Ann Surg Oncol

DOI 10.1245/s10434-016-5407-9

ORIGINAL ARTICLE BREAST ONCOLOGY

Operative and Oncologic Outcomes in 9861 Patients with

Operable Breast Cancer: Single-Institution Analysis of Breast
Conservation with Oncoplastic Reconstruction
Stacey A. Carter, MD1, Genevieve R. Lyons, MSPH2, Henry M. Kuerer, MD, PhD1, Roland L. Bassett Jr., MS2,
Scott Oates, MD3, Alastair Thompson, BSc(Hons), MB ChB, MD1, Abigail S. Caudle, MD, MS1,
Elizabeth A. Mittendorf, MD, PhD1, Isabelle Bedrosian, MD1, Anthony Lucci, MD1, Sarah M. DeSnyder, MD1,
Gildy Babiera, MD1, Min Yi, MD, PhD1, Donald P. Baumann, MD3, Mark W. Clemens, MD3, Patrick B. Garvey,
MD3, Kelly K. Hunt, MD1, and Rosa F. Hwang, MD1

1
Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX;
2
Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; 3Center for
Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX

ABSTRACT BCS ? R had a T1 or T2 tumor. There was no difference

Background. Oncoplastic reconstruction is an approach
that enables patients with locally advanced or adversely
located tumors to undergo breast conserving surgery
(BCS). The objectives were to identify the use of BCS with
oncoplastic reconstruction (BCS ? R) and determine the
operative and oncologic outcomes compared with other
breast surgical procedures for breast cancer.
Methods. This retrospective cohort study interrogated a
single institutions prospectively maintained databases to
identify patients who underwent surgery for breast cancer
between 2007 and 2014. Surgeries were categorized as
BCS, BCS ? R, total mastectomy (TM), or TM with
immediate reconstruction (TM ? R). Demographic and
clinicopathologic characteristics and postoperative com-
plications were analyzed.
Results. There were 10,607 operations performed for 9861
patients. Median follow-up was 3.4 years (range, 0
9.1 years). The use of BCS ? R had a nearly fourfold
increase in the percentage of all breast cancer surgeries
during the study period; 75 % of patients who underwent
Electronic supplementary material The online version of this
article (doi:10.1245/s10434-016-5407-9) contains supplementary
material, which is available to authorized users.
Society of Surgical Oncology 2016
First Received: 11 April 2016
R. F. Hwang, MD
e-mail: rhwang@mdanderson.org
in the use of BCS ? R compared with BCS for any
quadrant of the breast except the lower outer quadrant
(11.1 vs. 6.8 %; p \ .0001). BCS ? R had a lower rate of
seroma formation (13.4 vs. 18 %; p = .002) and positive
or close margins compared with BCS (5.8 vs. 8.3 %;
p = .04). There was no difference in overall survival or
recurrence-free survival when comparing BCS and
BCS ? R.
Conclusions. Patients undergoing BCS ? R are not dis-
advantaged in terms of complications and short-term (3-
year) outcomes compared with BCS patients or patients
who underwent TM.
Breast conserving surgery (BCS) with radiation offers
patients equivalent survival rates as mastectomy; however
many BCS-eligible patients still undergo mastectomy for a
number of reasons.1 Several reports indicate an increase in
bilateral mastectomy rates for unilateral in situ or invasive
disease.2,3 In the United States, the rate of mastectomy for
breast cancer patients has markedly increased in the past
decade with approximately 37.8 % of early-stage patients
undergoing mastectomy in 2011.2 While many factors may
be involved in this decision, a patients desire to avoid a poor
aesthetic outcome may be a major contributor. Oncoplastic
surgery has gained popularity as an approach that allows for
optimal oncologic resection while conserving the native
breast and achieving an acceptable aesthetic outcome for the
patient.49 Patients with locally advanced or adversely loca-
ted tumors who are considered poor candidates for BCS are

