[Articles] Neoadjuvant chemotherapy with or without anthracyclines in the presence of dual HER2 blockade for HER2-positive breast cancer (TRAIN-2): a multicentre, open-label, randomised, phase 3 trial

[Articles] Neoadjuvant chemotherapy with or without anthracyclines in the presence of dual HER2 blockade for HER2-positive breast cancer (TRAIN-2): a multicentre, open-label, randomised, phase 3 trial

 by Mette S van Ramshorst, Anna van der Voort, Erik D van Werkhoven, Ingrid A Mandjes, Inge Kemper, Vincent O Dezentjé, Irma M Oving, Aafke H Honkoop, Lidwine W Tick, Agnes J van de Wouw, Caroline M Mandigers, Laurence J van Warmerdam, Jelle Wesseling, Marie-Jeanne T Vrancken Peeters, Sabine C Linn, Gabe S Sonke, Dutch Breast Cancer Research Group (BOOG)  

The Lancet Oncology: Volume 19, issue 12, P1630-1640, December 01, 2018

In view of the high proportion of pathological complete responses recorded in both groups and the fact that febrile neutropenia was more frequent in the anthracycline group, omitting anthracyclines from neoadjuvant treatment regimens might be a preferred approach in the presence of dual HER2 blockade in patients with early HER2-positive breast cancer. Long-term follow-up is required to confirm these results.

Breast Implant Mycobacterial Infections: An Epidemiologic Review and Outcome Analysis

Breast Implant Mycobacterial Infections: An Epidemiologic Review and Outcome Analysis

Authors:  Al-Halabi, Becher; Viezel-Mathieu, Alex; Shulman, Zachary; Behr, Marcel A.; Fouda Neel, Omar  

Plastic and Reconstructive Surgery:  November 2018 - Volume 142 - Issue 5 

Background: Epidemiologic evidence of periprosthetic mycobacterial infections is limited. The recent boom in cosmetic surgery tourism has been associated with a rise of surgical-site infections in returning patients. This review aims to explore available data, examine trends of documented periprosthetic mycobacterial infections, and analyze outcomes of management techniques. Methods: A search in the Biosis, Embase, LILACS, MEDLINE, and Web of Science databases from inception until December of 2017 for “Breast Implants” and “Mycobacterial Infections” and equivalents was performed. Data were pooled after two screening rounds following full-text retrieval and cross-referencing.

Results: Forty-one reports describing 171 female patients who had breast prosthesis–related mycobacterial infections were identified. Bibliometric case-based analysis revealed a rise of periprosthetic mycobacterial infections in developing countries since the start of the millennium. The mean patient’s age was 37.9 years and the majority of patients had undergone bilateral breast augmentation. Most patients presented with breast pain or tenderness, after an average incubation period of 9 months. Mycobacterium fortuitum was isolated from 90 cases (52.6 percent). Immediate explantation with or without delayed reimplantation was the most commonly used surgical strategy, complemented by combination antimicrobial therapy for an average of 4.6 months. The mean follow-up time was 39.7 months, during which recurrence was observed in 21 of 171 patients (12.3 percent).

Conclusions: The emergence of periprosthetic mycobacterial infections in relation to cosmetic medical tourism alerts clinicians to the importance of educating the public about the associated risks. In addition, this study identifies risk factors associated with recurrence of periprosthetic mycobacterial infections.

Inflammatory breast cancer. A challenging disease with poor prognosis

Inflammatory breast cancer. A challenging disease with poor prognosis

by Mariam Salim, Hafsa Arif, Osama Shakeel, Amina Iqbal, Huma Majeed, Zulqarnain Chaudhry  

The Breast: October 2018 Volume 41, Supplement 1, Page S22

Introduction: Inflammatory breast cancer (IBC) is an aggressive angioinvasive form of breast cancer associated with a high incidence of early nodal and systemic metastasis. It is a rare cancer in our population, while its incidence is increasing worldwide especially in the United States. It accounts for 1-6% of total breast cancer cases. By its ability to metastasize rapidly, most IBC tumors are characterized as stage IIIB at the time of detection. It is known for aggressive histopathologic features and poor survival.

