The impact of postmastectomy radiotherapy on two-stage implant breast reconstruction

The impact of postmastectomy radiotherapy on two-stage implant breast reconstruction: An analysis of long-term surgical outcomes, aesthetic results and satisfaction over 13 years. Plastic and Reconstructive Surgery, October 2014, Vol. 134(4), p.588-95.

Cordeiro, P.G., et al.

http://journals.lww.com/plasreconsurg/Abstract/2014/10000/The_Impact_of_Postmastectomy_Radiotherapy_on.4.aspx

Postmastectomy radiation therapy is increasingly indicated in patients with node-positive breast cancer. The authors prospectively evaluated long-term outcomes in patients with two-stage implant-based reconstruction and postmastectomy radiation therapy to the permanent implant.

Invisible risks, emotional choices

Invisible risks, emotional choices: Mammography and medical decision making. NEJM, 2014; 371: 1549-52.

Rosenbaum, L.

http://www.nejm.org/doi/full/10.1056/NEJMms1409003?af=R&rss=currentIssue

Putting it all together: Managing pain in autologous and implant-based breast reconstruction

Putting it all together: Managing pain in autologous and implant-based breast reconstruction. Plastic and Reconstructive Surgery, October 2014, Vol. 134 (4S-2), p. 120S-125S.

Wilson, A.J., et al.

http://journals.lww.com/plasreconsurg/Fulltext/2014/10002/Putting_It_All_Together___Managing_Pain_in.19.aspx

Appropriate pain management in breast reconstruction improves outcomes and patient satisfaction. The purpose of this study is to review the current methodology and paradigms in pain management following breast reconstruction. Methods: A review of the scientific literature was performed. The protocols used at our institution were further examined and contrasted in the context of this published literature. Results: Pain following breast reconstruction is multifactorial and patient specific. Pain can originate from the mastectomy alone, from the donor site, or from tissue expansion. Counseling a patient is of upmost importance. The armamentarium to address pain includes narcotic analgesics, nonnarcotic analgesics, local anesthesia, and other nontraditional regimens. Each of these methods has an evidence-based efficacy and patient selection factors for application. Conclusions: The data contained herein provide a review of perioperative pain management following autologous and implant-based breast reconstruction.

Patient activated controlled expansion for breast reconstruction using controlled carbon dioxide inflation

Patient activated controlled expansion for breast reconstruction using controlled carbon dioxide inflation: Confirmation of a feasibility study. Plastic and Reconstructive Surgery, October 2014, Vol. 134(4), p.503e-511e.

Connell, T.

http://journals.lww.com/plasreconsurg/Fulltext/2014/10000/Patient_Activated_Controlled_Expansion_for_Breast.2.aspx

Women with breast cancer or those at high risk of developing breast cancer because of familial history of the disease or genetic mutations are frequently indicated for therapeutic or prophylactic mastectomy. Prosthetic reconstruction of the breast with placement of tissue expanders followed by implants offers favorable aesthetic and psychological results while adding only minimal additional surgical intervention. This study describes the confirmatory phase of an earlier feasibility trial that involved seven women who successfully underwent patient-activated controlled expansion for breast reconstruction with 10 AeroForm patient-controlled tissue expanders.

Methods: A prospective, open-label, single-arm, single-surgeon confirmatory study in Perth, Australia, evaluated outcomes of two-stage breast reconstruction using the investigational device. Each subject administered a preset 10-cc dose of carbon dioxide gas using a remote dosage controller, three times each day, with a 3-hour lockout between doses until full expansion was achieved.

Results: Thirty-three women with breast cancer, family history, or predisposition because of the BRCA1 or BRCA2 gene mutation underwent pedicled latissimus dorsi flap procedures with placement of 61 carbon dioxide–based tissue expanders. The mean number of days for subjects to achieve desired expansion was 17 ± 5. Operating the dosage controller was described by the surgeon as very easy in 94 percent of the cases and by 97 percent of the subjects. No serious adverse events were reported.

Conclusion: This study confirms that the AeroForm breast tissue expander has demonstrated the ability to provide, relative to saline expanders, a needle-free, patient-controlled, convenient, and time-saving method of tissue expansion.

