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10.1245/ASO.2005.12.046
Annals of Surgical Oncology 12:539-545 (2005)
© 2005 Society of Surgical Oncology
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Original Article

Comparative Study of Surgical Margins in Oncoplastic Surgery and Quadrantectomy in Breast Cancer

Navneet Kaur, MD1, Jean-Yves Petit, MD1, Mario Rietjens, MD1, Fausto Maffini, MD2, Alberto Luini, MD3, Giovanna Gatti, MD3, Pier Carlo Rey, MD1, Cicero Urban, MD1 and Francesca De Lorenzi, MD, PhD1

1 Department of Plastic and Reconstructive Surgery, European Institute of Oncology, Via Ripamonti, 435, 20141, Milan, Italy
2 Pathology Division, European Institute of Oncology, Via Ripamonti, 435, 20141, Milan, Italy
3 Breast Division, European Institute of Oncology, Via Ripamonti, 435, 20141, Milan, Italy

Correspondence: Address correspondence and reprint requests to: Jean-Yves Petit, MD; E-mail: jean.petit{at}ieo.it.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background: Oncoplastic surgery for breast cancer is a novel concept that combines a plastic surgical procedure with breast-conserving treatment to improve the final cosmetic results. The aim of this study was to evaluate the oncological safety of oncoplastic procedures by studying the status of the surgical margins of the excised tumor specimen in comparison with standard quadrantectomies.

Methods: Thirty consecutive breast cancer patients undergoing oncoplastic surgery (group 1) and 30 patients undergoing standard quadrantectomy (group 2) were prospectively studied with regard to the stage of breast cancer, the surgical procedures performed, the volume of breast tissue excised, and the histopathology of the tumor specimen, with specific details on surgical margins.

Results: Patients who underwent oncoplastic surgery (group 1) were younger (mean age, 48.73 years) than patients who had a classic quadrantectomy (group 2; mean age, 55.76 years; P = .022). The mean volume of the excised specimen in group 1 was 200.18 cm3, compared with 117.55 cm3 in group 2 (P = .016). Surgical margins were negative in 25 cases out of 30 in group 1 and 17 out of 30 in group 2 (P = .05). The average length of the surgical margin was 8.5 mm in group 1 and 6.5 mm in group 2, but the difference was not statistically significant (P = .074).

Conclusions: Oncoplastic surgery adds to the oncological safety of breast-conserving treatment because a larger volume of breast tissue can be excised and a wider negative margin can be obtained. It is especially indicated for large tumors, for which standard breast-conserving treatment has a high probability of leaving positive margins.

Key Words: Oncoplastic surgery • Quadrantectomy • Surgical margins • Breast cancer • Plastic surgery


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Breast-conserving treatment (BCT) is the standard treatment in early-stage breast cancers, and it is increasingly used for ductal carcinoma-in-situ (DCIS) and for larger breast cancers after neoadjuvant chemotherapy.1–4 Its goal is to provide a treatment as effective as mastectomy, with the added benefit of a preserved breast. However, it is sometimes difficult to achieve good cosmetic results, particularly in patients with large, ill-defined, or poorly situated tumors, for which clear margins are difficult to achieve without leaving deformed and asymmetrical breasts.5

Oncoplastic surgery, which combines a plastic surgical procedure with BCT, is a new surgical approach6 that allows wide excisions and prevents breast deformities by immediate reconstruction of large resection defects. The procedures are mostly useful for resection of 20% to 40% of the breast—a group of patients normally treated by mastectomy.7 Four features are integral to oncoplastic breast surgery: appropriate surgery to extirpate the cancer, partial reconstruction to correct wide excision defects, immediate reconstruction with the full range of available techniques, and correction of asymmetry relative to the contralateral breast.8,9 There are two fundamentally different approaches: (1) volume-replacement procedures, which combine resection with immediate reconstruction of the defect by using autologous tissue (local fasciocutaneous flaps and latissimus dorsi miniflaps),10–14 and (2) volume-displacement procedures, which combine resection with a variety of different breast-reduction and -reshaping techniques, according to the location of the tumor.15 This approach results in a net loss in volume of the breast and frequently requires a contralateral procedure to achieve symmetry. Several recent reports have demonstrated that oncoplastic techniques allow for extensive resections for BCT and result in favorable oncological and aesthetic outcomes.5,7,16