Can breast cancer metastasize to an unusual organ? : case report and review

Can breast cancer metastasize to an unusual organ? : case report and review

by Marija Karakolevska - Ilova  

The Breast: October 2018Volume 41, Supplement 1, Pages S21–S22

Introduction: Metastatic cancer in the thyroid is uncommon and large autopsy studies found out that the incidence of thyroid metastases in patients with a history of cancer ranges from 1.9% to 24%, so in any patient with a previous history of malignancy, a new thyroid mass should be considered as recurrence until proved otherwise. The most frequent primary cancers are renal cell (48.1%), colorectal (10.4%), lung (8.3%) and breast (7.8%) cancers.Most patients with thyroid metastases have widespread metastatic disease but occasionally the thyroid may be the only site of disease with the same impact on prognosis as nonthyroidal metastases.

Physicians attitudes and knowledge about fertility preservation

Physicians attitudes and knowledge about fertility preservation

by M. Lambertini  

The Breast: October 2018Volume 41, Supplement 1, Page S4

In young breast cancer patients diagnosed during their reproductive years, the possible occurrence of treatment-induced premature ovarian insufficiency is of particular concern being associated with important menopause-related symptoms, psychosocial issues as well as infertility. Over the past years, solid evidence has been accumulated to support the management of young patients facing issues related to fertility preservation and specific guidelines have been developed to help physicians in dealing with this topic.

Follow-up clinics: nurses to lead them?

Follow-up clinics: nurses to lead them?

by Y. Wengström  

The Breast: October 2018 Volume 41, Supplement 1, Page S3

Despite substantial evidence that intensive follow up after cancer treatment may not lead to improvements in survival or quality of life, is inefficient at detecting recurrence, and is highly cost ineffective, most patients with cancer are routinely seen in outpatient clinics for many years. The high degree of psychological and functional morbidity among cancer patients suggests a need for close monitoring and support; however, research shows that routine follow up in busy clinics actually provides an environment conducive to supporting patients after a diagnosis of cancer.

Preoperative Multimodal Analgesia Decreases Postanesthesia Care Unit Narcotic Use and Pain Scores in Outpatient Breast Surgery

Preoperative Multimodal Analgesia Decreases Postanesthesia Care Unit Narcotic Use and Pain Scores in Outpatient Breast Surgery

 by Barker, Jenny C.; DiBartola, Kaitlin; Wee, Corinne; Andonian, Nicole; Abdel-Rasoul, Mahmoud; Lowery, Deborah; Janis, Jeffrey E.  

Plastic and Reconstructive Surgery: October 2018 - Volume 142 - Issue 4 - p 443e–450e

Background: The opioid epidemic demands changes in perioperative pain management. Of the 33,000 deaths attributable to opioid overdose in 2015, half received prescription opioids. Multimodal analgesia is a practice-altering evolution that reduces reliance on opioid medications. Ambulatory breast surgery is an ideal opportunity to implement these strategies.

Methods: A retrospective review of 560 patients undergoing outpatient breast procedures was conducted. Patients received (1) no preoperative analgesia (n = 333); (2) intraoperative intravenous acetaminophen (n = 78); (3) preoperative oral acetaminophen and gabapentin (n = 95); or (4) preoperative oral acetaminophen, gabapentin and celecoxib (n = 54). Outcomes included postanesthesia care unit narcotic use, pain scores, postanesthesia care unit length of stay, rescue antiemetic use, and 30-day complications. Results: Both oral multimodal analgesia regimens significantly reduced postanesthesia care unit narcotic use (oral acetaminophen and gabapentin, 14.3 ± 1.7; oral gabapentin, acetaminophen, and celecoxib, 11.9 ± 2.2; versus no drug, 19.2 ± 1.1 mg oral morphine equivalents; p = 0.0006), initial pain scores (oral acetaminophen and gabapentin, 3.9 ± 0.4; oral gabapentin, acetaminophen, and celecoxib, 3.4 ± 0.7; versus no drug, 5.3 ± 0.3 on a 1 to 10 scale, p = 0.0002) and maximum pain scores (oral acetaminophen and gabapentin, 4.3 ± 0.4; oral gabapentin, acetaminophen, and celecoxib, 3.6 ± 0.7; versus no drug, 5.9 ± 0.3 on a 1 to 10 scale; p < 0.0001). Both oral regimens were better than no medications or intravenous acetaminophen alone in multivariate models after controlling for age, body mass index, American Society of Anesthesiologists class, length of surgery, prior narcotic prescription availability, and intraoperative local anesthetic. Postanesthesia care unit length of stay, antiemetic use, and 30-day complications were not different.

