Intravenous Tranexamic Acid in Implant-Based Breast Reconstruction Safely Reduces Hematoma without Thromboembolic Events

Link to article: Intravenous Tranexamic Acid in Implant-Based Breast Reconstruction Safely Reduces Hematoma without Thromboembolic Events

by Weissler, Jason M.; Banuelos, Joseph; Jacobson, Steven R.; Manrique, Oscar J.; Nguyen, Minh-Doan T.; Harless, Christin A.; Tran, Nho V.; Martinez-Jorge, Jorys

Plastic and Reconstructive Surgery: August 2020 - Volume 146 - Issue 2 - p 238-245

Background:

Antifibrinolytic medications, such as tranexamic acid, have recently garnered increased attention. Despite its ability to mitigate intraoperative blood loss and need for blood transfusion, there remains a paucity of research in breast reconstruction. The authors investigate whether intravenous tranexamic acid safely reduces the risk of hematoma following implant-based breast reconstruction.

Methods:

 A single-center retrospective cohort study was performed to analyze all consecutive patients undergoing immediate two-stage implant-based breast reconstruction following mastectomy between 2015 and 2016. The incidence of postoperative hematomas and thromboembolic events among all patients was reviewed. The patients in the intervention group received 1000 mg of intravenous tranexamic acid before mastectomy incision and 1000 mg at the conclusion of the procedure. Fisher’s exact test and the Mann-Whitney-Wilcoxon test were used. Multivariate logistic regression models were performed to study the impact of intravenous tranexamic acid after adjusting for possible confounders.

Results:

A total of 868 consecutive breast reconstructions (499 women) were reviewed. Overall, 116 patients (217 breasts) received intravenous tranexamic acid, whereas 383 patients (651 breasts) did not. Patient characteristics and comorbidities were similar between the two the groups. Patients who received tranexamic acid were less likely to develop hematomas [n = 1 (0.46 percent)] than patients who did not [n = 19 (2.9 percent)] after controlling for age, hypertension, and type of reconstruction (prepectoral and subpectoral) (p = 0.018). Adverse effects of intravenous tranexamic acid, including thromboembolic phenomena were not observed. Multivariate analysis demonstrated that age and hypertension independently increase risk for hematoma.

Conclusions:

 Intravenous tranexamic acid safely reduces risk of hematoma in implant-based breast reconstruction. Further prospective randomized studies are warranted to further corroborate these findings. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Long-Term Health-Related Quality of Life after Four Common Surgical Treatment Options for Breast Cancer and the Effect of Complications: A Retrospective Patient-Reported Survey among 1871 Patients

Link to article: Long-Term Health-Related Quality of Life after Four Common Surgical Treatment Options for Breast Cancer and the Effect of Complications: A Retrospective Patient-Reported Survey among 1871 Patients

by Kouwenberg, Casimir A. E.; de Ligt, Kelly M.; Kranenburg, Leonieke W.; Rakhorst, Hinne; de Leeuw, Daniëlle; Siesling, Sabine; Busschbach, Jan J.; Mureau, Marc A. M.

Plastic and Reconstructive Surgery: July 2020 - Volume 146 - Issue 1 - p 1-13

Background:

Differences in quality-of-life outcomes after different surgical breast cancer treatment options, including breast reconstruction, are relevant for counseling individual patients in clinical decision-making, and for (societal) evaluations such as cost-effectiveness analyses. However, current literature shows contradictory results, because of use of different patient-reported outcome measures and study designs with limited patient numbers. The authors set out to improve this evidence using patient-reported outcome measures in a large, cross-sectional study for different surgical breast cancer treatment options.

Methods:

Quality of life was assessed through the EQ-5D-5L, European Organization for Research and Treatment of Cancer Quality of Life Questionnaires C30 and BR23, and the BREAST-Q. Patients with different treatments were compared after propensity-weighted adjustment of pretreatment differences. The EQ-5D was used to value the effect of surgical complications.

Results:

A total of 1871 breast cancer patients participated (breast-conserving surgery, n = 615; mastectomy, n = 507; autologous reconstruction, n = 330; and implant-based reconstruction, n = 419). Mastectomy patients reported the lowest EQ-5D score (mastectomy, 0.805, breast-conserving surgery, 0.844; autologous reconstruction, 0.849; and implant-based reconstruction, 0.850) and functioning scores of the C30 questionnaire. On the BREAST-Q, autologous reconstruction patients had higher mean Satisfaction with Outcome, Satisfaction with Breasts, and Sexual Well-being scores than implant-based reconstruction patients. Complications in autologous reconstruction patients resulted in a substantially lower quality of life than in implant-based reconstruction patients.

Conclusions:

This study shows the added value of breast conservation and reconstruction compared with mastectomy; however, differences among breast-conserving surgery, implant-based reconstruction, and autologous breast reconstruction were subtle. Complications resulted in poorer health-related quality of life.

