[News] Promising radiotherapy classifier for early breast cancer

[News] Promising radiotherapy classifier for early breast cancer

by Manjulika Das 

The Lancet Oncology: NEWS| VOLUME 20, ISSUE 12, PE665, DECEMBER 01, 2019

A gene expression-based Adjuvant Radiotherapy Intensification Classifier (ARTIC) could differentiate between patients with early breast cancer who would benefit from whole-breast radiotherapy following breast-conserving surgery and those with a higher risk of locoregional recurrence who need more intensive treatment, according to a recent study.

Analysis of the Visual Perception of Female Breast Aesthetics and Symmetry: An Eye-Tracking Study

Analysis of the Visual Perception of Female Breast Aesthetics and Symmetry: An Eye-Tracking Study

by Pietruski, Piotr; Paskal, Wiktor; Paskal, Adriana M.; Jaworowski, Janusz; Paluch, Lukasz; Noszczyk, Bartlomiej

Plastic and Reconstructive Surgery: December 2019 - Volume 144 - Issue 6 - p 1257-1266

Background: Because of its subjective character, the term “breast attractiveness” is poorly defined and thus its reliable standardized assessment can be particularly challenging. Because of objective analysis of the observer’s gaze pattern, eye-tracking technology may provide a better insight into the visual perception of breast aesthetics and symmetry.

Methods: One hundred observers, 50 women and 50 men, assessed the aesthetics and symmetry of eight types of female breasts displayed as digital images on frontal, lateral, and oblique projections. The gaze pattern of each observer was recorded using eye-tracking technology, and gaze data were subsequently analyzed.

Results: Although sex and breast type exerted an effect on attention capturing by some areas of interest, key characteristics of gaze patterns in female and male observers were essentially the same. Irrespective of observers’ sex, the longest fixation duration and the highest fixation number were recorded for lower breast regions, in particular, for the nipple-areola complex. Mean fixation duration in this area corresponded to 58 and 57 percent of overall observation time for female and male observers, respectively, during the assessment of breast aesthetics; and to 56 and 52 percent of overall observation time for female and male observers, respectively, during the assessment of breast symmetry.

Conclusions: Nipple-areola complex and lower breast are key focus areas for the assessment of breast aesthetics and symmetry. Gaze data collected during this study may constitute a valuable source of reference values for future eye-tracking research on various patient groups’ visual perception of breast attractiveness and deformities.

Associations between absolute neutrophil count and lymphocyte-predominant breast cancer

Associations between absolute neutrophil count and lymphocyte-predominant breast cancer

by Chang Ik Yoon, Soeun Park, Yoon Jin Cha, Hye Sun Lee, Soong June Bae, Chihwan Cha, Da Young Lee, Sung Gwe Ahn, Joon Jeong

The Breast, https://doi.org/10.1016/j.breast.2019.09.013

Tumor-infiltrating lymphocytes (TILs) might be associated with host-cell mediated immunity, which could be partly reflected by peripheral blood cell counts. In addition, lymphocyte-predominant breast cancer (LPBC), which was defined as tumors having high TIL levels, showed a favorable prognosis among triple-negative breast cancer or HER2-positive breast cancer. We aimed to investigate whether peripheral blood cell counts are associated with LPBC.

Effect of implementing digital breast tomosynthesis (DBT) instead of mammography on population screening outcomes including interval cancer rates: Results of the Trento DBT pilot evaluation

Effect of implementing digital breast tomosynthesis (DBT) instead of mammography on population screening outcomes including interval cancer rates: Results of the Trento DBT pilot evaluation

by Daniela Bernardi, Maria A. Gentilini, Martina De Nisi, Marco Pellegrini, Carmine Fantò, Marvi Valentini, Vincenzo Sabatino, Andrea Luparia, Nehmat Houssami

The Breast, (in press) 2019.09.12

The Trento screening program transitioned to digital breast tomosynthesis (DBT) screening based on evidence that DBT improves breast cancer (BC) detection compared to mammography; an evaluation of the transition to DBT is reported in this pilot study.

