Hindawi

International Journal of Breast Cancer

Volume 2019, Article ID 4262589, 8 pages
https://doi.org/10.1155/2019/4262589

Clinical Study
Extreme Oncoplastic Surgery for Multifocal/Multicentric and
Locally Advanced Breast Cancer

Chaitanyanand B. Koppiker ,1 Aijaz Ul Noor,1 Santosh Dixit,1 Laleh Busheri,1

Gautam Sharan,2 Upendra Dhar,1 Hari Kiran Allampati,3 and Smeeta Nare1
1
Orchids Breast Health Clinic, Prashanti Cancer Care Mission, 1&2, Kapilavastu, Senapati Bapat Road, Pune,
Maharashtra 411016, India
2
Department of Radiation Oncology, Inlaks and Budhrani Hospital, Pune 411001, India
3
Ruby Hall Clinic, Pune, Maharashtra 411040, India

Correspondence should be addressed to Chaitanyanand B. Koppiker; obs.koppiker@gmail.com

Received 28 October 2018; Accepted 27 December 2018; Published 20 February 2019

Academic Editor: Vladimir F. Semiglazov

Copyright © 2019 Chaitanyanand B. Koppiker et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Introduction. Breast conserving surgery (BCS) followed by radiation therapy (RT) has become the preferred alternative to
mastectomy for patients with early stage breast cancer (BC). Randomized trials have confirmed equivalent locoregional control
and overall survival for BCS and mastectomy. Extreme Oncoplasty (EO) extends the indications of BCS for patients who
would otherwise require mastectomy, ensuring better aesthetic outcomes and oncological safety. Methods. BC patients with
multifocal/multicentric (MF/MC) tumors, extensive DCIS, or large tumor >50mm underwent EO at our breast unit. Therapeutic
reduction mammaplasty (TRM) with wise pattern preoperative markings and dual pedicle technique involving parenchymal
rearrangement was used for oncoplastic reconstructions in majority of the cases followed by RT. Patient reported outcome measures
(PROMs) were assessed using the validated Breast-Q questionnaire. Results. Of the 39 patients in the study, 36 had unilateral and
3 had bilateral BC. Mean age was 47.2 years. Median tumor size was 75mm. 17 (43.6%) patients received NACT; none achieved a
complete clinical response. 28 (71.8%) patients were administered to adjuvant chemotherapy. 33(84.6%) patients received RT to the
breast with a median dose of 50Gy in 28 fractions and a boost dose of 10Gy in 5 fractions to the tumor bed. No major complications
or local recurrences were observed. Excellent Breast-Q scores were observed in patients undergoing EO after 12 months of follow-up.
Conclusion. EO followed by RT results in acceptable local-regional control, low rate of complications, and high patient satisfaction.
In selected patients, EO could provide a safe alternative for breast conservation surgery instead of mastectomy.

1. Introduction At present, breast surgeons are attempting to extend

the scope of breast conservation so as to include scenarios
Breast conservation therapy (BCT) which includes breast which are otherwise contraindicated for BCS particularly
conservation surgery (BCS) and adjuvant radiation therapy in multicentric (MC) or multifocal (MF) tumors. Clinical
(RT) is a standard protocol to achieve high local control with management of MF/MC breast tumors is a challenge since
acceptable aesthetic outcomes [1–3]. Multiple prospective the choice of optimal surgical approach is controversial. Pre-
randomized trials [4], some with a follow-up of 20 years, viously, mastectomy was considered as the standard choice
have established equivalent survival rates between mastec- [8–10]. However, significant local recurrence rates (2.5% to ∼
tomy and breast conservation surgery (BCS) with negative 40%) have limited the utility of mastectomy in such scenarios
margins. Recent studies from various countries including [11–15].
India indicate that women treated with BCT have a significant In contrast, breast cancer (BC) patients with large T2 and
survival advantage when compared to mastectomy [5–7]. T3 tumors (size range: 40-120mm) who underwent BCT were
2 International Journal of Breast Cancer

