Thursday, 23 January 2020

Does Breast Implant–Associated ALCL Begin as a Lymphoproliferative Disorder?



by Kadin, Marshall E.; Adams, William P. Jr.; Inghirami, Giorgio; Di Napoli, Arianna 

Plastic and Reconstructive Surgery: January 2020 - Volume 145 - Issue 1 - p 30e-38e

Summary: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has been included as a provisional entity in the revised version of the World Health Organization Classification of Tumors of Haematopoietic and Lymphoid Tissue. To increase opportunities to intervene with early diagnosis, treatment, and possible prevention, it is important to consider that BIA-ALCL may evolve from a preexisting lymphoproliferative disorder characterized by (1) an indolent localized (in situ) disease in approximately 80 percent of reported cases; (2) a requirement for external cytokine stimulation for cell survival; (3) CD30+ cells in some clinically benign seromas/capsules; (4) undetected T-cell clonality in some cases; (5) JAK/STAT mutations in only a minority of cases; and (6) cure by capsulectomy and implant removal in most cases. BIA-ALCL resembles CD30+ cutaneous lymphoproliferative disorder: ALK−, CD30+ anaplastic cells with an aberrant T-cell phenotype; overexpression of oncogenes (JUNB, SATB1, pSTAT3, SOCS3) in lymphomatoid papulosis; frequent apoptosis; complete spontaneous regression in lymphomatoid papulosis; and partial spontaneous regression in cutaneous ALCL. Unlike CD30+ cutaneous lymphoproliferative disorder, BIA-ALCL cannot be readily observed over time to study the different steps in progression to ALCL. BIA-ALCL also shares features of lymphomas of mucosa-associated lymphoid tissue, which are clinically indolent, initially localized, antigen driven, and caused by Gram-negative bacteria. Further studies of cytokines, clonality, mutations, and other biomarkers are needed to identify possible premalignant steps in the evolution of benign late seromas to BIA-ALCL.

Outcomes of DIEP Flap and Fluorescent Angiography: A Randomized Controlled Clinical Trial



by Varela, Ramon; Casado-Sanchez, Cesar; Zarbakhsh, Shirin; Diez, Jesus; Hernandez-Godoy, Juan; Landin, Luis

Plastic and Reconstructive Surgery: January 2020 - Volume 145 - Issue 1 - p 1-10

Background: Breast reconstruction with the deep inferior epigastric perforator (DIEP) flap can be associated with complications such as fat necrosis. The authors’ objective was to assess the safety and efficacy of fluorescent angiography with indocyanine green to reduce fat necrosis. Methods: The authors designed a parallel, randomized, controlled clinical trial for unilateral breast reconstruction. The poorly vascularized tissues of the DIEP flap were removed based on a clinical evaluation in group 1 and based on angiographic criteria in group 2. The authors recorded the flap dimensions, perfusion in terms of fluorescence intensity, complications, reoperations, and BREAST-Q questionnaire scores for both groups. Results: The study included a total of 51 patients. The flaps showed no size differences after the tissue was excised. The flaps of group 2 presented higher perfusion rates (p = 0.001). The incidence of fat necrosis was 59.3 percent in group 1 and 8.3 percent in group 2 (p = 0.001). Four cases of partial necrosis were recorded in group 1 (18.2 percent) compared with none in group 2 (0 percent) (p = 0.131). Four patients underwent reoperation in group 1 (14.8 percent) compared with none in group 2 (0 percent) (p = 0.113). The patients in group 2 reported higher scores in all domains of the BREAST-Q. Conclusions: Fluorescent angiography with indocyanine green significantly reduced the incidence of fat necrosis without diminishing the flaps’ dimensions. The perfusion rates were significantly higher and the patients reported significantly greater satisfaction and quality of life. Fluorescent angiography with indocyanine green may be considered a safe and effective tool to enhance the outcomes of breast reconstruction with the DIEP flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Adjuvant denosumab in early breast cancer (D-CARE): an international, multicentre, randomised, controlled, phase 3 trial


by Robert Coleman, Dianne M Finkelstein, Carlos Barrios, Miguel Martin, Hiroji Iwata, Roberto Hegg, John Glaspy, Alvaro Montaño Periañez, Katia Tonkin, Ines Deleu, Joohyuk Sohn, John Crown, Suzette Delaloge, Tian Dai, Ying Zhou, Danielle Jandial, Arlene Chan

