Tuesday, 2 April 2019

[Comment] Assessment of breast cancer risk: which tools to use?

by Montserrat Garcia-Closas, Nilanjan Chatterjee  

The Lancet Oncology: Comment, Volume 20 issue 4, p.463-464, April 01 2019

Risk-assessment tools are used in routine clinical practice to identify women at increased risk of breast cancer and to inform counselling about lifestyle changes, genetic testing, screening timing or modality, and eligibility for risk-reducing drugs or surgery. In The Lancet Oncology, Mary Beth Terry and colleagues1 report a comparative validation of four models—the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm model (BOADICEA), BRCAPRO, the Breast Cancer Risk Assessment Tool (BCRAT), and the International Breast Cancer Intervention Study model (IBIS)—used in clinical practice to provide absolute risk estimates for breast cancer on the basis of different sets of factors.

Theories of Etiopathogenesis of Breast Implant–Associated Anaplastic Large Cell Lymphoma

by Rastogi, Pratik; Riordan, Edward; Moon, David; Deva, Anand K.  

Plastic and Reconstructive Surgery: March 2019 - Volume 143 - Issue 3S - p 23S–29S

Summary: Breast implant–associated anaplastic large cell lymphoma is a malignancy of T lymphocytes that is associated with the use of textured breast implants in both esthetic and reconstructive surgeries. Patients typically present with a delayed seroma 8–10 years following implantation or—less commonly—with a capsular mass or systemic disease. Current theories on disease pathogenesis focus on the interplay among textured implants, Gram-negative bacteria, host genetics, and time. The possible roles of silicone leachables and particles have been less well substantiated. This review aims to synthesize the existing scientific evidence regarding breast implant–associated anaplastic large cell lymphoma etiopathogenesis.

Utility of Two Surgical Techniques Using a Lateral Intercostal Artery Perforator Flap after Breast-Conserving Surgery: A Single-Center Retrospective Study

Kim, Jae Bong; Eom, Jeung Ryeol; Lee, Jeong Woo; Lee, Jeeyeon; Park, Ho Yong; Yang, Jung Dug  

Plastic and Reconstructive Surgery: March 2019 - Volume 143 - Issue 3 - p 477e–487e

Background: Immediate partial breast reconstruction after breast-conserving surgery has become a new paradigm in treating breast cancer. Among the volume replacement techniques used for small to moderate-sized breasts, the perforator flap method has many advantages. The authors present anatomical studies and two surgical techniques using lateral intercostal artery perforator flaps. Methods: Data from 40 patients who underwent breast reconstruction using the lateral intercostal artery perforator flap between January of 2011 and June of 2016 were included. The authors conducted comparative analyses of the propeller flap and the turnover flap. They used three-dimensional computed tomography in lateral intercostal artery perforator flap anatomical studies, analyzing the distribution probability of the dominant perforator, the vertical distance from the axillary fold, and the horizontal distance from the anterior border of the latissimus dorsi.
Results: The most dominant perforator used for lateral intercostal artery perforator flaps was the sixth lateral intercostal artery perforator (43.6 percent of cases), followed by the seventh lateral intercostal artery perforator (39.1 percent of cases); their mean distances from the latissimus dorsi and the axillary folds were determined and reported. Complications included three cases requiring additional treatment for fat necrosis (propeller method, two cases; turnover method, one case) and venous congestion in only two cases that used the propeller method. Cosmetic satisfaction was 90 percent or greater for both techniques, indicating that results were rated as either excellent or good. Conclusion: The authors believe that their study results can broaden the application of partial breast reconstruction by using the lateral intercostal artery perforator flap after breast-conserving surgery, with three-dimensional computed tomography for anatomical studies, and using one of the authors’ two described surgical techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The changes of quality of life and their correlations with psychosocial factors following surgery among women with breast cancer from the post-surgery to post-treatment survivorship

by Fei-Hsiu Hsiao, Wen-Hung Kuo, Guey-Mei Jow, Ming-Yang Wang, King-Jen Chang, Yu-Ming Lai, Yu-Ting Chen, Chiun-Sheng Huang

The Breast: April 2019, Volume 44, pages 59-65

This 14-month study aimed to examine the changes of quality of life following breast cancer surgery and associations of such changes with depression and anxiety levels, and protective factors (attachment styles in close relationship, and meaning in life) based on positive psychology theory.