Intraoperative Assessment of DIEP Flap Breast Reconstruction Using Indocyanine Green Angiography: Reduction of Fat Necrosis, Resection Volumes, and Postoperative Surveillance

Link to article: Intraoperative Assessment of DIEP Flap Breast Reconstruction Using Indocyanine Green Angiography: Reduction of Fat Necrosis, Resection Volumes, and Postoperative Surveillance

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

Plastic and Reconstructive Surgery: July 2020 - Volume 146 - Issue 1 - p 1e-10e

Background:

This study aims to characterize the effect of laser-assisted indocyanine green fluorescence angiography on fat necrosis and flap failure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction.

Methods:

 A retrospective review was performed on 1000 free flaps for breast reconstruction at a single center from 2010 to 2017. Indocyanine green angiography was used after completion of recipient-site anastomoses to subjectively assess for areas of hypoperfusion. A multivariable logistical analysis was conducted with 24 demographic and surgical factors and their effects on fat necrosis and flap failure.

Results:

Five hundred six DIEP flaps were included in the statistical analyses. Thirteen percent of flaps had fat necrosis. Indocyanine green angiography was used for 200 flaps and was independently associated with a decrease in the odds of fat necrosis (OR, 0.38; p = 0.004). There was no reduction in flap failure rates when using indocyanine green angiography (OR, 1.15; p = 0.85). However, there was a decrease in flap loss with increasing venous coupler diameter (OR, 0.031 per 1-mm increase; p = 0.012). The 84.9-g higher weight of resected tissue before inset without indocyanine green angiography versus the weight of the tissue resected with indocyanine green angiography was statistically significant (p = 0.01). Per single incident of fat necrosis, our cohort underwent an additional 0.69 revision procedures, 1.22 imaging studies, 0.77 biopsies, and 1.7 additional oncologic office visits.

Conclusion:

Intraoperative indocyanine green fluorescence angiography decreases the odds of fat necrosis, saves volume when flap trimming at inset, and can significantly reduce the postoperative surveillance burden in DIEP-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Attachments of the Breast to the Chest Wall: A Dissection Study

Link to article: The Attachments of the Breast to the Chest Wall: A Dissection Study

by Gaskin, Kathryn M.; Peoples, Gregory E.; McGhee, Deirdre E. 

Plastic and Reconstructive Surgery :  July 2020 - Volume 146 - Issue 1 - p 11-22e

Background: 

The anatomical descriptions of the attachments of the female breast to the chest wall vary in their structure, location, and terminology within the published literature.

Methods: 

A dissection study of the attachments of the breast to the chest wall was conducted on 18 female embalmed breasts in the coronal (n = 15) and sagittal planes (n = 3).

Results: 

Perimeter, posterior wall, and horizontal septum attachments were observed. The perimeter along its entire length was attached to the chest wall. Regional and anatomical variation was observed in this structure and location. Sharp dissection was required to remove it from the chest wall, in contrast to the blunt dissection required to remove the posterior wall and horizontal septum attachments.

Conclusions: 

The breast attaches to the chest wall along its entire perimeter, posterior wall, and horizontal septum, with the perimeter functioning as the primary anchor of the breast to the chest wall. The structure of the perimeter attachment is both periosteal and fascial and requires sharp dissection to remove it from the chest wall. The fascial structures of the posterior wall and horizontal septum require blunt dissection only. The structure of the perimeter has regional variation, and its location on the chest wall has anatomical variation. Detailed anatomical descriptions and illustrations are supported by photographic evidence of cadaver dissections in two planes. Clinical and anatomical terminology are linked, with clinical implications for medical anatomy education, breast modeling, and breast surgery.

Effects of weight reduction on the breast cancer-related lymphedema: A systematic review and meta-analysis

Effects of weight reduction on the breast cancer-related lymphedema: A systematic review and meta-analysis

by Chi-Lin Tsai, Chih-Yang Hsu, Wei-Wen Chang, Yen-Nung Lin 

The Breast: VOLUME 52, P116-121, AUGUST 01, 2020

Highlights

•Weight reduction decreases the volume of both arms in patients with BCRL.

•Weight reduction does not reduce the severity of BCRL measured objectively.

•Effects of weight reduction on preventing BCRL are yet unknown.

Abstract

Background:

Obesity has long been considered a risk factor for breast cancer–related lymphedema (BCRL), but the benefits of weight reduction in managing BCRL have not been clearly established.

Objective:

To evaluate the beneficial effects of weight loss interventions (WLIs) on the reduction and prevention of BCRL.

Methods:

We conducted a systematic review and meta-analysis by searching the PubMed, Scopus, and Embase databases from their earliest record to October 1st, 2019. We included randomized and non-randomized controlled trials involving adult patients with a history of breast cancer, that compared WLI groups with no-WLI groups, and provided quantitative measurements of lymphedema.

Results:

Initial literature search yielded 461 nonduplicate records. After exclusion based on title, abstract, and full-text review, four randomized controlled trials involving 460 participants were included for quantitative analysis. Our meta-analysis revealed a significant between-group mean difference (MD) regarding the volume of affected arm (MD = 244.7 mL, 95% confidence interval [CI]: 145.3–344.0) and volume of unaffected arm (MD = 234.5 mL, 95% CI: 146.9–322.1). However, a nonsignificant between-group MD of −0.07% (95% CI: 1.22–1.08) was observed regarding the interlimb volume difference at the end of the WLIs.

