Breast Surgery Bulletin - June 2022

 

Radiation recall dermatitis induced by COVID-19 vaccination in breast cancer patients treated with postoperative radiation therapy

by Vinante Lorenzo, Caroli Angela, Revelant Alberto, Bertini Federica, Giroldi Anna, Marson Marta, Franchin Giovanni, Muraro Elena, Brisotto Giulia, Steffan Agostino, Baboci Lorena 

 

The Breast: Published: July 01, 2022

 

Background

and purpose: Radiation recall dermatitis is an adverse event predominantly due to systemic therapy administration after a previous radiation therapy course. Few case reports describe radiation recall dermatitis in breast cancer patients treated with postoperative radiation therapy following COVID-19 vaccination. In this study we investigated the incidence and severity of radiation recall dermatitis after COVID-19 vaccination in irradiated breast cancer patients.

Methods

Patients that received at least one COVID-19 vaccination dose during the year after the end of postoperative breast radiation therapy were included in this observational monocentric study. Local symptoms occurring inside the radiation field after vaccination were patient-reported and scored according to the PRO-CTCAE questionnaire. Descriptive data of radiation recall dermatitis incidence and severity, and potential risk factors were evaluated.

Results

A cohort of 361 patients with 756 administered COVID-19 vaccinations was analyzed. Breast symptoms were reported by 7.5% of patients, while radiation recall dermatitis was considered for 5.5%. The incidence of radiation recall dermatitis per single dose of vaccine was 2.6%, with a higher risk for the first dose compared to the second/third (4.4% vs 1%, p = 0.003), especially when administered within the first month after the end of irradiation (12.5% vs 2.2%, p = 0.0004). Local symptoms were generally self-limited and a few cases required anti-inflammatory drugs.

Conclusions

Radiation recall dermatitis is an uncommon but not rare phenomenon in breast cancer patients that received COVID-19 vaccination within one year after breast irradiation. However, symptoms severity were generally low/mild and reversible. These findings can be useful for patient counseling.

 

A Novel Validated Breast Aesthetic Scale

by Duraes, Eliana F. R.; Durand, Paul; Morisada, Megan; Scomacao, Isis; Duraes, Leonardo C.; de Sousa, Joao Batista; Abedi, Nasim; Djohan, Risal S.; Bernard, Steven; Moreira, Andrea; Schwarz, Graham S. 

Plastic and Reconstructive Surgery: June 2022 - Volume 149 - Issue 6 - p 1297-1308

 

Background: 

Breast aesthetics impacts patients’ quality of life after breast reconstruction, but patients and surgeons frequently disagree on the final aesthetic evaluation. The need for a comprehensive, validated tool to evaluate breast aesthetics independently from the patient motivated this study.

Methods: 

The 13-item Validated Breast Aesthetic Scale was developed after several internal meetings, and worded to be understood by a nonspecialist. Three items are common for both breasts, with the remaining being side-specific. To test the internal consistency of the scale subitems, postoperative photographs after different breast reconstruction techniques were graded by a six-member panel. To test interrater and intrarater correlation across time, four physicians evaluated the results of abdominally based breast reconstructions following nipple-sparing mastectomies.

Results: 

Graded aesthetic outcomes of 53 patients showed that the Cronbach alpha of the subitems of the scale was 0.926, with no single item that, if excluded, would increase it. Twenty-two patients underwent aesthetic outcomes grading at four different time points. The mean overall appearance was 3.71 ± 0.62. The mean grade for overall nipple appearance was 4.0 ± 0.57. The coefficient alpha of the panel overall aesthetic grade across different time points was 0.957; whereas intragrader reliability for graders 1 through 4 individually showed alpha coefficients of 0.894, 0.9, 0.898, and 0.688, respectively. Similar results were found for the other items of the scale.

Conclusions: 

The proposed aesthetic scale evaluates different aspects of the breast reconstruction aesthetic result with excellent internal consistency among its subitems. Grading by a gender-balanced, diverse four-member panel using postoperative photographs showed higher reliability and reproducibility compared to single graders.

 

 

 

The role of postoperative radiation therapy in stage I–III male breast cancer: A population-based study from the Surveillance, Epidemiology, and End Results database

by Peiwen Wu, Dongjie He, Shuchai Zhu, Hao Chang, Qiming Wang, Qiuju Shao, Gaiyan Li 

The Breast: Published: June 22, 2022

 

Background

This study aimed to investigate the role of adjuvant radiation therapy in a large population-based cohort of patients with stage I–III male breast cancer (MaBC).

