Breast Cancer DOI 10.1007/s12282-014-0522-6
ORIGINAL ARTICLE
Postoperative courses of breast reconstruction using inferior adipofascial tissue repair Shoko Otsuka • Naoki Watanabe • Youko Sasaki Reiko Shimojima
•
Received: 5 November 2013 / Accepted: 3 February 2014 Ó The Japanese Breast Cancer Society 2014
Abstract Background Nevertheless in breast conserving surgery, the dissection of inferior part of breast mound will cause severe deformity, which affects the patient’s quality of life adversely. We have used an infra-mammary adipofascial tissue to repair the defect, and breast mound could be reconstructed concurrently in primary breast cancer surgery. Patients and surgical procedure From September 2009 to June 2012, we performed the infra-mammary adipofascial tissue repair (IATR) on 25 patients with breast cancer in inferior site of their breast mound. Surgeon makes the skin incision on the infra-mammary line and performs the quadrantectomy as planned. After verifying its negative surgical margin pathologically, we mobilize the adipofascial fat tissue associated with myofascia of the serratus anterior muscle from the infra-mammary area. This tongueshaped flap is reflected back, and fills the defect of breast mound. We performed routinely examination, mammography, and ultra-sound echogram to the IATR patients who visited our hospital after 1 year from the end of treatment. We, furthermore, performed the QOL questionnaire (QOLACD and QOL-ACD-B) to them and retrospectively compared their data to that from the other breast surgery patients. Results All patients with IATR were treated with irradiation, and no image findings of a partial or total necrosis of the flap recognized 1 year after examination. They produced good cosmetic results; however, they could not elevate the QOL score on the whole.
S. Otsuka (&) N. Watanabe Y. Sasaki R. Shimojima Department of Breast Surgery, Japanese Red Cross Society, Himeji Hospital, 1-12-1, Shimoteno, Himeji, Hyogo 670-8540, Japan e-mail: [email protected]
Keywords Breast reconstruction Inferior adipofascial tissue Breast cancer
Introduction The treatment of early breast cancer with breast conserving surgery is required to ensure local control of the malignancy while also providing acceptable cosmetic results. The resection of inferior portion of the breast mound may result in severe breast deformities than that of other upper and/or lateral portion, and thus the patient’s quality of life may be damaged. The mammary surgeons have often used the latissimus dorsi myocutaneous flap to refill the defects of the lateral and/or inferior portion of the breast. However, for this procedure, we need twice the postural changes between the tumor resection and the breast reconstruction, and needs the cooperation with a plastic surgeon. In practice, it is difficult to arrange the stuff of the operation flexibly, especially for the occasionally conversion of the surgical procedure. The technique of inferior adipofascial tissue (IAT) repair (IATR) has been firstly reported by the team of Mie University in 2007 [1]. They used the anterior sheath of the rectus abdominis muscle for feeding this flap. They also reported the follow-up data showing the excellent cosmetic result of this technique in later years [2, 3]. This surgical procedure is useful because it is rather easy for mammary surgeons to perform independently, and the IAT flap has good peripheral circulation [4, 5] and therefore, the microcalcification, which represents the necrosis of the flap [6– 8], has not been recognized in this flap during the longterm follow-up. We have modified this procedure, and used the myofascia of serratus anterior muscle to back and to feed the
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flap. Since 2009, we performed the concurrent reconstruction on this method in 21 patients with breast cancer in inferior section. In addition, we have treated all cases by the radiotherapy without any adverse events. After 1 year from the finish of treatment, we performed mammography and ultra-sound tomography on these flap, and examined the flap stiffness and necrotic change to provide enough evidence of safety. We concomitantly assessed their cosmetic satisfaction and quality of life (QOL), using the charts of questionnaires, QOL-ACD and QOL-ACD-B [9]. These questionnaire forms are provided by Public Health Research FoundationÓ [10], which is the public interest corporation involved by Japanese Health, Labour and Welfare Ministry.
Patients We performed IATR for 25 patients with breast cancer in the inferior portion from October 2010 to June 2013 (Table 1). The patients’ age ranged from 30 to 72 and the
average was 50.0. Eighteen patients had invasive ductal carcinomas, and five had non-invasive ductal carcinomas. Two patients had no residual carcinoma after the neoadjuvant chemotherapy. Sentinel lymph node biopsy was performed on the 18 cases (72 %), and axillary lymph node dissection was performed on 7 cases (28 %). Postoperative radiation therapy was performed in all the patients. Among these 25 cases, 21 had passed over 1 year from the finish of the treatment. We conducted a survey in the form of a questionnaire using the QOL-ACD and QOL-ACD-B [9] and assessed their QOL (as will hereinafter be described in detail). In the same period, we had a same questionnaire on the 234 patients, who had undergone breast surgery. Most of these cases did not need large resection of their breast mound (Partial resection 174/234, 74.4 %; Group ‘‘Major’’ had given a comparative major resection of breast, contains total mastectomy (Bt), and over 90° quadrantectomy, for example, (Bq) 120°, Bq 180°; Group ‘‘Minor’’ had given a comparative minor resection of breast, contains partial
Table 1 Character Group
Major
Minor
Inferior adipofascial tissue repair IATR
n (enroll in QOL examination)
(90)
(144)
25(20)
Age (average ± standard deviation)
52.6 ± 11.8 (range 33–85)
53.5 ± 11.3 (range 34–81)
50.0 ± 11.1 (range 30–72)
Postoperative days (average) Cancer site (n)
402.5
442.5
300.3
32 (29.1 %)
29 (15.3 %)
25 (100 %)
Inferior median (B) or lateral (D)
Other breast surgery
Resection (n) Partial (Bp)
81
2
Quadrantectomy Bq 60°
32
1
31
3
Quadrantectomy Bq 90° Quadrantectomy Bq 120°
20
17
Quadrantectomy Bq 180°
10
2
Bt
60
0
Sentinel lymph node biopsy (n)
63 (70 %)
121 (84.0 %)
18 (72 %)
Axillary lymph node dissection (n)
26 (30 %)
23 (16.0 %)
7 (28 %)
44/90 (48.9 %)
1/144 (0.6 %)
25/25 (100 %)
32 (35.6 %) 60 (66.7 %)
66 (45.8 %) 137 (95.8 %)
10 (40 %) 25 (all cases)
0
9
2
pTis
17
28
5
pT1
13
41
8
pT2
26
31
10
pT3
11
3
0
Cases request any special reconstruction surgery of the breast mound Adjuvant treatment Adjuvant chemotherapy (n) Radiotherapy against the residual breast mound (n) TNM classification (n) pT0 (post neoadjuvant chemotherapy)
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Breast Cancer
resection (Bp), Bq 60°, other under and 90° quadrantectomy) (Table 1). And thus, almost of Group ‘‘Minor’’ did not require any special technique to refill the defect of breast mound (1/144, 0.6 %). In this regard, about half case of Group ‘‘Major’’ requested the reconstruction at the time of or after the breast surgery (44/90, 48.9 %). In these cases, we performed an immediate tissue expander insertion at the time of breast cancer surgery. We routinely performed the radiotherapy to all cases of skin-sparing mastectomy. More than 1 year after the completion of radiotherapy, we would exchange the tissue expander to a permanent implant. In this report, we performed QOL research before the surgery to exchange.
