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Clinical Breast Cancer Feb 2020Implant-sparing mastectomy (ISM) is a skin-sparing mastectomy that preserves a retropectoral implant and potentially eliminates the need for tissue expansion or complex... (Comparative Study)
Comparative Study
INTRODUCTION
Implant-sparing mastectomy (ISM) is a skin-sparing mastectomy that preserves a retropectoral implant and potentially eliminates the need for tissue expansion or complex reconstruction. This study aimed to determine oncologic and surgical outcomes and reconstructive patterns in patients undergoing ISM.
PATIENTS AND METHODS
A single-institution, retrospective review of patients undergoing ISM from 2006 to 2018 was performed. Patient/tumor characteristics, stage, adjuvant therapy use, 90-day complication rates, reconstruction type, and disease recurrence were collected.
RESULTS
A total of 121 ISMs in 73 women were performed. Seventy (57.9%) ISMs were for breast cancer (BC) treatment and 51 (42.1%) for prophylaxis. Among BC cases, 72.3% were cT1/cT2 and 73.8% were cN0; 72.3% received systemic therapy and 33.8% received radiation therapy. There were 3 deaths owing to BC at the median follow-up of 35 months. Among 5 recurrences, only 1 was local. There was no BC identified after prophylactic ISM. Total 90-day complication rate per ISM was 15.7%. Rates were 0.8% for both seroma and wound infection, 2.5% for wound dehiscence, 3.3% for hematoma, and 8.2% for skin necrosis. The majority (72.6%) of patients required only implant exchange for reconstruction. Overall use of autologous reconstruction was low (12.3%); 77.8% of flaps were performed in patients receiving radiation therapy.
CONCLUSION
ISM is a unique approach for patients pursuing mastectomy for BC treatment or prevention with equivalent oncologic outcomes and complication rates to mastectomy with reconstruction. Reconstruction for the majority was markedly simplified by elimination of tissue expansion while maintaining a low rate of flap reconstruction.
Topics: Adult; Aged; Breast; Breast Implants; Breast Neoplasms; Chemotherapy, Adjuvant; Female; Follow-Up Studies; Humans; Mammaplasty; Mastectomy, Subcutaneous; Middle Aged; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Postoperative Complications; Radiotherapy, Adjuvant; Retrospective Studies; Surgical Flaps; Treatment Outcome; Young Adult
PubMed: 31780380
DOI: 10.1016/j.clbc.2019.08.007 -
Expert Review of Anticancer Therapy Mar 2020: The contralateral prophylactic mastectomy (CPM) rate in the U.S. has been steadily increasing. This is of particular concern because many women who undergo this... (Review)
Review
: The contralateral prophylactic mastectomy (CPM) rate in the U.S. has been steadily increasing. This is of particular concern because many women who undergo this procedure are candidates for breast-conserving surgery.: CPM's medical benefit is related to the risk of contralateral cancer development and whether CPM provides a survival benefit. Contralateral cancer rates have decreased, and CPM does not provide a survival benefit. Other potential benefits of the procedure may be improved quality of life; these data are reviewed. Research efforts have been undertaken to better understand the decision-making process of patients who consider, and ultimately undergo, this procedure.: Decisional traits, personal values, the desire for peace of mind, and the desire to obtain breast symmetry are important factors that drive a woman's decision to undergo CPM. Additionally, many patients lack the knowledge on how different types of breast surgery impact outcomes. To improve the shared decision-making process, a stepwise approach to address possible misconceptions, and clarify the real risks/benefits of this procedure should be utilized. A clear recommendation (for/against) should be made for every patient with newly diagnosed breast cancer who considers CPM. Communication tools to assist patients and surgeons in this process are sorely needed.
Topics: Breast Neoplasms; Communication; Decision Making; Female; Health Knowledge, Attitudes, Practice; Humans; Prophylactic Mastectomy; Quality of Life
PubMed: 32077338
DOI: 10.1080/14737140.2020.1732213 -
Annals of Surgical Oncology Mar 2020Neoadjuvant chemotherapy (NAC) for breast cancer increases breast-conserving surgery (BCS) rates, but many women opt for mastectomy with contralateral prophylactic...
BACKGROUND
Neoadjuvant chemotherapy (NAC) for breast cancer increases breast-conserving surgery (BCS) rates, but many women opt for mastectomy with contralateral prophylactic mastectomy (CPM). Here we evaluate factors associated with CPM use in women undergoing mastectomy post-NAC.
