Breast Surgery Bulletin - June 2022

 

Radiation recall dermatitis induced by COVID-19 vaccination in breast cancer patients treated with postoperative radiation therapy

by Vinante Lorenzo, Caroli Angela, Revelant Alberto, Bertini Federica, Giroldi Anna, Marson Marta, Franchin Giovanni, Muraro Elena, Brisotto Giulia, Steffan Agostino, Baboci Lorena 

 

The Breast: Published: July 01, 2022

 

Background

and purpose: Radiation recall dermatitis is an adverse event predominantly due to systemic therapy administration after a previous radiation therapy course. Few case reports describe radiation recall dermatitis in breast cancer patients treated with postoperative radiation therapy following COVID-19 vaccination. In this study we investigated the incidence and severity of radiation recall dermatitis after COVID-19 vaccination in irradiated breast cancer patients.

Methods

Patients that received at least one COVID-19 vaccination dose during the year after the end of postoperative breast radiation therapy were included in this observational monocentric study. Local symptoms occurring inside the radiation field after vaccination were patient-reported and scored according to the PRO-CTCAE questionnaire. Descriptive data of radiation recall dermatitis incidence and severity, and potential risk factors were evaluated.

Results

A cohort of 361 patients with 756 administered COVID-19 vaccinations was analyzed. Breast symptoms were reported by 7.5% of patients, while radiation recall dermatitis was considered for 5.5%. The incidence of radiation recall dermatitis per single dose of vaccine was 2.6%, with a higher risk for the first dose compared to the second/third (4.4% vs 1%, p = 0.003), especially when administered within the first month after the end of irradiation (12.5% vs 2.2%, p = 0.0004). Local symptoms were generally self-limited and a few cases required anti-inflammatory drugs.

Conclusions

Radiation recall dermatitis is an uncommon but not rare phenomenon in breast cancer patients that received COVID-19 vaccination within one year after breast irradiation. However, symptoms severity were generally low/mild and reversible. These findings can be useful for patient counseling.

 

A Novel Validated Breast Aesthetic Scale

by Duraes, Eliana F. R.; Durand, Paul; Morisada, Megan; Scomacao, Isis; Duraes, Leonardo C.; de Sousa, Joao Batista; Abedi, Nasim; Djohan, Risal S.; Bernard, Steven; Moreira, Andrea; Schwarz, Graham S. 

Plastic and Reconstructive Surgery: June 2022 - Volume 149 - Issue 6 - p 1297-1308

 

Background: 

Breast aesthetics impacts patients’ quality of life after breast reconstruction, but patients and surgeons frequently disagree on the final aesthetic evaluation. The need for a comprehensive, validated tool to evaluate breast aesthetics independently from the patient motivated this study.

Methods: 

The 13-item Validated Breast Aesthetic Scale was developed after several internal meetings, and worded to be understood by a nonspecialist. Three items are common for both breasts, with the remaining being side-specific. To test the internal consistency of the scale subitems, postoperative photographs after different breast reconstruction techniques were graded by a six-member panel. To test interrater and intrarater correlation across time, four physicians evaluated the results of abdominally based breast reconstructions following nipple-sparing mastectomies.

Results: 

Graded aesthetic outcomes of 53 patients showed that the Cronbach alpha of the subitems of the scale was 0.926, with no single item that, if excluded, would increase it. Twenty-two patients underwent aesthetic outcomes grading at four different time points. The mean overall appearance was 3.71 ± 0.62. The mean grade for overall nipple appearance was 4.0 ± 0.57. The coefficient alpha of the panel overall aesthetic grade across different time points was 0.957; whereas intragrader reliability for graders 1 through 4 individually showed alpha coefficients of 0.894, 0.9, 0.898, and 0.688, respectively. Similar results were found for the other items of the scale.