Immediate Breast Reconstruction in The Netherlands and the United States: A Proof-of-Concept to Internationally Compare Quality of Care Using Cancer Registry Data

Immediate Breast Reconstruction in The Netherlands and the United States: A Proof-of-Concept to Internationally Compare Quality of Care Using Cancer Registry Data

by Kamali, Parisa; van Bommel, Annelotte; Becherer, Babette; Cooter, Rodney; Mureau, Marc A. M.; Pusic, Andrea; Siesling, Sabine; van der Hulst, René R. J. W.; Lin, Samuel J.; Rakhorst, Hinne

Plastic and Reconstructive Surgery: October 2019 - Volume 144 - Issue 4 - p 565e-574e

Background: Studies based on large-volume databases have made significant contributions to research on breast cancer surgery. To date, no comparison between large-volume databases has been made internationally. This is the first proof-of-concept study exploring the feasibility of combining two existing operational databases of The Netherlands and the United States, focusing on breast cancer care and immediate breast reconstruction specifically.313/291

Methods: The National Breast Cancer Organization The Netherlands Breast Cancer Audit (NBCA) (2011 to 2015) and the U.S. Surveillance, Epidemiology, and End Results (SEER) database (2010 to 2013) were compared on structure and content. Data variables were grouped into general, treatment-specific, cancer-specific, and follow-up variables and were matched. As proof-of-concept, mastectomy and immediate breast reconstruction rates in patients diagnosed with invasive breast cancer or ductal carcinoma in situ were analyzed.

Results: The NBCA included 115 variables and SEER included 112. The NBCA included significantly more treatment-specific variables (n = 46 versus 6), whereas the SEER database included more cancer-specific variables (n = 74 versus 26). In patients diagnosed with breast cancer or ductal carcinoma in situ, immediate breast reconstruction was performed in 19.3 percent and 24.0 percent of the breast cancer cohort and 44.0 percent and 35.3 percent of the ductal carcinoma in situ cohort in the NBCA and SEER, respectively. Immediate breast reconstruction rates increased significantly over time in both data sets.

Conclusions: This study provides a first overview of available registry data on breast cancer care in The Netherlands and the United States, and revealed limited data on treatment in the United States. Comparison of treatment patterns of immediate breast reconstruction showed interesting differences. The authors advocate the urgency for an international database with alignment of (treatment) variables to improve quality of breast cancer care for patients across the globe.

[Articles] Endocrine treatment versus chemotherapy in postmenopausal women with hormone receptor-positive, HER2-negative, metastatic breast cancer: a systematic review and network meta-analysis

[Articles] Endocrine treatment versus chemotherapy in postmenopausal women with hormone receptor-positive, HER2-negative, metastatic breast cancer: a systematic review and network meta-analysis

The Lancet Oncology by Mario Giuliano, Francesco Schettini, Carla Rognoni, Manuela Milani, Guy Jerusalem, Thomas Bachelot, Michelino De Laurentiis, Guglielmo Thomas, Pietro De Placido, Grazia Arpino, Sabino De Placido, Massimo Cristofanilli, Antonio Giordano, Fabio Puglisi, Barbara Pistilli, Aleix Prat, Lucia Del Mastro, Sergio Venturini, Daniele Generali

ARTICLES| VOLUME 20, ISSUE 10, P1360-1369, OCTOBER 01, 2019

In the first-line or second-line setting, CDK4/6 inhibitors plus hormone therapies are better than standard hormone therapies in terms of progression-free survival. Moreover, no chemotherapy regimen with or without targeted therapy is significantly better than CDK4/6 inhibitors plus hormone therapies in terms of progression-free survival. Our data support treatment guideline recommendations involving the new combinations of hormone therapies plus targeted therapies as first-line or second-line treatments, or in both settings, in women with hormone-receptor-positive, HER2-negative metastatic breast cancer.

