What’s new in oncology: Breast Cancer

    

What's new in oncology  (UpToDate – you *may* need to be logged into UpToDate before accessing these links. You can access via Zenworks (on a Trust computer) and then register for your own account which enables you to use the app and collect CPD points)

Authors: April F Eichler, MD, MPH, Diane MF Savarese, MD, Sadhna R Vora, MD

Literature review current through: Nov 2018. | This topic last updated: Dec 12, 2018.

Atezolizumab and nab-paclitaxel in triple negative breast cancer (November 2018)

Overall survival with fulvestrant and palbociclib in advanced HR-positive, HER2-negative breast cancer (November 2018)

  

Aromatase inhibitor-induced joint pain and acupuncture (July 2018)

Updated guidelines on HER2 ISH interpretation in breast cancer (July 2018) 

Avoidance of adjuvant chemotherapy in women with HR-positive, node-negative breast cancer and intermediate Recurrence Score (RS) (July 2018) 

Duration of adjuvant trastuzumab in early HER2-positive breast cancer (July 2018)

 Ovarian suppression with either tamoxifen or an aromatase inhibitor in premenopausal women with early breast cancer (July 2018)

Mixed data regarding denosumab as adjuvant breast cancer treatment (July 2018)

Addition of carboplatin to neoadjuvant chemotherapy for triple negative breast cancer (May 2018)

Incision Choices in Nipple-Sparing Mastectomy: A Comparative Analysis of Outcomes and Evolution of a Clinical Algorithm

Incision Choices in Nipple-Sparing Mastectomy: A Comparative Analysis of Outcomes and Evolution of a Clinical Algorithm

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

Plastic and Reconstructive Surgery: December 2018 - Volume 142 - Issue 6 - p 826e–835e

Background: Nipple-sparing mastectomy allows for preservation of the entire nipple-areola complex using various incision patterns. Reconstructive trends and overall risk associated with these diverse nipple-sparing mastectomy incisions have yet to be fully elucidated.

Methods: All nipple-sparing mastectomies from 2006 to 2017 were identified; outcomes were stratified by type of mastectomy incision: lateral or vertical radial, inframammary fold, Wise pattern, previous, and periareolar.

Results: A total of 1207 nipple-sparing mastectomies were included for final analysis. Of these, 638 (52.9 percent) used an inframammary fold incision, 294 (24.4 percent) used a lateral radial incision, 161 (13.3 percent) used a vertical radial incision, 60 (5.0) used a Wise pattern incision, 35 (2.9 percent) used a previous incision, and 19 (1.6 percent) used a periareolar incision. The groups were heterogeneous and differed significantly with regard to various factors, including age (p < 0.001), body mass index (p < 0.001), reconstruction modality (p < 0.001), and others. In crude multivariate logistic regression analysis, vertical radial (16.1 percent) and inframammary fold incisions (21.0 percent) were associated with lower overall complication rates. In a reduced multivariate logistic regression model, inframammary fold incisions (p = 0.001) emerged as significantly protective of overall complications after controlling all variables.

Conclusions: Nipple-sparing mastectomy may be safely performed using various mastectomy incisions, each with unique advantages and limitations. Overall, inframammary fold incisions appear to be associated with the lowest risk, whereas Wise pattern incisions may increase risk. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Stacked Hemiabdominal Extended Perforator Flap for Autologous Breast Reconstruction

The Stacked Hemiabdominal Extended Perforator Flap for Autologous Breast Reconstruction

 by Beugels, Jop; Vasile, Julie V.; Tuinder, Stefania M. H.; Delatte, Stephen J.; St-Hilaire, Hugo; Allen, Robert J.; Levine, Joshua L.  

Plastic and Reconstructive Surgery: December 2018 - Volume 142 - Issue 6 - p 1424–1434

Background: Options for bilateral autologous breast reconstruction in thin women are limited. The aim of this study was to introduce a novel approach to increase abdominal flap volume with the stacked hemiabdominal extended perforator (SHAEP) flap. The authors describe the surgical technique and analyze their results.

Methods: A retrospective study was conducted of all SHAEP flap breast reconstructions performed since February of 2014. Patient demographics, operative details, complications, and flap reexplorations were recorded. The bipedicled hemiabdominal flap was designed as a combination of the deep inferior epigastric artery perforator (DIEP) and a second, more lateral pedicle: the deep or superficial circumflex iliac perforator vessels, the superficial inferior epigastric artery, or a lumbar artery or intercostal perforator.

