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CMAJ : Canadian Medical Association... Feb 2024
Topics: Humans; Decision Making; Withholding Treatment; Genetic Predisposition to Disease; Genes, BRCA2; Genes, BRCA1; Genetic Counseling; Prophylactic Mastectomy
PubMed: 38378220
DOI: 10.1503/cmaj.230750 -
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 -
Life (Basel, Switzerland) Jan 2024(1) Importance of problem: Breast cancer accounted for 685,000 deaths globally in 2020, and half of all cases occur in women with no specific risk factor besides gender... (Review)
Review
(1) Importance of problem: Breast cancer accounted for 685,000 deaths globally in 2020, and half of all cases occur in women with no specific risk factor besides gender and age group. During the last four decades, we have seen a 40% reduction in age-standardized breast cancer mortality and have also witnessed a reduction in the medium age at diagnosis, which in turn means that the number of mastectomies performed for younger women increased, raising the need for adequate breast reconstructive surgery. Advances in oncological treatment have made it possible to limit the extent of what represents radical surgery for breast cancer, yet in the past decade, we have seen a marked trend toward mastectomies in breast-conserving surgery-eligible patients. Prophylactic mastectomies have also registered an upward trend. This trend together with new uses for breast reconstruction like chest feminization in transgender patients has increased the need for breast reconstruction surgery. (2) Purpose: The purpose of this study is to analyze the types of reconstructive procedures, their indications, their limitations, their functional results, and their safety profiles when used during the integrated treatment plan of the oncologic patient. (3) Methods: We conducted an extensive literature review of the main reconstructive techniques, especially the autologous procedures; summarized the findings; and presented a few cases from our own experience for exemplification of the usage of breast reconstruction in oncologic patients. (4) Conclusions: Breast reconstruction has become a necessary step in the treatment of most breast cancers, and many reconstructive techniques are now routinely practiced. Microsurgical techniques are considered the "gold standard", but they are not accessible to all services, from a technical or financial point of view, so pediculated flaps remain the safe and reliable option, along with alloplastic procedures, to improve the quality of life of these patients.
PubMed: 38255753
DOI: 10.3390/life14010138 -
Plastic and Reconstructive Surgery.... Jan 2024The best breast reconstruction solution after mastectomy remains a topic of wide debate. Recently, the focus in the field of implant-based reconstruction has been on the...
The best breast reconstruction solution after mastectomy remains a topic of wide debate. Recently, the focus in the field of implant-based reconstruction has been on the increasing indications for prepectoral reconstruction. This offers undoubted advantages over subpectoral reconstruction, ranging from better aesthetic results and patient comfort to a less invasive procedure that spares the pectoralis major muscle, reducing pain and postoperative recovery time. The dermal sling is a reconstructive variant introduced by Bostwick in the 1990s and is commonly used to complete the subpectoral pocket in one- or two-stage reconstruction, creating a dual-plane reconstruction. This method may be indicated after mastectomy for both therapeutic and prophylactic purposes. It can also be used for unilateral and bilateral reconstructions. We propose a new meshed dermal sling technique that allows complete prepectoral reconstruction without the use of acellular dermal matrix, thus reducing the cost of reconstruction. It also allows the indication for complete prepectoral reconstruction to be extended to patients with medium breast volume and grade 1 or 2 ptosis, without the need to use acellular dermal matrix or the pectoralis major muscle to complete the breast pocket.
PubMed: 38235351
DOI: 10.1097/GOX.0000000000005534 -
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 -
Gland Surgery Dec 2023Due to differences in socioeconomic and cultural backgrounds, the characteristics and prognosis of Asian female patients choosing contralateral prophylactic mastectomy...
BACKGROUND
Due to differences in socioeconomic and cultural backgrounds, the characteristics and prognosis of Asian female patients choosing contralateral prophylactic mastectomy (CPM) are likely to be different from Western patients. To fill the research gap of CPM in Asian populations, this study aims to explore the application trend, survival benefits, decision-making factors, and satisfaction of CPM based on the Chinese patients undergoing CPM.
METHODS
The 0-III stage unilateral breast cancer (UBC) patients who received breast surgery in the Chinese PLA General Hospital from 2005 to 2017 were selected. The surgical procedures included simple mastectomy (SM), nipple-sparing mastectomy (NSM), breast conserving surgery (BCS), and CPM. Cox proportional regression analyses and Kaplan-Meier (KM) curve were performed to compare the overall survival (OS) and disease-free survival (DFS) rates between CPM group and unilateral mastectomy (UM) group. Proportional propensity score matching (PSM) with a 1:1 ratio was used to match the two groups and secondary survival analysis was performed. Logistic regression models were used to test predictive factors related to patients' CPM surgical decision-making.
RESULTS
Four thousand two hundred and seventy-six patients were included in the study, with 73 patients receiving CPM, 3,567 receiving SM, 151 receiving NSM, and 485 receiving BCS. CPM surgery was first used in 2007, with a peak application rate of 3.02% in 2016. Three thousand seven hundred and ninety-one patients were included in the survival analysis, with a median follow-up time of 66.60 months. Compared to UM patients, neither the KM survival curve nor Cox regression hazard analyses of CPM showed better OS (P=0.963; P=0.834). After PSM, CPM also did not exhibit significant survival benefits in OS (P=0.335) and DFS (P=0.409). The logistic regression analyses showed that NSM surgery and lower tumor-node-metastasis (TNM) stage were independent factors to promote the CPM decision-making of patients. The CPM group showed high overall satisfaction (84.9%) and relatively low appearance satisfaction (69.9%).