usually offered total mastectomy with or without recon-
struction as an alternative. However, if these patients are able
to undergo BCS with oncoplastic reconstruction, they may
have an improved aesthetic result compared with BCS alone
or even mastectomy. In addition, this approach may offer a
lower complication rate compared with total mastectomy
with implant-based or autologous reconstruction, particularly
if radiotherapy is given in the adjuvant setting.10 In addition,
the concern for disease recurrence may be another factor that
influences the decision for mastectomy. Whether BCS with
oncoplastic reconstruction has a similar oncologic outcome
compared with BCS alone or total mastectomy has not been
adequately investigated.11 In the current study, we sought to
explore the emerging trend of oncoplastic reconstruction in
patients undergoing breast conserving therapy at a single
institution and determine whether this approach affords a
similar complication profile and oncologic outcome as have
patients without reconstruction.
METHODS
A retrospective cohort design using the prospectively
maintained Breast Surgical Oncology Database at The
University of Texas MD Anderson Cancer Center (MDACC)
identified 9861 patients who underwent 10,607 individual
operations performed for in situ or invasive breast cancer
(TisT4) treated from January 1, 2007 through December 31,
2014. The 10,607 surgeries identified were categorized as
breast conserving surgery (BCS), BCS with reconstruction
(BCS ? R), total mastectomy (TM), and TM with immedi-
ate reconstruction (TM ? R). Exclusion criteria included
male patients, surgeries performed for benign lesions or
prophylaxis, lymph node only procedures, and patients who
did not consent to data collection. Clinicopathologic data
were recorded including staging according to the seventh
edition of the American Joint Committee on Cancer guide-
lines. Oncoplastic procedures, classified as BCS ? R, were
identified and classified according to CPT codes in an
institutional billing database (Supplemental Table 1) and
could have been performed by either the breast surgical
oncologist or a plastic reconstructive surgeon. Obesity was
defined as a body mass index greater than 30 kg/m.2 Data
related to complications for surgeries performed from Jan-
uary 1, 2010 to December 31, 2014 were compiled using
ICD-9 codes (Supplemental Table 1). This study was
approved by the institutional review board at MDACC (IRB
PA15-0289).
Statistical Analyses
Patient demographic and clinicopathologic characteris-
tics were summarized by surgical procedure subcategory
S. A. Carter et al.
using frequency tables. Demographic information was
captured once for patients who had multiple procedures.
Comparisons were made using a v2 or Fisher exact test as
appropriate. Numeric covariates were summarized using
mean and standard deviation and compared between
groups using a Wilcoxon or t test, as appropriate. Formal
comparisons were made with respect to the type of pro-
cedure performed. A Cochran-Armitage test for trend was
used to determine whether there was a trend over time in
the proportion of BCS ? R over the study period. Survival
analyses were performed using the KaplanMeier method
and Cox proportional hazards models. Overall survival was
calculated from the date of initial surgery at MDACC. The
3-year survival probabilities were estimated with 95 %
confidence intervals for each group. Statistical analysis was
done with SAS version 9.4 (Cary, NC).
RESULTS
Surgery Trends 20072014
A total of 10,607 operations were performed for 9861
patients in the study cohort. Overall, 33.6 % underwent
BCS, 11.1 % had BCS ? R, 30.8 % had TM, and 24.6 %
had TM ? R (Table 1). During the study period, the rate of
mastectomy increased from 49 to 54 %, with a corre-
sponding decline in any BCS from 51 to 46 % (Fig. 1a, b).
During the early years from 2007 to 2010, BCS ? R
accounted for 10 % or less of all surgeries and only 8
22 % of all breast conserving cases (Fig. 1ac). However,
the rate of BCS ? R increased steadily from 2011 to 2014,
making up more than 33 % of all breast conserving surg-
eries in 2014. More dramatically, the number of BCS ? R
procedures increased by more than fivefold from 2007 to
2014 (44243), with the steepest increase occurring after
2010 (p \ .0001 for BCS ? R trend over time). Compared
with all surgeries, the proportion of patients undergoing
BCS ? R increased from 4 to 15 % despite the overall rise
in the mastectomy rate.
Patient and Tumor Characteristics For the current study,
we focused on the patients who underwent BCS ? R
compared with the other 3 groups as shown in Table 1.
Other comparisons are shown in Supplemental Table 2.
The mean age of patients who had BCS ? R was slightly
younger than those who had BCS and older than patients
who underwent TM ? R (median, 57 vs. 59 vs. 50 years,
respectively; p \ .0001). The racial background was
similar for BCS ? R and BCS patients. Compared with
TM ? R patients, BCS ? R patients were more likely to
be black and less likely to be Asian or Hispanic
(p = .0004). Patients who underwent TM R were more
Breast Conservation & Oncoplastic Reconstruction

TABLE 1 Clinicopathologic characteristics by subgroup

Variable BCS BCS ? R TM TM ? R BCS R cf. BCS ?R cf. BCS ? R cf.
(n = 3559) (n = 1177) (n = 3263) (n = 2608) TM R BCS TM ? R
N % N % N % N % p value p value p value

