Long-Term Results and Reconstruction Failure in Patients Receiving Postmastectomy Radiation Therapy with a Temporary Expander or Permanent Implant in Place

Long-Term Results and Reconstruction Failure in Patients Receiving Postmastectomy Radiation Therapy with a Temporary Expander or Permanent Implant in Place

by Dicuonzo, Samantha; Leonardi, Maria Cristina; Radice, Davide; Morra, Anna; Gerardi, Marianna Alessandra; Rojas, Damaris Patricia; Surgo, Alessia; Dell’Acqua, Veronica; Luraschi, Rosa; Cattani, Federica; Rietjens, Mario; De Lorenzi, Francesca; Veronesi, Paolo; Galimberti, Viviana; Marvaso, Giulia; Fodor, Cristiana; Orecchia, Roberto; Jereczek-Fossa, Barbara Alicja

Plastic and Reconstructive Surgery: February 2020 - Volume 145 - Issue 2 - p 317-327

Background: This study investigated the risk of reconstruction failure after mastectomy, immediate breast reconstruction, and radiotherapy to either a temporary tissue expander or permanent implant.

Methods: Records of women treated at a single institution between June of 1997 and December of 2011 were reviewed. Two patient groups were identified based on type of immediate breast reconstruction: tissue expander followed by exchange with a permanent implant and permanent implant. The study endpoint was rate of reconstruction failure, defined as a replacement, loss of the implant, or conversion to flap.

Results: The tissue expander/permanent implant and the permanent implant groups consisted of 63 and 75 patients, respectively. The groups were well balanced for clinical and treatment characteristics. With a median follow-up of 116 months, eight implant losses, 50 implant replacements, and four flap conversions were recorded. Reconstruction failure occurred in 22 of 63 patients in the expander/implant group and in 40 of 75 patients in the permanent implant group. A traditional proportional hazards model showed a higher risk of reconstruction failure for the expander/implant group (hazard ratio, 2.01) and a significantly shorter time to reconstruction failure compared with the permanent implant group (109.2 months versus 157.7 months; p = 0.03); however, according to a competing risk model, the between-groups cumulative incidences were not significantly different (hazard ratio, 1.09).

Conclusions: Radiotherapy to either a tissue expander or a permanent implant presented a fairly large risk of reconstruction failure over time. The expander/implant group was not more likely to develop reconstruction failure compared to permanent implant group, but the timing of onset was shorter. More complex techniques should be investigated to lower the risk of reconstruction failure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Predicting Ischemic Complications in the Inframammary Approach to Nipple-Sparing Mastectomy: The Midclavicular-to–Inframammary Fold Measurement

Predicting Ischemic Complications in the Inframammary Approach to Nipple-Sparing Mastectomy: The Midclavicular-to–Inframammary Fold Measurement

by Willey, Shawna C.; Fan, Kenneth L.; Luvisa, Kyle; Graziano, Francis D.; Lau, Stephanie H. Y.; Black, Cara K.; Song, David H.; Pittman, Troy

Plastic and Reconstructive Surgery: February 2020 - Volume 145 - Issue 2 - p 251e-262e

Background: The authors refine their anatomical patient selection criteria with a novel midclavicular-to–inframammary fold measurement for nipple-sparing mastectomy performed through an inframammary approach.

Methods: Retrospective review was performed of all nipple-sparing mastectomies performed through an inframammary approach. Exclusion criteria included other mastectomy incisions, staged mastectomy, previous breast operation, and autologous reconstruction. Preoperative anatomical measurements for each breast, clinical course, and specimen weight were obtained.

Results: One hundred forty breasts in 79 patients were analyzed. Mastectomy weight, but not sternal notch–to-nipple distance, was strongly correlated with midclavicular-to–inframammary fold measurement on linear regression (R2 = 0.651; p < 0.001). Mastectomy weight was not correlated with ptosis. Twenty-five breasts (17.8 percent) had ischemic complications: 16 (11.4 percent) were nonoperative and nine (6.4 percent) were operative. Those with mastectomy weights of 500 g or greater were nine times more likely to have operative ischemic complications than those with mastectomy weights less than 500 g (p = 0.0048). Those with a midclavicular-to–inframammary fold measurement of 30 cm or greater had a 3.8 times increased incidence of any ischemic complication (p = 0.00547) and a 9.2 times increased incidence of operative ischemic complications (p = 0.00376) compared with those whose midclavicular-to–inframammary fold measurement was less than 30 cm.

