using OPS methodology.5 In 2003, Clough from the Institut Curie in Paris published a consecutive series of 101 patients, demonstrating that OPS allowed for extensive resections in all breast quadrants without compromising aesthetics, which is considered one of the pillars of OPS.6

But the greatest change with OPS is a philosophical one: to combine concepts of two different surgical specialties with seemingly opposite goals. Traditionally, plastic surgery and surgical oncology were two separate and non-interchangeable surgical specialties. These boundaries were respected not out of appreciation of the individuality of each specialty, but due to the fear that plastic surgery techniques would be less aggressive, optimising the aesthetic outcome and thus compromising the oncological radicality of the surgery, potentially leading to increased recurrences and decreased survival. It is clear, when analysing the progress of these two specialties in breast cancer surgery, that they have followed divergent pathways over the last 20 years (see Figure 1). While in plastic surgery the techniques have become even more sophisticated and complex, culminating in microsurgical flaps, in surgical oncology and breast surgery the techniques have become more individualised and less invasive. This divergence arrived at a possible point of convergence between the two specialties with the emerging concept of OPS in the 1990s (see Figure 2), where both specialties slowly began to advance in congruence. As the breast is an aesthetic and functional organ, surgery should take into account its importance to femininity and a woman’s identity, not just maximising locoregional control.

Initially, Audretsch considered the original concept of OPS to be tumour specific immediate reconstruction, or an immediate reconfiguring after partial or total mastectomy. This view was not shared by all surgeons, and did not achieve a consensus in the academic community, as some surgeons considered OPS as limited only to BCT. Now, after skin and nipple-sparing mastectomy techniques have become popularised, it is clear (although it was not considered a consensus until now) that the original concept was correct, and that the concept of OPS should not be limited to partial mastectomies. So, OPS is now considered a well-conducted oncologic resection, followed by immediate breast reconstruction, taking into consideration contralateral breast symmetry in the same surgery.

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Keywords: Oncoplastic surgery, breast-conserving treatment, breast cancer, breast reconstruction