Neoadjuvant chemotherapy is not a contraindication for nipple sparing mastectomy

The Breast, October 2015 Volume 24, Issue 5, Pages 661–666

Stefano Santoro, Andrea Loreti, Francesco Cavaliere, Leopoldo Costarelli, Massimo La Pinta, Elena Manna, Maria Mauri, Paola Scavina, Elena Santini, Ugo De Paula, Vito Toto, Lucio Fortunato

Nipple-sparing mastectomy (NSM) has been recently implemented to improve cosmetic outcome after mastectomy, but it is rarely considered today after neoadjuvant chemotherapy (NCH).

Shifting Autologous Breast Reconstruction into an Ambulatory Setting: Patient-Reported Quality of Recovery

Plastic and Reconstructive Surgery October 2015 - Volume 136 - Issue 4 - p 657–665

Davidge, Kristen et al

As bundled payment models gain popularity, it is imperative that providers use patient outcomes and patient experience to define evidence-based pathways of care. The purpose of this study was to evaluate the quality of recovery experienced by women undergoing early discharge (less than 24 hours) after autologous breast reconstruction with a pedicled flap and determine predictors of postoperative quality of recovery. Methods: A prospective cohort study was performed on all women undergoing autologous breast reconstruction at Women’s College Hospital between September of 2011 and July of 2013 that met study inclusion criteria. 

Use of Acellular Dermal Matrix in Postmastectomy Breast Reconstruction: Are All Acellular Dermal Matrices Created Equal?

Plastic and Reconstructive Surgery October 2015 - Volume 136 - Issue 4 - p 647–653

Ranganathan, Kavitha et al

AlloDerm and FlexHD are two types of acellular dermal matrices commonly used in implant-based reconstruction. Although the use of acellular dermal matrix has revolutionized immediate breast reconstruction in the setting of breast cancer, it remains unclear which type of acellular dermal matrix is best. The purpose of this retrospective cohort study was to compare postoperative complication rates between these two types of acellular dermal matrix. The authors reviewed the records of all patients who underwent implant-based breast reconstruction at their institution between 1998 and 2013. Dependent variables of seroma, hematoma, infection, delayed wound healing, implant exposure, and return to the operating room for management of complications were recorded.

Natrelle410 Extra-Full Projection Silicone Breast Implants: 2-Year Results from Two Prospective Studies

Plastic and Reconstructive Surgery October 2015 - Volume 136 - Issue 4 - p 638–646

Cordeiro, Peter G.; McGuire, Patricia; Murphy, Diane K.  

The safety and effectiveness of the Natrelle Style 410 highly cohesive silicone gel breast implant (Allergan, Inc., Irvine, Calif.) in full or moderate height and projection have been shown in a 10-year study. Extra-full projection implants may be an appropriate option for some women undergoing breast reconstruction. A total of 2795 women received at least one Natrelle 410 extra-full projection implant (X-style) for breast reconstruction in two similarly designed, prospective, multicenter studies…………..

TUGs into VUGs and Friendly BUGs: Transforming the Gracilis Territory into the Best Secondary Breast Reconstructive Option

TUGsinto VUGs and Friendly BUGs: Transforming the Gracilis Territory into the Best Secondary Breast Reconstructive Option

Plastic and Reconstructive Surgery 136(3):447-454, September 2015.

Park, Julie E.; Alkureishi, Lee W. T.; Song, David H.

The best secondary option for autologous breast reconstruction remains controversial. Limitations of the gracilis myocutaneous flap, including volume, skin paddle reliability, and donor morbidity, have been addressed by several modifications, hereby expanding its role in the decision tree for autologous breast reconstruction. This report documents the authors’ experience with gracilis flap breast reconstruction. This is a retrospective case series of a prospectively maintained database of patients undergoing breast reconstruction with the free gracilis myocutaneous flap, including the transverse upper gracilis, vertical upper gracilis, and bilateral stacked vertical upper gracilis.

