Oncoplastic breast surgery and radiotherapy-Adverse aesthetic outcomes, proposed classification of aesthetic components, and causality attribution

Abstract

The aim of this paper is to discuss and understand the interplay of surgical and radiotherapy (RT) techniques that potentially affect the aesthetic outcomes following breast conservation treatment. It reviews the reported cosmetic outcomes within the practice‐changing RT trials incorporating varied fractionation regimes as well as sequence (before, during, or after surgery) over the past two decades. The paper importantly highlights an overall improvement in breast surgical techniques particularly oncoplastic breast conservation techniques due to dedicated and streamlined training of late. Hence, erstwhile complications or sequel of breast surgery and associated post‐RT aesthetic concerns may not be of the same variety or magnitude that were noted in the past. Paper thus concludes by highlighting the paradigm shift in the breast surgical practice that will have a bearing on the accuracy of RT outcomes assessed (within or out with clinical trials) with implications as a potential research and outcomes assessment gap.

Patient satisfaction after unilateral oncoplastic volume displacement surgery for breast cancer, evaluated with the BREAST-Q™

“…This finding supports the approach to offer contralateral surgery in the primary setting only in selected cases, and otherwise as a secondary procedure after individual assessment. Since PRT can cause unpredictable changes to the breast [17, 18], it might be better to wait until the 1-year follow-up visit to see if contralateral surgery is needed. Achieving a better long-term symmetrical appearance when the “template,” in form of the cancer-treated breast, has reached its final outcome could be easier than trying to predict the change over time and compensate for this in the primary setting.…”

“…Tumor location in the medial, inferior, or central parts of the breast is also related to lower satisfaction after BCT [10, 11, 14, 15]. In addition, postoperative radiotherapy (PRT) can accentuate a suboptimal esthetic result by substantial and unpredictable shrinkage [16–18]. Other observed risk factors for lower patient satisfaction after BCT have been high body mass index (BMI) [12, 14], axillary clearance [12], postoperative complications [11, 12, 14], reoperative procedures [10, 12, 14], adjuvant chemotherapy [15], large scars after resection [10], and how the patient perceived the preoperative information and possibility to participate in decision-making regarding surgical technique [19].…”

Reply: Outcomes of Volume Replacement Oncoplastic Breast-Conserving Surgery Using Chest Wall Perforator Flaps: Comparison with Volume Displacement Oncoplastic Surgery and Total Breast Reconstruction

“…1 We thank the authors for their comments and are very grateful to them for giving us the opportunity to further discuss the potential challenges of delivering adjuvant tumor bed boost radiotherapy following this surgery. As the authors point out, whereas an accurate definition of the tumor bed has been well-established for traditional volume displacement oncoplastic breast-conserving surgery, where the cavity walls are apposed, [2][3][4][5] there has yet to be consensus for volume replacement oncoplastic surgery where the tumor bed is undisplaced, with the cavity walls separated by the perforator flap filling the surgical defect.…”

Dermatologic sequelae of breast cancer: From disease, surgery, and radiation

“…RT‐associated angiosarcoma typically presents as in‐field skin thickening, induration, edema, and/or pigmentary change 24 . Surgery is standard of care, often requiring a mastectomy and wide surgical margins of all irradiated skin, although recurrence rates are still high despite aggressive management 25,26 …”