First- and second-line treatment strategies for hormone-receptor (HR)-positive HER2-negative metastatic breast cancer: a real-world study

 

First- and second-line treatment strategies for hormone-receptor (HR)-positive HER2-negative metastatic breast cancer: a real-world study

by Debora Basile, Lorenzo Gerratana, Carla Corvaja, Giacomo Pelizzari, Giorgia Franceschin, Elisa Bertoli, Lorenza Palmero, Diego Zara, Martina Alberti, Silvia Buriolla, Lucia Da Ros, Marta Bonotto, Mauro Mansutti, Simon Spazzapan, Marika Cinausero, Alessandro Marco Minisini, Gianpiero Fasola, Fabio Puglisi 

The Breast: VOLUME 57, P104-112, JUNE 01, 2021 (Published: March 11, 2021)

Background

Endocrine therapy (ET) plus cyclin-dependent-kinases 4/6 inhibitors (CDK4/6i) represents the standard treatment for luminal-metastatic breast cancer (MBC). However, prospective head-to-head comparisons are still lacking for 1st line (L) options, and it is still crucial to define the best strategy between 1st and 2nd L.

Materials and methods

717 consecutive luminal-MBC pts treated between 2008 and 2020 were analyzed at the Oncology Department of Aviano and Udine, Italy. Differences about survival outcomes (OS, PFS and PPS) were tested by log-rank test. The attrition rate (AR) between 1st and 2ndL was calculated.

Results

At 1stL, pts were treated with ET (49%), chemotherapy (CT) (31%) and ET-CDKi (20%) while, at 2ndL, 33% received ET, 33% CT and 8% ET-CDKi. Overall AR was 10%, 7% for CT, 8% for ET and 17% for ET-CDKi. By multivariate analysis, 1stL ET-CDK4/6i showed a better mPFS1 and OS. Moreover, 2ndL ET-CDK4/6i demonstrated better mPFS2 compared to ET and CT. Notably, 1stL ET-CDKi resulted in higher mPFS than 2ndL ET-CDKi. Intriguingly, 1stL ET-CDK4/6i was associated with worse mPPS compared to CT and ET. Secondarily, 1stL ET-CDK4/6i followed by CT had worse OS compared to 1stL ET-CDK4/6i followed by ET. Notably, none of baseline characteristics at 2ndL influenced 2ndL treatment choice (ET vs. CT) after ET-CDKi.

Conclusion

Our real-world data demonstrated that ET-CDKi represents the best option for 1stL luminal-MBC compared to ET and CT. Also, the present study pointed out that 2ndL ET, potentially combined with other molecules, could be a feasible option after CDK4/6i failure, postponing CT on later lines.

Contralateral Prophylactic Mastectomy: A Narrative Review of the Evidence and Acceptability

 

Contralateral Prophylactic Mastectomy: A Narrative Review of the Evidence and Acceptability

 

by Josien C.C. Scheepens, Laura van ’t Veer, Laura Esserman, Jeff Belkora, Rita A. Mukhtar 

 

The Breast: February 10, 2021

 

The uptake of contralateral prophylactic mastectomy (CPM) has increased steadily over the last twenty years in women of all age groups and breast cancer stages. Since contralateral breast cancer is relatively rare and the breast cancer guidelines only recommend CPM in a small subset of patients with breast cancer, the drivers of this trend are unknown. This review aims to evaluate the evidence for and acceptability of CPM, data on patient rationales for choosing CPM, and some of the factors that might impact patient preferences. Based on the evidence, future recommendations will be provided. First, data on contralateral breast cancer risk and CPM rates and trends are addressed. After that, the evidence is structured around four main patient rationales for CPM formulated as questions that patients might ask their surgeon: Will CPM reduce mortality risk? Will CPM reduce the risk of contralateral breast cancer? Can I avoid future screening with CPM? Will I have better breast symmetry after CPM? Also, three different guidelines regarding CPM will be reviewed. Studies indicate a large gap between patient preferences for radical risk reduction with CPM and the current approaches recommended by important guidelines. We suggest a strategy including shared decision-making to enhance surgeons’ communication with patients about contralateral breast cancer and treatment options, to empower patients in order to optimize the use of CPM incorporating accurate risk assessment and individual patient preferences.

A multidisciplinary view of mastectomy and breast reconstruction: Understanding the challenges

 

A multidisciplinary view of mastectomy and breast reconstruction: Understanding the challenges

 

by Orit Kaidar-Person, Birgitte V. Offersen, Liesbeth J. Boersma, Dirk de Ruysscher, Trine Tramm, Thorsten Kühn, Oreste Gentilini, Zoltán Mátrai, Philip Poortmans 

 

The Breast: February 09, 2021

 

The current review paper was written in collaboration with breast cancer surgeons from the European Breast Cancer Research Association of Surgical Trialists (EUBREAST), a breast pathologist from the Danish Breast Cancer Group (DBCG), and representatives from the European SocieTy for Radiotherapy & Oncology (ESTRO) breast cancer course. Herein we summarize the different mastectomies and reconstruction procedures and define high-risk anatomical areas for breast cancer recurrences, to further specify the challenges in the surgical procedure, histopathological evaluation, and target volumes in case of postmastectomy irradiation, as recommended by the ESTRO guidelines according to the surgical procedure. The paper has original figures and illustrations for all disciplines for in-depth understanding of the differences between the procedures.

