ONCOPLASTIC BREAST SURGERY FOR EARLY BREAST CANCER

ONCOPLASTIC BREAST SURGERY FOR EARLY BREAST CANCER

By

Ahmed Mahmoud Eid Mahmoud, Abdoh Salem and Mahmoud Mohamed Ibrahim Mohamed

General Surgery Department, Faculty of Medicine, Al-Azhar University

Corresponding Author: Ahmed Mahmoud Eid Mahmoud

Phone No.: (+2), E-mail: droncoam1@yahoo.com

ABSTRACT

Background: Breast cancer is the most commonly diagnosed cancer worldwide, and is the second most common cause of cancer-related deaths between females, with about 18000 new cases diagnosed among female in 2014 in Egypt.

Objective: To evaluate the oncological outcomes and patient satisfaction on the esthetical side with oncoplastic surgery for patients with early stage breast cancer.

Patients and Methods: The present study was enrolled from January 2019 to January 2020 at Al- Azhar University Hospitals and Nasser's Institute Hospital for Research and Treatment. This were  a descriptive study done on 30 participants  with breast cancer who met inclusion criteria underwent various level II, III Oncoplastic breast surgery. The oncological and aesthetic satisfaction was evaluated.

Results: Our study results showed statistically significant difference between surgeons score on cosmetic outcome as regards wound dehiscence and fat necrosis.

Conclusion: Oncoplastic breast surgery techniques are effective and results in improved patient-reported outcomes in early breast cancer.

Keywords: Oncoplastic, Breast Surger, Early Breast Cancer.

INTRODUCTION

     Breast cancer represent 32% of cancers diagnosed in female population in Egypt with about 18000 new cases diagnosed among female in 2014 in Egypt (Ibrahim et al, 2014). Mortality rates had steadily declined since the 1970s. This decline is thought to be partly the result of advances in adjuvant therapy (Kohler et al., 2015).

     Breast-conserving surgery (BCS) followed by adjuvant radiotherapy, was documented to be equal to mastectomy with regard to oncological outcomes (Christiansen et al., 2018), and had to a large extent replaced total mastectomy in the last few decades. Oncoplastic breast surgery (OBS) was developed with the aim of further improving the esthetic and functional outcomes of BCS (Campbel & Romics, 2017 and Weber et al., 2017).

     Overall, oncoplastic breast reconstruction leads to better aesthetic outcomes and higher patient satisfaction relative to breast conserving oncologic surgery without reconstruction (Piper et al., 2015). Bogusevicius et al. (2014) found that 87.2% of patients had good to excellent aesthetic outcomes in patients with locally advanced breast cancer undergoing oncoplastic surgery.

     Losken et al. (2014) stated that the complication rate with oncoplastic surgery techniques is around 16%. Complications may be divided into two groups. First, there are the so-called early complications such as delayed healing, hematoma, seroma, abscess, skin or NAC necrosis. The second group describes the late complications, involving fibrosis of the scar, keloids and steatonecrosis. Preoperative antibiotic prophylaxis is very important in minimizing these complications occurrence, and may be extended in the following day on case to case basis (Shortt et al., 2014).

     A rational approach is needed to enable surgeons to act preventively on individual risk factors (obesity, smoking, diabetes, thyroid disorders, and hypertension) to lower complication rate in the postoperative period, as these factors are recognized as independently significant for the development of complications (Hart et al., 2017).

     The present work aimed to evaluate the oncological outcomes and patient satisfaction on the esthetical side with oncoplastic surgery for patients with early stage breast cancer.

PATIENTS AND METHODS

     The present study was enrolled from January 2019 to January 2020 at Al-Azhar University Hospital and Nasser's Institute Hospital for Research and Treatment. This were a descriptive study done on (30) participants.

     Informed consent was obtained from each subject before the procedure. Hospital administrative approval was taken to perform the study and collect data.

Inclusion criteria:

1.   Patients with a pre-operative diagnosis (clinical examination, imaging and needle biopsy) of Tis, T1 and T2 tumors.

2.   No skin involvement.

3.   > 10% volume resection.

