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Ann Surg Oncol

DOI 10.1245/s10434-016-5407-9

ORIGINAL ARTICLE BREAST ONCOLOGY

Operative and Oncologic Outcomes in 9861 Patients with


Operable Breast Cancer: Single-Institution Analysis of Breast
Conservation with Oncoplastic Reconstruction
Stacey A. Carter, MD1, Genevieve R. Lyons, MSPH2, Henry M. Kuerer, MD, PhD1, Roland L. Bassett Jr., MS2,
Scott Oates, MD3, Alastair Thompson, BSc(Hons), MB ChB, MD1, Abigail S. Caudle, MD, MS1,
Elizabeth A. Mittendorf, MD, PhD1, Isabelle Bedrosian, MD1, Anthony Lucci, MD1, Sarah M. DeSnyder, MD1,
Gildy Babiera, MD1, Min Yi, MD, PhD1, Donald P. Baumann, MD3, Mark W. Clemens, MD3, Patrick B. Garvey,
MD3, Kelly K. Hunt, MD1, and Rosa F. Hwang, MD1

1
Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX;
2
Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; 3Center for
Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX

ABSTRACT BCS ? R had a T1 or T2 tumor. There was no difference


Background. Oncoplastic reconstruction is an approach in the use of BCS ? R compared with BCS for any
that enables patients with locally advanced or adversely quadrant of the breast except the lower outer quadrant
located tumors to undergo breast conserving surgery (11.1 vs. 6.8 %; p \ .0001). BCS ? R had a lower rate of
(BCS). The objectives were to identify the use of BCS with seroma formation (13.4 vs. 18 %; p = .002) and positive
oncoplastic reconstruction (BCS ? R) and determine the or close margins compared with BCS (5.8 vs. 8.3 %;
operative and oncologic outcomes compared with other p = .04). There was no difference in overall survival or
breast surgical procedures for breast cancer. recurrence-free survival when comparing BCS and
Methods. This retrospective cohort study interrogated a BCS ? R.
single institutions prospectively maintained databases to Conclusions. Patients undergoing BCS ? R are not dis-
identify patients who underwent surgery for breast cancer advantaged in terms of complications and short-term (3-
between 2007 and 2014. Surgeries were categorized as year) outcomes compared with BCS patients or patients
BCS, BCS ? R, total mastectomy (TM), or TM with who underwent TM.
immediate reconstruction (TM ? R). Demographic and
clinicopathologic characteristics and postoperative com-
plications were analyzed. Breast conserving surgery (BCS) with radiation offers
Results. There were 10,607 operations performed for 9861 patients equivalent survival rates as mastectomy; however
patients. Median follow-up was 3.4 years (range, 0 many BCS-eligible patients still undergo mastectomy for a
9.1 years). The use of BCS ? R had a nearly fourfold number of reasons.1 Several reports indicate an increase in
increase in the percentage of all breast cancer surgeries bilateral mastectomy rates for unilateral in situ or invasive
during the study period; 75 % of patients who underwent disease.2,3 In the United States, the rate of mastectomy for
breast cancer patients has markedly increased in the past
decade with approximately 37.8 % of early-stage patients
undergoing mastectomy in 2011.2 While many factors may
Electronic supplementary material The online version of this
article (doi:10.1245/s10434-016-5407-9) contains supplementary be involved in this decision, a patients desire to avoid a poor
material, which is available to authorized users. aesthetic outcome may be a major contributor. Oncoplastic
surgery has gained popularity as an approach that allows for
Society of Surgical Oncology 2016 optimal oncologic resection while conserving the native
First Received: 11 April 2016 breast and achieving an acceptable aesthetic outcome for the
patient.49 Patients with locally advanced or adversely loca-
R. F. Hwang, MD
e-mail: rhwang@mdanderson.org ted tumors who are considered poor candidates for BCS are
S. A. Carter et al.

