Tuesday, 14 July 2020

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)



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



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



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



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



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



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.


Monday, 1 June 2020

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



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



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



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



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



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



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



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?



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.

Tuesday, 25 February 2020

Long-Term Results and Reconstruction Failure in Patients Receiving Postmastectomy Radiation Therapy with a Temporary Expander or Permanent Implant in Place



by Dicuonzo, Samantha; Leonardi, Maria Cristina; Radice, Davide; Morra, Anna; Gerardi, Marianna Alessandra; Rojas, Damaris Patricia; Surgo, Alessia; Dell’Acqua, Veronica; Luraschi, Rosa; Cattani, Federica; Rietjens, Mario; De Lorenzi, Francesca; Veronesi, Paolo; Galimberti, Viviana; Marvaso, Giulia; Fodor, Cristiana; Orecchia, Roberto; Jereczek-Fossa, Barbara Alicja

Plastic and Reconstructive Surgery: February 2020 - Volume 145 - Issue 2 - p 317-327

Background: This study investigated the risk of reconstruction failure after mastectomy, immediate breast reconstruction, and radiotherapy to either a temporary tissue expander or permanent implant.
Methods: Records of women treated at a single institution between June of 1997 and December of 2011 were reviewed. Two patient groups were identified based on type of immediate breast reconstruction: tissue expander followed by exchange with a permanent implant and permanent implant. The study endpoint was rate of reconstruction failure, defined as a replacement, loss of the implant, or conversion to flap.
Results: The tissue expander/permanent implant and the permanent implant groups consisted of 63 and 75 patients, respectively. The groups were well balanced for clinical and treatment characteristics. With a median follow-up of 116 months, eight implant losses, 50 implant replacements, and four flap conversions were recorded. Reconstruction failure occurred in 22 of 63 patients in the expander/implant group and in 40 of 75 patients in the permanent implant group. A traditional proportional hazards model showed a higher risk of reconstruction failure for the expander/implant group (hazard ratio, 2.01) and a significantly shorter time to reconstruction failure compared with the permanent implant group (109.2 months versus 157.7 months; p = 0.03); however, according to a competing risk model, the between-groups cumulative incidences were not significantly different (hazard ratio, 1.09).
Conclusions: Radiotherapy to either a tissue expander or a permanent implant presented a fairly large risk of reconstruction failure over time. The expander/implant group was not more likely to develop reconstruction failure compared to permanent implant group, but the timing of onset was shorter. More complex techniques should be investigated to lower the risk of reconstruction failure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Predicting Ischemic Complications in the Inframammary Approach to Nipple-Sparing Mastectomy: The Midclavicular-to–Inframammary Fold Measurement



by Willey, Shawna C.; Fan, Kenneth L.; Luvisa, Kyle; Graziano, Francis D.; Lau, Stephanie H. Y.; Black, Cara K.; Song, David H.; Pittman, Troy

Plastic and Reconstructive Surgery: February 2020 - Volume 145 - Issue 2 - p 251e-262e


Background: The authors refine their anatomical patient selection criteria with a novel midclavicular-to–inframammary fold measurement for nipple-sparing mastectomy performed through an inframammary approach.
Methods: Retrospective review was performed of all nipple-sparing mastectomies performed through an inframammary approach. Exclusion criteria included other mastectomy incisions, staged mastectomy, previous breast operation, and autologous reconstruction. Preoperative anatomical measurements for each breast, clinical course, and specimen weight were obtained.
Results: One hundred forty breasts in 79 patients were analyzed. Mastectomy weight, but not sternal notch–to-nipple distance, was strongly correlated with midclavicular-to–inframammary fold measurement on linear regression (R2 = 0.651; p < 0.001). Mastectomy weight was not correlated with ptosis. Twenty-five breasts (17.8 percent) had ischemic complications: 16 (11.4 percent) were nonoperative and nine (6.4 percent) were operative. Those with mastectomy weights of 500 g or greater were nine times more likely to have operative ischemic complications than those with mastectomy weights less than 500 g (p = 0.0048). Those with a midclavicular-to–inframammary fold measurement of 30 cm or greater had a 3.8 times increased incidence of any ischemic complication (p = 0.00547) and a 9.2 times increased incidence of operative ischemic complications (p = 0.00376) compared with those whose midclavicular-to–inframammary fold measurement was less than 30 cm.
Conclusions: Breasts undergoing nipple-sparing mastectomy by means of an inframammary approach with midclavicular-to–inframammary fold measurement greater than or equal to 30 cm are at higher risk for having ischemic complications, warranting consideration for a staged approach or other incision. The midclavicular-to–inframammary fold measurement is useful for assessing the entire breast and predicting the likelihood of ischemic complications in inframammary nipple-sparing mastectomies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.


3D digital breast cancer models with multimodal fusion algorithms



by Sílvia Bessa, Pedro F. Gouveia, Pedro H. Carvalho, Cátia Rodrigues, Nuno L. Silva, Fátima Cardoso, Jaime S. Cardoso, Hélder P. Oliveira, Maria João Cardoso

The Breast: FULL LENGTH ARTICLE| VOLUME 49, P281-290, FEBRUARY 01, 2020

Breast cancer image fusion consists of registering and visualizing different sets of a patient synchronized torso and radiological images into a 3D model. Breast spatial interpretation and visualization by the treating physician can be augmented with a patient-specific digital breast model that integrates radiological images. But the absence of a ground truth for a good correlation between surface and radiological information has impaired the development of potential clinical applications.A new image acquisition protocol was designed to acquire breast Magnetic Resonance Imaging (MRI) and 3D surface scan data with surface markers on the patient’s breasts and torso.

Second conservative treatment for second ipsilateral breast tumor event: A systematic review of the different re-irradiation techniques



by Lucile Montagne, Arthur Hannoun, Jean-Michel Hannoun-Levi 

The Breast: REVIEW| VOLUME 49, P274-280, FEBRUARY 01, 2020

To address the different partial breast re-irradiation techniques available in the context of second conservative treatment (SCT), as an alternative to salvage mastectomy, for 2nd ipsilateral breast tumor event (IBTE) and summarize their respective oncological and toxicity outcomes.