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Korean Journal of Radiology Jul 2023Prospective studies on postoperative residual breast tissue (RBT) after robotic-assisted nipple-sparing mastectomy (R-NSM) for breast cancer are limited. RBT presents an... (Review)
Review
OBJECTIVE
Prospective studies on postoperative residual breast tissue (RBT) after robotic-assisted nipple-sparing mastectomy (R-NSM) for breast cancer are limited. RBT presents an unknown risk of local recurrence or the development of new cancer after curative or risk-reducing mastectomies. This study investigated the technical feasibility of using magnetic resonance imaging (MRI) to evaluate RBT after R-NSM in women with breast cancer.
MATERIALS AND METHODS
In this prospective pilot study, 105 patients, who underwent R-NSM for breast cancer at Changhua Christian Hospital between March 2017 and May 2022, were subjected to postoperative breast MRI to evaluate the presence and location of RBT. The postoperative MRI scans of 43 patients (age, 47.8 ± 8.5 years), with existing preoperative MRI scans, were evaluated for the presence and location of RBT. In total, 54 R-NSM procedures were performed. In parallel, we reviewed the literature on RBT after nipple-sparing mastectomy, considering its prevalence.
RESULTS
RBT was detected in 7 (13.0%) of the 54 mastectomies (6 of the 48 therapeutic mastectomies and 1 of the 6 prophylactic mastectomies). The most common location for RBT was behind the nipple-areolar complex (5 of 7 [71.4%]). Another RBT was found in the upper inner quadrant (2 of 7 [28.6%]). Among the six patients who underwent RBT after therapeutic mastectomies, one patient developed a local recurrence of the skin flap. The other five patients with RBT after therapeutic mastectomies remained disease-free.
CONCLUSION
R-NSM, a surgical innovation, does not seem to increase the prevalence of RBT, and breast MRI showed feasibility as a noninvasive imaging tool for evaluating the presence and location of RBT.
Topics: Female; Humans; Adult; Middle Aged; Breast Neoplasms; Mastectomy; Prospective Studies; Nipples; Robotic Surgical Procedures; Pilot Projects; Magnetic Resonance Imaging; Retrospective Studies
PubMed: 37404106
DOI: 10.3348/kjr.2022.0708 -
EClinicalMedicine Feb 2024Developing strategies to prevent breast cancer-related arm lymphoedema (BCRAL) is a critical unmet need because there are no effective interventions to eradicate it once...
Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidance for the prevention of breast cancer-related arm lymphoedema (BCRAL): international Delphi consensus-based recommendations.
BACKGROUND
Developing strategies to prevent breast cancer-related arm lymphoedema (BCRAL) is a critical unmet need because there are no effective interventions to eradicate it once it reaches a chronic state. Certain strategies such as prospective surveillance programs and prophylactic lymphatic reconstruction have been reported to be effective in clinical trials. However, a large variation exists in practice based on clinician preference, organizational standards, and local resources.
METHODS
A two-round international Delphi consensus process was performed from February 27, 2023 to May 25, 2023 to compile opinions of 55 experts involved in the care and research of breast cancer and lymphoedema on such interventions.
FINDINGS
Axillary lymph node dissection, use of post-operative radiotherapy, relative within-arm volume increase one month after surgery, greater number of lymph nodes dissected, and high body mass index were recommended as the most important risk factors to guide selection of patients for interventions to prevent BCRAL. The panel recommended that prospective surveillance programs should be implemented to screen for and reduce risks of BCRAL where feasible and resources allow. Prophylactic compression sleeves, axillary reverse mapping and prophylactic lymphatic reconstruction should be offered for patients who are at risk for developing BCRAL as options where expertise is available and resources allow. Recommendations on axillary management in clinical T1-2, node negative breast cancer patients with 1-2 positive sentinel lymph nodes were also provided by the expert panel. Routine axillary lymph node dissection should not be offered in these patients who receive breast conservation therapy. Axillary radiation instead of axillary lymph node dissection should be considered in the same group of patients undergoing mastectomy.
