-
Plastic and Reconstructive Surgery Apr 2024Oncoplastic breast reconstruction seeks to address partial mastectomy defects in the setting of breast-conserving surgery to achieve superior aesthetic outcomes with... (Review)
Review
Oncoplastic breast reconstruction seeks to address partial mastectomy defects in the setting of breast-conserving surgery to achieve superior aesthetic outcomes with comparable oncologic safety compared with traditional breast conservation surgery. As such, oncoplastic breast-conserving surgery has grown in popularity in recent years. Several techniques have been used to displace the volume with the remaining breast tissue or replace it with local soft-tissue options, with decision-making guided by patient and tumor characteristics, additional treatment requirements, patient preference, and available tissue resources. The purpose of this review is to provide an overview of considerations in oncoplastic breast reconstruction with a focus on techniques and tips to achieve optimal outcomes.
Topics: Humans; Female; Mastectomy; Breast Neoplasms; Mammaplasty; Mastectomy, Segmental; Patient Preference
PubMed: 37220250
DOI: 10.1097/PRS.0000000000010731 -
Journal of Plastic, Reconstructive &... Oct 2023Although breast reconstruction in the setting of post-mastectomy radiotherapy (PMRT) is controversial, we offer nipple-sparing mastectomy and immediate implant-based...
BACKGROUND
Although breast reconstruction in the setting of post-mastectomy radiotherapy (PMRT) is controversial, we offer nipple-sparing mastectomy and immediate implant-based breast reconstruction ([N]SSM/IIBR) to women needing primary mastectomy regardless of PMRT. Nevertheless, some of these women have no reconstruction.
PURPOSE
To assess the uptake of breast reconstruction in women who undergo PMRT and the patient characteristics associated with such uptake. Additionally, we assessed the determinants of forgoing breast reconstruction.
METHODOLOGY
Demographic, physical and oncological characteristics of women who underwent mastectomy, PMRT and breast reconstruction were compared to the characteristics of those who did not undergo breast reconstruction from 2013 through 2018. As determinants of delaying or refraining from breast reconstruction, we distinguished between an oncological reason, patient's preference, patient's co-morbidity, combined tobacco abuse and obesity and the need for PMRT.
RESULTS
490 women received PMRT. Of these, 396 women (81%) underwent combined [N]SSM/IIBR and PMRT or mastectomy and PMRT with delayed breast reconstruction. Ninety-four additional women (19%) did not undergo breast reconstruction. The latter group differed significantly from those who did in demographic and physical characteristics but not in terms of oncological diagnosis and history. Patient's preference was the single most frequent determinant of not performing either immediate or delayed breast reconstruction among these 94 women. Oncological status was not a major determinant in refraining from reconstruction.
CONCLUSION
The significant difference in non-oncological characteristics between the reconstructed and non-reconstructed women confirms the importance of these characteristics in the preference for either reconstruction or non-reconstruction.
Topics: Female; Humans; Mastectomy; Breast Neoplasms; Radiotherapy, Adjuvant; Mammaplasty; Mastectomy, Subcutaneous; Postoperative Complications; Retrospective Studies
PubMed: 37544198
DOI: 10.1016/j.bjps.2023.07.035 -
Trends of Axillary Treatment in Sentinel Node-Positive Breast Cancer Patients Undergoing Mastectomy.Annals of Surgical Oncology Sep 2023The ACOSOG-Z0011- and the AMAROS-trial obviated the need for axillary surgery in most sentinel node-positive (SLN+) breast cancer patients undergoing breast-conserving...
BACKGROUND
The ACOSOG-Z0011- and the AMAROS-trial obviated the need for axillary surgery in most sentinel node-positive (SLN+) breast cancer patients undergoing breast-conserving surgery (BCS). Data for patients who undergo mastectomy is scarce. The purpose of this study was to investigate patterns of axillary treatment in SLN+ patients treated by mastectomy in the years after the publication of landmark studies regarding axillary treatment in SLN+ breast cancer patients undergoing BCS.
