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10.1245/s10434-006-9098-5
Annals of Surgical Oncology 14:605-614 (2007)
© 2007 Society of Surgical Oncology
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Original Article

Comparative Study of the Accuracy of Breast Resection in Oncoplastic Surgery and Quadrantectomy in Breast Cancer

Pierre-Ludovic Giacalone, MD, PhD1, Pascal Roger, MD, PhD2, Olivier Dubon, MD1, Nouredine El Gareh, MD1, Samia Rihaoui, MD1, Patrice Taourel, MD, PhD3 and Jean Pierre Daurés, MD, PhD4

1 Oncology Unit, Department of Obstetrics and Gynecology, Hôpital Arnaud de Villeneuve, 371 rue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
2 Department of Pathology, Hôpital Lapeyronie, 371 rue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
3 Department of Radiology, Hôpital Lapeyronie, 371 rue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
4 Clinical Research Center, Biostatistics Unit, 75 rue de la Cardonille, 34295, Montpellier Cedex 5, France

Correspondence: Address correspondence and reprint requests to: Pierre-Ludovic Giacalone, MD, PhD; E-mail: pl-giacalone{at}chu-montpellier.fr


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: The aim of this study was to determine whether oncoplastic surgery ensures accurate tumor resection and reduces the need for further surgery in comparison with standard quadrantectomies.

Methods: This was a prospective comparative study of 74 patients with breast tumor diameter ≥ 15 mm. The principal criterion for case selection was breast size that allowed either quadrantectomy or oncoplastic surgery to be scheduled. The following were recorded and compared between groups: the size of the glandular resection, the width of the nearest margins, the ratio of clear margins, and the need for further surgery.

Results: The patients who underwent oncoplastic surgery were younger than those who had quadrantectomy. All other demographic and oncological preoperative data were comparable. The median volume of the excised specimen in the oncoplastic group was higher than in the quadrantectomy group. The nearest lateral margin widths were larger in the oncoplastic group than in the quadrantectomy group. Free surgical margins ≥ 5 mm and ≥ 10 mm were obtained more frequently using oncoplastic surgery than standard quadrantectomy. However, the need for fewer secondary surgeries was not demonstrated in our study.

Conclusions: Oncoplastic surgery achieves more accurate tumor resection than standard quadrantectomy. This approach might be useful in extending the indications for conservative therapy.

Key Words: Oncoplastic surgery • Breast • Quadrantectomy • Specimen volume • Surgical margins


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Since the 1970s, when conservative surgery in combination with adjuvant radiotherapy was first used successfully to treat breast cancer, the clinical impetus for pursuing the development of surgical techniques has been the importance of preserving body integrity by providing a better cosmetic result.1,2 The dual concerns today are thus to increase the accuracy of local disease control and to maintain the breast’s shape and appearance.3–5 Achieving both goals in the same operation may be a considerable challenge, depending on the tumor location and relative size in the breast.

The term oncoplastic surgery is used differently depending on the speciality.6 In plastic surgery, the term typically refers to large partial mastectomy with a volume-replacement technique using a myocutane-ous flap.7 Oncoplastic surgery has also been used to describe several breast volume-displacement operations. Different methods of parenchymal redistribution have been described to fill small or moderate defects in the breast. These all fundamentally rely on advancement, rotation or transposition of a large area of breast to fill the defect. In its simplest form, this may entail mobilizing the breast plate from the area immediately around the excision. Larger defects may require whole-breast plate mobilization or breast-flap mastopexy closure.6,8 Several authors of noncomparative studies have reported that oncoplastic surgery results in the same survival rate as standard conservative treatment.9–14 Some of the published series have studied lower pole tumor locations and large or subareolar cancers.9,10,13,15,16 Others have reported on simultaneous mammaplasty to treat macromastia.11,17,18 Recently, Kaur et al.19 reported a prospective nonrandomized study that compared the status of surgical margins in onco-plastic surgery and quadrantectomy. The authors reported that larger specimen volumes and a higher free-margin rate were obtained with oncoplastic surgery than with quadrantectomy. This was the first prospective comparative study on this subject. However, the two groups were different in the distribution of tumor sizes and locations, which may have biased the results.