Surgical procedure The operations are performed under general anesthesia. At the start, we perform the ultra-sonography to confirm the location and the spread of the tumor and decide the resection border. To avoid the tumor contamination, we keep over 1 cm from the edge of tumor as a safety margin, and put a mark by injecting the pigment into subcutaneous layer under the vision of echogram. On a case-by-case basis, sentinel lymph node biopsy or axillary lymph nodes dissection will be performed. Surgery to the axilla is performed through an incision different from that for the breast surgery. The surgeon makes a skin incision on the infra-mammary line and performs adequate resection to the inferior site of breast mound. After verified that the margin of the specimen is pathologically negative, the adipofascial fat tissue of the infra-mammary area is mobilized from the same incision. In making the tongue-shaped graft, the myofascia of serratus anterior muscle, occasionally with partial muscle body, is mobilized with fat pad. In the case that the defect of breast mound was in its internal inferior site, we also use the myofascia of external oblique muscle as the feeding pedicle. In this process, feeder vessels raised from muscle body should be secured possibly. Being of importance, we never delaminate the myofascia from the serratus anterior muscle to the end, and must leave the lineal pedicle along the infra-mammary line (Fig. 1a, b). This adipofascial fat tissue is converted and is turn up into dead space, to refill the defect of breast mound. This fat flap is rotated about the linear pedicle on the inframammary line as an axis (Fig. 1c). The flap is fixed to the remnant breast, by being sutured between its myofascia and surgical stump of the breast. After checking the symmetry, a suction drain is placed in the infra-mammary area and the skin incision is then sutured finally (Fig. 1d). The dead space under the incision line will spontaneously disappear by aspiration by the suction tube and it makes the natural
infra-mammary line. The drainage period is required for 2 or 3 days postoperatively. Perioperative seroma happened around this infra-mammary area should cause the skin flap ischemia, and results in the skin necrosis. About 2–3 weeks after surgery, we follow as an outpatient and check the wound condition, and in many cases we puncture the seroma and suction by a syringe.
Results Assessment of safety The range of total operation time was 65–130 min; the mean time was 93 min. This includes the time for the pathological examination of stump contamination, and the time for IATR. The volume of blood loss ranged from 10 to 245 ml; the average was 83.6 ml. The time prolongation or the blood loss for IATR does not matter. After the completion of wound healing, all reconstructed breasts with IATR were followed by local radiotherapy after 30–60 days from the surgery. The radio wave itself causes to the necrosis of biological tissue. However, we had never experienced the IAT flap necrosis through the perioperative period and around the radiotherapy. Twenty-one patients among 25 had passed over 1 year after the treatment, and returned for follow-up. We performed the routine surveillance, mammography and ultrasound echogram, for detection of a new primary or inbreast recurrence. We fortunately had not experienced the local recurrence in 25 IATR cases since now. We had never recognized the findings of fat necrosis in IATR breasts, both in mammography, and ultra-sound echogram. In this regard, the representative features of necrotic lesion in mammography are ‘‘radiolucent oil cyst’’ and ‘‘dystrophic calcification’’. The features of fat necrosis in ultra-sound echogram are ‘‘solid mass’’, ‘‘anechoic with posterior acoustic enhancement’’, and ‘‘anechoic with posterior acoustic shadowing’’. We assessed the breast images with caution regarding these features, but did not recognize them in the lesion of all IAT flaps (Fig. 2). Assessment of cosmetic result and associated QOL At the time of outpatient’ visit, after 1 year from the treatment, we performed QOL research, by doing the questionnaires, QOL-ACD and QOL-ACD-B, against the IATR cases (n = 20). Besides in the same period, we did the same questionnaires against the other patients with breast surgery. Group ‘‘Major’’ (n = 90) had been given a comparative major invasive breast resection: Bt or Bq, central angle is over 90°. Group ‘‘Minor’’ (n = 144) had been given a comparative minor surgery: Bp * Bq 90° (Table 1).
