Information requirements of young women with breast cancer treated with mastectomy or breast conserving surgery: A systematic review

Information requirements of young women with breast cancer treated with mastectomy or breast conserving surgery: A systematic review
Recio-Saucedo A, Gerty S et al.
Online Publication (February 2016Volume 25, Pages 1–13)


Young women with breast cancer have poorer prognosis, greater lifetime risk of local recurrence, contralateral recurrence, and distant disease, regardless of surgery received. Here we systematically review published evidence relating to the information requirements and preferences of young women diagnosed with early-stage breast cancer offered a choice between mastectomy and Breast Conservation Surgery (BCS). Findings will inform the development of a surgical decision aid for young women.

The Profunda Artery Perforator Flap: Investigating the Perforasome Using Three-Dimensional Computed Tomographic Angiography

The Profunda Artery Perforator Flap: Investigating the Perforasome Using Three-Dimensional Computed Tomographic Angiography
Wong, C et al
Plastic & Reconstructive Surgery: November 2015 - Volume 136 - Issue 5 - p 915–919


Background: The profunda artery perforator flap has been emerging as an alternative method of autologous breast reconstruction. This flap uses upper posterior thigh tissue. The profunda artery perforator perforasome is investigated using three-dimensional computed tomographic angiography.
Methods: Ten cadaveric thighs were dissected centered over the profunda artery perforator. The perforator was injected with contrast medium and the flap was then subjected to computed tomographic scanning using a GE Lightspeed 16-slice scanner. The three-dimensional images were viewed, and measurements were obtained using Aquarius software, including horizontal and vertical extensions of the flap and areas of perfusion. Clinical examples are presented.
 Results: A profunda artery perforator (occasionally two) was consistently found in the upper medial thigh region, posterior to the gracilis muscle. The area of vascularity shown by the spread of contrast extends inferiorly beyond the usual lower border of the profunda artery perforator flap, which is usually 7 cm wide. In injected cadaveric flaps, the mean horizontal dimension was 16.7 cm and the mean vertical dimension was 16.5 cm. The mean area perfused was 8812 cm2. Conclusions: The profunda artery perforator flap is a vascularly sound flap, and is a good option for autologous breast reconstruction. Advantages include a reliable pedicle, no position changes required, and possibly an improved donor-site contour from a thigh lift. It is an excellent alternative to abdominally based free flaps and can also be used in conjunction with other flaps for further volume enhancement.

Comparison of Allergan, Mentor, and Sientra Contoured Cohesive Gel Breast Implants: A Single Surgeon’s 10-Year Experience

Comparison of Allergan, Mentor, and Sientra Contoured Cohesive Gel Breast Implants: A Single Surgeon’s 10-Year Experience


Plastic & Reconstructive Surgery: November 2015 - Volume 136 - Issue 5 - p 957–966


Doren, Erin L.


Background: Contoured cohesive gel breast implants have been recently approved in the United States. These implants have been available for premarket approval studies for selected surgeons. The purpose of this study was to assess a single surgeon’s outcomes in three specific clinical situations—breast augmentation, secondary augmentation, and breast reconstruction—using implants of all three contoured cohesive gel implant manufacturers (Allergan, Mentor, and Sientra) over a 10-year period.
Methods: The authors performed a prospective study of contoured cohesive silicone gel breast implants. Demographic and outcomes data were recorded. Complication rates were compared among the three implant manufacturers.
Results: From 2001 to 2013, 695 patients were included from U.S. Food and Drug Administration clinical trials......................

Breast Implant–Associated Infections: The Role of the National Surgical Quality Improvement Program and the Local Microbiome

Breast Implant–Associated Infections: The Role of the National Surgical Quality Improvement Program and the Local Microbiome

Plastic & Reconstructive Surgery: November 2015 - Volume 136 - Issue 5 - p 921–929


Cohen, Justin B. et al

Background: The most common cause of surgical readmission after breast implant surgery remains infection. Six causative organisms are principally involved: Staphylococcus epidermidis and S. aureus, Escherichia, Pseudomonas, Propionibacterium, and Corynebacterium. The authors investigated the infection patterns and antibiotic sensitivities to characterize their local microbiome and determine ideal antibiotic selection.
Methods: A retrospective review of 2285 consecutive implant-based breast procedures was performed. Included surgical procedures were immediate and delayed breast reconstruction, tissue expander exchange, and cosmetic augmentation. Patient demographics, chemotherapy and/or irradiation status, implant characteristics, explantation reason, time to infection, microbiological data, and antibiotic sensitivities were reviewed.
Results: Forty-seven patients (2.1 percent) required inpatient admission for antibiotics, operative explantation, or drainage by interventional radiology. The infection rate varied depending on surgical procedure, with the highest rate seen in mastectomy and immediate tissue expander reconstruction (6.1 percent). The mean time to explantation was 41 days. Only 50 percent of infections occurred within 30 days of the indexed National Surgical Quality Improvement Program operation. The most commonly isolated organisms were coagulase-negative Staphylococcus (27 percent), methicillin-sensitive S. aureus (25 percent), methicillin-resistant S. aureus (7 percent), Pseudomonas (7 percent), and Peptostreptococcus (7 percent). All Gram-positive organisms were sensitive to vancomycin, linezolid, tetracycline, and doxycycline; all Gram-negative organisms were sensitive to gentamicin and cefepime.
Conclusions: Empiric antibiotics should be vancomycin (with the possible inclusion of gentamicin) based on their broad effectiveness against the authors’ unique microbiome. Minor infections should be treated with tetracycline or doxycycline as a second-line agent. National Surgical Quality Improvement Program data are adequate for monitoring and comparing breast infections but certainly not comprehensive. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. 

Discussion: Use of Acellular Dermal Matrix in Postmastectomy Breast Reconstruction: Are All Acellular Dermal Matrices Created Equal?