A Propensity-Matched Analysis of the Influence of Breast Reconstruction on Subsequent Development of Lymphedema

A Propensity-Matched Analysis of the Influence of Breast Reconstruction on Subsequent Development of Lymphedema
Plastic & Reconstructive Surgery:
August 2015 - Volume 136 - Issue 2 - p 134e–143e

Basta M et al

Background: Recent literature demonstrates a lower incidence of lymphedema with breast reconstruction. This study compared the incidence of lymphedema after axillary dissection in a propensity-matched cohort of patients with and without immediate breast reconstruction. 
Methods: A review of patients undergoing axillary lymphadenectomy with or without immediate breast reconstruction from January 1, 2000, to July 1, 2013, was conducted. Comorbidities, cancer treatment, operative characteristics, and pathologic findings were reviewed. The primary outcome was postoperative lymphedema. Univariate analysis identified baseline differences between the patient groups. Cohorts were propensity-matched by age, body mass index greater than 30 kg/m2, adjuvant radiation therapy, cardiovascular disease, and hypertension. Subsequent multivariate regression was performed to identify independent predictors of lymphedema among matched patients. Results: A total of 4647 patients underwent breast cancer resection, with 1955 having axillary lymphadenectomy (no reconstruction, n = 1200; autologous, n = 563; implant-based, n = 192). Matching yielded a cohort of 239 reconstruction and 239 no-reconstruction patients demonstrating no differences in age, body mass index, hypertension, adjuvant radiation therapy, or axillary dissection extent. With 55.9 months’ follow-up, postoperative lymphedema was diagnosed in 94 patients (19.7 percent). Reconstruction patients developed lymphedema in 19.2 percent of cases versus 20.1 percent for no- reconstruction patients (p = 0.82). Regression identified two independent predictors of lymphedema: postoperative radiation therapy (OR, 2.90; p < 0.001) and obesity (OR, 2.36; p < 0.001). 
Conclusions: This study demonstrates a 19.7 percent incidence of lymphedema following axillary lymphadenectomy. Reconstruction does not appear to alter lymphedema risk, whereas postoperative radiation therapy, obesity, and extensive axillary dissection greatly increase risk.

Conservative surgery for multifocal/multicentric breast cancer

Conservative surgery for multifocal/multicentric breast cancer
The Breast Published Online: August 23, 2015


Matthijs V, et al


Multifocal (MF) and multicentric (MC) breast cancer is regularly considered a relative contraindication for breast-conserving therapy (BCT). There are two reasons for this wide spread notion:However, we concur that if optimal ‘cytoreductive surgery’ is achieved this will result in good local control....................

Prognostic significance of nodal involvement region in clinical stage IIIc breast cancer patients who received primary systemic treatment, surgery, and radiotherapy

Prognostic significance of nodal involvement region in clinical stage IIIc breast cancer patients who received primary systemic treatment, surgery, and radiotherapy
The Breast  Article in press
  
Jae Myoung Noh, et al

To evaluate the prognostic influence of involvement of both internal mammary nodes (IMNs) and supraclavicular nodes (SCNs) in clinical stage IIIc breast cancer patients who underwent primary systemic treatment, surgery, and radiotherapy (RT).

The locoregional recurrence post-mastectomy for ductal carcinoma in situ: Incidence and risk factors

The locoregional recurrence post-mastectomy for ductal carcinoma in situ: Incidence and risk factors
The Breast. In Press. Accepted: June 7, 2015; Published Online: August 12



The objective of this retrospective study was to determine the incidence of recurrence of breast cancer after mastectomy for ductal carcinoma in situ (DCIS) in our institution, and to evaluate the associated risk factors while comparing them to those proposed in the literature.

C-Y Trilobed Flap for Improved Nipple-Areola Complex Reconstruction

C-Y Trilobed Flap for Improved Nipple-Areola Complex Reconstruction
Plastic & Reconstructive Surgery:August 2015 - Volume 136 - Issue 2 - p 234–237

Butz, D, et al

Summary: Nipple-areola complex reconstruction has been shown to improve breast reconstruction patients’ overall satisfaction. Trilobed flap variations are some of the more commonly used flaps for nipple-areola complex reconstruction. The donor-site scar frequently extends outside the width of an ideal areolar tattoo diameter. There have been many modifications to the original flap design, but none of them addresses the length of the donor-site scar. The technique described uses a triangular stitch in the donor site to limit the length of the scar. This also creates tiny dog-ears within the future areola zone that give a natural wrinkled appearance when tattooed.

Patient-Reported Satisfaction and Quality of Life following Breast Reconstruction in Thin Patients: A Comparison between Microsurgical and Prosthetic Implant Recipients

Patient-Reported Satisfaction and Quality of Life following Breast Reconstruction in Thin Patients: A Comparison between Microsurgical and Prosthetic Implant Recipients
Plastic & Reconstructive Surgery: August 2015 - Volume 136 - Issue 2 - p 213–220

Weichman, K et al

Background: Patients undergoing autologous breast reconstruction have higher long-term satisfaction rates compared with those undergoing prosthetic reconstruction. Regardless, most patients still undergo prosthetic reconstruction. The authors compared outcomes of microsurgical reconstruction to those of prosthetic reconstruction in thin patients and evaluated the effect of reconstructive type on quality of life. Methods: After institutional review board approval was obtained, the authors reviewed all patients undergoing breast reconstruction at a single institution from November of 2007 to May of 2012. Thin patients were included for analysis and divided into two cohorts: microsurgical reconstruction and tissue expander/implant reconstruction........