Skirt size ups breast cancer risk

Skirt size ups breast cancer risk [UK study].  Health news from NHS Choices

http://feedly.com/#subscription%2Ffeed%2Fhttp%3A%2F%2Ffeeds.feedburner.com%2FNhsChoicesBehindTheHeadlines%3Fformat%3Dxml

The study was carried out by researchers from the Universities of London and Manchester, and was funded by the Medical Research Council, Cancer Research UK and the National Institute of Health Research, as well as the Eve Appeal.

The study was published in the peer-reviewed medical journal BMJ Open. As the name suggests, this is an open-access journal, so the study can be read for free online.

The paper was widely covered in the UK media. Coverage was fair, if uncritical.

Several headlines gave the impression that going up a single skirt size would raise breast cancer risk by 33%. Such a rise in risk would only be expected if a person went up a dress size every decade from their mid-twenties to when they were over 50 years old – the youngest age of the women recruited to the study.

Several media sources included useful comments from independent experts.

Current status of hormone therapy in patients with hormone receptor positive advanced breast cancer

Current status of hormone therapy in patients with hormone receptor positive (HR+) advanced breast cancer. The Breast, October 2014 [in press]

Dalmau, E., et al.

http://www.thebreastonline.com/article/S0960-9776(14)00171-4/abstract?rss=yes

The natural history of HR+ breast cancer tends to be different from hormone receptor-negative disease in terms of time to recurrence, site of recurrence and overall aggressiveness of the disease.

Nipple-sparing mastectomy in patients with prior breast irradiation

Nipple-sparing mastectomy in patients with prior breast irradiation: Are patients at higher risk for reconstructive complications? Plastic and Reconstructive Surgery Aug 2014, Vol. 134(2), p.202e-206e.

Alperovich, M., et al.

http://journals.lww.com/plasreconsurg/Abstract/2014/08000/Nipple_Sparing_Mastectomy_in_Patients_with_Prior.6.aspx

Reconstruction in the setting of prior breast irradiation is conventionally considered a higher-risk procedure. Limited data exist regarding nipple-sparing mastectomy in irradiated breasts, a higher-risk procedure in higher-risk patients.

Individual risk of surgical site infection

Individual risk of surgical site infection: An application of the breast reconstruction risk assessment score. Plastic and Reconstructive Surgery Sept 2014, Vol. 134(3), p.351e-362e.

Kim, J.Y.S., et al.

http://journals.lww.com/plasreconsurg/Fulltext/2014/09000/Individualized_Risk_of_Surgical_Site_Infection__.1.aspx

Risk factors for surgical-site infection following breast reconstruction have been thoroughly investigated at a population level. However, traditional population-based measures may not always capture the nuances of individual patients. The authors aimed to develop a validated breast reconstruction risk assessment calculator for surgical-site infection that informs risk at an individual level.

No reduction in death rate is seen with bilateral mastectomy

No reduction in death rate is seen with bilateral mastectomy. BMJ 2014; 349.

McCarthy, M.

http://www.bmj.com/content/349/bmj.g5402?rss=1&variant=short&hwoasp=authn%3A1409906788%3A4044144%3A3266341273%3A0%3A0%3A6BZxAKWi6ImzkhkTN57Ukg%3D%3D

Increasing numbers of US women with breast cancer are opting for double mastectomies, but the procedure is not associated with a lower 10 year mortality than breast conserving surgery with radiation, a study has found. The study was reported in the 3 September issue of JAMA. Allison W Kurian, of Stanford University School of Medicine in California, and colleagues, accessed data that had been collected from 1998 to 2011 on 189 734 women who had new diagnoses of early, unilateral breast cancer at stages 0-III. The data came from the California Cancer Registry—a population based registry that captures information on about 99% of the state’s breast cancer cases—and the median length of follow-up for patients was 89.1 months.

An algorithmic approach for selective acellular dermal matrix use in immediate two-stage breast reconstruction

An algorithmic approach for selective acellular dermal matrix use in immediate two-stage breast reconstruction: Indications and outcomes. Plastic and Reconstructive Surgery Aug 2014, Vol. 134(2), p.178-88.