Discussion:  Use of Acellular Dermal Matrix in Postmastectomy Breast Reconstruction: Are All Acellular Dermal Matrices CreatedEqual?



Plastic & Reconstructive Surgery: October 2015 - Volume 136 - Issue 4 - p 654–656


A discussion article about the use of acellular dermal matrix.

A Comparison of Elliptical Mastectomy to Inverted-T Pattern Mastectomy in Two-Stage Prosthetic Breast Reconstruction

A Comparison of Elliptical Mastectomy to Inverted-T Pattern Mastectomy in Two-Stage Prosthetic Breast Reconstruction

Plastic & Reconstructive Surgery: October 2015 - Volume 136 - Issue 4 - p 426e–433e

Kilgo, Matthew S et al.

Background: Patients with large or ptotic breasts undergoing mastectomy followed by tissue expander/implant-based reconstruction may benefit from a Wise (inverted-T) pattern reduction mammaplasty incision compared with the traditional horizontal elliptical incision. The authors compared these two groups of patients with regard to complication rates and outcomes.
Methods: Sixty-nine patients (117 breasts) were identified who underwent Wise pattern mastectomy and two-stage reconstruction. A control group of 89 patients (136 breasts) who underwent reconstruction after horizontal elliptical mastectomy were selected over the same period. Patient demographics, clinical characteristics, and complication rates were recorded and analyzed statistically.
Results: Patient demographics (age, body mass index, diabetes, smoking, and irradiation history) and clinical characteristics (laterality, expander size and fill volume, and time to expansion) were similar, with the exception of body mass index (control, 26.7 kg/m2; inverted-T, 28.7 kg/m2; p = 0.04) and mean intraoperative fill volume (control, 158.7 cc; inverted-T, 196.9 cc; p = 0.02). Of all complications (infection, seroma, flap necrosis, expander loss, and salvage), only the rate of mastectomy flap necrosis was significantly greater (p = 0.002) in patients undergoing inverted-T mastectomy (25.6 percent versus 11.0 percent). This difference did not result in a significantly higher rate of expander loss or need for salvage surgery.
Conclusions: The inverted-T mastectomy approach can be performed safely with acceptable complication rates. When compared with an internal control group, complication rates were similar, with the exception of mastectomy flap necrosis. Despite a higher rate of flap necrosis, 91 percent of inverted-T patients successfully completed the expansion process. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Breast conservative surgery and local recurrence

The Breast Published Online: September 29, 2015

 Mahdi Rezai, Stefan Kraemer, Rainer Kimmig, Peter Kern

Breast conservation is a legacy of Umberto Veronesi who laid the groundwork for the preservation of the body image of women affected by breast cancer (BC) with the Milan I study in the late 70ies of the last millennium. Breast conservative surgery (BCS) has two aspects: oncological safety of tumour resection with free margins and aesthetic preservation of the breast. Determinants of local control used to be T-size, nodal status and receptor status until biologically driven concepts defined risk of recurrence on the basis of molecular portraits. We explored whether these concepts of intrinsic subtypes prove at a large scale in the context of BCS and which surgical techniques procure best oncological and aesthetic outcomes, avoiding re-excision and necessity of conversion to mastectomy.

Optimal surgical management for high-risk populations

The Breast Published Online: September 29, 2015

Tari A. King, Melissa Pilewskie, Monica Morrow

The recognition that breast cancer is a group of genetically distinct diseases with differing responses to treatment and varying patterns of both local and systemic failure has led to many questions regarding optimal therapy for those considered to be high risk. Young patients, patients with triple-negative breast cancer (TNBC), and those who harbor a deleterious mutation in BRCA1 or BRCA2 are frequently considered to be at highest risk of local failure, leading to speculation that more-aggressive surgical treatment is warranted in these patients.

Exploring information provision in reconstructive breast surgery: A qualitative study

The Breast Published Online: September 29, 2015

Shelley Potter, Nicola Mills, Simon Cawthorn, Sherif Wilson, Jane Blazeby

Women considering reconstructive breast surgery (RBS) require adequate information to make informed treatment decisions. This study explored patients' and health professionals' (HPs) perceptions of the adequacy of information provided for decision-making in RBS.

Neoadjuvant chemotherapy is not a contraindication for nipple sparing mastectomy

The Breast, October 2015 Volume 24, Issue 5, Pages 661–666

Stefano Santoro, Andrea Loreti, Francesco Cavaliere, Leopoldo Costarelli, Massimo La Pinta, Elena Manna, Maria Mauri, Paola Scavina, Elena Santini, Ugo De Paula, Vito Toto, Lucio Fortunato

Nipple-sparing mastectomy (NSM) has been recently implemented to improve cosmetic outcome after mastectomy, but it is rarely considered today after neoadjuvant chemotherapy (NCH).

Shifting Autologous Breast Reconstruction into an Ambulatory Setting: Patient-Reported Quality of Recovery

Plastic and Reconstructive Surgery October 2015 - Volume 136 - Issue 4 - p 657–665

Davidge, Kristen et al

As bundled payment models gain popularity, it is imperative that providers use patient outcomes and patient experience to define evidence-based pathways of care. The purpose of this study was to evaluate the quality of recovery experienced by women undergoing early discharge (less than 24 hours) after autologous breast reconstruction with a pedicled flap and determine predictors of postoperative quality of recovery. Methods: A prospective cohort study was performed on all women undergoing autologous breast reconstruction at Women’s College Hospital between September of 2011 and July of 2013 that met study inclusion criteria. 

Use of Acellular Dermal Matrix in Postmastectomy Breast Reconstruction: Are All Acellular Dermal Matrices Created Equal?

