Breast Surgery Bulletin: September 2022

 

Neoadjuvant therapy in triple-negative breast cancer: A systematic review and network meta-analysis

 

by Ying-Yi Lin, Hong-Fei Gao, Xin Yang, Teng Zhu, Xing-xing Zheng, Fei Ji, Liu-Lu Zhang, Ci-Qiu Yang, Mei Yang, Jie-Qing Li, Min-Yi Cheng, Kun Wang

The Breast: August 19, 2022

Background

Evidence for the preferred neoadjuvant therapy regimen in triple-negative breast cancer (TNBC) is not yet established.

Methods

Literature search was conducted from inception to February 12, 2022. Phase 2 and 3 randomized controlled trials (RCTs) investigating neoadjuvant therapy for TNBC were eligible. The primary outcome was pathologic complete response (pCR); the secondary outcomes were all-cause treatment discontinuation, disease-free survival or event-free survival (DFS/EFS), and overall survival. Odd ratios (OR) with 95% credible intervals (CrI) were used to estimate binary outcomes; hazard ratios (HR) with 95% CrI were used to estimate time-to-event outcomes. Bayesian network meta-analysis was implemented for each endpoint. Sensitivity analysis and network meta-regression were done.

Results

41 RCTs (N = 7109 TNBC patients) were eligible. Compared with anthracycline- and taxane-based chemotherapy (ChT), PD-1 inhibitor plus platinum plus anthracycline- and taxane-based ChT was associated with a significant increased pCR rate (OR 3.95; 95% CrI 1.81–9.44) and a higher risk of premature treatment discontinuation (3.25; 1.26–8.29). Compared with dose-dense anthracycline- and taxane-based ChT, the combined treatment was not associated with significantly improved pCR (OR 2.57; 95% CrI 0.69–9.92). In terms of time-to-event outcomes, PD-1 inhibitor plus platinum plus anthracycline- and taxane-based ChT was associated with significantly improved DFS/EFS (HR 0.42; 95% CrI 0.19–0.81).

Conclusions

PD-1 inhibitor plus platinum and anthracycline- and taxane-based ChT was currently the most efficacious regimen for pCR and DFS/EFS improvement in TNBC. The choice of chemotherapy backbone, optimization of patient selection with close follow-up and proactive symptomatic managements are essential to the antitumor activity of PD-1 inhibitor.

 

Family history of breast cancer, mammographic breast density and breast cancer risk: Findings from a cohort study of Korean women

 

by Thi Xuan Mai Tran, Soyeoun Kim, Huiyeon Song, Boyoung Park 

 

The Breast: August 23, 2022

 

Background

This study investigated whether the association between family history of breast cancer in first-degree relatives and breast cancer risk varies by breast density.

Methods

Women aged 40 years and older who underwent screening between 2009 and 2010 were followed up until 2020. Family history was assessed using a self-reported questionnaire. Using Breast Imaging Reporting and Data System (BI-RADS), breast density was categorized into dense breast (heterogeneously or extremely dense) and non-dense breast (almost entirely fatty or scattered areas of fibro-glandular). Cox regression model was used to assess the association between family history and breast cancer risk.

Results

Of the 4,835,507 women, 79,153 (1.6%) reported having a family history of breast cancer and 77,238 women developed breast cancer. Family history led to an increase in the 5-year cumulative incidence in women with dense- and non-dense breasts. Results from the regression model with and without adjustment for breast density yielded similar HRs in all age groups, suggesting that breast density did not modify the association between family history and breast cancer. After adjusting for breast density and other factors, family history of breast cancer was associated with an increased risk of breast cancer in all three age groups (age 40–49 years: aHR 1.96, 95% confidence interval [CI] 1.85–2.08; age 50–64 years: aHR 1.70, 95% CI 1.58–1.82, and age ≥65 years: aHR 1.95, 95% CI 1.78–2.14).