Conclusions: Preoperative oral multimodal analgesia reduces narcotic use and pain scores in outpatient breast plastic surgery. These regimens are inexpensive, improve pain control, and contribute to narcotic-sparing clinical practice in the setting of a national opioid epidemic. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

[Review] Opportunities and priorities for breast surgical research

[Review] Opportunities and priorities for breast surgical research

 by Ramsey I Cutress, Stuart A McIntosh, Shelley Potter, Amit Goyal, Cliona C Kirwan, James Harvey, Adele Francis, Amtul R Carmichael, Raghavan Vidya, Jayant S Vaidya, Patricia Fairbrother, John R Benson, Malcolm W R Reed, Association of Breast Surgery Surgical Gap Analysis Working Group  

The Lancet Oncology: Review | vol. 19, issue 10, PE521-E533, October 2018

The 2013 Breast Cancer Campaign gap analysis established breast cancer research priorities without a specific focus on surgical research or the role of surgeons on breast cancer research. This Review aims to identify opportunities and priorities for research in breast surgery to complement the 2013 gap analysis. To identify these goals, research-active breast surgeons met and identified areas for breast surgery research that mapped to the patient pathway. Areas included diagnosis, neoadjuvant treatment, surgery, adjuvant therapy, and attention to special groups (eg, those receiving risk-reducing surgery).

The Functional Influence of Breast Implant Outer Shell Morphology on Bacterial Attachment and Growth

The Functional Influence of Breast Implant Outer Shell Morphology on Bacterial Attachment and Growth

by Jones, Phoebe; Mempin, Maria; Hu, Honghua; Chowdhury, Durdana; Foley, Matthew; Cooter, Rodney; Adams, William P. Jr; Vickery, Karen; Deva, Anand K.  

Plastic and Reconstructive Surgery: October 2018 - Volume 142 - Issue 4 - p 837–849

Background: The introduction of texture to the outer shell of breast implants was aimed at increasing tissue incorporation and reducing capsular contracture. It has also been shown that textured surfaces promote a higher growth of bacteria and are linked to the development of breast implant–associated anaplastic large cell lymphoma.

Methods: The authors aimed to measure the surface area and surface roughness of 11 available implants. In addition, the authors aimed to subject these implant shells to an in vitro bacterial attachment assay with four bacterial pathogens (Staphylococcus epidermidis, S. aureus, Pseudomonas aeruginosa, and Ralstonia pickettii) and study the relationship among surface area, surface roughness, and bacterial growth. Results: Surface area measurement showed grouping of implants into high, intermediate, low, and minimal. Surface roughness showed a correlation with surface area. The in vitro assay showed a significant linear relationship between surface area and bacterial attachment/growth. The high surface area/roughness implant texture grew significantly more bacteria at 24 hours, whereas the minimal surface area/roughness implant textures grew significantly fewer bacteria of all types at 24 hours. For implants with intermediate and low surface areas, some species differences were observed, indicating possible affinity of specific bacterial species to surface morphology.

 Conclusions: Implant shells should be reclassified using surface area/roughness into four categories (high, intermediate, low, and minimal). This classification is superior to the use of descriptive terms such as macrotexture, microtexture, and nanotexture, which are not well correlated with objective measurement and/or functional outcomes.

Novel Approach for Risk-Reducing Mastectomy: First-Stage Implant Placement and Subsequent Second-Stage Mastectomy

Novel Approach for Risk-Reducing Mastectomy: First-Stage Implant Placement and Subsequent Second-Stage Mastectomy

 by Lim, Geok Hoon; Baildam, Andrew D.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 607–610

Background: Risk-reducing mastectomy with tissue expander and then implant-based breast reconstruction conventionally involved immediate submuscular placement of tissue expanders during mastectomy and then, after expansion, replacement of expanders for permanent implants in a second-stage operation. Use of acellular dermal matrix can achieve a single-stage operation; however, acellular dermal matrices are costly and may have potential complications. The authors aim to assess the feasibility of placement of implants as a first-stage procedure before risk-reducing mastectomy as a novel technique of reconstruction that avoids the need for serial outpatient expansion and acellular dermal matrix.

