Breast Surgery Bulletin - April 2022

 

Global guidelines for breast cancer screening: A systematic review

 

by Wenhui Ren, Mingyang Chen, Youlin Qiao, Fanghui Zhao 

 

The Breast: Published: April 19, 2022

 

Highlights

• This systematic review comprehensively maps the recommendations of the latest international breast screening guidelines, providing valuable tools for clinical decision-making in different settings.

• Most guidelines recommended biennial mammographic screening between 40 to 74 years for the average-risk populations and annual MAM or annual MRI starting from a younger age for the high-risk populations. However, there are indeed discrepancies in screening age and method among countries.

• High-quality evidence and rigorous methodology are the keys to guidance development, but current guidelines varied in methodological quality.

Summary

Breast cancer screening guidelines could provide valuable tools for clinical decision-making by reviewing the available evidence and providing recommendations. Little information is known about how many countries have issued breast cancer screening guidelines and the differences among existed guidelines. We systematically reviewed current guidelines and summarized corresponding recommendations, to provide references for good clinical practice in different countries.

 

Validation of a prognostic scoring system for postmastectomy locoregional recurrence in breast cancer

by Van der Vorst Aline, Kindts Isabelle, Laenen Annouschka, Neven Patrick, Janssen Hilde, Weltens Caroline 

The Breast: Published: April 16, 2022

Background

To date, it remains unclear which patients with breast cancer (BC) benefit from post-mastectomy radiotherapy (PMRT). Cheng et al. developed and validated a scoring system based on 4 prognostic factors for locoregional recurrence (LRR) to identify patients in need for PMRT. These factors include age, estrogen receptor status, lymphovascular status and number of affected axillary lymph nodes.

Purpose

To validate the scoring system for LRR in BC developed by Cheng et al. by using an independent BC database.

Methods and materials

We retrospectively identified 1989 BC cases, treated with mastectomy (ME) with or without PMRT at the University Hospitals Leuven between 2000 and 2007. The primary endpoint was 5-year locoregional control rate with and without PMRT, according to the LRR score.

Results

Median follow-up time was 11.4 years. After excluding patients with missing variables 1103 patients were classified using the LRR scoring system: 688 (62.38%) patients were at low risk of recurrence (LRR score 0–1), 335 (30.37%) patients were at intermediate risk of recurrence (LRR score 2–3) and 80 (7.25%) patients were at high risk of recurrence (LRR score ≥4). 5-year locoregional control rates with and without PMRT were 99.20% versus 99.21% (p = 0.43) in the low-risk group; 98.24% versus 85.74% (p < 0.0001) in the intermediate-risk group and 96.87% versus 85.71% (p = 0.10) in the high-risk group respectively.

Conclusion

Our validation of the LRR scoring system suggests it can be used to point out patients that would benefit from PMRT. We recommend further validation of this scoring system by other independent institutions before application in clinical practice

 

Physical functioning, frailty and risks of locally-advanced breast cancer among older women

 

by Chandler Coleman, Connie H. Yan, Naomi Y. Ko, Nadia A. Nabulsi, Kent F. Hoskins, Brian C.-H. Chiu, Gregory S. Calip 

 

The Breast: Published: April 14, 2022

 

Objective

Women with multiple comorbidities have competing health needs that may delay screening for early detection of breast cancer. Our objective was to determine associations between physical functioning and frailty with risk of locally-advanced breast cancer (BC).

Methods

We conducted a retrospective cohort study of women 65 years and older diagnosed with first primary stage I-III BC using the Surveillance, Epidemiology and End Results Medicare Health Outcome Survey Data Resource. Physical health-related quality of life was measured using Veterans RAND 12 Item Health Survey scales within two years before diagnosis; frailty was determined by calculating deficit-accumulation frailty index (DAFI) scores. Multivariable modified Poisson regression models were used to estimate rate ratios (RR) and 95% confidence intervals (CI) for risk of locally-advanced (stage III) versus early-stage (I-II) BC.

Results

Among 2411 women with a median age of 75 years at BC diagnosis, 2189 (91%) were diagnosed with incident stage I-II BC and 222 (9%) were diagnosed at stage III. Compared to women with early-stage disease, women with locally-advanced BC had lower physical component scores (37.8 vs. 41.4) and more classified as pre-frail or frail (55% vs. 50%). In multivariable models, frailty was not associated with increased risk of locally-advanced disease. However, worse physical function subscale scores (lowest vs. upper quartile; RR = 1.56, 95% CI 1.04–2.34) were associated with risk of locally-advanced BC.