Conclusions:

In patients with BCRL, WLIs are associated with decreased volume of the affected and unaffected arms but not with decreased severity of BCRL measured by interlimb difference in arm volume.

Changes in breast cancer management during the Corona Virus Disease 19 pandemic: An international survey of the European Breast Cancer Research Association of Surgical Trialists (EUBREAST)

Changes in breast cancer management during the Corona Virus Disease 19 pandemic: An international survey of the European Breast Cancer Research Association of Surgical Trialists (EUBREAST)

by Maria Luisa Gasparri, Oreste Davide Gentilini, Diana Lueftner, Thorsten Kuehn, Orit Kaidar-Person, Philip Poortmans

The Breast: VOLUME 52, P110-115, AUGUST 01, 2020

Highlights

•Management of breast cancer patients was modified during the pandemic.

•Waiting time increased during the pandemic in 20% of the institutions.

•A workload reduction of ≥50% was reported in 1/3 and relocation of the centres in 13%.

•It is unknown whether these changes will affect outcome of breast cancer patients.

Abstract

Background

Corona Virus Disease 19 (COVID-19) had a worldwide negative impact on healthcare systems, which were not used to coping with such pandemic. Adaptation strategies prioritizing COVID-19 patients included triage of patients and reduction or re-allocation of other services. The aim of our survey was to provide a real time international snapshot of modifications of breast cancer management during the COVID-19 pandemic.

Methods

A survey was developed by a multidisciplinary group on behalf of European Breast Cancer Research Association of Surgical Trialists and distributed via breast cancer societies. One reply per breast unit was requested.

Results

In ten days, 377 breast centres from 41 countries completed the questionnaire. RT-PCR testing for SARS-CoV-2 prior to treatment was reported by 44.8% of the institutions. The estimated time interval between diagnosis and treatment initiation increased for about 20% of institutions. Indications for primary systemic therapy were modified in 56% (211/377), with upfront surgery increasing from 39.8% to 50.7% (p < 0.002) and from 33.7% to 42.2% (p < 0.016) in T1cN0 triple-negative and ER-negative/HER2-positive cases, respectively. Sixty-seven percent considered that chemotherapy increases risks for developing COVID-19 complications. Fifty-one percent of the responders reported modifications in chemotherapy protocols. Gene-expression profile used to evaluate the need for adjuvant chemotherapy increased in 18.8%. In luminal-A tumours, a large majority (68%) recommended endocrine treatment to postpone surgery. Postoperative radiation therapy was postponed in 20% of the cases.

Conclusions

Breast cancer management was considerably modified during the COVID-19 pandemic. Our data provide a base to investigate whether these changes impact oncologic outcomes.

Clinical outcome of adjuvant radiotherapy for squamous cell carcinoma of the breast; a multicenter retrospective cohort study

Clinical outcome of adjuvant radiotherapy for squamous cell carcinoma of the breast; a multicenter retrospective cohort study

by Mami Ogita, Kenshiro Shiraishi, Katsuyuki Karasawa, Kenji Tokumasu, Naomi Nakajima, Tachen Chang, Jiro Kawamori, Hideomi Yamashita, Keiichi Nakagawa

The Breast: VOLUME 52, P88-94, AUGUST 01, 2020

Highlights

•Clinical outcome of adjuvant radiotherapy for SCC of the breast was evaluated.

•Breast SCC had poor prognosis and a high incidence of locoregional recurrence.

•In-field recurrence following radiotherapy occurred frequently.

•Age and lymphatic invasion were significantly associated with increased risk of recurrence.

Abstract

Background:

Because primary squamous cell carcinoma (SCC) of the breast is a rare disease, the standard therapy has not been established. We examined the clinical outcomes of postoperative adjuvant radiotherapy for breast SCC.

Material and methods:

We conducted a multicenter retrospective cohort study. Patients diagnosed with primary breast SCC who received adjuvant radiotherapy as part of their primary definitive treatment were included. Overall survival (OS), breast cancer-specific survival (BCSS), and recurrence-free interval (RFi) were evaluated.

Results:

Between January 2002 and December 2017, 25 breast SCC patients received adjuvant radiotherapy as a primary treatment were included. Median follow-up time was 43.5 months. Three (12%), fifteen (60%) and seven (28%) patients had clinical stage I, II and III disease, respectively. Fourteen patients underwent breast-conserving surgery and subsequent adjuvant radiotherapy. Eleven patients underwent mastectomy and post-mastectomy radiotherapy. Ten patients received regional lymph node irradiation. Nine (36%) patients had disease recurrence. The first site of recurrence was locoregional in five, but distant metastasis arose in one. Concurrent local and distant metastasis were seen in two. Six cases of local recurrence occurred within the irradiated site. Seven patients died, and six of the deaths were due to breast cancer. Five-year OS, BCSS, and Rfi were 69%, 70%, and 63%, respectively. In multivariate analysis, age and lymphatic invasion were associated with increased risk of recurrence.

Conclusion:

Breast SCC has a high incidence of locoregional recurrence and poor prognosis. Age and lymphatic invasion are significant risk factors for recurrence.