Methods: Patients for whom risk-reducing mastectomy was planned were offered first-stage dual-plane placement of fixed volume silicone gel permanent implants by means of inframammary fold incisions. Risk-reducing mastectomy was undertaken several months later as the second operation, leaving the implants in place protected by the muscle and capsule pocket. Nipples were preserved or reconstructed according to the patient’s choice.

Results: Eight patients with 15 operated breasts were recruited. Anatomically shaped implants were used in all patients, and complete coverage of each implant was achieved. Mean implant volume was 433 ml (range, 290 to 545 ml). There were no complications, and good aesthetic outcomes were achieved.

Conclusions: This proof-of-principle study finds that placement of implants before risk-reducing mastectomy is a novel technique for women at high breast cancer risk that could reduce the use of tissue expanders and acellular dermal matrices and their associated problems. Two-stage risk-reducing mastectomy with first-stage implant placement and subsequent risk-reducing mastectomy leaving the implants in place is feasible, with no complications, and can produce a good cosmetic outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Robotic Nipple-Sparing Mastectomy with Immediate Prosthetic Breast Reconstruction: Surgical Technique

Robotic Nipple-Sparing Mastectomy with Immediate Prosthetic Breast Reconstruction: Surgical Technique

by Sarfati, Benjamin; Struk, Samuel; Leymarie, Nicolas; Honart, Jean-François; Alkhashnam, Heba; Kolb, Frédéric; Rimareix, Françoise  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 624–627

Summary: Robotic nipple-sparing mastectomy could be a significant advancement in the treatment and prophylaxis of selected breast cancers. Motion-scaling, high-resolution, three-dimensional optics; tremor elimination; and instruments with enhanced precision with 7 degrees of freedom have allowed surgeons to overcome the limitations experienced with the endoscopic approach in breast surgery. Advantages of this procedure, in comparison with the open technique, are a shorter and more acceptable scar located in the lateral thoracic region, and greater respect for the vascularization of the mastectomy skin flap, because there is no incision on the breast and no retractors are used. The authors recently received approval from both the French health authorities and the ethics committee to carry out a clinical trial in their institution to assess feasibility, reproducibility, and safety of robotic nipple-sparing mastectomy with immediate prosthetic breast reconstruction. The aims of this article are to describe the surgical technique they have developed, and to share, through a video, the clinical experience gained from over 60 procedures performed so far.

Not All Breast Implants Are Equal: A 13-Year Review of Implant Longevity and Reasons for Explantation

Not All Breast Implants Are Equal: A 13-Year Review of Implant Longevity and Reasons for Explantation

 by Van Slyke, Aaron C.; Carr, Michael; Carr, Nicholas J.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 281e–289e

Background: Augmentation mammaplasty is the most common aesthetic procedure. Textured implants control implant position and have improved capsular contracture rates; however, the impact of texturing on longevity and clinical findings at explantation is unclear.

Methods: All cases of explantation between January of 2005 and April of 2017 from an aesthetic practice were reviewed retrospectively. Patient demographics, implant characteristics, time to explantation, and clinical presentation and intraoperative findings at explantation were analyzed. Results: Five hundred thirty-nine breast implants were explanted during the study period: 249 saline, 147 smooth gel, 123 Biocell, and 20 other nonaggressively textured breast implants. Average time from placement to explantation was 7.5, 5.6, 4.9, and 4.0 years for saline, other textured, smooth gel, and Biocell implants, respectively (p = 3.25e-08). The percentage of implants removed associated with implant performance failure was 50.3, 57.4, 75.0, and 85.4 percent for smooth gel, saline, other textured, and Biocell implants, respectively (p = 7.25e-09). In addition, 21.1 percent of Biocell implants versus 1.4 percent of all other implants presented with pain (p = 2.71e-15). Forty-five Biocell implants had double capsules; this phenomenon was not observed with any other implant type (p = 5.85e-37). Seven Biocell implants had late seromas, compared to three late seromas with any other implant type (p = 0.0013).