usually offered total mastectomy with or without recon- using frequency tables. Demographic information was
struction as an alternative. However, if these patients are able captured once for patients who had multiple procedures.
to undergo BCS with oncoplastic reconstruction, they may Comparisons were made using a v2 or Fisher exact test as
have an improved aesthetic result compared with BCS alone appropriate. Numeric covariates were summarized using
or even mastectomy. In addition, this approach may offer a mean and standard deviation and compared between
lower complication rate compared with total mastectomy groups using a Wilcoxon or t test, as appropriate. Formal
with implant-based or autologous reconstruction, particularly comparisons were made with respect to the type of pro-
if radiotherapy is given in the adjuvant setting.10 In addition, cedure performed. A Cochran-Armitage test for trend was
the concern for disease recurrence may be another factor that used to determine whether there was a trend over time in
influences the decision for mastectomy. Whether BCS with the proportion of BCS ? R over the study period. Survival
oncoplastic reconstruction has a similar oncologic outcome analyses were performed using the KaplanMeier method
compared with BCS alone or total mastectomy has not been and Cox proportional hazards models. Overall survival was
adequately investigated.11 In the current study, we sought to calculated from the date of initial surgery at MDACC. The
explore the emerging trend of oncoplastic reconstruction in 3-year survival probabilities were estimated with 95 %
patients undergoing breast conserving therapy at a single confidence intervals for each group. Statistical analysis was
institution and determine whether this approach affords a done with SAS version 9.4 (Cary, NC).
similar complication profile and oncologic outcome as have
patients without reconstruction. RESULTS

METHODS Surgery Trends 20072014

A retrospective cohort design using the prospectively A total of 10,607 operations were performed for 9861
maintained Breast Surgical Oncology Database at The patients in the study cohort. Overall, 33.6 % underwent
University of Texas MD Anderson Cancer Center (MDACC) BCS, 11.1 % had BCS ? R, 30.8 % had TM, and 24.6 %
identified 9861 patients who underwent 10,607 individual had TM ? R (Table 1). During the study period, the rate of
operations performed for in situ or invasive breast cancer mastectomy increased from 49 to 54 %, with a corre-
(TisT4) treated from January 1, 2007 through December 31, sponding decline in any BCS from 51 to 46 % (Fig. 1a, b).
2014. The 10,607 surgeries identified were categorized as During the early years from 2007 to 2010, BCS ? R
breast conserving surgery (BCS), BCS with reconstruction accounted for 10 % or less of all surgeries and only 8
(BCS ? R), total mastectomy (TM), and TM with immedi- 22 % of all breast conserving cases (Fig. 1ac). However,
ate reconstruction (TM ? R). Exclusion criteria included the rate of BCS ? R increased steadily from 2011 to 2014,
male patients, surgeries performed for benign lesions or making up more than 33 % of all breast conserving surg-
prophylaxis, lymph node only procedures, and patients who eries in 2014. More dramatically, the number of BCS ? R
did not consent to data collection. Clinicopathologic data procedures increased by more than fivefold from 2007 to
were recorded including staging according to the seventh 2014 (44243), with the steepest increase occurring after
edition of the American Joint Committee on Cancer guide- 2010 (p \ .0001 for BCS ? R trend over time). Compared
lines. Oncoplastic procedures, classified as BCS ? R, were with all surgeries, the proportion of patients undergoing
identified and classified according to CPT codes in an BCS ? R increased from 4 to 15 % despite the overall rise
institutional billing database (Supplemental Table 1) and in the mastectomy rate.
could have been performed by either the breast surgical
oncologist or a plastic reconstructive surgeon. Obesity was Patient and Tumor Characteristics For the current study,
defined as a body mass index greater than 30 kg/m.2 Data we focused on the patients who underwent BCS ? R
related to complications for surgeries performed from Jan- compared with the other 3 groups as shown in Table 1.
uary 1, 2010 to December 31, 2014 were compiled using Other comparisons are shown in Supplemental Table 2.
ICD-9 codes (Supplemental Table 1). This study was The mean age of patients who had BCS ? R was slightly
approved by the institutional review board at MDACC (IRB younger than those who had BCS and older than patients
PA15-0289). who underwent TM ? R (median, 57 vs. 59 vs. 50 years,
respectively; p \ .0001). The racial background was
Statistical Analyses similar for BCS ? R and BCS patients. Compared with
TM ? R patients, BCS ? R patients were more likely to
Patient demographic and clinicopathologic characteris- be black and less likely to be Asian or Hispanic
tics were summarized by surgical procedure subcategory (p = .0004). Patients who underwent TM R were more
Breast Conservation & Oncoplastic Reconstruction

TABLE 1 Clinicopathologic characteristics by subgroup


Variable BCS BCS ? R TM TM ? R BCS R cf. BCS ?R cf. BCS ? R cf.
(n = 3559) (n = 1177) (n = 3263) (n = 2608) TM R BCS TM ? R
N % N % N % N % p value p value p value