The Lancet Oncology ARTICLES| VOLUME 21, ISSUE 1, P60-72, JANUARY 01, 2020

Background
Denosumab is a fully human monoclonal antibody that binds to, and inhibits, the receptor activator of RANKL (TNFSF11) and might affect breast cancer biology, as shown by preclinical evidence. We aimed to assess whether denosumab combined with standard-of-care adjuvant or neoadjuvant systemic therapy and locoregional treatments would increase bone metastasis-free survival in women with breast cancer.
Method
In this international, double-blind, randomised, placebo-controlled, phase 3 study (D-CARE), patients were recruited from 389 centres in 39 countries. We enrolled women (aged ≥ 18 years) with histologically confirmed stage II or III breast cancer and an Eastern Cooperative Oncology Group performance status of 0 or 1. On eligibility confirmation, investigators at each site telephoned an interactive voice response system to centrally randomly assign patients (1:1) based on a fixed stratified permuted block randomisation list (block size 4) to receive either denosumab (120 mg) or matching placebo subcutaneously every 3–4 weeks, starting with neoadjuvant or adjuvant chemotherapy, for about 6 months and then every 12 weeks for a total duration of 5 years. Stratification factors were breast cancer therapy, lymph node status, hormone receptor and HER2 status, age, and geographical region. The primary endpoint was the composite endpoint of bone metastasis-free survival. This trial is registered with ClinicalTrials.govNCT01077154.
Findings
Between June 2, 2010, and Aug 24, 2012, 4509 women were randomly assigned to receive denosumab (n=2256) or placebo (n=2253) and included in the intention-to-treat analysis. The primary analysis of the study was done when all patients had the opportunity to complete 5 years of follow-up with an analysis data cutoff date of Aug 31, 2017. The primary endpoint of bone metastasis-free survival was not significantly different between the groups (median not reached in either group; hazard ratio 0·97, 95% CI 0·82–1·14; p=0·70). The most common grade 3 or worse treatment-emergent adverse events, reported in patients who had at least one dose of the investigational product (2241 patients with denosumab vs 2218 patients with placebo), were neutropenia (340 [15%] vs 328 [15%]), febrile neutropenia (112 [5%] vs 142 [6%]), and leucopenia (62 [3%] vs 61 [3%]). Positively adjudicated osteonecrosis of the jaw occurred in 122 (5%) of 2241 patients treated with denosumab versus four (<1 152="" 2218="" 82="" acute="" and="" consciousness.="" deaths="" depressed="" due="" group="" hypocalcaemia="" in="" leukaemia="" level="" myeloid="" o:p="" occurred="" of="" patients="" placebo="" the="" to="" treated="" treatment-emergent="" treatment-related="" two="" versus="" with="">
Interpretation
Despite preclinical evidence suggesting RANKL inhibition might delay bone metastasis or disease recurrence in patients with early-stage breast cancer, in this study, denosumab did not improve disease-related outcomes for women with high-risk early breast cancer.
Funding
Amgen.