Tackling the diversity of breast cancer related lymphedema: Perspectives on diagnosis, risk assessment, and clinical management

by Anna Michelotti, Marco Invernizzi, Gianluca Lopez, Daniele Lorenzini, Francesco Nesa, Alessandro De Sire, Nicola Fusco  

The Breast: April 2019, Volume 44, Pages 15-23

Breast cancer related lymphedema (BCRL) develops as a consequence of surgical treatment and/or radiation therapy in a significant number of breast cancer patients. The etiology of this condition is multifactorial and has not yet been completely elucidated. Risk factors include high body mass index, radical surgical procedures (i.e. mastectomy and axillary lymph node dissection), number of lymph nodes removed and number of metastatic lymph nodes, as well as nodal radiation, and chemotherapy. However, these predisposing factors explain only partially the BCRL occurrence, suggesting the possible involvement of individual determinants.

Risk factors for metachronous contralateral breast cancer: A systematic review and meta-analysis

by Delal Akdeniz, Marjanka K. Schmidt, Caroline M. Seynaeve, Danielle McCool, Daniele Giardiello, Alexandra J. van den Broek, Michael Hauptmann, Ewout W. Steyerberg, Maartje J. Hooning  

The Breast: April 2019, Volume 44, pages 1-14

The risk of developing metachronous contralateral breast cancer (CBC) is a recurrent topic at the outpatient clinic. We aimed to provide CBC risk estimates of published patient, pathological, and primary breast cancer (PBC) treatment-related factors.

Current Risk Estimate of Breast Implant–Associated Anaplastic Large Cell Lymphoma in Textured Breast Implants

 by Collett, David J.; Rakhorst, Hinne; Lennox, Peter; Magnusson, Mark; Cooter, Rodney; Deva, Anand K.  

Plastic and Reconstructive Surgery: March 2019 - Volume 143 - Issue 3S - p 30S–40S

Background: With breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) now accepted as a unique (iatrogenic) subtype of ALCL directly associated with textured breast implants, we are now at a point where a sound epidemiologic profile and risk estimate are required. The aim of this article is to provide a comprehensive and up-to-date global review of the available epidemiologic data and literature relating to the incidence, risk, and prevalence of BIA-ALCL. Methods: All current literature relating to the epidemiology of BIA-ALCL was reviewed. Barriers relating to sound epidemiologic study were identified, and trends relating to geographical distribution, prevalence of breast implants, and implant characteristics were analyzed. Results: Significant barriers exist to the accurate estimate of both the number of women with implants (denominator) and the number of cases of BIA-ALCL (numerator), including poor registries, underreporting, lack of awareness, cosmetic tourism, and fear of litigation. The incidence and risk of BIA-ALCL have increased dramatically from initial reports of 1 per million to current estimates of 1/2,832, and is largely dependant on the “population” (implant type and characteristics) examined and increased awareness of the disease.
Conclusions: Although many barriers stand in the way of calculating accurate estimates of the incidence and risk of developing BIA-ALCL, steady progress, international registries, and collegiality between research teams are for the first time allowing early estimates. Most striking is the exponential rise in incidence over the last decade, which can largely be explained by the increasingly specific implant subtypes examined—driven by our understanding of the pathologic mechanism of the disease. High-textured high-surface area implants (grade 4 surface) carry the highest risk of BIA-ALCL (1/2,832).

Breast Implant Illness: A Way Forward

by Magnusson, Mark R.; Cooter, Rod D.; Rakhorst, Hinne; McGuire, Patricia A.; Adams, William P. Jr; Deva, Anand K.

Plastic and Reconstructive Surgery: March 2019 - Volume 143 - Issue 3S - p 74S–81S

Summary: The link between breast implants and systemic disease has been reported since the 1960s. Although many studies have looked at either supporting or refuting its existence, the issue still persists and has now been labeled “breast implant illness.” The rise of patient advocacy and communication through social media has led to an increasing number of presentations to plastic surgeons. This article summarizes the history of breast implants and systemic disease, critically analyzes the literature (and any associated deficiencies), and suggests a way forward through systematic scientific study.