Progress in the surgical management of breast cancer: Present and future

Published Online: August 03, 2015

 

Recognition of differing risks of locoregional recurrence (LRR) in breast cancer patients based on estrogen receptor, progesterone receptor, and HER2 status, coupled with a reduction in LRR in patients receiving adjuvant systemic therapy, offers the opportunity to tailor surgical treatment and reduce the morbidity of therapy. New guidelines for margins in breast-conserving therapy of tumor not touching ink and avoidance of axillary dissection in sentinel node positive patients undergoing breast-conserving therapy are examples of this approach which have entered practice.

http://dx.doi.org/10.1016/j.breast.2015.07.003 

Embrace the Change: IncorporatingSingle-Stage Implant Breast Reconstruction into Your Practice

Plastic & Reconstructive Surgery: August 2015 - Volume 136 - Issue 2 - p 221–231

Background: Multiple studies have reported on the safety of nipple-sparing mastectomy and low complication rates associated with single-stage implant breast reconstruction. Yet many plastic surgeons continue to be resistant to change. This article presents the senior author’s (M.A.C.) experience during his transition period from the latissimus dorsi flap with adjustable implants to a “one-and-done” approach using shaped implants and fetal bovine acellular dermal matrix. Methods: A literature review was performed selecting articles discussing single-stage implant reconstruction, indications, outcomes, technique, and complications. Additional articles were selected after review of the references of identified articles. Clinical pearls discussed include patient selection, implant selection, and mastectomy incision choices, with a detailed description of the senior author’s operative technique. Results: Twenty-seven single-stage implant reconstructions were performed. Average mastectomy weight was 343.82 g. The average implant volume was 367 cc. Shaped implants were most commonly used. Acellular dermal matrix was used in all breasts. Complications included erythema requiring intravenous antibiotics (three patients), skin ischemia caused by methylene blue (one patient), seroma (one patient), unilateral partial nipple necrosis (one patient), mastectomy skin necrosis (one patient), and exposed/infected implants that were salvaged using a sequential irrigation protocol described by Sforza et al. in 2014 (two patients). Conclusions: Breast reconstruction after mastectomy has evolved toward less invasive, single-stage procedures. Aesthetic refinements include nipple-sparing mastectomy, use of acellular dermal matrix, shaped implants, and fat grafting. Selected patients will benefit from a one-and-done breast implant reconstruction with no additional oncologic risk. Surgeons must embrace the change and provide their patients with a procedure that will offer the best aesthetic outcomes. 

Breast Implant–Associated Anaplastic Large Cell Lymphoma: Proposal for a Monitoring Protocol

Breast Implant–AssociatedAnaplastic Large Cell Lymphoma: Proposal for a Monitoring Protocol

Plastic & Reconstructive Surgery: August 2015 - Volume 136 - Issue 2 - p 144e–151e

Background: The authors report four cases of breast implant–associated anaplastic large cell lymphoma (ALCL) from a single institution and propose a multidisciplinary protocol. Methods: From 2012 to 2014, four breast implant–associated ALCL cases were diagnosed. The authors performed the original operation, and no patients were referred to their practice. Cases 1, 2, and 4 were CD4+/CD30+/ALK− ALCL with previous textured-implant reconstruction, whereas case 3 was CD8+/CD30+/ALK− ALCL with previous polyurethane-implant augmentation. A retrospective study of all patients who underwent breast implant positioning was performed to identify any misdiagnosed cases. Results: Of 483 patients, 226 underwent reconstruction with latissimus dorsi flap and prosthesis, 115 had skin-sparing/nipple-sparing mastectomy and prosthesis, 117 underwent an expander/implant procedure, and 25 underwent breast augmentation. Fifty-eight cases (12 percent) underwent implant replacement for capsular contracture, 15 (3.1 percent) experienced late-onset seroma, and four (0.83 percent) had both capsular contracture and seroma. Seventy-seven symptomatic patients (16 percent) underwent surgical revision (capsulectomy/capsulotomy) and/or seroma evacuation. The second look on histologic specimens did not identify misdiagnosed cases. A multidisciplinary protocol for suspected implant-associated ALCL was established. Ultrasound and cytologic examinations are performed in case of periprosthetic effusion. If implant-associated ALCL is diagnosed, implant removal with capsulectomy is performed. If disseminated disease is detected through positron emission tomography/computed tomography of the total body, the patient is referred to the oncology department. Conclusions: A multidisciplinary protocol is mandatory for both early diagnosis and patient management. Until definitive data emerge regarding the exact etiopathogenesis of breast implant–associated ALCL, the authors suggest offering only autologous reconstruction if patients desire it. 