METHODS
This was a population-based study in cT1-3N0M0 breast cancer patients treated by mastectomy and staged as SLN+ between 2009 and 2018. The performance of an axillary lymph node dissection (ALND) and/or administration of postmastectomy radiotherapy (PMRT) were primary outcomes and were studied over time.
RESULTS
The study included 10,633 patients. The frequency of ALND performance decreased from 78% in 2009 to 10% in 2018, whereas PMRT increased from 4 to 49% (P < 0.001). In ≥N1a patients, ALND performance decreased from 93 to 20%, whereas PMRT increased to 70% (P < 0.001). In N1mi and N0itc patients, ALND was abandoned during the study period, whereas PMRT increased to 38% and 13% respectively (P < 0.001), respectively. Age, tumor subtype, N-stage, and hospital type affected the likelihood that patients underwent ALND.
CONCLUSIONS
In this study in SLN+ breast cancer patients undergoing mastectomy, use of ALND decreased drastically over time. By the end of 2018 most ≥N1a patients received PMRT as the only adjuvant axillary treatment, whereas the majority of N1mi and N0itc patients received no additional treatment.
Topics: Humans; Female; Breast Neoplasms; Mastectomy; Lymphatic Metastasis; Sentinel Lymph Node; Lymph Node Excision; Sentinel Lymph Node Biopsy; Mastectomy, Segmental; Lymphadenopathy; Axilla
PubMed: 37225832
DOI: 10.1245/s10434-023-13568-3 -
Plastic and Reconstructive Surgery Oct 2023Excess fluid accumulation (seroma/hematoma) around the breast implant after reconstruction can lead to significant complications. Topical administration of tranexamic... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Excess fluid accumulation (seroma/hematoma) around the breast implant after reconstruction can lead to significant complications. Topical administration of tranexamic acid (TXA) may reduce fluid accumulation and reduce postoperative complications. This trial aims to investigate whether TXA-treated mastectomy pockets will exhibit less postoperative fluid production and complications.
METHODS
This paired, double-blind, randomized, controlled trial enrolled patients undergoing bilateral mastectomies with immediate direct-to-implant reconstruction. In each patient, one breast was randomized to receive 3 g of TXA (100 cc), and the other received 100 cc of normal saline. The blinded solutions were soaked in the mastectomy pocket for 5 minutes before implant placement. Postoperatively, daily drain outputs, complications, and baseline demographics were recorded.
RESULTS
Fifty-three eligible patients, representing 106 breasts, were enrolled. All patients underwent bilateral nipple-sparing mastectomies. After randomization, TXA was placed in the right breast in 30 patients (56.6%). The use of topical TXA resulted in a mean drain output reduction of 30.5% (range, -83.6% to 26.6%). Drains on the TXA-treated breast were eligible for removal 1.4 days (range, 0 to 4 days) sooner than the control side. The TXA-treated group had three complications (5.67%) versus 15 (28.3%) in the control group (OR, 0.1920; P = 0.0129). Specifically, for operative hematomas, the TXA group had none (0%), versus three in the control group (5.7%) (OR, 0.1348; P = 0.18).
CONCLUSIONS
Soaking the mastectomy bed with 3% topical TXA before implant insertion leads to a decrease in drain output and a decrease in complications. Topical administration of TXA represents an option to decrease complications in alloplastic breast reconstruction.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Therapeutic, I.
Topics: Humans; Female; Tranexamic Acid; Antifibrinolytic Agents; Breast Neoplasms; Blood Loss, Surgical; Mastectomy; Blood Transfusion; Administration, Topical; Mammaplasty; Double-Blind Method; Hematoma
PubMed: 36827482
DOI: 10.1097/PRS.0000000000010322 -
Cancer Medicine Oct 2023The efficacy of breast reconstruction for patients with N2-3M0 stage female breast cancer (FBC) remained unclear due to the lack of randomized clinical trials. This...