shown to have acceptable cosmesis without compromising carrying the nipple areolar complex (NAC) and filling in the
locoregional control or survival [16]. In the last decade, defect by appropriate mobilization of the internal local breast
oncoplastic breast surgery (OBS) has emerged as an inte- flaps.
grated approach to achieve optimal oncological outcomes Most of the cases in our study cohort have been operated
and cosmesis. This approach allows tumor excision with using the dual pedicle technique. NAC was carried on
wider margins during BCS without compromising the aes- superior pedicle and the inferior pedicle was used to fill the
thetic outcome [17]. In addition, OBS has shown comparable defect caused by excision of the tumor.
oncological efficacy with conventional BCS in achieving
adequate surgical margins and recurrence rates [18–21]. 2.2. Patient Selection. This is a single institutional study
In recent years, the technique of “Extreme Oncoplasty” involving retrospective analysis of prospectively collected
(EO) has emerged as a promising option in selective patients data. During the study duration, a total of 42 BC patients
with adequate breasts (cup size ≥ C) where in BCS is possible with large breasts having either MF/MC or large tumor (>50
inspite of large volume resections [22]. Indeed, EO could be mm) or previous oddly placed large scar or extensive DCIS
used to conserve breasts in scenarios for which mastectomy were included. All patients were initially recommended to
would be have been the treatment of choice offered by most have a mastectomy but agreed to breast conservation after
surgeons. These situations include (a) tumor size >50 mm, appropriate counseling by the breast oncoplastic surgeon.
(b) MF and MC tumors, (c) extensive ductal carcinoma For the purpose of this study, large breast is defined as
in situ (DCIS), (d) extensive intraductal component > 50 the one with a cup size of C or larger. Written informed
mm, (d) previously irradiated breast with a new or recur- consent was obtained from all patients for collection of study-
rent cancer within the same breast, (e) a locally advanced relevant medical data inclusive of clinical management and
breast carcinoma with limited or partial imaging response routine follow-up visits. Data collection included demog-
to neoadjuvant chemotherapy (NACT), and (f) patient with raphy, medical history, clinicopathological characteristics,
excision biopsy with inappropriate scar [22, 23]. Thus, EO details of adjuvant therapy, surgical intervention, postsurgery
provides an alternative to mastectomy, extends the scope of complications, and follow-up details.
breast conservation, provides better clinical outcomes, and Out of these 42 patients, 39 completed one-year post-
improves quality of life (QoL) [22]. surgery follow-up and were analyzed for surgical outcomes
There are very few reports in the literature which describe and patient reported outcome measures (PROMs).
the application of the EO technique in BC management.
Therefore, the aim of this study is to analyze the clinical,
postsurgical, and patient satisfaction outcomes in an EO 2.3. Clinical Management. BC diagnosis was based upon
study cohort at our breast unit. In this report, we describe clinical examination and radiological evaluation of breast and
our experience in a series of 39 BC patients who underwent axilla using Full Field Digital Mammography (FFDM) with
EO using wise pattern/vertical scar therapeutic reduction 3-D Tomosynthesis (Siemens Mammomat Inspiration) and
mammaplasty (TRM) technique. Ultrasonography (Siemens Acuson S2000). Histopatholog-
ical studies on Tru-Cut biopsy samples (majority of cases)
or vacuum assisted biopsy (for index tumors, Encor Ultra)
2. Material and Methods samples were performed for confirming diagnosis of breast
2.1. Surgical Technique. Our EO surgery technique encom- carcinoma. Similarly, ultrasonography and fine needle aspi-
passes excision of large volume of the breast dictated by ration cytology were used for investigating axillary lymph
the extent of tumor. This is facilitated by the technique node metastasis. Confirmed BC cases underwent EO surgery
of Therapeutic Reduction Mammoplasty (TRM) which is at a network hospital site. The oncologic management with
performed either by a wise pattern and/or vertical scar skin chemoradiation protocols was undertaken by a multidisci-
pattern. In some patients, the central wedge excision with plinary clinical team in accordance with the current NCCN
immediate nipple reconstruction (wise pattern) and in few guidelines.
patients nipple areolar grafting was performed. In exceptional
cases, lateral mammaplasty techniques were used. 2.4. Radiation Therapy. The Radiation Therapy (RT) dose
The surgery begins by marking out the wise pattern. planning was aimed at achieving a Biologically Effective
The next step is to localize the tumor and excise it with Dose (BED) of 50 Gy for all patients. The breast along
wide margins by going through one of the limbs of the wise with the supraclavicular region (if indicated) was irradiated
pattern. This localization is performed either preoperatively by 6 MV photon beams using Forward Plan Field-in-Field
by stereotactic guide-wire placement or by placement of wire Intensity Modulated Radiation Therapy (F-P FiF IMRT). Two
and needle on the operating table using a high resolution tangential fields along with multiple subfields were used for
ultrasonography. The tumor and its quadrant are then widely this treatment. CT images (5-mm thickness) were obtained
excised and further imaging of the specimen is performed at different transverse sections covering the region of inter-
using specimen mammography to ensure that the tumor is est with adequate margins to create a 3D image. Volume
excised with wide margins. After this step, the shaved margins delineation (CTV, Contralateral breast, Lung and Heart)
of the cavity are further excised and sent for frozen sections. on CT images was performed on an Eclipse contouring
Once clarity about the tumor margins of the excision cavity is station. Computerized treatment planning was performed on
achieved, the decision is made to use one of the pedicles for Eclipse treatment planning system (TPS) (Version 13.5.35).
International Journal of Breast Cancer 3