[News] Pyrotinib versus lapatinib in HER2-positive breast cancer

[News] Pyrotinib versus lapatinib in HER2-positive breast cancer

The Lancet Oncology by Elizabeth Gourd 

NEWS| VOLUME 20, ISSUE 10, PE562, OCTOBER 01, 2019

Patients with previously treated HER2-positive relapsed or metastatic breast cancer have significantly better outcomes when treated with pyrotinib plus capecitabine than with lapatinib plus capecitabine, according to a recent study.

A Simplified Cost-Utility Analysis of Inpatient Flap Monitoring after Microsurgical Breast Reconstruction and Implications for Hospital Length of Stay

A Simplified Cost-Utility Analysis of Inpatient Flap Monitoring after Microsurgical Breast Reconstruction and Implications for Hospital Length of Stay

by Jablonka, Eric M.; Lamelas, Andreas M.; Kanchwala, Suhail K.; Rhemtulla, Irfan; Smith, Mark L

Plastic and Reconstructive Surgery: October 2019 - Volume 144 - Issue 4 - p 540e-549e

Background: The number of free flap take-backs and successful salvages following microsurgical breast reconstruction decreases as time from surgery increases. As a result, the cost of extended inpatient monitoring to achieve a successful flap salvage rises rapidly with each postoperative day. This study introduces a simplified cost-utility model of inpatient flap monitoring and identifies when cost-utility exceeds the thresholds established for other medical treatments.

Methods: A retrospective review of a prospectively maintained database was performed of patients who underwent microsurgical breast reconstruction to identify flap take-back and salvage rates by postoperative day. The number of patients and flaps that needed to be kept on an inpatient basis each day for monitoring to salvage a single failing flap was determined. Quality-of-life measures and incremental cost-effectiveness ratios for inpatient flap monitoring following microsurgical breast reconstruction were calculated and plotted against a $100,000/quality-adjusted life-year threshold. Results: A total of 1813 patients (2847 flaps) were included. Overall flap take-back and salvage rates were 2.4 percent and 52.3 percent, respectively. Of the flaps taken back, the daily take-back and salvage rates were 56.8 and 60.0 percent (postoperative day 0 to 1), 13.6 and 83.3 percent (postoperative day 2), 11.4 and 40.0 percent (postoperative day 3), 9.1 and 25.0 percent (postoperative day 4), and 9.1 and 0.0 percent (>postoperative day 4), respectively. To salvage a single failing flap each day, the number of flaps that needed to be monitored were 121 (postoperative day 0 to 1), 363 (postoperative day 2), 907 (postoperative day 3), 1813 (postoperative day 4), and innumerable for days beyond postoperative day 4. The incremental cost-effectiveness ratio of inpatient flap monitoring begins to exceed a willingness-to-pay threshold of $100,000/quality-adjusted life-year by postoperative day 2.

Conclusion: The health care cost associated with inpatient flap monitoring following microsurgical breast reconstruction begins to rise rapidly after postoperative day 2.

Bilateral DIEP Flap Breast Reconstruction to a Single Set of Internal Mammary Vessels: Technique, Safety, and Outcomes after 250 Flaps

Bilateral DIEP Flap Breast Reconstruction to a Single Set of Internal Mammary Vessels: Technique, Safety, and Outcomes after 250 Flaps

by Opsomer, Dries; D’Arpa, Salvatore; Benmeridja, Lara; Stillaert, Filip; Noel, Warren; Van Landuyt, Koenraad 

Plastic and Reconstructive Surgery: October 2019 - Volume 144 - Issue 4 - p 554e-564e

Background: The deep inferior epigastric artery perforator (DIEP) flap is considered the gold standard in autologous breast reconstruction. In bilateral cases, both flaps are often anastomosed to the internal mammary vessels on either side of the sternum. The authors propose a method in which both flaps are anastomosed to only the right side internal mammary artery and vein.

