An Update on Oncoplastic Surgery

Sir:FigurePartial breast reconstruction following tumor resection has become a popular option for women with breast cancer who choose to preserve their breasts.1 Often referred to as the oncoplastic approach, this technique combines the principles of oncology with those of plastic surgery in an attempt to maintain low cancer recurrence rates while minimizing the potential for a poor aesthetic result. It is essentially an adjunct to breast conservation therapy. The benefits are numerous and its popularity continues to grow. The purpose of this communication is to look critically at what is being written about oncoplastic breast surgery and gain insight into trends, needs, and possible future direction. A PubMed search was conducted in January of 2011 using the keywords “oncoplastic” and “partial breast reconstruction,” and only publications related to breast surgery and more specifically breast conservation therapy and the above were included in the evaluation. There have been 216 publications on the topic published over the past 37 years, with the first one being published in 1973. The number of publications has significantly increased over the past 5 years, likely because the need and demand for this approach have increased. There were 35 publications in 1973–1999, 43 in 2000–2005, and 138 in 2006–2010. One can possibly also deduce from the increase in publications that more breast centers are realizing the utility of combining partial reconstruction with tumor resection. It is likely becoming a more accepted approach that is routinely offered as an option for some women at the time of tumor resection if indicated. The majority of publications were retrospective case series [15 of 216 (53 percent)]. However, there were 55 review articles, 35 editorials, and 11 case reports. As in any field, the oncoplastic publications are mainly level III to V evidence. The review articles provide the needed educational exposure to a field that is relatively new, and editorials highlight the novelty and uniqueness of oncoplastic surgery, raising concerns and controversies that should ultimately improve safety and quality. Although many of the initial publications were from Europe (especially Germany), more recently, publications have come from numerous other countries. Publications were from 25 countries throughout the world, with the following countries having more than 10 representative publications (United States, 55; France, 28; United Kingdom, 27; Germany, 16; Italy, 16; Spain, 15; Brazil, 14; and Japan, 14). As a whole, the oncoplastic approach was slower to catch on in some countries as discussed previously2; however, review of the recent literature shows some renewed interest in countries such as the United States and Brazil. Most publications were in English [174 of 216 (81 percent)], with 42 of 216 (19 percent) being non-English (French, 13; German, 11; Spanish, seven; Italian, five; Hungarian, two; Dutch, two; Bulgarian, one; and Belgian, one). Although it is difficult to accurately stratify by type of journal, we found that the majority of publications were in surgical [79 of 216 (37 percent)] and plastic surgery [73 of 216 (34 percent)], with the remainder being in medical/oncology journals [35 of 216 (16 percent)] and breast journals [29 of 216 (13 percent)]. The oncoplastic approach at any institution or breast unit requires a thorough understanding by the multidisciplinary team. Although the driving force seems to be coming from breast surgeons and plastic surgeons, the involvement of the medical oncologist, radiation oncologist, radiologist, and pathologist is also crucial. Reconstructing partial mastectomy defects most commonly uses local breast tissue (volume displacement techniques) or recruits tissue in the form of flaps (volume replacement techniques). Most of the review articles and some of the series looked at both techniques (n = 99). A local flap was the topic of reconstruction in 48 clinical series, and the reduction technique or tissue rearrangement technique was the topic in 64 series. Other topics included free flap reconstruction (n = 3), implant (n = 1), and training (n = 1). Although both types of reconstruction are popular, it seems as though the oncoplastic reduction techniques are reported on more often. Many of the initial reports in the literature introduced the topic of partial breast reconstruction as a way of correcting breast conservation therapy deformities years after completion of radiation therapy. European series were already discussing the immediate correction of defects at the time of tumor excision. The vast majority of publications are focused on the immediate reconstruction of tumor defects before irradiation. Of the 115 clinical series in the literature, 91.4 percent (105 of 115) were immediate reconstruction, 7.8 percent (nine of 115) were delayed reconstruction, and 0.8 percent (one of 115) covered both. There were, however, situations in the immediate series where reconstruction was delayed until confirmation of negative margins (delayed-immediate) but still before radiation therapy, which is determined by surgeon preference and patient selection factors. One could assume from the significant focus in the literature on immediate reconstruction that this is preferred clinically over the delayed reconstruction of breast conservation therapy deformities. The general sentiment in the field also seems to favor immediate reconstruction, for reasons previously pointed out in the literature.3 It is evident from reviewing the literature that the oncoplastic approach to breast conservation therapy has gained significant momentum over the past decade. As acceptance grows, refinements in technique will become evident. Optimizing results in terms of oncologic safety, morbidity, and aesthetic outcomes is crucial to continued evolution of these techniques. Although there are now some larger oncoplastic series,4 we definitely need more level I and II evidence-based studies. Multicenter, prospective, and possibly even randomized trials with direct comparisons will further support our assumptions and demonstrate additional safety and efficacy. Although many of the points discussed in this communication are based on speculations from reviewing the literature trends, it does provide us with some insight and a reasonable representation of the current thinking when it comes to oncoplastic breast surgery. Albert Losken, M.D. Bahair Ghazi, M.D. Division of Plastic and Reconstructive Surgery, Emory University, Atlanta, Ga.