Age
Median (years) (range) 59 (2593) 57 (2390) 56 (1998) 50 (2081) \.0001 \.0001 \.0001
Under 40 112 3.4 64 5.9 316 10.3 414 17.0
4049 558 17.1 207 19.0 655 21.3 785 32.2
5059 971 29.8 371 34.1 869 28.2 765 31.4
6069 970 29.8 329 30.3 745 24.2 414 17.0
7079 521 16.0 102 9.4 379 12.3 56 2.3
8084 80 2.5 6 .6 79 2.6 3 .1
85 and older 45 1.4 8 .7 37 1.2 0 .0
Race
White 2295 70.5 756 69.6 1978 64.2 1670 68.5 \.0001 .15 .0004
Asian 152 4.7 40 3.7 186 6.0 126 5.2
Black 373 11.5 147 13.5 417 13.5 231 9.5
Hispanic 373 11.5 126 11.6 427 13.9 357 14.7
Other 20 .6 4 .4 13 .4 11 .5
Unknown 44 1.4 14 1.3 59 1.9 42 1.7
Obesity
Yes 2156 64.9 625 55.9 2005 66.5 1552 64.6 .0384 .62 .46
No 22 .7 5 .5 38 1.3 18 .8
Not available 1146 34.5 489 43.7 972 32.2 833 34.7
Clinical T stage
Tis 717 20.2 234 19.9 395 12.1 659 25.3 \.0001 \.0001 \.0001
T1 1833 51.5 487 41.4 667 20.4 836 32.1
T2 875 24.6 395 33.6 1084 33.2 827 31.7
T3 48 1.4 32 2.7 440 13.5 134 5.1
T4 22 .6 10 .9 501 15.4 28 1.1
Not available 59 1.7 17 1.4 167 5.1 118 4.5
Clinical N stage
N0 3104 87.2 943 80.1 1710 52.4 2103 80.6 \.0001 \.0001 .052
N1 315 8.9 164 13.9 848 26.0 316 12.1
N2 25 .7 15 1.3 159 4.9 41 1.6
N3 65 1.8 38 3.2 405 12.4 51 2.0
Clinical M stage
M0 3490 98.1 1151 97.8 2969 91.0 2493 95.6 \.0001 .15 .44
M1 15 .4 9 .8 153 4.7 14 .5
Clinical stage
Stage 0 717 20.2 234 19.9 392 12.0 660 25.3 \.0001 \.0001 \.0001
Stage 1 1714 48.2 442 37.6 527 16.2 741 28.4
Stage 2 933 26.2 408 34.7 1145 35.1 930 35.7
Stage 3 115 3.2 67 5.7 886 27.2 144 5.5
Stage 4 15 .4 9 .8 154 4.7 14 .5
Not available 65 1.8 17 1.5 159 4.9 119 4
Tumor location
Upper inner 554 15.6 179 15.2 514 15.8 446 17.1 .22 .77 .15
Upper outer 1463 41.1 447 38.0 1390 42.6 1015 38.9 .51 .05 .58
Lower inner 228 6.4 64 5.4 281 8.6 167 6.4 .003 .23 .25
S. A. Carter et al.

TABLE 1 continued
Variable BCS BCS ? R TM TM ? R BCS R cf. BCS ?R cf. BCS ? R cf.
(n = 3559) (n = 1177) (n = 3263) (n = 2608) TM R BCS TM ? R
N % N % N % N % p value p value p value