Methods: Between November of 2009 and March of 2018, 125 patients underwent bilateral DIEP flap breast reconstruction with this technique. One flap is perfused by the anterograde proximal internal mammary artery and the second one by the retrograde distal internal mammary artery after presternal tunneling. Patient demographics and operative details were reviewed retrospectively. Results: Two hundred fifty flaps were performed. One hundred fifty-two flaps were prophylactic or primary reconstructions (60.8 percent), 70 were secondary reconstructions (28 percent), and 28 were tertiary reconstructions (11.2 percent). Mean patient age was 46 years, and the mean body mass index was 25 kg/m2. Sixty patients underwent radiation therapy or chemotherapy (48 percent). The authors encountered one significant partial failure (0.4 percent) and nine complete flap failures (3.6 percent). The authors did not see a statistically significant predisposition for failure comparing the retrograde with the anterograde flow flaps, nor when comparing the tunneled with the nontunneled flaps.

Conclusions: The authors’ results show that anastomosing both DIEP flaps to a single set of mammary vessels is safe and reliable. The authors conclude that the retrograde flow through the distal internal mammary artery is sufficient for free flap perfusion and that subcutaneous tunneling of a free flap pedicle does not predispose to flap failure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Benchmarking the Outcomes of Single-Stage Augmentation Mastopexy against Primary Breast Augmentation: A Single Surgeon’s Experience of 905 Consecutive Cases

Benchmarking the Outcomes of Single-Stage Augmentation Mastopexy against Primary Breast Augmentation: A Single Surgeon’s Experience of 905 Consecutive Cases

by Montemurro, Paolo; Cheema, Mubashir; Hedén, Per; Behr, Björn; Wallner, Christoph 

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 326-334

Background: Augmentation mastopexy may be a one- or two-stage procedure. Because of the opposing force vectors in augmentation and in mastopexy, some surgeons advocate a two-stage procedure. The literature appears divided on which operation has a more favorable complication profile. The purpose of this review was to benchmark the outcomes of single-stage augmentation mastopexy against those of a commonly performed aesthetic breast operation (primary breast augmentation).

Methods: The authors reviewed electronic patient records of all consecutive female patients who underwent single-stage augmentation mastopexy and primary breast augmentation performed by the first author at our clinic between April of 2009 and May of 2017 with at least a 6-month follow-up. Data from single-stage augmentation mastopexy were benchmarked against the outcomes of primary breast augmentations performed by the same surgeon, for the same period, and at the same clinic.

Results: One hundred four single-stage augmentation mastopexies and 801 primary breast augmentations were performed during this period, with mean follow-up of 15.4 months and 14.0 months, respectively. Augmentation mastopexy patients were significantly more likely to be older, have a higher body mass index, have more children, and were significantly less likely to use oral contraceptives. There was no statistically significant difference in overall complication rate between the two groups.

Conclusions: The authors’ experience suggests that single-stage augmentation mastopexy has outcomes comparable to those of primary breast augmentation. Smokers were more likely to undergo reoperation because of postoperative complication (seroma), but the rate of implant exchange was not different. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Fat Grafting and the Palpable Breast Mass in Implant-Based Breast Reconstruction: Incidence and Implications

Fat Grafting and the Palpable Breast Mass in Implant-Based Breast Reconstruction: Incidence and Implications

by Knackstedt, Rebecca W.; Gatherwright, James; Ataya, Dana; Duraes, Eliana F. R.; Schwarz, Graham S. 

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 265-275

Background: Fat grafting is a powerful and increasingly used technique in breast reconstruction. However, fat necrosis can lead to palpable postoperative changes that can induce anxiety and lead to unplanned diagnostic studies. The authors’ aim in this study was to evaluate the incidence, type, and timing of these unanticipated studies; the specialty of the ordering provider; and the factors that trigger the ordering process.

Methods: A retrospective chart review was conducted for patients from 2006 to 2015 who underwent fat grafting as part of implant-based breast cancer reconstruction and had at least 1-year follow-up after fat grafting.

Results: From 2006 to 2015, 166 patients underwent fat grafting as part of implant-based breast reconstruction. Forty-four women (26.5 percent) underwent at least one imaging procedure. Thirteen women (7.8 percent) underwent 17 biopsies. For a palpable mass, the initial imaging test most commonly ordered was ultrasound, followed by mammography/ultrasound. The percentage of patients with a diagnosis of fat necrosis on mammography, ultrasound, and biopsy was 4.2, 12.7, and 5.4 percent, respectively. Seven patients (4.2 percent) had distant metastases. Tissue diagnosis of local recurrence was never identified. Mean follow-up was 2.4 years.

