Breast Cancer–Related Lymphedema: Quality of Life after Lymph Node Transfer

Breast Cancer–Related Lymphedema: Quality of Life after Lymph Node Transfer

Plastic & Reconstructive Surgery:  June 2016 - Volume 137 - Issue 6 - p 1673–1680

 

De Brucker, B et al

Background: Breast cancer–related lymphedema affects multiple aspects of patients’ daily lives. The main aim of this study was to assess the impact of vascularized lymph node transfer on the quality of life in patients with lymphedema. Methods: Between 2007 and 2012, 25 female patients with breast cancer–related lymphedema underwent vascularized lymph node transfer. In 22 cases, the patients underwent a simultaneous deep inferior epigastric artery perforator flap breast reconstruction based on the superficial circumflex iliac artery. The influence on quality of life was evaluated using the Upper Limb Lymphedema-27 questionnaire, which includes physical, psychological, and social dimensions. The authors also investigated risk factors for lymphedema, such as body mass index, smoking, age, and time between start of lymphedema and vascularized lymph node transfer, and their impact on quality of life. Results: Twenty-one patients (84 percent) had an improvement of quality of life after vascularized lymph node transfer. The mean physical, psychological, and social scores were significantly improved postoperatively (p < 0.001). Risk factors for the development of lymphedema did not influence quality of life among patients with breast cancer–related lymphedema. Skin infections disappeared in 50 percent of the cases. Eleven patients (44 percent) discontinued compression therapy at a mean postoperative time interval of 29 months (range, 8 to 64 months). In the other patients (56 percent), the average frequency of compression therapy decreased from three sessions to one session per week. Conclusion: Vascularized lymph node transfer significantly improves quality of life among patients with breast cancer–related lymphedema.

The effects of physical self-management on quality of life in breast cancer patients: A systematic review

The effects of physical self-management on quality of life in breast cancer patients: A systematic review

The Breast August 2016Volume 28, Pages 20–28

Van Dijck, S et al.

The aim of this systematic review is to report on the effects of different physical self-management techniques on quality of life (QoL) of patients with breast cancer. Therefore a systematic literature search was performed using four different databases (PubMed, Cochrane, Embase, Web of science). The inclusion criteria were: 1) adults >18 y, 2) patients with breast cancer, 3) physical self-management techniques during or after initial treatment, 4) outcome measure needed to be an indicator of patients' quality of life 5), Randomized Controlled Trials of all ages.

Diagnostic performance of contrast-enhanced spectral mammography: Systematic review and meta-analysis

Diagnostic performance of contrast-enhanced spectral mammography: Systematic review and meta-analysis


The Breast August 2016 Volume 28, Pages 13–19
Tagliafico A S et al

To estimate sensitivity and specificity of CESM for breast cancer diagnosis.
Systematic review and meta-analysis of the accuracy of CESM in finding breast cancer in highly selected women. We estimated summary receiver operating characteristic curves, sensitivity and specificity according to quality criteria with QUADAS-2.

Margins in breast conserving surgery: The financial cost & potential savings associated with the new margin guidelines

Margins in breast conserving surgery: The financial cost & potential savings associated with the new margin guidelines


The Breast August 2016Volume 28, Pages 1–4

Singer L,Brown E, Lanni T.

In this study, we compare the indications for re-excision, the findings of additional tumor in the re-excision specimen as they relate to margin status, and costs associated with re-excision based on recent new consensus statements.

The Blood Supply of the Breast Revisited

The Blood Supply of the Breast Revisited


Plastic & Reconstructive Surgery: May 2016 - Volume 137 - Issue 5 - p 1388–1397
van Deventer, PV. Graewe, F R.

Background: Many surgeons are under the impression that the blood supply is clearly defined in textbooks. Unfortunately, the majority of textbooks supply inadequate information and illustrations can be misleading in many instances. None of the textbooks describe a segmental pattern of blood supply when in actual fact a basic segmental pattern does exist. The reason for inadequate information is the perpetuation of facts since the work of the pioneers Cooper and Manchot from one textbook to another. A paucity of research studies thereafter and the fact that the results of some of these studies did not find their way into textbooks is another contributing factor. Methods: The findings of research studies since the descriptions by Cooper and Manchot are analyzed and compared in an effort to find common ground and its clinical implication. Results: Researchers concurred on the main sources of blood supply; these are internal thoracic, lateral thoracic, anterior intercostal, and acromiothoracic (thoracoacromial) arteries. However, the different research studies showed considerable variation in the branches from the main sources to supply the nipple-areola complex. Conclusions: Even though the locations of the main sources of blood supply are constant, partial or complete absence of branches from the main sources does occur and therefore the blood supply to the nipple-areola complex is unpredictable. Cognizance of the basic segmental pattern and the variations resulting from embryologic development will be helpful for the surgeon to use or adapt a technique to minimize the risk of nipple necrosis.