Hospital-based or home-based administration of oncology drugs? A micro-costing study comparing healthcare and societal costs of hospital-based and home-based subcutaneous administration of trastuzumab

Hospital-based or home-based administration of oncology drugs? A micro-costing study comparing healthcare and societal costs of hospital-based and home-based subcutaneous administration of trastuzumab

by Margreet Franken, Tim Kanters, Jules Coenen, Paul de Jong, Agnes Jager, Carin Uyl-de Groot 

The Breast: VOLUME 52, P71-77, AUGUST 01, 2020

Highlights

• Home-based administration of SC trastuzumab almost triples the time of healthcare professionals.
• Healthcare costs are almost twice as much for home-based than for hospital-based administration.
• Patient and family costs are almost five times lower for home-based than for hospital-based administration.

Abstract

Objective

To investigate resource use and time investments of healthcare professionals, patients and their family and to compare healthcare and societal costs of one single hospital-based and one single home-based subcutaneous administration of trastuzumab in The Netherlands.

Method

We conducted a bottom-up micro-costing study. Patients diagnosed with HER2+ early or metastatic breast cancer were recruited in four Dutch hospitals. For healthcare costs, data were collected on drug use, consumables, use of healthcare facilities, time of healthcare professionals, and travelling distance of the nurse. For societal costs, data were collected on patient and family costs (including travelling expenses and time of informal caregivers) and productivity losses of paid and unpaid work.

Results

Societal costs of one single administration of SC trastuzumab were €1753 within the home-based and €1724 within the hospital-based setting. Drug costs of trastuzumab were identical in both settings (€1651). Healthcare costs were higher for home-based administration (€91 versus €47) mainly because of more time of healthcare professionals (110 versus 38 minutes). Costs for patient and family were, however, lower for home-based administration due to travelling expenses (€7 versus €0) and time of informal caregivers (€14 versus €4). Costs for productivity losses were similar for both settings.

Conclusions

Home-based subcutaneous administration of trastuzumab is more time consuming for healthcare professionals and therefore more costly than hospital-based administration. The total budget impact can be large considering that a large number of patients receive a large number of cycles of oncology treatments. If home-based administration is the way forward, novel approaches are crucial for ensuring efficiency of home-based care.

Impact of age at diagnosis of metastatic breast cancer on overall survival in the real-life ESME metastatic breast cancer cohort

Impact of age at diagnosis of metastatic breast cancer on overall survival in the real-life ESME metastatic breast cancer cohort

by Sophie Frank, Matthieu Carton, Coraline Dubot, Mario Campone, Barbara Pistilli, Florence Dalenc, Audrey Mailliez, Christelle Levy, Véronique D’Hondt, Marc Debled, Thomas Vermeulin, Bruno Coudert, Christophe Perrin, Anthony Gonçalves, Lionel Uwer, Jean-Marc Ferrero, Jean-Christophe Eymard, Thierry Petit, Marie-Ange Mouret-Reynier, Anne Patsouris, Tahar Guesmia, Thomas Bachelot, Mathieu Robain, Paul Cottu

The Breast:  VOLUME 52, P50-57, AUGUST 01, 2020

Highlights

•Young age is a poor prognosis factor in early stage breast cancer.

•Young age is associated with an aggressive presentation in metastatic breast cancer.

•Young age had no impact on overall survivall in metastatic breast cancer.

•Oppositely, older women (>60y) had a stightly poorer prognosis at the metastatic stage.

Abstract

Background

Young age is a poor prognostic factor in early stage breast cancer (BC) but its value is less established in metastatic BC (MBC). We evaluated the impact of age at MBC diagnosis on overall survival (OS) across three age groups (<40 40="" 60="" and="" nbsp="" to=""> 60 years(y)).

Methods

ESME MBC database is a national cohort, collecting retrospective data from 18 participating French cancer centers between January 01, 2008 and December 31, 2014.

Results

Among 14 403 women included, 1077 (7.5%), 6436 (44.7%) and 6890 (47.8%) pts were <40 40="" and="" nbsp=""> 60 y respectively. Pts <40 15.3="" age="" aggressive="" frequent="" groups:="" had="" her2="" in="" more="" other="" presentations="" significantly="" than="" vs="">60y) and triple negative subtypes (27.4 vs 14.6% in >60y), and more frequent visceral involvement (36.3 vs 29.8% in >60y). At a median follow-up of 48 months, median OS differed across age groups: 38.8, 38.4 and 35.6 months for pts <40 40="" and="" nbsp=""> 60y, respectively (p < 0.0001). Compared to pts <40y 40="" 74.9="" 81.9="" 86.6="" 95="" a="" all="" although="" and="" anti-her2="" as="" better="" causes="" clinical="" death="" diseases.="" explanation="" first-line="" for="" greater="" had="" her2="" higher="" ic="" in="" included="" is="" limited="" luminal="" nbsp="" of="" older="" os="" possible="" pts="" risk="" significant="" statistically="" therapies="" there="" treatments:="" trend="" use="" value="" was="" with="" y=""> 60y, respectively (p < 0.0001).

Conclusion

Although young age seems associated with more aggressive presentations at diagnosis of MBC, it has no deleterious effect on OS in this large series.

