Minimalist breast conserving surgical approaches for inferiorly sited cancers

Introduction

Contemporary data suggests that breast conservation treatment (BCT) may confer survival advantage compared to mastectomy (1,2). However, it is known that poor cosmetic outcomes with BCT are common pitfalls (3). In an effort to avoid poor cosmetic outcomes, oncoplastic breast surgery (OBS) techniques have been developed (4-6). These are classified into two broad categories: volume replacement and volume displacement techniques (6). Volume displacement, or tissue rearrangement, procedures do not involve the use of implants or autologous flaps, and are considered to be the preferred modality, as volume replacement is reportedly associated with higher complication rates (6). Still, many of these require mammoplasty-like manoeuvres with the creation of extensive local tissue flaps and contralateral reduction mammoplasty (4-6). A high level of surgical training and resource allocation are needed for these. Furthermore, there is data to support intuitive observation that such mammoplasty or mastopexy techniques require longer operating times and result in lower patient satisfaction with scar appearance than standard breast conservation surgery (7). OBS, which is advocated for its ability to offer larger margins without compromising aesthetics, has not been conclusively shown to improve local control (8). Data also indicates that mammoplasty and symmetrisation procedures are associated with higher complication rates than standard lumpectomy with full thickness parenchymal closure (4,6,7,9,10). The significant displacement of parenchymal pillars which formed the original cavity wall with mammoplasty techniques has raised concern as identification of involved margins and delivery of radiotherapy boosts may be impaired (11,12). These collective difficulties may be reduced by adopting the use of less extensive surgery, “reductionist” or “minimalist” approaches. Its essence lies in applying standard breast conserving surgery with direct parenchymal closure in its most uncomplicated form. The increased use of minimalist breast conserving surgery (mBCS) does not necessarily conflict with the objective of expanding BCT eligibility or improved cosmetic outcomes if innovative approaches are used when tumours are sited in positions conventionally considered to be relative contraindications to BCT.

Malignancies in the lower hemisphere of the breast pose a particular technical challenge for BCT. Resection of such tumours without due consideration for parenchymal repair often result in several forms of distortion. There may be unsightly depressions, irregular breast contours or “bird-beak” deformities (13). While many surgeons advocate mammoplasty-like techniques to avoid such poor aesthetic outcomes, it is possible to minimise distortion with less complex procedures. Here, several techniques are described which allow good cosmetic outcomes without the need for elaborate surgical procedures. These methods can potentially streamline surgical processes for more efficient treatment in terms of operating time and lower complication rates.

Operative Technique

Principles of surgical approach based on tumour position

There are a few deliberations to be made when planning surgical approach. Consideration is needed for tissues in two different planes, the first consisting of the skin and subcutaneous tissue and the second, breast parenchyma. Although interrelated, due regard should be made on the impact of one on the other. For best results, these two tissue components may occasionally have to be tackled separately during surgery. Incision design involves dissection down to the subcutaneous tissue while resection patterns address complete lesion extirpation from breast parenchyma in full thickness.

Tumour location is an important factor for determining both incision design and resection pattern. In line with this purpose, the lower hemisphere may be divided into three sections, the medial, central and lateral thirds (Figure 1A). This is considered in conjunction with distance from nipple-areolar complex (NAC), indicated by zones demarcated by three imaginary concentric circles drawn around the areola in proportionately increasing diameter (Figure 1B). Topography of nine sectors is thus provided for surgical planning. Depending on the sector(s) involved, a variety of incisions in conjunction with certain tissue resection patterns may be used to consistently achieve good cosmetic outcomes with standard BCT. These tissue resection patterns follow the patho-anatomy of the “sick lobe” to remove areas affected by genetic predisposition to carcinogenesis (14-16). A suggested algorithm for a standardised surgical approach according to the tumour site and extent of the lesion is provided in Figure 2. Some of these techniques have already been described. However, for clarity, the more commonly employed techniques will be expatiated here in further detail.

Figure 1 The sections of the lower hemisphere of the breast divided into medial, central and lateral thirds. (A) Distance from the NAC to the inframammary fold or the periphery of the breast may be divided into three zones, demarcated by concentric circles of increasing circumference, equidistant from the edge of the areola; (B) classification of zones are as follows: Zone zero (Z0)—retroareolar; Zone 1 (Z1)—away from, but in the concentric circle nearest to the areola; Zone 3 (Z3)—within the circle closest to the periphery of the breast or inframammary fold; Zone 2 (Z2)—within the circle midway between Zone 1 and Zone 3. NAC, nipple-areolar complex.

Figure 2 Suggested algorithm for incision design and surgical approach to breast conserving surgery for malignancies in the lower hemisphere.