BACKGROUND
The efficacy of breast reconstruction for patients with N2-3M0 stage female breast cancer (FBC) remained unclear due to the lack of randomized clinical trials. This retrospective study aimed to explore the efficacy of breast reconstruction for patients with N2-3M0 stage FBC.
METHODS
Two thousand five hundred forty-five subjects with FBC staged by N2-3M0 from 2010 to 2016 were retrieved from the Surveillance, Epidemiology, and End Results database. Generalized boosted model (GBM) and propensity score matching (PSM) analyses and multivariable Cox analyses were employed to assess the clinical prognostic effect of postmastectomy reconstruction for patients with N2-3M0 stage FBC in breast cancer-specific survival (BCSS).
RESULTS
Totally, 1784 candidates underwent mastectomy alone (mastectomy group), and 761 candidates underwent postmastectomy reconstruction (PMbR group), with 418 breast-specific deaths after a median follow-up time of 57 months (ranging from 7 to 227 months). BCSS in the mastectomy group showed no statistical difference from that in the PMbR group in the PSM cohort (HR = 0.93, 95% CI: 0.70-1.25, p = 0.400) and GBM cohort (HR = 0.75, 95% CI: 0.56-1.01, p = 0.057). In the multivariate analyses, there was no difference in the effect of PMbR and mastectomy on BCSS in the original cohort (HR = 0.85, 95% CI: 0.66-1.09, p = 0.197), PSM cohort (HR = 0.86, 95% CI: 0.64-1.15, p = 0.310), and GBM cohort (HR = 0.84, 95% CI: 0.61-1.17, p = 0.298). Triple-negative breast cancer (TNBC) was a detrimental factor affecting BCSS for patients in the PMbR group.
CONCLUSIONS
Our study demonstrated that PMbR is an oncologically safe surgical treatment and can be widely recommended in clinics for females with non-TNBC staged by T0-3N2-3M0.
Topics: Female; Humans; Breast Neoplasms; Mastectomy; Retrospective Studies; Propensity Score; Mammaplasty; Triple Negative Breast Neoplasms
PubMed: 37795774
DOI: 10.1002/cam4.6579 -
JAMA Surgery Mar 2024Robotic-assisted nipple-sparing mastectomies with multiport robots have been described in the US since 2015; however, significant hurdles to multiport robotic surgery...
IMPORTANCE
Robotic-assisted nipple-sparing mastectomies with multiport robots have been described in the US since 2015; however, significant hurdles to multiport robotic surgery exist in breast surgery.
OBJECTIVE
To demonstrate that the single-port da Vinci SP (Intuitive Surgical) robotic system is feasible in patients undergoing robotic nipple-sparing mastectomy (rNSM).
DESIGN, SETTING, AND PARTICIPANTS
An initial case series of 20 patients at a large university hospital underwent bilateral single-port robotic nipple-sparing mastectomies (SPrNSM) with tissue expander reconstruction from February 1, 2020, through January 4, 2023. Participants included women who met surgical criteria for nipple-sparing mastectomies, per standard of care.
INTERVENTION
Surgery using a single-port robot and the surgical technique of the authors.
MAIN OUTCOMES AND MEASURES
Age, indication, body mass index, breast size, operative time, conversion to open surgery, systemic complications, postoperative skin necrosis, and reported skin and nipple areolar complex (NAC) sensation.
