Optimising post-operative radiation therapy after oncoplastic and reconstructive procedures

by Trine Tramm, Orit Kaidar-Person 

The Breast: Published: March 28, 2023

Abstract

Surgical techniques for breast cancer have been refined over the past decades to deliver an aesthetic outcome as close as possible to the contralateral intact breast. Current surgery further allows excellent aesthetic outcome even in case of mastectomy, by performing skin sparing or nipple sparing mastectomy in combination with reconstruction. In this review we discuss how to optimise post-operative radiation therapy after oncoplastic and breast reconstructive procedures, including dose, fractionation, volumes, surgical margins, and boost application.

Highlights

• New surgical procedures for breast cancer poses new challenges for the radiation oncologists.

• Oncoplastic breast surgery may question the ability to apply or the need for a tumour bed boost.

• Skin sparing/nipple sparing mastectomies should be planned to assure clear superficial margins.

• Radiation therapy indications, target volumes, dose and fractionation should be adapted per case to provide maximal clinical benefit and reduce toxicity.

• Multidisciplinary teamwork is needed from the time of diagnosis to plan the most appropriate locoregional therapy.

 

Suggestion for the omission of post-mastectomy chest wall radiation therapy in patients who underwent skin-sparing/nipple-sparing mastectomy

 

by Nalee Kim, Won Park, Won Kyung Cho, Hae Young Kim, Doo Ho Choi, Seok Jin Nam, Seok Won Kim, Jeong Eon Lee, Jonghan Yu, Byung Joo Chae, Se Kyung Lee, Jai Min Ryu, Goo-Hyun Mun, Jai-Kyong Pyon, Byung-Joon Jeon 

 

The Breast: Published: September 23, 2022

 

Aim

Both skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) have been widely adopted. Although postmastectomy radiation therapy (PMRT) can improve clinical outcomes, it can worsen cosmesis following reconstruction. Therefore, identifying risk factors of ipsilateral breast tumor recurrence (IBTR) could help de-escalate PMRT after NSM/SSM in patients with pT1-2 disease.

Methods

We retrospectively reviewed patients treated with SSM (N = 400) and NSM (N = 156) in patients with pT1-2N0-1 disease between 2009 and 2016. Seventy-four patients received PMRT with 50–50.4 Gy in 25–28 fractions. The Cox proportional hazards model was used to analyze the prognostic factors of IBTR.

Results

With a median follow-up of 66.2 months, 17 IBTR events were observed, with 5-year IBTR-free rate of 97.2%. Although only one IBTR was observed after PMRT, there was no statistical difference in the 5-year IBTR-free rate (PMRT vs. no PMRT, 98.6% vs. 97.0%, p = 0.360). Multivariable analyses demonstrated that age ≤45 years and lymphovascular invasion (LVI) were adverse features of IBTR. The low-risk group (0 risk factor) showed a better 5-year IBTR-free rate than the high-risk group (≥1 risk factor) (100.0% vs. 95.8%, p = 0.003). In the high-risk group, PMRT slightly improved 5-year IBTR-free rate compared with no PMRT (98.6% vs. 95.2%, p = 0.166). In addition, PMRT increased 5-year cumulative incidence of reconstruction failure (10.0% vs. 2.8%, p = 0.001).

Conclusion

We identified risk factors (age and LVI) related to IBTR following upfront SSM/NSM with pT1-2 disease. As a hypothesis-generating study, de-escalation of PMRT by omitting chest wall irradiation in selective patients could improve reconstruction-related complications without compromising oncologic outcomes.

 

 

 

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

Breast Surgery Bulletin - March 2022

 

Local treatment options for young women with ductal carcinoma in situ: A systematic review and meta-analysis comparing breast conserving surgery with or without adjuvant radiotherapy, and mastectomy

 

by Ju-Chun Chien, Wen-Shan Liu, Wei-Tzu Huang, Liang-Chung Shih, Wen-Chung Liu, Yu-Chia Chen, Kang-Ju Chou, Yow-Ling Shiue, Pei-Chin Lin 

 

The Breast: VOLUME 63, P29-36, JUNE 01, 2022

 

 

Purpose

Young age is associated with poor prognosis in ductal carcinoma in situ (DCIS) of female breast and controversy exists regarding the optimal treatment modality for young patients. We aimed to compare treatment outcomes among breast conserving surgery (BCS), BCS with adjuvant radiotherapy (BCS + RT), and total mastectomy (MT) for young DCIS women.