Methods

Patients with stage I–III breast cancer treated with surgery were selected from the Surveillance, Epidemiology, and End Results cancer database from 2010 to 2015. Multivariate logistic regression identified the predictors of receiving radiation therapy. Multivariate Cox regression model were used to evaluate the predictors of survival.

Results

We identified 1321 patients. Age, stage, positive regional nodes, surgical procedure, and HER2 status were strong predictors of radiation therapy administration. There was no difference between patients who received radiation therapy and those who did not (P = 0.46); however, after propensity score matching, it was associated with improved OS (P = 0.04). In the multivariate analysis, the factors associated with better OS were administration of radiation therapy and chemotherapy. In the subset analysis, adjuvant radiation therapy was associated with improved OS in men undergoing breast-conserving surgery (BCS), with four or more node-positive or larger primary tumours (T3/T4). Furthermore, we found no benefit of radiation therapy, regardless of the type of axillary surgery in mastectomy (MS). In older MaBC patients with T1-2N1 who underwent MS, radiation therapy showed no significant effects, regardless of chemotherapy.

Conclusion

Adjuvant radiation therapy could improve the survival of MaBC patients undergoing BCS, with four or more node-positive or larger primary tumours. Moreover, it should be carefully considered in patients undergoing MS and older T1-2N1 patients.

 

A systematic assessment of online international breast density information

 

by Brooke Nickel, Tessa Copp, Tong Li, Hankiz Dolan, Meagan Brennan, Angela Verde, Lisa Vaccaro, Kirsten McCaffery, Nehmat Houssami 

 

The Breast: Published: June 22, 2022

 

Background

Breast density has become a topic of international discussion due to its associated risk of breast cancer. As online is often a primary source of women's health information it is therefore essential that breast density information it is understandable, accurate and reflects the best available evidence. This study aimed to systematically assess online international breast density information including recommendations to women.

Methods

Searches were conducted from five different English-speaking country-specific Google locations. Relevant breast density information was extracted from the identified websites. Readability was assessed using the SHeLL Editor, and understandability and actionability using the Patient Education Materials Assessment Tool (PEMAT). A content analysis of specific recommendations to women was also conducted.

Results

Forty-two eligible websites were identified and systematically assessed. The included informational content varied across websites. The average grade reading level across all websites was 12.4 (range 8.9–15.4). The mean understandability was 69.9% and the mean actionability was 40.1%, with 18/42 and 39/42 websites respectively scoring lower than adequate (70%). Thirty-six (85.7%) of the websites had breast density-related recommendation to women, with ‘talk to your doctor’ (n = 33, 78.6%) the most common.

Conclusions

Online information about breast density varies widely and is not generally presented in a way that women can easily understand and act on, therefore greatly reducing the ability for informed decision-making. International organisations and groups disseminating breast density information need to ensure that women are presented with health literacy-sensitive and balanced information, and be aware of the impact that recommendations may have on practice.

 

Moderate penetrance genes complicate genetic testing for breast cancer diagnosis: ATM, CHEK2, BARD1 and RAD51D

 

by R. Graffeo, H.Q. Rana, F. Conforti, B. Bonanni, M.J. Cardoso, S. Paluch-Shimon, O. Pagani, A. Goldhirsch, A.H. Partridge, M. Lambertini, J.E. Garber 

 

The Breast: Published: June 18, 2022

 

Breast cancer risk associated with germline likely pathogenic/pathogenic variants (PV) varies by gene, often by penetrance (high >50% or moderate 20–50%), and specific locus.

Germline PVs in BRCA1 and BRCA2 play important roles in the development of breast and ovarian cancer in particular, as well as in other cancers such as pancreatic and prostate cancers and melanoma. Recent studies suggest that other cancer susceptibility genes, including ATM, CHEK2, PALB2, RAD51C and RAD51D confer differential risks of breast and other specific cancers.

In the era of multigene panel testing, advances in next-generation sequencing technologies have notably reduced costs in the United States (US) and enabled sequencing of BRCA1/2 concomitantly with additional genes. The use of multigene-panel testing is beginning to expand in Europe as well.

Further research into the clinical implications of variants in moderate penetrance genes, particularly in unaffected carriers, is needed for appropriate counselling and risk management with data-driven plans for surveillance and/or risk reduction. For individuals at high risk without any pathogenic or likely pathogenic variant in cancer susceptibility genes or some carriers of pathogenic variants in moderate-risk genes such as ATM and CHEK2, polygenic risk scores offer promise to help stratify breast cancer risk and guide appropriate risk management options.

