Five Years of Breast Oncoplasty at KIMS and the Way Forward
The current COVID-19 pandemic has forced each one of us to pause, reassess where we stand, look at what we have done in the past, and to chart out a plan for the future.
At Kalinga Institute of Medical Sciences (KIMS), we have been working as a Surgical Oncology unit for the past seven years. The work that we have done, encompasses solid organ cancers and tumors of almost all parts of the body, be it Head and Neck, Thyroid, Parotid and Submandibular glands, Breast, Esophagus, Mediastinum, Thymus, Hepato- biliary-pancreatic, Gastrointestinal, Genitourinary, limbs, Skin, etc, by conventional, minimal access and innovative techniques. All of this has been done achieving excellent outcomes, extremely low morbidity and mortality rates.
Out of the above, one field that we discuss in this article is, Breast Oncoplasty.
In the initial years of our practice, we were doing breast conservation along with conventional mastectomies for Breast Cancer. We standardized our procedures such that we currently have one of the best outcomes possible, in terms of disease free survival, almost no breast skin flap failures and extremely low lymphoedema rates.
With conservative breast surgery, partial mastectomies, we found that simple closure techniques left a lot to be desired in terms of the final cosmetic outcomes following completion of adjuvant Radiotherapy. We thus embarked upon a journey (that continues even today), learning from international and national leaders in the field of Breast Oncoplasty and transferring the benefits to our patients.
Breast Oncoplasty is a niche field of Breast Cancer Surgery that combines the right application of proper oncological principles during disease resection and lymph node management, with local tissue displacement, replacement techniques to achieve optimum cosmetic goals of breast restoration.
It requires a good understanding of disease behaviour, management, human anatomy, different local and regional flaps, appreciation of the human form and how each individual is different from another in terms of their body constitution and self-image consciousness, disease, expectations and many other factors.
Breast Oncoplasty has been standardized and classified over the years, as per increasingly complex levels of expertise. Level I techniques employ simple closure with tissue mobilization in such a way as to cause minimal scarring and deformity. It is applicable to small volume deficits described to be up to 20% of breast volume.
Level II techniques include tissue mobilized from adjacent areas of the breast or perforator flaps around the breast to replace deficits of upto 40-50% of breast volume.
Level III techniques employ larger and more complex flaps, usually, free flaps to reconstruct deficits more than 50%. Sometimes, multiple perforator flaps can also achieve the same. Therapeutic, symmetrization reduction and mammoplasty techniques are also employed.
Detailed below are few examples of the work done so far.
We start with the first case that we had performed in 2015 on a young lady with a centrally located breast cancer right below and close to her nipple areola complex.
She underwent breast conservative surgery with wide excision (lumpectomy) of the lesion including the nipple and areola and axillary lymph node dissection.
The central defect and areola were reconstructed with a Lateral Dermoglandular flap designed from her own breast tissue. The results were excellent in terms of surgical parameters and patient satisfaction. She went on to receive Adjuvant Chemotherapy and Radiotherapy and is doing well.
The second case shown is a lady in her 50s with a large lump in the lower part of her left breast. She had a request for early surgery and a strong desire for breast conservation. Following Lumpectomy, her breast defect was almost of the magnitude of ¼ of her breast volume (quadrantectomy).
This required a large amount of tissue for reconstruction. This was mobilized in the form of a Lateral Thoracic flap. This is a technically challenging and rarely performed flap in breast reconstruction. Optimum results were obtained. She continues to be under regular follow up after adjuvant treatment.
The third case detailed below is of a lady who was found to have triple negative breast cancer (Negative for Estrogen, Progesterone and Her2 neu receptor amplification), BRCA mutation positive. On evaluation, she was found to have another small, non- palpable lesion in her opposite breast. This was also confirmed as carcinoma.
The larger lesion was on the lateral aspect with limited axillary lymphadenopathy. She underwent breast conservation with auxiliary dissection and level II Oncoplastic technique reconstruction (semilunar flap based on lateral intercostal artery perforators).
For the opposite breast, small lesion, she underwent Lumpectomy, closure with level I Oncoplasty techniques, with Sentinel lymph node biopsy. She has received Adjuvant chemotherapy and Bilateral Breast Radiotherapy and is currently under regular follow up.
The fourth case, a lady who had a lesion in the upper part of her breast, had to undergo lumpectomy with excision of overlying skin. Further excision was done because of suspicious tissue at margins resulting in a quadrantectomy. Reconstruction required a good volume of tissue. Lateral Thoracic artery perforator flap was raised and inserted to give good volume and symmetry to her breast. She also underwent axillary dissection through the same incision for raising the flap. She has completed her adjuvant treatment and is doing well.
The above mentioned are a few examples that highlight different situations and how breast Oncoplasty is integrated into the management of each case to achieve optimal outcomes.
Intraoperative frozen section analysis of lumpectomy margins and Sentinel lymph nodes is vital to the success of the above procedures. Cryostat and requisite expertise for frozen section analysis have been available at KIMS for more than 8 years now. We are thankful to our Pathology Team as well as Radiology Team for their support. We also have intra-operative breast sonography and specimen mammography facilities.
For the future, we should be improving our breast conservation rates, carrying out therapeutic, reducing mammaplasty, and implant based breast reconstruction among others.
To support the above, and carry out further research, basic and translational, we shall require specialized equipment like, perometry for more precise limb volume assessment, vacuum assisted biopsy for diagnostic and therapeutic uses, near infrared imaging for ICG based flap perfusion assessment, sentinel lymph node biopsy and lymphatic imaging.
We are currently carrying out research in close collaboration with the Research and Development wing of KIIT Deemed to be University and formulating new research questions to contribute to better patient outcomes.
The future is exciting and holds promise for more and more individualized treatment not just in terms of less radical and more appropriate surgery but also precision medical oncology, nuclear medicine and radiotherapy for neoadjuvant, adjuvant and palliative treatment of Breast Cancer Patients.