New criteria for breast symmetry evaluation after breast conserving surgery for cancer

a prospective study of patients undergoing BCS. These patients were photographed using the same criteria of evaluation. The references points used were the nipple height difference (NH), the nipple-manubrium distances (NM), nipple-sternum distances (NS) and the angle between the intramammary fold and the nipple (nipple angle; NA). ImageJ software was used. Three breast symmetry models were evaluated: excellent/others (model 1), excellent-good/others (model 2) and others/poor (model 3). The ROC curve was used to select acceptable criteria for the evaluation of symmetry. Decision tree model analysis was performed.

Results:

a total of 274 women were evaluated. The BCCT.core result was excellent in 5.8% (16), good in 24.1% (66), fair in 46.4% (127) and poor in 23.7% (65). The difference in NH was associated with good breast area (0.837-0.846); acceptable differences were below 3.1 cm, while unacceptable values were greater than 6.4 cm. Differences in the NM were associated with average breast area (0.709-0.789); a difference in value of less than 4.5 cm was acceptable, while values greater than 6.3 cm were unacceptable. In the decision tree combined model, a good-excellent outcome for patients with differential (d) dNH = 1 (0 to 5.30 cm) and dNM ≠ 3 (<6.28 cm); and for a poor/poor result, values dNM = 3 (> 6.35).

Conclusions:

the results presented here are simple tools that can assist the surgeon for breast symmetry evaluation.

Keywords:
Breast Neoplasms. Conservative Treatment. Mastectomy; Segmental. Body Image. ROC Analysis

	Model	Sensitivity	Specificity	Cut-off	Area under the ROC curve	CI	p
Difference
	1	87.5	69.3	≤ 3.1 cm	0.846	0.774-0.919	<0.0001
Nipple height (NH)	2	92.7	65.4	≤ 5.3 cm	0.844	0.798-0.889	<0.0001
	3	77.8	78.1	≤ 6.4 cm	0.837	0.781-0.894	<0.0001
	1	93.7	42.5	≤ 4.7 cm	0.682	0.580-0.784	0.014
Nipple-manubrium (NM)	2	89.0	47.9	≤ 5.0 cm	0.709	0.648-0.771	<0.0001
	3	83.9	64.6	≤ 6.3 cm	0.789	0.720-0.857	<0.0001
	1	93.7	40.9	≤ 20.2 cm	0.625	0.525-0.724	0.016
Nipple angle (NA)	2	77.8	46.2	≤ 20.2 cm	0.595	0.524-0.666	0.009
	3	66.8	51.6	≤ 20.6 cm	0.583	0.500-0.666	0.050
	1	-	-	-	0.565	0.414-0.716	0.41
Nipple-sternum (NS)	2	-	-	-	0.562	0.486-0.639	0.110
	3	60.1	68.7	≤ 2.2 cm	0.673	0.600-0.746	<0.0001
Contralateral breast shape
Pencil drop angle	1	75.0	81.6	≤ 112^o	0.813	0.689-0.937	<0.0001
	2	72.0	50.7	≤158^o	0.654	0.582-0.726	<0.0001
	3	53.6	75.4	≤144^o	0.634	0.562-0.706	0.001
Nipple angle*	1	100.0	48.4	> 6.9^o	0.736	0.649-0.824	0.002
	2	72.0	57.4	> 8.1^o	0.676	0.607-0745	<0.0001
	3	51.9	70.3	> 9.1^o	0.615	0.539-0.692	0.005
Nipple-manubrium	1	75.0	69.4	≤ 27.8 cm	0.733	0.622-0.845	0.002
	2	82.9	44.4	≤ 32.7 cm	0.652	0.582-0.721	<0.0001
	3	68.9	61.5	≤ 32.1 cm	0.684	0.613-0.756	<0.0001

Model	Points		dNH	dNM
4 points	1	Excellent	3.1 to 0	4.68 to 0
	2	Good	5.30 to 3.32	4.99 to 4.71
	3	Fair	6.40 to 5.36	6.28 to 5.02
	4	Poor	21.66 to 6.46	18.79 to 6.35
3 points	1	Excellent/Good	5.30 to 0	4.99 to 0
	2	Fair	6.40 to 5.36	6.28 to 5.02
	3	Poor	21.66 to 6.46	18.79 to 6.35

Model		Prediction
	Observed	Excellent/good	Fair	Poor	% correct
Simple	Excellent/good	81	0	1	98.8%
	Fair	78	0	45	0
	Poor	16	0	49	75.4%
	% General	64.8%	0%	35.2%	48.1%
Forced	Excellent/good	73	4	5	89.0%
	Fair	51	44	28	35.8%
	Poor	6	17	42	64.6%
	% General	48.1%	24.1%	27.8%	58.9%

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