Conclusion

Family history of breast cancer and breast density are independently associated with breast cancer. Both factors should be carefully considered in future risk prediction models of breast cancer.

 

Transverse Upper Gracilis Flap Breast Reconstruction: A 5-Year Consecutive Case Series of Patient-Reported Outcomes

 

by Jessica, Anne Savage; Zhao, Jade; Mackey, Simon; Blackburn, Adam Victor 

 

Plastic and Reconstructive Surgery: August 2022 - Volume 150 - Issue 2 - p 258-268

 

Background: 

The transverse upper gracilis flap is an important reconstructive option for patients who desire autologous reconstruction after mastectomy but in whom a deep inferior epigastric perforator flap is unavailable or undesirable. The authors present an analysis of outcomes and patient satisfaction results, from a consecutive series in a single institution.

Methods: 

Using a prospectively populated free flap database, all patients undergoing transverse upper gracilis flap breast reconstruction for a mastectomy defect between January of 2013 and December of 2017 were identified. Retrospective review of clinical notes, admissions, and discharge information was conducted to identify outcomes, secondary operations, and complications. All patients were contacted by letter and invited to take part in a patient satisfaction survey a minimum of 12 months after free-flap surgery.

Results: 

Seventy-eight patients underwent transverse upper gracilis flap breast reconstruction using a total of 103 transverse upper gracilis flaps to reconstruct 99 breast mounds in the 5-year period studied. Patient satisfaction is evidenced by BREAST-Q scores showing 81 ± 19 percent Satisfaction with Breasts, 80 ± 20 percent Psychosocial Well-Being, and 84 ± 19 percent Physical Well-Being of the chest. Forty-six of 53 (87 percent) report satisfaction with the postoperative appearance of their thigh unclothed and 51 of 53 (96 percent) report satisfaction clothed.

Conclusions: 

This is the first consecutive series of transverse upper gracilis flap breast reconstruction outcomes that presents BREAST-Q scores for multiple, postoperative reconstruction modules and details complications stratified by Clavien-Dindo score. The methodology can be easily replicated and benchmarked against. Our donor-site complication rates are lower than previous publications and patient satisfaction data reveal that this is a well-accepted option for patients.

 

 

 

 

Microneedling Outcomes in Early Postsurgical Scars

 

by Claytor, R. Brannon; Sheck, Casey Gene; Chopra, Vinod 

 

Plastic and Reconstructive Surgery: September 2022 - Volume 150 - Issue 3 - p 557e-561e

 

Background: 

Scars are a vexing sequela of surgery. Microneedling, also known as minimally invasive percutaneous collagen induction, has demonstrated impressive improvements in chronic acne scars; however, no evidence exists for treating postsurgical scars during active wound healing. The purpose of this study was to demonstrate the utility and safe use of minimally invasive percutaneous collagen induction in acute postsurgical scars.

Methods: 

Twenty-five patients who underwent surgery had scars treated with three treatments of minimally invasive percutaneous collagen induction in the postoperative period. Scar assessment was measured by Vancouver Scar Scale, Patient and Observer Scar Assessment Scale, and Global Aesthetic Improvement Scale after each of the three treatments and at final 2-month follow-up.

Results: 

Patients had positive improvement in Vancouver Scar Scale, Patient and Observer Scar Assessment Scale, and Global Aesthetic Improvement Scale scores at 16-week posttreatment initiation evaluation compared to initial measurement (p < 0.001). No statistically significant differences were noted when comparing the age of the patient, location of scars, or Fitzpatrick phototype scales among patients. When comparing patients who began treatment early (6 to 7 weeks postoperatively) to those who began treatment late (13 to 16 weeks postoperatively), there was a statistically significant difference in the Patient and Observer Scar Assessment Scale group (p < 0.04).