The oncological safety of BCT is determined by the status of surgical margins, which are assessed as a marker for residual disease after primary surgery. Achieving widely negative surgical margins is important for the oncological safety of BCT. Pathologic margin status is one of the most important risk factors associated with ipsilateral breast tumor recurrences.17,18 Patients with focally positive margins have a relative risk of developing local breast cancer recurrence of almost 15 times compared with patients with negative margins.19 Residual breast carcinoma at the resection margins may also be a source of systemic spread and, ultimately, disease-specific mortality.20 Despite this evidence, most centers report a rate of positive margins between 20% and 55% on the initial diagnostic biopsy.21,22

To evaluate the oncological safety of oncoplastic surgical procedures, we performed a retrospective study to analyze the histopathologic characteristics and, especially, the surgical margins in breast cancer specimens at the time of oncoplastic surgery by comparing them with specimens excised during standard quadrantectomy. We also compared the volume of the specimens excised during the two procedures.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
This comparative study was performed as a prospective nonrandomized analysis of the medical records of 60 consecutive patients who had undergone either a quadrantectomy or an oncoplastic operation in the Breast Unit at the European Institute of Oncology in Milan from January 2003 to July 2003. These patients were divided into two groups: group 1, 30 patients who underwent oncoplastic procedures; and group 2, patients who received a standard quadrantectomy. Patients’ medical records were evaluated in detail, and the following variables were recorded: age, tumor size, stage of breast cancer, axillary lymph node status, surgical procedure, volume of breast tissue excised, and histopathology of the excised specimens, especially regarding the status of the surgical margins.

Surgical Procedure
All patients in group 2 were operated on by the breast surgeons. Nine patients out of 30 received quadrantectomy alone, 10 patients had quadrantectomy with sentinel node biopsy, and 11 patients underwent quadrantectomy with complete axillary dissection.

Patients of group 1 (oncoplastic procedures) were operated on by two teams of surgeons: a breast surgeon and a plastic surgeon. In these patients, preoperative markings were made by the plastic surgeon the day before surgery with the patient in the standing position. These drawings guided the general surgeon to avoid making unnecessary skin incisions or damaging the skin flap blood supply or the nipple vascular pedicle. Markings were drawn according to classic reduction mammaplasty techniques in 22 patients (both superior and inferior pedicle reductions) and round block mastopexy in 3 patients, and a latissimus dorsi flap was planned in 2 patients to fill in the mammary defect. In three patients, a simple radial incision over the tumor in the superior quadrant was planned.

Tumor excision was performed with the aim of including the tumor with at least 1 cm of healthy tissue far from the macroscopic margins. During breast reshaping, the glandular tissue was mobilized over the pectoralis major muscle. This allowed a bimanual glandular evaluation and any additional pathology of suspicious areas (if any were discovered). In 28 of 30 cases, the quadrantectomy defect was filled up by opposing two glandular columns. In 2 of 30 patients, a flap was necessary to replace the excised glandular tissue. Nipple/areola transposition was performed when necessary to create an aesthetically pleasing breast.

A contralateral breast procedure was performed in 27 patients (90%) in group 1; in 20 patients, a superior reduction mammaplasty (Lejour) was performed, in 3 cases an inferior pedicle reduction mammaplasty was performed, and in 4 cases a round block mastopexy was performed. No operation in the healthy breast was performed in three patients.

Pathologic Analysis
All specimens were inked before cutting. Formalin-fixed and paraffin-embedded sections were stained with hematoxylin and eosin for routine examination.

There is no uniform definition of surgical margins. According to our institute guidelines, a negative margin is quantitatively defined as containing no tumor cells within 1 cm of the cut edge of the surgical specimen. However, in the literature, the largest group of studies have used >2 mm as the cutoff point for negative margins.23 To make the results of our study comparable with those of other studies, we also used a 2-mm surgical margin as the cutoff point for negative margins for the purpose of analysis in this study. Positive margins are defined as having tumor cells directly at the cut edge of the specimen. Close margins are defined as having tumor cells between the cut edge of the specimen and the boundary defined as negative (≤2 mm). The extent of the positive margin is assessed by measuring the linear involvement of the inked margins by the carcinoma. The volume of each specimen was calculated by multiplying measurements of length, width, and height.24

Statistics
Results obtained from the two groups were compared in terms of the average volume of the specimen excised, the status of the surgical margins, and the linear extent of the free margins. Statistical analysis for significance between variables was performed by unpaired Student’s t-test, Fisher’s exact test, and {chi}2 test.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Patient and Tumor Characteristics
The average age of patients in group 2 was 55.76 years (range, 34–81 years) and in group 1 was 48.73 years (range, 30–75 years). Patients undergoing oncoplastic surgery were considerably younger, and the difference was statistically significant (P = .022).