Results: A total of 90 SHAEP flap breast reconstructions were performed in 49 consecutive patients. Median operative time was 500 minutes (range, 405 to 797 minutes). Median hemiabdominal flap weight that was used for reconstruction was 598 g (range, 160 to 1389 g). No total flap losses were recorded. Recipient-site complications included partial flap loss (2.2 percent), hematoma (3.3 percent), fat necrosis (2.2 percent), and wound problems (4.4 percent). Minor donor-site complications occurred in five patients (10.2 percent). Most flaps were harvested on a combination of the DIEP and deep circumflex iliac artery vessels.

Conclusions: This study demonstrated that the SHAEP flap is an excellent option for bilateral autologous breast reconstruction in women who require significant breast volume but have insufficient abdominal tissue for a bilateral DIEP flap. The bipedicled SHAEP flap allows for enhanced flap perfusion, increased volume, and abdominal contour improvement using a single abdominal donor site. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Assessing Age as a Risk Factor for Complications in Autologous Breast Reconstruction

Assessing Age as a Risk Factor for Complications in Autologous Breast Reconstruction

by Torabi, Radbeh; Stalder, Mark W.; Tessler, Oren; Bartow, Matthew J.; Lam, Jonathan; Patterson, Charles; Wise, M. Whitten; Dupin, Charles L.; St. Hilaire, Hugo  

Plastic and Reconstructive Surgery: December 2018 - Volume 142 - Issue 6 - p 840e–846e

Background: Breast cancer is primarily a diagnosis of older women. Many patients seeking breast reconstruction are elderly women (aged 65 years or older). However, many surgeons anecdotally believe that surgery in elderly patients is inherently dangerous, or at least prone to more complications. 

Methods: The authors conducted a retrospective cohort study composed of chart review of all deep inferior epigastric perforator flap breast reconstruction patients at a single institution divided into an elderly cohort (65 years or older) and a nonelderly cohort (younger than 65 years). Cohort was the primary predictor variable. Demographic and comorbidity data were secondary predictor variables. Primary outcomes were complete flap loss, partial flap loss, or need for flap reexploration. Secondary outcomes such as wound healing problems, seroma, and others were also assessed. 

Results: There were 285 flaps in the nonelderly cohort and 54 flaps in the elderly cohort. The elderly cohort had higher rates of diabetes, hypertension, and hyperlipidemia. Chi-square analysis showed no significant differences in primary outcomes between the two cohorts. Breast wound dehiscence was significantly higher in the elderly cohort (p < 0.01). On logistic regression, being elderly was seen as a significant risk factor for complete flap loss (OR, 10.92; 95 percent CI, 0.97 to 122.67; p = 0.05). The overall success rate for the nonelderly cohort was 99.6 percent, whereas the success rate for the nonelderly cohort was 96.3 percent. 

Conclusions: Elderly women desire breast reconstruction. Free flap breast reconstruction is a viable and safe procedure in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Modern Primary Breast Augmentation: Best Recommendations for Best Results

Modern Primary Breast Augmentation: Best Recommendations for Best Results

 by Wan, Dinah; Rohrich, Rod J.  

Plastic and Reconstructive Surgery: December 2018 - Volume 142 - Issue 6 - p 933e–946e

Learning Objectives: After reading this article, the participant should be able to: 

1. Develop a practical method for preoperative implant size selection. 

2. List characteristics and examples of fourth- and fifth-generation silicone implants. 

3. Recognize the differences in “profile” designations across implant manufacturers. 

4. Recall updated statistics on breast implant–associated anaplastic large cell lymphoma and describe current guidelines on disease diagnosis and treatment. 

5. Apply atraumatic and aseptic surgical techniques in primary breast augmentation. 

Summary: Modern primary breast augmentation requires an intimate knowledge of the expanding breast implant market, including characteristics of current generation silicone implants and “profile” types. Optimal implant size selection requires balancing patient desires with tissue qualities. Evidence and awareness of breast implant–associated anaplastic large cell lymphoma continue to grow, and patients and surgeons alike should be informed on the most updated facts of the disease entity. Atraumatic surgical technique and aseptic adjuncts are critical in reducing periprosthetic inflammation and contamination, both of which are known instigators of capsular contracture and potentially breast implant–associated anaplastic large cell lymphoma.

Fat Graft Safety after Oncologic Surgery: Addressing the Contradiction between In Vitro and Clinical Studies

Fat Graft Safety after Oncologic Surgery: Addressing the Contradiction between In Vitro and Clinical Studies

by Orbay, Hakan; Hinchcliff, Katharine M.; Charvet, Heath J.; Sahar, David E.  

