Surgery is the main line of treatment of non-metastasizing breast cancer either breast-conserving surgery or modified radical mastectomy (MRM).[11]
Post-BCS cosmetic results are inversely proportional to specimen weight and scar length and are adversely affected by smaller breast cup size, medial tumor localization, and inappropriately located incision. [12, 13]
Zoltán Mátrai et al performed the retro glandular approach as a level I oncoplastic breast conservative surgery. Zoltán Mátrai et al study was done during the period from February 2016 and October 2017 on 102 females with breast malignancy. [14]
The current study was done on 67patients admitted to the Surgical Oncology Unit in Alexandria Main University Hospital with breast cancer diagnosis in the period from January 2019 to July 2021.
In Zoltán Mátrai et al study, the median age of patients was 55 years (range from 31–80 years) with a mean BMI of 26.5 ± 6.2. It was nearly the same as our study in which the median age of the studied patients was 52 years old (ranging from 31–63 years) with a mean BMI of 33.4 ± 3.4.
In Zoltán Mátrai et al study, the tumor was located in the upper outer quadrant in 44 patients (43.1%) and the lower outer quadrant in 20 patients (19.6%). In our study, the tumor was in the lower outer quadrant in 33 patients (49.3%) and in the upper outer quadrant in 14 patients (20.9%).
In our study only 14 patients received neoadjuvant chemotherapy (20.9%) in whom the hormonal profile was triple-negative and her2 neu positive, to reduce tumor size and achieve negative resection margins easier.
The average tumor size in Zoltán Mátrai et al study was 1.5 cm, but it was 1.9 cm in our study. Axillary lymph node dissection was done in only 6.9% of Zoltán Mátrai et al study in contrary to our study in which about 46.3% of the cases had positive axillary lymph nodes and subsequently ALND.
In the Zoltán Mátrai et al study, breast cup size was assessed preoperatively, and 30 patients (29.4%) were found to have to cup C, 30 patients (29.4%) were cup D,17 patients (16.7%) were cup B, 14 patients (13.7%) were cup A and only eleven patients (10%) were cup E. In our study, breast cup size was also assessed preoperatively and 53.7% of patients were found to have cup size B while 14.9% had cup size A and 31.3% patients had cup size C.
Also, Zoltán Mátrai et al reported that the median operative time was 40 minutes (20–80 min) while in our study the median operative time was125 minutes (110–140 min). This might be attributed to the longer time of frozen section examination in our institution and more cases that required ALND.
According to margin positivity, Zoltán Mátrai et al stated that only 17 patients (16.6%) had a positive margin on frozen section. In 14 patients, a negative margin was achieved after re-excision while only three patients had undergone mastectomy as a negative margin could not be achieved.
In our study 59 patients (88%) had a negative margin on frozen section from the first attempt while 9 patients (12%) needed re-excision to achieve negative margins. None of our patients proceeded to mastectomy. Yet, if MRM had been done, we believe this will be due to tumor factors, not technique failure i.e., it would have occurred with any frontal approaches. Skin-sparing or nipple-sparing mastectomy can be done through the same incision.
In Zoltán Mátrai et al study, about 67.7% were found to be IDC and 2.9% only showed DCIS only 23.5% were ILC. 57 patients (55.9%) were found to be at stage II and 22 patients(21.5%) were at stage I and 21 patients (20.6%) were stage III (12). In our study, 70.1% of our patients showed IDC NOS as a final pathology while 6% showed IDC with DCIS and 23.9% as ILC. 30 patients were diagnosed as stage I while 37 patients as stage II.
Seroma formation was the commonest complication in the Zoltán Mátrai et al study seen in 25 (24.5%) patients. Limited fat necrosis was found in 3 (2.9%) patients. Wound dehiscence was seen in 2 (1.9%) patients. Fat necrosis was seen in 4 (3.9%) patients in the follow-up.
The incidence of complications in our study occurred in 14.9% of cases, in whom seroma was the most common complication and was seen in 6 patients (8.9%) and it was treated with repeated aspirations. Wound infection and dehiscence were seen in 4 patients (6%). It was treated by frequent dressing and systemic antibiotics after culture and sensitivity.
Jenny Heiman Ullmark et al (4) reported complications in 11% of their patients, also in the form of seroma and wound infection.
In the Zoltán Mátrai et al study the median follow-up time of the patients was about 11 months with no evidence of locoregional or distant recurrence. In our study, the follow-up period was shorter ranging from 3 to 9 months with no signs of recurrent disease. In fact, in both studies, the follow-up period is not sufficient to judge the rate of recurrence. However, it is worth mentioning here, that the recurrence rate is related to the ability to achieve safe margins rather than the technique. Jenny Heiman Ullmark (4) reported that after a median follow-up of 35 months (29–40 months), all patients were alive and free of disease.
Cosmetic outcome after BCS is influenced negatively by increased specimen weight, inappropriate incisions, and increased scar length. Inframammary incision allowed resection of the tumor while preserving the skin envelope of the breast giving better cosmetic results.
In Zoltán Mátrai et al study, according to the results of the 4-point Likert score and the BCCT score points most of the patients had an excellent or good esthetic outcome. Thus, retro glandular OPS was able to fully preserve the initial natural appearance and shape of the breast while accomplishing radical tumor resection.
In our study cosmetic outcome was assessed by both surgeon aesthetic assessment 4-point Likert scale and patient satisfaction. According to surgeon assessment, 62.7% of patients showed excellent results, while 16.4% showed good results and 20.9% had fair results. 82.1% of our patients were satisfied with their results and only 12 patients (17.9%) were not satisfied with their results. Unsatisfactory results occurred in patients who needed re-resection that resulted in skin or nipple retraction. In Jenny Heiman Ullmark (4) post-operative patient satisfaction was assessed using the validated BREAST-QTM questionnaire, Breast-conserving therapy (BCT) module. The item 'Breast Satisfaction' had a mean RASCH score of 72.5, with a range of 18–100.