Regional Nodal Irradiation in Early-Stage Breast Cancer

N Engl J Med 2015; 373:317-327 July 23, 2015

BACKGROUND

Most women with breast cancer who undergo breast-conserving surgery receive whole-breast irradiation. We examined whether the addition of regional nodal irradiation to whole-breast irradiation improved outcomes.

Patterns and Trends in Immediate Postmastectomy Reconstruction in California: Complications and Unscheduled Readmissions

Patterns and Trends in Immediate Postmastectomy Reconstruction in California: Complications and UnscheduledReadmissions

Plastic & Reconstructive Surgery: July 2015 - Volume 136 - Issue 1 - p 10e–19e

Background: Immediate reconstruction rates after mastectomy are increasing but remain low. Little is known about hospital readmissions after these procedures. The authors studied unscheduled readmissions after immediate reconstruction. Methods: Using the Healthcare Cost and Utilization Project California State database, the authors identified patients undergoing mastectomy only or with immediate reconstruction for ductal carcinoma in situ and invasive breast cancer from 2005 to 2009. Immediate reconstruction included tissue expander/implant and autologous tissue reconstructions. The authors evaluated temporal trends in immediate reconstruction and factors associated with 30-day unscheduled readmissions after reconstruction. Results: The cohort contained 48,414 patients (mastectomy only, 35,648; immediate reconstruction, 12,766; tissue expander/implant, 10,437; autologous tissue, 2329). Readmission rates were not significantly different between mastectomy only and immediate reconstruction (3.55 percent versus 3.39 percent; p = 0.39); however, autologous tissue reconstruction was associated with a significantly higher readmission rate compared with tissue expander/implant reconstruction (4.08 percent versus 3.24 percent; p = 0.04). Conclusions: Immediate reconstruction does not result in higher readmission rates compared with mastectomy only. All women undergoing mastectomy should be offered consultation for reconstruction.

Challenges in optimizing care in advanced breast cancer patients: Results of an international survey linked to the ABC1 consensus conference

Challenges in optimizing care in advanced breast cancer patients: Results of an international survey linked to the ABC1consensus conference

Published Online: July 19, 2015

Until recently, many international guidelines have focussed on the treatment of early-stage breast cancer, with little emphasis on advanced-stage disease. To improve the management of advanced breast cancer (ABC), the European School of Oncology (ESO) established the ABC International Consensus Conference and Guidelines. Delegates from the first conference and additional groups selected by ESO were invited to complete a survey to identify current challenges and barriers associated with optimizing ABC management.

http://dx.doi.org/10.1016/j.breast.2015.06.008 

Surgical margin reporting in breast conserving surgery: Does compliance with guidelines affect re-excision and mastectomy rates?

Published Online: July 18, 2015

Margin status is important in guiding decisions to re-excise following breast-conserving surgery (BCS) for breast cancer. The College of American Pathologists (CAP) developed guidelines to standardize pathology reporting; however, compliance with margin documentation guidelines has been shown to vary. The aim of this retrospective study was to determine whether compliance with CAP guidelines affects re-excision and mastectomy rates.

 http://dx.doi.org/10.1016/j.breast.2015.06.007

Medication taking behaviors among breast cancer patients on adjuvant endocrine therapy

Published Online: July 16, 2015

To explore how symptoms and psychosocial factors are related to intentional and unintentional non-adherent medication taking behaviors.

http://dx.doi.org/10.1016/j.breast.2015.06.010

Potential of overcoming resistance to HER2-targeted therapies through the PI3K/Akt/mTOR pathway

Potential of overcoming resistance to HER2-targeted therapies through the PI3K/Akt/mTORpathway

Human epidermal growth factor receptor 2 (HER2) overexpression occurs in up to 30% of breast cancers and is a marker of aggressive disease. While HER2-targeted therapies have improved outcomes in these tumors, resistance to these agents develops in a large proportion of patients. Determining molecular mechanisms underlying resistance might help improve outcomes for patients with HER2-positive disease by allowing development of strategies to overcome resistance. Activation of signaling pathways involving the phosphoinositide 3-kinase/protein kinase B/mammalian target of rapamycin (PI3K/Akt/mTOR) pathway might contribute to the development of resistance to HER2-targeted therapies.


http://dx.doi.org/10.1016/j.breast.2015.06.002