Thursday, 28 February 2019

Predictable Location of Breast Sensory Nerves for Breast Reinnervation

 by Knackstedt, Rebecca; Gatherwright, James; Cakmakoglu, Cagri; Djohan, Michelle; Djohan, Risal  

Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 393–396

Summary: The sensory innervation to the breast originates from the medial and lateral cutaneous branches of the third to fifth intercostal nerves, which are at risk for injury or loss during mastectomy. Providing reinnervation after mastectomy was introduced almost 20 years ago, but it is not widely performed, perhaps because of the difficulty of locating a recipient nerve. The authors have performed cadaveric dissections to allow for precise anatomical localization of the lateral intercostal branch providing breast sensation. Bilateral chest dissections were performed on 10 female cadavers. The lateral intercostal nerve providing sensation to breast tissue was identified. The distances from the sternum, the midclavicular line, and the lateral pectoralis minor—in addition to nerve diameter—were measured. The nerve was successfully identified bilaterally in all cadavers. The majority of nerves (16 of 20) exited from under the fourth rib. The average distance from the sternum was 13.1 ± 1.3 cm (range, 10 to 15 cm) and the average distance from the midclavicular line was 11.8 ± 2.2 cm (range, 8 to 16 cm). The nerve exited at the lateral border of the pectoralis minor or within 2 cm from the lateral border for all cadavers. The diameter of the nerve was consistently 2 mm. The nerve traveled under the thoracodorsal vessels, aiding in identification. The authors identified the predictable location of the lateral intercostal nerve providing sensation to the breast. The authors hope that by enabling surgeons to locate this nerve, more well-conducted studies will be performed investigating techniques and outcomes for breast reinnervation.

Proliferative Lesions Found at Reduction Mammaplasty: Incidence and Implications in 995 Breast Reductions

 by Mastroianni, Melissa; Lin, Alex; Hughes, Kevin; Colwell, Amy S.

Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 271e–275e

Background: Reduction mammaplasty relieves symptomatic macromastia. Pathologic specimens occasionally reveal unsuspected proliferative lesions or carcinoma. Few studies examine the incidence, risk factors, and outcomes in this population.
Methods: A retrospective review was performed between 2000 and 2012. The pathologic condition was categorized as benign, proliferative, or cancer.
 Results: Five hundred seventy-two patients underwent 995 reduction mammaplasties. Cancer was detected in 23 specimens (2.3 percent) and proliferative lesions were detected in 137 (13.8 percent). Compared with patients with benign pathologic findings, patients with proliferative lesions or cancer were older (p < 0.001), had greater body mass index (p = 0.003), had increased unilateral procedures (p < 0.001), and more had history of cancer (p < 0.001). On multivariable regression analysis, age (OR, 1.058; 95 percent CI, 1.040 to 1.077; p < 0.001) and prior breast cancer (OR, 2.070; 95 percent CI, 1.328 to 3.227, p = 0.001) were independent risk factors for proliferative lesions, and age significantly predicted cancer (OR, 1.054; 95 percent CI, 1.012 to 1.097; p = 0.010). Forty-one percent of patients with proliferative lesions and no history of cancer had a change in management. If there was a history of cancer, 54 percent had a change in management.
Conclusions: Proliferative lesions of the breast may be more common than previously reported. Age and a history of breast cancer increase the risk for proliferative lesions. All should be referred to oncology, as nearly half of these patients will have a change in management. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Optimizing DIEP Flap Insetting for Immediate Unilateral Breast Reconstruction: A Prospective Cohort Study of Patient-Reported Aesthetic Outcomes

 by Razzano, Sergio; Marongiu, Francesco; Wade, Ryckie; Figus, Andrea  

Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 261e–270e

Background: To improve the aesthetic outcome of deep inferior epigastric perforator (DIEP) flap breast reconstruction, flaps should be tailored to the patient’s characteristics. A single method of DIEP flap insetting will not suffice for all women seeking breast reconstruction. The authors share the outcomes of a prospective longitudinal study on DIEP flap insetting and present an algorithm for reconstruction.
Methods: Over 4 years, 70 consecutive immediate unilateral DIEP flap breast reconstructions were prospectively evaluated. DIEP insetting was based on the characteristics of the donor site and contralateral breast, according to the authors’ algorithm. Baseline and outcome data were collected. Aesthetic outcomes were evaluated by a panel of three independent assessors, and patient-reported outcomes were quantified using the BREAST-Q at 1 year after reconstruction.
Results: Seventy women underwent reconstruction. There were no total or partial flap failures, four cases of fat necrosis, and 14 revision operations. Women reported a mean overall BREAST-Q score of 82 of 100, representing excellent satisfaction but poor satisfaction with sexual well-being. BREAST-Q scores were not associated with age or body mass index. Fat necrosis reduced satisfaction with the chest (absolute mean reduction, 13; 95 percent CI, 8 to 18; p = 0.002). Independent assessors scored the outcomes favorably, but there was no agreement between surgeons, nurses, and lay assessors. Conclusions: The authors’ algorithm can support surgeons in selecting individually tailored DIEP flap insetting to achieve excellent aesthetic outcomes. Further research is needed as to the relevance of scores from BREAST-Q in relation to interventions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Objective Methods for Breast Sensibility Testing