Methods

PubMed, Cochrane, and Embase were searched for studies reporting comparative results among BCS, BCS + RT, or MT in ≤50 years old (y/o) DCIS females. Study quality was assessed and meta-analysis with subgroup analysis was performed to pool the effect sizes of the outcomes-of-interest.

Results

We included 3 randomized control trials and 18 observational studies. For DCIS women ≤50 y/o, RT following BCS significantly reduced the risk for ipsilateral breast tumor recurrence (IBTR) (HR = 0.66, 95% CI 0.50–0.87). However, the benefit was less robust in extremely young patients and with long follow-ups. RT revealed no statistically significant preventive effect on ipsilateral invasive recurrence (HR = 1.38, 95% CI 0.98–1.94). On the other hand, MT yielded the lowest IBTR (BCS + RT vs MT: HR = 4.4, 95% CI 2.06–9.40), both in ipsilateral DCIS recurrence and ipsilateral invasive recurrence. There was great heterogeneity and could not reach an evident conclusion concerning survival outcomes.

Conclusion

This study highlighted the varying effect of RT for young DCIS females. The local control benefit of MT was definite without survival differences observed. Our study provided a moderate certainty of evidence to guide the treatment for young DCIS women. Further age-specific prospective trial is warranted.

 

Survival outcomes after breast-conserving therapy compared with mastectomy for patients with early-stage metaplastic breast cancer: a population-based study of 2412 patients

 

Survival outcomes after breast-conserving therapy compared with mastectomy for patients with early-stage metaplastic breast cancer: a population-based study of 2412 patients

by Junsheng Zhang, Ciqiu Yang, Chuqian Lei, Yi Zhang, Fei Ji, Hongfei Gao, Mei Yang, Liulu Zhang, Jieqing Li, Teng Zhu, Weiping Li, Xiaosheng Zhuang, Kun Wang 

The Breast: Published: March 31, 2021

Background

Previous studies revealed that patients with early-stage metaplastic breast cancer (MBC) underwent mastectomy more often than breast-conserving therapy (BCT) mainly due to the larger tumor size. This study was performed to compare the survival outcomes following BCT versus mastectomy for patients with early-stage MBC.

Methods

Surveillance, Epidemiology, and End Results (SEER) database was used to identify women diagnosed with early-stage MBC (T1-3N0-3M0) between 2001 and 2016, who were treated with either BCT or mastectomy. We assessed overall survival (OS) and breast cancer-specific survival (BCSS) using the Kaplan-Meier method and hazard ratios using Cox proportional hazards models.

Results

A total of 2412 MBC patients were identified, 881 (36.5%) of whom underwent BCT and 1531(63.5%) underwent mastectomy. The median follow-up time was 73 months. Most of patients had older age (≥50 years old), larger tumor size, higher American Joint Committee on Cancer (AJCC) stage and hormone receptor negativity. After adjustment for confounding variables, patients who underwent BCT had significantly improved OS (5-year OS: 84.3% vs 62.5%; 10-year OS: 73.0% vs 52.1%; adjusted HR=0.76, 95%CI: 0.59-0.97, p=0.028) and BCSS (5-year BCSS: 89.1% vs 70.8%; 10-year BCSS: 83.9% vs 67.5%; adjusted HR=0.72, 95%CI: 0.53-0.96, p=0.026) than those who underwent mastectomy, and this improvement remained significant for all T and N stages of MBC except for N2-3 stage.

Conclusion

BCT conferred improved OS and BCSS compared with mastectomy for patients with early-stage MBC, and the improvement persisted in almost all of the subgroups of different T and N stages.

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.

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.

Residual Breast Tissue After Robot-Assisted Nipple Sparing Mastectomy

 

Residual Breast Tissue After Robot-Assisted Nipple Sparing Mastectomy

 

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

 

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

 

Highlights

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

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

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Should we worry about residual disease after mastectomy?