[Articles] Atezolizumab plus nab-paclitaxel as first-line treatment for unresectable, locally advanced or metastatic triple-negative breast cancer (IMpassion130): updated efficacy results from a randomised, double-blind, placebo-controlled, phase 3 trial



by Peter Schmid, Hope S Rugo, Sylvia Adams, Andreas Schneeweiss, Carlos H Barrios, Hiroji Iwata, Véronique Diéras, Volkmar Henschel, Luciana Molinero, Stephen Y Chui, Vidya Maiya, Amreen Husain, Eric P Winer, Sherene Loi, Leisha A Emens, IMpassion130 Investigators

The Lancet Oncology: ARTICLES| VOLUME 21, ISSUE 1, P44-59, JANUARY 01, 2020

Consistent with the first interim analysis, this second interim overall survival analysis of IMpassion130 indicates no significant difference in overall survival between the treatment groups in the intention-to-treat population but suggests a clinically meaningful overall survival benefit with atezolizumab plus nab-paclitaxel in patients with PD-L1 immune cell-positive disease. However, this positive result could not be formally tested due to the prespecified statistical testing hierarchy. For patients with PD-L1 immune cell-positive metastatic triple-negative breast cancer, atezolizumab plus nab-paclitaxel is an important therapeutic option in a disease with high unmet need.

Breast Implant Illness: Are Social Media and the Internet Worrying Patients Sick?



by Adidharma, Widya; Latack, Kyle R.; Colohan, Shannon M.; Morrison, Shane D.; Cederna, Paul S. 

Plastic and Reconstructive Surgery: January 2020 - Volume 145 - Issue 1 - p 225e-227e

Physicians are seeing an increase in breast implant illness, a phrase describing ill-defined symptoms attributed to breast implants.1,2 Because of extensive media attention on breast implant-related issues, it is understandable why patients may confuse breast implant illness with other breast implant-related diagnoses, including breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a type of non-Hodgkin lymphoma.3,4 Given the increasing role of online media in disseminating medical information, understanding information regarding breast implant illness on such platforms and how it impacts patients’ understanding of breast implant illness may inform physicians how to more effectively communicate with their patients.3 In this study, we assessed Google Trends and Twitter content to identify catalysts to the increased incidence of breast implant illness…

A Nipple-Areola Stencil for Three-Dimensional Tattooing: Nipple by Number



by Azouz, Solomon; Swanson, Marco; Omarkhil, Mirwais; Rebecca, Alanna 

Plastic and Reconstructive Surgery: January 2020 - Volume 145 - Issue 1 - p 38-42

Summary: Medical tattooing is a critical reconstructive component in women following mastectomy. Recently, novel three-dimensional tattooing techniques mimicking depth by using light and shadow principles have allowed for aesthetically superior results. However, results are variable between providers, and professionals skilled in tattooing are often inaccessible to patients. To assess the need and obtain more background information regarding current practices, the authors recorded survey results from 753 plastic and reconstructive surgery offices. Results showed that 23 percent of facilities that offer reconstruction do not perform or refer for nipple-areola complex tattooing, leaving the patients to seek the service on their own. In this article, the authors present the nipple-by-number device, a three-dimensionally–printed stencil to ensure an accurate, consistent, and personalized aesthetic result during three-dimensional nipple-areola complex tattooing. The nipple-by-number device permits the plastic surgeon or supervised treating specialist to inexpensively, efficiently, and expeditiously perform the three-dimensional nipple-areola complex tattooing in their office. Furthermore, the device gives the patients the option of having their premorbid nipple-areola complex anatomy restored through preoperative photographs or choosing a different nipple-areola complex from a catalogue of designs. The device can be applied on any reconstructed breast mound whether or not a nipple projection procedure has been performed.

Tuesday, 17 December 2019

Preliminary Results Supporting the Bacterial Hypothesis in Red Breast Syndrome following Postmastectomy Acellular Dermal Matrix– and Implant-Based Reconstructions



by Danino, Michel A.; El Khatib, Arij M.; Doucet, Ophélie; Dao, Lan; Efanov, Johnny I.; Bou-Merhi, Joseph S.; Iliescu-Nelea, Monica

Plastic and Reconstructive Surgery: December 2019 - Volume 144 - Issue 6 - p 988e-992e