Our study was thus undertaken to compare onco-plastic surgery and standard quadrantectomy in women whose breast size and shape were such that either technique could be performed.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
From January 2004 to May 2005, 269 consecutive women with breast carcinoma underwent surgical treatment in the Department of Gynecologic Surgery at the University Hospital of Montpellier, France. The patients eligible for study inclusion were women with breast tumor diameter ≥ 15mm and breast size that would allow either quadrantectomy or onco-plastic surgery to be scheduled. Eighty four women had tumors <15 mm and did not enter the study. One hundred and fourteen women did not match the inclusion criteria because breast ptosis or volume was insufficient to permit oncoplastic surgery. Forty-six patients were excluded because of inflammatory carcinomas (n = 4 patients), locally advanced tumors with gross lymph node involvement (n = 15 patients), local failure of previous conservative treatment (n = 15 patients) or metastatic disease (n = 12 patients). The remaining 25 patients needed planned mastectomies.

A total of 74 patients were entered into this prospective study. Preoperative evaluation included physical examination of the breast, mammography, breast ultrasonography and contrast-enhanced MRI. Breast MRI was performed to rule out multifocal disease undetectable by mammography and to assess the enhancement kinetics of the tumor. A needle core biopsy, with radiology-based guidance when needed, was always performed to confirm the cancer diagnosis because we believe that a large quadrant resection should not be performed unless there is histological proof of malignancy. We also made the assumption that the women would want to be informed of the histological results. The majority of patients indeed indicated a desire to be involved in treatment decisions, so before surgery each woman received basic information on tumor location, size and histology. After this step, women who satisfied the criteria were invited to participate and were offered the choice between the two surgical approaches: mammaplasty concomitant with breast tumor removal and a contralateral symmetrizing procedure (oncoplastic group) or standard quadrantectomy without concomitant mammaplasty (quadrantectomy group). After being informed of the risks and benefits associated with each treatment alternative, the patients made their own decisions and were then assigned to either the oncoplastic group or the quadrantectomy group.

The first group consisted of all patients who underwent oncoplastic surgery of the breast (31 patients). The control group (43 patients) consisted of patients who underwent breast quadrantectomy. All patients were operated on within the same time period in the oncology department of our institution by two surgeons (PLG, NEG) trained in both breast and plastic surgery. Infraclinical tumors were excised after MRI- or radiologically-guided percutaneous location.

Patient and tumor characteristics, and details of adjuvant therapy, surgical intervention, and complications of surgery were all entered into a computerized database. Patients were examined for operative patterns and postoperative complications. Radio-therapy to the breast and lymph nodes, chemotherapy, endocrine therapy, and axillary lymph node dissection were carried out without modification to our standard protocols.

Surgical Procedures
For the oncoplastic patients, preoperative markings were made with the patient in the upright position. The drawing outlined the median intermam-mary line, the inframammary fold, and the sternal notch-to-nipple line. The vertical inframammary distance was fixed at 50 mm, and the vertical diameter of the areola, from 40 to 45 mm.20 Each patient was operated on in a semi-recumbent dorsal decubitus position. The area surrounding the nipple-areolar complex was deepithelialized (Fig. 1Go). The tumor excision was then performed with the aim of incorporating at least a 1-cm macroscopic margin of normal tissue (Fig. 2Go).10 The surgeon performed a wide quadrantectomy with no thought to the residual breast shape since it was to be remodeled by immediate mammaplasty. The remodeling procedure involved apposing the two glandular columns to fill in the defect (Fig. 3aGo), and recentralization of the nipple-areolar complex to recreate a harmonious size and shape (Fig. 3bGo). Surgical clips were left in place to mark the perimeter of the tumor resection site.


Figure 1
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  		FIG 1. Inverted-T technique. Operative view shows the area surrounding the nipple-areolar complex deepithelialized (arrow).

 

Figure 2
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  		FIG. 2. Inverted-T technique. Intraoperative demostration of the glandular resection (arrow). The inner limit of the resection is the retroareolar surface.

 

Figure 3
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  		FIG. 3. Inverted-T technique. Reshaping the remaining glandular tissue by moving upward the inferior and inner part of the breast (arrow) to restore the outer pole fullness (3a.) Reshaping the breast using a reduction mammaplasty procedure (3b).

 
The choice of oncoplastic technique depended on the degree of breast ptosis, the breast shape and the quadrant that was to be resected. The inverted-T procedure was used in five patients for moderate and large ptotic breasts to elevate the nipple areola, shorten and adjust the distance from areola to the inframammary crease, and shape the remaining breast (Fig. 4Go). Conversely, the round block technique (Fig. 5Go) was chosen for less ptotic breasts (26 women) when it was not necessary to deepithelialize circles of skin more than 11–12 cm diameter to elevate the nipple areola and shape the remaining breast (Fig. 6a–bGo).21 A contralateral breast mammaplasty procedure was performed in 25 patients to achieve symmetry.


