Evidence-based indication of
Oncoplastic Breast Surgery
Wonshik Han, M.D. Ph.D
Professor
Dept. of Surgery, Seoul National University College of Medicine
Chief of Breast Care Center, Seoul National University Hospital
Contents
• Goals and benefits of OPS BCS
• Indications of OPS BCS
• Classification of procedures
• My experience
What is Oncoplastic Surgery?
• Oncoplastic surgery (OPS):
Resection of the tumor
and reconstruction of the defect
using plastic surgical techniques
The term “Oncoplastic surgery” was introduced in 1993 and published in 1994 by Werner P. Audretsch et al.
Does not mean small incision, small Vol resection, nor microinvasive surgery
Oncologic outcomes must
NEVER be compromised
by cosmesis
Breast Surgeon’s Dilemma: Radicalityvs. Cosmesis
“You can have your cake and eat it too with OPS”
Advantages Disadvantages
Resection of larger breast
volumes
Longer duration of surgery
Wider free margins More visible scars
Less re-excision, Less conversion
to 2’ mastectomy
Higher complication rate possible
Better cosmetic results Experienced breast surgeon or
plastic surgeon is necessary
Extension of BCS indication
Advantages and disadvantages of OPS
Large breast
and
large tumor
Who Can Benefit From OPS Techniques?
Close to
the nipple
Unfavorable
Location
Contralateral ptosis
First international consensus conference on standardization
of oncoplastic breast conserving surgery (in Basel)
Weber, et al. BCRT 2017
A Meta-Analysis Comparing BCS alone (N=5494) to the OPS
Technique (N=3156)
OPS
reduction
OPS flap BCS alone P value
Tumor size
cm
2.5 2.9 1.23
Lumpectomy
weight g
249 184 64 <0.0001
Positive
margin %
12.4 12.2 20.6 <0.0001
Reexcision % 2.9 5.7 14.6 <0.0001
Satisfaction
%
89.2 91.9 83.0 <0.001
Losken, et al. Ann Plastic Surg 2014
OPS vs. Lumpectomy: Esthetic outcome
OPS group
(N=57)
Lumpectomy
group (N=57)
Adjusted p value
BCCT.core:
Excellent (%)
22.8 6.2 0.004
Specialists:
Excellent (%)
50.9 18.5 <0.001
Patients:
Excellent (%)
61.4 69.2 0.320
Santos, et al. Ann Surg Oncol 2015
Effect of cosmetic outcome on quality of life
after breast cancer surgery
• BCS (N=485), TM (N=87), TM with immed recon
(N=46) in SNUH
• BCCT.core, Specialists panel, Pt’s body image
perception (body image scale)
• General QoL was not associated with objectively
measured cosmetic results
• Self-perception of body image seems to be more
important for QoL
Kim MK, et al. EJSO 2015
OPS, self perception of cosmetic outcome,
and QoL
OPS doesn’t increase patients’ self perception of esthetic outcome
QoL is dependent on self perception of body image, not
surgeon’s measurement
?
OPS
surgeonPygmalion?
Positive margins and reexcision
• Carter, et al. (Ann Surg Oncol 2016)
– Lower rate of positive or close margins with OPS
(5.8% vs 8.3% with BCS, p=0.04)
• Down, et al. (Breast J 2013)
– Lower need for re-excision with OPS (5.4 vs. 28.9%
with BCS, p = 0.002)
A Meta-Analysis Comparing BCS alone (N=5494) to the OPS
Technique (N=3156)
OPS
reduction
OPS flap BCS alone P value
Tumor size
cm
2.5 2.9 1.23
Lumpectomy
weight g
249 184 64 <0.0001
Positive
margin %
12.4 12.2 20.6 <0.0001
Reexcision
%
2.9 5.7 14.6 <0.0001
Satisfaction % 89.2 91.9 83.0 <0.001
Losken, et al. Ann Plastic Surg 2014
First international consensus conference on standardization
of oncoplastic breast conserving surgery (in Basel)
Weber, et al. BCRT 2017
Large or multifocal tumor
• Chang, et al (Ann Surg 2012)
– 85 large tumors with PM and reduction
mammoplasty
– 29.4% tumor size >4cm
– 94% achieved successful conservation
• Clough, et al (Ann Surg Oncol 2015)
– 277 level II OPS (“quadrant per quadrant atlas”)
– Mean tumor size 26mm
– Margin positive rate 11.9%
– 91% achieved successful conservation
CLASSIFICATION OF
PROCEDURES
Clough, et al. Ann Surg Oncol 2010, BJS 2012
OPS for breast cancer based on tumour location and
a quadrant-per-quadrant atlas
OPS level
I Less than 20% of breast volume excised
No skin excison required
No mammoplasty required
II Anticipation of 20–50% breast volume excision
Excision of excess skin required to reshape breast
Based on mammoplasty techniques
Oncoplastic surgery for breast cancer based on
tumour location and a quadrant-per-quadrant atlas
Level II OPS
Clough, et al. Ann Surg Oncol 2010, BJS 2012
Upper
pole
inferior pedicle mammoplasty, via an
inverted-T incision, Round block
technique
UOQ lateral mammoplasty technique
(Tennis-Racket)
LOQ J-mammoplasty
Lower
pole
inverted-T mammoplasty with a
superior pedicle
LIQ V-mammoplasty
UIQ batwing technique, round block
Hoffmann Classification
Hoffmann and
Wallwiener.