Conclusions

Breast cancer screening among non-frail older women should be personalized to include women with limited physical functioning if the benefits of screening and early detection outweigh the potential harms

 

Assessing Long-Term Outcomes in Breast Implant Illness: The Missing Link? A Systematic Review

 

by Rohrich, Rod J.; Bellamy, Justin L.; Alleyne, Brendan 

 

Plastic and Reconstructive Surgery: April 2022 - Volume 149 - Issue 4 - p 638e-645e

 

The purpose of this special topic article is to explore the current state of outcomes-based literature related to breast implant illness and summarize the key understandings that emerge from the summation of existing studies. While implanted silicone devices are some of the most ubiquitous products in modern medicine, the safety of silicone breast implants has long remained under scientific scrutiny. In the era of social media and with breast implants once again under public scrutiny with the recent connection of texture silicone implants to breast implant–associated anaplastic large-cell lymphoma, the borders between breast implant illness and other implant-related diseases are becoming clouded in the public eye. The surgical management options for breast implant illness range from simple implant explantation alone to complete en bloc capsulectomies, or even secondary exploratory operations for additional capsulectomy in persistently symptomatic patients. In this review of outcomes-based studies related to breast implant illness, the authors found that a subset of patients improves with surgical intervention but limited evidence to inform most current surgical management practices. Further, the nature of this illness renders it difficult to study. A carefully designed, large, prospective, outcomes-based study is still required if an evidence-based and sound treatment approach for this condition is to be established.

 

The continuing conundrum in oligometastatic breast carcinoma: A real-world data

 

by Gangothri Selvarajan, Manikandan Dhanushkodi, Venkatraman Radhakrishnan, Carthikeyan Subramaniam Murali, Balasubramanian Ananthi, Priya Iyer, Arvind Krishnamurthy, Sridevi Velusamy, Selvaluxmy Ganesarajah, Tenali Gnana Sagar 

 

The Breast: Published: April 02, 2022

 

The optimal management in Oligometastatic (OM) breast carcinoma is not defined.

Objectives

To identify the prognostic factors influencing OM and the effect of Locoregional treatment (LRT) on survival in OM.

Methodology

Patients with ≤5 metastases and each with ≤ 5 cm size were defined as OM. Data of OM were extracted from the Institute Registry between 2012 and 2018. The impact of prognostic factors on survival was analysed by univariate and multivariate Cox regression. The Kaplan Meier survival curves were used to plot PFS and OS.

Results

There were 170 patients with OM. The median follow-up was 61 months. Median OS was 43.3 months. The median OS was 74 months in OMD vs 22.7 months in Oligorecurrent disease (ORD) with 5year OS rate of 55.3% vs 16.5% respectively. In the multivariate analyses of OMD both Ki67 ≤ 50% and hormone therapy (HT) showed significant favourable survival outcome. While premenopausal status and HT showed significant survival benefits in ORD. The worse survival outcome in ORD could be because of their aggressive biology and deficit in LRT compared to literature review. The prognostic factors were swayed by the uneven distribution of HR status, grade and Ki67.

Conclusion

The survival of OM was influenced by OMD, Ki67 ≤ 50%, premenopausal status and HT. The lesser survival rates of OM in the long term suggest the need for curative LRT to metastatic sites and primary tumor. The potential role of HT and targeted therapy with or without LRT need to be assessed in future randomised trials.

 

The role of percutaneous vertebral augmentation in patients with metastatic breast cancer: Literature review including report of two cases

by Ozge Gumusay, Laura A. Huppert, Spencer C. Behr, Hope S. Rugo 

The Breast: Published: April 01, 2022

Abstract

Patients with metastatic breast cancer are at high risk for developing vertebral compression fractures due to underlying bone metastases and bone density loss. Vertebral augmentation techniques including percutaneous vertebroplasty and percutaneous balloon kyphoplasty are techniques used to stabilize compression fractures and improve pain. However, rare complications from these interventions have been observed, including spinal cord compression, nerve root compression, venous cement embolism, and pulmonary cement embolism. These complications pose unique potential challenges for patients with cancer who may already have decreased lung function and potential for venous thromboembolism. In this review, we first describe the role of percutaneous vertebral augmentations in patients with metastatic cancer, with a particular focus on patients with breast cancer. Then, we describe complications of vertebral augmentation in two patients with metastatic breast cancer including long-term symptomatic and radiographic follow-up.

Highlights

•Balloon kyphoplasty and percutaneous vertebroplasty are used to stabilize compression fractures and improve pain.

•Leakage of bone cement can cause cement emboli which can depsit in locations such as the pulmonary and renal vasculature.

•Management of cement emboli depends on the amount of cement embolized and the severity of symptoms.

•Future studies are needed to better understand the long-term radiographic and clinical consequences of cement emboli.

 

Immediate Breast Reconstruction Using the Goldilocks Procedure: A Balance between More Surgery and Patient Satisfaction

 

Manrique, Oscar J.; Kuruoglu, Doga; Yan, Maria; Bustos, Samyd S.; Boughey, Judy C.; Harless, Christin A.; Tran, Nho V.; Martinez-Jorge, Jorys; Forte, Antonio J.; Nguyen, Minh-Doan T. 

 

Plastic and Reconstructive Surgery: April 2022 - Volume 149 - Issue 4 - p 801-809

 

Background: 

Since its first description in 2012, the Goldilocks procedure has become an option for immediate breast reconstruction, particularly for obese patients who are poor candidates for traditional implant or autologous reconstruction. In this work, the authors performed a longitudinal study of patients who underwent mastectomy with Goldilocks reconstruction to assess the incidence of additional surgical procedures, and to assess surgical outcomes and patient satisfaction.