Changes in weight, physical and psychosocial patient-reported outcomes among obese women receiving treatment for early-stage breast cancer: A nationwide clinical study

Changes in weight, physical and psychosocial patient-reported outcomes among obese women receiving treatment for early-stage breast cancer: A nationwide clinical study

by Antonio Di Meglio, Stefan Michiels, Lee W. Jones, Mayssam El-Mouhebb, Arlindo R. Ferreira, Elise Martin, Margarida Matias, Ana Elisa Lohmann, Florence Joly, Laurence Vanlemmens, Sibille Everhard, Anne-Laure Martin, Jerome Lemonnier, Patrick Arveux, Paul H. Cottu, Charles Coutant, Lucia Del Mastro, Ann H. Partridge, Fabrice André, Jennifer A. Ligibel, Ines Vaz-Luis

The Breast: VOLUME 52, P23-32, AUGUST 01, 2020

Background

Evidence on how weight loss correlates to health-related quality-of-life (HRQOL) among obese breast cancer (BC) patients is limited. We aimed to evaluate associations between weight changes and HRQOL.

Methods

We included 993 obese women with stage I-II-III BC from CANTO, a multicenter, prospective cohort collecting longitudinal, objectively-assessed anthropometric measures and HRQOL data (NCT01993498). Associations between weight changes (±5% between diagnosis and post-treatment [shortly after completion of surgery, adjuvant chemo- or radiation-therapy]) and patient-reported HRQOL (EORTC QLQ-C30/B23) were comprehensively evaluated. Changes in HRQOL and odds of severely impaired HRQOL were assessed using multivariable generalized estimating equations and logistic regression, respectively.

Results

14.1% women gained weight, 67.3% remained stable and 18.6% lost weight. Significant decreases in functional status and exacerbation of symptoms were observed overall post-treatment. Compared to gaining weight or remaining stable, obese women who lost weight experienced less of a decline in HRQOL, reporting better physical function (mean change [95%CI] for gain, stability and loss: −12.9 [-16.5,-9.3], −6.9 [-8.2,-5.5] and −6.2 [-8.7,-3.7]; pinteraction[weight-change-by-time] = 0.006), less dyspnea (+18.9 [+12.3,+25.6], +9.2 [+6.5,+11.9] and +3.2 [-1.0,+7.3]; pinteraction = 0.0003), and fewer breast symptoms (+22.1 [+16.8,+27.3], +18.0 [+15.7,+20.3] and +13.4 [+9.0,+17.2]; pinteraction = 0.044). Weight loss was also significantly associated with reduced odds of severe pain compared with weight gain (OR [95%CI] = 0.51 [0.31–0.86], p = 0.011) or stability (OR [95%CI] = 0.62 [0.41–0.95], p = 0.029). No associations between weight loss and worsening of other physical or psychosocial parameters were found.

Conclusions

This large contemporary study suggests that weight loss among obese BC patients during early survivorship was associated with better patient-reported outcomes, without evidence of worsened functionality or symptomatology in any domain of HRQOL.

Recommendations for triage, prioritization and treatment of breast cancer patients during the COVID-19 pandemic

Recommendations for triage, prioritization and treatment of breast cancer patients during the COVID-19 pandemic

by Giuseppe Curigliano, Maria Joao Cardoso, Philip Poortmans, Oreste Gentilini, Gabriella Pravettoni, Ketti Mazzocco, Nehmat Houssami, Olivia Pagani, Elzbieta Senkus, Fatima Cardoso, on behalf of the editorial board of The Breast

The Breast: VOLUME  52, P8-16, AUGUST  01, 2020

The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) associated disease (COVID-19) outbreak seriously challenges globally all health care systems and professionals. Expert projections estimate that despite social distancing and lockdown being practiced, we have yet to feel the full impact of COVID-19. In this manuscript we provide guidance to prepare for the impact of COVID-19 pandemic on breast cancer patients and advise on how to triage, prioritize and organize diagnostic procedures, surgical, radiation and medical treatments.

Dual-Plane versus Prepectoral Breast Reconstruction in High–Body Mass Index Patients

Dual-Plane versus Prepectoral Breast Reconstruction in High–Body Mass Index Patients

by Gabriel, Allen; Sigalove, Steven; Storm-Dickerson, Toni L.; Sigalove, Noemi M.; Pope, Nicole; Rice, Jami; Maxwell, G. Patrick

Plastic and Reconstructive Surgery: June 2020 - Volume 145 - Issue 6 - p 1357-1365

Background: Breast reconstruction in patients with a high body mass index (BMI) (≥30 kg/m2) is technically challenging and is associated with increased postoperative complications. The optimal reconstructive approach for these patients remains to be determined. This study compared outcomes of prepectoral and dual-plane reconstruction in high-BMI patients to determine whether there was an association between postoperative complications and the plane of reconstruction. 

Methods: High-BMI patients who underwent immediate dual-plane or prepectoral expander/implant reconstruction were included in this retrospective study. Patients were stratified by reconstructive approach (dual-plane or prepectoral), and postoperative complications were compared between the groups. Multivariate logistic regression analysis was performed to determine whether the plane of reconstruction was an independent predictor of any complication after adjusting for potential confounding differences in patient variables between the groups.