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Breast Cancer Fig. 1 We performed this method, inferior adipofascial tissue repair, to refill the defect of inferior part of breast mound due to the surgical procedure. Skin incision was placed on infra-mammary line, and the required quadrantectomy was performed from this scar. After the dissection, from the same incision, we mobilized the adipofascial tissue from the inferior area of the breast mound (a, b). This flap of a fat pad had a wide and linear pedicle on the inferior mammary line, and was backed by myofascia (break-line in schema) of the anterior serratus muscle, and occasionally the external oblique muscle (c). We kept as many perforating branches from the muscle body as possible. As shown in schema, we converted this flap into dead space, sutured the fascia to the stump of residual breast tissue, and set up to refill the defect of the mound (d)
QOL-ACD and QOL-ACD-B are composed of 40 questions (on a scale of one to five), and thus, those combined perfect score is 200 (QOL-ACD-total). According to the scoring instruction presented by the provider of QOL-ACD-B, we could narrow the list of questionnaires of QOL-ACD and QOL-ACD-B down to the purpose designed. They show a sample specialized for the assessment of body condition, social activity, and general QOL (QOL-ACD-body: 26 questions, the perfect score 130). We compared the QOL-ACD-total and QOL-ACD-body among Group ‘‘Major’’, Group ‘‘Minor’’, and Group ‘‘IATR’’ (the cases with IATR) (Table 2). Both QOL-ACD-total and QOL-ACD-body were not significantly different among them. Spearman correlation coefficients (two tailed) were used to evaluate which factors were mostly correlated with
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QOL-ACD-total and QOL-ACD-body score. The analyses were performed in SPSS version 10.0 for windows. Firstly, QOL-ACD-total and QOL-ACD-body highly correlate with each other (Spearman r = 0.924, n = 252, p \ 0.0001), and there may be no point talking about them as a separate thing. Among the various factors, pathological stage correlates with a highest degree of both QOLACD scores (with QOL-ACD-total: Spearman r = 0.210, n = 252, p = 0.001) and the next, the past history of adjuvant chemotherapy was correlated (with QOLACD-total: Spearman r = -0.204, n = 227, p = 0.002). However, IATR (with QOL-ACD-total: Spearman r = 0.001, n = 252, p = 0.982) and reconstruction protocol (with QOL-ACD-total: Spearman r = -0.038, n = 250, p = 0.552) showed no correlation with QOL-ACD.
Breast Cancer Fig. 2 This case (a), 48-yearold female, had T2 (2.2 cm) tumor on the inferior median area (b area) of the right breast. We performed surgical resection (breast quadrantectomy), and simultaneously reconstructed with IAT. She shows a good cosmetic result (BMI 21.308; postoperative days 372; QOLACD Score: total 138/200, body 106/130, cosmetics 13/15; adjuvant chemotherapy was done). The next case (b) was 41-year-old woman, and had T1 tumor with broadly extending DCIS (4.5 cm) in the inferior area of right breast (BDE area). We performed breast quadrantectomy and refilled the defect immediately with IAT. She was thin and thus we could not gain enough volume of IAT to repair the breast mound (BMI 19.961; postoperative days 354; QOL-ACD Score: total 138/200, body 93/130, cosmetics 13/15)
We thus selected three questions which simply asked about the cosmetics and cosmetic satisfaction among the QOL-ACD questionnaires: B6 ‘‘Have you been satisfied with the appearance of your breast (and/or scar)?’’, B15
‘‘Did you feel any inconvenience because you were unable to choose clothes that you wanted to wear?’’, and B16 ‘‘Do you feel reluctant to disrobe in the presence of other people, such as at a spa?’’.
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Breast Cancer Table 2 Asessment of cosmetic result and associated QOL Group
Other breast surgery Major
Minor
Inferior adipofascial tissue repair IATR
n (enroll in QOL examination)
90
144
20
QOL-ACD total (average ± standard deviation)
154.5 ± 24.6
159.0 ± 20.8
158.7 ± 14.0
QOL-ACD body QOL-ACD-cosmetic (B6 ? B15 ? B16)
101.8 ± 17.3 10.1 ± 3.2
105.1 ± 13.3 12.2 ± 2.8
105.9 ± 9.7 12.3 ± 2.6
Group ‘‘Major’’ had been given a comparative major invasive breast resection: Bt or Bq, central angle is over 90°. Group ‘‘Minor’’ had been given a minor surgery: Bp * Bq 90° QOL-ACD-total consists of QOL-ACD and QOL-ACD-B, which is composed of 40 questions (on a scale of one to five). Thus, those combined perfect score is 200 in total QOL-ACD-body shows a sample specialized for the assessment of body condition, social activity, and general QOL (26 questions, the perfect score 130) QOL-ACD-cosmetic, using question number B6, B15 and B16 shows a sample specialized for the assessment of cosmetic satisfaction.(3 questions, the perfect score 15)
There was no difference between the QOL-ACD-cosmetic of Group ‘‘IATR’’ and Group ‘‘Minor’’ (Fig. 3).
Discussion
Fig. 3 The comparison of QOL-ACD score (the sum of the scores; question B6 ? B15 ? B16) between Group ‘‘Major’’ [had given a comparative major resection of breast, contains total mastectomy (Bt)], Group ‘‘Minor’’ [had given a comparative minor resection of breast, contains partial resection (Bp)], and Group ‘‘IATR’’ (had reconstructed by IATR). Significances of individual differences were evaluated using the Scheffe test
Total score of these three questions (QOL-ACD-cosmetic) were compared among the Groups (Table 2). For multiple group comparisons, homogeneity of variance was assessed by the Bartlett test (B = 3.037, significant). Significances of individual differences were evaluated using the Scheffe test. QOL-ACD-cosmetic of Group ‘‘IATR’’ was significantly higher than that of Group ‘‘Major’’ (p \ 0.05).