Sensory Recovery of the Breast following Innervated and Noninnervated Lateral Thigh Perforator Flap Breast Reconstruction

 

Sensory Recovery of the Breast following Innervated and Noninnervated Lateral Thigh Perforator Flap Breast Reconstruction

by Beugels, Jop; van Kuijk, Sander M. J.; Lataster, Arno; van der Hulst, René R. W. J.; Tuinder, Stefania M. H. 

Plastic and Reconstructive Surgery: February 2021 - Volume 147 - Issue 2 - p 281-292

Background:

The lateral thigh perforator flap, based on the tissue of the upper lateral thigh, is an excellent option for autologous breast reconstruction. The aim of this study was to introduce the technique to perform a nerve coaptation in lateral thigh perforator flap breast reconstruction and to analyze the results by comparing the sensory recovery of the reconstructed breast and donor site between innervated and noninnervated lateral thigh perforator flaps.

Methods:

A prospective cohort study was conducted of patients who underwent an innervated or noninnervated lateral thigh perforator flap breast reconstruction between December of 2014 and August of 2018. Direct nerve coaptation was performed between a branch of the lateral femoral cutaneous nerve and the anterior cutaneous branch of the intercostal nerve. Sensory testing was performed with Semmes-Weinstein monofilaments to assess the sensation of the native skin, flap skin, and donor site during follow-up.

Results:

In total, 24 patients with 37 innervated lateral thigh perforator flaps and 18 patients with 26 noninnervated lateral thigh perforator flaps were analyzed (median follow-up, 17 and 15 months, respectively). Significantly lower mean monofilament values were found for the native skin (adjusted difference, −0.83; p = 0.011) and flap skin (adjusted difference, –1.11; p < 0.001) of the reconstructed breast in innervated compared to noninnervated flaps. For the donor site, no statistically significant differences were found between both groups.

Conclusions:

Nerve coaptation in lateral thigh perforator flap breast reconstruction resulted in a significantly better sensory recovery of the reconstructed breast compared to noninnervated flaps. The data also suggest that harvesting a sensory nerve branch does not compromise the sensory recovery of the upper lateral thigh.

 

Endoscopy-Assisted Total Mastectomy with and without Immediate Reconstruction: An Extended Follow-Up, Multicenter Study

 

Endoscopy-Assisted Total Mastectomy with and without Immediate Reconstruction: An Extended Follow-Up, Multicenter Study

by Kuo, Yao-Lung; Chang, Chih-Hao; Chang, Tzu-Yen; Chien, Hsiung-Fei; Liao, Li-Min; Hung, Chin-Sheng; Lin, Shih-Lung; Chen, Shou-Tung; Chen, Dar-Ren; Lai, Hung-Wen 

Plastic and Reconstructive Surgery: February 2021 - Volume 147 - Issue 2 - p 267-278

Background:

Endoscopy-assisted total mastectomy has been used for surgical intervention of breast cancer patients; however, large cohort studies with long-term follow-up data are lacking.

Methods:

Breast cancer patients who underwent endoscopy-assisted total mastectomy from May of 2009 to March of 2018 were collected prospectively from multiple centers. Clinical outcome, impact of different phases, oncologic results, and patient-reported aesthetic outcomes of endoscopy-assisted total mastectomy were reported.

Results:

A total of 436 endoscopy-assisted total mastectomy procedures were performed; 355 (81.4 percent) were nipple-sparing mastectomy, and 81 (18.6 percent) were skin-sparing mastectomy. Three hundred fourteen (75.4 percent) of the procedures were associated with immediate breast reconstruction; 255 were prosthesis based and 59 were associated with autologous flaps. The positive surgical margin rate for endoscopy-assisted total mastectomy was 2.1 percent. In morbidity evaluation, there were 19 cases (5.4 percent) with partial nipple necrosis, two cases (0.6 percent) with total nipple necrosis, and three cases (0.7 percent) with implant loss. Compared with the early phase, surgeons operating on patients in the middle or late phase had significantly decreased operation time and blood loss. With regard to patient-reported cosmetic outcomes, approximately 94.4 percent were satisfied with the aesthetic results. Patients who underwent breast reconstruction with preservation of the nipple had higher satisfaction rates. Over a median follow-up of 54.1 ± 22.4 months, there were 14 cases of locoregional recurrence (3.2 percent), three distant metastases (0.7 percent), and one mortality (0.2 percent).

Conclusion:

This multicenter study showed that endoscopy-assisted total mastectomy is a reliable surgical intervention for early breast cancer, with high patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Consecutive Bilateral Breast Reconstruction Using Stacked Abdominally Based and Posterior Thigh Free Flaps

 

Consecutive Bilateral Breast Reconstruction Using Stacked Abdominally Based and Posterior Thigh Free Flaps

 

by Haddock, Nicholas T.; Suszynski, Thomas M.; Teotia, Sumeet S. 