Plastic and Reconstructive Surgery: December 2018 - Volume 142 - Issue 6 - p 1489–1499

Background: The authors investigate the in vitro and in vivo interaction of human breast cancer cells and human adipose-derived stem cells to address the controversy on the safety of postmastectomy fat grafting. Methods: The authors co-cultured human adipose-derived stem cells and MDA-MB-231 breast cancer cells in an in vitro cell migration assay to examine the migration of breast cancer cells. In the in vivo arm, the authors injected breast cancer cells (group I), human breast cancer cells plus human adipose-derived stem cells (group II), human breast cancer cells plus human fat graft (group III), and human breast cancer cells plus human fat graft plus human adipose-derived stem cells (group IV) to the mammary fat pads of female nude mice (n = 20). The authors examined the tumors, livers, and lungs histologically after 2 weeks. Results: Migration of breast cancer cells increased significantly when co-cultured with adipose-derived stem cells (p < 0.05). The tumor growth rate in group IV was significantly higher than in groups I and II (p < 0.05). The tumor growth rate in group III was also higher than in groups I and II, but this difference was not statistically significant (p > 0.05). Histologically, there was no liver/lung metastasis at the end of 2 weeks. The vascular density in the tumors from group IV was significantly higher than in other groups (p < 0.01). Conclusion: The injection of breast cancer cells, fat graft, and adipose-derived stem cells together increases breast cancer xenograft growth rates significantly.

[Articles] Neoadjuvant chemotherapy with or without anthracyclines in the presence of dual HER2 blockade for HER2-positive breast cancer (TRAIN-2): a multicentre, open-label, randomised, phase 3 trial

[Articles] Neoadjuvant chemotherapy with or without anthracyclines in the presence of dual HER2 blockade for HER2-positive breast cancer (TRAIN-2): a multicentre, open-label, randomised, phase 3 trial

 by Mette S van Ramshorst, Anna van der Voort, Erik D van Werkhoven, Ingrid A Mandjes, Inge Kemper, Vincent O Dezentjé, Irma M Oving, Aafke H Honkoop, Lidwine W Tick, Agnes J van de Wouw, Caroline M Mandigers, Laurence J van Warmerdam, Jelle Wesseling, Marie-Jeanne T Vrancken Peeters, Sabine C Linn, Gabe S Sonke, Dutch Breast Cancer Research Group (BOOG)  

The Lancet Oncology: Volume 19, issue 12, P1630-1640, December 01, 2018

In view of the high proportion of pathological complete responses recorded in both groups and the fact that febrile neutropenia was more frequent in the anthracycline group, omitting anthracyclines from neoadjuvant treatment regimens might be a preferred approach in the presence of dual HER2 blockade in patients with early HER2-positive breast cancer. Long-term follow-up is required to confirm these results.

Breast Implant Mycobacterial Infections: An Epidemiologic Review and Outcome Analysis

Breast Implant Mycobacterial Infections: An Epidemiologic Review and Outcome Analysis

Authors:  Al-Halabi, Becher; Viezel-Mathieu, Alex; Shulman, Zachary; Behr, Marcel A.; Fouda Neel, Omar  

Plastic and Reconstructive Surgery:  November 2018 - Volume 142 - Issue 5 

Background: Epidemiologic evidence of periprosthetic mycobacterial infections is limited. The recent boom in cosmetic surgery tourism has been associated with a rise of surgical-site infections in returning patients. This review aims to explore available data, examine trends of documented periprosthetic mycobacterial infections, and analyze outcomes of management techniques. Methods: A search in the Biosis, Embase, LILACS, MEDLINE, and Web of Science databases from inception until December of 2017 for “Breast Implants” and “Mycobacterial Infections” and equivalents was performed. Data were pooled after two screening rounds following full-text retrieval and cross-referencing.

Results: Forty-one reports describing 171 female patients who had breast prosthesis–related mycobacterial infections were identified. Bibliometric case-based analysis revealed a rise of periprosthetic mycobacterial infections in developing countries since the start of the millennium. The mean patient’s age was 37.9 years and the majority of patients had undergone bilateral breast augmentation. Most patients presented with breast pain or tenderness, after an average incubation period of 9 months. Mycobacterium fortuitum was isolated from 90 cases (52.6 percent). Immediate explantation with or without delayed reimplantation was the most commonly used surgical strategy, complemented by combination antimicrobial therapy for an average of 4.6 months. The mean follow-up time was 39.7 months, during which recurrence was observed in 21 of 171 patients (12.3 percent).

Conclusions: The emergence of periprosthetic mycobacterial infections in relation to cosmetic medical tourism alerts clinicians to the importance of educating the public about the associated risks. In addition, this study identifies risk factors associated with recurrence of periprosthetic mycobacterial infections.