4.   Tumor located in the lower or medial poles or centrally.

Exclusion criteria:

1.   Breast cup size A and  non ptotic B.

2.   Contraindications for general anesthesia.

3.   First or second trimester of pregnancy.

4.   Previous receipt of radiotherapy.

5.   Diffuse micro-calcifications within the breast.

6.   Inflammatory breast cancer (Paget's disease of the breast)

7.   Older age (patients older than 60 years of age).

8.   Patients who received a previous breast surgery.

9.   Negative margin excision not possible.

10. Multicentric breast cancer

11. Patients with collagen vascular disease (e.g. Scleroderma and Systemic Lupus Erythromatosus).

     Eligible patients underwent various level II, III oncoplastic breast surgery, including but not limited to superior pedicle mammoplasty/inverted T, Superior pedicle mammoplasty, batwing, Inferior pedicle mammoplasty, racquet mammoplasty/radial scar, nipple sparring mastectomy and vertical-scar mammoplasty. Photographs were taken before and after the procedure, and were shown to patients on the follow up visit immediately following the operation.

     Patients were required to record their level of aesthetic satisfaction and quality of life on a likert scale from 0 to 5, with responses '1' indicating complete dissatisfaction, '2' indicating some dissatisfaction, '3' indicating partial satisfaction, '4' indicating satisfaction and '5' indicating complete satisfaction. In addition to the previous scores, patients were asked to fill a translated form of the patient satisfaction and cosmetic outcome (Appendices A, C). Fellow surgeons were also asked to fill an un translated form of Surgeons- score on cosmetic outcome (Chan et al., 2010).

Appendix (B): Quality of life was recorded using similar scoring procedure with scores ranging from '1' to '10', with level '1' indicating poor quality of life and level '10' indicating excellent quality of life. Surgical margin involvement was measured by millimeters from resection margin. Patients were received chemotherapy, radiotherapy endocrine therapy or Trastuzumab therapies per clinical and radiation oncologists plan.

Statistical analysis:

     Recorded data were analyzed using the statistical package for the social sciences, version 20.0 (SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as mean± standard deviation (SD)range, median, and inter-quartile range (IQR). Qualitative data were expressed as frequency and percentage.

The following tests were done:

•     A one-way analysis of variance (ANOVA) when comparing between more than two means.

•     Kruskall Wallis test: for multiple-group comparisons in non-parametric data.

•     Chi-square (x2) test of significance was used in order to compare proportions between qualitative parameters.

•     The confidence interval was set to 95% and the margin of error accepted was set to 5%.

•     P-value≤ 0.05 was considered significant.

RESULTS

     Age (years) ranged 31-56, with mean 42.70±7.11, Weight (kg) ranged 59-155, with mean 82.97±17.29, Height (cm) ranged 70-180, with mean 162.90±18.97 and BMI (wt/(ht)^2] ranged 23.18-34.48, with mean 29.07±2.789 (Table 1).

Table (1):  Distribution of cases according to their baseline characteristics regarding Age (years), Weight (kg), Height (cm) and BMI (wt/(ht)^2] (n=30)

     Smoking (6.7%), HTN (16.7%), DM (13.3%) and Chemotherapy adjuvant (100.0%) of risk factors (Table 2).

Table (2):  Distribution of cases according to their risk factors regarding smoking, HTN, DM, Chemotherapy, Invasive carcinoma, In situ carcinoma and Invasive/in situ(n=30)

Invasive carcinoma (76.7%), in situ carcinoma (13.3%) and invasive/in situ (16.7%) were of tumor histology (Table 3).

Table (3): Distribution of cases according to their risk factors regarding smoking, HTN, DM, chemotherapy, Invasive carcinoma, In situ carcinoma and Invasive/in situ (n=30)

     The median of before were 16 and after were 6 of axillary surgery (Table 4).

Table (4):Distribution of cases according to their tumor histology regarding axillary dissection and sentinel biopsy (n=30)

     The Superior-medial 6.7%, Superior 0%, Grisotti 6.7%, inferior pedicle 20%, Batwaing 10%, Round block 0%, Latissmus dorsi 6.7%, Thoracoepigastric flap 0%, Burrwo's triangle 6.7%, Lateral mammoplasty 13.3%, medial mammoplasty 6.7% and J mammoplasty 13.3% of mammoplasty technique (Table 5).