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Before concerning the immediate breast reconstructions, we should discuss about the feasibility of the skin sparing [11, 12]. Skin-sparing mastectomy or lumpectomy facilitates immediate breast reconstruction using an implant or myocutaneous flap, especially IATR, and results in excellent cosmetics. NCCN guideline [13] shows the principle that skin-sparing mastectomy has a risk of local and regional recurrence, but it is probably equivalent to standard mastectomy. Needless to say, this principle is applied only to an adequately selected case. Not only multi-centric tumors but also T1/T2, ductal carcinoma in situ [14], and prophylactic mastectomies are particularly suited to this technique. In principle, we apply the skin sparing to the case with the tumor which did not invade the superficial layer of superficial fascia in the images of ultra-sound tomography. Furthermore, we had performed the postoperative radiotherapy in all IATR cases in regardless of the pathological clearance of the surgical margins. Preoperative and postoperative radiotherapies are not a contraindication to skin-sparing mastectomy [15]. However the postoperative radiotherapy occasionally causes the fat necrosis on the surgical site, especially on the flap tending to be ischemic. To monitor the fat necrosis, we have to know the features of fat necrosis in breast imaging. Bilgan evaluated and described about the mammographic and US appearance of fat necrosis in the breast in large series. In this regard, they show the mammographic features of necrotic lesions: radiolucent oil cyst (26.9 %), dystrophic calcification (26.9 %),
Breast Cancer
Fig. 4 At the time of outpatient visit, after 1 year from the treatment, we performed the routine mammography (a) and ultra-sonography (b). There was no image finding which indicate the IAT flap necrosis
asymmetrical opacity–heterogeneity of subcutaneous tissues (15.8 %), and negative (9.5 %). In addition, the features in ultra-sonography are: increased echogenicity of subcutaneous tissues (26.9 %), anechoic with posterior acoustic enhancement (16.6 %), anechoic with posterior acoustic shadowing (15.8 %), and negative (11.1 %) [8]. Even though we had not performed the biopsy against the IATR flap, negative image findings such as fat necrosis should happen in a rare. IATR might be said to have succeeded to survive in all case, in spite of the completion of radiotherapy (Fig. 4). The QOL of breast cancer patients due to complex and diverse causes, and thus, assessment of QOL is also complex and hard to configure. QOL-ACD and QOLACD-B are representative questionnaires in Japan, and we routinely have done them to all breast cancer patients. However, it was revealed this time that the score of these questionnaires were under the strong influence of pathological stage and of the history of chemotherapy, and that the protocol of breast reconstruction had less effect on them on a whole. Thus we picked up three questions, which are simply dealing with the cosmetics. The sum of these questions’ score was significantly better in Group ‘‘IATR’’ in comparison with in Group ‘‘Major’’. Even through a large part of Group ‘‘IATR’’ (76 %) was comparably invasive to Group ‘‘Major’’, the QOL scores of Group ‘‘IATR’’ was not less than that of Group ‘‘Minor’’. In this report, we collected the questionnaire uniformly from the patients who had passed around 1 year form the treatment. After 3–5 years from the treatment, when the adverse influence of chemotherapy or the anxiety from the advance stage would be decreased,
we could see the result that we expected, even in QOLACD as a whole. In 1992, Sakai firstly reported the immediate reconstruction method of the breast mound using the adipofascial tissue. This pedicle flap [16] is harvested from the infra-mammary area and associated with the anterior rectus sheath. We agree his saying that the use of the latissimus dorsi myocutaneous flap or the rectus abdominis myocutaneous flap is too aggressive, and IATR is more adoptable and convenience to repair the partial defect of the breast mound. He designed and gained an approximately 7 cm in length, tongue-shaped flap. We modified this procedure, in which, we had used the myofascia or a partially body of the anterior serratus muscle, not the rectus abdominis. We could gain the same length of IAT using this procedure, and it might be easier to refill the inferior and lateral area of breast. In this report, we would ensure safety of our IATR method, and prove excellent efficacy in cosmetics. Conflict of interest
None declared.
References 1. Ogawa T, Hanamura N, Yamashita M, Ri Y, Kuriyama N, Isaji S. Usefulness of breast-volume replacement using an inframammary adipofascial flap after breast-conservation therapy. Am J Surg. 2007;193:514–8. 2. Ogawa T, Hanamura N, Yamashita M, Kimura H, Kashikura Y. Long-term results of breast volume replacement using an inframammary adipofascial flap after breast-conserving surgery. Breast Cancer, 2011. doi: 10.1007/s12282-011-0285-2
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Breast Cancer 3. Ogawa T, Hanamura N, Yamashita M, Kimura H, Ito M, Nakamura T, et al. Oncoplastic technique combining an adipofascial flap with an extended glandular flap for the breast-conserving reconstruction of small dense breasts. J Breast Cancer. 2012;15:468–73. 4. Kijima Y, Yoshinaka H, Owaki T, Funasako Y, Aikou T. Immediate reconstruction using inframammary adipofascial flap of the anterior rectus sheath after partial mastectomy. Am J Surg. 2007;193:789–91. 5. Kijima Y, Yoshinaka H, Hirata M, Mizoguchi T, Ishigami S, Arima H, et al. Immediate reconstruction using a modified inframammary adipofascial flap after partial mastectomy. Surg Today (Case Reports). 2013;43:456–60. 6. Eidelman Y, Liebling RW, Buchbinder S, Strauch B, Goldstein RD. Mammography in the evaluation of masses in breasts reconstructed with TRAM flaps. Ann Plast Surg. 1998;41:229–33. 7. Hogge JP, Robinson RE, Magnant CM, Zuurbier RA. The mammographic spectrum of fat necrosis of the breast. Radiographics: a review publication of the Radiological Society of North America, Inc. (Review) 1995;15:1347–56. 8. Bilgen IG, Ustun EE, Memis A. Fat necrosis of the breast: clinical, mammographic and sonographic features. Eur J Radiol. 2001;39:92–9. 9. Kurihara M, Shimizu H, Tsuboi K, Kobayashi K, Murakami M, Eguchi K, et al. Development of quality of life questionnaire in Japan: quality of life assessment of cancer patients receiving chemotherapy. Psychooncology. 1999;8:355–63.