Summary: Acellular dermal matrices have become a mandatory tool in reconstructive breast surgery. Since their introduction, they have been considered to be nonreactive and nonimmunogenic scaffolds. However, some patients who undergo implant-based breast reconstruction with acellular dermal matrices develop postoperative cutaneous erythema overlying their matrices, a condition commonly referred to as red breast syndrome. The aim of this study was to gain a better understanding of this phenomenon. An analysis was conducted on consecutive patients who underwent acellular dermal matrix– and implant-based breast reconstructions and developed red breast syndrome that was treated surgically between April of 2017 and June of 2018 at the authors’ institution. During surgery, 1-cm2 specimens of acellular dermal matrix were sampled and analyzed by scanning electron microscopy. Observations were charted to score and record the presence and thickness of biofilm, and for identification of bacteria. These measurements were performed using Adobe Photoshop CS6 Extended software. Six postmastectomy breast reconstruction patients were included, all with AlloDerm Ready-to-Use–based reconstructions. All specimens were colonized by various bacteria ranging from Gram-negative bacilli to Gram-positive microorganisms. Biofilm was present in all studied specimens. The cause of skin erythema overlying acellular dermal matrix grafts, and the so-called red breast syndrome, may be related to contamination with various bacteria. Although contamination was omnipresent in analyzed samples, its clinical significance is variable. Even if acellular dermal matrix–based reconstructions are salvaged, this could come at the price of chronic local inflammation.

Infections following Immediate Implant-Based Breast Reconstruction: A Case-Control Study over 11 Years



by Banuelos, Joseph; Sabbagh, M. Diya; Roh, Si-Gyun; Nguyen, Minh-Doan T.; Lemaine, Valerie; Tran, Nho V.; Jacobson, Steven R.; Boughey, Judy C.; Jakub, James W.; Hieken, Tina J.; Degnim, Amy C.; Mandrekar, Jay; Berbari, Elie; Sharaf, Basel

Plastic and Reconstructive Surgery: December 2019 - Volume 144 - Issue 6 - p 1270-1277

Background: Surgical-site infection after implant-based breast reconstruction adversely affects surgical outcomes and increases health care costs. This 11-year case-control study examines risk factors specific for surgical-site infection after immediate tissue expander/implant-based breast reconstruction.
Methods: The authors performed a retrospective review to identify all consecutive patients with breast implant infections between 2006 and 2016. Patients who developed surgical-site infection after immediate tissue expander/implant-based breast reconstruction were included. Surgical-site infection was defined using the Centers for Disease Control and Prevention criteria; specifically, infections requiring hospital admission, intravenous antibiotics, or surgical intervention were included. The authors matched a control patient to each infection case by patient age and date of surgery. Patient demographics, medical comorbidities, and perioperative surgical variables were examined. Univariate and multivariable conditional logistic regression models were constructed. Results: A total of 270 breasts in 252 patients were evaluated. On multivariate analysis, patients with a higher body mass index (OR, 1.1 per 1 body mass index point increase; 95 percent CI, 1.0 to 1.2; p = 0.02), hypertension (OR, 6.5; 95 percent CI, 1.9 to 22.3; p = 0.002), neoadjuvant chemotherapy (OR, 2.6; 95 percent CI, 1.0 to 6.3; p = 0.04), axillary lymph node dissection (OR, 7.1; 95 percent CI, 1.7 to 29.2; p = 0.006), seroma formation (OR, 15.34; 95 percent CI, 3.7 to 62.5; p = 0.0001), and wound healing complications (OR, 23.91; 95 percent CI, 6.1 to 93.4; p < 0.0001) were significantly associated with surgical-site infection.
Conclusions: Women with obesity, women with hypertension, and those treated with neoadjuvant chemotherapy are at increased risk of surgical-site infection. Further risks are also associated with postoperative seroma and wound complications. This may help patient selection and counseling, adjusted based on risk factors regarding complications of immediate implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Systematic Review of the Impact of Acellular Dermal Matrix on Aesthetics and Patient Satisfaction in Tissue Expander-to-Implant Breast Reconstructions



by DeLong, Michael R.; Tandon, Vickram J.; Farajzadeh, Matthew; Berlin, Nicholas L.; MacEachern, Mark P.; Rudkin, George H.; Da Lio, Andrew L.; Cederna, Paul S

Plastic and Reconstructive Surgery: December 2019 - Volume 144 - Issue 6 - p 967e-974e

Background: Acellular dermal matrix is used in most postmastectomy implant-based breast reconstructions in the United States. It is believed to be safe, despite a slightly increased complication rate. Although never established in a unifying study, the primary advantage of acellular dermal matrix is believed to be an enhanced aesthetic result, thus justifying the added expense. The purpose of this study was to assess the aesthetic benefits of acellular dermal matrix in expander-to-implant breast reconstruction.