METHODS
A retrospective institutional NAC database review identified women with clinical stage I-III, unilateral invasive breast cancer undergoing unilateral mastectomy (UM) or CPM mastectomy from 9/2013 to 12/2017. Clinical/pathologic characteristics, imaging, and presence of contraindications to BCS post-NAC were compared, with subset analysis of BCS candidates. The multivariable analysis was adjusted for potential confounders.
RESULTS
Five hundred sixty-nine women underwent mastectomy after NAC, 297 (52%) UM and 272 (48%) CPM. On univariable analysis, younger age, BRCA+, lower pre-NAC clinical stage, pathologic complete response, and axillary surgery extent were associated with CPM (all p < 0.01). Favorable post-NAC clinical factors of no residual palpable disease, clinically negative nodes, complete response on breast imaging, and no post-NAC contraindication to BCS were also associated with CPM (all p < 0.01). On multivariable analysis, young age (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.91-0.95), lower pre-NAC stage (OR 0.51, 95% CI 0.34-0.77), and no contraindication to BCS (OR 3.12, 95% CI 2.02-4.82) were significantly associated with CPM. Among the 203 (35%) women who had no contraindications to BCS post-NAC, 145 (71%) underwent CPM. BRCA+ and family history were reasons more frequently cited for mastectomy among CPM than UM (p < 0.001).
CONCLUSIONS
CPM was performed in 48% of women undergoing mastectomy after NAC; younger women with earlier-stage cancers were more likely to undergo CPM. While increased use of CPM in women with more favorable disease is medically appropriate, our findings indicate a lost opportunity for use of BCS.
Topics: Antineoplastic Combined Chemotherapy Protocols; Breast Neoplasms; Female; Follow-Up Studies; Humans; Middle Aged; Neoadjuvant Therapy; Prognosis; Prophylactic Mastectomy; Retrospective Studies
PubMed: 31732944
DOI: 10.1245/s10434-019-08038-8 -
Scandinavian Journal of Surgery : SJS :... Sep 2022The reported rate of surgical site infections (SSIs) in breast cancer surgery varies widely in previous literature. The use of antibiotic prophylaxis is controversial... (Review)
Review
BACKGROUND AND OBJECTIVE
The reported rate of surgical site infections (SSIs) in breast cancer surgery varies widely in previous literature. The use of antibiotic prophylaxis is controversial but recommended by several guidelines. The aim of this study was to evaluate the efficacy of routine antibiotic prophylaxis in patients with breast cancer undergoing mastectomy.
METHODS
In this retrospective single-institution study, we reviewed 1413 consecutive female breast cancer patients who underwent mastectomy and/or axillary lymph node surgery between years 2012 and 2019. Prophylactic antibiotics for all patients undergoing mastectomy was introduced in our hospital in 2016 and before that the prophylaxis was prescribed individually on surgeons' preference. All patient records for 30 postoperative days were evaluated in detail and all SSIs were recorded. The rate of SSIs was compared between patients who received antibiotic prophylaxis and those who did not. A multivariate logistic regression model was used to define the odds ratio (OR) for the efficacy of antibiotic prophylaxis.
RESULTS
A total of 335 patients underwent mastectomy without antibiotic prophylaxis and 1078 with prophylaxis. The rate of SSIs was 6.9% in patients who received prophylaxis and 6.3% in patients without prophylaxis ( = 0.70). The rate of SSIs was similar before and after the introduction of regular antibiotic prophylaxis and there was no difference in any of the patient subgroups investigated. In multivariable logistic regression analysis, the OR for antibiotic prophylaxis was 1.04 (95% CI: 0.62-1.73, = 0.88).
CONCLUSIONS
Routine use of antibiotic prophylaxis did not reduce the rate of SSIs in mastectomy. Unselective antibiotic prophylaxis for all patients does not seem mandatory in mastectomy.
Topics: Anti-Bacterial Agents; Antibiotic Prophylaxis; Breast Neoplasms; Female; Humans; Mastectomy; Retrospective Studies; Surgical Wound Infection
PubMed: 36000713
DOI: 10.1177/14574969221116940 -
Chirurgia (Bucharest, Romania : 1990) 2021The rate of contralateral prophylactic mastectomy (CPM) increased within the recent years. The main reasons are: genetic testing, availability of breast reconstruction,...