In group 2, 11 patients had pTis lesions picked up as microcalcifications on mammography, 14 had pT1 tumors, and 5 had pT2 tumors. In group 1, 4 patients had pTis lesions, 18 had pT1 tumors, 2 had bifocal pT1 tumors, and 6 had pT2 tumors. The average size of the tumor determined pathologically for pT1 tumors was 1.46 cm (range, 1–2 cm) in group 2 and 1.3 cm (range, .4–2 cm) in group 1. The average size for pT2 tumors was 2.8 cm (range, 2.3–4.3 cm) in quadrantectomy group and 3.98 cm (range, 2.6–5 cm) in the oncoplastic surgery group. Thus, both groups were similar in terms of tumor size for pT1 tumors. With regard to pT2 tumors, in group 1 tumors were bigger than in group 2, but the difference was not significant (P = .065).

Table 1Go shows the different tumor locations in the two groups. Breast cancers were placed in the superior external quadrant in 53% of patients of group 1 and 37% of group 2. Oncoplastic surgery was performed more often in cases of tumors located in the lower quadrant (11 patients, compared with 7 patients with the same location in group 1).


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  		TABLE 1. Location of the tumors in group 1 (oncoplastic surgery) and group 2 (quadrantectomy)
 
Volume of the Specimen and Tumor Margins
The mean volume of the specimen was 117.55 cm3 (range, 18–360 cm3) in the quadrantectomy group and 200.18 cm3 (range, 36–594 cm3) in group 1. Thus, a significantly larger volume of breast tissue was excised during oncoplastic procedures compared with standard quadrantectomy (P = .016).

In group 2, 17 patients (56.7%) had negative margins, 10 patients (33.3%) had close margins (8 patients with DCIS and 2 with infiltrating ductal carcinoma), and 1 patient (3.3%) had positive margins (DCIS). In two patients (6.7%), the status of margins was unknown. In the subgroup of patients with DCIS (11 patients), we had closed margins in 8 (72.8%) of 11 cases. The average length of surgical margins was 6.5 mm (SD, 4.9 mm), and the average length of negative margins was 9.5 mm (SD, 2.9 mm).

In group 1, margins were negative in 25 patients (83.4%) and close in 4 cases (13.3%). In one patient (3.3%), margins were positive. In the subgroup of patients with DCIS (four cases), margins were close in three (75%). The average length of surgical margin was 8.5 mm (SD, 3.1 mm), and the average negative margin was 9.3 mm (SD, 2.02 mm). Thus, negative margins were achieved in more patients in group 1 than group 2, and the difference is statistically significant (25 vs. 17 cases; P = .05).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Although oncoplastic procedures are a relatively novel approach to breast cancer treatment, several reports have been published demonstrating the wide spread of these techniques.25 In several centers, the boundaries between breast and plastic surgery are breaking down, and trainees from both specialties are beginning to acquire cross-specialty skills.7 Thus, the necessity of demonstrating the oncological safety of oncoplastic procedures stimulated our study and discussion about different aspects of this approach.

BCT of early breast cancer is widely accepted as the standard treatment, despite a higher risk of local recurrence.26 A poor cosmetic result after BCT is a very undesirable outcome, especially for younger women who have high expectancies and an active social life. Moreover, oncoplastic surgical techniques, which usually involve a plastic reshaping of the healthy breast, are well accepted by younger women. This can explain the younger age of patients undergoing oncoplastic surgery in our study (a mean of 46 years) compared with patients undergoing classic resections. Similar data have been reported previously.27

In most studies of oncoplastic surgery, patients are often selected with regard to tumor location. In fact, patients with tumors in the lower quadrants are generally offered oncoplastic techniques because poor cosmetic results usually follow simple lumpectomies in these areas. They can be suitably corrected by using superior pedicled reduction mammaplasty techniques5,26 (Fig. 1Go). Conversely, in our study, patients with tumors in all locations underwent oncoplastic surgery, mainly because of a poor tumor/breast volume ratio. A similar distribution of tumor location was present in both groups, as shown in Table 1Go. Although the superior pedicle reduction mammaplasty was the most common method used, the inferior pedicle reduction mammaplasty, round block mastopexy28 (Fig. 2Go), Grisotti technique,29 and latissimus dorsi flap (Fig. 3Go) were also performed.15,30


Figure 1
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  		FIG 1. Preoperative (A) and postoperative (B) appearance 6 months after left inferior quadrantectomy, breast reshaping, and superior pedicle right reduction mammaplasty.

 

Figure 2
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  		FIG 2. Preoperative (A) and postoperative (B) appearance 1 month after superior right quadrantectomy, breast reshaping, and left round block mastopexy.