Methods: 

A retrospective review of patients who underwent mastectomy with the Goldilocks procedure only at Mayo Clinic Rochester between January of 2012 and September of 2019 was performed. Demographics, complications, additional breast procedures performed to attain the final results, and patient-reported outcomes using the BREAST-Q were recorded. Univariate and multivariable analyses were performed to identify statistical associations and risk factors.

Results: 

Sixty-three patients (108 breasts) were included. Mean age was 57.8 years. Mean body mass index was 37.6 kg/m2. Median follow-up time after the mastectomy with the Goldilocks procedure was 15 months. The major complication rate within the first 30 days was 9.3 percent. Forty-four breasts (40.7 percent) underwent additional surgery. Dyslipidemia was significantly associated with an increased risk of additional surgery (adjusted hazard ratio, 2.00; p = 0.045). Scores in the four BREAST-Q domains were not statistically different between patients who had additional procedures and those who did not.

Conclusions: 

Based on the results, the authors recommend a thorough preoperative discussion with patients who are candidates for the Goldilocks procedure to explore all options for reconstruction and their expectations, because it is crucial to reduce the necessity for additional operations in this high-risk population.

 

Impact of Chemotherapy and Radiation Therapy on Inflammatory Response, Neovascularization, and Capsule Formation of Acellular Dermal Matrix in Breast Reconstruction: Analysis of the BREASTrial Biopsy Specimens

 

by Mendenhall, Shaun D.; Graham, Emily M.; Anderson, Layla A.; Ying, Jian; Liu, Ting; Agarwal, Jayant P. 

 

Plastic and Reconstructive Surgery: March 2022 - Volume 149 - Issue 3 - p 378e-385e

 

Background: 

The Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial is a single-center, blinded, prospective, randomized, controlled trial established to compare outcomes using two popular types of acellular dermal matrices, AlloDerm and DermaMatrix, in tissue expander breast reconstruction. This study used the acellular dermal matrix biopsy specimens from the trial to evaluate how adjuvant therapy influences inflammation, neovascularization, and capsule formation of the acellular dermal matrix.

Methods: 

Punch biopsy specimens were taken at the time of expander exchange and were analyzed by a blinded pathologist. The inflammatory response was quantified by the number of fibroblasts, giant cells, and lymphocytes. Neovascularization and capsule formation were similarly quantified by the number of new capillaries and capsule presence and thickness, respectively.

Results: 

Histology specimens were collected from 109 patients (170 breasts). In the absence of adjuvant therapy, there was no significant difference between AlloDerm and DermaMatrix in terms of inflammation, neovascularization, or capsule thickness. Both acellular dermal matrices showed a significant decrease in inflammation and neovascularization with adjuvant therapy. When chemotherapy and radiation therapy were used, the decrease in inflammation was greatest for the group reconstructed with DermaMatrix (p < 0.039).

Conclusions: 

Adjuvant therapy influences the inflammatory response, neovascularization, and capsule formation in both acellular dermal matrices. Adjuvant therapy has a protective effect on the inflammatory response toward both acellular dermal matrices in breast reconstruction. In the setting of chemotherapy and radiation therapy, DermaMatrix produced the greatest reduction in inflammation.

 

Effects of physical exercise on cognitive function of breast cancer survivors receiving chemotherapy: A systematic review of randomized controlled trials

by Xiaohan Ren, Xiaoqin Wang, Jiaru Sun, Zhaozhao Hui, Shuangyan Lei, Caihua Wang, Mingxu Wang 

The Breast: Published: March 27, 2022

Background

Cognitive impairment has a great negative impact on quality of life for breast cancer survivors. Emerging evidence suggested that physical exercise can improve cognitive function in order adults with Alzheimer's disease. However, less is known about the effects of physical exercise on cognitive function for breast cancer survivors. The purpose of this meta-analysis was to evaluate the effect of physical exercise on cognitive function in breast cancer survivors.

Methods

EMBASE, the Cochrane Library, Web of Science and PubMed were searched from the establishment of the databases to June 2021. Randomized controlled trials were included. All analysis were conducted using the Revman 5.3.

Results

12 studies (936 participants) indicated that exercise improved self-reported cognitive function (MD 10.12, 95% CI [5.49,14.76], p < 0.0001), cognitive fatigue (MD -5.41, 95% CI [-10.31,-0.51], p = 0.03) and executive function (MD -13.63, 95% CI [-21.86,-5.39], p = 0.0001).

Conclusion

Physical exercise can improve cognitive function for breast cancer survivors, particularly in self-reported cognitive function, and executive function. Future studies need to explore the effect of exercise on cognitive function from the frequency and duration of exercise.

 

Geriatric assessment tool application in treatment recommendations for older women with breast cancer

  by Asma Munir, Anita Huws, Sohail Khan, Yousef Sharaiha, Simon Holt, Saira Khawaja 

 The Breast: Published: March 26, 2022

 Treatment of early breast cancer in older women is usually not guideline concordant owing to lack of routine evaluation of their potential frailty. We assessed the feasibility and impact of a self-administered geriatric assessment on the decision-making process in women aged 65 and above treated in a UK District General Hospital.