Age
Median (years) (range) 59 (2593) 57 (2390) 56 (1998) 50 (2081) \.0001 \.0001 \.0001
Under 40 112 3.4 64 5.9 316 10.3 414 17.0
4049 558 17.1 207 19.0 655 21.3 785 32.2
5059 971 29.8 371 34.1 869 28.2 765 31.4
6069 970 29.8 329 30.3 745 24.2 414 17.0
7079 521 16.0 102 9.4 379 12.3 56 2.3
8084 80 2.5 6 .6 79 2.6 3 .1
85 and older 45 1.4 8 .7 37 1.2 0 .0
Race
White 2295 70.5 756 69.6 1978 64.2 1670 68.5 \.0001 .15 .0004
Asian 152 4.7 40 3.7 186 6.0 126 5.2
Black 373 11.5 147 13.5 417 13.5 231 9.5
Hispanic 373 11.5 126 11.6 427 13.9 357 14.7
Other 20 .6 4 .4 13 .4 11 .5
Unknown 44 1.4 14 1.3 59 1.9 42 1.7
Obesity
Yes 2156 64.9 625 55.9 2005 66.5 1552 64.6 .0384 .62 .46
No 22 .7 5 .5 38 1.3 18 .8
Not available 1146 34.5 489 43.7 972 32.2 833 34.7
Clinical T stage
Tis 717 20.2 234 19.9 395 12.1 659 25.3 \.0001 \.0001 \.0001
T1 1833 51.5 487 41.4 667 20.4 836 32.1
T2 875 24.6 395 33.6 1084 33.2 827 31.7
T3 48 1.4 32 2.7 440 13.5 134 5.1
T4 22 .6 10 .9 501 15.4 28 1.1
Not available 59 1.7 17 1.4 167 5.1 118 4.5
Clinical N stage
N0 3104 87.2 943 80.1 1710 52.4 2103 80.6 \.0001 \.0001 .052
N1 315 8.9 164 13.9 848 26.0 316 12.1
N2 25 .7 15 1.3 159 4.9 41 1.6
N3 65 1.8 38 3.2 405 12.4 51 2.0
Clinical M stage
M0 3490 98.1 1151 97.8 2969 91.0 2493 95.6 \.0001 .15 .44
M1 15 .4 9 .8 153 4.7 14 .5
Clinical stage
Stage 0 717 20.2 234 19.9 392 12.0 660 25.3 \.0001 \.0001 \.0001
Stage 1 1714 48.2 442 37.6 527 16.2 741 28.4
Stage 2 933 26.2 408 34.7 1145 35.1 930 35.7
Stage 3 115 3.2 67 5.7 886 27.2 144 5.5
Stage 4 15 .4 9 .8 154 4.7 14 .5
Not available 65 1.8 17 1.5 159 4.9 119 4
Tumor location
Upper inner 554 15.6 179 15.2 514 15.8 446 17.1 .22 .77 .15
Upper outer 1463 41.1 447 38.0 1390 42.6 1015 38.9 .51 .05 .58
Lower inner 228 6.4 64 5.4 281 8.6 167 6.4 .003 .23 .25
 S. A. Carter et al.

TABLE 1 continued
Variable BCS BCS ? R TM TM ? R BCS R cf. BCS ?R cf. BCS ? R cf.
(n = 3559) (n = 1177) (n = 3263) (n = 2608) TM R BCS TM ? R
N % N % N % N % p value p value p value