Conclusions: Fat-grafting sequelae may lead to early unplanned invasive and noninvasive procedures initiated by a variety of providers. In this study, fat grafting had no impact on local recurrence rate. As use of fat grafting grows, communication among breast cancer care providers and enhanced patient and caregiver education will be increasingly important in optimizing the multidisciplinary evaluation and monitoring of palpable breast lesions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Reducing Expansion Visits in Immediate Implant-Based Breast Reconstruction: A Comparative Study of Prepectoral and Subpectoral Expander Placement

Reducing Expansion Visits in Immediate Implant-Based Breast Reconstruction: A Comparative Study of Prepectoral and Subpectoral Expander Placement

by Wormer, Blair A.; Valmadrid, Al C.; Ganesh Kumar, Nishant; Al Kassis, Salam; Rankin, Timothy M.; Kaoutzanis, Christodoulos; Higdon, Kent K.

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 276-286

Background: The numerous office visits required to complete expansion in implant-based breast reconstruction impact patient satisfaction, office resources, and time to complete reconstruction. This study aimed to determine whether prepectoral compared to subpectoral immediate implant-based breast reconstruction offers expedited tissue expansion without affecting complication rates.

Methods: Consecutive patients who underwent immediate implant-based breast reconstruction with tissue expanders from January of 2016 to July of 2017 by a single surgeon were grouped into subpectoral (partial submuscular/partial acellular dermal matrix) or prepectoral (complete acellular dermal matrix coverage), and reviewed. The primary outcomes were total days and number of visits to complete expansion. Groups were compared by univariate analysis with significance set at p < 0.05.

Results: In total, 101 patients (subpectoral, n = 69; prepectoral, n = 32) underwent 184 immediate implant-based breast reconstructions (subpectoral, n = 124; prepectoral, n = 60). There was no difference in age, body mass index, smoking, or diabetes between the groups (all p > 0.05). Follow-up was similar between groups (179.3 ± 98.2 days versus 218.3 ± 119.8 days; p = 0.115). Prepectoral patients took fewer days to complete expansion (40.4 ± 37.8 days versus 62.5 ± 50.2 days; p < 0.001) and fewer office visits to complete expansion (2.3 ± 1 .7 versus 3.9 ± 1.8; p < 0.001), and were expanded to greater final volumes than subpectoral patients (543.7 ± 122.9 ml versus 477.5 ± 159.6 ml; p = 0.017). Between prepectoral and subpectoral reconstructions, there were similar rates of minor complications (25 percent versus 18.5 percent; p = 0.311), readmissions (5 percent versus 2.4 percent; p = 0.393), seromas (8.3 percent versus 5.6 percent; p = 0.489), reoperations for hematoma (3.3 percent versus 1.6 percent; p = 0.597), and explantations (5 percent versus 2.4 percent; p = 0.393).

Conclusion: This novel analysis demonstrates that prepectoral immediate implant-based breast reconstruction can facilitate expansion to higher total volumes in nearly half the office visits compared to subpectoral placement in similar populations without increasing complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Quantitative Analysis of Animation Deformity in Prosthetic Breast Reconstruction

A Quantitative Analysis of Animation Deformity in Prosthetic Breast Reconstruction

by Kim, John Y. S.; Qiu, Cecil S.; Chiu, Wen-Kuan; Feld, Lauren N.; Mioton, Lauren M.; Kearney, Aaron; Fracol, Megan

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 291-301

Background: Animation deformity is characterized by implant deformity with pectoralis contraction after subpectoral implant-based breast reconstruction. Extant methods to measure and analyze animation deformity are hampered by the paucity of objective, quantitative data. The authors endeavored to supplement subjective measures with an in-depth quantitative analysis.