Surgical treatment of breast lesions at a Day Centre: Experience of the European Institute of Oncology

Surgical treatment of breast lesions at a Day Centre: Experience of the European Institute of Oncology

The Breast June 2016Volume 27, Pages 169–174

Ballardini B et al.

Breast cancer is the commonest malignancy in women worldwide. The reduced aggressiveness of breast cancer surgery has made it possible treat patients in the day surgery setting. The European Institute of Oncology, Milan, opened its new Day Center in May 2010. From May 2010 to December 2014, 17,087 patients with breast conditions were treated by the Institute's Division of Senology, 4132 (24.2%) of these in the day surgery setting, including malignant and benign conditions; 204 (4.9%) were not discharged on the day of surgery, being converted to inpatients; five (0.1%) patients returned to hospital for persistent hematoma.

Positive psychological functioning in breast cancer: An integrative review

Positive psychological functioning in breast cancer: An integrative review


The Breast June 2016Volume 27, Pages 136–168
Casellas-Grau A, Vives J, Font A, Ochoa C

This integrative review aimed to analyze the research into positive psychological functioning after breast cancer, and to integrate the most relevant findings relating to sociodemographic, medical and psychosocial factors.Relevant outcomes were identified from electronic databases (Medline, PsycINFO, Web of Science, Scopus, Cochrane, CINAHL, and Wiley Online Library) up to July 2015. A Google search was performed to identify unindexed literature. Dissertations and theses were searched on Proquest Dissertations and Theses, DIALNET and TDX.

Current Trends and Controversies in Breast Augmentation

Current Trends and Controversies in Breast Augmentation

Plastic & Reconstructive Surgery: April 2016 - Volume 137 - Issue 4 - p 1142–1150


Hidalgo D, Sinno S.

Background: A survey was conducted to study current attitudes and common practices in breast augmentation. Methods: A 35-item electronic questionnaire was sent to the entire active American Society of Plastic Surgeons membership. It was divided into current controversies, new technologies, common practices, secondary procedures, and member demographics. Results: There were 1067 respondents. Fifty percent of surgeons never use anatomically shaped implants and another 42 percent do so less than half the time. Autologous fat is used infrequently as a primary technique but more often as a supplemental technique. Approximately 7 percent report a case of anaplastic large cell lymphoma. Eighty-five percent do not use preoperative three-dimensional imaging. More than half of surgeons use acellular dermal matrix in secondary procedures. Approximately half do not use insertion funnels. Preoperative sizing with silicone implants, inframammary incisions, partial submuscular pockets, and smooth silicone implants larger than 300 cc are dominant practice preferences. Postoperative massage is still popular with over half of respondents. Just over half do not use pharmacologic agents for capsular contracture. Capsular contracture and size change were the most frequent reasons for reoperation. Capsular contracture is typically treated with anterior capsulectomy the first time, and either total capsulectomy or anterior capsulectomy with acellular dermal matrix use when recurrent. Almost half of respondents perform fewer than 50 breast augmentations yearly. Conclusions: There is an established most common approach to breast augmentation among respondents. Most surgeons are slow to embrace controversial practices and to adopt new technologies, although acellular dermal matrix use is becoming more popular. The 7 percent incidence of anaplastic large cell lymphoma was noteworthy.

Shoulder function after breast reconstruction with the latissimus dorsi flap: A prospective cohort study – Combining DASH score and objective evaluation

Shoulder function after breast reconstruction with the latissimus dorsi flap: A prospective cohort study – Combining DASH score and objective evaluation

The Breast June 2016 Volume 27, Pages 78–86


Garusi C et al

The latissimus dorsi (LD) flap is well-known in breast reconstruction especially in previously-irradiated patients, in order to have a low capsular contraction rate whenever an implant is associated. The aim of this study is to closely evaluate the effect of LD flap harvesting on shoulder function as well as specific movements related to the LD, both objectively and subjectively.

Intracystic papillary carcinoma of the breast: A SEER database analysis of implications for therapy

Intracystic papillary carcinoma of the breast: ASEER database analysis of implications for therapy

The Breast June 2016 Volume 27, Pages 87–92

Mogal H et al.


Intracystic papillary carcinoma (IPC) of the breast is a rare breast malignancy with an indolent course. However, patients can develop metastatic disease. Indications for surgery and radiotherapeutic management have not been well elucidated.

Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction.

Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction.