 

Plastic and Reconstructive Surgery: February 2021 - Volume 147 - Issue 2 - p 294-303

 

Background:

Multiple perforator flap breast reconstruction is an option that avoids implants in selected patients with minimal donor tissue. The technique addresses the need for additional skin to help create a breast envelope with more natural ptosis and additional volume to help create a body-appropriate breast mound while avoiding serial fat grafting. Using four flaps for the reconstruction of two breasts (bilateral stacked flap reconstruction) has recently become feasible with the advancement of microsurgical techniques, increased experience with alternative perforator flaps, and use of co-surgery. In this article, we describe our early experience with bilateral stacked flap breast reconstruction.

Methods:

From January of 2014 to October of 2018, the senior co-surgeons performed 50 consecutive bilateral stacked flap operations at a single institution. All reconstructions were performed in delayed fashion with a mean operative time of 10 hours. Most breasts (94 percent) were reconstructed with a deep inferior epigastric perforator flap combined with a profunda artery perforator flap. Most flap microanastomoses (91.5 percent) were performed directly with internal mammary vessels. The larger of the two flaps was typically placed inferiorly (66 percent), but there was significant inset variability.

Results:

Of 200 flaps, five were lost (2.5 percent). Seven take-backs were needed for a flap-related concern, which included two negative explorations and a flap salvage. The most common non–flap-related complication was a thigh wound (17 total, eight requiring a procedure).

Conclusion:

The authors’ early experience suggests that bilateral stacked flap breast reconstruction is a powerful tool that can be performed with an acceptable microsurgical risk and an acceptable complication profile in highly selected patients.

Combined breast conservation therapy versus mastectomy for BRCA mutation carriers – A systematic review and meta-analysis

 

Combined breast conservation therapy versus mastectomy for BRCA mutation carriers – A systematic review and meta-analysis

by M.G. Davey, C.M. Davey, É.J. Ryan, A.J. Lowery, M.J. Kerin 

The Breast: February 04, 2021

Background

The non-inferiority of combined breast conservation surgery (BCS) and radiotherapy (breast conservation therapy or BCT) compared to mastectomy in sporadic breast cancer cases is well recognised. Uncertainty remains regarding optimal surgical practice in BRCA mutation carriers.

Aims

To evaluate the oncological safety of combined BCT versus mastectomy in BRCA mutation carriers following breast cancer diagnosis.

Methods

A systematic review was performed as per PRISMA and MOOSE guidelines. Observational studies comparing BCS and mastectomy in BRCA carriers were identified. Dichotomous variables were pooled as odds ratios (OR) using the Mantel–Haenszel method. Log hazard ratios (lnHR) for locoregional recurrence (LRR), contralateral breast cancer, disease-free and overall survival and their standard errors were calculated from Kaplan-Meier or cox-regression analyses and pooled using the inverse variance method.

Results

Twenty three studies of 3,807 patients met inclusion criteria; 2,200 (57.7%) were BRCA1 and 1212 (31.8%) were BRCA2 carriers. Median age at diagnosis was 41 years with 96 months follow up. BCS was performed on 2157 (56.7%) while 1408 (41.5%) underwent mastectomy. An increased risk of LRR was observed in patients treated with BCS (HR:4.54, 95% Confidence Interval: 2.77-7.42, P<0.001, heterogeneity (I2)=0%). However, the risks of contralateral breast cancer (HR:1.51, 95%CI: 0.44-5.11, P=0.510, I2=80%), disease recurrence (HR:1.16, 95%CI: 0.78-1.72, P=0.470, I2=44%), disease-specific recurrence (HR:1.58, 95%CI: 0.79-3.15, P=0.200, I2=38%) and death (HR:1.10, 95%CI: 0.72-1.69, P=0.660, I2=38%) were equivalent for combined BCT and mastectomy.

Conclusions

Survival outcomes following combined BCT is comparable to mastectomy in BRCA carriers. However, the risk of LRR is increased. Patient counselling should be tailored to incorporate these findings.

Breast cancer surgery with augmented reality

 

Breast cancer surgery with augmented reality

by Pedro F. Gouveia, Joana Costa, Pedro Morgado, Ronald Kates, David Pinto, Carlos Mavioso, João Anacleto, Marta Martinho, Daniel Simões Lopes, Arlindo R. Ferreira, Vasileios Vavourakis, Myrianthi Hadjicharalambous, Marco A. Silva, Nickolas Papanikolaou, Celeste Alves, Fatima Cardoso, Maria João Cardoso 

The Breast:  VOLUME  56, P14-17, APRIL 01, 2021 (Published online: January 26th, 2021)

Innovations in 3D spatial technology and augmented reality imaging driven by digital high-tech industrial science have accelerated experimental advances in breast cancer imaging and the development of medical procedures aimed to reduce invasiveness. Presentation of case: A 57-year-old post-menopausal woman presented with screen-detected left-sided breast cancer. After undergoing all staging and pre-operative studies the patient was proposed for conservative breast surgery with tumor localization. During surgery, an experimental digital and non-invasive intra-operative localization method with augmented reality was compared with the standard pre-operative localization with carbon tattooing (institutional protocol). The breast surgeon wearing an augmented reality headset (Hololens) was able to visualize the tumor location projection inside the patient’s left breast in the usual supine position. Discussion: This work describes, to our knowledge, the first experimental test with a digital non-invasive method for intra-operative breast cancer localization using augmented reality to guide breast conservative surgery. In this case, a successful overlap of the previous standard pre-operative marks with carbon tattooing and tumor visualization inside the patient’s breast with augmented reality was obtained. Conclusion: Breast cancer conservative guided surgery with augmented reality can pave the way for a digital non-invasive method for intra-operative tumor localization.

