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Surgery Today Jun 2021Advances in multi-modality treatments incorporating systemic chemotherapy, endocrine therapy, and radiotherapy for the management of breast cancer have resulted in a... (Comparative Study)
Comparative Study Review
Advances in multi-modality treatments incorporating systemic chemotherapy, endocrine therapy, and radiotherapy for the management of breast cancer have resulted in a surgical-management paradigm change toward less-aggressive surgery that combines the use of breast-conserving or -reconstruction therapy as a new standard of care with a higher emphasis on cosmesis. The implementation of skin-sparing and nipple-sparing mastectomies (SSM, NSM) has been shown to be oncologically safe, and breast reconstructive surgery is being performed increasingly for patients with breast cancer. NSM and breast reconstruction can also be performed as prophylactic or risk-reduction surgery for women with BRCA gene mutations. Compared with conventional breast construction followed by total mastectomy (TM), NSM preserving the nipple-areolar complex (NAC) with breast reconstruction provides psychosocial and aesthetic benefits, thereby improving patients' cosmetic appearance and body image. Implant-based breast reconstruction (IBBR) has been used worldwide following mastectomy as a safe and cost-effective method of breast reconstruction. We review the clinical evidence about immediate (one-stage) and delayed (two-stage) IBBR after NSM. Our results suggest that the postoperative complication rate may be higher after NSM followed by IBBR than after TM or SSM followed by IBBR.
Topics: Adult; Aged; Breast Implantation; Breast Implants; Breast Neoplasms; Combined Modality Therapy; Cost-Benefit Analysis; Female; Humans; Mammaplasty; Mastectomy, Segmental; Middle Aged; Mutation; Nipples; Organ Sparing Treatments; Prophylactic Mastectomy; Safety; Treatment Outcome; Ubiquitin-Protein Ligases
PubMed: 33185799
DOI: 10.1007/s00595-020-02175-4 -
JAMA Surgery Aug 2022Rates of lumpectomy for breast cancer management in the United States previously declined in favor of more aggressive surgical options, such as mastectomy and... (Observational Study)
Observational Study
IMPORTANCE
Rates of lumpectomy for breast cancer management in the United States previously declined in favor of more aggressive surgical options, such as mastectomy and contralateral prophylactic mastectomy (CPM).
OBJECTIVE
To evaluate longitudinal trends in the rates of lumpectomy and mastectomy, including unilateral mastectomy vs CPM rates, and to determine characteristics associated with current surgical practice using 3 national data sets.
DESIGN AND SETTING
Data from the National Surgical Quality Improvement Program (NSQIP), Surveillance, Epidemiology, and End Results (SEER) program, and National Cancer Database (NCDB) were examined to evaluate trends in lumpectomy and mastectomy rates from 2005 through 2017. Mastectomy rates were also evaluated with a focus on CPM. Longitudinal trends were analyzed using the Cochran-Armitage test for trend. Multivariate logistic regression models were performed on the NCDB data set to identify predictors of lumpectomy and CPM.
RESULTS
A study sample of 3 467 645 female surgical breast cancer patients was analyzed. Lumpectomy rates reached a nadir between 2010 and 2013, with a significant increase thereafter. Conversely, in comparison with lumpectomy rates, overall mastectomy rates declined significantly starting in 2013. Cochran-Armitage trend tests demonstrated an annual decrease in lumpectomy rates of 1.31% (95% CI, 1.30%-1.32%), 0.07% (95% CI, 0.01%-0.12%), and 0.15% (95% CI, 0.15%-0.16%) for NSQIP, SEER, and NCDB, respectively, from 2005 to 2013 (P < .001, P = .01, and P < .001, respectively). From 2013 to 2017, the annual increase in lumpectomy rates was 0.96% (95% CI, 0.95%-0.98%), 1.60% (95% CI, 1.59%-1.62%), and 1.66% (95% CI, 1.65%-1.67%) for NSQIP, SEER, and NCDB, respectively (all P < .001). Comparisons of specific mastectomy types showed that unilateral mastectomy and CPM rates stabilized after 2013, with unilateral mastectomy rates remaining higher than CPM rates throughout the entire time period.