BMC Cancer 2009
Basel classification
Weber, et al. EJSO 2017
First international consensus conference on standardization
of oncoplastic breast conserving surgery (in Basel)
• Most panels agreed Clough’s classification is useful
in clinical practice for indicating, planning, and
performing the procedure
• Hoffmann classification was recommended for
operating report and use for clinical research
• Basel classification useful for operative report and
for distinguishing BCS from OPS
Weber, et al. BCRT 2017
Aug 2011 – Dec 2014 Total 574 cases
Method Technique N
Volume
displacement
Tennis racket incision 290
Round block 104
Reduction mammoplasty
(Sup. or Inf. Pedicle) 37
S-shape oblique mammoplasty 6
Matrix rotation 18
Axillary skin rotation 5
J-plasty 23
B-plasty 16
V-plasty 13
Grissotti flap 7
Bat wing 4
Nipple reposition 4
etc 3
Volume
replacement
Mini- LD flap 32
Omental flap 12
Total 574
8
My experiences in SNUH
BCS
n= 1123
OPS
n=466
P value
Mean age 50.4 49.5 >0.05
Max. tumor diameter (cm)
(including DCIS)2.17 3.11 <0.001
Multifocal cancer 117 (11.0%) 64 (16.1%) 0.006
Distance to nipple(cm) 4.0 3.0 <0.001
Margin positive 7.4% 7.3% >0.05
Re-excision 6.3% 7.1% >0.05
Operation time(min) 57.2 95.6 <0.001
My experiences in SNUH
Now the number is decreasing due to
increased use of neoadjuvant therapy
and increased use of mastectomy and
immediate reconstruction
Number of breast reconstruction in SNUH
Hong KY, et al.
Arch Plast Surg
2018
National insurance
coverage of breast
reconstruction since
2015
BCS rate in SNUH
56.960.4
63.9
71.866.5
63.366.5
64.3 65.662.6
56.9
62.4
53.7
60.3
0
10
20
30
40
50
60
70
80
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
BCS rate
Tumor location Preferred procedure
Center Grisotti flap, Purse string suture
Periareolar Round block, Batwing technique
UpperInf. Pedicle mammoplasty,
S-shape oblique reduction mammoplasty
Upper outer,
Outer
Latissimus dorsi flap or mini-flap,
Tennis racket incision, B-Plasty
Upper inner Matrix rotation
Lower Sup pedicle mammoplasty, omental flap
Lower inner V-plasty, Omental flap
Lower outer J-plasty
My OPS procedures according to tumor location
A. Skin marking & resection
B. Rotation of the flaps(outer -> inner)
C. Final result after reshaping
Level II OPS: Rotation flap(Matrix rotation)
(Upper inner quadrant)
LUI 4x3 cm mass
Level II OPS: Grisotti flap
(Central portion)
De-epithelization of the flap and a skin island preservation
-> Glandular mobilization
Circumareolarskin incision and new NAC marking
Excision of NAC & tumor
Skin (new NAC circle) closure
Level II OPS: S-shape oblique reduction mammoplasty
(upper)
Final pathology:
Tumor extent including
DCIS 5.5x2.0x4.5cm
3.2cm mass on
MRI
Mini-LD flap (upper outer quadrant)
Lateral mammary fold skin incision.
Resection of breast tumor
The mini-LD flap harvest & fill the defect
Postoperative status
No need for incision on patient’s back
No need for patient position change
It takes only 1 hour and 30 min.
Sentinel LN biopsy and
identification of
Thoracodorsal vessels
Omental flap
(lower and lower inner quadrant)
Inf. mammary fold skin incision.
Wide resection of the lesion
Omentumharvest (laparoscopic by UGI surgeon)
Postoperative status
Delivery of dissected pedicled omentumthrough a hole just beside xiphoid process (2 finger breadth): be careful for twisting or choking of the omentum
Prospective trial investigating the association
between cosmetic result and quality of life
• N=400 in SNUH since 2016 (290 enrolled now)
• Only DCIS (to avoid the effect of adj therapy)
• BCS (with or without OPS) and TM with immediate
recon
• Patients interview and photo (preop and postop
1yr)
• BCCT.core and panel assessment for cosmetic result
• Breast-Q for QoL assessment
Summary
1. OPS improves objectively measured esthetic outcome, but
uncertain for patients perceived body image and QoL
2. OPS might reduce reoperation rate for positive resection
margins
3. OPS might not reduce local recurrence rate
4. OPS broaden the indication of BCS (large or multifocal
tumors)
5. OPS based on tumour location and a quadrant-per-quadrant
atlas (Clough’s classification) is useful in clinical practice
6. Now the number of oncoplastic BCS is decreasing in Korea
due to increased use of neoadjuvant therapy and increased
use of mastectomy and immediate reconstruction
7. We need more high level evidences, more tools for
assessment, and more standardization of the OPS procedures
Thank You for attention!