Should we worry about residual disease after mastectomy?

by Orit Kaidar-Person, Thorsten Kühn, Philip Poortmans 

The Lancet Oncology: volume 21, issue 8, p1001-1013. August 01, 2020

Breast cancer is the most frequently diagnosed cancer in women, accounting for 30% of new cancer cases, and leads to the highest proportion (15%) of cancer deaths.1 Surgical resection is the cornerstone of treatment with curative intent for patients with non-metastatic breast cancer, within comprehensive treatment from an integrated multidisciplinary team. The aim of resection is to remove all neoplastic tissue in the breast (both invasive cancer and ductal carcinoma in situ [DCIS]), to reduce the risk of further disease spread, including local and distant recurrence.

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

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.

Survival and Disease Recurrence Rates among Breast Cancer Patients following Mastectomy with or without Breast Reconstruction

Survival and Disease Recurrence Rates among Breast Cancer Patients following Mastectomy with or without Breast Reconstruction

by Siotos, Charalampos; Naska, Androniki; Bello, Ricardo J.; Uzosike, Akachimere; Orfanos, Philippos; Euhus, David M.; Manahan, Michele A.; Cooney, Carisa M.; Lagiou, Pagona; Rosson, Gedge D.

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 169e-177e

Background: Concerns have been expressed about the oncologic safety of breast reconstruction following mastectomy for breast cancer. This study aimed to evaluate the association of breast reconstruction with breast cancer recurrence, and 5-year survival among breast cancer patients. Methods: The authors analyzed data from The Johns Hopkins Hospital comprehensive cancer registry, comparing mastectomy-only to postmastectomy breast reconstruction in breast cancer patients to evaluate differences in breast cancer recurrence and 5-year survival. Kaplan-Meier curves were used to compare unadjusted estimates of survival or disease recurrence. Data were modeled through Cox proportional hazards regression, using as outcomes time to death from any cause or time to cancer recurrence.

Results: The authors analyzed data on 1517 women who underwent mastectomy for breast cancer at The Johns Hopkins hospital between 2003 and 2015. Of these, 504 (33.2 percent) underwent mastectomy only and 1013 (66.8 percent) underwent mastectomy plus immediate breast reconstruction. Women were followed up for a median of 5.1 years after diagnosis. There were 132 deaths and 100 breast cancer recurrences. A comparison of Kaplan-Meier survival estimates demonstrated a survival benefit among patients undergoing mastectomy plus reconstruction. After adjusting for various clinical and socioeconomic variables, there was still an overall survival benefit associated with breast reconstruction which, however, was not statistically significant (hazard ratio, 0.78; 95 percent CI, 0.53 to 1.13). Patients who underwent reconstruction had a similar rate of recurrence compared to mastectomy-only patients (hazard ratio, 1.08; 95 percent CI, 0.69 to 1.69). 

Conclusion: This study suggests that breast reconstruction does not have a negative impact on either overall survival or breast cancer recurrence rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reducing seroma formation and its sequelae after mastectomy by closure of the dead space: The interim analysis of a multi-center, double-blind randomized controlled trial (SAM trial)

Reducing seroma formation and its sequelae after mastectomy by closure of the dead space: The interim analysis of a multi-center, double-blind randomized controlled trial (SAM trial)

The Breast: August 2019 Volume 46, Pages 81–86

by Renée W.Y. Granzier, James van Bastelaar, Sander M.J. van Kuijk, Kim F.H. Hintzen, Cathelijne Heymans, Lotte L.B. Theunissen, Els R.M. van Haaren, Alfred Janssen, Geerard L. Beets, Yvonne L.J. Vissers

The main objective of this double-blind randomized controlled trial (RCT) was to assess seroma formation and its sequelae in patients undergoing mastectomy. Patients were randomized into one of three groups in which different wound closure techniques were applied: 1) conventional wound closure without flap fixation (CON) 2) flap fixation using sutures (FF–S) and 3) flap fixation using an adhesive tissue glue (FF-G).