CONCLUSIONS
This observational longitudinal analysis indicated a trend reversal with an increase in lumpectomy rates since 2013 and an associated decline in mastectomies. The steady increase in CPM rates from 2005 to 2013 has since stabilized. The reasons for the recent reversal in trends are likely multifactorial. Further qualitative and quantitative research is required to understand the factors driving these recent practice changes and their associations with patient-reported outcomes.
Topics: Breast Neoplasms; Female; Humans; Mastectomy; Mastectomy, Segmental; Postoperative Complications; Prophylactic Mastectomy; SEER Program; United States
PubMed: 35675047
DOI: 10.1001/jamasurg.2022.2065 -
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 -
Lymphatic Research and Biology Apr 2022Sexual functions in women with lymphedema secondary to breast cancer surgery have not been investigated sufficiently. This study aimed to compare patients with and...
Sexual functions in women with lymphedema secondary to breast cancer surgery have not been investigated sufficiently. This study aimed to compare patients with and without lymphedema after total mastectomy in terms of emotional state, sexual functions, and quality of life. We also investigated the factors affecting sexual functions in these patients. Married women 20-55 years of age, who presented to lymphedema polyclinic of Health Sciences University Ankara Training and Research Hospital after having undergone total mastectomy at least 1 year earlier owing to breast cancer were included. Twenty-five patients with lymphedema were assigned to the lymphedema group, and 20 without lymphedema to the control group. Hospital Anxiety and Depression Scale (HADS) was used to assess emotional state. We evaluated sexual functions of the participants by Female Sexual Function Index (FSFI) and quality of life with European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QOL-C30). There was no statistically significant difference in age and body mass index between the groups ( > 0.05). The mean HADS score was 13.4 ± 6.5 in lymphedema group and 13.4 ± 6.0 in control group. The groups were also similar in aspect of the HADS score ( > 0.05). FSFI and global health and physical function scores of EORTC QOL-C30 were statistically significantly lower in the lymphedema group ( < 0.05). A statistically significant correlation was found between FSFI and age and time elapsed postmenopause ( < 0.05, for both). We evaluated sexual functions of the patients who underwent mastectomy in this study. Although the HADS score is similar in patients with and without lymphedema, both sexual functions and quality of life are adversely affected in patients who undergo mastectomy and develop lymphedema. This study is important for investigating whether lymphedema developing after total mastectomy affects sexual functions of the patients.
Topics: Breast Neoplasms; Female; Humans; Lymphedema; Mastectomy; Mastectomy, Simple; Pilot Projects; Quality of Life; Surveys and Questionnaires
PubMed: 33646047
DOI: 10.1089/lrb.2020.0053 -
Clinical Breast Cancer Oct 2020Immediate breast reconstruction offers cosmetic and psychological advantages post-mastectomy. There are various options of reconstruction, and this study aims to... (Clinical Trial)
Clinical Trial
INTRODUCTION
Immediate breast reconstruction offers cosmetic and psychological advantages post-mastectomy. There are various options of reconstruction, and this study aims to evaluate the associated complications.
PATIENTS AND METHODS
This is a single-center retrospective study analyzing data from January 1, 2008 to December 31, 2017 for immediate breast reconstruction procedures post-mastectomy performed at an academic breast unit. Procedures included expander and implant insertion, latissimus dorsi, pedicle transverse rectus abdominis musculocutaneous (TRAM), free TRAM, and deep inferior epigastric perforator. Complications and reoperative complications (defined as those requiring a reoperation within the first 30-day period), and associated risk factors were investigated using separate logistic regressions, and odds ratios (ORs) were calculated.