Figure 4
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  		FIG. 4. The patient is shown immediately after the procedure and the opposite breast reduction. Intracuticular sutures are used to close the both the periareolar and the inverted T scars.

 

Figure 5
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  		FIG. 5. Circumareolar technique. Intraoperative view of a superior and medical deepithelialized pedicle (arrow), and of the breast tissue resection.

 

Figure 6
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  		FIG. 6. Circumareolar technique. Reshaping the remaining glandular tissue by moving upward the nipple areola complex (6a) and by concentrating the breast skin (6b) using a round block masto-pexy (6b).

 
Quadrantectomy was performed following the published guidelines for breast conservation.22,23 All patients were operated on in a dorsal decubitus position. After subcutaneous dissection, breast tissue was removed down to the chest wall. The tumor excision was then performed with the aim of incorporating at least a 1-cm macroscopic margin of normal tissue. The breast gland was lifted off the pectoralis muscle and the glandular defect was eliminated by approximation sutures of the mammary tissue to recreate a harmonious shape. A direct incision (radial incisions for lesions in the lower half of the breast and curvilinear incisions following Lan-gher’s lines for upper breast tumors) was used for 36 patients. A periareolar approach was used in the seven remaining cases. Axillary lymph node dissection was performed through an axillary route in cases of invasive tumor pattern.

Histological Procedure
In all cases, the breast tissue specimen was oriented in three dimensions by the surgeon, sent to the pathologist in a fresh state and measured. Intraop-erative radiography of the specimen was performed for infraclinical tumors and correlated with preop-erative radiography. The specimens were inked with multiple colors to assist in identifying margins. Following adequate formalin fixation, the tumor histopathological type was categorized according to the World Health Organization (WHO) classification. Details regarding tumor staging were recorded according to the International Union Against Cancer tumor node metastasis (TNM) staging system.

Margin status was analyzed on the anterior side of the specimen (close to the breast skin), the posterior side of the specimen (close to the pectoralis major muscle) and on the lateral sides. Tumor size, as determined by the maximal histological size and margin widths, were measured by ocular micrometry. For the study purpose, we used a 2-mm surgical margin on the lateral side of the specimen as the cut-off point for negative margins. Positive margins were defined as those with tumor cells directly at the cut edge of the specimen. Close margins were defined as those with tumor cells between the cut edge of the specimen and the boundary defined as negative (≤ 2 mm). A margin involved by in situ lobular carcinoma was considered a free margin.

The volume of each tumor was calculated using the following formula: tumor volume= (3.14/6)*(histo-logical size).3 The volume of each specimen was calculated by multiplying measurements of the length, width and height. Patients with free margins underwent full breast radiation therapy. When the surgeon and histologist agreed that secondary surgery was necessary, the multidisciplinary staff informed and guided the patient in choosing the strategy. When the lateral margins of the specimens were focally involved (<3 mm of the inked surface involved by tumor), reexcision was indicated, whereas mastectomy was chosen when the margins were extensively involved (>3 mm of the inked surface involved by tumor).

Outcome measures included preoperative radiological and histological tumor size, tumor location, and postoperative histological data. The latter were of particular importance for the purpose of the study, and included the size of the breast glandular resection, the width of the nearest margins obtained (lateral, anterior and posterior margins of the tissue specimen), the ratio of clear margins, and the number of patients who underwent secondary surgery (reex-cisional surgery or radical mastectomy). Finally, overall postoperative complications (during a 30-day postoperative period) were recorded for the two groups.

Statistical Analysis
The data analyst and pathologist were blinded to the surgery groups. Fifty-seven baseline preoperative variables were compared using {chi}2 analysis for categorical data or, when appropriate, Fisher’s exact test; the Mann-Whitney U-test compared the medians of nonparametric variables. Spearman correlation test and regression analysis were used to analyze the correlations between two different variables. P < .05 was considered statistically significant. Statistical analysis was performed with Stat View software (Stat View 512, Brain Power, Inc., Calabasas, CA).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Patient and Tumor Characteristics
The patients undergoing oncoplastic surgery were younger than the patients who chose quadrantectomy [mean (SD): 51.3 (12.1) years for the oncoplastic patients versus 58.5 (1.7) years for quadrantectomy ( =.01; Mann-Whitney U-test)]. However, the mean (SD) body mass index did not differ between the groups: 24.9 (5.3) kg/m2 versus 25.2 (4.8) kg/m2 (P = 0.69; Mann-Whitney U-test).