Lower outer 242 6.8 131 11.1 329 10.1 228 8.7 .003 \.0001 .02
Central 976 27.4 320 27.2 810 24.8 656 25.2 .005 .88 .19
Multicentric 25 .7 12 1.0 272 8.3 122 4.7 \.0001 .28 \.0001
Preoperative treatment
None 2861 81.4 874 74.6 1449 44.8 1817 71.3 \.0001 \.0001 .04
Chemotherapy 564 15.9 278 23.6 1656 50.8 656 25.2 \.0001 \.0001 .23
Hormonal 81 2.3 18 1.5 148 4.5 58 2.2 \.0001 .12 .16
Other 24 .7 7 .6 55 1.7 36 1.4 \.0001 .91 .02
Tumor grade
Low 526 14.8 156 13.3 259 7.9 276 10.6 \.0001 .01 .05
Intermediate 1667 46.8 521 44.3 1193 36.6 1173 45.0
High 1238 34.8 471 40.0 1600 49.0 1093 41.9
Not available 128 3.6 29 2.5 211 6.5 66 2.5
Multifocal
Yes 434 12.2 184 15.6 888 27.2 751 28.8 \.0001 .01 \.0001
No 2811 79.0 894 76.0 1636 50.1 1586 60.8
Not available 314 8.8 99 8.4 739 22.7 271 10.4
Lymphovascular invasion
Yes 449 12.6 169 14.4 983 30.1 447 17.1 \.0001 .0002 .02
No 2910 81.8 907 77.1 1960 60.1 1986 76.2
Not available 200 5.6 101 8.6 320 9.8 175 6.7
Margin status
Positive 74 2.1 12 1.0 12 .4 7 .3 \.0001 .04 \.0001
Close (\2 mm) 219 6.2 56 4.8 88 2.7 54 2.1
Negative 3231 90.8 1101 93.5 3140 96.2 2529 97.0
Not available 35 1.0 8 .7 23 .7 18 .7
ER
Positive 2958 83.1 963 81.8 2418 74.1 2078 79.7 \.0001 .76 .04
Negative 555 15.6 198 16.8 757 23.2 455 17.5
Not recorded 46 1.3 16 1.4 88 2.7 75 2.9
PR
Positive 2452 68.9 797 67.7 1890 57.9 1689 64.8 \.0001 .67 .02
Negative 1046 29.4 360 30.6 1273 39.0 832 31.9
Not recorded 61 1.7 20 1.7 100 3.0 87 3.3
HER2
Positive 293 8.2 126 10.7 599 18.4 327 12.5 \.0001 \.0001 \.0001
Negative 2585 72.6 843 71.6 2289 70.2 1727 66.2
Not recorded 681 208 17.7 375 41.7 554 21.3
Triple negative
Yes 352 9.9 128 10.9 456 14.0 246 9.4 .0021 .50 .47
No 2419 68.0 802 68.1 2196 67.3 1677 64.3
Not recorded 788 22.1 247 21.0 611 18.7 685 26.3
Adjuvant chemotherapy
Yes 819 23.0 302 25.7 1044 32.0 831 31.9 \.0001 \.0001 \.0001
No 2582 72.6 775 65.9 1950 59.8 1640 62.9
Not recorded 158 4.4 100 8.5 269 8.2 137 5.3
Breast Conservation & Oncoplastic Reconstruction

TABLE 1 continued
Variable BCS BCS ? R TM TM ? R BCS R cf. BCS ?R cf. BCS ? R cf.
(n = 3559) (n = 1177) (n = 3263) (n = 2608) TM R BCS TM ? R
N % N % N % N % p value p value p value

Adjuvant hormonal therapy


Yes 2227 62.6 644 54.7 1728 53.0 1417 54.3 \.0001 \.0001 \.0001
No 949 26.7 287 24.4 1089 33.4 849 32.6
Not recorded 383 10.8 246 20.9 446 13.7 342 13.1
Adjuvant radiation therapy
Yes 2808 78.9 895 76.0 1600 49.0 559 21.4 \.0001 \.0001 \.0001
No 486 13.7 132 11.2 1314 40.3 1786 68.5
Not recorded 265 7.5 150 12.7 349 10.7 263 10.1
BCS breast conserving surgery, BCS ? R breast conserving surgery with reconstruction, BCS R breast conserving surgery with or without
reconstruction, cf compare with, ER estrogen receptor, HER2 human epidermal growth factor receptor 2, PR progesterone receptor, SD standard
deviation, TM total mastectomy, TM ? R total mastectomy with reconstruction, TM R total mastectomy with or without reconstruction