Methods: A systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology was performed including all original studies examining aesthetic outcomes of expander-to-implant breast reconstructions with acellular dermal matrix compared to muscular coverage. Direct-to-implant and prepectoral studies were excluded from the evaluation. The results were aggregated and reported as a summary.

Results: Among 883 studies identified, 49 full-text articles were reviewed and nine articles ultimately met inclusion criteria. All nine studies were not randomized. Of these, three articles (1448 total patients) evaluated reconstruction aesthetic outcomes by patient satisfaction, whereas six articles evaluated the aesthetic outcomes by external observer (504 total patients). None of the articles evaluating patient satisfaction reported a difference between acellular dermal matrix and muscular reconstruction. Five of the six articles using objective outcomes demonstrated significant improvement in aesthetic outcome in the acellular dermal matrix group.

Conclusions: Although little evidence exists evaluating the aesthetic benefits of acellular dermal matrix for expander-to-implant breast reconstruction, the data suggest that objective observers consider acellular dermal matrix–assisted expander-to-implant breast reconstructions aesthetically superior to reconstruction with only muscular coverage, but patients appear to be equally satisfied with both reconstructive options.

[Articles] Palbociclib plus exemestane with gonadotropin-releasing hormone agonist versus capecitabine in premenopausal women with hormone receptor-positive, HER2-negative metastatic breast cancer (KCSG-BR15-10): a multicentre, open-label, randomised, phase 2 trial



by Yeon Hee Park, Tae-Yong Kim, Gun Min Kim, Seok Yun Kang, In Hae Park, Jee Hyun Kim, Kyoung Eun Lee, Hee Kyung Ahn, Moon Hee Lee, Hee-Jun Kim, Han Jo Kim, Jong In Lee, Su-Jin Koh, Ji-Yeon Kim, Kyung-Hun Lee, Joohyuk Sohn, Sung-Bae Kim, Jin-Seok Ahn, Young-Hyuck Im, Kyung Hae Jung, Seock-Ah Im, Korean Cancer Study Group (KCSG)

The Lancet Oncology: ARTICLES| VOLUME 20, ISSUE 12, P1750-1759, DECEMBER 01, 2019

Exemestane plus palbociclib with ovarian function suppression showed clinical benefit compared with capecitabine in terms of improved progression-free survival in premenopausal patients with hormone receptor-positive, HER2-negative metastatic breast cancer. Palbociclib plus exemestane with ovarian suppression is an active treatment option in premenopausal patients with hormone receptor-positive, HER2-negative metastatic breast cancer who have been pretreated with tamoxifen.

[Comment] Endocrine-based therapy versus chemotherapy in advanced breast cancer



by Marie Robert, Nicholas Turner 

The Lancet Oncology: COMMENT| VOLUME 20, ISSUE 12, P1632-1633, DECEMBER 01, 2019

Approximately 70% of metastatic breast cancers are oestrogen receptor-positive and HER2-negative. International guidelines recommend endocrine therapy as a preferred first-line treatment for oestrogen receptor-positive, HER2-negative metastatic breast cancer, “even in the presence of visceral disease, unless there is a visceral crisis or concern or proof of endocrine resistance”.1 However, several studies have reported that 35–60% of patients in Europe and North America receive chemotherapy as first-line treatment,2,3 especially younger patients and those with visceral disease,4 even though a retrospective study suggested worse outcomes for patients treated with chemotherapy than those treated with endocrine therapy.