Current knowledge of risk reducing mastectomy: Indications, techniques, results, benefits, harms

Current knowledge of risk reducing mastectomy: Indications, techniques, results, benefits, harms

The Breast: August 2019 Volume 46, Pages 48–51

by Andrew D. Baildam 

The last twenty years have seen a complete change in society's attitude to the strategy of risk reduction of breast cancer in high-risk individuals by means of proactive mastectomy. Once termed ‘prophylactic mastectomy’, risk reducing mastectomy (RRM) was considered two decades ago not only extreme, but in some quarters almost unethical. RRM is now commonly undertaken in specialist breast units for women at high individual breast cancer risk, by virtue of an inherited breast cancer related gene mutation or from calculated high statistical risk from family history data, and the efficacy of RRM in reducing subsequent incident diagnoses of breast cancer has been published from a number of centres.

Is There a Preferred Incision Location for Nipple-Sparing Mastectomy? A Systematic Review and Meta-Analysis

Is There a Preferred Incision Location for Nipple-Sparing Mastectomy? A Systematic Review and Meta-Analysis

Plastic and Reconstructive Surgery:  May 2019 - Volume 143 - Issue 5 - p 906e–919e

Background: The incidence of nipple-sparing mastectomy is rising, but no single incision type has been proven to be superior. This study systematically evaluated the rate and efficacy of various nipple-sparing mastectomy incision locations, focusing on nipple-areola complex necrosis and reconstructive method.

Methods: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines identifying studies on nipple-sparing mastectomy where incision type was described. Pooled descriptive statistics meta-analysis of overall (nipple-areola complex) necrosis rate and nipple-areola complex necrosis by incision type was performed.

Results: Fifty-one studies (9975 nipple-sparing mastectomies) were included. Thirty-two incision variations were identified and categorized into one of six groups: inframammary fold, radial, periareolar, mastopexy/prior scar/reduction, endoscopic, and other. The most common incision types were inframammary fold [3634 nipple-sparing mastectomies (37.8 percent)] and radial [3575 nipple-sparing mastectomies (37.2 percent)]. Meta-analysis revealed an overall partial nipple-areola complex necrosis rate of 4.62 percent (95 percent CI, 3.14 to 6.37 percent) and a total nipple-areola complex necrosis rate of 2.49 percent (95 percent CI, 1.87 to 3.21 percent). Information on overall nipple-areola complex necrosis rate by incision type was available for 30 of 51 studies (4645 nipple-sparing mastectomies). Periareolar incision had the highest nipple-areola complex necrosis rate (18.10 percent). Endoscopic and mastopexy/prior scar/reduction incisions had the lowest rates of necrosis at 4.90 percent and 5.79 percent, respectively, followed by the inframammary fold incision (6.82 percent). The rate of single-stage implant reconstruction increased during this period. Conclusions: For nipple-sparing mastectomy, the periareolar incision maintains the highest necrosis rate because of disruption of the nipple-areola complex blood supply. The inframammary fold incision has become the most popular incision, demonstrating an acceptable complication profile.

Predictable Location of Breast Sensory Nerves for Breast Reinnervation

Predictable Location of Breast Sensory Nerves for Breast Reinnervation

 by Knackstedt, Rebecca; Gatherwright, James; Cakmakoglu, Cagri; Djohan, Michelle; Djohan, Risal  

Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 393–396

Summary: The sensory innervation to the breast originates from the medial and lateral cutaneous branches of the third to fifth intercostal nerves, which are at risk for injury or loss during mastectomy. Providing reinnervation after mastectomy was introduced almost 20 years ago, but it is not widely performed, perhaps because of the difficulty of locating a recipient nerve. The authors have performed cadaveric dissections to allow for precise anatomical localization of the lateral intercostal branch providing breast sensation. Bilateral chest dissections were performed on 10 female cadavers. The lateral intercostal nerve providing sensation to breast tissue was identified. The distances from the sternum, the midclavicular line, and the lateral pectoralis minor—in addition to nerve diameter—were measured. The nerve was successfully identified bilaterally in all cadavers. The majority of nerves (16 of 20) exited from under the fourth rib. The average distance from the sternum was 13.1 ± 1.3 cm (range, 10 to 15 cm) and the average distance from the midclavicular line was 11.8 ± 2.2 cm (range, 8 to 16 cm). The nerve exited at the lateral border of the pectoralis minor or within 2 cm from the lateral border for all cadavers. The diameter of the nerve was consistently 2 mm. The nerve traveled under the thoracodorsal vessels, aiding in identification. The authors identified the predictable location of the lateral intercostal nerve providing sensation to the breast. The authors hope that by enabling surgeons to locate this nerve, more well-conducted studies will be performed investigating techniques and outcomes for breast reinnervation.