The groups were comparable for preoperative parameters (Table 1Go). The median (range) largest radiological tumor size was 20 (15–60) mm for the two groups (P = .98; Mann-Whitney U-test). Pre-operative histological patterns and distribution of tumor locations did not differ between groups.


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  		TABLE 1. Comparison of preoperative clinical variables between the oncoplastic and quadrantectomy groups
 
The average operative time in the oncoplastic group was longer than in the quadrantectomy group [mean (SD): 117 (48.1) minutes for the oncoplastic patients versus 80.8 (31.5) minutes for quadrantectomy (P = .001; Mann-Whitney U-test)]. However, no difference was found for the duration of postoperative stay [mean (SD): 5.1 (2.7) days for the onco-plastic patients versus 4.7 (2.5) days for quadrantectomy (P = .79; Mann-Whitney U-test)].

There were early complications in the patients of both groups. Delayed wound healing was recorded in five oncoplastic patients and one quandrantectomy patient. Postoperative hematoma was reported in two and three cases, respectively, whereas 21 cases of partial skin necrosis were seen in the oncoplastic group (P = .17; {chi}2 test).

Histological Data
The data on surgical management and the postoperative histological factors are shown on Table 2Go and Table 3Go. The distribution of pT stages did not differ. The median (range) ratio of volume of the breast specimen/tumor volume did not differ between groups [30 (0.4–1318) for the oncoplastic patients versus 24.8 (1.1-3076) for quadrantectomy (P = 0.62, Mann-Whitney U-test)]. The average volume of the breast specimens and the margin widths were bigger in the oncoplastic group, indicating that a larger volume of breast tissue was excised during oncoplastic surgery compared with standard quadrantectomy. The Spearman correlation test showed a significant correlation between the volume of glandular resection and the anterior margin width (R2 = .43; P = .0004), the posterior margin width (R2 = .35; P = .004), and the lateral margin width (R2 = .32; P = .02).


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  		TABLE 2. Postoperative clinicopathologic data
 

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  		TABLE 3. Postoperative histological data
 
With a 2-mm surgical margin on the lateral side of the specimen used as the cut-off point for negative margins, lateral free margins were not obtained sig-nificantly more frequently in the oncoplastic group than in the quadrantectomy group (P = .45; {chi}2 test). However, lateral free margins ≥ 5 mm [20 cases (67%) versus 18 cases (42%)] and ≥ 10 mm [20 cases (65%) versus 18 cases (42%)] were obtained significantly more frequently with oncoplastic surgery than standard quadrantectomy (P = .03 and .05, respectively; {chi}2 test).

Seven patients of the oncoplastic group and 14 of the quadrantectomy group had positive or close margins (Table 4Go). The mean (SD) body mass index (BMI) did not differ between oncoplastic group and quadrantectomy group patients: 25.1 (4.7) kg/m2 versus 25.2 (5.3) kg/m2, (P = .86; Mann-Whitney U-test). The patients were comparable for median (range) radiological tumor diameter [25 (15–50) mm for the oncoplastic group versus 20 (16-40) mm for the quadrantectomy group (P = .50; Mann-Whitney U-test)] and median (range) histological tumor diameter [27 (13-60) mm for the oncoplastic group versus 23.5 (5-40) mm for the quadrantectomy group(P = .32; Mann-Whitney U-test)]. In addition, the median (range) volume of breast specimen excised was not different in the oncoplastic group than in the quadrantectomy group [113 (39-200) versus 107 (18-201) (P = .86; Mann-Whitney U-test)], nor was the ratio of volume of the breast specimen to tumor volume [6.4 (0.4-111) versus 15 (1.1-3076); (P = .32; Mann-Whitney U-test)]. Of the seven patients in the oncoplastic group, four had positive margins and underwent secondary mastectomy, while the remaining three patients had close margins and were not subject to reoperation. Of the 14 patients in the quadrantectomy group, seven had positive margins and underwent secondary mastectomy and one had close margins and underwent reexcision surgery. The remaining six patients had close margins and were not subject to reoperation. All the patients with close margins underwent a 10-Gy radiation boost onto the tumor bed in addition to standard whole-breast radiation therapy.