High energy linear accelerator (Elekta Synergy, Elekta Medi- images for this patient are depicted in Figure 1. The maximum
cal System, UK) with 80 leaves Multileaf Collimator (MLCi) and mean doses of RT received by the structures are tabulated
was used for tangential treatments to the breast field. RT plan in Supplementary Table 1.
was accepted if at least 95% of prescribed dose covers the
100% of planning target volume (PTV). Hot spot in PTV was 3.2. Study Cohort Demography. Out of 42 EO cases, 39
accepted up to 110% of prescribed dose. Tumor bed boost, patients with large breasts who had completed 12 months
wherever indicated, was performed using either an electron post-surgery follow-up were included in the study. 36 patients
portal or Simultaneous Integrated Boost (SIB) technique. had unilateral and 3 had bilateral BCs. Tumors were found
in the upper outer quadrant of the breast in 22 (56.4%)
2.5. Study Assessments. Postsurgery outcomes were assessed patients, lower outer quadrant in 06 (15.4%) patients, and
by oncosurgeons. Complications such as hematoma, seroma, lower inner quadrant in 06 (15.4%) patients. The mean age of
infection, skin necrosis, nipple necrosis, and wound dehis- patients at diagnosis was 46.3 years. Majority of these patients
cence were recorded. Complications were classified as were at stages II or III. Most of the diagnosed BC cases
“major” when they required surgical intervention and were IDC and/or DCIS. 17 (43.6%) patients received NACT;
“minor” when they were managed conservatively. We also none achieved a complete clinical response. In addition,
noted the time between completion of the surgery and start adjuvant therapy was administered to 71.8% of patients. In the
of the adjuvant therapy to ascertain any delays in the adjuvant postoperative period, adjuvant chemotherapy and/or RT was
therapy. administered to patients according to clinical indications. 32
(82.05%) patients received RT (Table 1).
2.6. PROMs. The Patient Reported Outcomes Measures Demographic distribution of study participants and their
(PROMs) were used to evaluate patient satisfaction and qual- clinicopathological characteristics are summarized in Table 1.
ity of life (QoL) after EO. To assess PROMs, a standardized The median tumor size was 75mm. Clear margins were
Breast-Q questionnaire was utilized. The Breast-Q module achieved in all the patients on frozen section as well con-
was divided into multiple independent scales. Higher scores firmed on final histopathology analysis. The average mar-
indicate greater patient satisfaction and functionality [24]. gin achieved distance was 5mm. No local recurrence was
observed (Table 2). None of the patients in our study cohort
3. Results experienced any delays in their adjuvant therapies.

3.1. Representative Case Study. A 40-year-old patient with 3.3. Postoperative Outcomes. There were no major postoper-
E-cup breasts presented with a large diffuse lump in the ative complications (defined as requiring inpatient hospital-
left upper outer quadrant (UOQ). Mammogram revealed a ization or returning to the operating theatre). There were 3
MF/MC tumor that extended from 3 o’ clock position to 12 o’ cases of minor complications including 1 case of seroma and
clock position measuring 11.8 x 7.9 mm. Tru-Cut biopsy sug- 2 cases of minor wound healing. All of them were treated
gested DCIS of intermediate grade. Immunohistochemistry conservatively in the outpatient settings (Table 3).
revealed ER (Estrogen Receptor)/PR (Progesterone Receptor)
positive status. The patient was initially advised mastectomy 3.4. Radiation Therapy. Of the 39 patients included in this
but insisted on conserving her breast and sought a second study, 32 patients underwent RT as clinically indicated. It was
opinion. Hence, TRM was planned. The tumor was localized not possible to obtain RT-related data from the remaining 7
with localization wires under mammography guidance. The patients as they were lost to follow-up. While 22 of these 32
patient was marked for wise pattern incision and excision of patients received RT to the whole breast alone, 10 received
the whole UOQ was performed. Specimen mammography RT to the breast along with the supraclavicular region. Out of
was performed to confirm complete removal of tumor. Shave 32 patients, 18 patients had left-sided lesion and 14 patients
margins were sent for frozen section evaluation and were had right-sided lesion. Forward Plan Intensity Modulated
reported negative. The skin over lower, medial, lateral, and Radiation Therapy (IMRT) was used to treat 27 patients. 4 of
superomedial quadrants was mobilized in the mastectomy the 5 patients who were treated using Volumetric Modulated
plane and other quadrants were used to fill the defect. Since Arc Therapy (VMAT) also received Simultaneous Integrated
the dissected sentinel node was positive, further axillary Boost (SIB). (Supplementary Table 2)
dissections were performed through the same incision. 2/16
nodes were positive. Though the tumor location was close 3.5. PROMs. PROMs data was collected from the study
to the nipple, the nipple core and margins of the NAC were participants after 12 months postsurgery with the Breast-
negative for DCIS on frozen sections. The breast tissue was Q questionnaire. Out of 39 study participants, 29 (74.3%)
reshaped and reconstructed. The NAC was used as a nipple- responded to the questionnaire. These PROMs were used to
areola graft. The post-op histopathology revealed Grade II assess patient reported satisfaction and QoL after EO. The
IDC with extensive DCIS and a lesion spanning 75 mm results indicated improvement in the following four areas
in UOQ. The patient received adjuvant RT, followed by evaluated after surgery. The mean scores for BREAST-Q
electron boost to the tumor bed. The patient was counseled scales (±standard deviation) were Satisfaction with Breasts
for adjuvant therapy and chose to have adjuvant endocrine (78.0±16.6), Satisfaction with Outcome (85.7±13.7), Psy-
therapy. The patient tolerated treatment well and is disease- chosocial Wellbeing (90.8 ± 11.5) and Sexual Wellbeing
free after 4 years post-diagnosis. The pre- and postsurgery (75.8±11.7) (Table 4).
4 International Journal of Breast Cancer

