Friday, 16 September 2016

The Telemark Breast Score: A Reliable Method for the Evaluation of Results after Breast Surgery

The Telemark Breast Score: A Reliable Method for the Evaluation of Results after Breast Surgery

Plastic & Reconstructive Surgery:
September 2016 - Volume 138 - Issue 3 - p 390e–400e

Begic, A; Stark, B

Background: Validated instruments for assessing results after breast surgery are sparse. The authors present here a method used for the past 10 years at their institution for evaluation of outcome after breast-conserving surgery and microsurgical breast reconstruction. Methods: The Telemark Breast Score is a method based on standard two-dimensional photographs assessing the outcome after breast surgery in terms of volume, shape, and symmetry. Three panels comprising two plastic surgeons, two breast surgeons, and two nurses tested the Telemark Breast Score on 346 patients who underwent breast-conserving surgery for cancer and 31 other patients who underwent deep inferior epigastric perforator flap reconstruction. All patients were assessed at least 1 year after their operation. Consistency of agreement between and within the panels was studied. Results: Interobserver and intraobserver reliability was good after consensus discussion. Good rating stability was shown using test-retest measurements. Conclusion: The Telemark Breast Score is an inexpensive, statistically reliable method and can be applied for quality control after breast surgery.

Is Single-Stage Prosthetic Reconstruction Cost Effective? A Cost-Utility Analysis for the Use of Direct-to-Implant Breast Reconstruction Relative to Expander-Implant Reconstruction in Postmastectomy Patients

Is Single-Stage Prosthetic Reconstruction Cost Effective? A Cost-Utility Analysis for the Use of Direct-to-Implant Breast Reconstruction Relative to Expander-Implant Reconstruction in Postmastectomy Patients

Plastic & Reconstructive Surgery:
September 2016 - Volume 138 - Issue 3 - p 537–547

Krishnan NM et al

Background: Prosthetic breast reconstruction is most commonly performed using the two-stage (expander-implant) technique. However, with the advent of skin-sparing mastectomy and the use of acellular dermal matrices, one-stage prosthetic reconstruction has become more feasible. Prior studies have suggested that one-stage reconstruction has economic advantages relative to two-stage reconstruction despite a higher revision rate. This is the first cost-utility analysis to compare the cost and quality of life of both procedures to guide patient care. Methods: A comprehensive literature review was conducted using the MEDLINE, EMBASE, and Cochrane databases to include studies directly comparing matched patient cohorts undergoing single-stage or staged prosthetic reconstruction. Six studies were selected examining 791 direct-to-implant reconstructions and 1142 expander-implant reconstructions. Costs were derived adopting both patient and third-party payer perspectives. Utilities were derived by surveying an expert panel. Probabilities of clinically relevant complications were combined with cost and utility estimates to fit into a decision tree analysis. Results: The overall complication rate was 35 percent for single-stage reconstruction and 34 percent for expander-implant reconstruction. The authors’ baseline analysis using Medicare reimbursement revealed a cost decrease of $525.25 and a clinical benefit of 0.89 quality-adjusted life-year when performing single-stage reconstructions, yielding a negative incremental cost-utility ratio. When using national billing, the incremental cost-utility further decreased, indicating that direct-to-implant breast reconstruction was the dominant strategy. Sensitivity analysis confirmed the robustness of the authors’ conclusions. Conclusions: Direct-to-implant breast reconstruction is the dominant strategy when used appropriately. Surgeons are encouraged to consider single-stage reconstruction when feasible in properly selected patients.

Does the Use of Incisional Negative-Pressure Wound Therapy Prevent Mastectomy Flap Necrosis in Immediate Expander-Based Breast Reconstruction?

Does the Use of Incisional Negative-Pressure Wound Therapy Prevent Mastectomy Flap Necrosis in Immediate Expander-Based Breast Reconstruction?

Plastic & Reconstructive Surgery:
September 2016 - Volume 138 - Issue 3 - p 558–566