Conclusions: 

Postsurgical scars treated with minimally invasive percutaneous collagen induction in the maturation and remodeling phase had no adverse outcomes. Interestingly, the data show treatment initiated early in the maturation phase (6 to 7 weeks postoperatively), while natural collagen formation was tapering off, demonstrated improved aesthetic outcomes compared to treatments initiated late in the maturation phase (13 to 16 weeks postoperatively).

 

 

 

 

 

Nomogram for predicting overall survival in patients with triple-negative apocrine breast cancer: Surveillance, epidemiology, and end results-based analysis

 

by Yinggang Xu, Weiwei Zhang, Jinzhi He, Ye Wang, Rui Chen, Wenjie Shi, Xinyu Wan, Xiaoqing Shi, Xiaofeng Huang, Jue Wang, Xiaoming Zha 

 

The Breast: September 01, 2022

 

Purpose

Triple-negative apocrine carcinoma (TNAC) is a sort of triple-negative breast cancer (TNBC) that is rare and prognosis of these patients is unclear. The present study constructed an effective nomogram to assist in predicting TNAC patients overall survival (OS).

Methods

A total of 373 TNAC patients from the surveillance, epidemiology, and end results (SEER) got extracted from 2010 to 2016 and were divided into training (n = 261) and external validation (n = 112) groups (split ratio, 7:3) randomly. A Cox regression model was utilized to creating a nomogram according to the risk factors affecting prognosis. The predictive capability of the nomogram was estimated with receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).

Results

Multivariate Cox regression analysis revealed age, surgery, chemotherapy, stage, and first malignant primary as independent predictors of OS. A prediction model was constructed and virtualized using the nomogram. The time-dependent area under the curve (AUC) showed satisfactory discrimination of the nomogram. Good consistency was shown on the calibration curves in OS between actual observations and the nomogram prediction. What's more, DCA showed that the nomogram had incredible clinical utility. Through separating the patients into groups of low and high risk group that connects with the risk system that shows a huge difference between the low-risk and high risk OS (P < 0.001).

Conclusion

To predict the OS in TNAC patients, the nomogram utilizing the risk stratification system that is corresponding. These tools may help to evaluate patient prognosis and guide treatment decisions.

 

Current and future burden of breast cancer: Global statistics for 2020 and 2040

 

by Melina Arnold, Eileen Morgan, Harriet Rumgay, Allini Mafra, Deependra Singh, Mathieu Laversanne, Jerome Vignat, Julie R. Gralow, Fatima Cardoso, Sabine Siesling, Isabelle Soerjomataram 

 

The Breast: September 01, 2022

 

Background

Breast cancer is the most commonly diagnosed cancer worldwide, and its burden has been rising over the past decades. In this article, we examine and describe the global burden of breast cancer in 2020 and predictions for the year 2040.

Methods

Estimates of new female breast cancer cases and deaths in 2020 were abstracted from the GLOBOCAN database. Age-standardized incidence and mortality rates were calculated per 100,000 females by country, world region, and level of human development. Predicted cases and deaths were computed based on global demographic projections for the year 2040.

Results

Over 2.3 million new cases and 685,000 deaths from breast cancer occurred in 2020. Large geographic variation across countries and world regions exists, with incidence rates ranging from <40 per 100,000 females in some Asian and African countries, to over 80 per 100,000 in Australia/New Zealand, Northern America, and parts of Europe. Smaller geographical variation was observed for mortality; however, transitioning countries continue to carry a disproportionate share of breast cancer deaths relative to transitioned countries. By 2040, the burden from breast cancer is predicted to increase to over 3 million new cases and 1 million deaths every year because of population growth and ageing alone.

Conclusion

Breast cancer is the most common cancer worldwide and continues to have a large impact on the global number of cancer deaths. Global efforts are needed to counteract its growing burden, especially in transitioning countries where incidence is rising rapidly, and mortality rates remain high.