Lower medial third

In the past, skin crease incisions were recommended and radial incisions discouraged (17). However, the dual demands of raising the eligibility of BCT with reductionist surgical techniques and achieving optimum cosmetic outcomes in the lower inner quadrant of the breast require different approaches from conventional methods of the past, especially so in terms of skin incisions. For lesions close to the NAC, the boomerang incision or its modifications may be used (18) (Figures 3,4). The boomerang incision is so named as the prototype design, which is a combination of a short section of a crescent around the nipple and a tapered triangular radial limb, resembled a boomerang (18). This incision offers good exposure for lesions close to the nipple. Lesions at the periphery of the breast can be approached using different incisions, the arrowhead (19) or double arrowhead (Figure 5), depending on tumour extent.

Figure 3 Illustrates the use of the boomerang incision in lower medial third cancers. (A) This patient presented with multifocal breast cancer in the lower inner quadrant of the left breast. One lesion was palpable (outlined in a black ellipse) and the other (localised, approximate position marked with an “x”) in the retroareolar region; (B) depicts the surgical planning with a “boomerang” incision (in blue) and the relative positions of the tumours (in black). Both lesions were excised en bloc through an elliptical resection pattern, (in purple) which allowed uncomplicated tissue apposition beneath the radial limb of the incision, after mobilising parenchyma in the direction indicated by red arrows. Disruption of tissue architecture was minimised. Her final cosmetic result 6 months and 12 years after completion of treatment is demonstrated in (C-F). Over this period of time, the patient has gained some weight, making the indentation of the scar slightly more prominent. However, it does not detract from her continued rating of her cosmesis as “excellent”.

Figure 4 Illustrates the intraoperative steps for mBCS for a patient with a tumour in medial sector of the left breast. A boomerang incision was initially planned for this patient. (A) However, as this 25 mm tumour was sited in Z2, a decision was made to omit the periareolar crescent portion of the boomerang incision, in line with performing minimalist therapy. After resection of tissue shown in (B), leaving a defect seen in (C), mobilisation of tissue off the pectoralis major muscle allowed direct parenchymal approximation (D) and skin closure (E), leading to the cosmetic outcome depicted in (F) 2 years after completion of treatment.

Figure 5 Demonstrates two incision options for lower medial third tumours close to the inframammary fold. (A,B) Depict the use of the “single” arrowhead incision for a tumour sited in Zone 3 and the concomitant cosmetic outcome 1 year after treatment; (C) shows surgical planning for disease which was clinically 60 mm at presentation. Following neoadjuvant chemotherapy, residual imaging findings were approached through a double-arrowhead incision. The disease segment, which approximates the “sick lobe”, was resected through a trapezoid pattern. She is currently disease-free four years after treatment. Despite some asymmetry, the patient is satisfied with her cosmetic appearance (D) as the surgery resulted in an eversion of her congenitally inverted nipple without the complication of nipple necrosis occasionally seen with wise pattern mammoplasty procedures.

Through these incisions, full thickness tumour excision is performed using pre-planned tissue resection patterns. To optimise parenchymal closure and aesthetic results, resection patterns for medial third lesions are usually in similar axis to the incision, although there may be occasions when it is required to different. Elliptical parenchymal tissue resection pattern with the long axis aligned radially approximates closely to the affected “sick lobe” (Figure 3). A modified trapezoid resection pattern may be necessary to accommodate excision of a more extensive lesion. Full thickness parenchymal flaps are mobilised off the pectoralis major muscle, advanced and apposed using absorbable sutures. Skin flaps may need to be raised to avoid skin dune formation along the periphery of the incision. For best results, a skin crease incision in the lower medial third of the breast should be avoided.

Middle lower third (5–7 o’clock position)

Lesions in close proximity to the NAC in the lower central third of the breast may be approached through a golf-tee incision (20) (Figure 6A-F). This incision is a combination of two boomerang incisions symmetrically placed on either side of an imaginary radial axis, forming a shape resembling a golf-tee. When the tumour is in close proximity to the NAC, a diamond-shaped parenchymal resection pattern may be used. Following resection in this configuration, restoration of cosmesis is optimised after mobilisation of full-thickness tissue flaps with closure in two planes, in a sagittal plane as well as transversely. Lesions at the periphery can be approached through an anchor incision (21) (Figure 6G,H), and excised using either an elliptical or triangular tissue resection pattern. As always, the parenchymal pillars immediately adjacent to the tumour cavity are mobilised and apposed with sutures. This approach allows a good cosmetic result without the need for routine upward nipple displacement. As the parenchymal pillars surrounding the biopsy cavity are apposed beneath the incision, radiotherapy boost may be administered based on scar location. This obviates the need for multiple clips within the breast.

Figure 6 The use of the golf-tee incision is illustrated for lesions just below the lower edge of the areola. (A) This patient had a 22-mm non-invasive tumour. After full thickness resection of the lesion and mobilisation of the parenchymal walls (B), apposition of the in two planes is performed (C), followed by skin closure (D). Her result 2 years after treatment is shown in (E,F). If the lesion in lower, an anchor incision (G) may be applied, which is well hidden from the front view and with the patient’s arms at the side. It is only clearly demonstrated at an angle (H).