INTERPRETATION
An individualised approach based on patients' preferences, risk factors for BCRAL, availability of treatment options and expertise of the healthcare team is paramount to ensure patients at risk receive preventive interventions for BCRAL, regardless of where they are receiving care.
FUNDING
This study was not supported by any funding. RJC received investigator grant support from the Australian National Health and Medical Research Council (APP1194051).
PubMed: 38333542
DOI: 10.1016/j.eclinm.2024.102441 -
Frontiers in Oncology 2023While standard treatment has shown efficacy in patients with breast cancer gene () mutations, recurrence rates are high and additional effective therapies are needed....
While standard treatment has shown efficacy in patients with breast cancer gene () mutations, recurrence rates are high and additional effective therapies are needed. Olaparib, a poly adenosine diphosphate-ribose polymerase (PARP) inhibitor, approved for the treatment of metastatic germline / breast cancer (BC), has demonstrated evidence of a progression-free survival (PFS) benefit, good safety profile, and improved quality of life compared with standard chemotherapy. We here describe the case of a patient with mutated advanced BC and a long history of response to chemotherapy and immunotherapy who received systemic treatment with olaparib. First diagnosed in March 2011 at the age of 38 years with early-stage BC of the right breast, she underwent quadrantectomy plus ipsilateral axillary lymphadenectomy and adjuvant treatments with chemotherapy regimen containing 5-fluorouracil, epirubicin, and cyclophosphamide (FEC) followed by radiotherapy. Five years later, following a contralateral nodule detection leading to left breast quadrantectomy, she received adjuvant systemic treatment with docetaxel plus cyclophosphamide and radiotherapy. Gene testing showed a germline deleterious variant, and she underwent bilateral prophylactic mastectomy and oophorectomy. One year later, skin metastasis and bone infiltrations were detected, and she was started on first-line systemic treatment. The patient was enrolled in the IMpassion131 trial (investigating atezolizumab addition to paclitaxel) but unblinding showed that she was randomized in the placebo arm. She received second-line systemic therapy with LAG525 plus carboplatin (CLAG525B2101 trial) resulting in a PFS of 14 months. At disease progression, she was eligible for systemic third-line therapy with olaparib (300 mg twice daily) and had a complete response after 6 months of therapy and a PFS of 40 months at the time of writing. To the best of our knowledge, this is the first report of a complete response following treatment with third-line systemic olaparib in a long-responding patient and relatively good tolerability and quality of life, pre-treated with both chemotherapy and immunotherapy.
PubMed: 37601649
DOI: 10.3389/fonc.2023.1214660 -
Current Oncology (Toronto, Ont.) Oct 2023Pathogenic variants (PVs) in and increase the lifetime risks of breast and ovarian cancer. Guidelines recommend breast screening (magnetic resonance imaging (MRI) and...
Specialty Care and Counselling about Hereditary Cancer Risk Improves Adherence to Cancer Screening and Prevention in Newfoundland and Labrador Patients with Pathogenic Variants: A Population-Based Retrospective Cohort Study.
Pathogenic variants (PVs) in and increase the lifetime risks of breast and ovarian cancer. Guidelines recommend breast screening (magnetic resonance imaging (MRI) and mammogram) or risk-reducing mastectomy (RRM) and salpingo-oophorectomy (RRSO). We sought to (1) characterize the population of PV carriers in Newfoundland and Labrador (NL), (2) evaluate risk-reducing interventions, and (3) identify factors influencing screening and prevention adherence. We conducted a retrospective study from a population-based provincial cohort of PV carriers. The eligibility criteria for risk-reducing interventions were defined for each case and patients were categorized based on their level of adherence with recommendations. Chi-squared and regression analyses were used to determine which factors influenced uptake and level of adherence. A total of 276 PV carriers were identified; 156 living NL biological females composed the study population. Unaffected females were younger at testing than those with a cancer diagnosis (44.4 years versus 51.7 years; = 0.002). Categorized by eligibility, 61.0%, 61.6%, 39.0%, and 75.7% of patients underwent MRI, mammogram, RRM, and RRSO, respectively. Individuals with breast cancer were more likely to have RRM (64.7% versus 35.3%; < 0.001), and those who attended a specialty hereditary cancer clinic were more likely to be adherent to recommendations (73.2% versus 13.4%; < 0.001) and to undergo RRSO (84.1% versus 15.9%; < 0.001). Nearly 40% of the female PV carriers were not receiving breast surveillance according to evidence-based recommendations. Cancer risk reduction and uptake of breast imaging and prophylactic surgeries are significantly higher in patients who receive dedicated specialty care. Organized hereditary cancer prevention programs will be a valuable component of Canadian healthcare systems and have the potential to reduce the burden of disease countrywide.