Lower outer 242 6.8 131 11.1 329 10.1 228 8.7 .003 \.0001 .02
Central 976 27.4 320 27.2 810 24.8 656 25.2 .005 .88 .19
Multicentric 25 .7 12 1.0 272 8.3 122 4.7 \.0001 .28 \.0001
Preoperative treatment
None 2861 81.4 874 74.6 1449 44.8 1817 71.3 \.0001 \.0001 .04
Chemotherapy 564 15.9 278 23.6 1656 50.8 656 25.2 \.0001 \.0001 .23
Hormonal 81 2.3 18 1.5 148 4.5 58 2.2 \.0001 .12 .16
Other 24 .7 7 .6 55 1.7 36 1.4 \.0001 .91 .02
Tumor grade
Low 526 14.8 156 13.3 259 7.9 276 10.6 \.0001 .01 .05
Intermediate 1667 46.8 521 44.3 1193 36.6 1173 45.0
High 1238 34.8 471 40.0 1600 49.0 1093 41.9
Not available 128 3.6 29 2.5 211 6.5 66 2.5
Multifocal
Yes 434 12.2 184 15.6 888 27.2 751 28.8 \.0001 .01 \.0001
No 2811 79.0 894 76.0 1636 50.1 1586 60.8
Not available 314 8.8 99 8.4 739 22.7 271 10.4
Lymphovascular invasion
Yes 449 12.6 169 14.4 983 30.1 447 17.1 \.0001 .0002 .02
No 2910 81.8 907 77.1 1960 60.1 1986 76.2
Not available 200 5.6 101 8.6 320 9.8 175 6.7
Margin status
Positive 74 2.1 12 1.0 12 .4 7 .3 \.0001 .04 \.0001
Close (\2 mm) 219 6.2 56 4.8 88 2.7 54 2.1
Negative 3231 90.8 1101 93.5 3140 96.2 2529 97.0
Not available 35 1.0 8 .7 23 .7 18 .7
ER
Positive 2958 83.1 963 81.8 2418 74.1 2078 79.7 \.0001 .76 .04
Negative 555 15.6 198 16.8 757 23.2 455 17.5
Not recorded 46 1.3 16 1.4 88 2.7 75 2.9
PR
Positive 2452 68.9 797 67.7 1890 57.9 1689 64.8 \.0001 .67 .02
Negative 1046 29.4 360 30.6 1273 39.0 832 31.9
Not recorded 61 1.7 20 1.7 100 3.0 87 3.3
HER2
Positive 293 8.2 126 10.7 599 18.4 327 12.5 \.0001 \.0001 \.0001
Negative 2585 72.6 843 71.6 2289 70.2 1727 66.2
Not recorded 681 208 17.7 375 41.7 554 21.3
Triple negative
Yes 352 9.9 128 10.9 456 14.0 246 9.4 .0021 .50 .47
No 2419 68.0 802 68.1 2196 67.3 1677 64.3
Not recorded 788 22.1 247 21.0 611 18.7 685 26.3
Adjuvant chemotherapy
Yes 819 23.0 302 25.7 1044 32.0 831 31.9 \.0001 \.0001 \.0001
No 2582 72.6 775 65.9 1950 59.8 1640 62.9
Not recorded 158 4.4 100 8.5 269 8.2 137 5.3
Breast Conservation & Oncoplastic Reconstruction

TABLE 1 continued
Variable BCS BCS ? R TM TM ? R BCS R cf. BCS ?R cf. BCS ? R cf.
(n = 3559) (n = 1177) (n = 3263) (n = 2608) TM R BCS TM ? R
N % N % N % N % p value p value p value

Adjuvant hormonal therapy

Yes 2227 62.6 644 54.7 1728 53.0 1417 54.3 \.0001 \.0001 \.0001
No 949 26.7 287 24.4 1089 33.4 849 32.6
Not recorded 383 10.8 246 20.9 446 13.7 342 13.1
Adjuvant radiation therapy
Yes 2808 78.9 895 76.0 1600 49.0 559 21.4 \.0001 \.0001 \.0001
No 486 13.7 132 11.2 1314 40.3 1786 68.5
Not recorded 265 7.5 150 12.7 349 10.7 263 10.1
BCS breast conserving surgery, BCS ? R breast conserving surgery with reconstruction, BCS R breast conserving surgery with or without
reconstruction, cf compare with, ER estrogen receptor, HER2 human epidermal growth factor receptor 2, PR progesterone receptor, SD standard
deviation, TM total mastectomy, TM ? R total mastectomy with reconstruction, TM R total mastectomy with or without reconstruction

FIG. 1 Number of cases per year by subgroup (a), percent of total procedures per year by subgroup (b). Proportion of breast conserving
procedures with and without reconstruction by year (c), proportion of total mastectomy procedures with and without reconstruction by year (d)

likely to be obese (BMI [ 30 kg/m 2) compared with those
who underwent BCS R (36.1 vs. 28.2 %; p = .04).
However, the rate of obesity was similar in BCS ? R
patients compared with BCS or TM ? R.
Approximately 75 % of patients who underwent BCS
or BCS ? R had a T1 or T2 tumor, although the groups
differed in that the BCS ? R group had larger tumors
than the BCS group (24.6 % T2 tumors in BCS vs.
33.6 % in BCS ? R; p \ .0001; Table 1). Compared
with BCS ? R patients, the TM ? R group was more
likely to have Tis disease (25.3 vs. 19.9 %; p \ .0001).
In contrast, the TM-only patients had more advanced
disease, with the highest proportion of T4 tumors of any
group (15.4 %). BCS ? R patients were more likely to
have clinically node-positive disease than BCS patients
(18.4 vs. 11.4 %; p \ .0001), but with a similar rate to
TM ? R patients (15.6 %). The TM group had the
highest rate of nodal involvement (43.4 % with N1N3
disease) of any group, reflecting the more advanced stage
of these patients.
 S. A. Carter et al.