by Kostidou, Eleni; Schmelz, Martin; Hasemaki, Natasha; Kokotis, Panagiotis  

Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 398–404

Background: The breast and the factors that affect the sensitivity of the nipple-areola complex have been a significant subject of study in recent years. The main purpose of this study was to provide an objective assessment of the effect of volumetric differences on nipple-areola complex sensitivity. Methods: Data were collected examining the right breast of 34 female volunteers. The mechanosensitive Aβ-fiber and mechanoinsensitive C-fiber function of the nipple-areola complex was assessed after mechanical and chemical stimulation, respectively. Flare responses were elicited chemically by the application of histamine by means of iontophoresis and recorded by laser Doppler imaging. The correlation of the maximum flare area responses with the breast volume and nipple-areola complex and the response from the von Frey fiber test was estimated using linear regression analysis.
Results: Nipple-areola complex area increased with breast volume and, similarly, the area of histamine-induced axon reflex flare response follows the larger nipple-areola complex. However, a larger nipple-areola complex correlated with higher local mechanical thresholds. Higher mechanical thresholds were linked to smaller axon reflex area, suggesting combined small- and thick-fiber neuropathy.
Conclusions: Objective small-fiber assessment using laser Doppler imaging and subjective mechanical threshold tests were used successfully to quantify function of Aβ and C fibers in the nipple-areola complex. Increased breast volume was linked to larger nipples, but also to impairment of Aβ and C fibers. Sensory testing can be incorporated into preoperative and postoperative management of patients undergoing breast operations to assess changes of neuronal function of the nipple-areola complex after surgery.

Sexuality, a topic that surgeons should discuss with women before risk-reducing mastectomy and breast reconstruction

 by Rieky E.G. Dikmans, Tim C. van de Grift, Mark-Bram Bouman, Andrea L. Pusic, Margriet G. Mullender

The Breast: February 2019, Volume 43, Pages 120-122

While sexual health is an important aspect of quality of life, sexual issues usually go unaddressed during patient-provider communication. Breast cancer treatments and specifically breast surgery impact women's sexual well-being. However, women do not receive adequate information on this subject. Women who underwent prophylactic mastectomy and breast reconstruction invariably reported that they had underestimated the impact of mastectomy and reconstruction on their sexuality, and expressed a need for information and creating realistic expectations pertaining to sexuality.

Estimation of the benefit and harms of including clinical breast examination in an organized breast screening program

 by Huan Jiang, Stephen D. Walter, Patrick Brown, Parminder Raina, Anna M. Chiarelli

The Breast: February 2019, Volume 43, Pages 105-112

There is controversy about the value of clinical breast examination (CBE) in addition to mammography for breast screening. The study investigates the associations between risk factors such as mammographic density, hormone therapy use and family history and the effectiveness of screening mammography with or without CBE.

Phyllodes tumors of the breast. The treatment results for 340 patients from a single cancer centre

 by J.W. Mitus, P. Blecharz, J. Jakubowicz, M. Reinfuss, T. Walasek, W. Wysocki  

The Breast: February 2019, Volume 43, Pages 85-90

The primary treatment of choice for patients with phyllodes tumor of the breast (PTB) is surgery. Two major problems regarding the treatment of such patients remain unclear: what is the appropriate surgical margin and what role is played by adjuvant radiotherapy (ART).

Why upfront use of CDK inhibitors for the treatment of advanced breast cancer may be wasteful, and how we can increase their value

 by Saroj Niraula  

The Breast: February 2019, Volume 43, Pages 81-84

Three Cyclin Dependent Kinase 4/6 (CDK) inhibitors have been approved by the United Stated Food and Drug Administration for front line treatment of advanced hormone receptor positive breast cancer based on improvements in progression free survival against endocrine monotherapy. Two clinical trials have so far reported results on overall survival but both are negative. CDK inhibitors are usually tolerated well but they do add to inconvenience and cost - for example, grade III-IV neutropenia occur at a frequency of over 60% requiring frequent blood work at least during the initial months of treatment.