Conclusions: Here, the authors provide evidence that Biocell implants have the shortest time to explantation and the highest proportion of implants associated with implant performance failure. This information should complement the informed consent process when selecting an appropriate implant.

Opioid Use following Outpatient Breast Surgery: Are Physicians Part of the Problem?

Opioid Use following Outpatient Breast Surgery: Are Physicians Part of the Problem?

by Hart, Alexandra M.; Broecker, Justine S.; Kao, Leslieann; Losken, Albert  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 611–620

Background: The increasing rate of opioid abuse warrants standardization of postoperative pain management. The purpose of this study was to analyze the use of opioids in pain control and patient satisfaction following ambulatory breast surgery.

Methods: This was a prospective study of a consecutive series of patients undergoing secondary breast reconstruction (n = 60) or breast reduction (n = 35). All patients were given a pain questionnaire preoperatively. Postoperatively, women received 30 tablets of oxycodone 5.0 mg/acetaminophen 325 mg. Patients were contacted three times: postoperative days 3 to 5, 8 to 10, and 30 or higher. All patients were queried on narcotic use, pain level (0 to 10), and satisfaction with pain control. Patients with allergies or taking narcotics preoperatively were excluded.

Results: Most in the secondary breast reconstruction group (61.5 percent) had stopped taking opioids by postoperative day 5. Patients consumed a mean of 11.4 tablets following secondary breast reconstruction and a mean of 17.5 tablets after breast reduction. A majority reported feeling satisfied with their pain management. At postoperative day greater than 30, most experienced very mild pain, with an improvement of 3.74 points following breast reduction. There were 18.6 and 12.5 tablets per patient left over for secondary breast reconstruction and breast reduction, respectively. A total of 1551 unused tablets were left over for the entire cohort at postoperative day greater than 30. There was no significant difference in average pain scores or interference with enjoyment or activity between those who did or did not take pain medication.

Conclusions: This commonly prescribed pain regimen provides adequate pain relief and satisfaction for breast surgery, with a substantial number of leftover tablets. Physicians as prescribers should be aware of discrepancies. Prescription of 30 opioid tablets after outpatient breast surgery appears unnecessary and excessive. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Optimizing Perforator Selection: A Multivariable Analysis of Predictors for Fat Necrosis and Abdominal Morbidity in DIEP Flap Breast Reconstruction

Optimizing Perforator Selection: A Multivariable Analysis of Predictors for Fat Necrosis and Abdominal Morbidity in DIEP Flap Breast Reconstruction

by Hembd, Austin; Teotia, Sumeet S.; Zhu, Hong; Haddock, Nicholas T.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 583–592

Background: This study aims to elucidate the important predicting factors for fat necrosis and abdominal morbidity in the patient undergoing deep inferior epigastric artery perforator flap reconstruction.

 Methods: The authors conducted a retrospective review of 866 free-flap breast reconstructions performed at one institution from 2010 to 2016. Twenty-eight potential predictors were included in multivariable analyses to control for possible confounding interactions.

Results: Four hundred nine total deep inferior epigastric artery perforator flaps were included in the statistical analysis. Of these, 14.4 percent had flap fat necrosis, 21.3 percent had an abdominal wound or complication, and 6 percent had an abdominal bulge or hernia. Analysis showed an increase in the odds of fat necrosis with increasing flap weight (OR, 1.002 per 1-g increase; p = 0.0002). A decrease in the odds of fat necrosis was seen with lateral row (OR, 0.29; p = 0.001) and both medial and lateral row perforator flaps (OR, 0.21; p = 0.001), if indocyanine green angiography was used (OR, 0.46; p = 0.04), and with increasing total flow rate of the flap (OR, 0.62 per 1-mm/second increase; p = 0.05). Increased odds of abdominal bulge or hernia were seen with lateral row or both medial and lateral row perforators (OR, 3.21; p = 0.05) versus medial row perforator-based flaps, and with patients who had an abdominal wound postoperatively (OR, 2.59; p = 0.05).