There was no difference in the use of BCS ? R com-
pared with BCS for any quadrant of the breast except the
lower outer quadrant (11.1 % in BCS ? R vs. 6.8 % in
BCS; p \ .001; Table 1). Although oncoplastic recon-
struction is thought to be most beneficial for patients
undergoing BCS for tumors in difficult locations (upper
inner, lower inner, central breast), our data did not show a
difference in the rate of BCS ? R compared with BCS
alone or TM ? R for tumors in these locations. Under-
standably, patients with multicentric or multifocal tumors
were more likely to undergo TM R compared with any
BCS (28 % multifocal in TM R vs. 13 % in BCS R;
p \ .0001). Multifocal disease was also more likely in the
BCS ? R group than in the BCS group (15.6 vs. 12.2 %;
p = .01).
High-grade tumors were more common in patients who
underwent BCS ? R compared with BCS (40 vs. 34.8 %;
p = .01; Table 1). The presence of lymphovascular inva-
sion was slightly higher in the BCS ? R group compared
with BCS (14.4 vs. 12.6 %; p = .0002) and much higher in
patients who underwent any TM (17.130.1 %). The pro-
portion of ER or PR positive tumors was similar in BCS
and BCS ? R groups. HER2 positive tumors were more
common in BCS ? R patients compared with BCS (10.7
vs. 8.2 %; p \ .0001). The proportion of triple-negative
tumors was similar in BCS ? R compared with BCS and
TM ? R.
Patients who underwent BCS had the highest rate of
positive or close margins out of any group (8.3 %;
Table 1). The BCS ? R group had a lower rate of positive
or close margins compared with BCS alone (5.8 %;
p = .04), but this was higher than the rate for TM ? R
patients (2.4 %; p \ .0001).
Neoadjuvant and Adjuvant Therapy Neoadjuvant
chemotherapy was given more frequently in the
BCS ? R group compared with BCS (23.6 vs. 15.9 %;
p \ .0001; Table 1). Adjuvant chemotherapy was more
common in the BCS ? R group compared with BCS
alone (25.7 vs. 23.0 %; p \ .0001). As expected,
adjuvant radiation therapy was higher in patients who
underwent BCS R compared with TM R (78.2 vs.
36.8 %; p \ .001). Although the rate of adjuvant
radiation was slightly less in the BCS ? R group
compared with the BCS group (76 vs. 78.9 %;
p \ .0001), the difference is not likely to be clinically
significant. Overall, radiation therapy following
BCS R seemed low for our group of patients, which
may be related to incomplete data for women undergoing
radiation at an outside institution.
Complications Both wound-related complications and
surgical site infections (SSIs) were much lower in
patients who underwent BCS R compared with
TM R patients (p \ .0001; Table 2). The seroma rate
was lower in patients that underwent BCS ? R compared
with BCS (13.4 vs. 18.0 %; p = .002) and had a value
close to TM ? R patients. BCS ? R patients had a higher
rate of wound-related complications compared with BCS
(4.8 vs. 1.4 %; p \ .0001), but the hematoma and SSI rates
showed no difference. Compared with the TM ? R group,
the BCS ? R group had fewer hematomas, wound-related
complications, and SSIs (p \ .0001).
Recurrence and Survival Median follow-up for the study
population was 3.4 years (range, 09.1 years). Median
survival was not reached for any group since far fewer than
half the patients died. The overall survival (OS) and the
recurrence-free survival (RFS) are presented in Fig. 2.
There was no difference in OS when comparing BCS and
BCS ? R (p = .16; Fig. 2a) and no difference in 3-year
OS when comparing BCS and BCS ? R (96.8 vs. 95.8 %;
95 % CI, 9697 vs. 9497 %). Similarly, RFS was
equivalent between the 2 groups overall (p = .19;
Fig. 2b). However, TM ? R had the best OS of any
group, and was significantly better than the BCS ? R

TABLE 2 Complications by subgroup

Variable BCS BCS ? R TM TM ? R BCS R cf. BCS ?R cf. BCS ? R cf.
(n = 2258) (n = 939) (n = 2304) (n = 1824) TM R BCS TM ? R
N % N % N % N % p value p value p value

Hematoma 57 2.5 18 1.9 66 2.9 87 4.8 .0009 .3 .0002

Seroma 406 18.0 126 13.4 305 13.2 228 12.5 \.0001 .0016 .49
Wound 32 1.4 45 4.8 133 5.8 212 11.6 \.0001 \.0001 \.0001
Infection 92 4.1 42 4.5 178 7.7 237 13.0 \.0001 .61 \.0001
Implant complication 310 17.0
BCS breast conserving surgery, BCS ? R breast conserving surgery with reconstruction, BCS R breast conserving surgery with or without
reconstruction, cf compare with, TM total mastectomy, TM ? R total mastectomy with reconstruction, TM R total mastectomy with or without
reconstruction
Breast Conservation & Oncoplastic Reconstruction