(a) (b)

(c) (d)

Figure 1: Representative Case Study. (a) Preoperative images. (b) Lateral view shows skin and breast tissue that will be removed. (c)
Mammography shows lesion in UOQ. (d) Postoperative images.

4. Discussion was shown to be a safe alternative to mastectomy if negative

surgical margins were achieved during surgery [14]. Further-
BCT is considered a standard treatment option for selective more, a recent study comparing oncological outcomes after
BC patients with acceptable oncological safety, improved mastectomy or BCS in patients with unifocal or MF/MC
aesthetic outcomes, and better survival. In patients with large tumors shows significant increase in local recurrence rates
tumors, BCT is feasible if excision margins are free of tumor after mastectomy [15]. Recently, the EO technique introduced
and an acceptable cosmesis can be obtained [3, 4, 16]. Results by Silverstein et al. has demonstrated successful BCS out-
from NSABP-06 and EORTC-10801 trials have indicated that comes and improvement in QoL in patients with MF/MC and
BCT is safe for patients with tumors >20mm [4, 25]. large tumors (≥ 50mm). With this technique, the rate of local
OBS allows tumor excision with wider resection margins recurrence was comparable in patients with MF tumors that
and acceptable oncological and aesthetic outcomes [26]. underwent either EO or conventional BCS.
This approach can achieve higher rates of negative margins In our study, we report the oncoplastic outcomes after EO
with low local recurrence and better cosmesis. OBS has in a single institutional cohort of 39 patients with large breasts
been shown to have a positive impact on QoL and self- (cup size ≥ C) with MC/MF or large tumors (≥50mm). While
esteem of patients. [27]. OBS technique namely TRM allows no major complications were observed after EO procedure,
wide excision, reduced margin positivity, and better aesthetic a low rate of minor complications (7.7%) was observed.
outcome compared to conventional BCS [28–30]. Therefore, The PROMs in these patients indicate better acceptance
the indications for conventional BCS can be extended further of the EO procedure with improvement in QoL. Breast-
for large tumors (>40mm), central quadrant and MF/MC Q parameters such as satisfaction with breast, satisfaction
tumors and extensive DCIS. Indeed, TRM is considered as with outcome, psychosocial wellbeing, and sexual wellbeing
a suitable option for OBS, especially, in women with large showed a positive trend after EO.
breasts on which wide resections can be performed [31, 32]. RT is an integral component of BCT and improves locore-
Given the increased risk of local recurrence, defining gional tumor control along with disease-free and overall sur-
appropriate indication(s) for choosing BCS over mastectomy vival [34–36]. However, RT increases the risk of postoperative
in patients with MC/MF tumors is important [8–10]. How- complications such as severe capsular contracture in implant-
ever, current indications are ambivalent. Local recurrence based breast reconstructions [37–39]. Alternatively, autolo-
rates and overall survival after BCS did not differ in patients gous reconstruction can be a feasible option for patients that
with unifocal or multifocal tumors [33]. In contrast, in require PMRT [39]. However, this surgery type is associated
selected MF/MC cases, BCS followed by adjuvant therapy with significant morbidity, complication, and longer hospital
International Journal of Breast Cancer 5

Table 1: Demography and clinicopathological profile of study participants.

Characteristics (n=39) Number, %

<=35 04 (10.2%)
Age, years 36-50 23 (58.9%)
>51 12 (30.7%)
Upper Inner Quadrant 05 (15.4%)
Upper Pole Nil
Upper Outer Quadrant 22 (56.4%)
Central 02 (5.1%)
Tumor Location
Lower Outer Quadrant 06 (15.4%)
Lower Pole 01 (2.5%)
Lower Inner Quadrant 06 (15.4%)
Others 01(2.6%)
DCIS 02 (5.1%)
IDC 26 (66.7%)
Type of Tumor
IDC + DCIS 07(17.9%)
Others 4 (10.3%)
ER Positive 26 (66.7%)
PR Positive 20 (51.3%)
Receptor Status
Her-2 Positive 13 (33.3%)
TNBC 06 (15.14%)
I 1 (2.6%)
Grade∗ II 26 (66.7%)
III 08 (20.5%)
0 1 (2.6%)
I 3 (7.7%)
Stage∗
II 18(46.1%)
III 12(30.7%)
NACT - 17(43.6%)
Adjuvant Chemotherapy - 28 (71.8%)
RT - 32 (82.05%)
∗Data for all 39 patients could not be obtained due to being lost to follow-up.

