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ORIGINAL ARTICLE
Year : 2018  |  Volume : 37  |  Issue : 1  |  Page : 1-4

Lazy lateral technique: an innovative approach for upper outer quadrant breast cancer near the anterior axillary fold


Department of General and Laparoscopic Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission17-Mar-2017
Date of Acceptance07-May-2017
Date of Web Publication14-Feb-2018

Correspondence Address:
Mohamed I Abdelhamid
El Shimaa St, EL Kawmia, Zagazig, Sharkia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejs.ejs_38_17

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  Abstract 

Context Surgical treatment of breast cancer was challenged over years. Breast conservation is as oncologically safe as mastectomy and gives better cosmetic and psychological outcomes.
Aim The aim of our study was to evaluate the oncological and esthetic outcomes of the lazy lateral technique as a new approach for tumor located at the upper outer quadrant near anterior axillary fold.
Patients and methods Between October 2012 and September 2014, 18 patients with early breast cancer at the upper outer quadrant and near the anterior axillary fold were surgically treated with the lazy lateral technique.
Results The age of our patients ranged from 36 to 58 years (median: 47 years). Most of the patients in this study were diagnosed as having infiltrating ductal carcinoma (14 patients, 77.7%). The size of the tumor ranged from 0.9 to 3.8 cm. No involved margin on frozen section. Seroma was the most common postoperative complication and developed in two (11.1%) patients. The cosmetic outcome was excellent in 12 (66.6%) patients, good in five (27.7%) patients, and satisfactory in one (5.5%) patient. No local recurrence or systemic metastasis was noticed in our patients during a median follow-up period of 38 months (range: 27–49 months).
Conclusion The lazy lateral technique is a novel approach for surgical treatment of upper outer quadrant breast cancer near the anterior axillary fold. It is an oncologically safe procedure and promotes satisfactory esthetic outcomes.

Keywords: breast cancer, conservative surgery, oncoplastic techniques


How to cite this article:
Abdelhamid MI, Alkilany MM, Lotfy M. Lazy lateral technique: an innovative approach for upper outer quadrant breast cancer near the anterior axillary fold. Egypt J Surg 2018;37:1-4

How to cite this URL:
Abdelhamid MI, Alkilany MM, Lotfy M. Lazy lateral technique: an innovative approach for upper outer quadrant breast cancer near the anterior axillary fold. Egypt J Surg [serial online] 2018 [cited 2018 Feb 20];37:1-4. Available from: http://www.ejs.eg.net/text.asp?2018/37/1/1/225482


  Introduction Top


The breast is a significant symbol of femininity for women; total or partial excision of the breast alters the patient’s body image and causes many psychological disorders. Surgical treatment of breast cancer was challenged over years from radical mastectomy of Halsted passing through modified radical mastectomy until the era of breast conservation and lastly oncoplastic surgery [1],[2],[3],[4],[5],[6]. Oncoplastic surgery is the most recent expression of breast conserving surgery; it aims to conserve the breast parenchyma to give an excellent cosmetic outcome for the patient, respecting the oncological principles of radicality [7],[8],[9]. Breast conservation is as oncologically safe as mastectomy and gives better cosmetic and psychological outcomes [10],[11]. About 60% of breast cancer occurs at the upper outer quadrant [12],[13],[14]; hence, we try to find a new approach to allow safe resection of the tumor and give better cosmetic outcomes.


  Aim Top


The aim of our study was to evaluate the oncological and esthetic outcomes of the lazy lateral technique as a new approach for tumors located at the upper outer quadrant near the anterior axillary fold.


  Patients and methods Top


Between October 2012 and September 2014, 18 patients with early breast cancer in the upper outer quadrant and near the anterior axillary fold were included in the study. The study was conducted at the surgical oncology unit, Zagazig University Hospital, and was approved by the local ethical committee of our faculty.

Preoperative

All patients were diagnosed with early breast cancer by careful clinical evaluation, investigation (breast ultrasound and mammography), and proved by true cut biopsy. Chest radiography, pelviabdominal ultrasound, and bone scan were performed for staging of the disease.

Inclusion criteria

All female patients with early breast cancer at the upper outer quadrant and near the anterior axillary fold were included in the study.

Exclusion criteria

  1. Multicentric and multifocal tumor.
  2. Inflammatory breast cancer.
  3. Breast–tumor size ratio that does not allow oncoplastic surgery.
  4. Patient preference.


The technique was discussed with all patients and informed consent was obtained. Preoperative drawing of lazy lateral incision extends from the anterior axillary fold and envelops the tumor down along the circumference of the breast to the lateral end of the inframammary fold ([Figure 1]).
Figure 1 (a, b) Preoperative drawing of the incision

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Intraoperative

The tumor was resected with safety margin using the designed incision; frozen section of the specimen was prepared in order to assess the safety margin ([Figure 2]a and [Figure 2]b). Axillary clearance with removal of level I and level II lymph nodes was carried out through the same incision ([Figure 2]c). Closure with suction drain was performed ([Figure 3]).
Figure 2 (a) Cavity after tumor excision. (b) Excised tumor with the axillary lymph nodes. (c) Axilla after axillary clearance

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Figure 3 The breast after closure of the wound

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Postoperative

Suction drains were removed when the drain output was decreased to 20–30 ml per 24 h.

Our patients were referred to the Clinical Oncology Department to complete their adjuvant chemotherapy and radiotherapy according to protocols.

Technique-related complications

All patients were assessed for the onset of wound infection, hematoma, wound dehiscence, and seroma.