[News] Promising radiotherapy classifier for early breast cancer



by Manjulika Das 

The Lancet Oncology: NEWS| VOLUME 20, ISSUE 12, PE665, DECEMBER 01, 2019

A gene expression-based Adjuvant Radiotherapy Intensification Classifier (ARTIC) could differentiate between patients with early breast cancer who would benefit from whole-breast radiotherapy following breast-conserving surgery and those with a higher risk of locoregional recurrence who need more intensive treatment, according to a recent study.

Analysis of the Visual Perception of Female Breast Aesthetics and Symmetry: An Eye-Tracking Study



by Pietruski, Piotr; Paskal, Wiktor; Paskal, Adriana M.; Jaworowski, Janusz; Paluch, Lukasz; Noszczyk, Bartlomiej

Plastic and Reconstructive Surgery: December 2019 - Volume 144 - Issue 6 - p 1257-1266

Background: Because of its subjective character, the term “breast attractiveness” is poorly defined and thus its reliable standardized assessment can be particularly challenging. Because of objective analysis of the observer’s gaze pattern, eye-tracking technology may provide a better insight into the visual perception of breast aesthetics and symmetry.
Methods: One hundred observers, 50 women and 50 men, assessed the aesthetics and symmetry of eight types of female breasts displayed as digital images on frontal, lateral, and oblique projections. The gaze pattern of each observer was recorded using eye-tracking technology, and gaze data were subsequently analyzed.
Results: Although sex and breast type exerted an effect on attention capturing by some areas of interest, key characteristics of gaze patterns in female and male observers were essentially the same. Irrespective of observers’ sex, the longest fixation duration and the highest fixation number were recorded for lower breast regions, in particular, for the nipple-areola complex. Mean fixation duration in this area corresponded to 58 and 57 percent of overall observation time for female and male observers, respectively, during the assessment of breast aesthetics; and to 56 and 52 percent of overall observation time for female and male observers, respectively, during the assessment of breast symmetry.
Conclusions: Nipple-areola complex and lower breast are key focus areas for the assessment of breast aesthetics and symmetry. Gaze data collected during this study may constitute a valuable source of reference values for future eye-tracking research on various patient groups’ visual perception of breast attractiveness and deformities.


Thursday, 24 October 2019

Associations between absolute neutrophil count and lymphocyte-predominant breast cancer



by Chang Ik Yoon, Soeun Park, Yoon Jin Cha, Hye Sun Lee, Soong June Bae, Chihwan Cha, Da Young Lee, Sung Gwe Ahn, Joon Jeong

The Breast, https://doi.org/10.1016/j.breast.2019.09.013

Tumor-infiltrating lymphocytes (TILs) might be associated with host-cell mediated immunity, which could be partly reflected by peripheral blood cell counts. In addition, lymphocyte-predominant breast cancer (LPBC), which was defined as tumors having high TIL levels, showed a favorable prognosis among triple-negative breast cancer or HER2-positive breast cancer. We aimed to investigate whether peripheral blood cell counts are associated with LPBC.

Effect of implementing digital breast tomosynthesis (DBT) instead of mammography on population screening outcomes including interval cancer rates: Results of the Trento DBT pilot evaluation



by Daniela Bernardi, Maria A. Gentilini, Martina De Nisi, Marco Pellegrini, Carmine Fantò, Marvi Valentini, Vincenzo Sabatino, Andrea Luparia, Nehmat Houssami

The Breast, (in press) 2019.09.12

The Trento screening program transitioned to digital breast tomosynthesis (DBT) screening based on evidence that DBT improves breast cancer (BC) detection compared to mammography; an evaluation of the transition to DBT is reported in this pilot study.