Conclusions: Breasts undergoing nipple-sparing mastectomy by means of an inframammary approach with midclavicular-to–inframammary fold measurement greater than or equal to 30 cm are at higher risk for having ischemic complications, warranting consideration for a staged approach or other incision. The midclavicular-to–inframammary fold measurement is useful for assessing the entire breast and predicting the likelihood of ischemic complications in inframammary nipple-sparing mastectomies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

3D digital breast cancer models with multimodal fusion algorithms

3D digital breast cancer models with multimodal fusion algorithms

by Sílvia Bessa, Pedro F. Gouveia, Pedro H. Carvalho, Cátia Rodrigues, Nuno L. Silva, Fátima Cardoso, Jaime S. Cardoso, Hélder P. Oliveira, Maria João Cardoso

The Breast: FULL LENGTH ARTICLE| VOLUME 49, P281-290, FEBRUARY 01, 2020

Breast cancer image fusion consists of registering and visualizing different sets of a patient synchronized torso and radiological images into a 3D model. Breast spatial interpretation and visualization by the treating physician can be augmented with a patient-specific digital breast model that integrates radiological images. But the absence of a ground truth for a good correlation between surface and radiological information has impaired the development of potential clinical applications.A new image acquisition protocol was designed to acquire breast Magnetic Resonance Imaging (MRI) and 3D surface scan data with surface markers on the patient’s breasts and torso.

Second conservative treatment for second ipsilateral breast tumor event: A systematic review of the different re-irradiation techniques

Second conservative treatment for second ipsilateral breast tumor event: A systematic review of the different re-irradiation techniques

by Lucile Montagne, Arthur Hannoun, Jean-Michel Hannoun-Levi 

The Breast: REVIEW| VOLUME 49, P274-280, FEBRUARY 01, 2020

To address the different partial breast re-irradiation techniques available in the context of second conservative treatment (SCT), as an alternative to salvage mastectomy, for 2nd ipsilateral breast tumor event (IBTE) and summarize their respective oncological and toxicity outcomes.

Stand-alone artificial intelligence - The future of breast cancer screening?

Stand-alone artificial intelligence - The future of breast cancer screening?

by Ioannis Sechopoulos, Ritse M. Mann 

The Breast: FULL LENGTH ARTICLE| VOLUME 49, P254-260, FEBRUARY 01, 2020

Although computers have had a role in interpretation of mammograms for at least two decades, their impact on performance has not lived up to expectations. However, in the last five years, the field of medical image analysis has undergone a revolution due to the introduction of deep learning convolutional neural networks – a form of artificial intelligence (AI). Because of their considerably higher performance compared to conventional computer aided detection methods, these AI algorithms have resulted in renewed interest in their potential for interpreting breast images in stand-alone mode.

Artificial intelligence in digital breast pathology: Techniques and applications

Artificial intelligence in digital breast pathology: Techniques and applications

by Asmaa Ibrahim, Paul Gamble, Ronnachai Jaroensri, Mohammed M. Abdelsamea, Craig H. Mermel, Po-Hsuan Cameron Chen, Emad A. Rakha

The Breast: ORIGINAL ARTICLE| VOLUME 49, P267-273, FEBRUARY 01, 2020

Breast cancer is the most common cancer and second leading cause of cancer-related death worldwide. The mainstay of breast cancer workup is histopathological diagnosis - which guides therapy and prognosis. However, emerging knowledge about the complex nature of cancer and the availability of tailored therapies have exposed opportunities for improvements in diagnostic precision. In parallel, advances in artificial intelligence (AI) along with the growing digitization of pathology slides for the primary diagnosis are a promising approach to meet the demand for more accurate detection, classification and prediction of behaviour of breast tumours.

Statistical modelling of HER2-positivity in breast cancer: Final analyses from two large, multicentre, non-interventional studies in Germany

Statistical modelling of HER2-positivity in breast cancer: Final analyses from two large, multicentre, non-interventional studies in Germany

by Josef Rüschoff, Annette Lebeau, Peter Sinn, Hans-Ulrich Schildhaus, Thomas Decker, Johannes Ammann, Claudia Künzel, Winfried Koch, Michael Untch

The Breast: ORIGINAL ARTICLE| VOLUME 49, P246-253, FEBRUARY 01, 2020

The German NIU HER2 model was developed based on five variables found to have statistically significant influences on HER2-positivity, to allow exploration of deviations between model-predicted and actual HER2-positivity rates as a measure of testing quality. The prospective, non-interventional EPI HER2 BC study (NCT02666261) compared NIU and EPI data, aiming to validate the NIU model.

Winter is over: The use of Artificial Intelligence to individualise radiation therapy for breast cancer

Winter is over: The use of Artificial Intelligence to individualise radiation therapy for breast cancer

by Philip M.P. Poortmans, Silvia Takanen, Gustavo Nader Marta, Icro Meattini, Orit Kaidar-Person 

The Breast: FULL LENGTH ARTICLE| VOLUME 49, P194-200, FEBRUARY 01, 2020

Artificial intelligence demonstrated its value for automated contouring of organs at risk and target volumes as well as for auto-planning of radiation dose distributions in terms of saving time, increasing consistency, and improving dose-volumes parameters. Future developments include incorporating dose/outcome data to optimise dose distributions with optimal coverage of the high-risk areas, while at the same time limiting doses to low-risk areas. An infinite gradient of volumes and doses to deliver spatially-adjusted radiation can be generated, allowing to avoid unnecessary radiation to organs at risk.