Conclusions: 

The proposed aesthetic scale evaluates different aspects of the breast reconstruction aesthetic result with excellent internal consistency among its subitems. Grading by a gender-balanced, diverse four-member panel using postoperative photographs showed higher reliability and reproducibility compared to single graders.

 

 

 

The role of postoperative radiation therapy in stage I–III male breast cancer: A population-based study from the Surveillance, Epidemiology, and End Results database

by Peiwen Wu, Dongjie He, Shuchai Zhu, Hao Chang, Qiming Wang, Qiuju Shao, Gaiyan Li 

The Breast: Published: June 22, 2022

 

Background

This study aimed to investigate the role of adjuvant radiation therapy in a large population-based cohort of patients with stage I–III male breast cancer (MaBC).

Methods

Patients with stage I–III breast cancer treated with surgery were selected from the Surveillance, Epidemiology, and End Results cancer database from 2010 to 2015. Multivariate logistic regression identified the predictors of receiving radiation therapy. Multivariate Cox regression model were used to evaluate the predictors of survival.

Results

We identified 1321 patients. Age, stage, positive regional nodes, surgical procedure, and HER2 status were strong predictors of radiation therapy administration. There was no difference between patients who received radiation therapy and those who did not (P = 0.46); however, after propensity score matching, it was associated with improved OS (P = 0.04). In the multivariate analysis, the factors associated with better OS were administration of radiation therapy and chemotherapy. In the subset analysis, adjuvant radiation therapy was associated with improved OS in men undergoing breast-conserving surgery (BCS), with four or more node-positive or larger primary tumours (T3/T4). Furthermore, we found no benefit of radiation therapy, regardless of the type of axillary surgery in mastectomy (MS). In older MaBC patients with T1-2N1 who underwent MS, radiation therapy showed no significant effects, regardless of chemotherapy.

Conclusion

Adjuvant radiation therapy could improve the survival of MaBC patients undergoing BCS, with four or more node-positive or larger primary tumours. Moreover, it should be carefully considered in patients undergoing MS and older T1-2N1 patients.

 

A systematic assessment of online international breast density information

 

by Brooke Nickel, Tessa Copp, Tong Li, Hankiz Dolan, Meagan Brennan, Angela Verde, Lisa Vaccaro, Kirsten McCaffery, Nehmat Houssami 

 

The Breast: Published: June 22, 2022

 

Background

Breast density has become a topic of international discussion due to its associated risk of breast cancer. As online is often a primary source of women's health information it is therefore essential that breast density information it is understandable, accurate and reflects the best available evidence. This study aimed to systematically assess online international breast density information including recommendations to women.

Methods

Searches were conducted from five different English-speaking country-specific Google locations. Relevant breast density information was extracted from the identified websites. Readability was assessed using the SHeLL Editor, and understandability and actionability using the Patient Education Materials Assessment Tool (PEMAT). A content analysis of specific recommendations to women was also conducted.

Results

Forty-two eligible websites were identified and systematically assessed. The included informational content varied across websites. The average grade reading level across all websites was 12.4 (range 8.9–15.4). The mean understandability was 69.9% and the mean actionability was 40.1%, with 18/42 and 39/42 websites respectively scoring lower than adequate (70%). Thirty-six (85.7%) of the websites had breast density-related recommendation to women, with ‘talk to your doctor’ (n = 33, 78.6%) the most common.

Conclusions

Online information about breast density varies widely and is not generally presented in a way that women can easily understand and act on, therefore greatly reducing the ability for informed decision-making. International organisations and groups disseminating breast density information need to ensure that women are presented with health literacy-sensitive and balanced information, and be aware of the impact that recommendations may have on practice.

 

Moderate penetrance genes complicate genetic testing for breast cancer diagnosis: ATM, CHEK2, BARD1 and RAD51D

 

by R. Graffeo, H.Q. Rana, F. Conforti, B. Bonanni, M.J. Cardoso, S. Paluch-Shimon, O. Pagani, A. Goldhirsch, A.H. Partridge, M. Lambertini, J.E. Garber 

 

The Breast: Published: June 18, 2022

 

Breast cancer risk associated with germline likely pathogenic/pathogenic variants (PV) varies by gene, often by penetrance (high >50% or moderate 20–50%), and specific locus.

