Orbs A New Era in Breast Cancer Surgery

Breast cancer is the commonest cancer amongst the Indian women and an estimated 400.000 women die annually from this disease worldwide. Though the mortality rates have fallen over last two decades, the incidence continues to rise with an average life time risk of approx.10 {abffe3e1318a9624791ae4064333f2f75374704dc13d09152fd440b16c9e1c0c}. The incidence recorded in Delhi is 24.8 new cases of breast cancer a year per 100,000 women which rose to 32.2 in 2005. The incidence begins to rise in the early thirties of age and reaches a peak in the 50-65 age group of the population. The risk of breast cancer approximately doubles if woman has a first-degree relative (mother, sister, and daughter) who has been diagnosed with breast cancer.

The most significant risk factors for breast cancer are gender (being a woman) and age (growing older). About 90{abffe3e1318a9624791ae4064333f2f75374704dc13d09152fd440b16c9e1c0c} of breast cancers are due to genetic abnormalities that happen as a result of the aging process and life in general.

About 20-30{abffe3e1318a9624791ae4064333f2f75374704dc13d09152fd440b16c9e1c0c} of women diagnosed with breast cancer have a family history of breast cancer.

About 5-10{abffe3e1318a9624791ae4064333f2f75374704dc13d09152fd440b16c9e1c0c} of breast cancers are caused by gene mutations inherited from mother or father. Mutations of the BRCA1 and BRCA2 genes are the most common. Women with these mutations have up to an 80{abffe3e1318a9624791ae4064333f2f75374704dc13d09152fd440b16c9e1c0c} risk of developing breast cancer during their lifetime and they often are diagnosed at a younger age (before age 50). The early diagnosis of Breast cancer plays an instrumental role to achieve a cure for this cancer.

The Era of surgical management started with supraradical operations down to Radical operations i.e. Traditional Halsted mastectomy then came an era of modified approach. These aggressive surgical operations have not shown any improvement in overall survival (OS). Patients used to have not only a psychological trauma but in long-term they have lots of other complications like Lymph edema of arm etc. To overcome these shortcomings of aggressive approach, we started the conservative surgery. Then favorable results were reported as an outcome of largest long term trials which demonstrated comparable survival which is independent of the surgical modality i.e. mastectomy versus BCT. This overview has prompted us to incorporate the aesthetic approach in conservative surgeries for Breast Cancer. This has led a new era in the surgical management of Breast Cancer and the modality is called an ORBS.

ORBS mean oncoplastic and reconstructive Breast surgery. Oncoplastic surgery combines Oncosurgical principles with plastic surgical techniques.

The oncoplastic concept is a wave of future for surgical management of Breast Cancer. This is a fast emerging and most innovative technique which has not only changed the surgical management of Breast cancer but had alleviated psychological trauma of loosing their breast or living with disfigured breast. Gone are the days when surgeons simply left the cavity to fill with haematoma or allow forming a seroma. The oncoplastic surgery is becoming an essential skill for all dedicated Breast Surgeons, or General Surgeon and Plastic Surgeon in combination.

Today, breast conserving therapy has become the standard of care for many women diagnosed with breast cancer. Till now we were practicing the Breast conserving Surgery a part of Standard BCT where the primary treatment is partial mastectomy (Lumpectomy or Quadrantectomy) with adjuvant radiation and chemotherapy. But the incidence of poor cosmetic results is relatively high with standard BCT. Now the oncoplastic technique has not only preserved the breast but maintains a breast that is aesthetic, symmetrical, and well shaped. The poor planning in breast conserving surgery (BCT) had resulted some times an unacceptable deformity.

This technique eliminates the poor cosmetic results after wide excision of the Tumor. Oncoplastic resection is a therapeutic procedure, not a breast biopsy. It is performed on patients with a proven diagnosis of breast cancer. Our main goal is to go to the operating room a single time and to perform a definitive procedure that does not require re-operation. Whenever possible the initial breast biopsy, should be made using a minimally invasive percutaneous technique i.e. vacuum assisted syringe and needle or a core biopsy. The cut of core biopsy is very small and can be closed with a Steri Strip.

The ORBS is basically a lumpectomy or quadrantectomy combined with rotating the same breast tissue or mobilizing the flap to fill up the resected cavity in one surgical procedure at the same time. It also includes to correct the comparative change in shape and size in relation to unaffected breast and if need arises reshaping the unaffected breast. The deferred plan of reconstruction is not included in the oncoplastic technique. Both the procedures are carried out by dedicated breast surgeon.