Table (5):Distribution of cases according to their mammoplasty technique regarding Superior-medial, Superior, Grisotti, inferior pedicle, Batwaing, Round block, Latissmus dorsi, Thoracoepigastric flap, Burrwo's triangle, Lateral mamoplasty, medial mammoplasty and J mammoplast(n=30)

     The Skin necrosis 6.7%, Partial NAC necrosis 0%, NAC necrosis 0%, Infection 3.3%, wound dehiscence 6.7%, Hematoma 3.3% and Fat necrosis 6.7% of complications (Table 6).

Table (6):Distribution of cases according to their complications regarding Skin necrosis, Partial NAC necrosis, NAC necrosis, Infection, Wound dehiscence, Hematoma and Fat necrosis (n=30)

     No (6.7%) and Yes (93.3%) of are you satisfied With your postoperative appearance?, also asymmetric (33.3%), no difference (3.3%), Normal (53.3%), Without Nipple (6.7%) and Wound signs (3.3%) of compare to untreated breast, how is the difference of the treated breast?, also No (96.7%), Subcutaneous Mastectomy With implant (3.3%) of if you choose again, will you choose another kind of breast surgery?, while Implant (3.3%), Mastopexy of another breast (3.3%), Nipple reconstruction (6.7%), nipples reconstruction (3.3%) and No (83.3%) of will you consider further surgery for reshaping of the treated breast?. No statistically significant difference between surgeons outcome according to baseline characteristics. Fair were (3.3%), good (40%) and excellent (56,7%) of Surgeon’s score on cosmetic outcome (Table 7).

Table (7):  Distribution of cases according to their patient questionnaire for satisfaction and cosmetic outcome (n=30), Surgeon’s score on cosmetic outcome

     There were no statistically significant difference between surgeon`s outcome according to baseline characteristics. There were statistically significant difference between surgeon`s outcome according to smoking, DM and HTN. While There were no statistically significant difference between surgeon`s outcome according to their tumor histology (Table 8).

Table (8):Comparison between surgeon’s score on cosmetic outcome according to baseline characteristics, risk factors and  tumor histology

Using: F-One Way Analysis of Variance & x2- Chi-square test

     There were statistically significant decrease median in good and excellent compared to fair according to lymph nodes. While no  statistically significant difference between surgeons’ outcome according to their superior-medial. However were statistically significant difference between surgeon’s outcome according to their wound dehiscence and fat necrosis (Table 9).

Table (9):Comparison between surgeon’s score on cosmetic outcome according to mammoplasty technique, axillary surgery and complications

Using: x2- Chi-square test; k- Kruskal Wallis test

Homogenous groups had the same letter "a,b,c". through Mann-Whitney test;

DISCUSSION

     Oncoplastic breast surgery (OBS) was developed as an extension of breast-conserving surgery (BCS) in an effort to improve esthetic and functional outcome following surgery for breast cancer (Rose et al., 2020).

     The current study aimed to evaluate oncoplastic surgery outcomes and patient satisfaction in patients with early stage breast cancer. Regarding the baseline characteristics of the patients in our study we found that, the mean age of patients was (42.70±7.11), the mean weight was (82.97±17.29), the mean height was (162.90±18.97) and mean BMI was (29.07±2.78). Our results agreed with Green et al. (2011), they reported similar mean height measures, while this value by Johansen et al. (2012) was 61years old with 25.3% being younger than 50, in another study, the mean of patients age was 50 (Deutsch and Flickinger, 2013). Our results consistent with the demographic data by Zeeneldin et al. (2014) who claimed the peak incidence of breast cancer between 40 and 59 years old. Also, our results agreed with the data of Mahmoud and Saleh (2020).

     Increased body mass index (BMI) has been associated with the risk of developing breast cancer. It has been demonstrated that breast cancer patients with higher BMI estimated as obesity or overweight have a worse prognosis disease regardless of tumor subtype (Calle et al., 2013). In accordance with our results, Singh and Jangra (2013) found out significant association between BMI and breast cancer.