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10. Foundation PHR. Comprehensive support project for oncology research. 1-1-7 Nishiwaseda, Shinjuku-ku, Tokyo, 169-0051 JAPAN: Public Health Research Foundation; 2013. http://csp.or. jp/. (Updated 2013; cited 2013/10/1). 11. Fersis N, Hoenig A, Relakis K, Pinis S, Wallwiener D. Skinsparing mastectomy and immediate breast reconstruction: incidence of recurrence in patients with invasive breast cancer. Breast. 2004;13:488–93. 12. Medina-Franco H, Vasconez LO, Fix RJ, Heslin MJ, Beenken SW, Bland KI, et al. Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg. 2002;235:814–9. 13. Network NCC. NCCN guidelines for treatment of cancer by site. In: Theriault RL, Carlson RC, Allred C, Anderson BO, editors. Breast Cancer version 32013. www.NCCN.com; 2013. 14. Carlson GW, Page A, Johnson E, Nicholson K, Styblo TM, Wood WC. Local recurrence of ductal carcinoma in situ after skinsparing mastectomy. J Am Coll Surg. 2007;204:1074–8 (discussion 8–80). 15. Cunnick GH, Mokbel K. Skin-sparing mastectomy. Am J Surg (Review). 2004;188:78–84. 16. Sakai S, Suzuki I, Izawa H. Adipofascial (anterior rectus sheath) flaps for breast reconstruction. Ann Plast Surg. 1992;29:173–7.
ORIGINAL ARTICLE
Postoperative courses of breast reconstruction using inferior adipofascial tissue repair Shoko Otsuka • Naoki Watanabe • Youko Sasaki Reiko Shimojima
•
Received: 5 November 2013 / Accepted: 3 February 2014 Ó The Japanese Breast Cancer Society 2014
Abstract Background Nevertheless in breast conserving surgery, the dissection of inferior part of breast mound will cause severe deformity, which affects the patient’s quality of life adversely. We have used an infra-mammary adipofascial tissue to repair the defect, and breast mound could be reconstructed concurrently in primary breast cancer surgery. Patients and surgical procedure From September 2009 to June 2012, we performed the infra-mammary adipofascial tissue repair (IATR) on 25 patients with breast cancer in inferior site of their breast mound. Surgeon makes the skin incision on the infra-mammary line and performs the quadrantectomy as planned. After verifying its negative surgical margin pathologically, we mobilize the adipofascial fat tissue associated with myofascia of the serratus anterior muscle from the infra-mammary area. This tongueshaped flap is reflected back, and fills the defect of breast mound. We performed routinely examination, mammography, and ultra-sound echogram to the IATR patients who visited our hospital after 1 year from the end of treatment. We, furthermore, performed the QOL questionnaire (QOLACD and QOL-ACD-B) to them and retrospectively compared their data to that from the other breast surgery patients. Results All patients with IATR were treated with irradiation, and no image findings of a partial or total necrosis of the flap recognized 1 year after examination. They produced good cosmetic results; however, they could not elevate the QOL score on the whole.
S. Otsuka (&) N. Watanabe Y. Sasaki R. Shimojima Department of Breast Surgery, Japanese Red Cross Society, Himeji Hospital, 1-12-1, Shimoteno, Himeji, Hyogo 670-8540, Japan e-mail: [email protected]
Keywords Breast reconstruction Inferior adipofascial tissue Breast cancer
Introduction The treatment of early breast cancer with breast conserving surgery is required to ensure local control of the malignancy while also providing acceptable cosmetic results. The resection of inferior portion of the breast mound may result in severe breast deformities than that of other upper and/or lateral portion, and thus the patient’s quality of life may be damaged. The mammary surgeons have often used the latissimus dorsi myocutaneous flap to refill the defects of the lateral and/or inferior portion of the breast. However, for this procedure, we need twice the postural changes between the tumor resection and the breast reconstruction, and needs the cooperation with a plastic surgeon. In practice, it is difficult to arrange the stuff of the operation flexibly, especially for the occasionally conversion of the surgical procedure. The technique of inferior adipofascial tissue (IAT) repair (IATR) has been firstly reported by the team of Mie University in 2007 [1]. They used the anterior sheath of the rectus abdominis muscle for feeding this flap. They also reported the follow-up data showing the excellent cosmetic result of this technique in later years [2, 3]. This surgical procedure is useful because it is rather easy for mammary surgeons to perform independently, and the IAT flap has good peripheral circulation [4, 5] and therefore, the microcalcification, which represents the necrosis of the flap [6– 8], has not been recognized in this flap during the longterm follow-up. We have modified this procedure, and used the myofascia of serratus anterior muscle to back and to feed the
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flap. Since 2009, we performed the concurrent reconstruction on this method in 21 patients with breast cancer in inferior section. In addition, we have treated all cases by the radiotherapy without any adverse events. After 1 year from the finish of treatment, we performed mammography and ultra-sound tomography on these flap, and examined the flap stiffness and necrotic change to provide enough evidence of safety. We concomitantly assessed their cosmetic satisfaction and quality of life (QOL), using the charts of questionnaires, QOL-ACD and QOL-ACD-B [9]. These questionnaire forms are provided by Public Health Research FoundationÓ [10], which is the public interest corporation involved by Japanese Health, Labour and Welfare Ministry.