Plastic and Reconstructive Surgery October 2015 - Volume 136 - Issue 4 - p 647–653

Ranganathan, Kavitha et al

AlloDerm and FlexHD are two types of acellular dermal matrices commonly used in implant-based reconstruction. Although the use of acellular dermal matrix has revolutionized immediate breast reconstruction in the setting of breast cancer, it remains unclear which type of acellular dermal matrix is best. The purpose of this retrospective cohort study was to compare postoperative complication rates between these two types of acellular dermal matrix. The authors reviewed the records of all patients who underwent implant-based breast reconstruction at their institution between 1998 and 2013. Dependent variables of seroma, hematoma, infection, delayed wound healing, implant exposure, and return to the operating room for management of complications were recorded.

Natrelle410 Extra-Full Projection Silicone Breast Implants: 2-Year Results from Two Prospective Studies

Plastic and Reconstructive Surgery October 2015 - Volume 136 - Issue 4 - p 638–646

Cordeiro, Peter G.; McGuire, Patricia; Murphy, Diane K.  

The safety and effectiveness of the Natrelle Style 410 highly cohesive silicone gel breast implant (Allergan, Inc., Irvine, Calif.) in full or moderate height and projection have been shown in a 10-year study. Extra-full projection implants may be an appropriate option for some women undergoing breast reconstruction. A total of 2795 women received at least one Natrelle 410 extra-full projection implant (X-style) for breast reconstruction in two similarly designed, prospective, multicenter studies…………..

TUGs into VUGs and Friendly BUGs: Transforming the Gracilis Territory into the Best Secondary Breast Reconstructive Option

TUGsinto VUGs and Friendly BUGs: Transforming the Gracilis Territory into the Best Secondary Breast Reconstructive Option

Plastic and Reconstructive Surgery 136(3):447-454, September 2015.

Park, Julie E.; Alkureishi, Lee W. T.; Song, David H.

The best secondary option for autologous breast reconstruction remains controversial. Limitations of the gracilis myocutaneous flap, including volume, skin paddle reliability, and donor morbidity, have been addressed by several modifications, hereby expanding its role in the decision tree for autologous breast reconstruction. This report documents the authors’ experience with gracilis flap breast reconstruction. This is a retrospective case series of a prospectively maintained database of patients undergoing breast reconstruction with the free gracilis myocutaneous flap, including the transverse upper gracilis, vertical upper gracilis, and bilateral stacked vertical upper gracilis.

A Propensity-Matched Analysis of the Influence of Breast Reconstruction on Subsequent Development of Lymphedema

A Propensity-Matched Analysis of the Influence of Breast Reconstruction on Subsequent Development of Lymphedema
Plastic & Reconstructive Surgery:
August 2015 - Volume 136 - Issue 2 - p 134e–143e

Basta M et al

Background: Recent literature demonstrates a lower incidence of lymphedema with breast reconstruction. This study compared the incidence of lymphedema after axillary dissection in a propensity-matched cohort of patients with and without immediate breast reconstruction. 
Methods: A review of patients undergoing axillary lymphadenectomy with or without immediate breast reconstruction from January 1, 2000, to July 1, 2013, was conducted. Comorbidities, cancer treatment, operative characteristics, and pathologic findings were reviewed. The primary outcome was postoperative lymphedema. Univariate analysis identified baseline differences between the patient groups. Cohorts were propensity-matched by age, body mass index greater than 30 kg/m2, adjuvant radiation therapy, cardiovascular disease, and hypertension. Subsequent multivariate regression was performed to identify independent predictors of lymphedema among matched patients. Results: A total of 4647 patients underwent breast cancer resection, with 1955 having axillary lymphadenectomy (no reconstruction, n = 1200; autologous, n = 563; implant-based, n = 192). Matching yielded a cohort of 239 reconstruction and 239 no-reconstruction patients demonstrating no differences in age, body mass index, hypertension, adjuvant radiation therapy, or axillary dissection extent. With 55.9 months’ follow-up, postoperative lymphedema was diagnosed in 94 patients (19.7 percent). Reconstruction patients developed lymphedema in 19.2 percent of cases versus 20.1 percent for no- reconstruction patients (p = 0.82). Regression identified two independent predictors of lymphedema: postoperative radiation therapy (OR, 2.90; p < 0.001) and obesity (OR, 2.36; p < 0.001). 
Conclusions: This study demonstrates a 19.7 percent incidence of lymphedema following axillary lymphadenectomy. Reconstruction does not appear to alter lymphedema risk, whereas postoperative radiation therapy, obesity, and extensive axillary dissection greatly increase risk.

Conservative surgery for multifocal/multicentric breast cancer

Conservative surgery for multifocal/multicentric breast cancer
The Breast Published Online: August 23, 2015


Matthijs V, et al


Multifocal (MF) and multicentric (MC) breast cancer is regularly considered a relative contraindication for breast-conserving therapy (BCT). There are two reasons for this wide spread notion:However, we concur that if optimal ‘cytoreductive surgery’ is achieved this will result in good local control....................

Prognostic significance of nodal involvement region in clinical stage IIIc breast cancer patients who received primary systemic treatment, surgery, and radiotherapy

Prognostic significance of nodal involvement region in clinical stage IIIc breast cancer patients who received primary systemic treatment, surgery, and radiotherapy
The Breast  Article in press
  
Jae Myoung Noh, et al

To evaluate the prognostic influence of involvement of both internal mammary nodes (IMNs) and supraclavicular nodes (SCNs) in clinical stage IIIc breast cancer patients who underwent primary systemic treatment, surgery, and radiotherapy (RT).

The locoregional recurrence post-mastectomy for ductal carcinoma in situ: Incidence and risk factors

The locoregional recurrence post-mastectomy for ductal carcinoma in situ: Incidence and risk factors
The Breast. In Press. Accepted: June 7, 2015; Published Online: August 12



The objective of this retrospective study was to determine the incidence of recurrence of breast cancer after mastectomy for ductal carcinoma in situ (DCIS) in our institution, and to evaluate the associated risk factors while comparing them to those proposed in the literature.