RESULTS
Twenty women aged 29 to 63 years (median, 40 years) underwent bilateral SPrNSM. Eleven patients completed prophylactic surgery due to a high risk for breast cancer (more than 20% lifetime risk) and 9 patients had breast cancer. Breast size ranged from A through D cup with median B cup and a body mass index range of 19.7 through 27.8 (median 24.4). The total duration of the procedure from incision to skin closure for both sides ranged from 205 minutes to 351 minutes (median, 277). The median robotic time for bilateral SPrNSM was 116 minutes and varied by cup size (A cup, 95 minutes; B cup, 140 minutes; C cup, 118 minutes; D cup, 114 minutes) with no inflection point in learning curve. No cases were converted to open and no immediate complications, such as hematoma, positive margins, or recurrence, were seen. In the first 10 patients prior to routine sensation testing, 20 resected breasts had measurable NAC sensation at a range from 4 to 36 months post-index resection (65%). In the second 10 patients of the cohort, measurable NAC was preserved in 13 of 20 resected breasts 2 weeks following the index operation (65%).
CONCLUSION AND RELEVANCE
In this case series, SPrNSM with immediate reconstruction was feasible and performed safely by an experienced breast surgeon with limited previous robotic training. Further studies confirming the preliminary data demonstrating improved NAC and skin sensation following SPrNSM are warranted.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT05245812.
Topics: Humans; Female; Mastectomy; Robotics; Robotic Surgical Procedures; Breast Neoplasms; Nipples; Feasibility Studies
PubMed: 38231502
DOI: 10.1001/jamasurg.2023.6999 -
Annals of Plastic Surgery May 2024After breast surgery, patients experience significant alterations to breast sensation, which can diminish quality of life. Nerve coaptation technique, introduced in the... (Review)
Review
BACKGROUND
After breast surgery, patients experience significant alterations to breast sensation, which can diminish quality of life. Nerve coaptation technique, introduced in the 1990s, has gained traction in recent years. We performed a scoping review of the literature to determine the available outcomes in sensate breast reconstruction.
METHODS
The review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews statement guidelines. EMBASE and PubMed databases were queried using standardized terminology. Studies were included if they reported original sensory outcomes following innervation techniques during breast reconstruction and were published from January 1, 1990, to April 18, 2022. Data extraction and analyses were performed on Microsoft Excel.
RESULTS
From 602 screened articles, 27 studies met the inclusion criteria. Innervated autologous reconstructive procedures were described in 24, whereas the remaining 3 (all published after 2019) described direct reinnervation of the nipple-areola complex. Most (88.9%) of the studies comparing innervated versus noninnervated reconstruction reported improved sensory outcomes in at least 1 modality. Two studies investigated patient-reported outcomes using validated questionnaires, both of which reported improvement with innervated reconstruction.
CONCLUSIONS
Sensate breast reconstruction has the potential to improve outcomes for patients. There is a recent progressive increase in studies involving direct nipple-areolar reinnervation. Larger, prospective studies are needed to better characterize the quality-of-life outcome using validated scales, as well as evaluate sensory and patient-reported outcomes with implant and autologous reconstruction.
Topics: Humans; Mammaplasty; Female; Quality of Life; Breast Neoplasms; Nipples; Mastectomy; Breast
PubMed: 38685499
DOI: 10.1097/SAP.0000000000003832 -
Breast Cancer Cryoablation Fundamentals Past and Present: Technique Optimization and Imaging Pearls.Academic Radiology Oct 2023Surgical treatment for breast cancer has evolved from radical mastectomy to modified radical mastectomy to breast-conserving surgery. As the de-escalation of surgical... (Review)
Review
Surgical treatment for breast cancer has evolved from radical mastectomy to modified radical mastectomy to breast-conserving surgery. As the de-escalation of surgical treatment for breast cancer continues, nonsurgical treatment for early-stage breast cancer with favorable ancillary features (low grade, positivity for hormone receptors) is being explored. Of the nonsurgical treatment options, cryoablation has demonstrated the greatest appeal, proven to be effective, safe, well tolerated, and feasible in an outpatient setting with local anesthetic alone. Results of past and interim results of current trials of cryoablation of stage I low-grade breast cancer with curative intent are promising, with an overall clinical success rate of 98% and recurrence rates consistent with those expected following lumpectomy. Cryoablation is also an alternative palliative treatment for patients who cannot tolerate or who have disease that is refractory to or recurs after standard-of-care breast cancer treatment and may have immunological therapeutic effects, warranting future research. Understanding the indications and optimal technique for breast cancer cryoablation and understanding typical imaging findings after cryoablation are essential to ensure the success of the procedure in carefully selected patients.