FIG. 1 Number of cases per year by subgroup (a), percent of total procedures per year by subgroup (b). Proportion of breast conserving
procedures with and without reconstruction by year (c), proportion of total mastectomy procedures with and without reconstruction by year (d)

likely to be obese (BMI [ 30 kg/m 2) compared with those likely to have Tis disease (25.3 vs. 19.9 %; p \ .0001).
who underwent BCS R (36.1 vs. 28.2 %; p = .04). In contrast, the TM-only patients had more advanced
However, the rate of obesity was similar in BCS ? R disease, with the highest proportion of T4 tumors of any
patients compared with BCS or TM ? R. group (15.4 %). BCS ? R patients were more likely to
Approximately 75 % of patients who underwent BCS have clinically node-positive disease than BCS patients
or BCS ? R had a T1 or T2 tumor, although the groups (18.4 vs. 11.4 %; p \ .0001), but with a similar rate to
differed in that the BCS ? R group had larger tumors TM ? R patients (15.6 %). The TM group had the
than the BCS group (24.6 % T2 tumors in BCS vs. highest rate of nodal involvement (43.4 % with N1N3
33.6 % in BCS ? R; p \ .0001; Table 1). Compared disease) of any group, reflecting the more advanced stage
with BCS ? R patients, the TM ? R group was more of these patients.
S. A. Carter et al.

There was no difference in the use of BCS ? R com- common in the BCS ? R group compared with BCS
pared with BCS for any quadrant of the breast except the alone (25.7 vs. 23.0 %; p \ .0001). As expected,
lower outer quadrant (11.1 % in BCS ? R vs. 6.8 % in adjuvant radiation therapy was higher in patients who
BCS; p \ .001; Table 1). Although oncoplastic recon- underwent BCS R compared with TM R (78.2 vs.
struction is thought to be most beneficial for patients 36.8 %; p \ .001). Although the rate of adjuvant
undergoing BCS for tumors in difficult locations (upper radiation was slightly less in the BCS ? R group
inner, lower inner, central breast), our data did not show a compared with the BCS group (76 vs. 78.9 %;
difference in the rate of BCS ? R compared with BCS p \ .0001), the difference is not likely to be clinically
alone or TM ? R for tumors in these locations. Under- significant. Overall, radiation therapy following
standably, patients with multicentric or multifocal tumors BCS R seemed low for our group of patients, which
were more likely to undergo TM R compared with any may be related to incomplete data for women undergoing
BCS (28 % multifocal in TM R vs. 13 % in BCS R; radiation at an outside institution.
p \ .0001). Multifocal disease was also more likely in the
BCS ? R group than in the BCS group (15.6 vs. 12.2 %; Complications Both wound-related complications and
p = .01). surgical site infections (SSIs) were much lower in
High-grade tumors were more common in patients who patients who underwent BCS R compared with
underwent BCS ? R compared with BCS (40 vs. 34.8 %; TM R patients (p \ .0001; Table 2). The seroma rate
p = .01; Table 1). The presence of lymphovascular inva- was lower in patients that underwent BCS ? R compared
sion was slightly higher in the BCS ? R group compared with BCS (13.4 vs. 18.0 %; p = .002) and had a value
with BCS (14.4 vs. 12.6 %; p = .0002) and much higher in close to TM ? R patients. BCS ? R patients had a higher
patients who underwent any TM (17.130.1 %). The pro- rate of wound-related complications compared with BCS
portion of ER or PR positive tumors was similar in BCS (4.8 vs. 1.4 %; p \ .0001), but the hematoma and SSI rates
and BCS ? R groups. HER2 positive tumors were more showed no difference. Compared with the TM ? R group,
common in BCS ? R patients compared with BCS (10.7 the BCS ? R group had fewer hematomas, wound-related
vs. 8.2 %; p \ .0001). The proportion of triple-negative complications, and SSIs (p \ .0001).
tumors was similar in BCS ? R compared with BCS and
TM ? R. Recurrence and Survival Median follow-up for the study
Patients who underwent BCS had the highest rate of population was 3.4 years (range, 09.1 years). Median
positive or close margins out of any group (8.3 %; survival was not reached for any group since far fewer than
Table 1). The BCS ? R group had a lower rate of positive half the patients died. The overall survival (OS) and the
or close margins compared with BCS alone (5.8 %; recurrence-free survival (RFS) are presented in Fig. 2.
p = .04), but this was higher than the rate for TM ? R There was no difference in OS when comparing BCS and
patients (2.4 %; p \ .0001). BCS ? R (p = .16; Fig. 2a) and no difference in 3-year
OS when comparing BCS and BCS ? R (96.8 vs. 95.8 %;
Neoadjuvant and Adjuvant Therapy Neoadjuvant 95 % CI, 9697 vs. 9497 %). Similarly, RFS was
chemotherapy was given more frequently in the equivalent between the 2 groups overall (p = .19;
BCS ? R group compared with BCS (23.6 vs. 15.9 %; Fig. 2b). However, TM ? R had the best OS of any
p \ .0001; Table 1). Adjuvant chemotherapy was more group, and was significantly better than the BCS ? R