C-Y Trilobed Flap for Improved Nipple-Areola Complex Reconstruction

C-Y Trilobed Flap for Improved Nipple-Areola Complex Reconstruction
Plastic & Reconstructive Surgery:August 2015 - Volume 136 - Issue 2 - p 234–237

Butz, D, et al

Summary: Nipple-areola complex reconstruction has been shown to improve breast reconstruction patients’ overall satisfaction. Trilobed flap variations are some of the more commonly used flaps for nipple-areola complex reconstruction. The donor-site scar frequently extends outside the width of an ideal areolar tattoo diameter. There have been many modifications to the original flap design, but none of them addresses the length of the donor-site scar. The technique described uses a triangular stitch in the donor site to limit the length of the scar. This also creates tiny dog-ears within the future areola zone that give a natural wrinkled appearance when tattooed.

Patient-Reported Satisfaction and Quality of Life following Breast Reconstruction in Thin Patients: A Comparison between Microsurgical and Prosthetic Implant Recipients

Patient-Reported Satisfaction and Quality of Life following Breast Reconstruction in Thin Patients: A Comparison between Microsurgical and Prosthetic Implant Recipients
Plastic & Reconstructive Surgery: August 2015 - Volume 136 - Issue 2 - p 213–220

Weichman, K et al

Background: Patients undergoing autologous breast reconstruction have higher long-term satisfaction rates compared with those undergoing prosthetic reconstruction. Regardless, most patients still undergo prosthetic reconstruction. The authors compared outcomes of microsurgical reconstruction to those of prosthetic reconstruction in thin patients and evaluated the effect of reconstructive type on quality of life. Methods: After institutional review board approval was obtained, the authors reviewed all patients undergoing breast reconstruction at a single institution from November of 2007 to May of 2012. Thin patients were included for analysis and divided into two cohorts: microsurgical reconstruction and tissue expander/implant reconstruction........

Progress in the surgical management of breast cancer: Present and future

Published Online: August 03, 2015

 

Recognition of differing risks of locoregional recurrence (LRR) in breast cancer patients based on estrogen receptor, progesterone receptor, and HER2 status, coupled with a reduction in LRR in patients receiving adjuvant systemic therapy, offers the opportunity to tailor surgical treatment and reduce the morbidity of therapy. New guidelines for margins in breast-conserving therapy of tumor not touching ink and avoidance of axillary dissection in sentinel node positive patients undergoing breast-conserving therapy are examples of this approach which have entered practice.

http://dx.doi.org/10.1016/j.breast.2015.07.003 

Embrace the Change: IncorporatingSingle-Stage Implant Breast Reconstruction into Your Practice

Plastic & Reconstructive Surgery: August 2015 - Volume 136 - Issue 2 - p 221–231

Background: Multiple studies have reported on the safety of nipple-sparing mastectomy and low complication rates associated with single-stage implant breast reconstruction. Yet many plastic surgeons continue to be resistant to change. This article presents the senior author’s (M.A.C.) experience during his transition period from the latissimus dorsi flap with adjustable implants to a “one-and-done” approach using shaped implants and fetal bovine acellular dermal matrix. Methods: A literature review was performed selecting articles discussing single-stage implant reconstruction, indications, outcomes, technique, and complications. Additional articles were selected after review of the references of identified articles. Clinical pearls discussed include patient selection, implant selection, and mastectomy incision choices, with a detailed description of the senior author’s operative technique. Results: Twenty-seven single-stage implant reconstructions were performed. Average mastectomy weight was 343.82 g. The average implant volume was 367 cc. Shaped implants were most commonly used. Acellular dermal matrix was used in all breasts. Complications included erythema requiring intravenous antibiotics (three patients), skin ischemia caused by methylene blue (one patient), seroma (one patient), unilateral partial nipple necrosis (one patient), mastectomy skin necrosis (one patient), and exposed/infected implants that were salvaged using a sequential irrigation protocol described by Sforza et al. in 2014 (two patients). Conclusions: Breast reconstruction after mastectomy has evolved toward less invasive, single-stage procedures. Aesthetic refinements include nipple-sparing mastectomy, use of acellular dermal matrix, shaped implants, and fat grafting. Selected patients will benefit from a one-and-done breast implant reconstruction with no additional oncologic risk. Surgeons must embrace the change and provide their patients with a procedure that will offer the best aesthetic outcomes. 

Breast Implant–Associated Anaplastic Large Cell Lymphoma: Proposal for a Monitoring Protocol

Breast Implant–AssociatedAnaplastic Large Cell Lymphoma: Proposal for a Monitoring Protocol

Plastic & Reconstructive Surgery: August 2015 - Volume 136 - Issue 2 - p 144e–151e

Background: The authors report four cases of breast implant–associated anaplastic large cell lymphoma (ALCL) from a single institution and propose a multidisciplinary protocol. Methods: From 2012 to 2014, four breast implant–associated ALCL cases were diagnosed. The authors performed the original operation, and no patients were referred to their practice. Cases 1, 2, and 4 were CD4+/CD30+/ALK− ALCL with previous textured-implant reconstruction, whereas case 3 was CD8+/CD30+/ALK− ALCL with previous polyurethane-implant augmentation. A retrospective study of all patients who underwent breast implant positioning was performed to identify any misdiagnosed cases. Results: Of 483 patients, 226 underwent reconstruction with latissimus dorsi flap and prosthesis, 115 had skin-sparing/nipple-sparing mastectomy and prosthesis, 117 underwent an expander/implant procedure, and 25 underwent breast augmentation. Fifty-eight cases (12 percent) underwent implant replacement for capsular contracture, 15 (3.1 percent) experienced late-onset seroma, and four (0.83 percent) had both capsular contracture and seroma. Seventy-seven symptomatic patients (16 percent) underwent surgical revision (capsulectomy/capsulotomy) and/or seroma evacuation. The second look on histologic specimens did not identify misdiagnosed cases. A multidisciplinary protocol for suspected implant-associated ALCL was established. Ultrasound and cytologic examinations are performed in case of periprosthetic effusion. If implant-associated ALCL is diagnosed, implant removal with capsulectomy is performed. If disseminated disease is detected through positron emission tomography/computed tomography of the total body, the patient is referred to the oncology department. Conclusions: A multidisciplinary protocol is mandatory for both early diagnosis and patient management. Until definitive data emerge regarding the exact etiopathogenesis of breast implant–associated ALCL, the authors suggest offering only autologous reconstruction if patients desire it. 