Results: Of 133 patients, 65 (128 breasts) underwent dual-plane and 68 (129 breasts) underwent prepectoral reconstruction. Rates of seroma (13.3 percent versus 3.1 percent), surgical-site infection (9.4 percent versus 2.3 percent), capsular contracture (7.0 percent versus 0.8 percent), and any complication (25.8 percent versus 14.7 percent) were significantly higher in patients who had dual-plane versus prepectoral reconstruction (p < 0.05). Multivariate logistic regression identified dual-plane, diabetes, neoadjuvant radiotherapy, and adjuvant chemotherapy as significant, independent predictors of any complication (p < 0.05). Dual-plane reconstruction increased the odds of any complication by 3-fold compared with the prepectoral plane.

Conclusion: Compared with the dual-plane approach, the prepectoral approach appears to be associated with a lower risk of postoperative complications following immediate expander/implant breast reconstruction and may be a better reconstructive option in high-BMI patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Patient-Reported Outcomes after Irradiation of Tissue Expander versus Permanent Implant in Breast Reconstruction: A Multicenter Prospective Study

Patient-Reported Outcomes after Irradiation of Tissue Expander versus Permanent Implant in Breast Reconstruction: A Multicenter Prospective Study

by Yoon, Alfred P.; Qi, Ji; Kim, Hyungjin M.; Hamill, Jennifer B.; Jagsi, Reshma; Pusic, Andrea L.; Wilkins, Edwin G.; Kozlow, Jeffrey H.

Plastic and Reconstructive Surgery: May 2020 - Volume 145 - Issue 5 - p 917e-926e

Background: Whether to irradiate the tissue expander before implant exchange or to defer irradiation until after exchange in immediate, two-stage expander/implant reconstruction remains uncertain. The authors evaluated the effects of irradiation timing on complication rates and patient-reported outcomes in patients undergoing immediate expander/implant reconstruction.

Methods: Immediate expander/implant reconstruction patients undergoing postmastectomy radiation therapy at 11 Mastectomy Reconstruction Outcomes Consortium sites with demographic, clinical, and complication data were analyzed. Patient-reported outcomes were assessed with BREAST-Q, Patient-Reported Outcomes Measurement Information System, and European Organisation for Research and Treatment of Cancer Breast Cancer–Specific Quality-of-Life Questionnaire surveys preoperatively and 2 years postoperatively. Survey scores and complication rates were analyzed using bivariate comparison and multivariable regressions.

Results: Of 317 patients who met inclusion criteria, 237 underwent postmastectomy radiation therapy before expander/implant exchange (before-exchange cohort), and 80 did so after exchange (after-exchange cohort). Timing of radiation had no significant effect on risks of overall complications (OR, 1.25; p = 0.46), major complications (OR, 1.18; p = 0.62), or reconstructive failure (OR, 0.72; p = 0.49). Similarly, radiation timing had no significant effect on 2-year patient-reported outcomes measured by the BREAST-Q or the European Organisation for Research and Treatment of Cancer survey. Outcomes measured by the Patient-Reported Outcomes Measurement Information System showed less anxiety, fatigue, and depression in the after-exchange group. Compared with preoperative assessments, 2-year patient-reported outcomes significantly declined in both cohorts for Satisfaction with Breasts, Physical Well-Being, and Sexual Well-Being, but improved for anxiety and depression.

Conclusions: Radiation timing (before or after exchange) had no significant effect on complication risks or on most patient-reported outcomes in immediate expander/implant reconstruction. Although lower levels of anxiety, depression, and fatigue were observed in the after-exchange group, these differences may not be clinically significant. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Direct-to-Implant Breast Reconstruction with Simultaneous Nipple-Sparing Mastopexy Utilizing an Inferiorly Based Adipodermal Flap: Our Experience with Prepectoral and Subpectoral Techniques

Direct-to-Implant Breast Reconstruction with Simultaneous Nipple-Sparing Mastopexy Utilizing an Inferiorly Based Adipodermal Flap: Our Experience with Prepectoral and Subpectoral Techniques

by Mosharrafa, Ali M.; Mosharrafa, Tamir M.; Zannis, Victor J. 

Plastic and Reconstructive Surgery: May 2020 - Volume 145 - Issue 5 - p 1125-1133

Background: Direct-to-implant breast reconstruction continues to grow in popularity among reconstructive breast surgeons and patients alike. Women with large breasts and ptosis are often thought not to be candidates for nipple sparing or direct-to-implant reconstruction. The authors utilized a single-stage, nipple-sparing, direct-to-implant reconstruction with simultaneous mastopexy, while the nipple-areolar complex was kept viable on an inferiorly based adipodermal flap in a single stage. They report their experience and outcomes using this approach in women with breast ptosis and/or macromastia.

Methods: The authors reviewed all direct-to-implant reconstructions with simultaneous nipple-sparing mastopexies performed from June of 2015 to March of 2019. Sixty-five patients and 125 breast reconstructions were analyzed.