 

A systematic review and meta-analysis of BRCA1/2 mutation for predicting the effect of platinum-based chemotherapy in triple-negative breast cancer

 

by Xiaomeng Jia, Kainan Wang, Lingzhi Xu, Ning Li, Zuowei Zhao, Man Li 

 

The Breast: September 02, 2022

Introduction

Platinum-based chemotherapy (PBC) remains the mainstay of treatments for triple-negative breast cancer (TNBC). TNBC is a heterogeneous group, the issue of whether BRCA1/2 mutation carriers have a particular sensitivity to platinum agents is inconclusive. We conducted a meta-analysis to explore the relationship between BRCA1/2 mutation and PBC susceptibility in individuals with TNBC, aiming to gain more information on the size of the benefit of PBC in BRCA1/2 mutation carriers.

Materials and methods

All studies applying PBC with a subgroup of BRCA1/2 status were included. All endpoints, including pCR and RCB in the neoadjuvant phase, DFS in the adjuvant phase, ORR, PFS, and OS in the advanced phase, were assessed using HRs and 95% Cl.

Results

From the 22 studies included, there were 2158 patients with TNBC, with 392 (18%) bearing the BRCA1/2 gene mutation. Based on 13 studies applying neoadjuvant PBC, we discovered that BRCA1/2 mutation was substantially associated with a 17.6% increased pCR rate (HR 1.32, 95% CI 1.17–1.49, p < 0.00001; I2 = 51%). Same result was observed in RCB0/I index (HR 1.38, 95% CI 1.08–1.76, P = 0.009; I2 = 0%). The meta-analysis of 6 trials addressing advanced therapy revealed that ORR rates were significantly higher in patients with BRCA1/2 mutation (HR 1.91, 95% CI 1.48–2.47, p < 0.00001; I2 = 32%), as well as PFS(HR 1.13, 95% CI 0.81–1.57, P = 0.47; I2 = 0%) and OS (HR 1.89, 95% CI 1.22–2.92, P = 0.004; I2 = 0%).

Conclusion

According to our meta-analysis of 22 trials in TNBC, BRCA1/2 mutation carriers were significantly more sensitive to PBC regimens, especially in neoadjuvant and advanced therapy.

 

Treatment and survival outcomes in older women with primary breast cancer: A retrospective propensity score-matched analysis

 

by Yuting Sang, Benlong Yang, Miao Mo, Shiyang Liu, Xujie Zhou, Jiajian Chen, Shuang Hao, Xiaoyan Huang, Guangyu Liu, Zhimin Shao, Jiong Wu 

 

The Breast: September 06, 2022

 

Purpose

Changes in biological features and functional status make management decisions in older women with primary breast cancer complicated. We aimed to provide an overview of the clinicopathological characteristics and survival outcomes of older breast cancer patients based on the current treatment strategies.

Methods

Female patients diagnosed with primary invasive breast cancer at Fudan University Shanghai Cancer Centre from 2008 to 2016 were included. Patients were divided into a younger group (<65 years) and older group (≥65 years). Propensity score matching was utilised to generate balanced cohorts.

Results

A total of 13,707 patients met the study criteria. Compared with younger patients, older patients had a higher Charlson Comorbidity Index (p < 0.001), less lymph node metastasis (p = 0.009), more advanced tumour stage (p = 0.038), and a larger proportion of estrogen receptor-positive (p < 0.001) and epidermal growth factor receptor 2-negative (p < 0.001) tumours. Older patients were likely to receive mastectomy and axillary lymph node dissection in addition to a lower proportion of adjuvant chemotherapy. Adjuvant chemotherapy (HR [hazard ratio] 0.69, p = 0.039) was independently correlated with better overall survival in the older patients. This survival benefit (HR 0.58, p = 0.041) was confirmed in matched cohorts. Among the older patients with larger tumours (HR 0.48, p = 0.038) and more lymph node involvement (HR 0.44, p = 0.040), adjuvant chemotherapy was associated with a significant survival benefit.