 

Figure 3
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  		FIG 3. Preoperative (A) and postoperative (B) appearance 1 month after left superior quadrantectomy and replacement with a latissimus dorsi muscle flap.

 
A large tumor size is an indication for oncoplastic surgical procedures.5,16 Moreover, pathologic studies report consistent evidence that tumor size is not predictive of multifocality.31 Because a large amount of breast tissue can be excised, also in the case of large tumors adequate negative margins can be achieved. In group 1, T2 tumors were larger (3.98 cm) than T2 tumors in group 2 (2.8 cm). However, 20 patients in group 1 had T1 tumors, 2 of which were bifocal cancers. We suppose that many of these patients requested oncoplastic procedures to simultaneously improve the cosmetic appearance of the healthy large or ptotic breast.

The amount of breast tissue excised during oncoplastic surgery was more than that excised during BCT in our study and in the literature.5,16,24 The average volume of the specimens after oncoplastic surgery was 200.18 cm3, compared with 117.55 cm3 after quadrantectomy. In our previous report, the mean weight was 157 g, which was almost three times the weight of regular tumorectomy.16 Clough et al.5 reported an average weight of 220 g, compared with 40 g with lumpectomy. However, these wider glandular excisions are necessary to achieve symmetry with the contralateral breast and not to obtain wider surgical margins. What we strongly wanted to investigate with this study, because it had not yet been reported, was whether oncoplastic procedures also offer a wider surgical margin and, consequently, enhance the oncological safety of the procedure. As shown in our results, negative margins were achieved in significantly more cases of oncoplastic surgery than standard quadrantectomy (25 vs. 17; P = .05). In addition, the average surgical margin was longer (8.5 vs. 6.5 mm) with oncoplastic surgery.

Many patients in our study had close margins for in situ lesions (4 and 10 cases, respectively, in group 1 and 2). This result can be explained by the histopathologic nature of the intraductal lesions. In fact, although most small lesions involve only a single duct, they can spread along several branches of the same duct. Such branches may be farther apart than the distance designated as a negative margin. Skip lesions (areas of DCIS interspersed with areas of normal tissue) are not unusual. Thus, depending on the plane of sectioning, it may be difficult to determine whether a margin that is histologically negative really signifies complete excision of DCIS. Moreover, because DCIS is multifocal, it has been suggested that a very large margin may be necessary to ensure low rates of local recurrence. Negative margins as large as 5 mm or even 10 to 15 mm have been proposed.32,33 In group 1, there were four specimens with close margins. That means that, despite the large amount of resected glandular tissue, we are not always able to remove the tumor with enough surrounding healthy tissue. Therefore, the plastic surgical procedure should be performed with consideration of the original location of the cancer and not only of conventional plastic surgical techniques and cosmetic results.

In addition, patients undergoing BCT after neoadjuvant chemotherapy deserve special attention. Although we did not include these patients in our study, they are also candidates for larger excisions because pathologic examination of the excised glandular tissue has shown multiple foci of scattered residual tumor cells interspersed with areas of marked fibrosis after tumor regression.34

An important aspect we would like to stress is the local control of breast cancer after surgery. We demonstrated that oncoplastic procedures offer wider surgical margins and consequently enhance the oncological safety of the procedure. Unfortunately, our series consisted of 60 consecutive patients who underwent operation in 2003; thus, the follow-up was short, and the local recurrence rate is without any meaning. However, in the literature, several studies dealing with this aspect have been published. Clough et al.5 reported a local recurrence rate of 9.4% with a mean follow-up of 3.8 years. Raja et al.11 reported a recurrence rate of 3% with a mean follow-up of 5 years.

Finally, the contralateral procedure on the healthy breast is an important point of the oncoplastic approach. In our series, 90% of patients received a contralateral reduction mammaplasty or mastopexy. Besides improving the cosmetic results, this may also allow diagnosis of occult lesions in up to 5% of patients, thus interfering with subsequent medical treatment.35 Another advantage of the bilateral approach is that it reduces postradiotherapy asymmetry and retraction,36 and it can also optimize radiotherapy by reducing the inhomogeneous dosing that is found in larger breasts.37


   CONCLUSIONS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Oncoplastic surgery adds to the oncological safety of BCT. A much larger volume of breast tissue can be excised, and wider surgical margins can be achieved. This is especially useful for larger tumors, in which a standard resection can lead to poor cosmetic results and tumor-involved surgical margins.

Received for publication December 30, 2003. Accepted for publication January 31, 2005.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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