Tuesday 17 December 2019

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



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

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

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

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



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

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

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

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



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

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

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

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

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

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

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



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

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

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

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



by Marie Robert, Nicholas Turner 

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

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

[News] Promising radiotherapy classifier for early breast cancer



by Manjulika Das 

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

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

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



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

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

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