Jordan, S.W., et al.

http://journals.lww.com/plasreconsurg/Fulltext/2014/08000/An_Algorithmic_Approach_for_Selective_Acellular.4.aspx

Acellular dermal matrix use has gained widespread acceptance—despite higher material costs—because of its ease of use and potential for enhanced cosmesis. The authors developed a resource-sensitive algorithm for selective acellular dermal matrix use with indications and contraindications based on body mass index, breast size, radiation therapy, flap vascularity, and pectoralis anatomy. Methods: The algorithm incorporates preoperative and intraoperative decision points. Complication rates and aesthetic scores were compared for procedures performed before and after adoption of the algorithm. Multiple logistic regression was used to determine the independent influence of the algorithm on postoperative outcomes.

Breast reconstruction with tissue expanders

Breast reconstruction with tissue expanders: Implementation of a standardized best practices protocol to reduce infection rates. Plastic and Reconstructive Surgery July 2014, Vol. 134(1), p.11-18.

Khansa, I., et al.

http://journals.lww.com/plasreconsurg/Abstract/2014/07000/Breast_Reconstruction_with_Tissue_Expanders__.4.aspx

Periprosthetic infection remains a frustrating and costly complication of breast reconstruction with tissue expanders. Although some specific steps have been previously shown to reduce periprosthetic infections, no comprehensive protocol addressing all aspects of preoperative, intraoperative, and postoperative patient management has been evaluated in the literature. The authors’ goal was to evaluate the effectiveness of their protocol at reducing periprosthetic infections.

Silicone gel breast implants: Science and testing

Silicone gel breast implants: Science and testing. Plastic and Reconstructive Surgery, July 2014, Vol.134 (1s).

Kinney, B.M., et al.

http://journals.lww.com/plasreconsurg/Fulltext/2014/07001/Silicone_Gel_Breast_Implants___Science_and_Testing.9.aspx

Since the first generation of breast implants, major design innovations, including consistency of the gel, palpability and thickness of the shell, and barrier materials in the shell, have been introduced. Surgeons have not had metrics to assess and compare available implants.

Methods: Research at independent laboratories included 4 tests: gel elasticity (the gel’s ability to retain its shape), gel compression fracture (the resistance to permanent gel deformation), gel-shell peel (the integration of the gel with shell as a cohesive unit), and morphological analysis.

Breast embryology and the double-bubble deformity

Breast embryology and the double-bubble deformity. Plastic and Reconstructive Surgery, July 2014, Vol. 134(1), p.161e-162e.

Gigliofiorito, P., et al.

http://journals.lww.com/plasreconsurg/Fulltext/2014/07000/Breast_Embryology_and_the_Double_Bubble_Deformity.42.aspx

Breast surgery remains one of the most popular branches of plastic surgery. More than 286,000 breast implants were placed in 2012 in the United States, and these numbers will probably increase in the next decade. The double-bubble deformity can be a disappointing complication during breast surgery, and patients often relate to it as a surgical mistake. However, as the author stated, it can also be a consequence of a patient’s own susceptibility.

NEJM Audio Summary: Breast cancer

NEJM Audio Summary: Breast cancer risk. Aug 2014 [podcast]

Breast-cancer risk and mutations in PALB2

http://podcast.nejm.org/summaries/nejm_2014.371.issue-6.summary.mp3

Postmastectomy radiation therapy after immediate two-stage tissue expander/implant breast reconstruction

Postmastectomy radiation therapy after immediate two-stage tissue expander/implant breast reconstruction: A University of British Columbia perspective. Plastic and Reconstructive Surgery, July 2014, Vol. 134(1), p.1e-10e.

Ho, A.L., et al.

http://journals.lww.com/plasreconsurg/Fulltext/2014/07000/Postmastectomy_Radiation_Therapy_after_Immediate.2.aspx

 An increasing number of women who undergo immediate two-stage tissue expander/implant breast reconstruction will require postmastectomy radiation therapy. An important variable is the timing of radiotherapy relative to surgery. The authors report their experience treating a large consecutive series of patients who underwent postmastectomy radiation therapy to the tissue expander before exchange for a permanent implant.