Table 2: Salient features of EO cohort. Conventionally, a RT plan encompasses a total dose of 45-
Characteristics(n =39) Extreme (>50mm)
50 Gy in 25 daily fractions over 5 weeks followed by a boost
of 10-16 Gy in 5-8 fractions. Nowadays, hypofractionated RT
N 39
(dose >2 Gy per fraction) delivered in fewer fractions over
Mean Age 46.3 a shorter treatment period is an alternative option [40]. In
Mean Volume 432.8 cc addition, a tumor bed boost delivered to selective patients
Median Span 75 mm by an electron beam of specific energy after whole breast
NACT 17/39 (43.6%) irradiation (WBI) has been shown to improve local control,
Margins (0.1 – 0.9mm) Nil particularly, in patients <40 years [41]. Currently, newer RT
Margins (>1 mm) 39/39 (100%) techniques such as Simultaneous Integrated Boost (SIB) have
been introduced to deliver boost dose concomitant to WBI,
Average Margin Distance 5 mm away (approximately)
thereby reducing skin toxicity and fibrosis [42]. Indeed, in our
Re-excision Nil
study cohort, the 4 EO patients who received an SIB-IMRT
Mastectomy Nil did not develop any major complications. This observation
Any Local Recurrence Nil indicates the feasibility of using SIB-IMRT for in patients who
Follow-Up 12 months have undergone EO surgery.
Despite the promising results related to post-EO surgery
outcomes and RT-associated complications, our study has a
stay. Therefore, choice of optimal RT technique is critical few limitations. This study only describes data from single
in OBS to ensure satisfactory oncological outcomes with breast unit with small number of patients (n = 39) with a 12-
minimal postoperative complications. month postsurgery follow-up. To overcome these limitations,
6 International Journal of Breast Cancer

Table 3: Summary of postoperative complications.

Complications Number, %
Characteristics
(n = 39)
Hematoma (requiring surgical evacuation) Nil
Infection (requiring surgical drainage/debridement under general
Nil
Major Complications anesthesia
Skin Necrosis (requiring surgical debridement under general
Nil
anesthesia)
Nipple Necrosis (requiring surgical debridement/complete nipple
Nil
loss)
Wound Dehiscence (requiring return to theatre for resuturing) Nil
Total Nil
Seroma (requiring aspiration) 1 (2.6%)
Hematoma (managed conservatively) Nil
Minor Complications Infection (requiring antibiotics) Nil
Skin Necrosis (managed conservatively by dressings) Nil
Nipple Necrosis (managed conservatively by dressings) Nil
Wound Dehiscence (managed conservatively) 2 (5.1%)
Total 3 (7.7%)

Table 4: PROMs from EO study participants. QoL: Quality of Life

RT: Radiation Therapy
S. No. Breast-Q Parameters Mean±S.D.(𝑛 = 29)
SIB: Simultaneous Integrated Boost
1. Satisfaction with Breast 78.0 ±16.6 TRM: Therapeutic Reduction Mammaplasty
2 Satisfaction with Outcome 85.7 ±13.7 UOQ: Upper Outer Quadrant.
3. Psychosocial Wellbeing 90.8 ± 11.5
4. Sexual Wellbeing 75.8 ± 11.7
Data Availability
The figures and tables used to support the findings of this
we are continually recruiting patients to increase the sample study are included within the article. The figures and tables
size and ensure long-term follow-up. In future, a multicentric used to support the findings of this study are included within
study will be needed to avoid investigator bias. the supplementary information file(s). The medical records
and related data used to support the findings of this study
5. Conclusion are restricted by the Independent Ethics Committee (IEC)
The preliminary results of our study indicate that selective of the parent institute (Prashanti Cancer Care Mission) in
patients (with MF/MC or large tumors) who were initially order to protect the patient privacy. Data will be available
considered for mastectomy can be alternatively treated using from corresponding author upon request after approval of the
EO followed by RT (with an optional boost to tumor bed, IEC.
if indicated). EO can be considered as a safe and feasible
surgical option for such patients without compromising Ethical Approval
aesthetic outcomes.
The study was approved by the Independent Ethics Commit-
Abbreviations (Arranged Alphabetically) tee.