     Risk factors were determined in the present study and results showed that chemotherapy adjuvant was delivered to all patients (100%); 76.7% had invasive carcinoma, 16.7% had invasive/in situ carcinoma, 16.7% presented with HTN, 13.3% had DM, 13.3% had in situ carcinoma and 6.7% were smokers.

     In agreement with our results, Hannah (2019) also found that the most common tumor histopathologies were invasive ductal carcinoma in 58.3%, followed by ductal carcinoma in situ in 16.6%, and invasive lobular carcinoma in 12.5%. Erić et al. (2018) found that invasive ductal carcinoma was the most frequent histological type of tumor. Also, Goldvaser et al. (2017) found that most common histology was invasive ductal carcinoma 80.8%, followed by invasive lobular carcinoma 12.4%. Also, Roshdy et al. (2015) reported that the majority 93.3% of the tumors were confirmed as invasive ductal carcinoma, followed by invasive lobular carcinoma 3.3% and medullary carcinoma 3.3%.

     Our results disagreed with Currie et al. (2013), Adamson et al. (2019), and Mahmoud & Saleh (2020).

     Data regarding history of smoking in other studies were different as Goldvaser et al. (2017) revealed that 28.2% of patients had a history of smoking.

     As regards axillary surgery, sentinel biopsy was done in 3.3% of patients. Before axillary dissection, the median range of patients were 16 while after axillary dissection, the median range of patients was 6.

Sentinel node biopsy is considered the gold standard for nodal staging in patients with early breast cancer (Franceschini et al., 2015). In contrast to our results, Tanaka et al. (2010) performed sentinel lymph node biopsy in all cases. Sentinel lymph node biopsy was performed in 64.5% of the patients in the study of Çakmak et al. (2020).

     In the work of Roshdy et al. (2015), all patients underwent Levels I and II axillary dissection.

     In the current study, results showed mammoplasty technique was inferior pedicle in 20%, superior-medial, Lateral mammoplasty13.3% of patients, J-mammoplasty in 13.3% of patients. Batwing in 10% of patients, Latissmus dorsi 6.7%of patients, Burrwo's triangle 6.7% of patients, medial mammoplasty6.7%, Grisotti in 6.7% of patients in each category. Superior pedicle 0% of patients, Round block 0% of patients, Thoracoepigastric flap in 0% of patients.

     The choice of the oncoplastic techniques depends on the achievement of free safety margins, the breast volume, and its ptotic degree. For example, Grisotti technique is suitable in ptotic breasts while reduction vertical mammoplasty is suitable for large and huge breasts (Farouk et al., 2015).

     In contrast, the most common pedicle used in Aggarwal et al. (2016) cohort was superomedial (62%) followed by inferior pedicle (34%). In Adimulam et al. (2014), 48.5% had curvilinear incision with breast parnchymal advancement flap.

     As regards complications, the present study results showed that skin necrosis; wound dehiscence and fat necrosis appeared in 6.7% of patients. No patients had partial NAC necrosis or NAC necrosis. Infection and hematoma appeared in 3.3% of patients.

     In the literature, the most common complications following therapeutic mammoplasty were minor wound infections and haematoma formation, followed by delayed wound healing and minor wound dehiscence (McIntosh and O' Donoghue, 2012).

     Also, similar results were obtained by van Paridon et al. (2017) recorded postoperative complications including seroma in 4.3%), hematoma in 2.1%, and localized fat necrosis in 2.1%. Farouk et al. (2015) recorded wound dehiscence in 13.3 %, donor site seroma in 13.3 %, and surgical site infection in 3.3 % of cases. A study by Gulcelik et al. (2011) using the inferior pedicle reported an incidence of 3% minor wound dehiscence, 1% major wound dehiscence, 1% areolar necrosis, and 5% seroma.

     In contrast to the present study, Dal et al. (2012) recorded wound infections in 66.7% of cases, with 22.2% experiencing a second wound infection. Hematoma, seroma or fat necrosis did not occur in any patients. In the work of Mahmoud and Saleh (2020), complications occurred only in 16% of cases, in the form of hematoma (4%) and infection (8%).