Screening an asymptomatic person for genetic risk

Screening an asymptomatic person for genetic risk. NEJM, June 2014, 370: 2442-45 [Clinical Decisons]

Department of Bioethics and Humanities, University of Washington, Seattle

http://www.nejm.org/doi/pdf/10.1056/NEJMclde1311959

Case Study: Jim Mathis is a 45-year-old health-conscious man who has been a patient in an internal medicine–primary care practice for several years. At today’s visit, he talks about the family tree that he has sketched out and his discovery that three of his relatives had cancer — one had breast cancer, one ovarian cancer, and one prostate cancer.

Postmastectomy radiation in breast cancer with one to three involved lymph nodes

Postmastectomy radiation in breast cancer with one to three involved lymph nodes: ending the debate. The Lancet, June 2014, Vol. 383(9935), p.2104-06.

Poortmans, P.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60192-6/fulltext?rss=yes

Many trials in breast cancer have investigated various aspects of locoregional and systemic treatments. Combination of the results of these trials in a meticulous meta-analysis, as has been done several times by the Early Breast Cancer Trialists' Collaborative Group (EBCTCG), fills the gaps in evidence and knowledge by conclusively showing significant trends and differences.

Adjuvant exemestane with ovarian suppression in premenopausal breast cancer

Adjuvant exemestane with ovarian suppression in premenopausal breast cancer. NEJM, June 2014 [online]

Pagani, O., et al.

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1404037

The most effective adjuvant endocrine therapy for premenopausal women with hormone-receptor (estrogen, progesterone, or both)–positive breast cancer is uncertain. Tamoxifen for at least 5 years is a standard of care. Adjuvant suppression of ovarian function (hereafter, ovarian suppression) may be recommended in addition. For postmenopausal women, adjuvant therapy with an aromatase inhibitor, as compared with tamoxifen, improves outcomes.

Portrait, treatment choices and management of breast cancer in nonagenarians

Portrait, treatment choices and management of breast cancer in nonagenarians: An ongoing challenge. The Breast, June 2014, Vol. 23(3), p.221-5.

Merv, B., et al.

http://www.thebreastonline.com/article/S0960-9776(14)00050-2/abstract?rss=yes?rss=yes

There are only scarce data on the management of nonagenarians with breast cancer, and more particularly on the place of radiation therapy (RT). We report a retrospective study on patients aged 90 years old or older, with breast cancer, receiving RT. Records from RT departments from five institutions were reviewed to identify patients 90 years old of age and older undergoing RT over past decade for breast cancer. Tumors' characteristics were examined, as well treatment specificities and treatment intent. 

44 patients receiving RT courses were identified, mean age 92 years. Treatment was given with curative and palliative intent in 72.7% and 27.3% respectively. Factors associated with a curative treatment were performance status (PS), place of life, previous surgery, and tumor stage. Median total prescribed dose was 40 Gy (23–66). Hypo fractionation was used in 77%. Most toxicities were mild to moderate. RT could not be completed in 1 patient (2.3%). No long-term toxicity was reported. Among 31 patients analyzable for effectiveness, 24 patients (77.4%) had their diseased controlled until last follow-up, including 17 patients (54.8%) experiencing complete response. At last follow-up, 4 patients (12.9%) were deceased, cancer being cause of death for two of them.

The study shows that breast/chest RT is feasible in nonagenarians. Although the definitive benefit of RT could not be addressed here, hypofractionated therapy allowed a good local control with acceptable side effects.

Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality

Effect of radiotherapy after mastectomy and axillary survey on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. The Lancet, June 2014, Vol. 383(9935), p.2127-35.

Early Breast Cancer Trialists' Collaborative Group

http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673614604888.pdf?id=baafQEJCKe7tA85F7c8Bu

Postmastectomy radiotherapy was shown in previous meta-analyses to reduce the risks of both recurrence and breast cancer mortality in all women with node-positive disease considered together. However, the benefit in women with only one to three positive lymph nodes is uncertain. We aimed to assess the effect of radiotherapy in these women after mastectomy and axillary dissection.