Cancer patients whose tumours are driven by the loss of function of both copies of a predisposition gene may benefit from therapies targeting the biological alterations induced by the dysfunctional gene e.g. poly ADP ribose polymerase (PARP) inhibitors and other novel pathway agents in cancers with DNA repair deficiencies. A better understanding of mechanisms by which germline variants drive various malignancies may lead to improvements in both therapeutic and preventive management options.

 

Surgical and Patient-Reported Outcomes of Autologous versus Implant-Based Reconstruction following Infected Breast Device Explantation

 

by Asaad, Malke; Slovacek, Cedar; Mitchell, David; Liu, Jun; Selber, Jesse C.; Clemens, Mark W.; Chu, Carrie K.; Mericli, Alexander F.; Butler, Charles E. 

 

Plastic and Reconstructive Surgery: June 2022 - Volume 149 - Issue 6 - p 1080e-1089e

 

Background: 

Implant-based breast reconstruction infections often require implant explantation. Whereas some plastic surgeons pursue autologous reconstruction following the first implant-based breast reconstruction failure caused by infection, others argue that a second attempt is acceptable.

Methods: 

The authors conducted a retrospective study of patients who underwent a second reconstruction attempt with implant-based or free flap breast reconstruction following explantation because of infection between 2006 and 2019. Surgical and patient-reported outcomes were compared between the two groups.

Results: 

A total of 6093 implant-based breast reconstructions were performed during the study period, of which 130 breasts met our inclusion criteria [implant-based, n = 86 (66 percent); free flap, n = 44 (34 percent)]. No significant differences in rates of overall (25 percent versus 36 percent; p = 0.2) or major (20 percent versus 21 percent; p = 0.95) complications were identified between the free flap and implant-based cohorts, respectively. Implant-based breast reconstruction patients were more likely to experience a second infection (27 percent versus 2 percent; p = 0.0007) and reconstruction failure (21 percent versus 5 percent; p = 0.019). Among irradiated patients, reconstruction failure was reported in 44 percent of the implant-based and 7 percent of the free flap cohorts (p = 0.02). Free flap patients reported significantly higher scores for Satisfaction with Breasts (73.7 ± 20.1 versus 48.5 ± 27.9; p = 0.0046).

Conclusions: 

Following implant-based breast reconstruction explantation because of infection, implant-based and free flap breast reconstruction had similar rates of overall and major complications; however, implant-based breast reconstruction had considerably higher rates of infection and reconstructive failures and lower patient-reported scores for Satisfaction with Breasts. Given the high rates of implant-based breast reconstruction failure in patients with prior radiotherapy and infection-based failure, plastic surgeons should strongly consider autologous reconstruction in this patient population.

 

Breast cancer patients’ most important quality of life themes for a radiotherapy decision aid

 by Cheryl Roumen, Hajar Hasannejadasl, Rachelle Swart, Daniela Raphael, Leonard Wee, Matthijs Sloep, Desiree H.J.G. van den Bongard, Helena Verkooijen, Salina Thijssen, Mirjam Velting, Maaike Schuurman, Nicola S. Russell, Rianne Fijten, Liesbeth J. Boersma

 The Breast: Published: June 10, 2022

 

Background and aim

The BRASA patient decision aid (BRASA-PtDA) facilitates shared decision making for breast cancer patients (BCPs) facing a radiotherapy treatment decision. During evaluations, patients indicated the wish for quantitative information on side effects. Therefore, this study assessed BCPs opinion on which and how information on side effects should be incorporated in the BRASA-PtDA.

Methods

A workshop was organized with BCPs (n = 9), researchers (n = 5) and clinicians (n = 3). Subsequently, a survey was sent to BCPs (n = 744) investigating the generalisability of the workshop findings, and posing additional questions. The survey entailed multiple choice questions on quality of life themes, the use of a decision aid and risk communication.

Results

The workshop revealed BCPs wish for a layered, all encompassing information system. Information on the impact of side effects on daily life was preferred above the risk of these side effects. The survey revealed that important quality of life (QoL) themes were having energy (81%; n = 605), arm function (61%; n = 452), pain (55%; n = 410). Despite the focus on qualitative effects in the workshop, 89% of the survey respondents also wanted to be informed on individualized risks of side effects. 54% Of the survey respondents had never heard of a PtDA.