Patients We performed IATR for 25 patients with breast cancer in the inferior portion from October 2010 to June 2013 (Table 1). The patients’ age ranged from 30 to 72 and the
average was 50.0. Eighteen patients had invasive ductal carcinomas, and five had non-invasive ductal carcinomas. Two patients had no residual carcinoma after the neoadjuvant chemotherapy. Sentinel lymph node biopsy was performed on the 18 cases (72 %), and axillary lymph node dissection was performed on 7 cases (28 %). Postoperative radiation therapy was performed in all the patients. Among these 25 cases, 21 had passed over 1 year from the finish of the treatment. We conducted a survey in the form of a questionnaire using the QOL-ACD and QOL-ACD-B [9] and assessed their QOL (as will hereinafter be described in detail). In the same period, we had a same questionnaire on the 234 patients, who had undergone breast surgery. Most of these cases did not need large resection of their breast mound (Partial resection 174/234, 74.4 %; Group ‘‘Major’’ had given a comparative major resection of breast, contains total mastectomy (Bt), and over 90° quadrantectomy, for example, (Bq) 120°, Bq 180°; Group ‘‘Minor’’ had given a comparative minor resection of breast, contains partial
Table 1 Character Group
Major
Minor
Inferior adipofascial tissue repair IATR
n (enroll in QOL examination)
(90)
(144)
25(20)
Age (average ± standard deviation)
52.6 ± 11.8 (range 33–85)
53.5 ± 11.3 (range 34–81)
50.0 ± 11.1 (range 30–72)
Postoperative days (average) Cancer site (n)
402.5
442.5
300.3
32 (29.1 %)
29 (15.3 %)
25 (100 %)
Inferior median (B) or lateral (D)
Other breast surgery
Resection (n) Partial (Bp)
81
2
Quadrantectomy Bq 60°
32
1
31
3
Quadrantectomy Bq 90° Quadrantectomy Bq 120°
20
17
Quadrantectomy Bq 180°
10
2
Bt
60
0
Sentinel lymph node biopsy (n)
63 (70 %)
121 (84.0 %)
18 (72 %)
Axillary lymph node dissection (n)
26 (30 %)
23 (16.0 %)
7 (28 %)
44/90 (48.9 %)
1/144 (0.6 %)
25/25 (100 %)
32 (35.6 %) 60 (66.7 %)
66 (45.8 %) 137 (95.8 %)
10 (40 %) 25 (all cases)
0
9
2
pTis
17
28
5
pT1
13
41
8
pT2
26
31
10
pT3
11
3
0
Cases request any special reconstruction surgery of the breast mound Adjuvant treatment Adjuvant chemotherapy (n) Radiotherapy against the residual breast mound (n) TNM classification (n) pT0 (post neoadjuvant chemotherapy)
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Breast Cancer
resection (Bp), Bq 60°, other under and 90° quadrantectomy) (Table 1). And thus, almost of Group ‘‘Minor’’ did not require any special technique to refill the defect of breast mound (1/144, 0.6 %). In this regard, about half case of Group ‘‘Major’’ requested the reconstruction at the time of or after the breast surgery (44/90, 48.9 %). In these cases, we performed an immediate tissue expander insertion at the time of breast cancer surgery. We routinely performed the radiotherapy to all cases of skin-sparing mastectomy. More than 1 year after the completion of radiotherapy, we would exchange the tissue expander to a permanent implant. In this report, we performed QOL research before the surgery to exchange.
Surgical procedure The operations are performed under general anesthesia. At the start, we perform the ultra-sonography to confirm the location and the spread of the tumor and decide the resection border. To avoid the tumor contamination, we keep over 1 cm from the edge of tumor as a safety margin, and put a mark by injecting the pigment into subcutaneous layer under the vision of echogram. On a case-by-case basis, sentinel lymph node biopsy or axillary lymph nodes dissection will be performed. Surgery to the axilla is performed through an incision different from that for the breast surgery. The surgeon makes a skin incision on the infra-mammary line and performs adequate resection to the inferior site of breast mound. After verified that the margin of the specimen is pathologically negative, the adipofascial fat tissue of the infra-mammary area is mobilized from the same incision. In making the tongue-shaped graft, the myofascia of serratus anterior muscle, occasionally with partial muscle body, is mobilized with fat pad. In the case that the defect of breast mound was in its internal inferior site, we also use the myofascia of external oblique muscle as the feeding pedicle. In this process, feeder vessels raised from muscle body should be secured possibly. Being of importance, we never delaminate the myofascia from the serratus anterior muscle to the end, and must leave the lineal pedicle along the infra-mammary line (Fig. 1a, b). This adipofascial fat tissue is converted and is turn up into dead space, to refill the defect of breast mound. This fat flap is rotated about the linear pedicle on the inframammary line as an axis (Fig. 1c). The flap is fixed to the remnant breast, by being sutured between its myofascia and surgical stump of the breast. After checking the symmetry, a suction drain is placed in the infra-mammary area and the skin incision is then sutured finally (Fig. 1d). The dead space under the incision line will spontaneously disappear by aspiration by the suction tube and it makes the natural
infra-mammary line. The drainage period is required for 2 or 3 days postoperatively. Perioperative seroma happened around this infra-mammary area should cause the skin flap ischemia, and results in the skin necrosis. About 2–3 weeks after surgery, we follow as an outpatient and check the wound condition, and in many cases we puncture the seroma and suction by a syringe.