Kim, DY et al

Background: Mastectomy flap necrosis is one of the most common and significant complications in immediate expander-based breast reconstruction. Negative-pressure wound therapy is widely used for open wounds but is not commonly used for closed incisional wounds. However, the postoperative use of incisional negative-pressure wound therapy is demonstrated to reduce complication rates. The authors evaluate the incidence of mastectomy flap necrosis in patients with incisional negative-pressure wound therapy after immediate expander-based breast reconstruction compared with the incidence in patients with conventional dressing. Methods: A retrospective review was conducted to identify patients who underwent immediate expander-based breast reconstruction between January of 2010 and February of 2015 at a single institution. Patients were divided into a conventional dressing group and an incisional negative-pressure wound therapy group. Patient demographics, intraoperative findings, and complications were compared between the two groups. Results: A total of 228 breasts (206 patients) were included in this study. Of these, the incisional negative-pressure wound therapy group included 45 breasts (44 patients) and the conventional dressing group included 183 breasts (162 patients). The incisional negative-pressure wound therapy group had a lower overall complication rate (11.1 percent versus 27.9 percent; p = 0.019), overall mastectomy flap necrosis rate (8.9 percent versus 23.5 percent; p = 0.030), and major mastectomy flap necrosis rate (2.2 percent versus 13.7 percent; p = 0.031) compared with the conventional dressing group. Conclusions: Incisional negative-pressure wound therapy reduced the incidence of mastectomy flap necrosis. This simple and reliable dressing technique can be effective in preventing mastectomy flap necrosis in immediate expander-based breast reconstruction. 

The Subtleties of Success in Simultaneous Augmentation-Mastopexy

 The Subtleties of Success in Simultaneous Augmentation-Mastopexy

Plastic & Reconstructive Surgery:
September 2016 - Volume 138 - Issue 3 - p 585–592

Doshier, Laura J et al

Background: Many have challenged the safety of performing breast augmentation and mastopexy simultaneously. However, staging these procedures incurs the increased risk and inconvenience of two periods of anesthesia and recuperation. The authors set out to evaluate the occurrence of complications across the populations of patients undergoing (1) combined augmentation-mastopexy, (2) isolated augmentation, and (3) isolated mastopexy. Methods: A retrospective analysis of one surgeon’s consecutive series of each of these procedures from 2000 to 2009 was conducted. Preoperative risk factors were characterized. Sixteen different complications were examined, and those necessitating operative revision were tracked. Statistical analysis was performed looking for significant differences between the surgical groups. Results: No instances of infection, tissue loss, or implant exposure occurred among the 297 patients over an average follow-up period of 15.5 months. The isolated mastopexy group did not provide sufficient data for statistical comparison. Tissue-related complications were most common in the combined procedure group. The operative revision rate for isolated augmentation was 7.97 percent compared with a combined procedure revision rate of 12.4 percent (p = 0.28). Conclusions: The majority of complications in this series comparing simultaneous augmentation-mastopexy to isolated augmentation were minor. Complications requiring operative revision were not found to be significantly different between the two groups. There was a much lower reoperation rate (12.4 percent) with the combined procedure compared with a 100 percent reoperation rate when the procedure is staged. Thus, the authors feel the combined procedure can safely be part of every plastic surgeon’s practice.

Low risk of recurrence in elderly patients treated with breast conserving therapy in a single institute

Low risk of recurrence in elderly patients treated with breast conserving therapy in a single institute

The Breast December 2016 Volume 30,  Pages 19- 25

van der LeijF et al

To guide decision making in preventing over- or under-treatment in older breast cancer patients who have undergone breast conserving surgery, we analyzed prognostic factors and risk of recurrence in a consecutive series of patients ≥ 65 years old with breast cancer and identified subgroups that may benefit or not from more intensive treatment.

Prognostic significance of preoperative 18F-FDG PET/CT for breast cancer subtypes

Prognostic significance of preoperative 18F-FDG PET/CT for breast cancer subtypes

The Breast December 2016 Volume 30,  Pages 5–12

Higuchi T et al

Adjuvant treatments for operable breast cancers are determined according to subtypes defined based on estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) status. The ER+/HER2− subtype can be divided into luminal A and luminal B usually by Ki67 expression levels. Although tumor size, lymph node metastasis and tumor grade have been widely accepted in daily clinical practice, the identification of further prognostic indicators especially in the ER+/HER2− subtype is warranted.

Therapeutic attitude towards internal mammary chain drainage in patients with breast cancer

Therapeutic attitude towards internal mammary chain drainage in patients with breast cancer

The Breast December 2016 Volume 30, Pages 1–4

García KF et alInternal mammary chain (IMC) is one of the main local lymph drainages in breast cancer. However, internal mammary chain sentinel lymph node biopsy (IMC-SLNB) is not always performed.The purpose of this research is to evaluate the outcomes of IMC-SLNB in our institution from 2008 to 2014. We analyzed 1346 women with breast cancer. Six-hundred twenty-two sentinel node biopsies were carried out, one out of ten in IMC territory. Adjuvant radiotherapy in this area was added when positive.IMC-SLNB is feasible, it may change tumour stage, modify adjuvant therapy and change prognosis in selected patients.