Results: Among the 65 patients (125 breast reconstructions), 15 (23 percent) had implants placed in the prepectoral space, and 50 (77 percent) had them placed subpectorally. Forty-seven patients (72 percent) had acellular dermal matrix used. Partial nipple-areolar complex necrosis occurred in six patients (9 percent). Other complications included partial mastectomy flap necrosis (n = 8 patients, 12 percent), implant exposure (n = 3, 4 percent), infection (n = 1, 1 percent), capsular contracture (n = 4, 6 percent), and reoperation (n = 11, 16 percent). Mean follow-up was 17 months (range, 3 to 47 months). There have been no cancer recurrences reported in any participants to date.

Conclusions: Nipple-sparing mastectomy with mastopexy and immediate direct-to-implant reconstruction dramatically improved the authors’ results for implant-based breast reconstruction patients. The higher than expected explantation rate of 7 percent early in the study has since improved. This approach provides an opportunity to expand indications for nipple-sparing mastectomy and direct-to-implant reconstruction to women with breast ptosis and/or macromastia. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Immediate Contralateral Mastopexy/Breast Reduction for Symmetry Can Be Performed Safely in Oncoplastic Breast-Conserving Surgery

Immediate Contralateral Mastopexy/Breast Reduction for Symmetry Can Be Performed Safely in Oncoplastic Breast-Conserving Surgery

by Deigni, Olivier A.; Baumann, Donald P.; Adamson, Karri A.; Garvey, Patrick B.; Selber, Jesse C.; Caudle, Abigail S.; Smith, Benjamin D.; Hanson, Summer E.; Robb, Geoffrey L.; Schaverien, Mark V.

Plastic and Reconstructive Surgery: May 2020 - Volume 145 - Issue 5 - p 1134-1142

Background: Oncoplastic breast-conserving surgery expands the indications for breast conservation. When performed using modified mastopexy/breast reduction techniques, the optimal timing of the contralateral symmetrizing mastopexy/breast reduction remains unclear. This study examined the effect of the timing of symmetrizing mastopexy/breast reduction on oncoplastic breast-conserving surgery outcomes.

Methods: A retrospective study was conducted of all patients who underwent oncoplastic breast-conserving surgery using mastopexy/breast reduction techniques at a single center from 2010 to 2016. Patients who received synchronous (immediate) contralateral breast symmetrizing mastopexy were compared with those who underwent a delayed symmetrizing mastopexy procedure. Demographic, treatment, and outcome data were collected. Descriptive statistics were used and multivariate analysis was performed to evaluate the various relationships.

Results: There were 429 patients (713 breasts) included in the study; of these, 284 patients (568 breasts) underwent oncoplastic breast-conserving surgery involving mastopexy/breast reduction techniques and immediate symmetrizing mastopexy, and 145 patients underwent delayed contralateral symmetrizing mastopexy. The overall complication rate was similar between the immediate and delayed groups (25.4 percent versus 26.9 percent, respectively; p = 0.82), as was the major complication rate (10.6 percent versus 6.2 percent; p = 0.16). Complications resulted in a delay in adjuvant therapy in 18 patients (4.2 percent); in two patients (0.7 percent), this delay resulted from a complication in the contralateral symmetrizing mastopexy breast. Immediate contralateral symmetrizing mastopexy was not associated with increased risk of complications per breast (p = 0.82) or delay to adjuvant therapy (p = 0.6).

Conclusion: Contralateral mastopexy/breast reduction for symmetry can be performed at the time of oncoplastic breast-conserving surgery in carefully selected patients without significantly increasing the risk of complications or delay to adjuvant radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Outcome of Quality of Life for Women Undergoing Autologous versus Alloplastic Breast Reconstruction following Mastectomy: A Systematic Review and Meta-Analysis

Outcome of Quality of Life for Women Undergoing Autologous versus Alloplastic Breast Reconstruction following Mastectomy: A Systematic Review and Meta-Analysis

by Eltahir, Yassir; Krabbe-Timmerman, Irene S.; Sadok, Nadia; Werker, Paul M. N.; de Bock, Geertruida H. 

Plastic and Reconstructive Surgery: May 2020 - Volume 145 - Issue 5 - p 1109-1123

Background: This review aimed to meta-analyze the quality of life of alloplastic versus autologous breast reconstruction, when measured with the BREAST-Q.

Methods: An electronic PubMed and EMBASE search was designed to find articles that compared alloplastic versus autologous breast reconstruction using the BREAST-Q. Studies that failed to present BREAST-Q scores and studies that did not compare alloplastic versus autologous breast reconstruction were excluded. Two authors independently extracted data from the included studies. A standardized data collection form was used. Quality was assessed using the Newcastle-Ottawa Scale. The mean difference and 95 percent confidence intervals between breast reconstruction means were estimated for each BREAST-Q subscale. Forest plots and the I2 statistic were used to assess heterogeneity and funnel plot publication bias. The Z test was used to assess overall effects. Results: Two hundred eighty abstracts were found; 10 articles were included. Autologous breast reconstruction scored significantly higher in the five subscales than alloplastic breast reconstruction. The Satisfaction with Breasts subscale indicated the greatest difference, with a mean difference of 6.41 (95 percent CI, 3.58 to 9.24; I2 = 70 percent). The Satisfaction with Results subscale displayed a mean difference of 5.52. The Sexual Well-Being subscale displayed a mean difference of 3.85. The Psychosocial Well-Being subscale displayed a mean difference of 2.64. The overall difference in physical well-being was significant, with high heterogeneity (mean difference, 3.33; 95 percent CI, 0.18 to 6.48; I2 = 85).