Impact of radiation dose on complications among women with breast cancer who underwent breast reconstruction and post-mastectomy radiotherapy: a multi-institutional validation study

 

Impact of radiation dose on complications among women with breast cancer who underwent breast reconstruction and post-mastectomy radiotherapy: a multi-institutional validation study

by Seung Yeun Chung, Jee Suk Chang, Kyung Hwan Shin, Jin Ho Kim, Won Park, Haeyoung Kim, Kyubo Kim, Ik Jae Lee, Won Sup Yoon, Jihye Cha, Kyu-Chan Lee, Jin Hee Kim, Jin Hwa Choi, Sung-Ja Ahn, Boram Ha, Sun Young Lee, Dong Soo Lee, Jeongshim Lee, Sei One Shin, Sea-Won Lee, Jinhyun Choi, Mi Young Kim, Yeon Joo Kim, Jung Ho Im, Chang-Ok Suh, Yong Bae Kim 

 

The Breast :  VOLUME  56, P7-13, APRIL 01, 2021 (published online: January 20, 2021)

Purpose

Emerging data suggest that higher radiation doses in post-mastectomy radiotherapy may be associated with an increased risk of reconstruction complications. This study aimed to validate previous findings regarding the impact of radiation dose on complications among women with breast cancer using a multi-center dataset.

Methods

Fifteen institutions participated, and women with breast cancer who received radiotherapy after either autologous or prosthetic breast reconstruction were included. The primary endpoint was major post-radiation therapy complications requiring re-operation for explantation, flap failure, or bleeding control.

Results

In total, 314 patients were included. Radiotherapy was performed using both conventional fractionation and hypofractionation in various schedules. The range of the radiation therapy dose in Equivalent Dose in 2 Gy fractions (EQD2; α/β = 3.5) varied from 43.4 to 71.0 Gy (median dose: 48.6 Gy). Boost radiation therapy was administered to 49 patients. Major post-radiation therapy complications were observed in 24 (7.6%) patients. In multivariate analysis, an increasing EQD2 per Gy (odds ratio [OR]: 1.58, 95% confidence interval [CI]: 1.26–1.98; p < 0.001), current smoking status (OR: 25.48, 95% CI: 1.56–415.65; p = 0.023), and prosthetic breast reconstruction (OR: 9.28, 95% CI: 1.84–46.70; p = 0.007) were independently associated with an increased risk of major complications.

Conclusion

A dose-response relationship between radiation dose and the risk of complications was validated in this multi-center dataset. In this context, we hypothesize that the use of hypofractionated radiotherapy (40 Gy in 15 fractions) may improve breast reconstruction outcomes. Our multi-center prospective observational study (NCT03523078) is underway to further validate this hypothesis.

Selection of neoadjuvant treatment based on the 21-GENE test results in luminal breast cancer

 

Selection of neoadjuvant treatment based on the 21-GENE test results in luminal breast cancer

 

by Serafin Morales Murillo, Ariadna Gasol Cudos, Joel Veas Rodriguez, Carles Canosa Morales, Jordi Melé Olivé, Felip Vilardell Villellas, Douglas Rene Sanchez Guzman, Edelmiro Iglesias Martínez, Antonieta Salud Salvia 

 

The Breast: January 15, 2021

 

Neoadjuvant chemotherapy (NAC) is an optimal option in early breast cancer, but in ER-positive/HER2-negative (luminal) is still controversial, although a survival benefit has recently been observed when a histological response by Symmans’ method type 0 or I is achieved. The 21-gene Oncotype DX Breast Recurrence Score® assay (Oncotype DX®) is a validated test to assess the survival benefit of adjuvant chemotherapy in these patients but its role in the neoadjuvant setting is less established. We analyzed the results of the Oncotype DX® test in a cohort of 122 consecutive patients selected to receive NAC based on classical clinicopathological parameters and the correlation between the Oncotype DX® results and the pathological response assessed by Symmans’ method.Median age was 56.5 (range 31–84) years.