From technological advances to biological understanding: The main steps toward high-precision RT in breast cancer

From technological advances to biological understanding: The main steps toward high-precision RT in breast cancer


The Breast October 2016Volume 29, Pages 213–222
Leonardi MC et al

Radiotherapy improves local control in breast cancer (BC) patients which increases overall survival in the long term. Improvements in treatment planning and delivery and a greater understanding of BC behaviour have laid the groundwork for high-precision radiotherapy, which is bound to further improve the therapeutic index. Precise identification of target volumes, better coverage and dose homogeneity have had a positive impact on toxicity and local control. The conformity of treatment dose due to three-dimensional radiotherapy and new techniques such as intensity modulated radiotherapy makes it possible to spare surrounding normal tissue.

Thursday, 18 August 2016

Race and Breast Cancer Reconstruction: Is There a Health Care Disparity?

Race and Breast Cancer Reconstruction: Is There a Health Care Disparity?
 Plastic and Reconstructive Surgery
Sharma K et al

Background: Racial disparity continues to be a well-documented problem afflicting contemporary health care. Because the breast is a symbol of femininity, breast reconstruction is critical to mitigating the psychosocial stigma of a breast cancer diagnosis. Whether different races have equitable access to breast reconstruction remains unknown. Methods: Two thousand five hundred thirty-three women underwent first-time autologous versus implant-based reconstruction following mastectomy. Information regarding age, smoking, diabetes, obesity, provider, race, pathologic stage, health insurance type, charge to insurance, and socioeconomic status was recorded. Established statistics compared group medians and proportions. A backward-stepwise multivariate logistic regression model identified independent predictors of breast reconstruction type. Results: Compared with whites, African Americans were more likely to be underinsured (p < 0.01), face a lesser charge for reconstruction (p < 0.01), smoke (p < 0.01), have diabetes (p < 0.01), suffer from obesity (p < 0.01), live in a zip code with a lower median household income (p < 0.01), and undergo autologous-based reconstruction (p = 0.01). On multivariate analysis, only African American race (OR, 2.23; p < 0.01), charge to insurance (OR, 1.00; p < 0.01), and provider (OR, 0.96; p < 0.01) independently predicted type of breast reconstruction, whereas age (OR, 1.02; p = 0.06) and diabetes (OR, 0.48; p = 0.08) did not. Conclusions: African American race remains the most clinically significant predictor of autologous breast reconstruction, even after controlling for age, obesity, pathologic stage, health insurance type, charge to patient, socioeconomic status, smoking, and diabetes. Future research may address whether this disparity stems from patient preferences or more profound sociocultural and economic forces, including discrimination. 

The rise in bilateral mastectomies: Evidence, ethics, and physician's role

The rise in bilateral mastectomies: Evidence, ethics, and physician's role

The Breast
Yang YT et al

This viewpoint reviews double mastectomies' trend, medical evidence and ethical considerations, as well as the role of the physician in counseling the patient. It concludes that physicians should encourage patients to pursue alternative preventive measures, and promote bilateral mastectomies only for high-risk patients for whom the potential benefits of the surgery are sufficient to justify the surgery's increased risks. 

An Analysis of the Decisions Made for Contralateral Prophylactic Mastectomy and Breast Reconstruction

An Analysis of the Decisions Made for Contralateral Prophylactic Mastectomy and Breast Reconstruction
Plastic and Reconstructive Surgery
Buchanan PJ et al

Background: Little is known about the role breast reconstruction plays in decisions made for contralateral prophylactic mastectomy. This study explores factors critical to patient medical decision-making for contralateral prophylactic mastectomy and reconstruction among women with early stage, unilateral breast cancer. Methods: A mixed methods approach was used to gain an understanding of patients’ choices and experiences. Patients with stage 0 to III unilateral breast cancer who underwent reconstruction were recruited, and semistructured interviews were conducted. Patient-reported outcomes were evaluated using the Concerns About Recurrence Scale and the BREAST-Q. Results: Thirty patients were enrolled; 13 (43 percent) underwent unilateral mastectomy and 17 (57 percent) underwent contralateral prophylactic mastectomy. Three broad categories emerged from patient interviews: medical decision-making, quality of life after mastectomy, and breast reconstruction expectations. Patients who chose contralateral prophylactic mastectomy made the decision for mastectomy based primarily on worry about recurrence. Quality of life after mastectomy was characterized by relief of worry, especially in patients who chose contralateral prophylactic mastectomy [n = 14 (82.4 percent)]. Patients’ desires for symmetry, although not the primary reason for contralateral prophylactic mastectomy, played a role in supporting decisions made. Levels of worry after treatment were similar in both groups (72.7 percent). Patients with contralateral prophylactic mastectomy had higher mean scores for satisfaction with breast (82.4 versus 70.6) and satisfaction with outcome (89.9 versus 75.2). Conclusions: The choice for contralateral prophylactic mastectomy is greatly influenced by fear of recurrence, with desires for symmetry playing a secondary role in decisions made. 