Germline PVs in BRCA1 and BRCA2 play important roles in the development of breast and ovarian cancer in particular, as well as in other cancers such as pancreatic and prostate cancers and melanoma. Recent studies suggest that other cancer susceptibility genes, including ATM, CHEK2, PALB2, RAD51C and RAD51D confer differential risks of breast and other specific cancers.

In the era of multigene panel testing, advances in next-generation sequencing technologies have notably reduced costs in the United States (US) and enabled sequencing of BRCA1/2 concomitantly with additional genes. The use of multigene-panel testing is beginning to expand in Europe as well.

Further research into the clinical implications of variants in moderate penetrance genes, particularly in unaffected carriers, is needed for appropriate counselling and risk management with data-driven plans for surveillance and/or risk reduction. For individuals at high risk without any pathogenic or likely pathogenic variant in cancer susceptibility genes or some carriers of pathogenic variants in moderate-risk genes such as ATM and CHEK2, polygenic risk scores offer promise to help stratify breast cancer risk and guide appropriate risk management options.

Cancer patients whose tumours are driven by the loss of function of both copies of a predisposition gene may benefit from therapies targeting the biological alterations induced by the dysfunctional gene e.g. poly ADP ribose polymerase (PARP) inhibitors and other novel pathway agents in cancers with DNA repair deficiencies. A better understanding of mechanisms by which germline variants drive various malignancies may lead to improvements in both therapeutic and preventive management options.

 

Surgical and Patient-Reported Outcomes of Autologous versus Implant-Based Reconstruction following Infected Breast Device Explantation

 

by Asaad, Malke; Slovacek, Cedar; Mitchell, David; Liu, Jun; Selber, Jesse C.; Clemens, Mark W.; Chu, Carrie K.; Mericli, Alexander F.; Butler, Charles E. 

 

Plastic and Reconstructive Surgery: June 2022 - Volume 149 - Issue 6 - p 1080e-1089e

 

Background: 

Implant-based breast reconstruction infections often require implant explantation. Whereas some plastic surgeons pursue autologous reconstruction following the first implant-based breast reconstruction failure caused by infection, others argue that a second attempt is acceptable.

Methods: 

The authors conducted a retrospective study of patients who underwent a second reconstruction attempt with implant-based or free flap breast reconstruction following explantation because of infection between 2006 and 2019. Surgical and patient-reported outcomes were compared between the two groups.

Results: 

A total of 6093 implant-based breast reconstructions were performed during the study period, of which 130 breasts met our inclusion criteria [implant-based, n = 86 (66 percent); free flap, n = 44 (34 percent)]. No significant differences in rates of overall (25 percent versus 36 percent; p = 0.2) or major (20 percent versus 21 percent; p = 0.95) complications were identified between the free flap and implant-based cohorts, respectively. Implant-based breast reconstruction patients were more likely to experience a second infection (27 percent versus 2 percent; p = 0.0007) and reconstruction failure (21 percent versus 5 percent; p = 0.019). Among irradiated patients, reconstruction failure was reported in 44 percent of the implant-based and 7 percent of the free flap cohorts (p = 0.02). Free flap patients reported significantly higher scores for Satisfaction with Breasts (73.7 ± 20.1 versus 48.5 ± 27.9; p = 0.0046).

Conclusions: 

Following implant-based breast reconstruction explantation because of infection, implant-based and free flap breast reconstruction had similar rates of overall and major complications; however, implant-based breast reconstruction had considerably higher rates of infection and reconstructive failures and lower patient-reported scores for Satisfaction with Breasts. Given the high rates of implant-based breast reconstruction failure in patients with prior radiotherapy and infection-based failure, plastic surgeons should strongly consider autologous reconstruction in this patient population.