Topics: Humans; Female; Breast Neoplasms; Cryosurgery; Mastectomy; Mastectomy, Segmental; Diagnostic Imaging
PubMed: 37455177
DOI: 10.1016/j.acra.2023.05.019 -
Journal of the American College of... Sep 2023Although obesity has previously been associated with poor outcomes after mastectomy and breast reconstruction, its impact across the WHO obesity classification spectrum... (Review)
Review
BACKGROUND
Although obesity has previously been associated with poor outcomes after mastectomy and breast reconstruction, its impact across the WHO obesity classification spectrum and the differential effects of various optimization strategies on patient outcomes have yet to be delineated. We sought to examine the impact of WHO obesity classification on intraoperative surgical and medical complications, postoperative surgical and patient-reported outcomes of mastectomy and autologous breast reconstruction, and delineate outcomes optimization strategies for obese patients.
STUDY DESIGN
This is a review of consecutive patients who underwent mastectomy and autologous breast reconstruction from 2016 to 2022. Primary outcomes were complication rates. Secondary outcomes were patient-reported outcomes and optimal management strategies.
RESULTS
We identified 1,640 mastectomies and reconstructions in 1,240 patients with mean follow-up of 24.2 ± 19.2 months. Patients with class II/III obesity had higher adjusted risk of wound dehiscence (odds ratio [OR] 3.20; p < 0.001), skin flap necrosis (OR 2.60; p < 0.001), deep venous thrombosis (OR 3.90; p < 0.033), and pulmonary embolism (OR 15.3; p = 0.001) than nonobese patients. Obese patients demonstrated significantly lower satisfaction with breasts (67.3 ± 27.7 vs 73.7 ± 24.0; p = 0.043) and psychological well-being (72.4 ± 27.0 vs 82.0 ± 20.8; p = 0.001) than nonobese patients. Unilateral delayed reconstructions were associated with independently shorter hospital stay (β -0.65; p = 0.002) and lower adjusted risk of 30-day readmission (OR 0.45; p = 0.031), skin flap necrosis (OR 0.14; p = 0.031), and pulmonary embolism (OR 0.07; p = 0.021).
CONCLUSIONS
Obese women should be closely monitored for adverse events and lower quality of life, offered measures to optimize thromboembolic prophylaxis, and advised on the risks and benefits of unilateral delayed reconstruction.
Topics: Humans; Female; Mastectomy; Quality of Life; Beauty; Breast Neoplasms; Mammaplasty; Obesity; Postoperative Complications; Pulmonary Embolism; Necrosis; Retrospective Studies
PubMed: 37144798
DOI: 10.1097/XCS.0000000000000736 -
Journal of Breast Imaging Jan 2024Patients with BRCA1 or BRCA2 gene mutations are at high risk for the development of breast cancer. This article reviews the current evidence for breast cancer screening... (Review)
Review
Patients with BRCA1 or BRCA2 gene mutations are at high risk for the development of breast cancer. This article reviews the current evidence for breast cancer screening of patients with BRCA1 or BRCA2 pathogenic gene mutations if they have not undergone prophylactic mastectomy. It will review the current evidence-based imaging recommendations for different modalities and ages of screening initiation in screening this patient population at high risk. Special considerations in transgender BRCA1 and BRCA2 mutation carriers are also discussed.
Topics: Humans; Female; Breast Neoplasms; Mammography; Mastectomy; Mutation; Genes, BRCA2
PubMed: 38166173
DOI: 10.1093/jbi/wbad093