Acellular Dermal Matrix–Assisted Direct-to-Implant Breast Reconstruction and Capsular Contracture: A 13-Year Experience

Acellular Dermal Matrix–Assisted Direct-to-Implant Breast Reconstruction and Capsular Contracture: A 13-Year Experience
Plastic and Reconstructive Surgery
Salzburg C et al

Background: Use of acellular dermal matrix for implant-based breast reconstruction appears to be associated with a lower incidence of capsular contracture compared with standard reconstruction. The majority of acellular dermal matrix studies were, however, of short duration; thus, long-term incidence of capsular contracture with acellular dermal matrix use is unknown. Methods: Patients undergoing acellular dermal matrix–assisted breast reconstruction from December of 2001 to May of 2014 at two institutions were evaluated. Cumulative incidence of capsular contracture was determined by the performing surgeon. A retrospective chart review was performed on prospectively gathered data on patient-, breast-, surgery-, and implant-related characteristics that were analyzed as potential risk factors for the development of capsular contracture. Results: A total of 1584 breast reconstructions in 863 patients were performed.....................

Comparison of Outcomes following Autologous Breast Reconstruction Using the DIEP and Pedicled TRAM Flaps: A 12-Year Clinical Retrospective Study and Literature Review

Comparison of Outcomes following Autologous Breast Reconstruction Using the DIEP and Pedicled TRAM Flaps: A 12-Year Clinical Retrospective Study and Literature Review
Plastic and Reconstructive Surgery
Knox AD, et al

Background: There are few studies that compare the deep inferior epigastric artery perforator (DIEP) flap to the pedicled transverse rectus abdominis myocutaneous (pTRAM) flap for use in reconstructive breast surgery. The authors examined four factors that aid in decision-making: donor-site morbidity, need for surgery related to abdominal morbidity, operative time, and complications. Methods: This is a retrospective review of patients undergoing breast reconstruction using the DIEP or pTRAM flap at the University of British Columbia between 2002 and 2013. The authors compared operative time and abdomen- and flap-related complications in both groups. Results: Reconstruction was performed in 507 patients; 25.6 percent received DIEP flaps (n = 183 breasts) and 74.4 percent underwent pTRAM flap surgery (n = 444 breasts). Pedicled TRAM flap patients were more likely to require abdominal closure with mesh (44.2 percent versus 8.1 percent; p < 0.001); 21.2 percent of them had a postoperative bulge and/or hernia versus 3.1 percent of DIEP flap patients; and 12.7 percent of pTRAM flap patients required surgery for hernia/bulge. Controlling for confounders, there were five times the odds of a hernia/bulge in the pTRAM flap group. DIEP flap surgery was 234 minutes longer than pTRAM flap surgery. Conclusions: The benefits of the pTRAM flap may be offset by the need to correct abdominal wall complications. DIEP flap reconstruction had lower donor complications but increased operative time. A cost analysis is needed to determine the most economical procedure. 

Validated biomarkers: The key to precision treatment in patients with breast cancer

Validated biomarkers: The key to precision treatment in patients with breast cancer

The Breast
Duffy MJ et al

Recent DNA sequencing and gene expression studies have shown that at a molecular level, almost every case of breast cancer is unique and different from other breast cancers. For optimum management therefore, every patient should receive treatment that is guided by the molecular composition of their tumor, i.e., precision treatment. While such a scenario is still some distance into the future, biomarkers are beginning to play an important role in preparing the way for precision treatment. In particular, biomarkers are increasingly being used for predicting patient outcome and informing as to the most appropriate type of systemic therapy to be administered. Mandatory biomarkers for every newly diagnosed case of breast cancer are estrogen receptors and progesterone receptors in selecting patients for endocrine treatment and HER2 for identifying patients likely to benefit from anti-HER2 therapy. Amongst the best validated prognostic biomarker tests are uPA/PAI-1, MammaPrint and Oncotype DX. Although currently, there are no biomarkers available for predicting response to specific forms of chemotherapy, uPA/PAI-1 and Oncotype DX can aid the identification of lymph node-negative patients that are most likely to benefit from adjuvant chemotherapy, in general. In order to accelerate progress towards precision treatment for women with breast cancer, we need additional predictive biomarkers, especially for enhancing the positive predictive value for endocrine and anti-HER2 therapies, as well as biomarkers for predicting response to specific forms of chemotherapy. The ultimate biomarker test for achieving the goal of precision treatment for patients with breast cancer will likely require a combination of gene sequencing and transcriptomic analysis of every patient's tumor.