Regional Nodal Irradiation in Early-Stage Breast Cancer

N Engl J Med 2015; 373:317-327 July 23, 2015

BACKGROUND

Most women with breast cancer who undergo breast-conserving surgery receive whole-breast irradiation. We examined whether the addition of regional nodal irradiation to whole-breast irradiation improved outcomes.

Patterns and Trends in Immediate Postmastectomy Reconstruction in California: Complications and Unscheduled Readmissions

Patterns and Trends in Immediate Postmastectomy Reconstruction in California: Complications and UnscheduledReadmissions

Plastic & Reconstructive Surgery: July 2015 - Volume 136 - Issue 1 - p 10e–19e

Background: Immediate reconstruction rates after mastectomy are increasing but remain low. Little is known about hospital readmissions after these procedures. The authors studied unscheduled readmissions after immediate reconstruction. Methods: Using the Healthcare Cost and Utilization Project California State database, the authors identified patients undergoing mastectomy only or with immediate reconstruction for ductal carcinoma in situ and invasive breast cancer from 2005 to 2009. Immediate reconstruction included tissue expander/implant and autologous tissue reconstructions. The authors evaluated temporal trends in immediate reconstruction and factors associated with 30-day unscheduled readmissions after reconstruction. Results: The cohort contained 48,414 patients (mastectomy only, 35,648; immediate reconstruction, 12,766; tissue expander/implant, 10,437; autologous tissue, 2329). Readmission rates were not significantly different between mastectomy only and immediate reconstruction (3.55 percent versus 3.39 percent; p = 0.39); however, autologous tissue reconstruction was associated with a significantly higher readmission rate compared with tissue expander/implant reconstruction (4.08 percent versus 3.24 percent; p = 0.04). Conclusions: Immediate reconstruction does not result in higher readmission rates compared with mastectomy only. All women undergoing mastectomy should be offered consultation for reconstruction.

Challenges in optimizing care in advanced breast cancer patients: Results of an international survey linked to the ABC1 consensus conference

Challenges in optimizing care in advanced breast cancer patients: Results of an international survey linked to the ABC1consensus conference

Published Online: July 19, 2015

Until recently, many international guidelines have focussed on the treatment of early-stage breast cancer, with little emphasis on advanced-stage disease. To improve the management of advanced breast cancer (ABC), the European School of Oncology (ESO) established the ABC International Consensus Conference and Guidelines. Delegates from the first conference and additional groups selected by ESO were invited to complete a survey to identify current challenges and barriers associated with optimizing ABC management.

http://dx.doi.org/10.1016/j.breast.2015.06.008 

Surgical margin reporting in breast conserving surgery: Does compliance with guidelines affect re-excision and mastectomy rates?

Published Online: July 18, 2015

Margin status is important in guiding decisions to re-excise following breast-conserving surgery (BCS) for breast cancer. The College of American Pathologists (CAP) developed guidelines to standardize pathology reporting; however, compliance with margin documentation guidelines has been shown to vary. The aim of this retrospective study was to determine whether compliance with CAP guidelines affects re-excision and mastectomy rates.

 http://dx.doi.org/10.1016/j.breast.2015.06.007

Medication taking behaviors among breast cancer patients on adjuvant endocrine therapy

Published Online: July 16, 2015

To explore how symptoms and psychosocial factors are related to intentional and unintentional non-adherent medication taking behaviors.

http://dx.doi.org/10.1016/j.breast.2015.06.010

Potential of overcoming resistance to HER2-targeted therapies through the PI3K/Akt/mTOR pathway

Potential of overcoming resistance to HER2-targeted therapies through the PI3K/Akt/mTORpathway

Human epidermal growth factor receptor 2 (HER2) overexpression occurs in up to 30% of breast cancers and is a marker of aggressive disease. While HER2-targeted therapies have improved outcomes in these tumors, resistance to these agents develops in a large proportion of patients. Determining molecular mechanisms underlying resistance might help improve outcomes for patients with HER2-positive disease by allowing development of strategies to overcome resistance. Activation of signaling pathways involving the phosphoinositide 3-kinase/protein kinase B/mammalian target of rapamycin (PI3K/Akt/mTOR) pathway might contribute to the development of resistance to HER2-targeted therapies.


http://dx.doi.org/10.1016/j.breast.2015.06.002 

Nipple-Sparing Mastectomy and Ptosis: Perforator Flap Breast Reconstruction .................

Nipple-Sparing Mastectomy and Ptosis: Perforator Flap Breast Reconstruction Allows Full Secondary Mastopexy with Complete Nipple Areolar Repositioning

Plastic & Reconstructive Surgery: July 2015 - Volume 136 - Issue 1 - p 1e–9e

doi: 10.1097/PRS.0000000000001325

DellaCroce, Frank J. et al.

http://journals.lww.com/plasreconsurg/Fulltext/2015/07000/Nipple_Sparing_Mastectomy_and_Ptosis___Perforator.3.aspx

Background: Patients with moderate to severe ptosis are often considered poor candidates for nipple-sparing mastectomy. This results from the perceived risk of nipple necrosis and/or the inability of the reconstructive surgeon to reliably and effectively reposition the nipple-areola complex on the breast mound after mastectomy.