BC: Breast Cancer

BCS: Breast Conservation Surgery Consent
BCT: Breast Conservation Therapy
All subjects gave their consent for the use of their personal
DCIS: Ductal Carcinoma In Situ
and medical information including images in the publication
EO: Extreme Oncoplasty
of this study.
IDC: Intraductal Carcinoma
MF/MC: Multifocal/Multicentric
NAC: Nipple Areolar Complex Conflicts of Interest
OBS: Oncoplastic Breast Surgery
PROMs: Patient Reported Outcome Measures The authors declare no conflicts of interest.
International Journal of Breast Cancer 7

Acknowledgments [8] K. A. Leopold, A. Recht, S. J. Schnitt et al., “Results of conser-

vative surgery and radiation therapy for multiple synchronous
The study authors would like to thank all participants who cancers of one breast,” International Journal of Radiation Oncol-
consented to participate in this study. We also acknowledge ogy Biology Physics, vol. 16, no. 1, pp. 11–16, 1989.
Bajaj Auto Ltd. for providing support to research activities [9] J. M. Kurtz, J. Jacquemier, R. Amalric et al., “Breast-conserving
at Prashanti Cancer Care Mission, Pune. We are grateful therapy for macroscopically multiple cancers,” Annals of
to the MAPI Research Trust for giving permission to use Surgery, vol. 212, no. 1, pp. 38–44, 1990.
BREAST-Q (http://www.mapitrust.org). The contribution of [10] L. D. Wilson, M. Beinfield, C. F. McKhann, and B. G. Haffty,
Dr. Laxmi Shekhawat, Dr. Nutan Gangurde, Dr. Dhara Patel, “Conservative surgery and radiation in the treatment of syn-
and Dr. Devaki Kelkar is acknowledged. We also thank Prof. chronous ipsilateral breast cancers,” Cancer, vol. 72, no. 1, pp.
L. S. Shashidhara (Indian Institute of Science Education and 137–142, 1993.
Research, Pune) for suggestions and advice throughout the [11] L. C. Cho, N. Senzer, and G. N. Peters, “Conservative surgery
work. We would also like to thank management and staff of and radiation therapy for macroscopically multiple ipsilateral
Ruby Hall Clinic, Pune, where all surgeries where performed. invasive breast cancers,” The American Journal of Surgery, vol.
183, no. 6, pp. 650–654, 2002.
[12] J. Kaplan, G. Giron, P. I. Tartter, I. J. Bleiweiss, A. Estabrook, and
Supplementary Materials S. R. Smith, “Breast conservation in patients with multiple ipsi-
lateral synchronous cancers,” Journal of the American College of
Supplementary Table 1: Dose Received by Different Structures Surgeons, vol. 197, no. 5, pp. 726–729, 2003.
(for Representative Case Study). Supplementary Table 2: RT [13] S. Okumura, M. Mitsumori, C. Yamauchi et al., “Feasibility of
data for EO Cohort. (Supplementary Materials) breast-conserving therapy for macroscopically multiple ipsilat-
eral breast cancer,” International Journal of Radiation Oncology
Biology Physics, vol. 59, no. 1, pp. 146–151, 2004.
References
[14] O. Gentilini, E. Botteri, N. Rotmensz et al., “Conservative
[1] M. Clarke, R. Collins, S. Darby et al., “Effects of radiotherapy surgery in patients with multifocal/multicentric breast cancer,”
and of differences in the extent of surgery for early breast cancer Breast Cancer Research and Treatment, vol. 113, no. 3, pp. 577–
on local recurrence and 15-year survival: an overview of the 583, 2009.
randomized trial,” The Lancet, vol. 366, no. 9503, pp. 2087–2106, [15] R. Woods, K. A. Gelmon, S. Tyldesley, H. F. Kennecke, C. Speers,
2005. and R. Yerushalmi, “Impact of mulitfocal/multicentric versus
[2] J. A. van Dongen, A. C. Voogd, I. S. Fentiman et al., “Long- unifocal breast cancer on local recurrence,” Journal of Clinical
