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.