CDK 4/6 inhibitors mired in uncertainty in HR positive and HER2 negative early breast cancer

 

CDK 4/6 inhibitors mired in uncertainty in HR positive and HER2 negative early breast cancer

The Breast:  VOLUME  55, P75-78, FEBRUARY 01, 2021

by Serena Di Cosimo, Luca Porcu, Fatima Cardoso 

Highlights

•HR+/HER2-early BC patients have continuous risk of relapse and need new therapies

•Current short follow-up precludes any final conclusion re. adjuvant CDK4/6 inhibitors

•The proportional hazard assumption was hampered by the low number of events

•Wide point estimate 95%CI translated into imprecise number needed to treat (NNT)

•Besides efficacy, toxicity, compliance and cost are issues to consider in decision-making

•Research efforts need to continue to establish CDK4/6 inhibitor predictive biomarkers

Abstract

Cell-cycle abnormalities are common in estrogen receptor- and/or progesterone receptor-positive, and HER2-non-overexpressing (HR+/HER2-) breast cancer, and have long been considered potential therapeutic targets. Cyclin-dependent kinase (CDK) 4/6 inhibitors have dramatically changed the therapeutic management of HR+/HER2-advanced breast cancer by prolonging progression-free and overall survival when given in combination with endocrine therapy. In this article, available data from PALLAS and monarchE trials regarding the efficacy and toxicity of adjuvant combined therapy with CDK 4/6 inhibitors and endocine therapy in HR+/HER2-early breast cancer are reviewed, and relevant issues including study hypothesis, patient selection, and duration of follow-up are discussed.

Acute Postoperative Complications in Prepectoral versus Subpectoral Reconstruction following Nipple-Sparing Mastectomy

 

Acute Postoperative Complications in Prepectoral versus Subpectoral Reconstruction following Nipple-Sparing Mastectomy

 

 

by Avila, Azalia; Bartholomew, Alex J.; Sosin, Michael; Deldar, Romina; Griffith, Kayla F.; Willey, Shawna C.; Song, David H.; Fan, Kenneth L.; Tousimis, Eleni A.

 

Plastic and Reconstructive Surgery:  December 2020 - Volume 146 - Issue 6 - p 715e-720e

 

Background:

Nipple-sparing mastectomy is associated with improved aesthetics and oncologic safety. Recently, there has been a resurgence in prepectoral reconstruction. Because of limited data comparing complication rates on patients undergoing prepectoral breast reconstruction, this study compared 30-day postoperative complications by plane of prosthetic placement.

Methods:

A retrospective review was conducted on all consecutive patients undergoing nipple-sparing mastectomy with implant-based reconstruction with either prepectoral or subpectoral placement from 2014 to 2018. The primary outcome was a composite, acute 30-day postoperative complication, including nipple-areola complex necrosis, mastectomy flap necrosis, wound dehiscence, infection, hematoma, and seroma. Secondary outcomes included nipple loss and rates of unintended reoperations. Univariate and mixed effects multivariate logistic regression were used to compare outcomes.

Results:

A total of 228 patients and 405 breasts were included in the final cohort, with 202 in the subpectoral cohort and 203 in the prepectoral cohort. The overall complication rate was 7.65 percent, with no significant difference between subpectoral and prepectoral cohorts (9.41 percent versus 5.91 percent, respectively; p = 0.148). Prepectoral reconstruction was associated with significantly reduced ischemic complications, including nipple loss because of necrosis (2.97 percent versus 0.49 percent, respectively; p = 0.015) and mastectomy flap necrosis (5.45 percent versus 0 percent; p = 0.003). There were no significant differences in rates of infection, hematoma, seroma, or implant loss/exchange.

Conclusions:

Prepectoral reconstruction is associated with similar overall 30-day postoperative complications and reoperations compared to traditional subpectoral implants. However, prepectoral reconstruction was associated with significantly decreased ischemic complications, including mastectomy flap necrosis and nipple-areola complex loss because of necrosis. Clinical Question/Level of Evidence: Therapeutic, III.

Mammographic sensitivity as a function of tumor size: a novel estimation based on population-based screening data

 

 Mammographic sensitivity as a function of tumor size: a novel estimation based on population-based screening data

 

by Jing Wang, Pam Gottschal, Lilu Ding, Daniëlle.W.A van Veldhuizen, Wenli Lu, Nehmat Houssami, Marcel J.W. Greuter, Geertruida H. de Bock

 

The Breast: VOLUME  55, P69-74, FEBRUARY 01, 2021

 

Highlights

•Mammographic sensitivity is a key indicator of screening effectiveness.

•Previous model using logistic function might overestimate size-specific sensitivity.

•Our model showed that sensitivity increased from 0 to 85% for tumor sizes from 2 to 20 mm.

•Our model may provide a better representation of data observed in screening programs.

Background

Instead of a single value for mammographic sensitivity, a sensitivity function based on tumor size more realistically reflects mammography’s detection capability. Because previous models may have overestimated size-specific sensitivity, we aimed to provide a novel approach to improve sensitivity estimation as a function of tumor size.

Methods

Using aggregated data on interval and screen-detected cancers, observed tumor sizes were back-calculated to the time of screening using an exponential tumor growth model and a follow-up time of 4 years. From the observed number of detected cancers and an estimation of the number of false-negative cancers, a model for the sensitivity as a function of tumor size was determined. A univariate sensitivity analysis was conducted by varying follow-up time and tumor volume doubling time (TVDT). A systematic review was conducted for external validation of the sensitivity model.

Results

Aggregated data of 22,915 screen-detected and 10,670 interval breast cancers from the Dutch screening program were used. The model showed that sensitivity increased from 0 to 85% for tumor sizes from 2 to 20 mm. When TVDT was set at the upper and lower limits of the confidence interval, sensitivity for a 20-mm tumor was 74% and 93%, respectively. The estimated sensitivity gave comparable estimates to those from two of three studies identified by our systematic review.