term results of a randomized trial comparing breast-conserving Oncology, vol. 28, no. 15, pp. 514-514, 2010.
therapy with mastectomy: european organization for research [16] P. Romestaing, Y. Lehingue, C. Carrie et al., “Role of a 10-
and treatment of cancer 10801 trial,” Journal of the National Gy boost in the conservative treatment of early breast cancer:
Cancer Institute, vol. 92, no. 14, pp. 1143–1150, 2000. results of a randomized clinical trial in Lyon, France,” Journal of
[3] U. Veronesi, N. Cascinelli, L. Mariani et al., “Twenty-year Clinical Oncology, vol. 15, no. 3, pp. 963–968, 1997.
follow-up of a randomized study comparing breast-conserving [17] G. Zucca-Matthes, A. Manconi, R. A. da Costa Viera et al., “The
surgery with radical mastectomy for early breast cancer,” The evolution of mastectomies in the oncoplastic breast surgery era,”
New England Journal of Medicine, vol. 347, no. 16, pp. 1227–1232, Gland Surgery, vol. 2, no. 2, pp. 102–106, 2013.
2002. [18] K. B. Clough, M. Soussaline, F. Campana et al., “Mammoplasty
[4] B. Fisher, S. Anderson, J. Bryant et al., “Twenty-year follow- combined with irradiation: conservative treatment of cancers
up of a randomized trial comparing total mastectomy, lumpec- located in the lower quadrants,” Annales de Chirurgie Plastique
tomy, and lumpectomy plus irradiation for the treatment of Esthétique, vol. 35, no. 2, pp. 117–122, 1990.
invasive breast cancer,” The New England Journal of Medicine, [19] I. Cothier-Savey, Y. Otmezguine, E. Calitchi et al., “Value of
vol. 347, no. 16, pp. 1233–1241, 2002. reduction mammoplasty in the conservative treatment of breast
[5] S. Hofvind, Å. Holen, T. Aas, M. Roman, S. Sebuødegård, and neoplasm. A propos of 70 cases,” Annales de Chirurgie Plastique
L. A. Akslen, “Women treated with breast conserving surgery Esthétique, vol. 41, no. 4, pp. 346–353, 1996.
do better than those with mastectomy independent of detection [20] J. Y. Petit, M. Rietjens, C. Garusi, M. Greuze, and C. Perry, “Inte-
mode, prognostic and predictive tumor characteristics,” Euro- gration of plastic surgery in the course of breast-conserving
pean Journal of Surgical Oncology, vol. 41, no. 10, pp. 1417–1422, surgery for cancer to improve cosmetic results and radicality of
2015. tumor excision,” Recent Results in Cancer Research, vol. 152, pp.
[6] O. J. Hartmann-Johnsen, R. Kåresen, E. Schlichting, and J. 202–211, 1998.
F. Nygård, “Survival is better after breast conserving therapy [21] S. L. Spear, C. V. Pelletiere, A. J. Wolfe, T. N. Tsangaris, and
than mastectomy for early stage breast cancer: a registry- M. F. Pennanen, “Experience with reduction mammaplasty
based follow-up study of norwegian women primary operated combined with breast conservation therapy in the treatment of
between 1998 and 2008,” Annals of Surgical Oncology, vol. 22, breast cancer,” Plastic and Reconstructive Surgery, vol. 111, no. 3,
no. 12, pp. 3836–3845, 2015. pp. 1102–1109, 2002.
[7] A. Nandakumar, G. K. Rath, A. C. Kataki et al., “Decreased [22] M. J. Silverstein, N. Savalia, S. Khan, and J. Ryan, “Extreme
survival with mastectomy vis-à-vis breast-conserving surgery oncoplasty: breast conservation for patients who need mastec-
in stage II and III breast cancers: a comparative treatment tomy,” The Breast Journal, vol. 21, no. 1, pp. 52–59, 2015.
effectiveness study,” Journal of Global Oncology, vol. 3, no. 4, pp. [23] K. B. Clough, J. S. Lewis, B. Couturaud, A. Fitoussi, C. Nos,
304–313, 2017. and M.-C. Falcou, “Oncoplastic techniques allow extensive
8 International Journal of Breast Cancer