FIG. 2 Overall survival (a) and recurrence-free survival (b) by subgroup

TABLE 3 Univariate and multivariate Cox proportional hazards models for recurrence-free survival
Variable Reference level Hazard ratio 95 % confidence interval Overall p value Pairwise p value

Univariate
Age (Numeric) 1.008 1.0031.014 .0040
Nodal stage pN13 versus pN0 3.257 2.8443.731 \.0001
Grade Intermediate/high versus low 2.298 1.7123.084 \.0001
Margins Close or positive versus negative 1.953 1.4752.586 \.0001
Lymphovascular invasion Present versus absent 5.562 4.2287.315 \.0001
Triple negative Yes versus no 3.074 2.6293.596 \.0001
Adjuvant radiation therapy Yes versus no 1.198 1.0351.388 .0158
Surgery type cf. BCS ? R BCS .907 .6751.220 \.0001 .5196
TM 2.799 2.1223.693 \.0001
TM ? R .671 .483.932 .0174
Multivariate
Age (Numeric) .999 .9901.008 .83
Nodal stage pN13 versus pN0 2.197 1.6132.992 \.0001
Grade Intermediate/high versus low 1.406 .6173.204 .42
Margins Close or positive versus negative 1.676 1.1092.532 .0143
Lymphovascular invasion Present versus absent 2.874 1.5835.219 .0005
Triple negative Yes versus no 4.299 3.3415.530 \.0001
Adjuvant radiation therapy Yes versus no .853 .6381.141 .28
Surgery type BCS versus BCS ? R .949 .524 \.0001 .86
TM versus BCS ? R 2.313 1.359 .0020
TM ? R versus BCS ? R .729 .383 .34
BCS breast conserving surgery, BCS ? R breast conserving surgery with reconstruction, BCS R breast conserving surgery with or without
reconstruction, TM total mastectomy, TM ? R total mastectomy with reconstruction, TM R total mastectomy with or without reconstruction

group (p = .0007), which was also reflected in the 3-year
OS probabilities (97.7 vs. 96.8 %; 95 % CI, 9597 vs. 93
96 %). This is likely due to the large proportion of patients
with stage 0 disease in this group. Accordingly, RFS was
longer in the TM ? R patients than the BCS ? R group
(p = .01), as was 3-year RFS (96.6 vs. 94.6 %; 95 % CI,
9697 vs. 9396 %).
By univariate analysis, age, nodal status, grade, margin
status, lymphovascular invasion, and triple-negative status
were strongly associated with RFS (Table 3). On