Conclusion: Autologous breast reconstruction had superior outcomes compared with alloplastic breast reconstruction as measured by the BREAST-Q.

Prepectoral Direct-to-Implant Breast Reconstruction: Safety Outcome Endpoints and Delineation of Risk Factors

Prepectoral Direct-to-Implant Breast Reconstruction: Safety Outcome Endpoints and Delineation of Risk Factors

by Nealon, Kassandra P.; Weitzman, Rachel E.; Sobti, Nikhil; Gadd, Michele; Specht, Michelle; Jimenez, Rachel B.; Ehrlichman, Richard; Faulkner, Heather R.; Austen, William G. Jr; Liao, Eric C.

Plastic and Reconstructive Surgery: May 2020 - Volume 145 - Issue 5 - p 898e-908e

Background: Continued evolution of implant-based breast reconstruction involves immediate placement of the implant above the pectoralis muscle. The shift to prepectoral breast reconstruction is driven by goals of decreasing morbidity such as breast animation deformity, range-of-motion problems, and pain, and is made possible by improvements in mastectomy skin flap viability. To define clinical factors to guide patient selection for direct-to-implant prepectoral implant reconstruction, this study compares safety endpoints and risk factors between prepectoral and subpectoral direct-to-implant breast reconstruction cohorts. The authors hypothesized that prepectoral direct-to-implant breast reconstruction is a safe alternative to subpectoral direct-to-implant breast reconstruction.

Methods: Retrospective chart review identified patients who underwent prepectoral and subpectoral direct-to-implant breast reconstruction, performed by a team of five surgical oncologists and two plastic surgeons. Univariate analysis compared patient characteristics between cohorts. A penalized logistic regression model was constructed to identify relationships between postoperative complications and covariate risk factors.

Results: A cohort of 114 prepectoral direct-to-implant patients was compared with 142 subpectoral direct-to-implant patients. The results of the penalized regression model demonstrated equivalence in safety metrics between prepectoral direct-to-implant and subpectoral direct-to-implant breast reconstruction, including seroma (p = 0.0883), cancer recurrence (p = 0.876), explantation (p = 0.992), capsular contracture (p = 0.158), mastectomy skin flap necrosis (p = 0.769), infection (p = 0.523), hematoma (p = 0.228), and revision (p = 0.122).

Conclusions: This study demonstrates that prepectoral direct-to-implant reconstruction is a safe alternative to subpectoral direct-to-implant reconstruction. Given the low morbidity and elimination of animation deformity, prepectoral direct-to-implant reconstruction should be considered when the mastectomy skin flap is robust. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

[Articles] Quality of life after breast-conserving therapy and adjuvant radiotherapy for non-low-risk ductal carcinoma in situ (BIG 3-07/TROG 07.01): 2-year results of a randomised, controlled, phase 3 trial

[Articles] Quality of life after breast-conserving therapy and adjuvant radiotherapy for non-low-risk ductal carcinoma in situ (BIG 3-07/TROG 07.01): 2-year results of a randomised, controlled, phase 3 trial

by Madeleine T King, Emma K Link, Tim J Whelan, Ivo A Olivotto, Ian Kunkler, Antonia Helen Westenberg, Guenther Gruber, Penny Schofield, Boon H Chua, BIG 3-07/TROG 07.01 trial investigators

The Lancet Oncology:  VOLUME 21, ISSUE 5, P685-698, MAY 01, 2020

Tumour bed boost was associated with persistent adverse effects on cosmetic status and arm and shoulder functional status, which might inform shared decision making while local recurrence analysis is pending.

Radiological audit of interval breast cancers: Estimation of tumour growth rates

Radiological audit of interval breast cancers: Estimation of tumour growth rates

by Emma G. MacInnes, Stephen W. Duffy, Julie A. Simpson, Matthew G. Wallis, Anne E. Turnbull, Louise S. Wilkinson, Keshthra Satchithananda, Rumana Rahim, David Dodwell, Brian V. Hogan, Oleg Blyuss, Nisha Sharma

The Breast: VOLUME 51, P114-119, JUNE 01, 2020

This multicentre, retrospective study aimed to establish correlation between estimated tumour volume doubling times (TVDT) from a series of interval breast cancers with their clinicopathological features. The potential impact of delayed diagnosis on prognosis was also explored.

What are the appropriate thresholds for High Quality Performance Indicators for breast surgery in Australia and New Zealand?

What are the appropriate thresholds for High Quality Performance Indicators for breast surgery in Australia and New Zealand?

by Shehnarz Salindera, Michelle Ogilvy, Andrew Spillane 

The Breast:  VOLUME 51, P94-101, JUNE 01, 2020

To evaluate BreastSurgANZ members’ compliance at various threshold rates for 4 evaluable High-Quality Performance Indicators (HQPIs) introduced to improve patient care. To benchmark global best practice to assist in determining the eventual threshold standards.