RESULTS
A total of 243 post-mastectomy immediate breast reconstruction procedures and complications rates were analyzed. The overall complication rate was 27.6%, comprised mainly of reconstruction-specific complications such as post-TRAM hernia or bulges, fat necrosis, and implant capsular contracture and leakage. The rate of reoperative complications was relatively low at 6.6%. The flap failure rate was similar between expander/implant reconstruction and autologous reconstruction methods at 3.3% and 5.6%, respectively (P = .60). Logistic regression identified significantly higher risks associated with diabetes mellitus (OR, 5.21; P = .022), obesity (OR, 5.80; P = .016), and free pedicle autologous reconstruction (OR, 3.975; P = .046) for reoperative complications.
CONCLUSION
Different methods of immediate breast reconstruction post-mastectomy are feasible and safe. However, patient variables and procedure choice should be taken into consideration when counseling patients on reconstructive options, as they are strong predictors for postoperative complications.
Topics: Adult; Breast Neoplasms; Female; Follow-Up Studies; Humans; Mammaplasty; Mastectomy; Middle Aged; Postoperative Complications; Prognosis; Retrospective Studies; Risk Factors; Time Factors
PubMed: 32665188
DOI: 10.1016/j.clbc.2019.12.002 -
Journal of Plastic, Reconstructive &... Jun 2022Women with an increased hereditary risk of breast cancer can undergo risk-reducing prophylactic mastectomy. However, there is a balance between how much subcutaneous...
BACKGROUND
Women with an increased hereditary risk of breast cancer can undergo risk-reducing prophylactic mastectomy. However, there is a balance between how much subcutaneous tissue should be resected to achieve maximal reduction of glandular tissue, while leaving viable skin flaps.
METHODS
Forty-five women previously operated with prophylactic mastectomy underwent magnetic resonance tomography (MRT) and ultrasound (US) to investigate the correlation between skin flap thickness and residual glandular tissue. Residual glandular tissue was documented as being present or not present, but not quantified, as the amount of residual glandular tissue in many cases was considered too small to make reliable volume quantifications with available tools. Since a mastectomy skin flap thickness of 5 mm is discussed as an oncologically safe thickness in the literature, this was used as a cut-off.
RESULTS
Following prophylactic mastectomy, residual glandular tissue was detected in 39.3% of all breasts and 27.9% of all the breast quadrants examined by MRT, and 44.1% of all breasts and 21.7% of all the breast quadrants examined by US. Residual glandular tissue was detected in 6.9% of the quadrants in skin flaps ≤ 5 mm and in 37.5% of the quadrants in skin flaps > 5 mm (OR 3.07; CI = 1.41-6.67; p = 0.005). Furthermore, residual glandular tissue increased significantly already when the skin flap thickness exceeded 7 mm.
CONCLUSIONS
This study highlights that complete removal of glandular breast tissue during a mastectomy is difficult and suggests that this is an unattainable goal. We demonstrate that residual glandular tissue is significantly higher in skin flaps > 5 mm in comparison to skin flaps ≤ 5 mm, and that residual glandular tissue increases significantly already when the flap thickness exceeds 7 mm.
Topics: Breast Neoplasms; Female; Humans; Magnetic Resonance Imaging; Mammaplasty; Mastectomy; Prophylactic Mastectomy; Surgical Flaps
PubMed: 35177362
DOI: 10.1016/j.bjps.2022.01.031 -
The Cochrane Database of Systematic... Mar 2023Skin-sparing mastectomy (SSM) is a surgical technique that aims to maximize skin preservation, facilitate breast reconstruction, and improve cosmetic outcomes. Despite... (Review)
Review
BACKGROUND
Skin-sparing mastectomy (SSM) is a surgical technique that aims to maximize skin preservation, facilitate breast reconstruction, and improve cosmetic outcomes. Despite its use in clinical practice, the benefits and harms related to SSM are not well established.