Lower lateral third/lower outer quadrant (LOQ)

Several incision patterns may be used for lesions in the LOQ. For lesions close to the NAC, a boomerang incision consisting of an inferior crescent and a lateral limb is preferred by the author (Figure 7A,B). The length of the lateral limb may be adjusted according to the extent of the disease. Tumour is usually excised through an elliptical resection pattern (Figure 7C). Full thickness parenchymal closure is then performed, followed by skin closure (Figure 7D), which results in acceptable cosmesis (Figure 7E,F). Depending on position and extent of lesion(s), a modified golf-tee incision may also be used (Figure 7G,H). Larger tumours involving a segment extending to the periphery of the breast close to the inframammary fold may be approached through an arrowhead incision (Figure 7I,J).

Figure 7 This 39-year-old patient was diagnosed to have a multifocal tumour in the LOQ of the left breast at another specialised breast unit centre and was offered a mastectomy. (A) Having sought a second opinion with the author, she was agreeable for an attempt at breast conservation. A boomerang incision was selected. However, the long axis of the resection was slightly different from the axis of the lateral limb of the incision (indicated by purple broken lines in B). After en bloc resection of both lesions with clear margins, apposition of the parenchymal walls in the direction of the red arrows are made after adequate mobilisation of the entire thickness of breast tissue off the pectoralis major muscle (B,C,D). Her final cosmetic result is shown in (E,F), and the mild asymmetry is acceptable to the patient. An alternative incision would be modified golf-tee incision (G,H). Extensive lesions closer to the inframammary fold in a large ptotic may be approached through an arrowhead incision. The scar is well hidden when viewed from the front, and only a mild asymmetry is discernible (I,J).

Skin crease incisions may be used for tumours sited midway between the nipple and the inframammary fold in the LOQ, both for women with smaller breasts with minimal ptosis and those with larger ptotic breasts (Figure 8). In such cases, optimum results are obtained with diamond-shaped tissue resection patterns instead of elliptical excisions. The mobilised parenchymal flaps are apposed both in the radial and circumferential (anti-radial) planes.

Figure 8 Skin-crease incisions may be used for lesions in the lower lateral third of the breast for both women with smaller and larger mammary volumes. The patient depicted in (A-F) presented with a palpable lesion. The options for incision design were either a boomerang incision, or a skin crease incision. She was assessed to have adequate breast volume for a skin crease incision, which was eventually decided upon. Note the excised specimen illustrating the resection pattern (B). Final histology revealed was 20 mm grade 3 invasive ductal carcinoma without lymph node involvement. Her final result the next year after treatment is shown in (E,F). The patient depicted in (G,H) was diagnosed to have a 20 mm ductal carcinoma in situ by excision biopsy at another centre. Margins were involved. Mastectomy was recommended by her first surgeon, citing small volume breast tissue as the reason. Hence, she sought a second opinion. As she already had a prior biopsy, surgery was performed using the original incision. And a diamond-shaped resection pattern was used for tumour extirpation. Her final result after wide excision with clear margins is shown in (H). The outcome for these two patients illustrates that this technique may be used for breast volume of varying sizes with acceptable cosmesis.

For very large lesions in the LOQ, there may be rare occasions when mammoplasty procedures are required if more than 25% of tissue volume is expected to be removed.

Comments

Techniques which raise eligibility for breast conservation are particularly relevant in the current context of potential improved survival and local control with BCT when compared to mastectomy (1,2). A minimalist approach offers shorter operating times, lower complication rates without compromising local control or survival outcomes (4,6-10). Interestingly, data suggests that patients view cosmetic outcomes differently from specialists and computer software programmes, and may rate standard BCT results more favourably than those achieved through mammoplasty (7,22,23). Serious cosmetic deformity can result from OBS (24), while mild distortion and minor asymmetry, as potentially seen with mBCS, may be acceptable to the patient without any impact on quality of life (23). Hence, routinely preforming OBS procedures like reduction mammoplasty for T1 lesions 2–13 mm in size (25,26) may be considered overtreatment.

The use of Level II OBS operations may be further reduced with adoption of neoadjuvant chemotherapy for downstaging (27) and current standards of “no ink on tumour” for margin width (28). Intraoperative assessment with frozen section analysis (29) can offer similar or lower re-excision rates than those reported with mammoplasty (25). Using a combination of available medical technology, resection volume may be reduced to its minimum to achieve negative margins, ensuring adequacy of retained tissue parenchyma for tissue repair in its most uncomplicated form. Neither cosmesis nor local control is significantly compromised, offering possibilities for high conservation rates in populations previously considered to be poor candidates for BCT (30).

The modern era of breast cancer therapy focuses on appropriate therapeutic de-escalation to minimise adverse iatrogenic impact of treatment (31). “Minimalist” or “reductionist” procedures comprising irreducible surgical elements without compromising stringent oncologic principles of negative margins and good cosmetic outcomes would be consistent with this philosophy. In contrast, the routine use of mammoplasty with contralateral symmetrisation, as proposed by some (32), would be antithetic to this concept. This diversity can serve as an impetus for future research to clarify selection criteria for the appropriate use of mBCS, OBS and mastectomy to individualise surgical treatment for optimum outcomes.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Informed Consent: Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.

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