Topics: Humans; Female; Breast Neoplasms; BRCA1 Protein; Mastectomy; Retrospective Studies; BRCA2 Protein; Early Detection of Cancer; Genetic Predisposition to Disease; Newfoundland and Labrador; Canada; Counseling
PubMed: 37887578
DOI: 10.3390/curroncol30100678 -
The American Surgeon Apr 2024For patients with ductal carcinoma in situ (DCIS) undergoing breast conservation surgery (BCS), guidelines advise a margin width of at least 2 mm, with studies...
BACKGROUND
For patients with ductal carcinoma in situ (DCIS) undergoing breast conservation surgery (BCS), guidelines advise a margin width of at least 2 mm, with studies demonstrating decreased recurrence risk compared to narrower margins. However, limited data exist establishing if this margin is appropriate in mastectomies, and specifically for nipple-sparing mastectomy (NSM). Consequently, we evaluated the margins of DCIS patients undergoing NSM and resulting oncologic outcomes.
METHODS
A single-institution retrospective review was performed in patients with DCIS or DCIS with microinvasion (DCIS + MI) undergoing NSM from April 2010 to December 2021. Patient and tumor characteristics, margin status, treatment, and outcomes information were collected. The association between margins and local-regional (LRR) and distant recurrence (DR) were examined.
RESULTS
161 patients were included, comprising 284 NSM (164 therapeutic, 120 prophylactic). 153 patients had DCIS and 8 had DCIS + MI. Most patients had hormone sensitive, 123 (76.4%), and nuclear grade 2, 72 (44.7%), disease. In total, 35 (21.7%) patients had positive or <2 mm margins. Of these, 21 (60%) involved the anterior margin. At a median follow-up of 45 months (range 0-151), 2.5% (n = 4) had a LRR and .6% (n = 1) had a DR. Of patients with a recurrence, only 2 had positive or <2 mm margins, 1 had received endocrine therapy, and none received adjuvant radiation.
DISCUSSION
No specific margin status was found to correlate with recurrence for patients with DCIS or DCIS + MI undergoing NSM, with an altogether low recurrence risk. Overall, this suggests that recommended DCIS margins in BCS doesn't necessarily apply in NSM, where margins of <2 mm may be acceptable.
PubMed: 38605446
DOI: 10.1177/00031348241246179 -
The American Surgeon Oct 2023Breast surveillance in patients with BRCA mutations include mammography (MMG) and MRI. Patients may elect to undergo risk-reducing bilateral prophylactic mastectomies...
INTRODUCTION
Breast surveillance in patients with BRCA mutations include mammography (MMG) and MRI. Patients may elect to undergo risk-reducing bilateral prophylactic mastectomies (BPM). Sentinel lymph node biopsies (SLNB) are frequently performed and associated with increased morbidity. This study sought to determine the correlation between preoperative imaging and the final pathology and evaluate the role of SLNB in these high-risk patients.
METHODS
A prospective database identified BRCA patients who underwent BPM between 2006 and 2022. Imaging, pathology, and operative reports were reviewed.