     A higher complications rate was reported by Denewer et al. (2013) on using an inferior pedicle. They reported an incidence of 17.6% of wound dehiscence, 14.7% of seroma, and 3% of partial areolar necrosis. Roshdy et al. (2015) stated that neither areolar necrosis nor wound dehiscence was encountered.

     In our study, patient questionnaire answers regarding satisfaction and cosmetic outcome revealed that (93.3%) of patients were satisfied with their postoperative appearance. (53.3%) of patients decided that the untreated breast was normal compared to treated breast while (33.3%) decided that the untreated breast was asymmetrical compared to treated breast.

     Excellent patient satisfaction with oncoplastic breast surgery was also obtained in some studies (Franceschini et al., 2015, Piper et al., 2015 and Campbel & Romics, 2017).

     Also, in agreement with our results, Chan et al. (2010) determined that 94% of patients were very satisfied or moderately satisfied with the cosmetic outcome; 85% of patients felt that the treated breast was nearly identical or only slightly different from the untreated breast.

     Haloua et al. (2013) observed good cosmetic outcome in 84% to 89% of patients. In the work of Meretoja et al. (2010), the use of oncoplastic techniques achieved negative margins with acceptable cosmetic results in the majority (84%) of patients. In that of Adimulam et al. (2014), 96% of patients were moderately to extremely satisfy with the surgery.

     In contrast to the present study, Dal et al. (2012) recorded postoperative asymmetry of the breasts in a high proportion of the patients, with the control breast being more ptotic and larger in size than the treated breast. 96.7% of patients were satisfied with the performed type of breast surgery, while (3.3%) preferred subcutaneous mastectomy with implant. (83.3%) of patients did not suggest reshaping of treated breast; (6.7%) chose nipple reconstruction.

     These results agreed with Chan et al. (2010) as 88% of patients expressed no regret over having undergone breast-conserving surgery and would not choose another kind of breast surgery even if they could choose again. In addition, 94% of patients were satisfied with the present cosmetic outcome and would not consider further reshaping or reconstructive surgery for the treated breast.

     Regarding surgeons score on cosmetic outcome, results of the present study showed that 56.7% of patients gave excellent score for the surgeon performance, 40% gave good and 3.3% fair.

     Other results were obtained by Ha et al. (2015) as they found that in doctor`s cosmetic assessment result: 24.9% cases, and 46.8% cases were scored as excellent and good, respectively. Only 4.0% were scored as poor. Farouk et al. (2015) recorded that patient satisfaction was excellent in 70 % patients, good in 20 % patients, and fair in 10 % patients.

     The present study showed no statistically significant difference between surgeons score on cosmetic outcome regarding baseline characteristics of patients. Also, Olfatbakhsh et al. (2015) found that the association between patient`s age with cosmetic outcome score was not statistically significant.

     On the other side, Adimulam et al. (2014) showed similar results of better cosmesis in younger patients.

     The current study showed statistically significant difference between surgeons’ score on cosmetic outcome regarding smoking and DM and none statistically significant regarding superior-medial mammoplasty technique and tumor histology. Also, there was statistically significant decrease in good and excellent scores compared to fair regarding axillary surgery.

     In contrast, Olfatbakhsh et al. (2015) found no correlation between axillary incision types with cosmetic score.

     Our study showed statistically significant difference between surgeons’ score on cosmetic outcome as regards wound dehiscence and fat necrosis.

CONCLUSION

     Oncoplastic breast surgery techniques were effective and resulted in improved patient reported outcomes.