OBJECTIVES
To assess the effectiveness and safety of skin-sparing mastectomy for the treatment of breast cancer.
SEARCH METHODS
We searched Cochrane Breast Cancer's Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP), and ClinicalTrials.gov on 9 August 2019.
SELECTION CRITERIA
Randomized controlled trials (RCTs), quasi-randomized or non-randomized studies (cohort and case-control) comparing SSM to conventional mastectomy for treating ductal carcinoma in situ (DCIS) or invasive breast cancer.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. The primary outcome was overall survival. Secondary outcomes were local recurrence free-survival, adverse events (including overall complications, breast reconstruction loss, skin necrosis, infection and hemorrhage), cosmetic results, and quality of life. We performed a descriptive analysis and meta-analysis of the data.
MAIN RESULTS
We found no RCTs or quasi-RCTs. We included two prospective cohort studies and twelve retrospective cohort studies. These studies included 12,211 participants involving 12,283 surgeries (3183 SSM and 9100 conventional mastectomies). It was not possible to perform a meta-analysis for overall survival and local recurrence free-survival due to clinical heterogeneity across studies and a lack of data to calculate hazard ratios (HR). Based on one study, the evidence suggests that SSM may not reduce overall survival for participants with DCIS tumors (HR 0.41, 95% CI 0.17 to 1.02; P = 0.06; 399 participants; very low-certainty evidence) or for participants with invasive carcinoma (HR 0.81, 95% CI 0.48 to 1.38; P = 0.44; 907 participants; very low-certainty evidence). For local recurrence-free survival, meta-analysis was not possible, due to high risk of bias in nine of the ten studies that measured this outcome. Informal visual examination of effect sizes from nine studies suggested the size of the HR may be similar between groups. Based on one study that adjusted for confounders, SSM may not reduce local recurrence-free survival (HR 0.82, 95% CI 0.47 to 1.42; P = 0.48; 5690 participants; very low-certainty evidence). The effect of SSM on overall complications is unclear (RR 1.55, 95% CI 0.97 to 2.46; P = 0.07, I = 88%; 4 studies, 677 participants; very low-certainty evidence). Skin-sparing mastectomy may not reduce the risk of breast reconstruction loss (RR 1.79, 95% CI 0.31 to 10.35; P = 0.52; 3 studies, 475 participants; very low-certainty evidence), skin necrosis (RR 1.15, 95% CI 0.62 to 2.12; P = 0.22, I = 33%; 4 studies, 677 participants; very low-certainty evidence), local infection (RR 2.04, 95% CI 0.03 to 142.71; P = 0.74, I = 88%; 2 studies, 371 participants; very low-certainty evidence), nor hemorrhage (RR 1.23, 95% CI 0.47 to 3.27; P = 0.67, I = 0%; 4 studies, 677 participants; very low-certainty evidence). We downgraded the certainty of the evidence due to the risk of bias, imprecision, and inconsistency among the studies. There were no data available on the following outcomes: systemic surgical complications, local complications, explantation of implant/expander, hematoma, seroma, rehospitalization, skin necrosis with revisional surgery, and capsular contracture of the implant. It was not possible to perform a meta-analysis for cosmetic and quality of life outcomes due to a lack of data. One study performed an evaluation of aesthetic outcome after SSM: 77.7% of participants with immediate breast reconstruction had an overall aesthetic result of excellent or good versus 87% of participants with delayed breast reconstruction.
AUTHORS' CONCLUSIONS
Based on very low-certainty evidence from observational studies, it was not possible to draw definitive conclusions on the effectiveness and safety of SSM for breast cancer treatment. The decision for this technique of breast surgery for treatment of DCIS or invasive breast cancer must be individualized and shared between the physician and the patient while considering the potential risks and benefits of available surgical options.