Conclusions: The authors’ results suggest that using larger caliber perforators and perforators from the lateral row alone, or in addition to medial row perforators, can decrease fat necrosis more than simply harvesting more perforators alone. However, lateral and both medial and lateral row perforator flaps come at the cost of increasing abdominal bulge rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

[Review] Statistical analysis of patient-reported outcome data in randomised controlled trials of locally advanced and metastatic breast cancer: a systematic review

The Lancet Oncology: Review: Volume 19, issue 9, PE459-PE469, September 01, 2018

Although patient-reported outcomes (PROs), such as health-related quality of life, are important endpoints in randomised controlled trials (RCTs), there is little consensus about the analysis, interpretation, and reporting of these data. We did a systematic review to assess the variability, quality, and standards of PRO data analyses in advanced breast cancer RCTs. We searched PubMed for English language articles published in peer-reviewed journals between Jan 1, 2001, and Oct 30, 2017. Eligible articles were those that reported PRO results from RCTs of adult patients with advanced breast cancer receiving anti-cancer treatments with reported sample sizes of at least 50 patients—66 RCTs met the selection criteria.

[News] New triple-negative breast cancer risk genes identified

[News] New triple-negative breast cancer risk genes identified

by Elizabeth Gourd

The Lancet Oncology : News: Volume 19, issue 9 PE445, September 01, 2018

Multigene hereditary cancer panel testing could be used to identify women with an elevated risk of triple-negative breast cancer as a result of deleterious mutations in five genes, according to a recent study.

Quality of life and patient satisfaction after one-stage implant-based breast reconstruction with an acellular dermal matrix versus two-stage breast reconstruction (BRIOS): primary outcome of a randomised, controlled trial

Quality of life and patient satisfaction after one-stage implant-based breast reconstruction with an acellular dermal matrix versus two-stage breast reconstruction (BRIOS): primary outcome of a randomised, controlled trial

by Vera Lidwina Negenborn, Danny Aschwin Young-Afat, Rieky Elise Gustina Dikmans, Jan Maerten Smit, Henri Adolf Hubert Winters, Johan Peter William Don Griot, Johannes Wilhelmus Rembertus Twisk, Pieter Quinten Ruhé, Marcus Antonius Maria Mureau, Oren Lapid, Esther Moerman, Adriaan Anne William Martinus van Turnhout, Mathias Joseph Petrus Franciscus Ritt, Mark-Bram Bouman, Margriet Gezina Mullender

The Lancet Oncology: Volume 19, issue 9, P1205-1214, September 01, 2018

Taken together with our previously published findings, one-stage IBBR with ADM does not yield superior results in terms of patient-reported QOL compared with two-stage IBBR. Risks for adverse outcomes were significantly higher in the one-stage ADM group. Use of ADM for one-stage IBBM should be considered on a case-by-case basis.

Comparison of Immediate versus Delayed DIEP Flap Reconstruction in Women Who Require Postmastectomy Radiotherapy

Comparison of Immediate versus Delayed DIEP Flap Reconstruction in Women Who Require Postmastectomy Radiotherapy

By O’Connell, Rachel L.; Di Micco, Rosa; Khabra, Komel; Kirby, Anna M.; Harris, Paul A.; James, Stuart E.; Power, Kieran; Ramsey, Kelvin W. D.; Rusby, Jennifer E.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 594–605

Background: The authors investigated aesthetic outcome and patient satisfaction in women who have undergone deep inferior epigastric artery perforator (DIEP) flap reconstruction in the setting of postmastectomy radiotherapy. Patients who underwent DIEP flap reconstruction without postmastectomy radiotherapy were the control group.