10 year survival after breast-conserving surgery plus radiotherapy compared with mastectomy in early breast cancer in the Netherlands: a population-based study

10 year survival after breast-conserving surgery plus radiotherapy compared with mastectomy in early breast cancer in the Netherlands: a population-based study
  The Lancet Oncology
van Maaren MC et al
Adjusting for confounding variables, breast-conserving surgery plus radiotherapy showed improved 10 year overall and relative survival compared with mastectomy in early breast cancer, but 10 year distant metastasis-free survival was improved with breast-conserving surgery plus radiotherapy compared with mastectomy in the T1N0 subgroup only, indicating a possible role of confounding by severity. These results suggest that breast-conserving surgery plus radiotherapy is at least equivalent to mastectomy with respect to overall survival and may influence treatment decision making for patients with early breast cancer.

Thursday, 7 July 2016

Ribociclib plus letrozole in early breast cancer: A presurgical, window-of-opportunity study

Ribociclib plus letrozole inearly breast cancer: A presurgical, window-of-opportunity study

The Breast August 2016 Volume 28, Pages 191–198

Curigliano G et al

Cyclin D–cyclin-dependent kinase (CDK) 4/6–inhibitor of CDK4/6–retinoblastoma (Rb) pathway hyperactivation is associated with hormone receptor-positive (HR+) breast cancer (BC). This study assessed the biological activity of ribociclib (LEE011; CDK4/6 inhibitor) plus letrozole compared with single-agent letrozole in the presurgical setting.

Positive margins prediction in breast cancer conservative surgery: Assessment of a preoperative web-based nomogram

Positive margins prediction in breast cancer conservative surgery: Assessment of a preoperative web-based nomogram

The Breast August 2016 Volume 28, Pages 167–173

Alves-Ribeiro L et al

Margin status of the surgical specimen has been shown to be a prognostic and risk factor for local recurrence in breast cancer surgery. It has been studied as a topic of intervention to diminish reoperation rates and reduce the probability of local recurrence in breast conservative surgery (BCS).This study aims to validate the Dutch Breast Conservation nomogram, created by Pleijhus et al., which predicts preoperative probability of positive margins in BCS.Patients with diagnosis of breast cancer stages cT1-2, who underwent BCS at the Breast Center of São João University Hospital (BC-CHSJ) in 2013–2014, were included.

Five-year results of a prospective clinical trial investigating accelerated partial breast irradiation using 3D conformal radiotherapy after lumpectomy for early stage breast cancer

Five-year results of aprospective clinical trial investigating accelerated partial breast irradiation using 3D conformal radiotherapy after lumpectomy for early stage breast cancer

The Breast August 2016 Volume 28, Pages 178–183

Horst KC et al

Accelerated partial breast irradiation (APBI) is emerging as an alternative to whole-breast irradiation. This study presents the results of a prospective trial evaluating 3-dimensional conformal radiotherapy (3D-CRT) to deliver APBI for early-stage breast cancer.

Decision making, psychological wellbeing and psychosocial outcomes for high risk women who choose to undergo bilateral prophylactic mastectomy – A review of the literature

Decision making, psychologicalwellbeing and psychosocial outcomes for high risk women who choose to undergobilateral prophylactic mastectomy – A review of the literature

The Breast August 2016 Volume 28, Pages 130–135

Glassey R, Ives A, Saunders C, Musiello T

A bilateral prophylactic, or preventative, mastectomy (BPM) for women at high risk of developing breast cancer (BC) can reduce their risk of developing the disease by up to 90% (relative risk reduction). An increasing number of women, including young women, are taking up this option. However, there is a dearth of information for younger women (under 40 years) choosing preventative mastectomy. In fact, no studies to date have specifically focused on younger women's experiences of a BPM and investigated their informational needs.

Chemotherapy port related lymphedema after axillary lymph node dissection

Chemotherapy port related lymphedema after axillary lymph node dissection
The Breast August 2016 Volume 28, Pages 145–147

Turfe Z et al

The Mascagni lymphatic pathway comprises superficial channels along the clavicle that drain upper extremity lymph. A 65 year-old woman with recurrent left breast cancer presented with a non-functioning chemotherapy port in the right deltopectoral groove. She had undergone right mastectomy with axillary lymph node dissection (ALND). After port removal and wound closure she developed right upper extremity lymphedema. Patients who have undergone ALND may depend solely on this pathway for upper extremity lymphatic drainage.