Reduction Mammoplasty to Improve Breast Conservation Therapy Results in Patients with Macromastia
Newman, Lisa A; Kuerer, Henry Mark; Gunter, Joseph; Ames, Fred C; Ross, Merick I; McNeese, Marsha D; Robb, Geoffery; Singletary, S Eva

BACKGROUND:

Macromastia has been considered a contraindication to breast conservation therapy (BCT) because of difficulties with radiation therapy. This study evaluates the feasibility of bilateral reduction mammoplasty as a component of BCT for breast cancer patients with pendulous breasts.

METHODS:

Of 153 patients undergoing reduction mammoplasty at the University of Texas M.D. Anderson Cancer Center, 28 were identified as breast patients with macromastia receiving BCT. Median follow-up was 23.8 months.

RESULTS:

Median patient age was 55 years. Nearly all patients were described as obese. Median weight of the reduction mammoplasty specimen on the cancerous side was 766 grams. One patient (4%) required completion mastectomy for inadequate margin control. Major postoperative complications occurred in two patients (7%). There were no major post-radiation complications. Patient survey revealed a satisfaction rate of 86%.

CONCLUSION:

Bilateral reduction mammoplasty is a reasonable and safe option for breast cancer patients with macromastia who desire BCT.

Breast conservation therapy, consisting of a margin-negative segmental mastectomy and breast irradiation, is a standard and oncologically safe treatment modality for patients with early stage breast cancer, and for many patients with locally advanced disease, if their tumors can be downstaged sufficiently with induction chemotherapy. Multicentric lesions, or a medical contraindication to chest wall irradiation, however mandate mastectomy for definitive locoregional disease control. The presence of obesity or other body habitus associated with large, pendulous breasts can complicate the efficacy and suitability of both treatment approaches.

A unilateral mastectomy for a woman with macromastia can cause an unacceptable degree of asymmetry that will make prosthesis fitting very difficult, and results in substantial imbalance that can adversely affect quality of life. On the other hand, delivery of radiotherapy to a bulky and ptotic breast can be very challenging technically, and may result in excessive radiation toxicity.

Bilateral reduction mammoplasty in conjunction with tumor-directed segmental mastectomy is a surgical technique that can potentially improve the efficacy of radiation therapy in this setting, alleviate the neuropathic symptoms that can accompany macromastia, and increase rates of breast-preserving surgery for breast cancer patients. However, this option is frequently overlooked by surgeons managing newly-diagnosed breast cancer patients, and consequently there is limited reported data regarding the success rate of this approach. The purpose of this study was to evaluate the outcome of reduction mammoplasty in conjunction with breast conservation therapy as measured by complication rates and patient satisfaction.

The medical records were reviewed for 153 patients coded as having undergone reduction mammoplasty at the University of Texas M.D. Anderson Cancer Center between 1994 and 1999. Twenty-eight patients were identified as breast cancer patients who underwent bilateral reduction mammoplasty as a component of conservation therapy because of macromastia or excessively ptotic breasts (Table I). The mammoplasty incision followed the general pattern described by Wise. Attempts were made to contact all patients via telephone for participation in a patient satisfaction survey. All contacted patients were queried regarding the need for any additional revisional breast plastic reconstruction surgery. Patient satisfaction with result was scored as excellent, modestly satisfied or unsatisfied (patient regretted undergoing the reduction mammoplasty). Median follow-up from date of surgery was 23.8 months.

The discussion regarding reduction mammoplasty was initiated by the patient's request for a smaller breast size in 11 cases (39%) and by the physician because of suspected radiation-related difficulties in the remaining 17 cases (61%). Three patients received neodajuvant chemotherapy for locally advanced primary tumors (greater than 4 centimeters).

Median weight of the reduction mammoplasty specimen (including the weight of the tumor Ðbearing segmental mastectomy tissue) on the cancerous side was 766 grams (range, 150-3,250 grams) and 645 grams on the non-cancerous side (range, 150-3,230 grams). Adequate margin control (more than 2 mm microscopically negative margin) was achieved in all except for two patients (7%). Extensive ductal carcinoma in situ was found in one patient, necessitating completion mastectomy; a single microscopic focus of cancer was found at the deep margin, approaching the pectoral fascia in the other patient. No significant pathology (atypia, in situ, or invasive cancer) was found in any of the contralateral reduction mammoplasty specimens.