Methods: Participants who had undergone DIEP flap reconstruction between September 1, 2009, and September 1, 2014, were recruited, answered the BREAST-Q, and underwent three-dimensional surface-imaging. A panel assessed the aesthetic outcome by reviewing these images. Results: One hundred sixty-seven women participated. Eighty women (48 percent) underwent immediate DIEP flap reconstruction and no postmastectomy radiotherapy; 28 (17 percent) underwent immediate DIEP flap reconstruction with postmastectomy radiotherapy; 38 (23 percent) underwent simple mastectomy, postmastectomy radiotherapy, and DIEP flap reconstruction; and 21 (13 percent) underwent mastectomy with temporizing implant, postmastectomy radiotherapy, and DIEP flap reconstruction. Median satisfaction scores were significantly different among the groups (p < 0.05). Post hoc comparison demonstrated that women who had an immediate DIEP flap reconstruction were significantly less satisfied if they had postmastectomy radiotherapy. In women requiring radiotherapy, those undergoing delayed reconstruction after a simple mastectomy were most satisfied, but there was no significant difference between the immediate DIEP flap and temporizing implant groups. Median panel scores differed among groups, being significantly higher if the immediate reconstruction was not subjected to radiotherapy. There was no significant difference in panel assessment among the three groups of women who had received radiotherapy.

Conclusions: Patients who avoid having their immediate DIEP flap reconstruction irradiated are more satisfied and have better aesthetic outcome than those who undergo postmastectomy radiotherapy. In women requiring radiotherapy and who wish to have an immediate or “delayed-immediate” reconstruction, there were no significant differences in panel or patient satisfaction. Therefore, immediate DIEP flap reconstruction or mastectomy with temporizing implant then DIEP flap surgery are acceptable treatment pathways in the context of post-mastectomy radiotherapy.

Nitroglycerin Ointment for Reducing the Rate of Mastectomy Flap Necrosis in Immediate Implant-Based Breast Reconstruction

Nitroglycerin Ointment for Reducing the Rate of Mastectomy Flap Necrosis in Immediate Implant-Based Breast Reconstruction

by Turin, Sergey Y.; Li, Daniel D.; Vaca, Elbert E.; Fine, Neil  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 264e–270e

Background: Mastectomy flap necrosis remains a challenging complication in immediate tissue expander breast reconstruction. Nitroglycerin ointment has been shown to reduce the incidence of mastectomy flap necrosis in a randomized controlled study, using 45 g per breast and treating one side only in bilateral cases. This study was conducted to determine the efficacy of 15 g of nitroglycerin ointment per breast, therefore permitting application to both breasts in cases of bilateral mastectomy. Methods: A retrospective cohort study of patients undergoing immediate tissue expander breast reconstruction performed by a single reconstructive surgeon was conducted. The intervention cohort consisted of all patients between June 10, 2015, and June 9, 2016 (94 patients, 158 breasts), where 15 g of nitroglycerin ointment was routinely applied per breast. The control cohort consisted of all patients from June 10, 2014, to June 9, 2015 (107 patients, 170 breasts), where nitroglycerin was not applied. All complications were tracked, including minor wound healing problems. Results: There was an overall 22 percent decreased incidence of mastectomy flap necrosis in the nitroglycerin ointment cohort (47.5 percent versus 60.6 percent; p = 0.002), with a 44 percent reduction in full-thickness mastectomy flap necrosis that trended toward statistical significance (9.5 percent versus 16.5 percent; p = 0.06). On multivariate analysis, nitroglycerin application was independently associated with a decrease in mastectomy flap necrosis or need for mastectomy flap débridement. There was no significant difference in the incidence of postoperative hypotension (3.8 percent versus 2.9 percent) or headache among cohorts. Conclusion: Topical nitroglycerin ointment application to mastectomy skin flaps at 15 g per breast is a cost-effective means of decreasing the incidence of mastectomy flap necrosis in unilateral and bilateral immediate tissue expander breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Efficacy of scalp cooling in reducing alopecia in early breast cancer patients receiving contemporary chemotherapy regimens

Efficacy of scalp cooling in reducing alopecia in early breast cancer patients receiving contemporary chemotherapy regimens

by Arlene Chan, Astrid Bauwens, Sally Pontre, Sally Jackson, Frances McGlone, Tracie Ernenwein, Jun Chih, Christopher Reid  

The Breast: October 2018 Volume 41, Pages 127–132

Hair loss as a result of chemotherapy for early breast cancer (EBC) is a frequent and distressing side effect. Minimising hair loss may improve mood and body image. Our aim was to determine scalp cooling (SC) efficacy in EBC patients receiving contemporary chemotherapy regimen, to inform future patients choice to use SC or not.