Ann Surg Oncol. 2016 Mar 4. [Epub ahead of print]

Dolen UC et al

BACKGROUND: Delayed wound healing or infection leads to premature tissue expander (TE) explantation after immediate postmastectomy breast reconstruction. A large study with sufficient duration of follow-up focusing on the impact of chemotherapy (CT) on premature TE removal after immediate breast reconstruction is lacking.
METHODS: A retrospective review of patients undergoing immediate TE reconstruction was conducted. Multivariate analyses identified factors contributing to premature removal of TEs including neoadjuvant and adjuvant CT, specific chemotherapeutic regimens, and other factors like cancer stage, body mass index, smoking, radiation, and age. Kaplan-Meier curves were plotted to study the timing of premature TE removal.
RESULTS: Of 899 patients with TEs, 256 received no, 295 neoadjuvant, and 348 adjuvant CT. Premature removal occurred more frequently in the neoadjuvant (17.3 %) and adjuvant (19.9 %) cohorts than the no-CT (12.5 %) cohort (p = 0.056). Premature TE removal occurred earlier (p = 0.005) in patients who received no CT than those with adjuvant CT. Radiation in patients receiving neoadjuvant CT prolonged the mean time to premature removal (p = 0.003). In the absence of radiation, premature removal occurred significantly sooner with neoadjuvant than adjuvant CT (p = 0.035).

DISCUSSION: Premature removal of a TE occurs more commonly in patients treated with neoadjuvant or adjuvant CT and is most commonly observed 2-3 months after placement-well after the follow-up period recorded by the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database. These findings can be used to aid preoperative counseling and guide the timing of follow-up for these patients.

Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction.

Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction.

Ann Surg Oncol. 2016 Mar 4. [Epub ahead of print]

Dolen UC et al


BACKGROUND: Delayed wound healing or infection leads to premature tissue expander (TE) explantation after immediate postmastectomy breast reconstruction. A large study with sufficient duration of follow-up focusing on the impact of chemotherapy (CT) on premature TE removal after immediate breast reconstruction is lacking.
METHODS: A retrospective review of patients undergoing immediate TE reconstruction was conducted. Multivariate analyses identified factors contributing to premature removal of TEs including neoadjuvant and adjuvant CT, specific chemotherapeutic regimens, and other factors like cancer stage, body mass index, smoking, radiation, and age. Kaplan-Meier curves were plotted to study the timing of premature TE removal.
RESULTS: Of 899 patients with TEs, 256 received no, 295 neoadjuvant, and 348 adjuvant CT. Premature removal occurred more frequently in the neoadjuvant (17.3 %) and adjuvant (19.9 %) cohorts than the no-CT (12.5 %) cohort (p = 0.056). Premature TE removal occurred earlier (p = 0.005) in patients who received no CT than those with adjuvant CT. Radiation in patients receiving neoadjuvant CT prolonged the mean time to premature removal (p = 0.003). In the absence of radiation, premature removal occurred significantly sooner with neoadjuvant than adjuvant CT (p = 0.035).

DISCUSSION: Premature removal of a TE occurs more commonly in patients treated with neoadjuvant or adjuvant CT and is most commonly observed 2-3 months after placement-well after the follow-up period recorded by the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database. These findings can be used to aid preoperative counseling and guide the timing of follow-up for these patients.

Revisiting the Management of Capsular Contracture in Breast Augmentation: A Systematic Review

Revisiting the Management of Capsular Contracture in Breast Augmentation: A Systematic Review

Plastic & Reconstructive Surgery: March 2016 - Volume 137 - Issue 3 - p 826–841 doi: 10.1097/01.prs.0000480095.23356.ae


Wan, D, Rohrich, R



Background: Capsular contracture is a complication of breast augmentation that frequently requires revision surgery. “Capsulectomy, site change, and implant exchange” has been referred to as the gold standard treatment of clinically significant contractures. However, the actual clinical evidence behind this algorithm remains elusive at best. A systematic review of the literature was performed to clarify the true evidence behind the surgical management of capsular contracture. Methods: A search of the MEDLINE database was performed for clinical studies involving the surgical treatment of capsular contracture following breast augmentation. Resulting articles were reviewed using a priori criteria. Results: The systematic review was performed in April of 2015. The primary search for “breast augmentation” yielded 9490 articles. When filtered for “treatment of capsular contracture,” 461 articles resulted. Review of these articles and pertinent references using a priori criteria yielded 24 final articles. No controlled trials met final inclusion criteria. Conclusions: There is limited clinical evidence behind the surgical management of capsular contracture. Site change and implant exchange are associated with reduced contracture recurrence rates and likely play a beneficial role in treating capsular contracture. The data on capsulectomy are less conclusive. Acellular dermal matrix may be a useful adjunct but still requires long-term data.