The rate of contralateral prophylactic mastectomy (CPM) increased within the recent years. The main reasons are: genetic testing, availability of breast reconstruction, more often use of preoperative breast MRI, improvement of postoperative aesthetic results and reimbursement of breast reconstruction. The purpose of this study was to analyze the indication of CPM, it's evolution and the surgical techniques used for this type of surgery. Materials and methods: This prospective study enrolled patients with unilateral breast cancer for which conservative treatment was not an option and underwent CPM concomitant with therapeutic mastectomy, using different techniques, followed by immediate breast reconstruction using alloplastic materials. A total of 45 patients with unilateral breast cancer underwent therapeutic mastectomy and CPM followed by immediate breast reconstruction, between January 2015-December 2020. The mean age was 43.5 years, 64,44% patients had stage I and II breast cancer and 22,22% were triplenegative. The indications for CPM were: pathogenic mutation of BRCA or of other genes associated with high risk of breast cancer, strong family history, suspicious findings on breast MRI, extended micro-calcifications, dense breasts, and extreme anxiety. A growing rate of bilateral mastectomy for unilateral breast cancer was observed. Availability of immediate breast reconstruction and reimbursement plays an important role for patients in choosing CPM. Factors associated with CPM include: young age, pathogenic BRCA mutation, significant family history and triple-negative disease. The rate of immediate postoperative complications was low. CPM is a valid option to reduce the risk of contralateral breast cancer and to achieve a good aesthetic outcome for patients with unilateral breast cancer with high risk of contralateral breast cancer.
Topics: Adult; Breast Neoplasms; Humans; Mastectomy; Prophylactic Mastectomy; Prospective Studies; Treatment Outcome
PubMed: 33963696
DOI: No ID Found -
Chinese Clinical Oncology Dec 2021The purpose of this review is to outline the surgical management of inflammatory breast cancer (IBC) including the clinical decision making, operative approach and... (Review)
Review
OBJECTIVE
The purpose of this review is to outline the surgical management of inflammatory breast cancer (IBC) including the clinical decision making, operative approach and current controversies.
BACKGROUND
IBC is a rare and aggressive form of breast cancer. Trimodality therapy consisting of neoadjuvant therapy, modified radical mastectomy (MRM) and radiation therapy improves survival and is the recommended course of treatment. Advancements in systemic therapy and de-escalation strategies in non-IBC have accelerated discussions regarding several aspects of care in IBC including feasibility of de-escalation of surgical care, timing of reconstruction and the role of surgery in de novo stage IV disease. We discuss the evidence to support the surgical approach and decision-making in this rare disease.
METHODS
We reviewed existing literature using multiple electronic databases and clinical consensus guidelines to identify historical and current publications addressing current management recommendations and clinical controversies in IBC.
CONCLUSIONS
Breast conserving surgery (BCS), skin- or nipple-sparing mastectomy should not be performed in IBC as surgical resection to negative margins results in improved locoregional recurrence rates. Level I and II axillary lymph node dissection should be performed regardless of response to therapy and initial nodal status. Reconstruction should be delayed and contralateral prophylactic mastectomy (CPM) is discouraged in IBC. Surgery may be considered for de novo stage IV IBC patients who demonstrate durable response to neoadjuvant therapy to improve local-regional control.
Topics: Breast Neoplasms; Female; Humans; Inflammatory Breast Neoplasms; Mastectomy; Mastectomy, Segmental; Neoadjuvant Therapy; Neoplasm Recurrence, Local
PubMed: 35016511
DOI: 10.21037/cco-21-113 -
Cancers May 2021Risk-reducing mastectomy (RRM) is often advocated for BRCA1/2 mutation carriers who face a heightened lifetime risk of breast cancer. However, many carrier patients seek...
Risk-reducing mastectomy (RRM) is often advocated for BRCA1/2 mutation carriers who face a heightened lifetime risk of breast cancer. However, many carrier patients seek alternative risk-reducing measures. In a phase II nonrandomized trial, we previously reported that prophylactic irradiation to the contralateral breast among BRCA carriers undergoing breast-conserving treatment significantly reduced subsequent contralateral breast cancer. Herein, we report the outcome of salvage mastectomy and reconstruction in 11 patients that suffered reoccurrences of breast cancer in either the ipsilateral or contralateral breast or elected to have the procedure for risk reduction during the eight-year follow-up period. Patients' satisfaction with the procedure and physicians' assessment of the cosmetic outcome were not inferior for previously irradiated compared to non-irradiated breasts. Although the numbers are small, the results are encouraging and sustain hope in a challenging population. Our findings support continuing research as well as a discussion of risk-reduction alternatives besides mastectomy, including prophylactic breast irradiation, in BRCA1/2 mutation carriers.
PubMed: 34070748
DOI: 10.3390/cancers13112694 -
Cancer Causes & Control : CCC Dec 2023Despite lack of survival benefit, demand for contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer remains high. High uptake of CPM has been...