Immediate Breast Reconstruction in The Netherlands and the United States: A Proof-of-Concept to Internationally Compare Quality of Care Using Cancer Registry Data



by Kamali, Parisa; van Bommel, Annelotte; Becherer, Babette; Cooter, Rodney; Mureau, Marc A. M.; Pusic, Andrea; Siesling, Sabine; van der Hulst, René R. J. W.; Lin, Samuel J.; Rakhorst, Hinne

Plastic and Reconstructive Surgery: October 2019 - Volume 144 - Issue 4 - p 565e-574e

Background: Studies based on large-volume databases have made significant contributions to research on breast cancer surgery. To date, no comparison between large-volume databases has been made internationally. This is the first proof-of-concept study exploring the feasibility of combining two existing operational databases of The Netherlands and the United States, focusing on breast cancer care and immediate breast reconstruction specifically.313/291
Methods: The National Breast Cancer Organization The Netherlands Breast Cancer Audit (NBCA) (2011 to 2015) and the U.S. Surveillance, Epidemiology, and End Results (SEER) database (2010 to 2013) were compared on structure and content. Data variables were grouped into general, treatment-specific, cancer-specific, and follow-up variables and were matched. As proof-of-concept, mastectomy and immediate breast reconstruction rates in patients diagnosed with invasive breast cancer or ductal carcinoma in situ were analyzed.
Results: The NBCA included 115 variables and SEER included 112. The NBCA included significantly more treatment-specific variables (n = 46 versus 6), whereas the SEER database included more cancer-specific variables (n = 74 versus 26). In patients diagnosed with breast cancer or ductal carcinoma in situ, immediate breast reconstruction was performed in 19.3 percent and 24.0 percent of the breast cancer cohort and 44.0 percent and 35.3 percent of the ductal carcinoma in situ cohort in the NBCA and SEER, respectively. Immediate breast reconstruction rates increased significantly over time in both data sets.
Conclusions: This study provides a first overview of available registry data on breast cancer care in The Netherlands and the United States, and revealed limited data on treatment in the United States. Comparison of treatment patterns of immediate breast reconstruction showed interesting differences. The authors advocate the urgency for an international database with alignment of (treatment) variables to improve quality of breast cancer care for patients across the globe.

[Articles] Endocrine treatment versus chemotherapy in postmenopausal women with hormone receptor-positive, HER2-negative, metastatic breast cancer: a systematic review and network meta-analysis



The Lancet Oncology by Mario Giuliano, Francesco Schettini, Carla Rognoni, Manuela Milani, Guy Jerusalem, Thomas Bachelot, Michelino De Laurentiis, Guglielmo Thomas, Pietro De Placido, Grazia Arpino, Sabino De Placido, Massimo Cristofanilli, Antonio Giordano, Fabio Puglisi, Barbara Pistilli, Aleix Prat, Lucia Del Mastro, Sergio Venturini, Daniele Generali

ARTICLES| VOLUME 20, ISSUE 10, P1360-1369, OCTOBER 01, 2019

In the first-line or second-line setting, CDK4/6 inhibitors plus hormone therapies are better than standard hormone therapies in terms of progression-free survival. Moreover, no chemotherapy regimen with or without targeted therapy is significantly better than CDK4/6 inhibitors plus hormone therapies in terms of progression-free survival. Our data support treatment guideline recommendations involving the new combinations of hormone therapies plus targeted therapies as first-line or second-line treatments, or in both settings, in women with hormone-receptor-positive, HER2-negative metastatic breast cancer.

[News] Pyrotinib versus lapatinib in HER2-positive breast cancer



The Lancet Oncology by Elizabeth Gourd 

NEWS| VOLUME 20, ISSUE 10, PE562, OCTOBER 01, 2019

Patients with previously treated HER2-positive relapsed or metastatic breast cancer have significantly better outcomes when treated with pyrotinib plus capecitabine than with lapatinib plus capecitabine, according to a recent study.