An axillary lymph node dissection was performed via a separate axillary incision in 26 patients (93%) with a median of 15 lymph nodes identified (range, 6-33). Six patients underwent lymphatic mapping and sentinel lymph node dissection; a sentinel lymph node was identified in four of these cases. In one patient with a failed lymphatic mapping procedure preoperative chemotherapy had been administered , and in the other patient a prior excisional biopsy of the primary tumor had been performed. Both of these patients underwent completion axillary lymph node dissections. In three of the four successful mapping procedures a completion axillary lymph node dissection was performed, revealing no false negative cases, and in one of these patients the sentinel lymph node was the isolated site of axillary metastasis.

There were no postoperative complications in 18 of the 28 patients (64%). Minor wound infections requiring oral antibiotics developed in five patients (18%). Major wound complications developed in two patients (7%): one experienced significant cellulitis that was treated with a course of intravenous antibiotics, and the other developed incisional necrosis requiring surgical debridement.

At the time of this review, 21 patients have completed their postoperative radiation therapy, with post-radiation sequelae described as mild erythema in 11 (53%) and no notable adverse effects in the others.

With a median follow-up of 23.8 months from the date of surgery, no patients have experienced a local recurrence, and 2 (7%) distant treatment failures have been detected. Twenty-seven patients (96%) are alive; 1 (4%) with stable metastatic disease and 26 (93%) without evidence of disease.

A telephone survey regarding outcome and patient satisfaction was completed by 14 patients. Two (14%) reported having to undergo minor additional revisional/correctional plastic surgery on their breasts, and 12 (86%) reported being very satisfied with their final cosmetic result. Only 2 (14%) expressed regret regarding their surgery because of poor cosmetic outcome and wished they had undergone a mastectomy instead.

Breast conservation therapy for early stage breast cancer includes a segmental mastectomy with an attempt obtain a gross negative margin of at least one centimeter, is the treatment of choice for patients with unicentric primary breast tumors under four centimeters in greatest diameter. Postoperative breast radiation therapy is an essential component of breast conservation therapy, and results in 12-year local recurrence rates of 10% compared to 39% seen in women who undergo lumpectomy without irradiation. For women with locally advanced breast cancers, breast-preserving therapy remains an option if the tumor can e appropriately downstaged with induction chemotherapy, and postoperative breast irradiation yields local recurrence rates that are similar to those seen with early stage disease. It is clear that the ability to deliver adequate radiation therapy is critical for successful breast conservation therapy.

Obesity is a risk factor for breast cancer development in postmenopausal women because of the increased rate of conversion of the adrenal estrogen precursor androstenedione, to estrone by enzymes located in fat cells. The predominantly fatty replaced breast is generally easier to screen for mammographic densities suggestive of small cancers, and a unilateral mastectomy for the very large-breasted woman can result in an excessively uncomfortable degree of asymmetry and imbalance. It might therefore be inferred that obese women with large, fatty breasts should be appropriate, and perhaps better candidates for breast conserving treatment of early-stage disease.

However, breast cancer patients with macromastia (whether related to obesity or individual body habitus) present particular challenges to the radiation oncologists. The large breast may require higher energy photons to ensure radiation delivery to the deeper tissue, and the dose inhomogeneity that can result may lead to significant radiation toxicity to the skin. The very ptotic breast may also be difficult for reproducible fixation and positioning during the many treatments, and significantly worse aesthetic results form breast-conserving treatment associated with large, pendulous breasts have been documented in several series, as shown in Table II.

This series demonstrates that bilateral reduction mammoplasty is an excellent maneuver to improve breast conservation therapy feasibility in women with macromastia. The safety of this approach is affirmed by the finding of only two patients experiencing significant postoperative complications, and no major radiation-related complication developing and excellent patient satisfaction rate was reported. In addition , lymphatic mapping with sentinel lymph node biopsy was performed in only a small number of patients, but our results suggest that the identification rate and accuracy of the procedure are not significantly impaired by the reduction mammoplasty.

In summary, we believe that bilateral reduction mammoplasty can be performed safely at the time of definitive breast cancer surgery and prior to breast irradiation in patients with macromastia. Breast conservation therapy has previously been considered relatively contraindicated in this patient population. Utilization of this technique should improve the ability to deliver the radiation component of breast conservation therapy to women with large, pendulous breast with acceptably low complication rates.

FIGURE 1A	FIGURE 2A
FIGURE 1B	FIGURE 2B
Fig 1.A. Preoperative photograph of breast cancer patient with macromastia with skin markings for bilateral reduction mammoplasty. Fig 1.B. Postoperative photograph of same patient following resection of over 3000 g of tissue from each breast.	Fig 2.A,B. Pre- and Post-operative photographs (respectively) of breast cancer patient with macromastia and bilateral reduction mammoplasty.

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