 

Breast cancer patients’ most important quality of life themes for a radiotherapy decision aid

 by Cheryl Roumen, Hajar Hasannejadasl, Rachelle Swart, Daniela Raphael, Leonard Wee, Matthijs Sloep, Desiree H.J.G. van den Bongard, Helena Verkooijen, Salina Thijssen, Mirjam Velting, Maaike Schuurman, Nicola S. Russell, Rianne Fijten, Liesbeth J. Boersma

 The Breast: Published: June 10, 2022

 

Background and aim

The BRASA patient decision aid (BRASA-PtDA) facilitates shared decision making for breast cancer patients (BCPs) facing a radiotherapy treatment decision. During evaluations, patients indicated the wish for quantitative information on side effects. Therefore, this study assessed BCPs opinion on which and how information on side effects should be incorporated in the BRASA-PtDA.

Methods

A workshop was organized with BCPs (n = 9), researchers (n = 5) and clinicians (n = 3). Subsequently, a survey was sent to BCPs (n = 744) investigating the generalisability of the workshop findings, and posing additional questions. The survey entailed multiple choice questions on quality of life themes, the use of a decision aid and risk communication.

Results

The workshop revealed BCPs wish for a layered, all encompassing information system. Information on the impact of side effects on daily life was preferred above the risk of these side effects. The survey revealed that important quality of life (QoL) themes were having energy (81%; n = 605), arm function (61%; n = 452), pain (55%; n = 410). Despite the focus on qualitative effects in the workshop, 89% of the survey respondents also wanted to be informed on individualized risks of side effects. 54% Of the survey respondents had never heard of a PtDA.

Conclusions

BCPs preferred information on the impact of side effects, but also their individualized risks on side effects. Most important QoL themes were having enough energy, arm function and pain. Consequently, the BRASA-PtDA should be reshaped, starting with quality of life themes, rather than side effects.

 

A nested case-control study on radiation dose-response for cardiac events in breast cancer patients in Germany

  by Dan Baaken, Hiltrud Merzenich, Marcus Schmidt, Inga Bekes, Lukas Schwentner, Wolfgang Janni, Achim Woeckel, Manfred Mayr, Stephan Mose, Thomas Merz, Voica Ghilescu, Jona Renner, Detlef Bartkowiak, Thomas Wiegel, Maria Blettner, Heinz Schmidberger, Daniel Wollschläger 

 The Breast: Published: June 09, 2022

Background

Previous studies with the majority of breast cancer (BC) patients treated up to 2000 provided evidence that radiation dose to the heart from radiotherapy (RT) was linearly associated with increasing risk for long-term cardiac disease. RT techniques changed substantially over time. This study aimed to investigate the dose-dependent cardiac risk in German BC patients treated with more contemporary RT.

Methods

In a cohort of 11,982 BC patients diagnosed in 1998–2008, we identified 494 women treated with 3D-conformal RT who subsequently developed a cardiac event. Within a nested case-control approach, these cases were matched to 988 controls. Controls were patients without a cardiac event after RT until the index date of the corresponding case. Separate multivariable conditional logistic regression models were used to assess the association of radiation to the complete heart and to the left anterior heart wall (LAHW) with cardiac events.

Results

Mean dose to the heart for cases with left-sided BC was 4.27 Gy and 1.64 Gy for cases with right-sided BC. For controls, corresponding values were 4.31 Gy and 1.66 Gy, respectively. The odds ratio (OR) per 1 Gy increase in dose to the complete heart was 0.99 (95% confidence interval (CI): 0.94–1.05, P = .72). The OR per 1 Gy increase in LAHW dose was 1.00 (95% CI: 0.98–1.01, P = .68).

Conclusions

Contrary to previous studies, our study provided no evidence that radiation dose to the heart from 3D-conformal RT for BC patients treated between 1998 and 2008 was associated with risk of cardiac events.