PRINCIPLE:

The goal of breast reconstruction after Tumor resection is to improve the appearance when the woman is full clothed and avoids the external prosthesis. The oncoplastic technique extends the scope for conserving surgery by combing an extensive local excision of the breast parenchyma with a simultaneous reconstruction of the defect to avoid local deformity. This technique does not compromise oncological principles as it gives a free hand to the Onco Breast surgeon.

The sole guiding factor for the evolution of this technique was that we might have compromise the oncological principle for effective local control to achieve the cosmetic results while operating the patient with standard BCT. Secondly Standard BCT may produce the poor cosmetic results which may be difficult to correct after the radiotherapy.

Broadly it means the adaptation of breast reduction and mastopexy techniques to some of the cancer surgery procedure.

The ORBS uses either the adjoining breast tissue which is rotated to fill the defect at the time of Lumpectomy or larger “quadrantectomy” procedures or transfer the tissue from distant area by means of Flap which serves dual purposes to fill up the cavity and cover the skin have to take in account the potential delay in adjuvant treatment which may occur as a result of complications.

Secondly, we have to consider the adverse effect of adjuvant treatment upon the reconstruction.

Decision of the patient

All the patients who are opting for ORBS must be informed in details about this technique so that she can take a suitable decision herself. These patients usually have very high expectations about the out come of reconstruction. She should be aware of potential long term implications, may require multiple surgical procedures in case she wants .

Nipple – Areola reconstruction.

The women who decide against immediate reconstruction should be told about the delayed reconstruction also.

Sometimes women may be benefited with the service of psychologist who help them through the decision making process. The patient has to be told about the scaring, loss of sensation, changes at any donor site, or complications of surgery. The family and the partner of the patient should be equally involved. It have been observed that women opting ORBS over mastectomy are more concern about their body image and strongly believe for good figured breast a necessity for their good image. They react very badly to the idea of losing the breast. The personality characteristics also influence a woman’s decision.

An Informed Consent

The pre-operative preparation, assessment and type of Anesthesia are the same as for other operations but of course the risk factor should be recorded.

Indications

ORBS should be considered in those patients where adequate local excision can not be achieved without significant risk of local deformity. This usually happens:

lumpectomy excision.

Contraindications:

1) Patients with inflammatory carcinoma2) Patients with T4 tumors3) Multicentric disease in breast4) Extensive malignant mammographic microcalcification

Selection of the reconstructive Procedure:

The principle to select a reconstructive procedure depends upon three important points(1) whether we want to either replace the volume or displace the volume(2) This further depends upon the site of the tumor, extent of resection in relation to the size of opp.breast(3) The likelihood displacement of Nipple -Areola complex has to be most common reconstructive technique for volume replacement is the use of latissimus dorsi mobilization of local glandular or dermoglandular flaps is the most accepted technique used for volume displacement.Simultaneous contra lateral reduction to achieve the symmetry is always a point for details of above said procedures or other techniques are beyond the scope of this article and can be referred in the Text book.

Advantages:1. This technique gives us greater margins of resection -Size of the breast tissue that is excised surrounding the Tumor.2. The inframammary fold is preserved.3. The resulted operated area is of good quality and least scarred.4. Both breasts will look the same.

The reduced breasts are functional and have full sensation whereas the reconstructed breasts lack both.

The rate of recurrences, survival (OS), and disease -free survival (DFS) with oncoplastic surgery are all equivalent to those of traditional breast cancer treatment.

This technique may further widen the scope of conservative surgical treatment i.e. after Neoadjuvant chemotherapy.

Disadvantage:

The long term results of this technique are to be published as yet. Patients with tumor larger than 2 cm were at greater risk of local recurrences and distant metastasis but are same as for standard BCT.

Procedure:

The surgical procedure is depicted by the fallowing conditions:Volume Displacement??? Planning Tumour Exision Depth??? Glandular Flap Final Result & Implant ShownVolume Replacement??? Planning Exition & Depth??? Overhanging Ld Flap Final Result

Review Of Literature:

The published data indicates that the immediate breast reconstruction does not adversely affect breast cancer outcome. The reconstruction does interfere with further treatment and there is no significant difference in the overall survival rates between immediate or delayed reconstruction.

Conclusion:

To conclude this article it is stated with firmity that this technique achieves both ultimate goals: Firstly an adequate local control of the disease and good aesthetic results, secondly it provides survival equivalent to mastectomy. The oncoplastic surgery adds to the oncological safety of breast conserving treatment because a large volume of breast tissue can be excised and a wider negative margin can be obtained. It is especially indicated for large tumors, for which standard breast conserving treatment has a high probability of leaving positive margins with disfigured breast. The long term results of this technique are to be published as yet but they are comparable. It is safe to offer this technique to our women who are more concern for their body image.