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  		TABLE 4. Clinicopathologic features of patients with positive margins
 
We analyzed the histological parameters in each group separately. The oncoplastic and quadrantecto-my groups were divided into two subgroups: the negative margins subgroup (24 and 29 patients, respectively) and the positive or close margins subgroup (7 and 14 patients, respectively; Table 5Go). In the oncoplastic group, no difference was found in the average radiological diameter between the negative margins and positive or close margins subgroups (P = .26; Mann-Whitney U-test) or the average his-tological diameter (P = .15; Mann-Whitney U-test). Interestingly, the average volume of specimen resection was more than 3-fold higher in the negative margins subgroup than in the positive or close margins subgroup [262 cm3 versus 77 cm3 (P = .02; Mann-Whitney U-test)]. In addition, the ratio of the volume of the breast specimen to the tumor volume ratio was seven times higher in the negative margins subgroup than in the positive or close margins subgroup [43 versus 6 (P = .01; Mann-Whitney U-test)]. Last, no difference between the tumor histological status was shown for the two subgroups (P =.27; {chi}2 test). DCIS tumors and tumors with extensive intra-ductal components (EIC) were found in 62% of the excised specimens from the negative margins subgroup versus 85% from the positive or close margins subgroup, but this difference was not significant.


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  		TABLE 5. Comparison of histological features of negative margins and positive or clear margins subgroups in the oncoplastic and quadrantectomy groups
 
In the quadrantectomy group, no differences were found between the subgroups for radiological tumor size (P = .28; Mann-Whitney U-test), histological tumor size (P = .13; Mann-Whitney U-test), excised specimen volume or volume ratio (P = .84; Mann-Whitney U-test). Last, the tumor histological status was different between the two subgroups (P = .04; {chi}2 test). DCIS tumors and tumors with EIC were found less frequently in the excised specimens from the negative margins subgroup (34%) than in the positive or close margins subgroup (79 %) [P = .04].


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Our comparative study showed the clear advantage of oncoplastic surgery versus quadrantectomy in terms of the volume of the resected breast specimen, the size of the nearest margin width, and the frequency of clear margins of more than 5 mm and 10 mm.

In our study, BMI and breast morphologies did not differ between groups. The average radiological and histological tumor sizes, the distribution of pT stages, the tumor locations within the breast and the histological patterns of the tumors were comparable between groups. Interestingly, the average specimen height was not different between groups, which con-firmed that breast resection was performed down to the chest wall with both oncoplasty and quadran-tectomy. Conversely, the average specimen width and length were greater in the oncoplastic group because of the large glandular exposure created by onco-plastic surgery. This allows larger subcutaneous dissection, and provides larger tissue resection laterally and greater margin width. This is of great importance as the impact of the surgical margin status on long-term local control rates for breast cancer in women treated with lumpectomy and radiation therapy is considered one of the most important risk factors for local recurrence in invasive and ductal carcinoma of the breast.24,25

A 10-mm clear margin width was also obtained more frequently by oncoplastic surgery than by quadrantectomy. This too is of great importance, as reported by Holland et al. in DCIS tumors.26 The authors showed that, when margin widths exceed 10 mm, the likelihood of residual disease is small. In addition, in multivariate analysis if the tumor margin width is greater that 10 mm, tumor size does not seem to be an independent predictor of local relapse after breast-conserving therapy.27

Very few studies have analyzed the excised specimen volumes. When we analysed the data of our 74 patients, we found that margin width was signifi-cantly correlated with the volume of the breast specimen. Interestingly, in the oncoplastic group, the volume of the breast specimen and the ratio of the volume of the breast specimen to tumor volume were dramatically higher in the negative margins subgroup than in the positive or close margins subgroup. Because of the small number of patients, a logistic regression could not be performed, but these results strongly suggest the importance of the resection specimen volume to obtain clear margins. Similarly, in a retrospective study of 146 patients with DCIS receiving breast-conserving therapy, Vicini et al. concluded that the risk of recurrence was directly correlated with the volume of the glandular specimen.28 These authors found that patients with smaller excised volumes (<60 cm3) had higher rates of local recurrence than patients with excised volumes of more than 60 cm3. This difference appeared to be more pronounced as tumor size increased. Finally, the 5- and 10-year local recurrence rate decreased as the specimen volume to tumor volume ratio increased. Using multivariate analysis, this ratio was the only treatment-related variable associated with local recurrence.28 Margin status was no longer associated with outcome. Pass et al. reported on changes in management technique over time (1981–1996) in 607 patients from a single institution. The authors concluded that the higher percentage of patients with clear margins obtained in the most recent period of the study (1991–1996), compared with the earliest (1980–1985), may be attributed to the larger volumes of breast tissue excised by the surgeons (189 cm3 versus 115 cm3).