Sexuality, a topic that surgeons should discuss with women before risk-reducing mastectomy and breast reconstruction

Sexuality, a topic that surgeons should discuss with women before risk-reducing mastectomy and breast reconstruction

 by Rieky E.G. Dikmans, Tim C. van de Grift, Mark-Bram Bouman, Andrea L. Pusic, Margriet G. Mullender

The Breast: February 2019, Volume 43, Pages 120-122

While sexual health is an important aspect of quality of life, sexual issues usually go unaddressed during patient-provider communication. Breast cancer treatments and specifically breast surgery impact women's sexual well-being. However, women do not receive adequate information on this subject. Women who underwent prophylactic mastectomy and breast reconstruction invariably reported that they had underestimated the impact of mastectomy and reconstruction on their sexuality, and expressed a need for information and creating realistic expectations pertaining to sexuality.

[Articles] Short-term safety outcomes of mastectomy and immediate implant-based breast reconstruction with and without mesh (iBRA): a multicentre, prospective cohort study

[Articles] Short-term safety outcomes of mastectomy and immediate implant-based breast reconstruction with and without mesh (iBRA): a multicentre, prospective cohort study

 by Shelley Potter, Elizabeth J Conroy, Ramsey I Cutress, Paula R Williamson, Lisa Whisker, Steven Thrush, Joanna Skillman, Nicola L P Barnes, Senthurun Mylvaganam, Elisabeth Teasdale, Abhilash Jain, Matthew D Gardiner, Jane M Blazeby, Chris Holcombe, iBRA Steering Group, Breast Reconstruction Research Collaborative  

The Lancet Oncology: Volume 20, issue 2, P254-266, February 01, 2019

Complications after immediate implant-based breast reconstruction are higher than recommended by national standards. A randomised clinical trial is needed to establish the optimal approach to immediate implant-based breast reconstruction.

The Use of Tumescent Technique in Mastectomy and Related Complications: A Meta-Analysis

by Siotos, Charalampos; Aston, Jeffrey W.; Euhus, David M.; Seal, Stella M.; Manahan, Michele A.; Rosson, Gedge D

Plastic and Reconstructive Surgery: January 2019 - Volume 143 - Issue 1 - p 39–48

Background: Postoperative skin necrosis in surgical patients is costly to hospitals and health care providers. Tumescent dissection technique is commonly used in mastectomy and immediate breast reconstruction, as it helps reduce blood loss; however, it may increase the risk of mastectomy skin flap necrosis. In this context, the authors have conducted a systematic review of the literature to perform a meta-analysis of the relationship between tumescent technique in mastectomy with or without breast reconstruction and complication rates.

Methods: The authors screened the PubMed (1966 to 2016), Scopus (2004 to 2016), Embase (1966 to 2016), and Web of Science (1964 to 2016) databases for relevant articles through March 30, 2017. The authors included studies on the use of tumescent technique in the context of mastectomy with or without immediate breast reconstruction. The primary outcome the authors evaluated was the rate of skin flap necrosis; the secondary outcomes were the rates of breast hematomas and infections. Because of the heterogeneity of the studies, the authors performed a meta-analysis using the random effects model.

Results: After screening, the authors evaluated five studies including 3982 mastectomies. Mastectomies performed under the preoperative application of tumescent solution had statistically higher rates of skin flap necrosis overall (p = 0.03) and major (p < 0.01) and minor skin necrosis (p = 0.03). However, the rates of hematoma and infection were not correlated with the use of tumescent technique.