Methods: Patients undergoing subpectoral implant-based breast reconstruction were followed prospectively with video analysis of animation deformity. Nipple displacement and surface area of contour deformity in resting and contracted states were quantified using imaging software. Degree of animation was compared to breast size, body mass index, division of pectoralis muscle, complications, and radiation therapy.

Results: One hundred forty-five reconstructed breasts (88 patients) were analyzed. Mean nipple displacement was 2.12 ± 1.04 cm, mean vector of nipple displacement was 62.5 ± 20.6 degrees, and mean area of skin contour irregularity was 16.4 ± 15.41 percent. Intraoperative pectoralis division, smooth/round implants, and bilateral reconstructions were associated with greater deformity. A three-tiered grading system based on thresholds of 2-cm net nipple displacement and 25 percent skin contour irregularity placed 41.4 percent of breasts in grade 1, 35.9 percent in grade 2, and 22.8 percent in grade 3. Interrater variability testing demonstrated 89.5 percent overall agreement (kappa = 0.84).

Conclusions: This study presents the first quantitative analysis of animation deformity in prosthetic breast reconstruction. Geometric analysis of nipple displacement vector and increasing animation with pectoralis division both implicate the inferior pectoralis myotome as a primary driver of animation deformity. A concomitant grading schema was developed to provide a standardized framework for discussing animation from patient to patient and from study to study.

Sensory Recovery of the Breast following Innervated and Noninnervated DIEP Flap Breast Reconstruction

Sensory Recovery of the Breast following Innervated and Noninnervated DIEP Flap Breast Reconstruction

by Beugels, Jop; Cornelissen, Anouk J. M.; van Kuijk, Sander M. J.; Lataster, Arno; Heuts, Esther M.; Piatkowski, Andrzej; Spiegel, Aldona J.; van der Hulst, René R. W. J.; Tuinder, Stefania M. H

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 178e-188e

Background: The sensory recovery of the breast remains an undervalued aspect of autologous breast reconstruction. The aim of this study was to evaluate the effect of nerve coaptation on the sensory recovery of the breast following DIEP flap breast reconstruction and to assess the associations of length of follow-up and timing of the reconstruction.

Methods: A prospective comparative study was conducted of all patients who underwent either innervated or noninnervated DIEP flap breast reconstruction and returned for follow-up between September of 2015 and July of 2017. Nerve coaptation was performed to the anterior cutaneous branch of the third intercostal nerve. Semmes-Weinstein monofilaments were used for sensory testing of the native skin and flap skin.

Results: A total of 48 innervated DIEP flaps in 36 patients and 61 noninnervated DIEP flaps in 45 patients were tested at different follow-up time points. Nerve coaptation was significantly associated with lower monofilament values in all areas of the reconstructed breast (adjusted difference, −1.2; p < 0.001), which indicated that sensory recovery of the breast was significantly better in innervated compared with noninnervated DIEP flaps. For every month of follow-up, the mean monofilament value decreased by 0.083 in innervated flaps (p < 0.001) and 0.012 in noninnervated flaps (p < 0.001). Nerve coaptation significantly improved sensation in both immediate and delayed reconstructions. 

Conclusions: This study demonstrated that nerve coaptation in DIEP flap breast reconstruction is associated with a significantly better sensory recovery in all areas of the reconstructed breast compared with noninnervated flaps. The length of follow-up was significantly associated with the sensory recovery.

Trastuzumab duocarmazine in locally advanced and metastatic solid tumours and HER2-expressing breast cancer: a phase 1 dose-escalation and dose-expansion study

[Articles] Trastuzumab duocarmazine in locally advanced and metastatic solid tumours and HER2-expressing breast cancer: a phase 1 dose-escalation and dose-expansion study

by Udai Banerji, Carla M L van Herpen, Cristina Saura, Fiona Thistlethwaite, Simon Lord, Victor Moreno, Iain R Macpherson, Valentina Boni, Christian Rolfo, Elisabeth G E de Vries, Sylvie Rottey, Jill Geenen, Ferry Eskens, Marta Gil-Martin, Ellen C Mommers, Norbert P Koper, Philippe Aftimos

The Lancet Oncology: Articles| volume  20, issue  8, p1124-1135, August  01, 2019

Trastuzumab duocarmazine shows notable clinical activity in heavily pretreated patients with HER2-expressing metastatic cancer, including HER2-positive trastuzumab emtansine-resistant and HER2-low breast cancer, with a manageable safety profile. Further investigation of trastuzumab duocarmazine for HER2-positive breast cancer is ongoing and trials for HER2-low breast cancer and other HER2-expressing cancers are in preparation.