Conclusions

BCPs preferred information on the impact of side effects, but also their individualized risks on side effects. Most important QoL themes were having enough energy, arm function and pain. Consequently, the BRASA-PtDA should be reshaped, starting with quality of life themes, rather than side effects.

 

A nested case-control study on radiation dose-response for cardiac events in breast cancer patients in Germany

  by Dan Baaken, Hiltrud Merzenich, Marcus Schmidt, Inga Bekes, Lukas Schwentner, Wolfgang Janni, Achim Woeckel, Manfred Mayr, Stephan Mose, Thomas Merz, Voica Ghilescu, Jona Renner, Detlef Bartkowiak, Thomas Wiegel, Maria Blettner, Heinz Schmidberger, Daniel Wollschläger 

 The Breast: Published: June 09, 2022

Background

Previous studies with the majority of breast cancer (BC) patients treated up to 2000 provided evidence that radiation dose to the heart from radiotherapy (RT) was linearly associated with increasing risk for long-term cardiac disease. RT techniques changed substantially over time. This study aimed to investigate the dose-dependent cardiac risk in German BC patients treated with more contemporary RT.

Methods

In a cohort of 11,982 BC patients diagnosed in 1998–2008, we identified 494 women treated with 3D-conformal RT who subsequently developed a cardiac event. Within a nested case-control approach, these cases were matched to 988 controls. Controls were patients without a cardiac event after RT until the index date of the corresponding case. Separate multivariable conditional logistic regression models were used to assess the association of radiation to the complete heart and to the left anterior heart wall (LAHW) with cardiac events.

Results

Mean dose to the heart for cases with left-sided BC was 4.27 Gy and 1.64 Gy for cases with right-sided BC. For controls, corresponding values were 4.31 Gy and 1.66 Gy, respectively. The odds ratio (OR) per 1 Gy increase in dose to the complete heart was 0.99 (95% confidence interval (CI): 0.94–1.05, P = .72). The OR per 1 Gy increase in LAHW dose was 1.00 (95% CI: 0.98–1.01, P = .68).

Conclusions

Contrary to previous studies, our study provided no evidence that radiation dose to the heart from 3D-conformal RT for BC patients treated between 1998 and 2008 was associated with risk of cardiac events.

Breast Surgery Bulletin - May 2022

 

Effective Treatment of Chronic Mastectomy Pain with Intercostal Sensory Neurectomy

 

by Hart, Sarah E.; Agarwal, Shailesh; Hamill, Jennifer B.; Brown, David L.

 

Plastic and Reconstructive Surgery: May 2022 - Volume 149 - Issue 5 - p 876e-880e

 

Chronic postmastectomy pain affects up to 40 percent of patients and leads to diminished quality of life and increased risk of opioid dependence. The cause of this pain is incompletely understood; however, one hypothesis is that direct injury to cutaneous intercostal nerves at the time of mastectomy and/or reconstruction leads to chronic pain. As a result, proximal neurectomy of the involved sensory nerve(s) has been suggested to be effective for these patients. The purpose of this study was to determine whether chronic pain in postmastectomy patients can be diagnosed reliably in an office setting and pain reduced by intercostal sensory neurectomy. The authors performed a retrospective review of seven patients with a history of breast surgery and chronic pain who underwent intercostal neurectomy combined with muscle or dermal wrapping of the proximal end of the resected nerve. All patients were diagnosed by history and physical examination, and suspected nerves were further identified with local anesthetic nerve blocks. An average of 3.14 neurectomies were performed per patient (range, one to six). There was a significant reduction in visual analogue scale pain scores following surgery, from 9 preoperatively to 1 postoperatively (p = 0.02). Eighty-six percent of patients were pain-free or “considerably improved” at their latest follow-up appointment (average, 6.14 months). It is concluded that intercostal sensory nerve injury at the time of mastectomy and/or reconstruction can lead to chronic mastectomy pain, which can be easily diagnosed and effectively treated with intercostal neurectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

 

Long term outcome data from the EORTC 75111-10114 ETF/BCG randomized phase II study: Pertuzumab and trastuzumab with or without metronomic chemotherapy for older patients with HER2-positive metastatic breast cancer, followed by T-DM1 after progression

 

by Hans Wildiers, Thomas Meyskens, Sandrine Marréaud, Lissandra Dal Lago, Peter Vuylsteke, Giuseppe Curigliano, Simon Waters, Barbara Brouwers, Bart Meulemans, Berta Sousa, Coralie Poncet, Etienne Brain 

 

The Breast: Published: May 19, 2022

 

Introduction

Older patients are at higher risk of chemotherapy-induced toxicity, raising interest in less toxic anti-HER2 regimens for older persons with HER2-positive (HER2+) metastatic breast cancer (MBC).