EarlyR signature predicts response to neoadjuvant chemotherapy in breast cancer

 by Steven A. Buechler, Yesim Gökmen–Polar, Sunil S. Badve  

The Breast: February 2019, Volume 43, Pages 74-80

•EarlyR gene signature uses expression of 5 genes to stratify ER + breast cancer patients by prognosis.
•EarlyR has been previously validated in 2 randomized clinical trials.
•The current study documents the ability of EarlyR to predict pathological complete response (pCR).
•EarlyR predicts survival in NACT-treated ER + patients.
•EarlyR is both a prognostic assay and a predictive assay.

Agreement between digital breast tomosynthesis and pathologic tumour size for staging breast cancer, and comparison with standard mammography

by M. Luke Marinovich, Daniela Bernardi, Petra Macaskill, Anna Ventriglia, Vincenzo Sabatino, Nehmat Houssami  

The Breast: February 2019, Volume 43, Pages 59-66

Tomosynthesis is proposed to improve breast cancer assessment and staging. We compared tomosynthesis and mammography in estimating the size of newly-diagnosed breast cancers.

Implant-Based Breast Reconstruction: Hot Topics, Controversies, and New Directions

by Frey, Jordan D.; Salibian, Ara A.; Karp, Nolan S.; Choi, Mihye

Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 404e–416e

Learning Objectives: After studying this article, the participant should be able to: 1. Evaluate appropriate patients best suited for one- or two-stage alloplastic breast reconstruction. 2. Discuss and apply the unique advantages and disadvantages of scaffold use and different implant types in breast reconstruction to maximize outcomes. 3. Develop a plan for patients undergoing implant-based breast reconstruction requiring postmastectomy radiation therapy. 4. Analyze the evidence with regard to antibiotic prophylaxis in implant-based breast reconstruction. 5. Recognize and critique novel technical and device developments in the field of alloplastic breast reconstruction, enabling appropriate patient selection. Summary: Implant-based, or alloplastic, breast reconstruction is the most common method of breast reconstruction in the United States. Within implant-based reconstruction, many techniques and reconstructive strategies exist that must be tailored for each individual patient to yield a successful reconstruction. Not unexpectedly, many hot topics and controversies in this field have emerged, including stages of reconstruction, use of scaffolds, permanent implant type, strategies for postmastectomy radiation therapy, and antibiotic prophylaxis. In addition, there has been an evolution in technical and device development in recent years. Therefore, plastic surgeons must be on the forefront of knowledge to approach implant-based breast reconstruction in an evidence-based fashion to best treat their patients.

Autologous Breast Reconstruction after Failed Implant-Based Reconstruction: Evaluation of Surgical and Patient-Reported Outcomes and Quality of Life

by Coriddi, Michelle; Shenaq, Deana; Kenworthy, Elizabeth; Mbabuike, Jacques; Nelson, Jonas; Pusic, Andrea; Mehrara, Babak; Disa, Joseph J.  

Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 373–379

Background: There is a subset of patients who initially undergo implant-based breast reconstruction but later change to autologous reconstruction after failure of the implant reconstruction. The purpose of this study was to examine outcomes and quality of life in this group of patients.
Methods: After institutional review board approval, a retrospective chart review of a prospectively maintained database was performed and BREAST-Q surveys were evaluated.
Results: One hundred thirty-seven patients underwent autologous breast reconstruction following failed implant-based reconstruction with 192 total flaps. Failure of implant reconstruction was defined as follows: capsular contracture causing pain and/or cosmetic deformity [n = 106 (77 percent)], dissatisfaction with the aesthetic result [n = 15 (11 percent)], impending exposure of the implant/infection [n = 8 (6 percent)], and unknown [n = 8 (6 percent)]. Complications requiring operative intervention included partial flap loss [n = 5 (3 percent)], hematoma [n = 5 (3 percent)], vascular compromise requiring intervention for salvage [n = 2 (1 percent)], and total flap loss [n = 1 (1 percent)]. Thirty-four patients (23 percent) had BREAST-Q surveys. There was a statistically significant increase in overall outcomes (p < 0.001), satisfaction with appearance of breasts (p < 0.001), psychosocial well-being (p < 0.001), and physical well-being of the chest (p = 0.003). A statistically significant decrease in physical well-being of the abdomen was observed (p = 0.001). Conclusions: Autologous breast reconstruction after failed implant-based reconstruction has an acceptable complication rate and is associated with significantly improved patient satisfaction and quality of life. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.