Methods: A retrospective review identified patients with grade II/III ptosis who underwent nipple-sparing mastectomy with immediate perforator flap reconstruction and subsequently underwent a mastopexy procedure. The mastopexies included complete, full-thickness periareolar incisions with peripheral undermining around the nipple-areola complex to allow for full transposition of the nipple-areola complex relative to the surrounding skin envelope.

Results: Seventy patients with 116 nipple-sparing mastectomies met inclusion criteria. The most common complications were minor incisional dehiscence (7.7 percent) and variable degrees of necrosis in the preserved breast skin (3.4 percent) after the initial mastectomy. There were no cases of nipple-areola complex necrosis following the secondary mastopexy.

Conclusions: The authors demonstrate that full mastopexy, including a complete full-thickness periareolar incision and nipple-areola complex repositioning on the breast mound, can be safely performed after nipple-sparing mastectomy and perforator flap breast reconstruction. The underlying flap provides adequate vascular ingrowth to support the perfusion of the nipple-areola complex despite complete incisional interruption of the surrounding cutaneous blood supply. These findings may allow for inclusion of women with moderate to severe ptosis in the candidate pool for nipple-sparing mastectomy if oncologic criteria are otherwise met. These findings also represent a significant potential advantage of autogenous reconstruction over implant reconstruction in women with breast ptosis who desire nipple-sparing mastectomy.

Evolution of Bilateral Free Flap Breast Reconstruction over 10 Years: Optimizing Outcomes and Comparison to Unilateral Reconstruction

Evolution of Bilateral Free Flap Breast Reconstruction over 10 Years: Optimizing Outcomes and Comparison to Unilateral Reconstruction

Plastic & Reconstructive Surgery: June 2015 - Volume 135 - Issue 6 - p 946e–953e

doi: 10.1097/PRS.0000000000001233

Chang, Edward I. et al

http://journals.lww.com/plasreconsurg/Fulltext/2015/06000/Evolution_of_Bilateral_Free_Flap_Breast.3.aspx

Background: There is an increasing trend for contralateral prophylactic mastectomy, but studies focusing on bilateral free flap breast reconstruction are lacking.

Methods: A retrospective review was performed of all bilateral free flap breast reconstructions performed from 2000 to 2010.

Results: Overall, 488 patients underwent bilateral breast reconstruction (bilateral immediate, n = 283; bilateral delayed, n = 93; and bilateral immediate/delayed, n = 112), which more than doubled from the years 2000–2005 to 2006–2010 [147 versus 341 (232.0 percent)]. Comparison of contralateral prophylactic mastectomy demonstrated a similar increase over the decade [139 versus 282 (203.9 percent)]. There was an increasing trend toward perforator flaps [70 versus 203 (290 percent)] compared to traditional transverse rectus abdominis myocutaneous flaps [99 versus 17 (17 percent)] between the first and second halves of the decade. Patients undergoing a bilateral immediate/delayed reconstruction were significantly more likely to undergo a revision (p = 0.05), particularly on the immediate reconstructed breast (OR, 1.59; p = 0.05). Delayed reconstruction and obesity were significantly associated with postoperative complications. Obesity, smoking, and radiation therapy significantly increased fat necrosis rates, 2.77 (p = 0.01), 2.31 (p = 0.03), and 2.38 times (p = 0.03), respectively. In comparison to unilateral reconstruction, bilateral reconstruction had significantly higher flap loss rates (p = 0.004), comparable donor-site complications, and equivalent rates of revisions.

 Conclusions: There has been an increase in bilateral free flap breast reconstruction. Bilateral immediate/delayed reconstruction had higher revision rates of the prophylactic breast to achieve symmetry. Obesity, smoking, and radiation therapy were associated with increased complications, including fat necrosis, but successful reconstruction can be achieved with acceptable risks. 

Antibiotic Prophylaxis for Preventing Surgical-Site Infection in Plastic Surgery...

Antibiotic Prophylaxis for Preventing Surgical-Site Infection in Plastic Surgery: An Evidence-Based Consensus Conference Statement from the American Association of Plastic Surgeons

Plastic & Reconstructive Surgery: June 2015 - Volume 135 - Issue 6 - p 1723–1739 doi: 10.1097/PRS.0000000000001265

Ariyan, Stephan et al

http://journals.lww.com/plasreconsurg/Fulltext/2015/06000/Antibiotic_Prophylaxis_for_Preventing.34.aspx

Background: There is a growing concern for microbial resistance as a result of overuse of antibiotics. Although guidelines have focused on the use of antibiotics for surgery in general, few have addressed plastic surgery specifically. The objective of this expert consensus conference was to evaluate the evidence for efficacy and safety of antibiotic prophylaxis in plastic surgical procedures.

Methods: The authors: searched for existing high-quality systematic reviews for antibiotic prophylaxis in the literature from the MEDLINE, Cochrane Library, and Embase databases. All synonyms for antibiotics were combined with terms for relevant plastic surgery procedures. The searches were not limited by language, and included all study designs. In addition, supplemental hand searches were performed of bibliographies of relevant articles, and extensive “related articles.” Meta-analyses were performed and reviewed by experts selected by the American Association of Plastic Surgeons to reach consensus recommendations.

Results: Database searches identified 4300 articles, from which 2042 full-text articles were identified for eligibility. De novo meta-analyses were performed for each plastic surgical category. In total, 67 studies met the inclusion criteria, including nine for breast surgery, 17 for head and neck surgery, 10 for orthognathic surgery, seven for rhinoplasty/septoplasty, 19 for hand surgery, five for skin surgery, and two for abdominoplasty.

Conclusions: Systemic antibiotic prophylaxis is recommended for clean breast surgery and for contaminated surgery of the hand or the head and neck. It is not recommended to reduce infection in clean surgical cases of the hand, skin, head and neck, or abdominoplasty.