RESULTS
170 patients with BRCA 1/2 mutations were identified. 162 (95.3%) had imaging within one year of BPM. Of these, 28 (17.3%) patients had a MMG/ultrasound, 53 (32.7%) had an MRI, and 81 (50%) had both; 21/162 (13.0%) patients had abnormal imaging. Bilateral SLNB were performed in 31 (18.2%) patients, of which 7 had abnormal imaging; unilateral SLNB were performed in 4 (2.4%) patients, of which 3 had abnormal imaging. 11/170 (6.4%) patients had a malignancy and only one (9%) of these patients had imaging abnormalities. 1/170 (0.6%) patient had an invasive carcinoma requiring an axillary lymph node dissection (ALND), and 10/170 (5.9%) patients had ductal carcinoma in situ (DCIS). 25/170 (14.7%) had ADH/ALH. Only 7/170 (4.1%) patients had imaging abnormalities and abnormal pathology. All SLNB and ALND performed demonstrated no metastatic disease.
DISCUSSION
There is a high rate of discordance between preoperative imaging prior to surgery in BRCA patients undergoing prophylactic mastectomies and final pathology. This study does not support routine SLNB at the time of BPM.
Topics: Humans; Female; Sentinel Lymph Node Biopsy; Prophylactic Mastectomy; Incidence; Mastectomy; Lymph Node Excision; Carcinoma, Intraductal, Noninfiltrating; Breast Neoplasms; Mutation; Axilla
PubMed: 37184070
DOI: 10.1177/00031348231175498 -
Plastic and Reconstructive Surgery.... May 2024Breast reconstruction is a standard procedure in postmastectomy plastic surgery. The necessity of routine histological examinations for mastectomy scars during delayed...
BACKGROUND
Breast reconstruction is a standard procedure in postmastectomy plastic surgery. The necessity of routine histological examinations for mastectomy scars during delayed reconstruction remains a topic of debate. We evaluated the need for histological examination of scars during delayed breast reconstruction.
METHODS
We conducted a systematic review using PubMed, TDnet, and Cochrane Central in August 2023. Inclusion criteria involved delayed breast reconstruction with histological scar analysis and malignancy reporting. Exclusion criteria encompassed noncancerous breast diseases, prophylactic mastectomies, articles lacking relevant information, case reports, technique descriptions, and reviews. We independently assessed articles. Differences in recurrence rates were determined using a Z-test for proportions. A linear regression model explored the relationship between reconstruction timing and pathological results. The number needed to treat was calculated based on the literature. The Wilcoxon test was used to compare mean reconstruction times and postreconstruction follow-up between groups.
RESULTS
Our analysis covered 11 retrospective observational studies published between 2003 and 2018, including 3754 mastectomy scars. The malignancy recurrence rate was 0.19%, consistent with previous reports, with a number needed to treat of 144.93-188.68 patients. The timing of breast reconstruction postmastectomy averaged 19.9 months, without statistically significant association between reconstruction timing and recurrence rates. Postreconstruction follow-up periods ranged from 60 to 87 months. The postreconstruction adverse outcomes ratio was 2.21%.
CONCLUSIONS
Assessing the necessity of histological examination in breast reconstruction is complex. Based on the literature and this study, we do not recommend routine histological examination of mastectomy scars during delayed reconstruction. A selective approach based on risk factors may be beneficial, warranting further research.
PubMed: 38798931
DOI: 10.1097/GOX.0000000000005847 -
JPRAS Open Dec 2023Bilateral mastectomy for both therapeutic and prophylactic reasons is becoming increasingly important. To achieve good results after mastectomy, synthetic meshes are...
BACKGROUND
Bilateral mastectomy for both therapeutic and prophylactic reasons is becoming increasingly important. To achieve good results after mastectomy, synthetic meshes are often used as an alternative to acellular dermal matrices (ADMs). The aim of this study is to analyze the results of subcutaneous mastectomies and direct-to-implant breast reconstruction using SERASYNTH MESH BR.
METHODS
In this work, data from mastectomies ( = 32) in 22 patients without prior radiation after breast reconstruction with SERASYNTH MESH BR from a single center were retrospectively analyzed with 1 year follow-up. Complications were categorized as serious (need for revision surgery) and minor events. Statistical analysis was performed using the -test in SPSS. Data were compared with the existing literature.