REFERENCES

1. Adamson K, Chavez-MacGregor M and Caudle A (2019): Neoadjuvant Chemotherapy does not Increase Complications in Oncoplastic Breast-Conserving Surgery. Ann Surg Oncol. 26(9): 2730-2737.
2. Adimulam G, Challa VR, Dhar A, Chumber S, Seenu V and Srivastava A (2014): Assessment of cosmetic outcome of oncoplastic breast conservation surgery in women with early breast cancer: a prospective cohort study. Indian J Cancer, 51(1): 58-62.
3. Aggarwal S, Marla S, Nyanhongo D, Kotecha S and Basu NN (2016): Current Practice of Therapeutic Mammaplasty: A Survey of Oncoplastic Breast Surgeons in England. Int J Surg Oncol. 2016: 1-5.
4. Bogusevicius A, Cepuliene D and Sepetauskiene E (2014): The integrated evaluation of the results of oncoplastic surgery for locally advanced breast cancer. Breast J, 20: 53-60.
5. Çakmak GK, Emiroğlu S and Sezer A (2020): Surgical Trends in Breast Cancer in Turkey: An Increase in Breast-Conserving Surgery. JCO Glob Oncol., 6: 285-292.
6. Calle EE, Rodriguez C and Walker-Thurmond K (2013): Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med.  348: 1625-38.
7. Campbel EJ and Romics L (2017): Oncological safety and cosmetic outcomes in oncoplastic breast conservation surgery, a review of the best level of evidence literature. Breast Cancer 9: 521-530
8. Chan SW, Cheung PS and Lam SH (2010): Cosmetic outcome and percentage of breast volume excision in oncoplastic breast conserving surgery. World J Surg. 34(7): 1447-52.
9. Christiansen P, Carstensen SL, Ejlertsen B, Kroman N, Offersen B, Bodilsen A and Jensen MB (2018): Breast conserving surgery versus mastectomy: overall and relative survival-a population based study by the Danish Breast Cancer Cooperative Group (DBCG). Acta Oncol. 57(1): 19-25.
10. Currie A and Chong K and Davies GL (2013): Using therapeutic mammoplasty to extend the role of breast-conserving surgery in women with larger or ptotic breasts. Ann R Coll Surg Engl. 95(3): 192-195.
11. Dal Cin A, Knight C, Whelan KF and Farrokhyar F (2012): Bilateral reduction mammoplasty following breast cancer: A case-control study. Can J Plast Surg. 20(1): e6-e9.
12. Denewer A, Elnahas W, Hussein O, Khater A, El-sadda W and Abouelkher K (2013): Evaluation of inferior pedicle therapeutic mammoplasty as a primary procedure for upper quadrants early breast cancer. Adv Breast Cancer Res.  2: 86-90.
13. Deutsch M and Flickinger JC (2013): Patient characteristics and treatment factors affecting cosmesis following lumpectomy and breast irradiation. Am J Clin Oncol. 26, 350-3.
14. Erić I, Petek Erić A, Kristek J, Koprivčić I and Babić M (2018): Breast cancer in young women: pathologic and immunohistochemical features. Acta Clin Croat. 57(3): 497-502.
15. Farouk O, Attia E and Roshdy S (2015): The outcome of oncoplastic techniques in defect reconstruction after resection of central breast tumors. World J Surg Oncol. 13: 285-293.
16. Franceschini G, Martin Sanchez A and Di Leone A (2015): New trends in breast cancer surgery: a therapeutic approach increasingly efficacy and respectful of the patient. G Chir. 36(4): 145-152.
17. Goldvaser H, Gal O and Rizel S (2017): The association between smoking and breast cancer characteristics and outcome. BMC Cancer. 17(1): 624-632.
18. Green J, Cairns BJ and Casabonne D (2011): Height and cancer incidence in the Million Women Study: prospective cohort, and meta-analysis of prospective studies of height and total cancer risk. Lancet Oncol. 12(8): 785-794.
19. Gulcelik MA, Dogan L and Camlibel M (2011): Early complications of a reduction mammoplasty technique in the treatment of macromastia with or without breast cancer. Clin Breast Cancer, 11(6): 395-399.
20. Ha S, Kim TH, Lee A and Byun K and Han JW (2015): Cosmetic outcomes and patients' satisfaction of oncoplastic surgery in Korean patient with breast cancer. Korean Journal Of Oncology. 11(2): 67-73.