resections for breast-conserving therapy of breast carcinomas,” implant-based breast reconstructions,” Plastic and Reconstruc-
Annals of Surgery, vol. 237, no. 1, pp. 26–34, 2003. tive Surgery, vol. 128, no. 2, pp. 353–359, 2011.
[24] A. L. Pusic, A. F. Klassen, A. M. Scott, J. A. Klok, P. G. [39] S. E. Gabriel, J. E. Woods, W. M. O’Fallon, C. M. Beard, L. T.
Cordeiro, and S. J. Cano, “Development of a new patient- Kurland, and L. J. Melton III, “Complications leading to surgery
reported outcome measure for breast surgery: the BREAST-Q,” after breast implantation,” The New England Journal of Medicine,
Plastic and Reconstructive Surgery, vol. 124, no. 2, pp. 345–353, vol. 336, no. 10, pp. 677–682, 1997.
2009. [40] S. M. Bentzen, R. K. Agrawal, E. G. Aird et al., “The UK
[25] S. Litière, G. Werutsky, I. S. Fentiman et al., “Breast conserving Standardisation of Breast Radiotherapy (START) trial a of
therapy versus mastectomy for stage I-II breast cancer: 20 year radiotherapy hypofractionation for treatment of early breast
follow-up of the EORTC 10801 phase 3 randomised trial,” The cancer: a randomised trial,” The Lancet Oncology, vol. 9, no. 4,
Lancet Oncology, vol. 13, no. 4, pp. 412–419, 2012. pp. 331–341, 2008.
[26] L. Mansfield, A. Agrawal, and R. I. Cutress, “Oncoplastic breast [41] H. Bartelink, J. C. Horiot, P. M. Poortmans et al., “Impact of a
conserving surgery,” Gland Surgery, vol. 2, no. 3, pp. 158–162, higher radiation dose on local control and survival in breast-
2013. conserving therapy of early breast cancer: 10-year results of the
[27] D. F. Veiga, J. Veiga-Filho, L. M. Ribeiro et al., “Quality-of-life randomized boost versus no boost EORTC 22881-10882 trial,”
and self-esteem outcomes after oncoplastic breast-conserving Journal of Clinical Oncology, vol. 25, no. 22, pp. 3259–3264, 2007.
surgery,” Plastic and Reconstructive Surgery, vol. 125, no. 3, pp. [42] M. Guerrero, X. Allen, M. Earl et al., “Simultaneous integrated
811–817, 2010. boost for breast cancer using imrt: a radiobiological and
[28] N. Kaur, J.-Y. Petit, M. Rietjens et al., “Comparative study of treatment planning study,” International Journal of Radiation
surgical margins in oncoplastic surgery and quadrantectomy in Oncology Biology Physics, vol. 59, no. 5, pp. 1513–1522, 2004.
breast cancer,” Annals of Surgical Oncology, vol. 12, no. 7, pp.
539–545, 2005.
[29] P.-L. Giacalone, P. Roger, O. Dubon, N. El Gareh, J.-P. Daurés,
and F. Laffargue, “Lumpectomy vs oncoplastic surgery for
breast-conserving therapy of cancer. A prospective study about
99 patients,” Annales De Chirurgie, vol. 131, no. 4, pp. 256–261,
2006.
[30] P.-L. Giacalone, P. Roger, O. Dubon et al., “Comparative study
of the accuracy of breast resection in oncoplastic surgery and
quadrantectomy in breast cancer,” Annals of Surgical Oncology,
vol. 14, no. 2, pp. 605–614, 2007.
[31] F. Hernanz, S. Regaño, A. Vega, and M. Gómez Fleitas, “Reduc-
tion mammaplasty: an advantageous option for breast conserv-
ing surgery in large-breasted patients,” Surgical Oncology, vol.
19, no. 4, pp. e95–e102, 2010.
[32] A. M. Munhoz, E. Montag, and R. Gemperli, “Current aspects
of therapeutic reduction mammaplasty for immediate early
breast cancer management: an update,” World Journal of Clinical
Oncology, vol. 5, no. 1, pp. 1–18, 2014.
[33] W. Lim, E.-H. Park, S.-L. Choi et al., “Breast conserving surgery
for multifocal breast cancer,” Annals of Surgery, vol. 249, no. 1,
pp. 87–90, 2009.
[34] T. J. Whelan, J. Julian, J. Wright, A. R. Jadad, and M. L. Levine,
“Does locoregional radiation therapy improve survival in breast
cancer? A meta-analysis,” Journal of Clinical Oncology, vol. 18,
no. 6, pp. 1220–1229, 2000.
[35] J. Van De Steene, G. Soete, and G. Storme, “Adjuvant radiother-
apy for breast cancer significantly improves overall survival: the
missing link,” Radiotherapy & Oncology, vol. 55, no. 3, pp. 263–
272, 2000.
[36] M. Clarke, R. Collins, S. Darby et al., “Effects of radiotherapy
and of differences in the extent of surgery for early breast cancer
on local recurrence and 15-year survival: an overview of the
randomized trials,” Lancet, vol. 366, no. 9503, pp. 2087–2106,
2005.
[37] A. O. Momoh, R. Ahmed, B. P. Kelley et al., “A systematic
review of complications of implant-based breast reconstruction
with prereconstruction and postreconstruction radiotherapy,”
Annals of Surgical Oncology, vol. 21, no. 1, pp. 118–124, 2014.
[38] M. B. Nava, A. E. Pennati, L. Lozza, A. Spano, M. Zambetti, and
G. Catanuto, “Outcome of different timings of radiotherapy in
 MEDIATORS of

INFLAMMATION

The Scientific Gastroenterology Journal of

World Journal
Hindawi Publishing Corporation
Research and Practice
Hindawi
Hindawi
Diabetes Research
Hindawi
Disease Markers
Hindawi
www.hindawi.com Volume 2018
http://www.hindawi.com
www.hindawi.com Volume 2018
2013 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018

Journal of International Journal of

Immunology Research
Hindawi
Endocrinology
Hindawi
www.hindawi.com Volume 2018 www.hindawi.com Volume 2018

Submit your manuscripts at

www.hindawi.com

BioMed
PPAR Research
Hindawi
Research International
Hindawi
www.hindawi.com Volume 2018 www.hindawi.com Volume 2018

Journal of
Obesity

Evidence-Based
Journal of Stem Cells Complementary and Journal of
Ophthalmology
Hindawi
International
Hindawi
Alternative Medicine
Hindawi Hindawi
Oncology
Hindawi
www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2013

Parkinson’s
Disease

Computational and
Mathematical Methods
in Medicine
Behavioural
Neurology
AIDS
Research and Treatment
Oxidative Medicine and
Cellular Longevity
Hindawi Hindawi Hindawi Hindawi Hindawi
www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018