Esthetic outcomes

The cosmetic appearance was evaluated at 6 months postoperatively using objective and subjective scoring system and the mean was calculated. Using a grading system, a score of 5 to 1 (5, excellent; 4, good; 3, satisfactory; 2, poor; 1, very poor) was given after assessment of breast symmetry, nipple–areola complex symmetry, and shape of the breast ([Figure 4]) [15].
Figure 4 The breast at 6 months after excision of the tumor

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Oncological outcomes

Our patients were followed up for early detection of local recurrence and patient support. Follow-up was every 2 weeks for 1 month, monthly for 3 months, every 3 months for 1 year, every 6 months for 2 years, and then annually. During follow-up, oncology nurse navigators answer questions, support patients, coordinate care, and educate patients about physical therapy, nutrition, and maintaining health after treatment.

Breast ultrasonography and CA15-3 were performed every 3 months. Mammogram was performed every year. MRI was performed when breast ultrasonography and mammography revealed suspicious data.


  Results Top


The age of our patients ranged from 36 to 58 years (median: 47 years). All patients had tumors located at the upper outer quadrant and closely related to the anterior axillary fold. Most of the patients in this study were diagnosed as having infiltrating ductal carcinoma (14 patients, 77.7%). The size of the tumor ranged from 0.9 to 3.8 cm. [Table 1] summarizes demographic, clinical, and pathological features of patients in the study.
Table 1 Demographic, clinical, and pathological features of patients in the study (N=18)

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The safety margins of our specimens ranged from 1 to 5 cm; and no involved margin on frozen section. Seroma developed in two (11.1%) patients and was treated by means of frequent aspiration. One patient developed a small firm area along the suture line at 11 months postoperatively and was investigated using ultrasonography and true cut biopsy revealing traumatic fat necrosis that was treated with surgical excision. [Table 2] summarizes technique-related complications.
Table 2 Technique-related complication (N=18)

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The cosmetic appearance was evaluated at 6 months postoperatively. Twelve (66.6%) patients showed excellent results, five (27.7%) women showed good results, one (5.5%) patient showed satisfactory result, and no patient showed poor result.

No local recurrence or systemic metastasis was noticed in our patients during a median follow-up period of 38 months (range: 27–49 months).


  Discussion Top


Most of the breast tumors occur at the upper outer quadrant [12],[13],[14]. Therefore, upper quadrant techniques are commonly used in patients undergoing surgeries. Lateral mammoplasty technique is the most famous one used for the treatment of tumor located in the upper quadrant. One of the major complications of the lateral mammoplasty is obvious scar and nipple deviation [16],[17]. Our incision is completely present laterally; hence, it gives better cosmetic appearance, and nipple deviation is less commonly to occur. Obtaining negative margin is an essential requirement to decrease tumor recurrence and prevent conversion to mastectomy [18],[19],[20]; our technique allows complete excision of a large tumor with safety margin and reexcision was not required. Local recurrence did not occur after a median follow-up period of 38 months (range: 27–49 months).

The oncological safety of this approach over a longer period of follow-up is going to be addressed in another publication

Finally, the advantages of this technique over different techniques used in this site are as follows: it is a very simple technique, with good cosmetic appearance and an easy learning curve, and allows easy axillary dissection.


  Conclusion Top


The lazy lateral technique is a novel approach for surgical treatment of upper outer quadrant breast cancer near anterior axillary fold. It is oncologically safe procedure and promotes satisfactory esthetic outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Veronesi U, Saccozzi R, del Vecchio M. Comparing radical mastectomy with quad-rantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast. N Engl J Med 1981; 305:6–11.  Back to cited text no. 5
    
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Clough K, Kaufmann G, Nos C. Improving breast cancer surgery: a classifica-tion and quadrant per quadrant atlas for oncoplastic surgery. Ann Surg Oncol 2010; 17:1375–1391.  Back to cited text no. 10
    
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White J, Achuthan R, Turton P, Lansdown M. Breast conservation surgery: state of the art. Int J Breast Cancer 2011; 2011:107981.  Back to cited text no. 11
    
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Lee A. Why is carcinoma of the breast more frequent in the upper outer quadrant? A case series based on needle core biopsy diagnoses. Breast 2005; 14:151–152.  Back to cited text no. 13
    
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Darbre P. Recorded quadrant incidence of female breast cancer in Great Britain suggests a disproportionate increase in the upper outer quadrant of the breast. Anticancer Res 2005; 25:2543–2550.  Back to cited text no. 14
    
15.
Giacalone L, Dubon O, Roger P. Doughnut mastopexy lumpectomy versus standard lumpectomy in breast cancer surgery: a prospective study Eur J Surg Oncol 2007; 33:301–306.  Back to cited text no. 15
    
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Veronesi U, Volterrani F, Luini A. Quadrantectomy vs. lumpectomy for small size breast cancer. Eur J Cancer 1990; 26:671–673.  Back to cited text no. 16
    
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Fisher B, Redmond C, Poisson R. Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1989; 320:822–828.  Back to cited text no. 17
    
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Hussein O, El-Khodary T. Diamond mammoplasty as a part of conservative management of breast cancer: description of a new technique. Int J Surg Case Rep 2012; 3:203–206.  Back to cited text no. 19
    
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Chakravorty A, Shrestha A, Sanmugalingam N. How safe is oncoplastic breast conservation? Comparative analysis with standard breast conserving surgery. Eur J Surg Oncol 2012; 38:395–398.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Aim
Patients and methods
Results
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