21. Haloua MH, Krekel NM and Winters HA (2013): A systematic review of oncoplastic breast-conserving surgery: current weaknesses and future prospects. Ann Surg. 257(4): 609-620.
22. Hannah DK (2019): Oncological Safety, Surgical Outcome and Patient Satisfaction of Oncoplastic Breast Conserving Surgery with Contralateral Balancing Reduction Mammoplasty. Int J Transplant & Plastic Surg. 3(2): 137-149.
23. Hart A, Funderburk CD and Chu CK (2017): The impact of diabetes mellitus on wound healing in breast reconstruction. Ann Plast Surg. 78(3): 260-3.
24. Ibrahim, A S, Hussein M K,   Nh M, H, B, and Hossam K, (2014): Cancer incidence in egypt: results of the national population-based cancer registry program.” Journal of cancer epidemiology vol. 2014: 437-971.
25. Johansen J, Overgaard J and Rose C (2012): Cosmetic outcome and breast morbidity in breast-conserving treatment--results from the Danish DBCG-82TM national randomized trial in breast cancer. Acta Oncol. 41: 369-80.
26. Kohler BA, Sherman RL and Howlader N (2015): Annual report to the nation on the status of cancer, 1975-2011, featuring incidence of breast cancer subtypes by race/ethnicity, poverty, and state. J Natl Cancer Inst. 107: 6-7.
27. Losken A, Dugal CS, Styblo TM and Carlson GW (2014): A meta-analysis comparing breast conservation therapy alone to the oncoplastic technique. Ann Plast Surg. 72(2): 145-9.
28. Mahmoud MA and Saleh MA (2020): Evaluation of donut mammoplasty in early breast cancer near to nipple-areola complex. Egypt J Surg. 39: 11-22.
29. McIntosh J and O-Donoghue JM (2012): Therapeutic mammaplasty - a systematic review of the evidence. Eur J Surg Oncol. 38: 196-202.
30. Meretoja TJ, Svarvar C and Jahkola TA (2010): Outcome of oncoplastic breast surgery in 90 prospective patients. Am J Surg. 200(2): 224-228.
31. Olfatbakhsh A, Mehrdad N and Ebrahimi M (2015): Evaluation of factors impacting cosmetic outcome of breast conservative surgery a study in Iran. Asian Pac J Cancer Prev. 16(6): 2203-2207.
32. Piper M, Peled AW and Sbitany H (2015): Oncoplastic breast surgery: current strategies. Gland Surg. 4(2): 154-163.
33. Rose M, Svensson H, Handler J, Hoyer U, Ringberg A and Manjer J (2020): Patient-reported outcome after oncoplastic breast surgery compared with conventional breast-conserving surgery in breast cancer. Breast Cancer Res Treat. 180(1): 247-256.
34. Roshdy S, Hussein O and Khater A (2015): Safety and esthetic outcomes of therapeutic mammoplasty using medial pedicle for early breast cancer. Breast Cancer (Dove Med Press). 7: 173-178.
35. Shortt R, Cooper MJ, Farrokhyar F and Bain J (2014): Meta-analysis of antibiotic prophylaxis in breast reduction surgery. Plast Surg. (Oakv), 22(2): 91-4.
36. Singh M and Jangra B (2013): Association between body mass index and risk of breast cancer among females of north India. South Asian J Cancer. 2(3): 121-125.
37. Tanaka S, Nohara T and Iwamoto M (2010): Sentinel lymph node biopsy in breast cancer patients undergoing skin/nipple-sparing mastectomy and immediate autologous reconstruction. Oncol Lett. 1(1): 99-101.
38. van Paridon MW, Kamali P and Paul MA (2017): Oncoplastic breast surgery: Achieving oncological and aesthetic outcomes. J Surg Oncol. 116(2): 195-202.
39. Weber WP, Soysal SD, Fulco I, Barandun M, Babst D, Kalbermatten D, Schaefer DJ, Oertli D, Kappos EA and Haug M (2017): Standardization of oncoplastic breast conserving surgery. Eur J Surg Oncol, 43(7): 1236-1243.
40. Zeeneldin A, Ramadan and Gaber A (2013): Clinico-pathological features of breast carcinoma in elderly Egyptian patients: a comparison with the non-elderly using population-based data. J Egypt Natl Cancer Inst. 25: 5-11.