title: Breast conservative surgery and local recurrence.
abstract: BACKGROUND
  Breast conservation is a legacy of Umberto Veronesi who laid the groundwork for the preservation of the body image of women affected by breast cancer (BC) with the Milan I study in the late 70ies of the last millennium. Breast conservative surgery (BCS) has two aspects: oncological safety of tumour resection with free margins and aesthetic preservation of the breast. Determinants of local control used to be T-size, nodal status and receptor status until biologically driven concepts defined risk of recurrence on the basis of molecular portraits. We explored whether these concepts of intrinsic subtypes prove at a large scale in the context of BCS and which surgical techniques procure best oncological and aesthetic outcomes, avoiding re-excision and necessity of conversion to mastectomy.
  
  
  METHODS
  We analyzed 1035 BCS patients with primary unilateral breast cancer (2004-2009) with regards to the local recurrence as a function of tumour location, surgical technique, resection volume, T-size, nodal status, grading, histopathological and intrinsic subtype and margins.
  
  
  RESULTS
  Five surgical techniques were applied to 944 eligible patients at a median follow-up of 5.2 years with the following frequency: Glandular rotation mammoplasty (63.8%), tumour-adapted rotation mammoplasty (20.9%), dermoglandular rotation mammoplasty (6.7%), 4.4% (lateral thoracic wall advancement), 0.7% latissimus dorsi flap (0.7%) and others (13.5%). Tumour-free margins were achieved in 88.6% of all patients at first surgery. Recurrence was independent of the surgical technique used, resection volume, T-size (in a T1/T2-cohort), nodal status (in low N-stages: NO/N1) and histopathology (inv.-ductal vs. lobular), however non-invasive subtype (DCIS), high grading (G3 vs. G1), non-luminal Her2 positive BC and triple-negative breast cancer (TNBC) were significantly associated with local recurrence.
  
  
  CONCLUSIONS
  Five defined oncoplastic principles presented in our nomogramme (targeted breast surgery) allow the reconstruction of major segmental resection defects during breast-conserving therapy with high clinical applicability and result in favorable oncological and aesthetic outcome. Recurrence was not a function of traditional prognostic factors like T-size or nodal status (in a T1/T2, N0/N1 cohort), but of grading, intrinsic subtypes and non-invasive breast cancer components. Lobular histology, multi-centricity and DCIS were predictive for breast preservation failure and conversion to mastectomy.
authors.affiliation: European Breast Center - Dr. Rezai, Hans-Günther-Sohl-Str.6-10, D-40235 Düsseldorf, Germany. Electronic address: mahdi@rezai.org.
authors.forename: Mahdi
authors.initials: M
authors.lastname: Rezai
authors.affiliation: University Medical Center Cologne, Kerpener Str. 34, D-50931 Cologne, Germany. Electronic address: stefan.kraemer@uk-koeln.de.
authors.forename: Stefan
authors.initials: S
authors.lastname: Kraemer
authors.affiliation: University Hospital of Essen, Women's Department, Hufelandstr.55, D-45147 Essen, Germany. Electronic address: rainer.kimmig@uk-essen.de.
authors.forename: Rainer
authors.initials: R
authors.lastname: Kimmig
authors.affiliation: University Hospital of Essen, Women's Department, Hufelandstr.55, D-45147 Essen, Germany. Electronic address: Peter.Kern@uk-essen.de.
authors.forename: Peter
authors.initials: P
authors.lastname: Kern
mesh_terms: D001943:Breast Neoplasms / Q000737:chemistry / Q000473:pathology* / Q000601:surgery*; D018270:Carcinoma, Ductal, Breast / Q000737:chemistry / Q000556:secondary / Q000601:surgery*; D002285:Carcinoma, Intraductal, Noninfiltrating / Q000737:chemistry / Q000473:pathology*; D018275:Carcinoma, Lobular / Q000737:chemistry / Q000556:secondary / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008207:Lymphatic Metastasis; D016462:Mammaplasty / Q000379:methods*; D015412:Mastectomy, Segmental; D060787:Neoplasm Grading; D009364:Neoplasm Recurrence, Local / Q000737:chemistry; D009367:Neoplasm Staging; D018365:Neoplasm, Residual; D049451:Nomograms; D018719:Erb-b2 Receptor Tyrosine Kinases / Q000032:analysis; D011960:Receptors, Estrogen / Q000032:analysis; D011980:Receptors, Progesterone / Q000032:analysis; D047368:Tumor Burden
chemical_list: D018719:Erb-b2 Receptor Tyrosine Kinases; D011960:Receptors, Estrogen; D011980:Receptors, Progesterone; C508053:ERBB2 protein, human
keywords: Breast cancer; Breast conservative surgery; Local recurrence; Predictors of breast preservation failure; Surgical technique; Targeted breast surgery