Nipple-Sparing Mastectomy in Patients with Previous Breast Surgery: Comparative Analysis of 775 Immediate Breast Reconstructions

Nipple-Sparing Mastectomy in Patients with Previous Breast Surgery: Comparative Analysis of 775 Immediate Breast Reconstructions

Plastic & Reconstructive Surgery: June 2015 - Volume 135 - Issue 6 - p 954e–962e

doi: 10.1097/PRS.0000000000001283

Frederick, Michael J. et al

http://journals.lww.com/plasreconsurg/Fulltext/2015/06000/Nipple_Sparing_Mastectomy_in_Patients_with.4.aspx

Background: An increasing number of women are candidates for nipple preservation with mastectomy. It is unclear how previous breast surgery impacts nipple-sparing mastectomy and immediate breast reconstruction. 

Methods: A single-institution retrospective review was performed between June of 2007 and June of 2013. 

Results: Four hundred forty-four patients underwent 775 immediate breast reconstructions after nipple-sparing mastectomy. Of these, 160 patients and 187 reconstructions had previous breast surgery, including 154 lumpectomies, 27 breast augmentations, and six reduction mammaplasties. Two hundred eighty-four patients with 588 reconstructions without previous breast surgery served as the control group. The previous breast surgery patients were older (49.6 years versus 45.8 years; p < 0.001) but otherwise had similar demographics. Previous breast surgery reconstructions were more often unilateral, therapeutic, and associated with preoperative radiotherapy (p < 0.001 for each). Extension of breast scars was common with previous breast surgery, whereas the inframammary incision was most frequent if no scars were present (p < 0.001). Multivariate regression analysis showed that previous breast surgery was not a significant risk factor for ischemic complications or nipple loss. Subgroup analysis showed extension of prior irradiated incisions was predictive of skin flap necrosis (OR, 9.518; p = 0.05). A higher number of lumpectomy patients had preoperative radiotherapy (41 versus 11; p < 0.001), and patients with breast augmentation had more single-stage reconstructions (85.2 percent versus 62.9 percent; p = 0.02). 

Conclusion: Nipple-sparing mastectomy and immediate reconstruction can be performed in patients with prior breast surgery with no significant increase in nipple loss or ischemic complications. 

Bilateral Mastectomy versus Breast-Conserving Surgery for Early-Stage Breast Cancer:..

Bilateral Mastectomy versus Breast-Conserving Surgery for Early-Stage Breast Cancer: The Role of Breast Reconstruction

Albornoz, Claudia R et al

Plastic & Reconstructive Surgery: June 2015 - Volume 135 - Issue 6 - p 1518–1526 

doi: 10.1097/PRS.0000000000001276

http://journals.lww.com/plasreconsurg/Fulltext/2015/06000/Bilateral_Mastectomy_versus_Breast_Conserving.2.aspx

Background: Although breast-conserving surgery is oncologically safe for women with early-stage breast cancer, mastectomy rates are increasing. The objective of this study was to examine the role of breast reconstruction in the surgical management of unilateral early-stage breast cancer. 

Methods: A retrospective cohort study of women diagnosed with unilateral early-stage breast cancer (1998 to 2011) identified in the National Cancer Data Base was conducted. Rates of breast-conserving surgery, unilateral and bilateral mastectomy with contralateral prophylactic procedures (per 1000 early-stage breast cancer cases) were measured in relation to breast reconstruction. The association between breast reconstruction and surgical treatment was evaluated using a multinomial logistic regression, controlling for patient and disease characteristics. 

Results: A total of 1,856,702 patients were included. Mastectomy rates decreased from 459 to 360 per 1000 from 1998 to 2005 (p < 0.01), increasing to 403 per 1000 in 2011 (p < 0.01). The mastectomy rates rise after 2005 reflects a 14 percent annual increase in contralateral prophylactic mastectomies (p < 0.01), as unilateral mastectomy rates did not change significantly. Each percentage point of increase in reconstruction rates was associated with a 7 percent increase in the probability of contralateral prophylactic mastectomies, with the greatest variation explained by young age(32 percent), breast reconstruction (29 percent), and stage 0 (5 percent). 

Conclusions: Since 2005, an increasing proportion of early-stage breast cancer patients have chosen mastectomy instead of breast-conserving surgery. This trend reflects a shift toward bilateral mastectomy with contralateral prophylactic procedures that may be facilitated by breast reconstruction availability.

Combined breast surgery and abdominoplasty

Combined breast surgery and abdominoplasty: Strategies for success. Plastic and Reconstructive Surgery, May 2015, Vol. 135(5), p.849(e)-860(e).

Matarasso, A. and Smith, D.M.

http://journals.lww.com/plasreconsurg/Abstract/2015/05000/Combined_Breast_Surgery_and_Abdominoplasty__.17.aspx

Abdominoplasty and breast surgery are frequently appealing to patients as combined procedures. The practice of combining abdominoplasty with other procedures originates from abdominoplasty performed in conjunction with intraabdominal or gynecologic surgery. Initially, the focus of combined surgery was on ensuring safety and minimizing local (e.g., wound healing) complications. As surgeons began combining abdominoplasty with distant procedures such as breast surgery, because the individual procedures have little adverse impact on one another and are not altered because of the combination, concerns with systemic morbidity surpassed the initial focus on avoiding local complications. 

Breast reduction in patients with prior breast irradiation

Breast reduction in patients with prior breast irradiation: Outcomes using a central mound technique. Plastic and Reconstructive Surgery, May 2015, Vol. 135(5), p.1276-82.