A Simplified Cost-Utility Analysis of Inpatient Flap Monitoring after Microsurgical Breast Reconstruction and Implications for Hospital Length of Stay



by Jablonka, Eric M.; Lamelas, Andreas M.; Kanchwala, Suhail K.; Rhemtulla, Irfan; Smith, Mark L

Plastic and Reconstructive Surgery: October 2019 - Volume 144 - Issue 4 - p 540e-549e

Background: The number of free flap take-backs and successful salvages following microsurgical breast reconstruction decreases as time from surgery increases. As a result, the cost of extended inpatient monitoring to achieve a successful flap salvage rises rapidly with each postoperative day. This study introduces a simplified cost-utility model of inpatient flap monitoring and identifies when cost-utility exceeds the thresholds established for other medical treatments.
Methods: A retrospective review of a prospectively maintained database was performed of patients who underwent microsurgical breast reconstruction to identify flap take-back and salvage rates by postoperative day. The number of patients and flaps that needed to be kept on an inpatient basis each day for monitoring to salvage a single failing flap was determined. Quality-of-life measures and incremental cost-effectiveness ratios for inpatient flap monitoring following microsurgical breast reconstruction were calculated and plotted against a $100,000/quality-adjusted life-year threshold. Results: A total of 1813 patients (2847 flaps) were included. Overall flap take-back and salvage rates were 2.4 percent and 52.3 percent, respectively. Of the flaps taken back, the daily take-back and salvage rates were 56.8 and 60.0 percent (postoperative day 0 to 1), 13.6 and 83.3 percent (postoperative day 2), 11.4 and 40.0 percent (postoperative day 3), 9.1 and 25.0 percent (postoperative day 4), and 9.1 and 0.0 percent (>postoperative day 4), respectively. To salvage a single failing flap each day, the number of flaps that needed to be monitored were 121 (postoperative day 0 to 1), 363 (postoperative day 2), 907 (postoperative day 3), 1813 (postoperative day 4), and innumerable for days beyond postoperative day 4. The incremental cost-effectiveness ratio of inpatient flap monitoring begins to exceed a willingness-to-pay threshold of $100,000/quality-adjusted life-year by postoperative day 2.
Conclusion: The health care cost associated with inpatient flap monitoring following microsurgical breast reconstruction begins to rise rapidly after postoperative day 2.

Bilateral DIEP Flap Breast Reconstruction to a Single Set of Internal Mammary Vessels: Technique, Safety, and Outcomes after 250 Flaps



by Opsomer, Dries; D’Arpa, Salvatore; Benmeridja, Lara; Stillaert, Filip; Noel, Warren; Van Landuyt, Koenraad 

Plastic and Reconstructive Surgery: October 2019 - Volume 144 - Issue 4 - p 554e-564e


Background: The deep inferior epigastric artery perforator (DIEP) flap is considered the gold standard in autologous breast reconstruction. In bilateral cases, both flaps are often anastomosed to the internal mammary vessels on either side of the sternum. The authors propose a method in which both flaps are anastomosed to only the right side internal mammary artery and vein.
Methods: Between November of 2009 and March of 2018, 125 patients underwent bilateral DIEP flap breast reconstruction with this technique. One flap is perfused by the anterograde proximal internal mammary artery and the second one by the retrograde distal internal mammary artery after presternal tunneling. Patient demographics and operative details were reviewed retrospectively. Results: Two hundred fifty flaps were performed. One hundred fifty-two flaps were prophylactic or primary reconstructions (60.8 percent), 70 were secondary reconstructions (28 percent), and 28 were tertiary reconstructions (11.2 percent). Mean patient age was 46 years, and the mean body mass index was 25 kg/m2. Sixty patients underwent radiation therapy or chemotherapy (48 percent). The authors encountered one significant partial failure (0.4 percent) and nine complete flap failures (3.6 percent). The authors did not see a statistically significant predisposition for failure comparing the retrograde with the anterograde flow flaps, nor when comparing the tunneled with the nontunneled flaps.
Conclusions: The authors’ results show that anastomosing both DIEP flaps to a single set of mammary vessels is safe and reliable. The authors conclude that the retrograde flow through the distal internal mammary artery is sufficient for free flap perfusion and that subcutaneous tunneling of a free flap pedicle does not predispose to flap failure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.