Is oncoplastic breast conserving surgery oncologically safe? A meta-analysis of 18,103 patients

https://doi.org/10.1016/j.amjsurg.2019.12.019Get rights and content

Highlights

  • A pool of 18,103 patients was found in Pubmed and Web of Science for meta-analysis.

  • Oncoplastic surgery cancer recurrence rates were not significantly different to traditional methods.

  • Re-operation rates were also not significantly different to established techniques.

  • Oncoplastic breast conserving surgery is a safe alternative to traditional procedures.

Abstract

Background

Oncoplastic Breast Conserving Surgery (OBCS) allows adequate resection margins of tumours unsuitable for standard breast conserving surgery (SBCS) whilst allowing for better cosmesis and reduced morbidity when compared to mastectomy. However, there is limited evidence on its oncological safety.

Methods

This study aims to compare oncological safety of OBCS with SBCS and mastectomy by examining the relative risk of cancer recurrence and re-operation rates through meta-analysis.

Results

18 studies met the search criteria including 18,103 patients. The primary outcome measure (recurrence) was not significantly different between OBCS and SBCS or mastectomy (RR 0.861; 95% CI 0.640–1.160; p = 0.296). The secondary outcome measure (re-operation) initially achieved significance in favour of OBCS (RR 0.64; 95% CI 0.46–0.89; p = 0.01). However, after adjustment for publication bias this was attenuated to insignificance between the two study groups (RR 0.86; 95% CI 0.56–1.31; p = 0.44).

Conclusions

For both cancer recurrence and re-operation rate, there was no significant difference between OBCS and traditional techniques. OBCS is of comparable oncological safety to more established surgical procedures and a useful option in suitable patients.

Introduction

In modern terms, Standard Breast Conserving Surgery (SBCS) includes wide local excision and quadrantectomy procedures. These less invasive surgical measures were developed in response to patient morbidity caused by the historically popular Halsted’s radical mastectomy. The need for an alternative technique combined with breakthroughs in surgical technology such as radiotherapy in the 1940s allowed the development of increasingly conservative procedures.1,2 Continuing along these lines and given the psychosocial importance of the female breast, it was only natural that surgical techniques for breast cancer would continue to evolve with improvements in technology in order to achieve minimal morbidity. Over the past few decades, by combining facets of reconstructive plastic surgery with more traditional resection techniques, Oncoplastic Breast Conserving Surgery (OBCS) was developed.

OBCS may encompass numerous techniques, but these can be broadly classified as level 1 or 2. Level 1 procedures do not require specialist plastic surgical techniques, and are generally used on tumours which are <20% of breast volume and require simple reshaping (without skin excision) using glandular flaps, which may include relocation of the nipple areola complex. In comparison, level 2 procedures do require specialist techniques, which generally can be separated into either volume displacement (such as therapeutic mammoplasty) or volume replacement (such as fasciocutaneous or myocutaneous flap) techniques.3,4

In theory, the role of OBCS is that of a middle ground between SBCS and mastectomy - it allows adequate resection margins of tumours unsuitable for SBCS such as large or multifocal tumours, those with high tumour to breast tissue ratio, or those in an incompatible location,3 whilst allowing for less morbidity and a better cosmesis than a modified radical mastectomy might provide. However, as this is a relatively new procedure, there is limited evidence on its oncological safety which can be considered the ultimate goal of any breast cancer surgery.4

This paper aims to compare the oncological safety of OBCS with SBCS and mastectomy by examining the recurrence and re-operation rates for both techniques through meta-analysis, in order to add to the current literature.

Section snippets

Outcome measures

The purpose of this paper is to test the oncological safety of OBCS versus SBCS and mastectomy. Therefore, the primary outcome measure being analysed is the relative risk of recurrence, whilst the secondary measure is the relative risk of re-operation (as a marker of positive or borderline excision margins).

Literature search

Literature search was conducted by one author on both Pubmed and Web of Science databases. The following search terms were used: (1) ‘oncoplastic surgery’; (2) ‘oncoplasty’; (3) ‘therapeutic

Demographics

In total, 645 studies were initially found using the search terms described previously. Titles were then screened for relevance and 114 study abstracts were selected for further analysis. From these, 33 studies were found to be relevant to the meta-analysis. After duplicate results were removed, a total of 22 remained. On reading these manuscripts, one was excluded for having no control arm, another for having a duplicate dataset to another study, and the final two for having no data relevant

Discussion

OBCS offers an alternative surgical option for patients who may not be suitable for wide local excisions or full mastectomy by combining the ability to resect a large amount of tissue whilst aiming to maintain a cosmetic ideal not possible with radical surgery. The focus of this paper is on oncological safety of such procedures, and we have found that when compared to a pool of SBCS and mastectomy procedures, OBCS appears to be comparable to more traditional techniques when considering

Conclusions

For both recurrence of cancer and re-operation rate, we found no significant difference between OBCS and more traditional techniques. This is in line with other findings in the literature and would suggest that OBCS is of comparable oncological safety to more established procedures. Combined with the ability to perform extensive resections with good aesthetic outcomes, there would appear to be few disadvantages to considering OBCS in suitable patients.

Declaration of competing interest

Grant funding was received from the charity Breast Cancer Hope. To the best of my knowledge, no financial or personal conflicts of interest exist which may have inappropriately influenced the results contained in this manuscript.

Acknowledgements

The team would like to thank our statistician Igor Naumets for lending his expertise towards the preparation of the methods and results sections of this manuscript. Grant funding was received from the charity Breast Cancer Hope.

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