Conclusion

Derived from aggregated breast screening outcomes data, our model’s estimation of sensitivity as a function of tumor size may provide a better representation of data observed in screening programs than other models.

Decisional conflict in breast cancer patients considering immediate breast reconstruction

 

Decisional conflict in breast cancer patients considering immediate breast reconstruction

 

The Breast: Published: December 09, 2020

 

by Jacqueline A. ter Stege, Hester S.A. Oldenburg, Leonie A.E. Woerdeman, Arjen J. Witkamp, Jacobien M. Kieffer, Martine A. van Huizum, Frederieke H. van Duijnhoven, Daniela E.E. Hahn, Miranda A. Gerritsma, Marianne A. Kuenen, Nicola (A.N.) Kimmings, Quinten (P.Q.) Ruhé, Irene S. Krabbe-Timmerman, Martijne van’t Riet, Eveline M.L. Corten, Kerry A. Sherman, Eveline M.A. Bleiker

Highlights

•A majority of patients considering immediate breast reconstruction experience decisional conflict.

•Patients without a strong preference for breast reconstruction are more likely to experience decisional conflict.

•Patients with more anxiety are more likely to experience decisional conflict.

Background

Breast cancer (BC) patients who are treated with mastectomy are frequently offered immediate breast reconstruction. This study aimed to assess decisional conflict in patients considering immediate breast reconstruction, and to identify factors associated with clinically significant decisional conflict (CSDC).

Methods

Baseline data of a multicenter randomized controlled trial evaluating the impact of an online decision aid for BC patients considering immediate breast reconstruction after mastectomy were analyzed. Participants completed questionnaires assessing sociodemographic and clinical characteristics, decisional conflict and other patient-reported outcomes related to decision-making such as breast reconstruction preference, knowledge, information resources used, preferred involvement in decision-making, information coping style, and anxiety. Multivariable logistic regression analysis was performed to identify factors associated with CSDC (score > 37.5 on decisional conflict).

Results

Of the 250 participants, 68% experienced CSDC. Patients with a slight preference for breast reconstruction (odds ratio (OR) = 6.19, p <.01), no preference for or against breast reconstruction (OR = 11.84, p <.01), and a strong preference for no breast reconstruction (OR = 5.20, p <.05) were more likely to experience CSDC than patients with a strong preference for breast reconstruction. Furthermore, patients with more anxiety were more likely to experience CSDC (OR = 1.03, p = .01).

Conclusion

A majority of BC patients who consider immediate breast reconstruction after mastectomy experience clinically significant decisional conflict. The findings emphasize the need for decision support, especially for patients who do not have a strong preference for breast reconstruction.

 

The Influence of Fat Grafting on Breast Imaging after Postmastectomy Reconstruction: A Matched Cohort Analysis

 

The Influence of Fat Grafting on Breast Imaging after Postmastectomy Reconstruction: A Matched Cohort Analysis

 

by Cason, Roger W.; Shammas, Ronnie L.; Broadwater, Gloria; Glener, Adam D.; Sergesketter, Amanda R.; Vernon, Rebecca; Le, Elliot; Wickenheisser, Victoria A.; Marks, Caitlin E.; Orr, Jonah; Pyfer, Bryan J.; Hollenbeck, Scott T.

 

Plastic and Reconstructive Surgery: December 2020 - Volume 146 - Issue 6 - p 1227-1236

 

Background:

Fat grafting to the reconstructed breast may result in the development of benign lesions on physical examination, prompting further investigation with imaging and biopsy. The aim of this study was to assess the influence of fat grafting on the incidence of imaging and biopsies after postmastectomy reconstruction.

Methods:

Patients who underwent autologous or implant-based reconstruction following mastectomy from 2010 to 2018 were identified. Those receiving fat grafting as part of their reconstructive course were propensity matched 1:1 to those that did not with body mass index, reconstruction timing, and reconstruction type as covariates in a multivariable logistic regression model.

Results:

A total of 186 patients were identified, yielding 93 propensity-matched pairs. Fat-grafted patients had higher incidences of palpable masses (38.0 percent versus 18.3 percent; p = 0.003) and postreconstruction imaging (47.3 percent versus 29.0 percent; p = 0.01), but no significant difference in the number of biopsies performed (11.8 percent versus 7.5 percent; p = 0.32). Imaging was predominately interpreted as normal (Breast Imaging-Reporting and Data System 1, 27.9 percent) or benign (Breast Imaging-Reporting and Data System 2, 48.8 percent), with fat necrosis being the most common finding [n = 20 (45.5 percent)]. No demographic, oncologic, reconstructive, or fat grafting–specific variables were predictive of receiving postreconstruction imaging on multivariate analysis. Fat grafting was not associated with decreased 5-year overall survival or locoregional recurrence-free survival.

Conclusions:

Fat grafting to the reconstructed breast is associated with increased incidences of palpable masses and subsequent postreconstruction imaging with benign radiographic findings. Although the procedure is oncologically safe, both patients and providers should be aware that concerning physical examination findings can be benign sequelae of fat grafting and may lead to increased imaging after breast reconstruction. Clinical Question/Level of Evidence: Therapeutic, III.

Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction

 

Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction

by Winocour, Sebastian; Tarassoli, Sam; Chu, Carrie K.; Liu, Jun; Clemens, Mark W.; Selber, Jesse C.  

Plastic and Reconstructive Surgery:  December 2020 - Volume 146 - Issue 6 - p 1221-1225

 

Background:

Robotically assisted latissimus dorsi harvest permits harvest of the latissimus dorsi muscle without a back incision, as compared to the traditional open technique. The authors hypothesized that robotic harvest has lower donor-site complication rates, decreased opioid requirements, and a shorter length of stay than the traditional open technique.

Methods:

A retrospective review was performed of all consecutive pedicled latissimus dorsi flaps for breast reconstruction between 2011 and 2015. All procedures were conducted by two surgeons who performed both robotic and open cases.

Results:

Fifty-two patients were identified; 25 underwent robotically assisted latissimus dorsi harvest and 27 underwent the open technique. Demographic data between the two groups were similar. Median length of stay for robotic harvest was shorter than that for the traditional technique (2 days versus 3 days; p = 0.031). Postoperative morphine requirement was less in the robotic compared to the traditional technique, but the difference was not significant (158 mg versus 184 mg; p = 0.826). Seroma rate was higher in the robotic group (16 percent versus 0 percent; p = 0.034). The mean duration of surgery was longer in the robotic cohort (388 minutes versus 311 minutes; p = 0.002).

Conclusions:

This study demonstrates robotically assisted latissimus dorsi harvest as an effective alternative to the traditional open technique in select patients. Advantages of robotic harvest include no back scar, a shorter length of stay, and lower opioid requirements, although the difference was not significant; disadvantages include longer operative time and a higher seroma rate. Clinical Question/Level of Evidence: Therapeutic, III.

A Systematic Review and Meta-analysis on the Effect of Neoadjuvant Chemotherapy on Complications Following Immediate Breast Reconstruction

 

A Systematic Review and Meta-analysis on the Effect of Neoadjuvant Chemotherapy on Complications Following Immediate Breast Reconstruction

The Breast: VOLUME  55, P55-62, FEBRUARY 01, 2021

by Jajini Varghese, Shireen S. Gohari, Hirah Rizki, F.R.C.S. ichael Faheem, Benjamin Langridge, Sherko Kümmel, Laura Johnson, Peter Schmid

 

Background

The impact of neoadjuvant chemotherapy (NACT) on surgical outcomes following immediate breast reconstruction (IBR) remains unclear. While it is generally considered safe practice to perform an IBR post NACT, reported complication rates in published data are highly variable with the majority of studies including fewer than 50 patients in the NACT and IBR arm. To evaluate this further, we conducted a systematic review and meta-analysis on the effect of NACT on autologous and implant based immediate breast reconstructions. We aimed to assess for differences in the post-operative course following IBR between patients who received NACT with those who did not.

Methods

PubMed, EMBASE, and Cochrane Library were searched from 1995 to Sept 2, 2020 to identify articles that assessed the impact of NACT on IBR. All included studies assessed outcomes following IBR. Only studies comparing reconstructed patients receiving NACT to a control group of women who did not receive NACT were included. Unadjusted relative risk of outcomes between patients who received or did not receive NACT were synthesized using a fixed-effect meta-analysis. The evidence was assessed using the Newcastle Ottawa Scale scores and GRADE. Primary effect measures were risk ratios (RRs) with 95% confidence intervals.

Results

A total 17 studies comprising 3249 patients were included in the meta-analyses. Overall, NACT did not increase the risk of complications after immediate breast reconstructions (risk ratio [RR]: 0.91, 95% CI 0.74 to 1.11, p = 0.34). There was a moderate, but not significant, increase in flap loss following NACT compared with controls (RR: 1.23, 95% CI 0.70 to 2.18, p = 0.47; I2 = 0%). Most notably, there was a statistically significant increase in implant/expander loss after NACT (RR: 1.54, 95% CI 1.04 to 2.29, p = 0.03; I2 = 34%). NACT was not shown to significantly increase the incidence of hematomas, seromas or wound complications, or result in a significant delay to commencing adjuvant therapy (RR: 1.59, 95% CI 0.66 to 3.87, p = 0.30).

Conclusion

Immediate breast reconstruction after NACT is a safe procedure with an acceptable post-operative complication profile. It may result in a slight increase in implant loss rates, but it does not delay commencing adjuvant therapy.

Residual Breast Tissue After Robot-Assisted Nipple Sparing Mastectomy

 

Residual Breast Tissue After Robot-Assisted Nipple Sparing Mastectomy

 

The Breast:  VOLUME  55, P25-29, FEBRUARY 01, 2021

 

by Ko Un Park, Gary H. Tozbikian, David J. Ferry RNFA, Allan Tsung, Mathew D. Chetta, Steven A. Schulz, Roman J. Skoracki

 

Highlights

•Robot-assisted nipple sparing mastectomy (RNSM) is technically feasible.

•Residual breast tissue after RNSM is histologically detected only from the periareolar location.

•Further clinical trials are underway to determine oncologic safety of RNSM.