A Comparison of Methods to Assess Mastectomy Flap Viability in Skin-Sparing Mastectomy and Immediate Reconstruction: A Prospective Cohort Study

A Comparison of Methods to Assess Mastectomy Flap Viability in Skin-Sparing Mastectomy and Immediate Reconstruction: A Prospective Cohort Study

Plastic & Reconstructive Surgery: February 2016 - Volume 137 - Issue 2 - p 395–401 doi: 10.1097/01.prs.0000475744.10344.1e


Rinker, B et al

BACKGROUND: Skin-sparing mastectomy with immediate reconstruction can yield excellent aesthetic results, but high rates of mastectomy flap necrosis have been reported. A prospective cohort study was undertaken to compare three methods of assessing mastectomy flap viability following skin-sparing mastectomy and immediate reconstruction to determine which is most effective in reducing mastectomy flap necrosis.
METHODS: The study group included 60 consecutive patients (99 breasts) undergoing skin-sparing mastectomy and immediate reconstruction with either tissue expanders (n = 39) or transverse rectus abdominis musculocutaneous flaps (n = 21). Mastectomy flap viability was assessed either visually (n = 20), with fluorescein dye and Wood's lamp imaging (n = 20), or by indocyanine green angiography (n = 20). Variation across groups was analyzed using analysis of variance for continuous variables and chi-square test for dichotomous variables.
RESULTS: The mean follow-up was 10 months. There were no significant differences in mean age, body mass index, medical history, smoking history, pathologic diagnosis, chemotherapy, or reconstruction type. Mastectomy flap necrosis was observed in eight of 30 breasts in the direct visualization group (27 percent), compared with 14 percent in the indocyanine green angiography group and 3 percent in the fluorescein group (p = 0.03). The reoperation rate in the direct visualization group was 20 percent, compared with 15 percent in the indocyanine green angiography group and 0 percent in the fluorescein group.

CONCLUSIONS: Fluorescein dye was associated with the lowest rate of complications after skin-sparing mastectomy, but indocyanine green angiography was also shown to reduce mastectomy flap necrosis compared with direct visualization. Routine imaging of mastectomy flap perfusion seems to be beneficial in skin-sparing mastectomy, but intravenous fluorescein may be as effective as more expensive modalities.

Using the Retrograde Internal Mammary System for Stacked Perforator Flap Breast Reconstruction: 71 Breast Reconstructions in 53 Consecutive Patients

Using the Retrograde Internal Mammary System for Stacked Perforator Flap Breast Reconstruction: 71 Breast Reconstructions in 53 Consecutive Patients

Plastic & Reconstructive Surgery: February 2016 - Volume 137 - Issue 2 - p 265e–277e doi:10.1097/01.prs.0000475743.08559.b6

Stalder, M et al


Background: Abdominal tissue is the preferred donor source for autologous breast reconstruction, but in select patients with inadequate tissue, additional volume must be recruited to achieve optimal outcomes. Stacked flaps are an effective approach in these cases, but can be limited by the need for adequate recipient vessels. This article reports outcomes for the use of the retrograde internal mammary system for stacked flap breast reconstruction in a large number of consecutive patients. Methods: Fifty-three patients underwent stacked autologous tissue breast reconstruction with a total of 142 free flaps. Thirty patients underwent unilateral stacked deep inferior epigastric perforator (DIEP) flap reconstruction, five had unilateral stacked profunda artery perforator flap reconstruction, one had bilateral stacked DIEP/superior gluteal artery perforator flap reconstruction, and 17 underwent bilateral stacked DIEP/profunda artery perforator flap reconstruction. In all cases, the antegrade and retrograde internal mammary vessels were used for anastomoses. In situ manometry studies were also conducted comparing the retrograde internal mammary arteries in 10 patients to the corresponding systemic pressures. Results: There were three total flap losses (97.9 percent flap survival rate), two partial flap losses, four reexplorations for venous congestion, and three patients with operable fat necrosis. The mean weight of the stacked flaps for each reconstructed breast was 622.8 g. The retrograde internal mammary mean arterial pressures were on average 76.6 percent of the systemic mean arterial pressures. Conclusions: The results demonstrate that the retrograde internal mammary system is capable of independently supporting free tissue transfer. These vessels provide for convenient dissection and improved efficiency of these cases, with successful postsurgical outcomes.

Time for a randomised clinical trial evaluating breast conserving surgery compared to mastectomy in ipsilateral mutlifocal breast cancer (MFBC)?