Conclusions: The authors’ systematic review of the literature provides a better understanding of the consequences of the application of tumescent technique in mastectomy. The authors’ findings suggest that tumescent technique may increase the risk of skin necrosis in mastectomy with or without breast reconstruction.

Incision Choices in Nipple-Sparing Mastectomy: A Comparative Analysis of Outcomes and Evolution of a Clinical Algorithm

Incision Choices in Nipple-Sparing Mastectomy: A Comparative Analysis of Outcomes and Evolution of a Clinical Algorithm

by Frey, Jordan D.; Salibian, Ara A.; Levine, Jamie P.; Karp, Nolan S.; Choi, Mihye  

Plastic and Reconstructive Surgery: December 2018 - Volume 142 - Issue 6 - p 826e–835e

Background: Nipple-sparing mastectomy allows for preservation of the entire nipple-areola complex using various incision patterns. Reconstructive trends and overall risk associated with these diverse nipple-sparing mastectomy incisions have yet to be fully elucidated.

Methods: All nipple-sparing mastectomies from 2006 to 2017 were identified; outcomes were stratified by type of mastectomy incision: lateral or vertical radial, inframammary fold, Wise pattern, previous, and periareolar.

Results: A total of 1207 nipple-sparing mastectomies were included for final analysis. Of these, 638 (52.9 percent) used an inframammary fold incision, 294 (24.4 percent) used a lateral radial incision, 161 (13.3 percent) used a vertical radial incision, 60 (5.0) used a Wise pattern incision, 35 (2.9 percent) used a previous incision, and 19 (1.6 percent) used a periareolar incision. The groups were heterogeneous and differed significantly with regard to various factors, including age (p < 0.001), body mass index (p < 0.001), reconstruction modality (p < 0.001), and others. In crude multivariate logistic regression analysis, vertical radial (16.1 percent) and inframammary fold incisions (21.0 percent) were associated with lower overall complication rates. In a reduced multivariate logistic regression model, inframammary fold incisions (p = 0.001) emerged as significantly protective of overall complications after controlling all variables.

Conclusions: Nipple-sparing mastectomy may be safely performed using various mastectomy incisions, each with unique advantages and limitations. Overall, inframammary fold incisions appear to be associated with the lowest risk, whereas Wise pattern incisions may increase risk. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Novel Approach for Risk-Reducing Mastectomy: First-Stage Implant Placement and Subsequent Second-Stage Mastectomy

Novel Approach for Risk-Reducing Mastectomy: First-Stage Implant Placement and Subsequent Second-Stage Mastectomy

 by Lim, Geok Hoon; Baildam, Andrew D.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 607–610

Background: Risk-reducing mastectomy with tissue expander and then implant-based breast reconstruction conventionally involved immediate submuscular placement of tissue expanders during mastectomy and then, after expansion, replacement of expanders for permanent implants in a second-stage operation. Use of acellular dermal matrix can achieve a single-stage operation; however, acellular dermal matrices are costly and may have potential complications. The authors aim to assess the feasibility of placement of implants as a first-stage procedure before risk-reducing mastectomy as a novel technique of reconstruction that avoids the need for serial outpatient expansion and acellular dermal matrix.

Methods: Patients for whom risk-reducing mastectomy was planned were offered first-stage dual-plane placement of fixed volume silicone gel permanent implants by means of inframammary fold incisions. Risk-reducing mastectomy was undertaken several months later as the second operation, leaving the implants in place protected by the muscle and capsule pocket. Nipples were preserved or reconstructed according to the patient’s choice.

Results: Eight patients with 15 operated breasts were recruited. Anatomically shaped implants were used in all patients, and complete coverage of each implant was achieved. Mean implant volume was 433 ml (range, 290 to 545 ml). There were no complications, and good aesthetic outcomes were achieved.

Conclusions: This proof-of-principle study finds that placement of implants before risk-reducing mastectomy is a novel technique for women at high breast cancer risk that could reduce the use of tissue expanders and acellular dermal matrices and their associated problems. Two-stage risk-reducing mastectomy with first-stage implant placement and subsequent risk-reducing mastectomy leaving the implants in place is feasible, with no complications, and can produce a good cosmetic outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.