MRI versus mammography for breast cancer screening in women with familial risk (FaMRIsc): a multicentre, randomised, controlled trial

[Articles] MRI versus mammography for breast cancer screening in women with familial risk (FaMRIsc): a multicentre, randomised, controlled trial

by Sepideh Saadatmand, H Amarens Geuzinge, Emiel J T Rutgers, Ritse M Mann, Diderick B W de Roy van Zuidewijn, Harmien M Zonderland, Rob A E M Tollenaar, Marc B I Lobbes, Margreet G E M Ausems, Martijne van 't Riet, Maartje J Hooning, Ingeborg Mares-Engelberts, Ernest J T Luiten, Eveline A M Heijnsdijk, Cees Verhoef, Nico Karssemeijer, Jan C Oosterwijk, Inge-Marie Obdeijn, Harry J de Koning, Madeleine M A Tilanus-Linthorst, FaMRIsc study group

The Lancet Oncology: Articles| volume 20 issue 8, p1136-1147, August 01, 2019

MRI screening detected cancers at an earlier stage than mammography. The lower number of late-stage cancers identified in incident rounds might reduce the use of adjuvant chemotherapy and decrease breast cancer-related mortality. However, the advantages of the MRI screening approach might be at the cost of more false-positive results, especially at high breast density.

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.

Synergistic Interaction Increases Complication Rates following Microvascular Breast Reconstruction

Synergistic Interaction Increases Complication Rates following Microvascular Breast Reconstruction

By Roy, Mélissa; Sebastiampillai, Stephanie; Zhong, Toni; Hofer, Stefan O. P.; O’Neill, Anne C. 

Plastic and Reconstructive Surgery: July 2019 - Volume 144 - Issue 1 - p 1e-8e

Background: Microvascular breast reconstruction is a complex procedure that can be associated with high complication rates. Although a number of individual predictors of perioperative complications have been identified, few studies have explored interaction between risk factors. Understanding the synergistic effects of multiple risk factors is central to accurate and personalized preoperative risk prediction.

Methods: The authors conducted a retrospective cohort study of patients who underwent microvascular breast reconstruction at their institution between 2009 and 2017. All intraoperative and postoperative complications were recorded. A multivariable logistic regression exploratory model identified independent predictors of complications. Interactions between individual variables were then assessed using the relative excess risk index (RERI) and the synergy index (SI).

Results: Nine hundred twelve patients were included in the study and 26.1 percent experienced at least one perioperative complication. Obesity (OR, 1.54; p = 0.009), immediate reconstruction (OR, 1.49; p = 0.028), and comorbidities (OR, 1.43; p = 0.033) were identified as independent predictors of complications. Obesity and comorbidities had significant synergistic interactions with immediate reconstruction (RERI, 0.86; SI, 2.35; p = 0.0002; and RERI, 0.54; SI, 1.78; p = 0.001), bilateral reconstruction (RERI, 0.12; SI, 1.15; p = 0.002; and RERI, 0.59; SI, 3.16; p = 0.005), and previous radiotherapy (RERI, 0.62; SI, 4.43; p = 0.01; and RERI, 0.11; SI, 1.23; p = 0.040). Patients undergoing immediate breast reconstruction who were both obese and smokers had a 12-fold increase in complication rates (OR, 12.68; 95 percent CI, 1.36 to 118.46; p = 0.026) with a very strong synergistic interaction between variables (RERI, 10.55; SI, 10.33).

Conclusion: Patient- and treatment-related variables interact in a synergistic manner to increase the risk of complications following microvascular breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.