Our study is in accord with the study of Kaur et al.,19 who compared two groups of patients undergoing either oncoplastic surgery or quadrantectomy. However, their inclusion criteria were not as strict as ours, which explains some of the differences in breast tumor location and the distribution of pT stages. In addition, a latissimus dorsi flap was used for breast volume replacement in two patients. This study is nevertheless important because it was the first to compare two surgical procedures for breast conservation therapy in early breast cancers. The women of our oncoplastic group were younger than the quad-rantectomy patients, as reported by Kaur et al.19 We thus assumed that in most cases the bust symmetry offered by the oncoplastic technique was more important to the younger women. Indeed, breast conservation with pleasing esthetic results is a demonstrated source of strong patient satisfaction.

We report excised breast tissue volumes somewhat comparable with those of Kaur et al.19 In their study, the mean volume was 200.18 cm3 for the oncoplastic patients and 117.5 cm3 for the quadrantectomy group. Because of the non-Gaussian distribution of our data, we present volume medians of 190 cm3 and 99 cm3, respectively. Had we chosen to present the mean (±SD) value, we would have had volumes of 234 (197) cm3 and 114 (83) cm3, respectively, which are quite similar to those reported in Kaur’s comparative study. Our results confirm that the amount of breast tissue excised during oncoplastic surgery is higher than that excised during standard quadran-tectomy. Interestingly, these results were obtained without additional postoperative complications or longer hospital stays.

According to the literature, oncoplastic surgery has mainly been used for selected patients with large tumors, large breasts or tumors located in the lower quadrants of the breast. Although the average volume of resected breast tissue was not reported in these series, a close correlation between the reported specimen weight and the volume may be assumed since breast tissue is a mixture of fat (gravity = .92) and water (gravity=1); i.e., g of tissue=1 cm3.30 Clough et al. reported an average specimen weight of 222 g (2 cm3) in a series of 101 large tumors located in the lower pole of the breast, compared with 40 g with lumpectomy in the same institution.10 The same team also reported bilateral oncoplastic surgery in about 50 patients with large tumors (mean diameter 32.5 mm) in the lower pole of the breast.13 The average specimen weight was 270 g. Reporting our results, we strongly believe that on-coplastic surgery may be used for patients with normal or moderately sized breasts, offering good cosmetic results that greatly contribute to patient satisfaction.

In our study, oncoplastic surgery also resulted in fewer secondary surgeries than standard quadran-tectomy (13% versus 18.5%). This parameter did not reach statistical significance in part because of the small number of cases, and also because this decision was made by the patients (three of seven patients from the oncoplastic group, and six of fourteen patients from the quadrantectomy group did not accept secondary surgery as indicated). However, had they chosen to follow the multidisciplinary recommendations, secondary surgery would have been performed in 23% of the oncoplastic patients versus 33% of the quadrantectomy patients. Similarly, Kaur et al.19 reported that negative margins were achieved more frequently with oncoplastic surgery than quadran-tectomy (83.4% versus 56.7%, P = .05). The number of secondary surgeries was unfortunately unreported, but we can assume it would have been smaller in the oncoplastic group than in the quadrantectomy group.

The most rigorous method to determine the differences between the two types of surgical management would have been a randomized trial. We nevertheless think we were able to limit some of the bias by using narrowly defined inclusion criteria. This study design therefore may have sufficient statistical power to encourage serious consideration of our results and—we hope—to generate further comparative studies with longer follow-up. This study reports on a small number of patients in self-selected comparison groups. Despite these shortcomings, the data strongly indicate that oncoplastic surgery of breast tumors may well be not only as safe as, but also more efficient than, standard quadrantectomy in terms of accurate breast tissue resection. Obviously, a large controlled trial with a longer follow-up that rigorously analyzes both oncological and economic aspects is needed to confirm what we already suspect: oncoplastic management will one day be the gold standard of breast conservative surgery.

Since the 1970s, the drive has been to improve the accuracy of tumor removal while reducing disfigure-ment in women with breast tumors. The oncoplastic approach has been a response to this drive, with the palette of techniques now available to oncological surgeons greatly enriched by the contributions of plastic surgeons.

Received for publication May 1, 2006. Accepted for publication June 5, 2006.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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