Conclusion

Older breast cancer patients showed less aggressive biological characteristics, intensive surgical and moderate medical preferences. The addition of adjuvant chemotherapy should be considered for older patients, especially for patients with large tumours and more lymph node involvement.

 

Does the 21-gene recurrence score have clinical utility in HR+/HER2+ breast cancer?

by Nadeem Bilani, Fionnuala Crowley, Mohammad Mohanna, Mira Itani, Marita Yaghi, Diana Saravia, Iktej Jabbal, Barbara Dominguez, Hong Liang, Zeina Nahleh 

 

The Breast: September 06, 2022

The 21-gene recurrence score assay has been validated as a predictive biomarker in early-stage HR+ and HER2-breast cancer. It is not indicated for use in HER2+ disease based on national guidelines. In this study, we assessed the value of 21-gene recurrence score, or OncotypeDX (ODX), testing in HR+/HER2+ breast cancer.

We used the National Cancer Database to identify patients with stages I-II, HR+/HER2+ breast cancer who received multi-gene testing with ODX. We the explored the prognostic and predictive value of this biomarker through various forms of survival modeling.

ODX testing was performed in n = 5,280 patients. N = 2,678 patients (50.7%) had a RS < 26, while n = 2,602 (49.3%) had a RS≥26. In Kaplan-Meier survival modeling for patients with recurrence scores <26, there was no significant difference in overall survival (p = 0.445) between patients receiving different systemic treatment regimens. However, when recurrence scores were ≥26, there was a statistically-significant difference in overall survival between systemic treatment regimens (p < 0.001). 5-year overall survival was highest (97.4%) for patients receiving triple therapy (anti-HER2 with chemotherapy and endocrine therapy), followed by those receiving dual therapy with endocrine and anti-HER2 (96.7%), and endocrine with chemotherapy (94.9%). Patients receiving endocrine therapy alone exhibited the lowest 5-year overall survival (88.5%).

Results

from this large national cancer registry suggest that multigene testing may have predictive value in treatment selection of patients with early-stage, HR+/HER2+ breast cancer. Prospective trials are warranted to identify subgroups of patients with HR+/HER2+ breast cancer who can be spared anti-HER2 treatments and cytotoxic chemotherapy.

 

 

Prognosis stratification and postoperative radiation therapy utilization in adenoid cystic carcinoma of the breast

by Di Zhang, Lixi Li, Fei Ma 

The Breast: September 10, 2022

Purpose

Adenoid cystic carcinoma of the breast (ACCB) is a rare malignancy with a favorable prognosis. Little information exists regarding the impact of postoperative radiation therapy (RT) on survival outcome in patients with ACCB. This study aimed to evaluate the clinical significance of postoperative RT in ACCB.

Methods

Data of patients with ACCB were extracted from the Surveillance, Epidemiology, and End Results database (2000–2019). Univariate and multivariable Cox regression analyses were performed to identify prognostic factors. In addition, a nomogram model was constructed and internally validated for discrimination and calibration. The value of postoperative RT was respectively accessed in each risk subgroup according to nomogram-deduced individualized score.

Results

A total of 689 eligible patients were included in the analysis. Partial mastectomy was associated with an increased risk of death compared with partial mastectomy plus postoperative RT (P = 0.020), but total mastectomy with or without postoperative RT was comparable (P = 0.624). Then, in-depth analysis was performed for patients receiving breast-conversing therapy (n = 485, the training set vs. the testing set = 340 vs. 145). Age at diagnosis, histological grade, and T stage were identified as prognostic factors for overall survival (OS) (All P < 0.05). A nomogram was constructed to provide predictive accuracy toward individual OS rates of ACCB and to divide patients into different risk subgroups. Notably, compared with non-RT, postoperative RT significantly improved OS in the high-risk subgroup (P = 0.006 for the training set, and P = 0.013 for the overall population) but not in the low-risk subgroup (P = 0.807 for the training set, and P = 0.293 for the overall population), suggesting that these patients may be able to exempt from postoperative RT.