Results Assessment of safety The range of total operation time was 65–130 min; the mean time was 93 min. This includes the time for the pathological examination of stump contamination, and the time for IATR. The volume of blood loss ranged from 10 to 245 ml; the average was 83.6 ml. The time prolongation or the blood loss for IATR does not matter. After the completion of wound healing, all reconstructed breasts with IATR were followed by local radiotherapy after 30–60 days from the surgery. The radio wave itself causes to the necrosis of biological tissue. However, we had never experienced the IAT flap necrosis through the perioperative period and around the radiotherapy. Twenty-one patients among 25 had passed over 1 year after the treatment, and returned for follow-up. We performed the routine surveillance, mammography and ultrasound echogram, for detection of a new primary or inbreast recurrence. We fortunately had not experienced the local recurrence in 25 IATR cases since now. We had never recognized the findings of fat necrosis in IATR breasts, both in mammography, and ultra-sound echogram. In this regard, the representative features of necrotic lesion in mammography are ‘‘radiolucent oil cyst’’ and ‘‘dystrophic calcification’’. The features of fat necrosis in ultra-sound echogram are ‘‘solid mass’’, ‘‘anechoic with posterior acoustic enhancement’’, and ‘‘anechoic with posterior acoustic shadowing’’. We assessed the breast images with caution regarding these features, but did not recognize them in the lesion of all IAT flaps (Fig. 2). Assessment of cosmetic result and associated QOL At the time of outpatient’ visit, after 1 year from the treatment, we performed QOL research, by doing the questionnaires, QOL-ACD and QOL-ACD-B, against the IATR cases (n = 20). Besides in the same period, we did the same questionnaires against the other patients with breast surgery. Group ‘‘Major’’ (n = 90) had been given a comparative major invasive breast resection: Bt or Bq, central angle is over 90°. Group ‘‘Minor’’ (n = 144) had been given a comparative minor surgery: Bp * Bq 90° (Table 1).
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Breast Cancer Fig. 1 We performed this method, inferior adipofascial tissue repair, to refill the defect of inferior part of breast mound due to the surgical procedure. Skin incision was placed on infra-mammary line, and the required quadrantectomy was performed from this scar. After the dissection, from the same incision, we mobilized the adipofascial tissue from the inferior area of the breast mound (a, b). This flap of a fat pad had a wide and linear pedicle on the inferior mammary line, and was backed by myofascia (break-line in schema) of the anterior serratus muscle, and occasionally the external oblique muscle (c). We kept as many perforating branches from the muscle body as possible. As shown in schema, we converted this flap into dead space, sutured the fascia to the stump of residual breast tissue, and set up to refill the defect of the mound (d)
QOL-ACD and QOL-ACD-B are composed of 40 questions (on a scale of one to five), and thus, those combined perfect score is 200 (QOL-ACD-total). According to the scoring instruction presented by the provider of QOL-ACD-B, we could narrow the list of questionnaires of QOL-ACD and QOL-ACD-B down to the purpose designed. They show a sample specialized for the assessment of body condition, social activity, and general QOL (QOL-ACD-body: 26 questions, the perfect score 130). We compared the QOL-ACD-total and QOL-ACD-body among Group ‘‘Major’’, Group ‘‘Minor’’, and Group ‘‘IATR’’ (the cases with IATR) (Table 2). Both QOL-ACD-total and QOL-ACD-body were not significantly different among them. Spearman correlation coefficients (two tailed) were used to evaluate which factors were mostly correlated with
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QOL-ACD-total and QOL-ACD-body score. The analyses were performed in SPSS version 10.0 for windows. Firstly, QOL-ACD-total and QOL-ACD-body highly correlate with each other (Spearman r = 0.924, n = 252, p \ 0.0001), and there may be no point talking about them as a separate thing. Among the various factors, pathological stage correlates with a highest degree of both QOLACD scores (with QOL-ACD-total: Spearman r = 0.210, n = 252, p = 0.001) and the next, the past history of adjuvant chemotherapy was correlated (with QOLACD-total: Spearman r = -0.204, n = 227, p = 0.002). However, IATR (with QOL-ACD-total: Spearman r = 0.001, n = 252, p = 0.982) and reconstruction protocol (with QOL-ACD-total: Spearman r = -0.038, n = 250, p = 0.552) showed no correlation with QOL-ACD.
Breast Cancer Fig. 2 This case (a), 48-yearold female, had T2 (2.2 cm) tumor on the inferior median area (b area) of the right breast. We performed surgical resection (breast quadrantectomy), and simultaneously reconstructed with IAT. She shows a good cosmetic result (BMI 21.308; postoperative days 372; QOLACD Score: total 138/200, body 106/130, cosmetics 13/15; adjuvant chemotherapy was done). The next case (b) was 41-year-old woman, and had T1 tumor with broadly extending DCIS (4.5 cm) in the inferior area of right breast (BDE area). We performed breast quadrantectomy and refilled the defect immediately with IAT. She was thin and thus we could not gain enough volume of IAT to repair the breast mound (BMI 19.961; postoperative days 354; QOL-ACD Score: total 138/200, body 93/130, cosmetics 13/15)
We thus selected three questions which simply asked about the cosmetics and cosmetic satisfaction among the QOL-ACD questionnaires: B6 ‘‘Have you been satisfied with the appearance of your breast (and/or scar)?’’, B15
‘‘Did you feel any inconvenience because you were unable to choose clothes that you wanted to wear?’’, and B16 ‘‘Do you feel reluctant to disrobe in the presence of other people, such as at a spa?’’.