TABLE 2 Complications by subgroup


Variable BCS BCS ? R TM TM ? R BCS R cf. BCS ?R cf. BCS ? R cf.
(n = 2258) (n = 939) (n = 2304) (n = 1824) TM R BCS TM ? R
N % N % N % N % p value p value p value

Hematoma 57 2.5 18 1.9 66 2.9 87 4.8 .0009 .3 .0002


Seroma 406 18.0 126 13.4 305 13.2 228 12.5 \.0001 .0016 .49
Wound 32 1.4 45 4.8 133 5.8 212 11.6 \.0001 \.0001 \.0001
Infection 92 4.1 42 4.5 178 7.7 237 13.0 \.0001 .61 \.0001
Implant complication 310 17.0
BCS breast conserving surgery, BCS ? R breast conserving surgery with reconstruction, BCS R breast conserving surgery with or without
reconstruction, cf compare with, TM total mastectomy, TM ? R total mastectomy with reconstruction, TM R total mastectomy with or without
reconstruction
Breast Conservation & Oncoplastic Reconstruction

FIG. 2 Overall survival (a) and recurrence-free survival (b) by subgroup

TABLE 3 Univariate and multivariate Cox proportional hazards models for recurrence-free survival
Variable Reference level Hazard ratio 95 % confidence interval Overall p value Pairwise p value

Univariate
Age (Numeric) 1.008 1.0031.014 .0040
Nodal stage pN13 versus pN0 3.257 2.8443.731 \.0001
Grade Intermediate/high versus low 2.298 1.7123.084 \.0001
Margins Close or positive versus negative 1.953 1.4752.586 \.0001
Lymphovascular invasion Present versus absent 5.562 4.2287.315 \.0001
Triple negative Yes versus no 3.074 2.6293.596 \.0001
Adjuvant radiation therapy Yes versus no 1.198 1.0351.388 .0158
Surgery type cf. BCS ? R BCS .907 .6751.220 \.0001 .5196
TM 2.799 2.1223.693 \.0001
TM ? R .671 .483.932 .0174
Multivariate
Age (Numeric) .999 .9901.008 .83
Nodal stage pN13 versus pN0 2.197 1.6132.992 \.0001
Grade Intermediate/high versus low 1.406 .6173.204 .42
Margins Close or positive versus negative 1.676 1.1092.532 .0143
Lymphovascular invasion Present versus absent 2.874 1.5835.219 .0005
Triple negative Yes versus no 4.299 3.3415.530 \.0001
Adjuvant radiation therapy Yes versus no .853 .6381.141 .28
Surgery type BCS versus BCS ? R .949 .524 \.0001 .86
TM versus BCS ? R 2.313 1.359 .0020
TM ? R versus BCS ? R .729 .383 .34
BCS breast conserving surgery, BCS ? R breast conserving surgery with reconstruction, BCS R breast conserving surgery with or without
reconstruction, TM total mastectomy, TM ? R total mastectomy with reconstruction, TM R total mastectomy with or without reconstruction

group (p = .0007), which was also reflected in the 3-year (p = .01), as was 3-year RFS (96.6 vs. 94.6 %; 95 % CI,
OS probabilities (97.7 vs. 96.8 %; 95 % CI, 9597 vs. 93 9697 vs. 9396 %).
96 %). This is likely due to the large proportion of patients By univariate analysis, age, nodal status, grade, margin
with stage 0 disease in this group. Accordingly, RFS was status, lymphovascular invasion, and triple-negative status
longer in the TM ? R patients than the BCS ? R group were strongly associated with RFS (Table 3). On
S. A. Carter et al.

