Aims and background: Breast conserving treatment (BCT) should provide similar quality of local control as mastectomy and avoid psychological distress due to mutilation. Randomized trials have demonstrated the value of conservative surgery for small tumors. Several publications have indicated the possibility of improving the cosmetic result when quadrantectomy is combined with plastic surgery. These papers focused on two techniques involving reduction mammaplasty and latissimus dorsi flap procedures. At the European Institute of Oncology (EIO) we use various plastic procedures to reshape the breast and to improve symmetry. The choice of these techniques depends on tumor size and location, as well as on breast volume.
Methods and study design: In two years (1995 and 1996) 111 patients were treated at the EIO with quadrantectomy and concomitant plastic surgery. Preoperative tumor staging was as follows: T1 57.5%, T2 29%, T3 4.5%, Tis 8%, and sarcoma 1%. The tumor locations were upper quadrant 50%, lower quadrant 40%, and central quadrant 10%. The plastic surgery techniques used included local glandular flaps, areola transposition, mastopexy or classical reduction mastoplasty procedures, the round block technique, prosthesis insertion, and distal musculocutaneous flaps. Cosmetic evaluation on the basis of predefined cosmetic criteria was carried out on photographs after a mean follow-up of 21 months. In 48 cases the patients' own rating of breast cosmesis was asked.
Results: The global results were good in 77.5%, fair in 17%, and poor in 5.5% of the patients. No statistical difference was observed between different tumor locations, although the percentage of good cosmetic results, which was similar in the upper and lower quadrantectomy groups, was slightly lower for centrally located tumors. With regard to the different techniques, we obtained 100% good results with the round block technique and the Grisotti flap, 87% good results with the inferior pedicle, 74% good results with the Lejour and superior pedicle techniques, 67% good results with the latissimus dorsi flap, and 58% good results with prosthetic implants. The outcome was less satisfactory when no contralateral mastoplasty was performed (14 of the 111 cases): 72% good, 14% fair, and 14% poor results. These differences were not statistically significant. The median weight of the specimens was 157 g, which is almost three-fold the usual weight in regular tumorectomies. Six carcinomas were found in contralateral breasts (4 DCIS and 2 infiltrating).
Conclusions: The double-team approach (plastic surgeons and oncologists) to BCT may improve the final cosmetic result following large tumor excisions. It can also extend the indications for breast preserving surgery. Moreover, it allows surgical and histological exploration of the contralateral breast when a surgical procedure for symmetry is required.