Monday, 19 January 2009

Annals of Surgery January 2009 vol 249 iss 1

Total Skin-Sparing Mastectomy: Complications and Local Recurrence Rates in 2 Cohorts of Patients
Elisabeth R. Garwood, BS; Dan Moore, PhD; Cheryl Ewing, MD; E Shelley Hwang, MD; Michael Alvarado et al
Purpose: Dissemination of the total skin-sparing mastectomy (TSSM) technique is limited by concerns of nipple viability, flap necrosis, local recurrence risk, and the technical challenge of this procedure. We sought to define the impact of surgical and reconstructive variables on complication rates and assess how changes in technique affect outcomes.
Patients and Methods: We compared the outcomes of TSSM in 2 cohorts of patients. Cohort 1: the first 64 TSSM procedures performed at our institution, between 2001 and 2005. Cohort 2: 106 TSSM performed between 2005 and 2007. Outcomes of cohort 1 were analyzed in 2005. At that time, potential risk factors for complications were identified, and efforts to minimize these risks by altering operative and reconstructive technique were then applied to patients in cohort 2. The impact of these changes on outcomes was assessed. Logistic regression was used to determine the association between predictor variables and adverse outcomes (Stata 10).
Results: The predominant incision type in cohort 2 involved less than a third of the nipple areola complex (NAC), and the most frequent reconstruction technique was tissue expander placement. Between cohort 1 and cohort 2, nipple survival rates rose from 80% to 95% (P = 0.003) and complication rates declined: necrotic complications (30% -> 13%; P = 0.01), implant loss (31% -> 10%; P = 0.005), skin flap necrosis (16%-11%; not significant), and significant infections (17%-9%, not significant). Incisions involving >30% of the NAC (P < 0.001) and reconstruction with autologous tissue (P < 0.001) were independent risk factors for necrotic complications. The local recurrence rate was 0.6% at a median follow-up of 13 months (range, 1-65), with no recurrences in the NAC.
Conclusion: Focused improvement in technique has resulted in the development of TSSM as a successful intervention at our institution that is oncologically safe with high nipple viability and early low rates of recurrence. Identifying factors that contribute to complications and changing surgical and reconstructive techniques to eliminate risk factors has greatly improved outcomes.

Breast Conserving Surgery for Multifocal Breast Cancer
Woosung Lim, MD; Eun-Hwa Park, MD; Sung-Lim Choi, MD; Jin-Young Seo, MD; Hee-Jung Kim, MD; Mi-Ae Chang et al
Objective: The purpose of this study is to examine the oncological safety of breast conserving surgery (BCS) for patients with multifocal breast cancer.
Summary Background Data: Few studies have reported about BCS for multifocal breast cancer. BCS for multifocal cancer has a risk of local failure in previous reports, whereas recent studies reported the feasibility of BCS. However, because all studies have dealt with a small number of patients, multifocal breast cancer is still considered a relative contraindication for BCS.
Methods: This retrospective study includes 478 patients with multifocal breast cancer who underwent BCS or mastectomy and 930 with unifocal cancer who underwent BCS for stage 0-II. Multifocal cancer was defined as 2 or more distinct cancers in the same quadrant. Of 478 patients, 147 underwent BCS and 331 underwent mastectomy. We compared the local recurrence rate (LRR), disease free survival, and overall survival for BCS with mastectomy for multifocal cancer. In addition, the LRR of BCS for multifocal cancer was compared for unifocal cancer.
Results: There is no significant difference in stage distribution and other clinical and pathologic characteristics except Her-2/neu for stage IIA between BCS and mastectomy for multifocal caner. The mean follow-up period was 59.33 months (range, 1.00-177.20) for breast conserving group and 64.98 months (range, 6.23-196.03) for mastectomy group. The 5-year overall survival was 93.38% for BCS and 94.53% for mastectomy (log rank P = 0.208). The 5-year disease-free survival was 89.08% for BCS and 91.88% for mastectomy (log rank P = 0.451). The local failure occurred in 3 (2.0%) of 147 patient underwent BCS, 3 (0.9%) of 331 patients underwent mastectomy (P = 0.378). Compared with BCS for unifocal cancer patients, the LRR of patients with multifocal cancer was not statistically different (2.0% for multifocal, 1.3% for unifocal; P = 0.445).
Conclusions: Our study demonstrates that BCS for multifocal breast cancer is oncologically safe in selected patients.

Video-Assisted Skin-Sparing Breast-Conserving Surgery for Breast Cancer and Immediate Reconstruction With Autologous Tissue
Hiroo Nakajima, MD, PhD; Ikuya Fujiwara, MD, PhD; Naruhiko Mizuta, MD, PhD; Koichi Sakaguchi, MD, PhD; Yasushi Hachimine, MD