multivariate analysis, these factors remained significant For postoperative complications, there were fewer
except for age and grade. However, when comparing sur- seromas for BCS ? R compared with BCS. With
gical procedures, only TM was significantly different from oncoplastic reconstruction, tissue rearrangement fills the
BCS ? R. TM patients have approximately 2.3 times the void left by the tumor resection and minimizes the dead
hazard of recurrence or death compared to BCS ? R. space for seroma formation. As the procedures increased in
complexity, the SSI rates increased, with BCS having the
DISCUSSION lowest rate, followed by BCS ? R, TM, and TM ? R
having the highest rate of SSI. These results correlate with
BCS ? R for patients with breast cancer has emerged as previous reports showing a low incidence of complications
an approach that may increase the number of eligible related to BCS ? R.4,1820 A recent study from our insti-
patients who can undergo breast conservation.5,8,11,12 tution also found that obese women experience fewer
Oncoplastic reconstruction involves local tissue rear- complications after BCS ? R than immediate reconstruc-
rangement for reshaping the breast or more advanced tion with implant-based or autologous reconstruction.10
mammoplasty techniques that allow for larger resections of With a low risk of surgical complications, BCS ? R does
the breast volume.7 Using data from a single institution, we not delay the initiation of adjuvant therapy.21
demonstrate that the use of BCS ? R for breast cancer Our results indicate that BCS ? R is an oncologically
patients has markedly increased from 2007 to 2014 with a safe procedure with complication rates that are equivalent
nearly fourfold increase in the percentage of all breast to or less frequent than BCS or TM ? R. However, our
cancer surgeries during that time period. BCS ? R and mean follow-up period of 3.4 years is relatively short,
BCS are both approaching an equal share of the patients which may make the oncologic safety difficult to interpret.
undergoing breast conserving surgery, with BCS ? R Other studies have demonstrated that patient reported sat-
increasing from 9 to 33 % of all breast conservation cases isfaction after BCS ? R is high and aesthetic outcomes are
in our study group. With 1177 patients in the BCS ? R excellent.22 BCS ? R also offers patients a single-stage
group, this is the largest study of oncoplastic reconstruction procedure, whereas TM ? R (by any reconstructive
for breast cancer patients reported to our knowledge.11 modality) is generally a minimum of 2 procedures. This
Patients who undergo BCS ? R are slightly younger means that patients who select BCS R will generally
than BCS patients but older than TM ? R patients. For have a shorter surgical course of treatment. In this regard,
reconstruction patients, with every decade after the age of patients who are expected to require radiation after mas-
40 the rate of BCS ? R increased by 10 % or more over tectomy should consider BCS because it may offer better
TM ? R. This may be related to surgeons and patients outcomes in terms of better aesthetics, lower complica-
perceptions that older patients will have higher complica- tions, and fewer procedures. However, BCS ? R does
tion rates and poorer outcomes with more extensive require careful planning and coordination between the
surgery.13 The BCS ? R group had a more advanced breast surgical oncologist, the plastic reconstructive sur-
clinical stage of breast cancer compared to the BCS group geon, and the radiation oncologist, especially as the role of
and other pathologic risk factors were also worse for BCS ? R has expanded to involve more challenging cases
BCS ? R compared with BCS (lymphovascular invasion, (multifocal, multicentric). Since oncoplastic surgery can
high-grade, HER2 amplification, and multifocality). make it difficult to target the tumor bed with radiation
Despite these risk factors, there was no significant differ- therapy for the local boost, it is essential to mark the
ence in OS or RFS for BCS ? R patients compared with resection cavity with metallic markers.2327 In some cases,
BCS-alone patients. Other groups have reported on the oncoplastic reconstruction may facilitate radiation planning
oncologic safety of BCS ? R in smaller series as well.1416 and delivery by reshaping a large ptotic breast and cen-
Indeed, several studies have shown that oncoplastic BCS tralizing the breast mound to facilitate whole breast
results in wider negative margins and larger specimens radiation. If performed in a planned, multidisciplinary
compared with standard BCS and reduces the re-excision fashion, BCS ? R should be offered as an alternative to
rate.5,8,15 Although these factors could potentially lower mastectomy for patients who might not otherwise be con-
the risk of recurrence, we did not observe a significant sidered traditional candidates for BCS.
difference in our analyses in keeping with the guidelines
established by the Society of Surgical Oncology in col- ACKNOWLEDGMENTS This work was supported in part by the
Cancer Center Support Grant (NCI Grant P30 CA016672). We greatly
laboration with the American Society for Radiation wish to acknowledge Deborah Adair, Helen Zou, and Kelly Merri-
Oncology.17 BCS ? R was significantly different from TM man, MPH, PhD, for their assistance with data collection for this
in multivariate analysis. project.
Breast Conservation & Oncoplastic Reconstruction

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