Weichman, K.E., et al.

http://journals.lww.com/plasreconsurg/Fulltext/2015/05000/Breast_Reduction_in_Patients_with_Prior_Breast.2.aspx

 Breast reduction in patients with a history of lumpectomy and irradiation is controversial because of a heightened risk of infection and wound healing complications. Persistent macromastia or asymmetry remains a problem in this patient population that is commonly not addressed. The authors studied the safety and efficacy of a central mound technique with minimal dissection for breast reduction or mastopexy in patients with a history of breast irradiation.

Methods: A case-control study of all patients undergoing bilateral breast reduction mammaplasty between 2008 and 2013 at Memorial Sloan Kettering Cancer Center was conducted. Patients who had unilateral breast irradiation and bilateral reduction using the central mound technique were included. Each patient had a control breast and an irradiated breast. Complications and outcomes were analyzed.

Results: Thirteen patients were included for analysis. Their average age was 50.23 ± 9.9 years, and average time from irradiation to breast reduction mammaplasty was 41.3 ± 48.5 months (range, 9 to 132 months). The average specimen weight of irradiated breasts was less than that of control breasts; however, this failed to reach statistical significance (254.2 ± 173.5 g versus 386.9 ± 218.5 g; p = 0.099). One patient developed fat necrosis in the previously irradiated breast and underwent biopsy. There was no incidence of nipple necrosis or breast cancer in either irradiated or nonirradiated breasts.

Conclusions: Breast reduction mammaplasty in patients who have had irradiation is feasible and can be performed safely in select cases. The central mound technique provides reliable and reproducible results and should be considered in patients with macromastia/asymmetry and a history of irradiation.

Family breast cancer "as treatable as other tumours"

Family breast cancer" as treatable as other tumours". BBC News Online, 20.5.15

http://www.bbc.co.uk/news/health-32777696

The unfolding story of cancer

The unfolding story of cancer. The Lancet, May 2015, Vol. 385(9980), p.1824

Campbell, P.T.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60915-1/fulltext?rss=yes

Few diseases provoke the visceral fear of cancer. This reaction is justified: more than 14 million people worldwide this year will be diagnosed with cancer. We have learned a great deal about the prevention, causes, treatment, biology, socioeconomics, and political implications of cancer since the time of the ancients when, in writing about treatment for breast cancer, the Egyptian Imhotep wrote “there is none”. Currently, nearly nine of ten women diagnosed with breast cancer in the UK and the USA will live 5 years or more beyond diagnosis. And there have been advances for other cancers, such as leukaemia. Indeed, cancer mortality in the past 20 years has decreased by about 20–30% in the UK and the USA. Despite these clinical and public health advances, at least 8 million people worldwide are expected to die from cancer this year.

Diagnosis and management of galactorrhea after breast augmentation

Diagnosis and management of galactorrhea after breast augmentation. Plastic and Reconstructive Surgery, May 2015, Vol. 135(5), p.1349-56.

Basile, F.V. and Basile, A.R.

http://journals.lww.com/plasreconsurg/Abstract/2015/05000/Diagnosis_and_Management_of_Galactorrhea_after.15.aspx

 A known but not fully understood complication of breast augmentation is galactorrhea. To date, all publications on this subject have been case reports. The purpose of this retrospective study was to examine a large group of consecutive patients who had undergone breast augmentation and identify the incidence of galactorrhea and galactocele, and the associated preoperative and intraoperative risk factors. The authors also evaluated the treatment algorithm used.

Current attitudes to breast reconstruction surgery for women at risk of post-mastectomy radiatherapy

Current attitudes to breast reconstruction surgery for women at risk of post-mastectomy radiotherapy:  A survey of UK breast surgeons. The Breast [in press], published online May 2015.

Duxbury, P.J., et al.

http://www.thebreastonline.com/article/S0960-9776(15)00108-3/abstract?rss=yes

Decision-making for women requiring reconstruction and post-mastectomy radiotherapy (PMRT) includes oncological safety, cosmesis, patient choice, potential delay/interference with adjuvant treatment and surgeon/oncologist preference. This study aimed to quantitatively assess surgeons' attitudes and perceptions about reconstructive options in this setting, and to ascertain if surgical volume influenced advice given.

How to compare the oncological safety of oncoplastic breast conservation surgery

How to compare the oncological safety of oncoplastic breast conservation surgery - to wide local excision or mastectomy? The Breast, May 2015 [in press]

Mansell, J., et al.

http://www.thebreastonline.com/article/S0960-9776(15)00109-5/abstract?rss=yes

Comparative studies suggest that patients treated with oncoplastic breast conservation surgery (OBCS) have similar pathology to patients treated with wide local excision (WLE). However, patients treated with OBCS have never been compared to patients treated with mastectomy. The aim of this study was to identify which control group was comparable to patients undergoing OBCS.

Evaluation of effect of self-examination and physical examination on breast cancer

Evaluation of effect of self-examination and physical examination on breast cancer. The Breast, May 2015 [in press]

Hassan, L.M., et al.

http://www.thebreastonline.com/article/S0960-9776(15)00105-8/abstract?rss=yes

Breast cancer is the number one cancer of women in the world. More than 90% of breast cancers can be cured with early diagnosis followed by effective multimodality treatment. The efficacy of screening by breast self-examination (BSE) and breast physical examination (BPx) is best evaluated using randomized screening trials.

Factors influencing time between surgery and radiotherapy

Factors influencing time between surgery and radiotherapy: A population based study of breast cancer patients. The Breast, May 2015 [in press]

Katik, S., et al.

http://www.thebreastonline.com/article/S0960-9776(15)00099-5/abstract?rss=yes

This study describes variation in the time interval between surgery and radiotherapy in breast cancer (BC) patients and assesses factors at patient, hospital and radiotherapy centre (RTC) level influencing this variation. To do so, the factors were investigated in BC patients using multilevel logistic regression. The study sample consisted of 15,961 patients from the Netherlands Cancer Registry at 79 hospitals and 19 (RTCs) with breast-conserving surgery or mastectomy directly followed by radiotherapy.