Topics: Humans; Female; Carcinoma, Intraductal, Noninfiltrating; Breast Neoplasms; Mastectomy; Mammaplasty; Necrosis
PubMed: 36972145
DOI: 10.1002/14651858.CD010993.pub2 -
Same-day mastectomy and axillary lymph node dissection is safe for most patients with breast cancer.Journal of Surgical Oncology Apr 2022The aim of this study was to evaluate the safety of same-day mastectomy, with or without a sentinel node biopsy (SNB) and/or axillary lymph node dissection (ALND).
BACKGROUND AND OBJECTIVE
The aim of this study was to evaluate the safety of same-day mastectomy, with or without a sentinel node biopsy (SNB) and/or axillary lymph node dissection (ALND).
METHODS
In this retrospective study, we reviewed 913 consecutive women who underwent a simple mastectomy for breast cancer between the years 2014 and 2019 and were treated either with same-day surgery (SDS) or an overnight stay (OS) regime. We reviewed all surgical complications, any unplanned return to care (RTC) and the rehospitalization rate for 30 postoperative days.
RESULTS
A total of 259 patients (28%) were treated with SDS and 654 patients (72%) with an OS regime. There was no difference in RTC (odds ratio: 0.79 [95% confidence interval: 0.53-1.18], p = 0.26) or any major complications between the groups. None of the investigated subgroups, such as patients with previous neoadjuvant therapy, diabetes, obesity (up to a body mass index of 40 kg/m ), the American Society of Anaesthesiologist Class of 3, or elderly patients aged 75-84 years, showed an increased complication rate when treated with the SDS regime.
CONCLUSION
A same-day simple mastectomy is safe with SNB and/or ALND. It can be performed safely for most patients with stable co-morbidities.
Topics: Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Mastectomy; Neoplasm Staging; Retrospective Studies; United States
PubMed: 35050499
DOI: 10.1002/jso.26799 -
The Lancet. Oncology Nov 2020
Topics: Breast Neoplasms; Humans; Mastectomy; Mastectomy, Segmental; Neoplasm, Residual
PubMed: 33152292
DOI: 10.1016/S1470-2045(20)30526-X -
Plastic and Reconstructive Surgery Jul 2023Nipple-sparing mastectomy (NSM) has emerged as an alternative procedure for skin-sparing mastectomy (SSM), followed by immediate breast reconstruction. Because oncologic... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Nipple-sparing mastectomy (NSM) has emerged as an alternative procedure for skin-sparing mastectomy (SSM), followed by immediate breast reconstruction. Because oncologic safety appears similar, patient-reported outcomes (PROs) and complication risks may guide decision-making in individual patients. Therefore, the aim of this systematic review was to compare PROs and complication rates after NSM and SSM.
METHODS
A systematic literature review evaluating NSM versus SSM was performed using the Embase, MEDLINE, and Cochrane databases. Methodologic quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies. Primary outcomes were PROs and complications. Studies that evaluated BREAST-Q scores were used to perform meta-analyses on five BREAST-Q domains.
RESULTS
Thirteen comparative studies including 3895 patients were selected from 1202 articles found. Meta-analyses of the BREAST-Q domains showed a significant mean difference of 7.64 in the Sexual Well-being domain ( P = 0.01) and 4.71 in the Psychosocial Well-being domain ( P = 0.03), both in favor of NSM. Using the specifically designed questionnaires, no differences in overall satisfaction scores were found. There were no differences in overall complication rates between the two groups.
CONCLUSIONS
Patient satisfaction scores were high after both NSM and SSM; however, NSM led to a higher sexual and psychosocial well-being. No differences in complication rates were found. In combination with other factors, such as oncologic treatments, complication risk profile, and fear of cancer recurrence, the decision for NSM or SSM has to be made on an individual basis and only if NSM is considered to be oncologically safe.
Topics: Humans; Female; Mastectomy; Nipples; Quality of Life; Breast Neoplasms; Mammaplasty; Retrospective Studies
PubMed: 36728484
DOI: 10.1097/PRS.0000000000010155