Are Breast Implants Safe?

Are Breast Implants Safe?

by Rohrich, Rod J.; Kaplan, Jordan 

Plastic and Reconstructive Surgery: February 2020 - Volume 145 - Issue 2 - p 587-589

Breast implants are among the most well-studied implantable medical devices placed in humans. They have been used in both reconstructive and aesthetic breast surgery for more than 60 years. The safety of the device has been affirmed repeatedly through extensive long-term studies and further research continues to take place in order to ensure patient safety.1 Recent scientific studies have shown an infrequent correlation between textured breast implants and anaplastic large cell lymphoma (ALCL), which has resulted in a specific subset of textured breast implants to be removed from market secondary to a higher incidence of this disease.2 Such action reaffirms the importance of ongoing research in all aspects of plastic surgery as we always place patient safety first and foremost.

As physicians who took a Hippocratic oath to do no harm, we must adhere to these same scientific standards if we are to meaningfully define the wide range of symptoms that have collectively become known on social media as “breast implant illness.” This condition has been attributed to any and all types of saline and silicone breast implants and their surrounding silicone shells. It has been postulated that the implant shell itself may have toxins or other yet-to-be-defined elements that cause a myriad of symptoms yet to be articulated in a scientific manner.3 A 2006 study published in the Annals of Chemistry evaluated the total platinum concentration in both patient tissue and breast implant samples. The authors concluded that women with silicone breast implants have platinum levels that exceed that of the general population.4 However, a critical analysis highlighted that platinum concentrations in blood and urine samples showed no statistically significant difference and that both the control and implanted groups were shown to have platinum levels comparable to those in platinum industry workers. Furthermore, the study design was deemed nonreproducible.5,6 Pinpointing a material explanation for breast implant illness symptoms has been impeded by poor data collection and lack of science and dissemination of misinformation on social media, which places patients with breast implants at risk of making improperly informed decisions.

This is not to say that breast implant illness does not exist—both patient advocacy groups and the U.S. Food and Drug Administration recognize various symptoms as being risks related to breast implants7—but rather that there is no current scientific evidence to support such claims. It is therefore the responsibility of plastic surgeons to advise patients who may present with symptoms associated with breast implant illness to seek full evaluation by our medical and rheumatology colleagues to ensure we are not missing any type of disease process; the American Society of Plastic Surgeons is taking the lead in working with patients and with the Food and Drug Administration to investigate these widely reported symptoms in an effort to supplant speculation with data and science.

Recent Advances in Implant-Based Breast Reconstruction

Recent Advances in Implant-Based Breast Reconstruction

by Colwell, Amy S.; Taylor, Erin M. 

Plastic and Reconstructive Surgery: February 2020 - Volume 145 - Issue 2 - p 421e-432e

Learning Objectives: After reading this article, the participant should be able to: 1. Understand the indications for implant-based breast reconstruction and the indications for nipple preservation compared to skin-sparing or skin-reducing patterns. 2. Understand the indications for direct-to-implant breast reconstruction versus tissue expander/implant breast reconstruction and the advantages and disadvantages of total, partial, or no muscle coverage. 3. Understand the role of acellular dermal matrix or mesh in reconstruction. 4. Learn the advantages and disadvantages of different types and styles of implants and develop a postoperative plan for care and pain management. 

Summary: Breast reconstruction with implants has seen a decade of advances leading to more natural breast reconstructions and lower rates of complications.

CDK4/6 inhibitor treatment for patients with hormone receptor-positive, HER2-negative, advanced or metastatic breast cancer: a US Food and Drug Administration pooled analysis

CDK4/6 inhibitor treatment for patients with hormone receptor-positive, HER2-negative, advanced or metastatic breast cancer: a US Food and Drug Administration pooled analysis

by Jennifer J Gao, Joyce Cheng, Erik Bloomquist, Jacquelyn Sanchez, Suparna B Wedam, Harpreet Singh, Laleh Amiri-Kordestani, Amna Ibrahim, Rajeshwari Sridhara, Kirsten B Goldberg, Marc R Theoret, Paul G Kluetz, Gideon M Blumenthal, Richard Pazdur, Julia A Beaver, Tatiana M Prowell

The Lancet Oncology: VOLUME 21, ISSUE 2, P250-260, FEBRUARY  01, 2020

Since the addition of CDKI to endocrine therapy seemed to benefit all clinicopathological subgroups of interest in this pooled analysis, further research is needed to identify patient subgroups for whom endocrine therapy alone might be appropriate for first-line or second-line treatment of hormone receptor-positive, HER2-negative metastatic breast cancer.