Patients and methods

This phase II study randomized (1:1) patients with HER2+ MBC, aged 70+ or frail 60+, to first line chemotherapy with metronomic oral cyclophosphamide (M) + Trastuzumab (T) and Pertuzumab (P) or TP alone. T-DM1 was offered in case of progression.

Results

In total, 39 and 41 patients were randomized to TP and TPM arm respectively. Median follow-up is 54.0 months. 24-month PFS was 18.7% (95% CI 8.2–32.4) and 28.7% (95% CI 15.8–43.0), respectively. A total of 49 (61.3%) patients died of whom 37 (75.5%) from disease progression; number of deaths per arm was 27 (69.2%) for TP and 22 (53.7%) for TPM. There was no significant difference in OS between the two arms (median OS TP vs TPM: 32.1 vs 37.5 months, p 0.25). Among the 40 patients who have started T-DM1 after disease progression on TP/TPM, PFS rate at 6 months after start of T-DM1 was 43.6% (95% CI: 27.7–58.5) and grade 3 or higher AE occurred in 18 pts (45%).

Conclusions

Metronomic chemotherapy-based dual blockade (TPM), followed by T-DM1 after progression, provides an active and relatively well tolerated treatment option in an older/frail HER2+ MBC population, with a median survival of over 3 years. Nevertheless, the majority of this older/frail population died from breast cancer, highlighting the need for well tolerated and efficacious treatments in these patients.

 

The impact of medication side effects on adherence and persistence to hormone therapy in breast cancer survivors: A quantitative systematic review

 

by Leanne Fleming, Sommer Agnew, Nicola Peddie, Megan Crawford, Diane Dixon, Iain MacPherson 

 

The Breast: VOLUME 64, P63-84, AUGUST 01, 2022 (Published: May 13, 2022)

 

 Background

Hormone Therapy (HT) is recommended for most women with HR-positive primary breast cancer. When taken as intended, HT reduces breast cancer recurrence by 40% and mortality by one-third. The recommended duration of treatment ranges from 5 to 10 years depending on risk of recurrence and the specific HT regimen. However, recent data indicates that rates of HT non-adherence are high and research suggests this may be due to the impact of HT side effects. The contribution of side effects to non-adherence and non-persistence behaviours has rarely been systematically explored, thereby hindering the implementation of targeted intervention strategies. Our aim is to identify, evaluate and summarise the relationship between HT side effects and patterns of adherence and persistence.

Methods

Electronic searches were conducted from inception and were completed by September 2021, utilising Cochrane CENTRAL, Medline, Embase, Web of Science and PsycINFO databases. Searches included a combination of terms related to breast cancer, adherence, hormone therapy and side effects.

Results

Sixty-two eligible papers were identified and study quality varied by study type. Most observational and cross-sectional studies were rated good quality, whereas most controlled intervention studies were rated fair quality. Three studies were rated poor quality. The most frequently measured side effects were pain, low mood, hot flashes, insomnia, anxiety, fatigue, weight gain, concentration/memory problems.

Conclusions

This review identified a lack of consistency in the measurement of adherence and the definition of persistence across studies. The instruments used to measure side effects also varied significantly. This variation and lack of consistency makes it difficult to evaluate and summarise the role of HT side effects in HT adherence and persistence behaviour.

 

Prospective Longitudinal Patient-Reported Satisfaction and Health-Related Quality of Life following DIEP Flap Breast Reconstruction: Effects of Reconstruction Timing

 

by Ochoa, Oscar; Garza, Ramon III; Pisano, Steven; Chrysopoulo, Minas; Ledoux, Peter; Arishita, Gary; Ketchum, Norma; Michalek, Joel E.; Nastala, Chet 

 

Plastic and Reconstructive Surgery: May 2022 - Volume 149 - Issue 5 - p 848e-857e

 

Background: 

Without reconstruction, mastectomy alone can produce significant detrimental effects on health-related quality of life. The magnitude of quality-of-life benefits following breast reconstruction may be unique based on timing of reconstruction. Facilitated by the BREAST-Q questionnaire, characterization of how reconstruction timing differentially affects patient-reported quality of life is essential for improved evidence-based clinical practice.