multivariate analysis, these factors remained significant
except for age and grade. However, when comparing sur-
gical procedures, only TM was significantly different from
BCS ? R. TM patients have approximately 2.3 times the
hazard of recurrence or death compared to BCS ? R.
DISCUSSION
BCS ? R for patients with breast cancer has emerged as
an approach that may increase the number of eligible
patients who can undergo breast conservation.5,8,11,12
Oncoplastic reconstruction involves local tissue rear-
rangement for reshaping the breast or more advanced
mammoplasty techniques that allow for larger resections of
the breast volume.7 Using data from a single institution, we
demonstrate that the use of BCS ? R for breast cancer
patients has markedly increased from 2007 to 2014 with a
nearly fourfold increase in the percentage of all breast
cancer surgeries during that time period. BCS ? R and
BCS are both approaching an equal share of the patients
undergoing breast conserving surgery, with BCS ? R
increasing from 9 to 33 % of all breast conservation cases
in our study group. With 1177 patients in the BCS ? R
group, this is the largest study of oncoplastic reconstruction
for breast cancer patients reported to our knowledge.11
Patients who undergo BCS ? R are slightly younger
than BCS patients but older than TM ? R patients. For
reconstruction patients, with every decade after the age of
40 the rate of BCS ? R increased by 10 % or more over
TM ? R. This may be related to surgeons and patients
perceptions that older patients will have higher complica-
tion rates and poorer outcomes with more extensive
surgery.13 The BCS ? R group had a more advanced
clinical stage of breast cancer compared to the BCS group
and other pathologic risk factors were also worse for
BCS ? R compared with BCS (lymphovascular invasion,
high-grade, HER2 amplification, and multifocality).
Despite these risk factors, there was no significant differ-
ence in OS or RFS for BCS ? R patients compared with
BCS-alone patients. Other groups have reported on the
oncologic safety of BCS ? R in smaller series as well.1416
Indeed, several studies have shown that oncoplastic BCS
results in wider negative margins and larger specimens
compared with standard BCS and reduces the re-excision
rate.5,8,15 Although these factors could potentially lower
the risk of recurrence, we did not observe a significant
difference in our analyses in keeping with the guidelines
established by the Society of Surgical Oncology in col-
laboration with the American Society for Radiation
Oncology.17 BCS ? R was significantly different from TM
in multivariate analysis.
S. A. Carter et al.
For postoperative complications, there were fewer
seromas for BCS ? R compared with BCS. With
oncoplastic reconstruction, tissue rearrangement fills the
void left by the tumor resection and minimizes the dead
space for seroma formation. As the procedures increased in
complexity, the SSI rates increased, with BCS having the
lowest rate, followed by BCS ? R, TM, and TM ? R
having the highest rate of SSI. These results correlate with
previous reports showing a low incidence of complications
related to BCS ? R.4,1820 A recent study from our insti-
tution also found that obese women experience fewer
complications after BCS ? R than immediate reconstruc-
tion with implant-based or autologous reconstruction.10
With a low risk of surgical complications, BCS ? R does
not delay the initiation of adjuvant therapy.21
Our results indicate that BCS ? R is an oncologically
safe procedure with complication rates that are equivalent
to or less frequent than BCS or TM ? R. However, our
mean follow-up period of 3.4 years is relatively short,
which may make the oncologic safety difficult to interpret.
Other studies have demonstrated that patient reported sat-
isfaction after BCS ? R is high and aesthetic outcomes are
excellent.22 BCS ? R also offers patients a single-stage
procedure, whereas TM ? R (by any reconstructive
modality) is generally a minimum of 2 procedures. This
means that patients who select BCS R will generally
have a shorter surgical course of treatment. In this regard,
patients who are expected to require radiation after mas-
tectomy should consider BCS because it may offer better
outcomes in terms of better aesthetics, lower complica-
tions, and fewer procedures. However, BCS ? R does
require careful planning and coordination between the
breast surgical oncologist, the plastic reconstructive sur-
geon, and the radiation oncologist, especially as the role of
BCS ? R has expanded to involve more challenging cases
(multifocal, multicentric). Since oncoplastic surgery can
make it difficult to target the tumor bed with radiation
therapy for the local boost, it is essential to mark the
resection cavity with metallic markers.2327 In some cases,
oncoplastic reconstruction may facilitate radiation planning
and delivery by reshaping a large ptotic breast and cen-
tralizing the breast mound to facilitate whole breast
radiation. If performed in a planned, multidisciplinary
fashion, BCS ? R should be offered as an alternative to
mastectomy for patients who might not otherwise be con-
sidered traditional candidates for BCS.
ACKNOWLEDGMENTS This work was supported in part by the
Cancer Center Support Grant (NCI Grant P30 CA016672). We greatly