PURPOSE
Despite lack of survival benefit, demand for contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer remains high. High uptake of CPM has been demonstrated in Midwestern rural women. Greater travel distance for surgical treatment is associated with CPM. Our objective was to examine the relationship between rurality and travel distance to surgery with CPM.
METHODS
Women diagnosed with stages I-III unilateral breast cancer between 2007 and 2017 were identified using the National Cancer Database. Logistic regression was used to model likelihood of CPM based on rurality, proximity to metropolitan centers, and travel distance. A multinomial logistic regression model compared factors associated with CPM with reconstruction versus other surgical options.
RESULTS
Both rurality (OR 1.10, 95% CI 1.06-1.15 for non-metro/rural vs. metro) and travel distance (OR 1.37, 95% CI 1.33-1.41 for those who traveled 50 + miles vs. < 30 miles) were independently associated with CPM. For women who traveled 30 + miles, odds of receiving CPM were highest for non-metro/rural women (OR 1.33 for 30-49 miles, OR 1.57 for 50 + miles; reference: metro women traveling < 30 miles). Non-metro/rural women who received reconstruction were more likely to undergo CPM regardless of travel distance (ORs 1.11-1.21). Both metro and metro-adjacent women who received reconstruction were more likely to undergo CPM only if they traveled 30 + miles (ORs 1.24-1.30).
CONCLUSION
The impact of travel distance on likelihood of CPM varies by patient rurality and receipt of reconstruction. Further research is needed to understand how patient residence, travel burden, and geographic access to comprehensive cancer care services, including reconstruction, influence patient decisions regarding surgery.
Topics: Female; Humans; Mastectomy; Breast Neoplasms; Unilateral Breast Neoplasms; Prophylactic Mastectomy; Probability
PubMed: 37095280
DOI: 10.1007/s10552-023-01689-9 -
Frontiers in Oncology 2022Breast Oncoplastic Surgery (OS) has established itself as a safe procedure associated with the treatment of breast cancer, but the term is broad, encompassing procedures... (Review)
Review
Breast Oncoplastic Surgery (OS) has established itself as a safe procedure associated with the treatment of breast cancer, but the term is broad, encompassing procedures associated with breast-conserving surgeries (BCS), conservative mastectomies and fat grafting. Surgeons believe that OS is associated with an increase in quality of life (QOL), but the diversity of QOL questionnaires and therapeutic modalities makes it difficult to assess from the patient's perspective. To answer this question, we performed a search for systematic reviews on QOL associated with different COM procedures, and in their absence, we selected case-control studies, discussing the main results. We observed that: (1) Patients undergoing BCS or breast reconstruction have improved QoL compared to those undergoing mastectomy; (2) In patients undergoing BCS, OS has not yet shown an improvement in QOL, a fact possibly influenced by patient selection bias; (3) In patients undergoing mastectomy with reconstruction, the QoL results are superior when the reconstruction is performed with autologous flaps and when the areola is preserved; (4) Prepectoral implants improves QOL in relation to subpectoral implant-based breast reconstruction; (5) ADM do not improves QOL; (6) In patients undergoing prophylactic mastectomy, satisfaction is high with the indication, but the patient must be informed about the potential complications associated with the procedure; (7) Satisfaction is high after performing fat grafting. It is observed that, in general, OS increases QOL, and when evaluating the procedures, any preservation or repair, or the use of autologous tissues, increases QOL, justifying OS.
PubMed: 36713564
DOI: 10.3389/fonc.2022.1099125 -
Journal of the American College of... Nov 2020Mastectomy may be performed to treat breast cancer or as a prophylactic approach in women with a high risk of developing breast cancer. In addition, mastectomies may be... (Review)
Review
Mastectomy may be performed to treat breast cancer or as a prophylactic approach in women with a high risk of developing breast cancer. In addition, mastectomies may be performed with or without reconstruction. Reconstruction approaches differ and may be autologous, involving a transfer of tissue (skin, subcutaneous fat, and muscle) from other parts of the body to the chest wall. Reconstruction may also involve implants. Implant reconstruction may occur as a single procedure or as multistep procedures with initial use of an adjustable tissue expander allowing the mastectomy tissues to be stretched without compromising blood supply. Ultimately, a full-volume implant will be placed. Reconstructions with a combination of autologous and implant reconstruction may also be performed. Other techniques such as autologous fat grafting may be used to refine both implant and flap-based reconstruction. This review of imaging in the setting of mastectomy with or without reconstruction summarizes the literature and makes recommendations based on available evidence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Topics: Breast Neoplasms; Diagnostic Imaging; Female; Humans; Mammaplasty; Mastectomy; Societies, Medical; United States
PubMed: 33153553
DOI: 10.1016/j.jacr.2020.09.009