Methods: 

Consecutive DIEP flap breast reconstruction patients prospectively completed BREAST-Q questionnaires preoperatively and at two different time intervals postoperatively. The first (postoperative time point A) and second (postoperative time point B) postoperative questionnaires were completed 1 month postoperatively and following breast revision/symmetry procedures, respectively. Postoperative flap and donor-site complications were recorded prospectively. Stratified by timing (immediate versus delayed) of reconstruction, preoperative clinical data, operative morbidity, and BREAST-Q scores were compared at all time points.

Results: 

Between July of 2012 and August of 2016, 73 patients underwent 130 DIEP flap breast reconstructions. Collectively, breast satisfaction, psychosocial well-being, and sexual well-being scores significantly (p < 0.001) increased postoperatively versus baseline. Chest and abdominal physical well-being scores returned to baseline levels by postoperative time point B. Preoperatively, patients undergoing delayed breast reconstruction reported significantly (p < 0.05) lower breast satisfaction, psychosocial well-being, and sexual well-being scores compared to immediate reconstruction patients. Postoperatively, delayed and immediate reconstruction patients reported similar quality-of-life scores. Outcome satisfaction and flap and donor-site morbidity were similar between groups irrespective of timing of reconstruction.

Conclusions: 

In this prospective study, patient-reported outcomes demonstrate significant improvements in breast satisfaction, psychosocial well-being, and sexual well-being among patients following DIEP flap reconstruction. Moreover, preoperative differences in quality-of-life scores among delayed/immediate reconstruction patients were eliminated postoperatively.

 

Does receiving high or low breast cancer risk estimates produce a reduction in subsequent breast cancer screening attendance? Cohort study

 

by David P. French, Lorna McWilliams, Anthony Howell, D Gareth Evans 

 

The Breast: VOLUME 64, P47-49, AUGUST 01, 2022 (Published: May 09, 2022)

 

Risk-stratified breast cancer screening may improve the balance of screening benefits to harms.

We assess a potential new harm: reduced screening attendance in women receiving below average-risk (false reassurance) or higher-risk results (screening avoidance). Following initial screening, 26,668 women in the PROCAS study received breast cancer risk estimates, with attendance recorded for two subsequent screening rounds. First-screen attendance was slightly reduced in below-average (85.6%) but not higher-risk women, compared to other women (86.4%). Second-screen attendance increased for women at higher-risk (89.2%) but not below-average, compared to other women (78.8%). Concerns about this potential harm of risk-stratified screening therefore appear unfounded.

 

Reverse Lymphatic Mapping and Immediate Microsurgical Lymphatic Reconstruction Reduces Early Risk of Breast Cancer–Related Lymphedema

 

Weinstein, Brielle; Le, Nicole K.; Robertson, Ellen; Zimmerman, Amanda; Tavares, Tina; Tran, Thanh; Laronga, Christine; Panetta, Nicholas J. 

 

Plastic and Reconstructive Surgery: May 2022 - Volume 149 - Issue 5 - p 1061-1069

 

Background: 

Breast cancer–related lymphedema is a progressive disease that poses tremendous physical, psychosocial, and financial burden on patients. Immediate lymphaticovenular anastomosis at the time of axillary lymph node dissection is emerging as a potential therapeutic paradigm to decrease the incidence of breast cancer–related lymphedema in high-risk patients.

Methods: 

Eighty-one consecutive patients underwent reverse lymphatic mapping and, when feasible, supermicrosurgical immediate lymphaticovenular anastomosis at the time of axillary lymph node dissection at a tertiary care cancer center. Patients were followed prospectively in a multidisciplinary lymphedema clinic (plastic surgery, certified lymphatic therapy, dietary, case management) at 3-month intervals with clinical examination, circumferential limb girth measurements, and bioimpedance spectroscopy. An institutional control cohort was assessed for the presence of objectively diagnosed and treated breast cancer–related lymphedema. Data were analyzed by a university statistician.

Results: 

Seventy-eight patients met inclusion, and 66 underwent immediate lymphaticovenular anastomosis. Mean follow-up was 250 days. When compared to a retrospective control group, the rate of lymphedema in patients who underwent immediate lymphaticovenular anastomosis was significantly lower (6 percent versus 44 percent; p < 0.0001). Patients with 6-month follow-up treated with combined adjuvant radiation therapy and chemotherapy had significantly greater risk of developing breast cancer–related lymphedema (p = 0.04) compared to those without combined adjuvant therapy. Arborized anastomotic technique had a statistically shorter operative time than end-to-end anastomosis (p = 0.005).