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Breast Cancer Table 2 Asessment of cosmetic result and associated QOL Group
Other breast surgery Major
Minor
Inferior adipofascial tissue repair IATR
n (enroll in QOL examination)
90
144
20
QOL-ACD total (average ± standard deviation)
154.5 ± 24.6
159.0 ± 20.8
158.7 ± 14.0
QOL-ACD body QOL-ACD-cosmetic (B6 ? B15 ? B16)
101.8 ± 17.3 10.1 ± 3.2
105.1 ± 13.3 12.2 ± 2.8
105.9 ± 9.7 12.3 ± 2.6
Group ‘‘Major’’ had been given a comparative major invasive breast resection: Bt or Bq, central angle is over 90°. Group ‘‘Minor’’ had been given a minor surgery: Bp * Bq 90° QOL-ACD-total consists of QOL-ACD and QOL-ACD-B, which is composed of 40 questions (on a scale of one to five). Thus, those combined perfect score is 200 in total QOL-ACD-body shows a sample specialized for the assessment of body condition, social activity, and general QOL (26 questions, the perfect score 130) QOL-ACD-cosmetic, using question number B6, B15 and B16 shows a sample specialized for the assessment of cosmetic satisfaction.(3 questions, the perfect score 15)
There was no difference between the QOL-ACD-cosmetic of Group ‘‘IATR’’ and Group ‘‘Minor’’ (Fig. 3).
Discussion
Fig. 3 The comparison of QOL-ACD score (the sum of the scores; question B6 ? B15 ? B16) between Group ‘‘Major’’ [had given a comparative major resection of breast, contains total mastectomy (Bt)], Group ‘‘Minor’’ [had given a comparative minor resection of breast, contains partial resection (Bp)], and Group ‘‘IATR’’ (had reconstructed by IATR). Significances of individual differences were evaluated using the Scheffe test
Total score of these three questions (QOL-ACD-cosmetic) were compared among the Groups (Table 2). For multiple group comparisons, homogeneity of variance was assessed by the Bartlett test (B = 3.037, significant). Significances of individual differences were evaluated using the Scheffe test. QOL-ACD-cosmetic of Group ‘‘IATR’’ was significantly higher than that of Group ‘‘Major’’ (p \ 0.05).
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Before concerning the immediate breast reconstructions, we should discuss about the feasibility of the skin sparing [11, 12]. Skin-sparing mastectomy or lumpectomy facilitates immediate breast reconstruction using an implant or myocutaneous flap, especially IATR, and results in excellent cosmetics. NCCN guideline [13] shows the principle that skin-sparing mastectomy has a risk of local and regional recurrence, but it is probably equivalent to standard mastectomy. Needless to say, this principle is applied only to an adequately selected case. Not only multi-centric tumors but also T1/T2, ductal carcinoma in situ [14], and prophylactic mastectomies are particularly suited to this technique. In principle, we apply the skin sparing to the case with the tumor which did not invade the superficial layer of superficial fascia in the images of ultra-sound tomography. Furthermore, we had performed the postoperative radiotherapy in all IATR cases in regardless of the pathological clearance of the surgical margins. Preoperative and postoperative radiotherapies are not a contraindication to skin-sparing mastectomy [15]. However the postoperative radiotherapy occasionally causes the fat necrosis on the surgical site, especially on the flap tending to be ischemic. To monitor the fat necrosis, we have to know the features of fat necrosis in breast imaging. Bilgan evaluated and described about the mammographic and US appearance of fat necrosis in the breast in large series. In this regard, they show the mammographic features of necrotic lesions: radiolucent oil cyst (26.9 %), dystrophic calcification (26.9 %),
Breast Cancer
Fig. 4 At the time of outpatient visit, after 1 year from the treatment, we performed the routine mammography (a) and ultra-sonography (b). There was no image finding which indicate the IAT flap necrosis
asymmetrical opacity–heterogeneity of subcutaneous tissues (15.8 %), and negative (9.5 %). In addition, the features in ultra-sonography are: increased echogenicity of subcutaneous tissues (26.9 %), anechoic with posterior acoustic enhancement (16.6 %), anechoic with posterior acoustic shadowing (15.8 %), and negative (11.1 %) [8]. Even though we had not performed the biopsy against the IATR flap, negative image findings such as fat necrosis should happen in a rare. IATR might be said to have succeeded to survive in all case, in spite of the completion of radiotherapy (Fig. 4). The QOL of breast cancer patients due to complex and diverse causes, and thus, assessment of QOL is also complex and hard to configure. QOL-ACD and QOLACD-B are representative questionnaires in Japan, and we routinely have done them to all breast cancer patients. However, it was revealed this time that the score of these questionnaires were under the strong influence of pathological stage and of the history of chemotherapy, and that the protocol of breast reconstruction had less effect on them on a whole. Thus we picked up three questions, which are simply dealing with the cosmetics. The sum of these questions’ score was significantly better in Group ‘‘IATR’’ in comparison with in Group ‘‘Major’’. Even through a large part of Group ‘‘IATR’’ (76 %) was comparably invasive to Group ‘‘Major’’, the QOL scores of Group ‘‘IATR’’ was not less than that of Group ‘‘Minor’’. In this report, we collected the questionnaire uniformly from the patients who had passed around 1 year form the treatment. After 3–5 years from the treatment, when the adverse influence of chemotherapy or the anxiety from the advance stage would be decreased,
we could see the result that we expected, even in QOLACD as a whole. In 1992, Sakai firstly reported the immediate reconstruction method of the breast mound using the adipofascial tissue. This pedicle flap [16] is harvested from the infra-mammary area and associated with the anterior rectus sheath. We agree his saying that the use of the latissimus dorsi myocutaneous flap or the rectus abdominis myocutaneous flap is too aggressive, and IATR is more adoptable and convenience to repair the partial defect of the breast mound. He designed and gained an approximately 7 cm in length, tongue-shaped flap. We modified this procedure, in which, we had used the myofascia or a partially body of the anterior serratus muscle, not the rectus abdominis. We could gain the same length of IAT using this procedure, and it might be easier to refill the inferior and lateral area of breast. In this report, we would ensure safety of our IATR method, and prove excellent efficacy in cosmetics. Conflict of interest
None declared.
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