Sherif F Naguib1. 1. The Department of Surgical Oncology, National Cancer Institute, Cairo University.
Abstract
BACKGROUND: Patients with central breast neoplasms account for 5 to 20% of breast cancer cases and, for a long time, they have been denied Breast Conservation Surgery (BCS) and conventionally treated with mastectomy. The high incidence of Nipple-Areola-Complex (NAC) involvement usually associated with these tumors necessitates nipple and areolar resection together with an adequate safety margin around the tumor, which yields an unacceptable cosmetic result. With the help of Oncoplastic Surgical Techniques, BCS can be offered to these patients. In this study central quadrantectomy and breast reconstruction by an infero-laterally based pedicled flap were evaluated. PATIENTS AND METHODS: This study comprised 23 women with central breast tumors treated at the National Cancer Institute (NCI), Cairo University and at the Aswan Cancer Center, Egyptian Ministry of Health. Their ages ranged from 31 to 62 years (mean: 48.4+/-10.2 years). Twenty-two had a palpable mass, while only 1 had Paget's disease of the nipple without mass. The size of their tumors ranged from 4 to 33 m (mean: 16.9+/-8.6mm). Only 9 women showed clinical suspicion of NAC involvement in the form of nipple retraction. Seventeen cases had their tumors strictly in the retro-areolar region, while 5 had tumors extending for a maximum of 1.5 cm beyond the areolar edge. All patients underwent central quadrantectomy with NAC resection removing a cylinder of breast tissue reaching down to the pectoral muscle together with axillary dissection. Advancement of an infero-laterally based skin-glandular flap was then carried out. All patients received adjuvant radiotherapy with or without chemotherapy or hormonal therapy. RESULTS: Fourteen patients showed pathological evidence of nipple infiltration (60.8%). The free safety margin (SM) ranged from 9 to 13 mm (mean: 10.2+/-0.9 mm). This could be accomplished from the first attempt in 18 patients;however, in 5 patients a second wider excision was needed to obtain an adequate margin. Positive axillary nodes were found in 10 / 23 patients (43.5%). The procedure lasted a mean time of 195+/-12.7 minutes and blood loss was estimated at a mean of 225+/-64.8 mL. Hospital stay ranged from 2 to 10 days (median: 4 days). Post-operatively, superficial flap sloughing occurred in 2 / 23 patients and full thickness sloughing in 1 /23 patients. Cosmetic results were evaluated by both patient and surgeon according to a scoring system and were found excellent in 26.1%, good in 34.8%, satisfactory in 30.4%, poor in 8.7% and very poor in none. The procedure did not delay the start of adjuvant treatment nor did it hamper clinical and mammographic follow-up. CONCLUSION: Oncoplastic techniques have succeeded in expanding the role of BCS to retro-areolar tumors. Central quadrantectomy with repair by a skin-glandular flap is a relatively simple procedure that yields very satisfactory cosmetic results with minimal complications and it may be considered as one of the noteworthy therapeutic options for patients with central breast tumors.
BACKGROUND:Patients with central breast neoplasms account for 5 to 20% of breast cancer cases and, for a long time, they have been denied Breast Conservation Surgery (BCS) and conventionally treated with mastectomy. The high incidence of Nipple-Areola-Complex (NAC) involvement usually associated with these tumors necessitates nipple and areolar resection together with an adequate safety margin around the tumor, which yields an unacceptable cosmetic result. With the help of Oncoplastic Surgical Techniques, BCS can be offered to these patients. In this study central quadrantectomy and breast reconstruction by an infero-laterally based pedicled flap were evaluated. PATIENTS AND METHODS: This study comprised 23 women with central breast tumors treated at the National Cancer Institute (NCI), Cairo University and at the Aswan Cancer Center, Egyptian Ministry of Health. Their ages ranged from 31 to 62 years (mean: 48.4+/-10.2 years). Twenty-two had a palpable mass, while only 1 had Paget's disease of the nipple without mass. The size of their tumors ranged from 4 to 33 m (mean: 16.9+/-8.6mm). Only 9 women showed clinical suspicion of NAC involvement in the form of nipple retraction. Seventeen cases had their tumors strictly in the retro-areolar region, while 5 had tumors extending for a maximum of 1.5 cm beyond the areolar edge. All patients underwent central quadrantectomy with NAC resection removing a cylinder of breast tissue reaching down to the pectoral muscle together with axillary dissection. Advancement of an infero-laterally based skin-glandular flap was then carried out. All patients received adjuvant radiotherapy with or without chemotherapy or hormonal therapy. RESULTS: Fourteen patients showed pathological evidence of nipple infiltration (60.8%). The free safety margin (SM) ranged from 9 to 13 mm (mean: 10.2+/-0.9 mm). This could be accomplished from the first attempt in 18 patients;however, in 5 patients a second wider excision was needed to obtain an adequate margin. Positive axillary nodes were found in 10 / 23 patients (43.5%). The procedure lasted a mean time of 195+/-12.7 minutes and blood loss was estimated at a mean of 225+/-64.8 mL. Hospital stay ranged from 2 to 10 days (median: 4 days). Post-operatively, superficial flap sloughing occurred in 2 / 23 patients and full thickness sloughing in 1 /23 patients. Cosmetic results were evaluated by both patient and surgeon according to a scoring system and were found excellent in 26.1%, good in 34.8%, satisfactory in 30.4%, poor in 8.7% and very poor in none. The procedure did not delay the start of adjuvant treatment nor did it hamper clinical and mammographic follow-up. CONCLUSION: Oncoplastic techniques have succeeded in expanding the role of BCS to retro-areolar tumors. Central quadrantectomy with repair by a skin-glandular flap is a relatively simple procedure that yields very satisfactory cosmetic results with minimal complications and it may be considered as one of the noteworthy therapeutic options for patients with central breast tumors.