Conclusions: 

This series of consecutive patients demonstrate a 6 percent incidence of early-onset breast cancer–related lymphedema with immediate lymphaticovenular anastomosis and an increased risk in those undergoing combined adjuvant treatment. These early data represent an encouraging and substantial decrease of breast cancer–related lymphedema in high-risk patients.

 

A Comparison of Complications in Therapeutic versus Contralateral Prophylactic Mastectomy Reconstruction: A Paired Analysis

by Sergesketter, Amanda R.; Marks, Caitlin; Broadwater, Gloria; Shammas, Ronnie L.; Greenup, Rachel A.; Clancy, Sharon; Plichta, Jennifer K.; Hollenbeck, Scott T.; Phillips, Brett T. 

Plastic and Reconstructive Surgery: May 2022 - Volume 149 - Issue 5 - p 1037-1047

 

Background: 

Although breast reconstruction after bilateral mastectomies including a contralateral prophylactic mastectomy is known to have a higher overall complication profile, whether reconstructive complication rates differ between the therapeutic mastectomy and contralateral prophylactic mastectomy sides remains unclear.

Methods: 

Women undergoing bilateral mastectomies with autologous or implant-based breast reconstruction for a unilateral breast cancer at a single institution were identified (2009 to 2019). Postoperative complications were stratified by laterality (therapeutic mastectomy versus contralateral prophylactic mastectomy). Paired data were analyzed to compare the risks of complications between prophylactic and therapeutic reconstruction sides in the same patient.

Results: 

A total of 130 patients (260 reconstructions) underwent bilateral autologous or implant-based reconstruction. Although most women underwent a simple mastectomy, a higher proportion of therapeutic mastectomies were modified radical mastectomies including axillary lymph node dissections compared to contralateral prophylactic mastectomies (15.4 percent versus 0 percent). Forty-four percent of women completed postmastectomy radiation therapy of the therapeutic side before definitive reconstruction. Overall, both therapeutic and prophylactic reconstructions had a similar incidence of reconstructive failure (p = 0.57), return to the operating room (p = 0.44), mastectomy skin flap necrosis (p = 0.32), seroma (p = 0.82), fat necrosis (p = 0.16), wound infection (p = 0.56), and cellulitis (p = 0.56). Nearly one-fifth of patients experienced complications limited to the prophylactic side [contralateral prophylactic mastectomy reconstruction complications, n = 26 (20.0 percent); therapeutic mastectomy reconstruction complications, n = 15 (11.5 percent)].

Conclusion: 

Despite a history of local radiation therapy and more extensive oncologic surgery on the therapeutic side, there are no significant differences in the incidence of postsurgical complications on the therapeutic mastectomy and contralateral prophylactic mastectomy sides after bilateral reconstruction.

 

Creating a Biological Breast Implant with an Omental Fat-Augmented Free Flap

 by Nguyen, Dung H.; Ma, Irene T.; Choi, Youna K.; Zak, Yulia; Dua, Monica M.; Wapnir, Irene L. 

 Plastic and Reconstructive Surgery: April 2022 - Volume 149 - Issue 4 - p 832-835

Women with inadequate myocutaneous or fasciocutaneous soft-tissue donor sites for breast reconstruction after mastectomy are mostly limited to implants. Alternative substitutes are needed for those who do not want—or in whom there are contraindications for—implant-based reconstruction. The authors report a novel technique using an omental fat-augmented free flap to create an autologous breast mound that has comparable shape and projection to a breast implant. Three patients with breast cancer who desired unilateral reconstruction were identified in the period 2019 to 2020. All had insufficient traditional autologous sites and were averse to the use of implants. A nipple-sparing mastectomy was performed, and the omentum was laparoscopically harvested and fat-grafted ex vivo and then encased in acellular dermal matrix for microvascular anastomoses. The body mass indexes of the three patients were 17.6, 25, and 28.3 kg/m2. Each individual’s mastectomy specimens and corresponding omentum plus fat-grafting weights were 113.7/228, 271/293, and 270/360 g. No postoperative complications occurred. The reconstructed breast remains soft, with stable breast volume at 6 months and without evidence of fat necrosis. This novel use of fat grafting into an omental flap enveloped in acellular dermal matrix, the omental fat-augmented free flap, provides a viable and successful autologous alternative for patients who are not candidates for traditional autologous breast reconstruction options because of body habitus or personal preference.