RESULTS
Major complications occurred in 15.6% ( = 5). Two out of five revisions were due to hematoma. In three cases, a seroma followed by other complications (e.g., infections, necrosis) necessitated revision. Minor complications occurred in 12.5% of cases. Due to the safety aspect, implants were replaced in each revision. There was no significant difference in complication rates between prophylactic and therapeutic mastectomies ( = 0.3815, SE = 0.171). There was no statistically significant difference in esthetic outcomes ( = 0.3846).
CONCLUSION
The application of the absorbable polymer poly-p-dioxanone SERASYNTH MESH BR has complication rates comparable to those reported in the existing literature. Careful patient selection is paramount in order to limit the complication rate. SERASYNTH MESH BR can be considered a safe tool to achieve esthetic results in combination with direct-to-implant breast reconstruction.
PubMed: 37745008
DOI: 10.1016/j.jpra.2023.08.001 -
Plastic and Reconstructive Surgery.... Oct 2023Infections are problematic in postmastectomy implant-based reconstruction with infection rates as high as 30%. Strategies to reduce the risk of infection have...
Infections are problematic in postmastectomy implant-based reconstruction with infection rates as high as 30%. Strategies to reduce the risk of infection have demonstrated various efficacies. A prolonged course of systemic, oral antibiotics has not shown evidence-based benefit. Although absorbable antibiotic beads have been described for orthopedic procedures and pressure wounds, their use has not been well studied during breast reconstruction, particularly for prepectoral implant placement. The purpose of this study was to evaluate the selective use of prophylactic absorbable calcium sulfate antibiotic beads during high-risk implant-based, prepectoral breast reconstruction after mastectomy. Patients who underwent implant-based, prepectoral breast reconstruction between 2019 and 2022 were reviewed. Groups were divided into those who received antibiotic beads and those who did not. Outcome variables included postoperative infection at 90 days. A total of 148 patients (256 implants) were included: 15 patients (31 implants) who received biodegradable antibiotic beads and 133 patients (225 implants) in the control group. Patients who received antibiotic beads were more likely to have a history of infection (66.7%) compared with the control group (0%) ( < 0.01). Surgical site infection occurred in 3.2% of implants in the antibiotic bead group compared with 7.6%, but this did not reach statistical significance. The incidence of infection in high-risk patients who have absorbable antibiotic beads placed during the time of reconstruction seems to be normalized to the control group in this pilot study. We present a novel use of prophylactic absorbable antibiotic beads in prepectoral breast implant reconstruction.
PubMed: 37850203
DOI: 10.1097/GOX.0000000000005353 -
Plastic and Reconstructive Surgery.... Nov 2023Poland syndrome is classically described as symbrachydactyly, with hypoplasia of the pectoralis major and other upper thoracic musculoskeletal structures. It is thought...
BACKGROUND
Poland syndrome is classically described as symbrachydactyly, with hypoplasia of the pectoralis major and other upper thoracic musculoskeletal structures. It is thought to be caused by intrauterine interruption in subclavian arterial flow and often includes breast hypoplasia. Affected vasculature can pose a challenge for reconstruction with free flaps because inflow may not be reliable in this patient population.
METHODS
We present the rare case of a 28-year-old woman with left-sided Poland syndrome, significant family history of breast cancer, and mutation who underwent bilateral prophylactic nipple-sparing mastectomies with successful immediate bilateral deep inferior epigastric artery perforator free flap reconstruction. The surgical literature in this clinical scenario is also reviewed.
RESULTS
Preoperative computed tomography angiography of the chest successfully demonstrated the patency and quantified the caliber of the internal mammary vessels to support free flap breast reconstruction.
CONCLUSIONS
Free tissue transfer is a viable option for breast reconstruction in patients with Poland syndrome undergoing mastectomy guided by preoperative computed tomography angiography to characterize the internal mammary vasculature.
PubMed: 37936827
DOI: 10.1097/GOX.0000000000005374