Conclusion

A robust and effective nomogram was developed to predict prognosis and assist in treatment decisions in patients with ACCB undergoing partial mastectomy.

 

 

 

 

Defining the Relationship between Pocket and Breast Implant Surface Area as the Basis for a New Classification System for Capsular Contracture

 

by Hammond, Dennis C.; Chaudhry, Arif 

 

Plastic and Reconstructive Surgery: September 2022 - Volume 150 - Issue 3 - p 496-509

 

Background: 

The precise cause of and treatment for capsular contracture remains uncertain, at least partially because there is no reliable quantitative measurement tool. To address this, it is postulated that the surface area of an implant as defined by the surrounding pocket may provide a quantifiable variable that can be measured to evaluate the degree of capsular contracture.

Methods: 

A bench model for capsular contracture was developed. The surface area of a series of spherical test objects and noncontracted and contracted breast implants was measured using a wax-coating technique and three-dimensional reconstructions created from computed tomographic scan images.

Results: 

Comparison of the mathematically calculated surface areas to the wax and computed tomographic scan results for spheres of known dimension provided nearly identical values, documenting the accuracy of the two experimental methods. Comparison of the surface area measurements between the test groups showed that the average decrease in surface area for all implants was 20 percent, ranging from a high of 30.9 percent for a low-profile implant to a low of 14.1 percent for a high-profile implant. The anatomically shaped devices demonstrated nearly uniform degrees of surface area change over three different heights with volume and projection held relatively constant.

Conclusions: 

The described bench model provides a useful tool for the study of capsular contracture. Surface area is a descriptive variable that can assess the degree of capsular contracture that is present. A classification system based on surface area is presented.

 

 

 

The Batwing Mastopexy in Immediate Implant-Based Breast Reconstruction: An Aesthetic Enhancement for Patients with Cancer

 

by Kadakia, Nikita; Kubiak, Jeremy W.; Landau, Mark J.; Mohiuddin, Waseem; Lewis, Priya G.; Kim, Hahns Y. 

 

Plastic and Reconstructive Surgery: September 2022 - Volume 150 - Issue 3 - p 487-495

 

Background: 

Historically, many patients with breast ptosis have been excluded from nipple-sparing mastectomies. By performing mastopexy at the time of immediate reconstruction, more patients with breast ptosis can be considered for nipple-sparing mastectomies. The authors review their experience of simultaneous batwing mastopexy performed at the time of immediate implant-based reconstruction.

Methods: 

Using retrospective chart review, the authors identified patients who underwent immediate implant-based breast reconstruction from 2015 through 2020 at a single institution. The patients were divided into two cohorts—batwing mastopexy and standard reconstruction (no mastopexy)—and compared.

Results: 

A total of 324 breast operations in 188 patients were included (80 concurrent batwing and 244 standard implant-based reconstructions). Patient characteristics were similar between the groups, except that patients in the batwing group had greater ptosis and more patients in the standard group underwent adjuvant chemotherapy. Mean follow-up was 15.9 months (range, 3.19 to 55.20 months). Complication rates were comparable in the batwing and standard groups, with no statistically significant differences in rates of hematoma (1.3 versus 3.3 percent; = 0.34), seroma (5.0 versus 8.2 percent; p = 0.34), major infection (8.8 versus 9.0 percent; p = 0.94), skin or nipple necrosis (6.3 versus 11.5 percent; p = 0.18), or explantation (11.3 versus 14.8 percent; p = 0.43). The rate of minor infections was higher in the group with concurrent batwing mastopexy (10.0 versus 3.7 percent; p = 0.03).

Conclusions: 

The authors demonstrate that simultaneous batwing mastopexy can be performed safely at the time of immediate breast reconstruction. This technique provides comparable complication rates, improves aesthetic outcomes in patients with significant ptosis or macromastia, and allows nipple-sparing mastectomy to be an option for those who would otherwise be excluded.