wish to acknowledge Deborah Adair, Helen Zou, and Kelly Merri-
man, MPH, PhD, for their assistance with data collection for this
project.
Breast Conservation & Oncoplastic Reconstruction
REFERENCES
1. Clarke M, Collins R, Darby S, 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 ran-
domised trials. Lancet. 2005;366:2087106.
2. Kummerow KL, Du L, Penson DF, Shyr Y, Hooks MA.
Nationwide trends in mastectomy for early-stage breast cancer.
JAMA Surg. 2015;150:916.
3. Habermann EB, Thomsen KM, Hieken TJ, Boughey JC. Impact
of availability of immediate breast reconstruction on bilateral
mastectomy rates for breast cancer across the United States: data
from the nationwide inpatient sample. Ann Surg Oncol.
2014;21:32906.
4. Chakravorty A, Shrestha AK, Sanmugalingam N, Rapisarda F,
Roche N, Querci Della Rovere G, Macneill FA. How safe is
oncoplastic breast conservation? Comparative analysis with
standard breast conserving surgery. Eur J Surg Oncol.
2012;38:3958.
5. Clough KB, Benyahi D, Nos C, Charles C, Sarfati I. Oncoplastic
surgery: pushing the limits of breast-conserving surgery. Breast J.
2015;21:1406.
6. Clough KB, Ihrai T, Oden S, Kaufman G, Massey E, Nos C.
Oncoplastic surgery for breast cancer based on tumour location
and a quadrant-per-quadrant atlas. Br J Surg. 2012;99:138995.
7. 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;17:137591.
8. Clough KB, Lewis JS, Couturaud B, Fitoussi A, Nos C, Falcou
MC. Oncoplastic techniques allow extensive resections for
breast-conserving therapy of breast carcinomas. Ann Surg.
2003;237:2634.
9. Rezai M, Kraemer S, Kimmig R, Kern P. Breast conservative
surgery and local recurrence. Breast. 2015;24 Suppl 2:S1007.
10. Tong WM, Baumann DP, Villa MT, et al. Obese women expe-
rience fewer complications after oncoplastic breast repair
following partial mastectomy than after immediate total breast
reconstruction. Plast Reconstr Surg. 2016;137:77791.
11. Yiannakopoulou EC, Mathelin C. Oncoplastic breast conserving
surgery and oncological outcome: Systematic review. Eur J Surg
Oncology. 2016;42:62530.
12. Silverstein MJ, Savalia N, Khan S, Ryan J. Extreme oncoplasty:
breast conservation for patients who need mastectomy. Breast J.
2015;21:529.
13. Oh DD, Flitcroft K, Brennan ME, Spillane AJ. Patterns and
outcomes of breast reconstruction in older womena systematic
review of the literature. Eur J Surg Oncol. 2016;42:60415.
14. Chang EI, Peled AW, Foster RD, et al. Evaluating the feasibility
of extended partial mastectomy and immediate reduction
mammoplasty reconstruction as an alternative to mastectomy.
Ann Surg. 2012;255:11517.
15. Down SK, Jha PK, Burger A, Hussien MI. Oncological advan-
tages of oncoplastic breast-conserving surgery in treatment of
early breast cancer. Breast J. 2013;19:5663.
16. Kaviani A, Safavi A, Mohammadzadeh N, Jamei K, Ansari-Da-
mavandi M, Salmon RJ. Oncoplastic surgery in breast
conservation: a prospective evaluation of the patients, techniques,
and oncologic outcomes. Am J Surg. 2014;208:72734.
17. Buchholz TA, Somerfield MR, Griggs JJ, et al. Margins for
breast-conserving surgery with whole-breast irradiation in stage I
and II invasive breast cancer: American Society of Clinical
Oncology endorsement of the Society of Surgical Oncology/
American Society for Radiation Oncology consensus guideline. J
Clin Oncol. 2014;32:15026.
18. Fitoussi AD, Berry MG, Fama F, et al. Oncoplastic breast surgery
for cancer: analysis of 540 consecutive cases [outcomes article].
Plast Reconstr Surg. 2010;125:45462.
19. Losken A, Dugal CS, Styblo TM, Carlson GW. A meta-analysis
comparing breast conservation therapy alone to the oncoplastic
technique. Ann Plast Surg. 2014;72:1459.
20. Rose M, Manjer J, Ringberg A, Svensson H. Surgical strategy, methods
of reconstruction, surgical margins and postoperative complications in
oncoplastic breast surgery. Eur J Plast Surg. 2014;37:20514.
21. Khan J, Barrett S, Forte C, Stallard S, Weiler-Mithoff E, Doughty
JC, Romics L Jr. Oncoplastic breast conservation does not lead to
a delay in the commencement of adjuvant chemotherapy in breast
cancer patients. Eur J Surg Oncol. 2013;39:88791.
22. Rezai M, Knispel S, Kellersmann S, Lax H, Kimmig R, Kern P.
Systematization of oncoplastic surgery: selection of surgical
techniques and patient-reported outcome in a cohort of 1,035
patients. Ann Surg Oncol. 2015;22:37307.
23. Furet E, Peurien D, Fournier-Bidoz N, et al. Plastic surgery for
breast conservation therapy: how to define the volume of the
tumor bed for the boost? Eur J Surg Oncol. 2014;40:8304.
24. Kronowitz SJ, Kuerer HM, Buchholz TA, Valero V, Hunt KK. A
management algorithm and practical oncoplastic surgical tech-
niques for repairing partial mastectomy defects. Plast Reconstr
Surg. 2008;122:163147.
25. Maguire PD, Adams A, Nichols MA. Oncoplastic surgery and
radiation therapy for breast conservation: early outcomes. Am J
Clin Oncol. 2015;38:3537.
26. Pezner RD, Tan MC, Clancy SL, Chen YJ, Joseph T, Vora NL.
Radiation therapy for breast cancer patients who undergo
oncoplastic surgery: localization of the tumor bed for the local
boost. Am J Clin Oncol. 2013;36:5359.
27. Thomas K, Rahimi A, Spangler A, Anderson J, Garwood D.
Radiation practice patterns among United States radiation
oncologists for postmastectomy breast reconstruction and
oncoplastic breast reduction. Pract Radiat Oncol. 2014;4:46671.