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Current practice and short‐term outcomes of therapeutic mammaplasty in the international TeaM multicentre prospective cohort study. BJS 2018; 105: 1778-1792.

Published: 22nd August 2018

Authors: R. L. O'Connell, E. Baker, A. Trickey, T. Rattay, L. Whisker, R. D. Macmillan et al.

Background

Therapeutic mammaplasty, which combines breast reduction and mastopexy techniques with tumour excision, may extend the boundaries of breast‐conserving surgery and improve outcomes for patients, but current practice is unknown and high‐quality outcome data are lacking. This prospective multicentre cohort study aimed to explore the practice and short‐term outcomes of the technique.

Method

Consecutive patients undergoing therapeutic mammaplasty at participating centres between 1 September 2016 and 30 June 2017 were recruited to the study. Demographic, preoperative, operative, oncological and complication data were collected. The primary outcome was unplanned reoperation for complications within 30 days of surgery. Secondary outcomes included re‐excision rates and time to adjuvant therapy.

Results

Overall, 880 patients underwent 899 therapeutic mammaplasty procedures at 50 centres. The most common indications were avoidance of poor cosmetic outcomes associated with standard breast‐conserving surgery (702 procedures, 78·1 per cent) or avoidance of mastectomy (379, 42·2 per cent). Wise‐pattern skin incisions were the most common (429 of 899, 47·7 per cent), but a range of incisions and nipple–areola pedicles were used. Immediate contralateral symmetrization was performed in one‐third of cases (284 of 880, 32·3 per cent). In total, 205 patients (23·3 per cent) developed a complication, but only 25 (2·8 per cent) required reoperation. Median postoperative lesion size was 24·5 (i.q.r. 16–38) mm. Incomplete excision was seen in 132 procedures (14·7 per cent), but completion mastectomy was required for only 51 lesions (5·7 per cent). Median time to adjuvant therapy was 54 (i.q.r. 42–66) days.

Conclusion

Therapeutic mammaplasty is a safe and effective alternative to mastectomy or standard breast‐conserving surgery. Further work is required to explore the impact of the technique on quality of life, and to establish cost‐effectiveness.

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2 Comments

Maria Joao Cardoso

11 months ago

The authors must be praised for this important collaborative effort. This is a significant step for the standardized outcome analysis of one of the most frequently used techniques in oncoplastic breast conserving surgery.

However some important comments need to be addressed and hopefully lead to an impact in the publication of the median and long-term outcomes of the current work and data collection.

It is a worldwide recommendation for breast centre certification that each surgeon should have at least 50 breast cases operated per/year. It is surprising to realize that the experience of these centres per year is very small (we can additionally presume that the distribution is not even) impacting not only on statistical analysis but also on the conclusions of the current paper and surely on the long-term outcomes(1) .

Moreover when we analyse the reason to undergo a therapeutic mammaplasty, in 78% of cases the declared intention is to avoid a poor cosmetic outcome. In only one third of the patients a bilateral procedure was undertaken, leaving the reader with the impression that the median and long term cosmetic outcomes of this study will not match one of the major objectives of the current technique, that is an improved cosmetic outcome(2).

The gathering of data is fundamental and a collaborative effort can help in a prospective way to understand how things happen in the real world, nonetheless measures should be reported including all determinant factors(3).

Maria-Joao Cardoso
Champalimaud Foundation
Lisbon
Portugal
maria.joao.cardoso@fundacaochampalimaud.pt

References:
1. Wilson AR, Marotti L, Bianchi S, Biganzoli L, Claassen S, Decker T, et al. The requirements of a specialist Breast Centre. Eur J Cancer 2013;49(17):3579-87.
2. Lagendijk M, Vos EL, Nieboer D, Verhoef C, Corten EML, Koppert LB. Evaluation of cosmetic outcome following breast-conserving therapy in trials: panel versus digitalized analysis and the role of PROMs. Breast J 2018;24(4):519-525.
3. Piper ML, Esserman LJ, Sbitany H, Peled AW. Outcomes Following Oncoplastic Reduction Mammoplasty: A Systematic Review. Ann Plast Surg 2016;76 Suppl 3:S222-6.

    Shelley Potter

    10 months ago

    We thank Dr Cardoso for her comments.

    The recommendation that specialist breast surgeons should perform a minimum of 50 cases per year refers to all primary breast cancer surgery. National audits demonstrate that UK breast surgeons and those participating in the current study fulfil these criteria (1,2). The TeaM study, however, focuses specifically on therapeutic mammoplasty or so called ‘level 2 oncoplastic procedures’ (3). These require specialist training and expertise and are only indicated in a proportion of patients. This case selection explains the apparently small numbers of cases per centre/surgeon in the study.

    The apparently low proportion of patients undergoing simultaneous contralateral symmetrisation is an interesting finding. There are several potential explanations; Symmetrisation may not be required as a degree of asymmetry may be acceptable for example in the 25% of patients who underwent a round-block procedure. In addition some surgeons may prefer to offer delayed symmetrisation. This can be debated and may be influenced by organisational restrictions such as limitations on theatre time or funding (4). Reasons for variation in practice do warrant further exploration and justification as we believe immediate symmetrisation is more efficient for the patient and the NHS and associated with very acceptable long-term outcomes.

    The TeaM study aimed to establish the current practice and short-term outcomes of therapeutic mammoplasty as the first step in establishing a definitive evidence-base for the technique. This work will inform a future study including validated patient-reported and cosmetic outcomes which will allow the true impact of the technique to be assessed.

    Shelley Potter
    Lisa Whisker
    R Douglas Macmillan
    On behalf of the TeaM Study Group

    Bristol Centre for Surgical Research
    Population Health Sciences
    Bristol Medical School
    2.14 Canynge Hall
    Whatley Road
    Bristol BS8 2PS
    UK
    shelley.potter@bristol.ac.uk

    References:
    1. NHS breast screening programme and Association of Breast Surgery. An audit of screen detected breast cancers for the year of screening April 2016 to March 2017. PHE publications June 2018 https://associationofbreastsurgery.org.uk/media/64800/nhsbsp_abs_breast_screening_audit-2016-2017-v2-today.pdf
    2. https://www.nabcop.org.uk/content/uploads/2018/03/NABCOP-2017-Annual-Report-V1.1.pdf
    3. Clough KB, Kaufman GJ, Nos C, Buccimazza I, Sarfati IM. Improving breast cancer surgery: a classification and quadrant per quadrant atlas for oncoplastic surgery. Ann Surg Oncol. 2010 May;17(5):1375-91. doi: 10.1245/s10434-009-0792-y. Epub 2010 Feb 6.
    4. Breast Cancer Now. Rebuilding my body. Breast Reconstruction in England June 2018. https://breastcancernow.org/sites/default/files/public/rebuilding_my_body_report_june_2018.pdf