Time for a randomised clinical trial evaluating breast conserving surgery compared to mastectomy in ipsilateral mutlifocal breast cancer (MFBC)?

The Breast [Article in Press]

Winters Z et al

Nijenhuis et al. (2015) are to be commended for reviewing the role of breast-conserving surgery (BCS) in the treatment of Multifocal Breast Cancers (MFBC) [1]. Currently, evidence-based guidelines on recommended surgical treatments in MFBC are based on limited evidence. A systematic review [2] critically evaluating the published literature has led us to conclude the following: 1) Studies of MFBC would benefit from standardized imaging, ideally with MRI providing detailed and accurate anatomic extent; 2) Modern trials would ideally evaluate neoadjuvant therapy, where therapeutic response can be evaluated; 3) Tumour subtype (immunohistochemical markers) of each cancer should be used in a minimized randomization design; 4) There is poor clinical evidence for the feasibility of dual tumour bed radiotherapy (RT) boosting and its impact on outcomes; 5) Meta-analyses on RT for unifocal cancers underline the significance of 10-year first recurrence and not breast cancer death; 6) Effect-sizes for 5-year local recurrence requires intergroup comparisons of surgery types (BCS versus mastectomy) far in excess of reported studies, where multicentric cancers are included and MFBC are clinically diagnosed; 7) Lack of convincing outcomes data on 5-year local recurrence after BCS is motivating a large international collaborative supported by respective international and national associations of breast surgery.

Patient-reported outcomes and their predictors at 2- and 3-year follow-up after immediate latissimus dorsi breast reconstruction and adjuvant treatment.

Br J Surg. 2016 Feb 29. doi: 10.1002/bjs.10102. [Epub ahead of print]

Winters Z E, et al


BACKGROUND: The aim of this study was to estimate the impact 2 and 3 years after surgery of implant-assisted latissimus dorsi (LDI) and autologous latissimus dorsi (ALD) flap breast reconstructions on patient-reported outcomes (PROs), and, secondarily, to determine whether baseline characteristics can predict PROs.
METHODS: This was a multicentre prospective cohort study. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30) and breast cancer module (QLQ-BR23), Functional Assessment of Cancer Therapy - Breast (FACT-B), and Hospital Anxiety and Depression Scale (HADS) PROs were completed before surgery and at 2 and 3 years after breast reconstruction. The effects of LDI and ALD, adjusted for baseline clinicodemographic characteristics, were estimated with multiple linear regressions. Effect sizes above 0·5 were considered clinically important.
RESULTS: Some 206 patients (LDI 93, ALD 113) were recruited in 2007-2013; 66·5 per cent were node-negative and 34·6 per cent received radiotherapy. Women with adverse clinicopathological factors were more likely to have received radiotherapy and to undergo ALD. Patients in both surgical groups showed clinically important effects at 2 and 3 years, including improvements in emotional scales, but worse physical functioning, social well-being, body image and anxiety. Radiotherapy adversely affected social functioning at 2 years (P = 0·002). Women undergoing ALD reconstruction had significantly improved sexual functioning at 3 years (P = 0·003) relative to those who had LDI procedures, even after adjusting for case mix (P = 0·007). At 3 years, younger women experienced worse physical well-being than older women (P = 0·006), and chemotherapy was associated with worse arm symptoms (P = 0·005).

CONCLUSION: Clinically important changes occurred in physical functioning, breast symptoms, body image and psychological distress. These results will guide selections of key PRO domains and sample-size calculation of future studies.

Implant-based breast reconstruction:Strategies to achieve optimal outcomes and minimize complications.

J Surg Oncol. 2016 Feb 26. doi: 10.1002/jso.24210. [Epub ahead of print]

Nahabedian MY

Abstract: Breast reconstruction using prosthetic devices is the most commonly performed procedure in women following mastectomy. The goal is to provide an outcome that is predictable and reproducible while minimizing complications and optimizing aesthetics. There are various strategies by which this can be achieved. It begins with proper patient selection because most adverse events occur in high-risk patients. This in turn is related to the timing of the reconstruction that can be performed immediately following the mastectomy or on a delayed basis. Many surgeons have been combining the use of acellular dermal matrices with prosthetic devices that require strict attention to detail to ensure success. There are various options for achieving device coverage that include total muscle, partial muscle, and subcutaneous coverage. The radiated patient poses additional challenges and limitations that must be understood to achieve a desired outcome. Finally, autologous fat grafting has become a valuable tool to improve outcomes in both radiated and non-radiated women. These factors will be reviewed with the intent of improving outcomes and minimizing complications in the setting of prosthetic breast reconstruction.