Introduction

While the long-term oncologic safety of robot-assisted nipple sparing mastectomy (RNSM) remains to be elucidated, histologically detected residual breast tissue (RBT) can be a surrogate for oncologically sound mastectomy. The objective of this study is to determine the presence of RBT after RNSM.

Methods

Between August 2019–January 2020, we completed 5 cadaveric RNSMs. Full thickness biopsies from the mastectomy skin flap were obtained from predefined locations radially around the mastectomy skin envelop and nipple areolar complex to histologically evaluate for RBT.

Results

The first case was not technically feasible due to inability to obtain adequate insufflation. Five mastectomy flaps were analyzable. The average mastectomy flap thickness was 2.3 mm (range 2–3 mm) and the average specimen weight was 382.72 g (range 146.9–558.3 g). Of 70 total biopsies, RBT was detected in 11 (15.7%) biopsies. Most common location for RBT was in the nipple-areolar complex, with no RBT detected from the peripheral skin flaps.

Conclusions

In this cadaveric study, RNSM is feasible leaving minimal RBT on the mastectomy flap. The most common location for RBT is in the periareolar location consistent with previous published findings after open NSM. Clinical studies are underway to evaluate the safety of RNSM.

Hypofractionated versus conventional fractionated radiotherapy for breast cancer in patients with reconstructed breast: toxicity analysis

 Hypofractionated versus conventional fractionated radiotherapy for breast cancer in patients with reconstructed breast: toxicity analysis

The Breast: VOLUME  55, P37-44, FEBRUARY 01, 2021

by Dong-Yun Kim, Eonju Park, Chan Yeong Heo, Ung Sik Jin, Eun Kyu Kim, Wonshik Han, Kyung Hwan Shin, In Ah Kim

Highlights

•There was no significant difference in the occurrence of breast complications between the two fractionation regimens.

•Hypofractionated RT may be used comparable to conventional fractionated RT in reconstructed breast cancer patients.

•The prospective randomized trial would be necessary to clarify this issue.

Purpose

This study investigated whether hypofractionated adjuvant radiotherapy (RT) increased breast-related complication(s) compared to conventional fractionated RT in reconstructed breast cancer patients.

Methods

We conducted a retrospective review including 349 breast cancer patients who underwent immediate breast reconstruction following mastectomy or breast-conserving surgery (BCS) between 2009 and 2018 at two institutions. All patients were treated with adjuvant RT via either a conventional fractionated or hypofractionated regimen. We defined a major breast complication as a breast-related toxic event requiring re-operation or re-hospitalization during the follow-up period after the end of RT.

Results

The median follow-up was 32.3 months (4.8–118.5 months); 126 patients had conventional fractionated RT, and 223 patients received hypofractionated RT. In patients with mastectomy, there was no significant difference in the occurrence of any or major breast-related complications between the two fractionation regimens. In patients undergoing BCS, incidence of any breast complication showed no difference between two RT groups and no major breast complication was reported as well. Hypofractionated RT did not increase major wound problem (infection and dehiscence) compared to conventional RT. Incidence of major contracture was significantly lower in hypofractionated RT.

Conclusions

There was no significant difference in the occurrence of any or major breast-related complications between the two different fractionation regimens, even in patients with mastectomy. Hypofractionated RT may be used comparable to conventional fractionated RT in terms of breast-related complications in reconstructed breast cancer patients. The prospective randomized trial would be necessary to clarify this issue.

Impact of Body Mass Index on Overall Survival in patients with metastatic breast cancer Body Mass Index in metastatic breast cancer

 

Impact of Body Mass Index on Overall Survival in patients with metastatic breast cancer Body Mass Index in metastatic breast cancer

 

The Breast: VOLUME  55, P16-24, FEBRUARY 01, 2021

 

Highlights

•This is the first large multicenter cohort reporting BMI’s effect on outcomes among patients with metastatic breast cancer.

•Overweight or obese status does not negatively influence outcome of metastatic breast cancer patients, whatever the subtype.

•Underweight is a strong negative independent prognostic factor on outcomes, whatever the subtype.

Background

High Body mass index (BMI) is a risk factor for breast cancer among postmenopausal women and an adverse prognostic factor in early-stage. Little is known about its impact on clinical outcomes in patients with metastatic breast cancer (MBC).

Methods

The National ESME-MBC observational cohort includes all consecutive patients newly diagnosed with MBC between Jan 2008 and Dec 2016 in the 18 French comprehensive cancer centers.

Results

Of 22 463 patients in ESME-MBC, 12 999 women had BMI data available at MBC diagnosis. Median BMI was 24.9 kg/m2 (range 12.1–66.5); 20% of women were obese and 5% underweight. Obesity was associated with more de novo MBC, while underweight patients had more aggressive cancer features. Median overall survival (OS) of the BMI cohort was 47.4 months (95% CI [46.2–48.5]) (median follow-up: 48.6 months). Underweight was independently associated with a worse OS (median OS 33 months; HR 1.14, 95%CI, 1.02–1.27) and first line progression-free survival (HR, 1.11; 95%CI, 1.01; 1.22), while overweight or obesity had no effect.

Conclusion

Overweight and obesity are not associated with poorer outcomes in women with metastatic disease, while underweight appears as an independent adverse prognostic factor.