 

Hair safe study: Effects of scalp cooling on hair preservation and hair regrowth in breast cancer patients receiving chemotherapy - A prospective interventional study

 

by Christine Brunner, Miriam Emmelheinz, Ricarda Kofler, Samira Abdel Azim, Marlene Lehmann, Verena Wieser, Magdalena Ritter, Christian Marth, Daniel Egle 

 

The Breast: VOLUME 64, P50-55, AUGUST 01, 2022 (Published: April 29, 2022)

 

Breast cancer is the most common cancer in women worldwide. When detected early, the chance of long-term survival can be as high as 90% due to massive improvements in therapeutic options over the past decades.

A substantial proportion of patients with breast cancer still receive chemotherapy as part of their treatment, which, however, has detrimental side effects.

Among the most common toxicities are nausea, emesis, premature menopause and hair loss.

Although chemotherapy-induced alopecia is not a life-threatening side effect, it ranks amongst the most troublesome side effects concerning the patients’ quality of life and body image.

Due to the high chance of a cure by improved systemic therapy, quality of life (QoL) is becoming an increasingly important aspect. Chemotherapy-induced alopecia also affects psychological well-being and has been associated with depression.

Currently, the most promising method to prevent chemotherapy-induced alopecia is scalp cooling (SC). To date, various studies have reported its efficacy in small patient populations

SC leads to vasoconstriction, which inhibits cellular drug uptake, furthermore, hypothermia reduces the metabolic rate of hair follicles, finally lowering susceptibility to chemotherapy damage. Concerns that SC might increase scalp metastases have limited its clinical use in the past. However, a recent meta-analysis by Rugo et al. showed no association of scalp metastases with SC.

Initial studies on SC were conducted primarily with taxane- and only rarely anthracycline-based chemotherapy.

A high efficacy of SC was previously demonstrated for chemotherapy containing taxanes only; however, this does not reflect clinical reality considering that most chemotherapy regimens contain two or more cytostatic agents.

This prospective study aims to evaluate the efficacy of SC in different chemotherapy regimens and hair recovery in the follow-up period.

 

 

 

Relevance of the 21-gene expression assay in male breast cancer: A systematic review and meta-analysis

 

by Matthew G. Davey, Ciara M. Davey, Luis Bouz, Eoin Kerin, Carson McFeetors, Aoife J. Lowery, Michael J. Kerin 

 

The Breast: VOLUME 64, P41-46, AUGUST 01, 2022 (Published: April 28, 2022)

 

Introduction

The 21-gene assay provides prognostication for estrogen receptor positive, human epidermal growth factor receptor-2 negative (ER+/HER2-) early female breast cancer patients. This signature has not been validated in male breast cancer (MBC).

Methods

A systematic review and meta-analysis was performed in accordance to the PRISMA guidelines. Retrospective cohort studies comparing 21-gene assay scores in female and MBC were included. Dichotomous variables were pooled as odds ratios (OR) and associated 95% confidence intervals (CI) using the Mantel–Haenszel method.

Results

Six studies including 176,338 patients were included (mean age of 63.4 years, range: 33–88). Of these, 1.0% had MBC (1826/176,338) and 99.0% were female patients (174,512/176,338). MBC patients were more likely to have increased tumour stage, nodal involvement, and grade 3 disease (all P < 0.001) In MBC patients, the mean score was 18.8 (range: 11–26) vs. 13.4 (range 0–33) in female patients (P < 0.001). In MBC patients, 22.4% had scores >30 (408/1822) versus 18.3% in female patients (31,852/174,500). In female patients, 52.0% had scores <18 (90,787/174,500) versus 47.8% in MBC (471/1822). Overall, patients with female patients were as likely to have scores <18 (OR: 1.04, 95% CI: 0.94–1.16), scores 18–30 (OR: 1.12, 95% CI: 1.00–1.26) and scores >30 (OR: 0.69, 95% CI: 0.45–1.07) as MBC patients.

Conclusion

There are similar anticipated scores for female and MBC undergoing 21-gene expression assay testing for early stage, ER+/HER2-breast cancer. In the absence of stage matching, cautious interpretation of these results is required. Validation of the 21-gene assay in MBC is still required.

Keywords

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