CONCLUSIONS
CPM was practiced for the first time since 2007 in our hospital. CPM does not provide any OS and DFS benefits compared to UM and the appearance satisfaction procedure was relatively low. Therefore, clinicians should fully communicate with patients before surgery and be more cautious in giving CPM recommendations.
PubMed: 38229836
DOI: 10.21037/gs-23-384 -
Clinical Breast Cancer Apr 2024It seems the most probable beneficiaries from the molecular era are those harboring hereditary genetic variants, which are responsible for 5% to 10% of all breast cancer...
It seems the most probable beneficiaries from the molecular era are those harboring hereditary genetic variants, which are responsible for 5% to 10% of all breast cancer diagnoses. There are several key implications of such variants on clinical practice, from expedited anticipation of primary cancer diagnoses, which can have their risk mitigated by risk reduction surgery, to pragmatism surrounding the management of male breast cancer patients. This communication discusses the implications of highly penetrant (or pathogenic) hereditary variants in contemporary breast surgery practice.
Topics: Humans; Male; Breast Neoplasms; Mastectomy; Breast Neoplasms, Male; Genetic Predisposition to Disease; Genetic Testing
PubMed: 38218718
DOI: 10.1016/j.clbc.2024.01.001 -
Nature Cell Biology Jan 2024Inheritance of a BRCA2 pathogenic variant conveys a substantial life-time risk of breast cancer. Identification of the cell(s)-of-origin of BRCA2-mutant breast cancer...
Inheritance of a BRCA2 pathogenic variant conveys a substantial life-time risk of breast cancer. Identification of the cell(s)-of-origin of BRCA2-mutant breast cancer and targetable perturbations that contribute to transformation remains an unmet need for these individuals who frequently undergo prophylactic mastectomy. Using preneoplastic specimens from age-matched, premenopausal females, here we show broad dysregulation across the luminal compartment in BRCA2 tissue, including expansion of aberrant ERBB3 luminal progenitor and mature cells, and the presence of atypical oestrogen receptor (ER)-positive lesions. Transcriptional profiling and functional assays revealed perturbed proteostasis and translation in ERBB3 progenitors in BRCA2 breast tissue, independent of ageing. Similar molecular perturbations marked tumours bearing BRCA2-truncating mutations. ERBB3 progenitors could generate both ER and ER cells, potentially serving as cells-of-origin for ER-positive or triple-negative cancers. Short-term treatment with an mTORC1 inhibitor substantially curtailed tumorigenesis in a preclinical model of BRCA2-deficient breast cancer, thus uncovering a potential prevention strategy for BRCA2 mutation carriers.
Topics: Female; Humans; Breast Neoplasms; Mastectomy; Mutation; BRCA2 Protein; Carcinogenesis; Cell Transformation, Neoplastic; BRCA1 Protein
PubMed: 38216737
DOI: 10.1038/s41556-023-01315-5 -
Cancers Dec 2023Hereditary breast and ovarian cancers (HBOCs) pose significant health risks worldwide and are mitigated by prophylactic interventions. However, a meta-analysis of their... (Review)
Review
BACKGROUND
Hereditary breast and ovarian cancers (HBOCs) pose significant health risks worldwide and are mitigated by prophylactic interventions. However, a meta-analysis of their efficacy and the impact of different genetic variants on their effectiveness is lacking.
METHODS
A systematic review and meta-analysis were conducted, adhering to Cochrane guidelines. The review encompassed studies that involved prophylactic interventions for healthy women with BRCA variants, focusing on cancer incidence and mortality outcomes. The Newcastle-Ottawa Scale was used for risk of bias assessment. We pooled the extracted outcomes using random effects models and conducted subgroup analyses stratified by intervention, variant, and cancer types.
RESULTS
A total of 21 studies met the inclusion criteria. The meta-analysis revealed that prophylactic interventions significantly reduced cancer risk and mortality. The subgroup analysis showed a greater protective effect for BRCA2 than BRCA1 variant carriers. Risk-reducing surgeries (RRS) were more effective than chemoprevention, with RRS notably reducing cancer risk by 56% compared to 39% for chemoprevention. Prophylactic oophorectomy significantly reduced HBOC risks, while the effect of prophylactic mastectomy and chemoprevention on mortality was less conclusive.
CONCLUSIONS
Prophylactic interventions significantly reduce the risk of HBOC and associated mortality. This comprehensive analysis provides insights for future economic evaluations and clinical decision-making in HBOC interventions.
PubMed: 38201529
DOI: 10.3390/cancers16010103 -
Cancer Medicine Jan 2024There is preliminary evidence suggesting that FCR is a major problem for breast cancer survivors carrying a BRCA1/2 mutation. The goal of this qualitative study,...
BACKGROUND
There is preliminary evidence suggesting that FCR is a major problem for breast cancer survivors carrying a BRCA1/2 mutation. The goal of this qualitative study, conducted among women who were treated for breast cancer, was to provide a deeper understanding of how FCR is experienced in the context of a genetic predisposition to breast cancer.
METHOD
Three focus groups (90-110 min) were conducted with 19 breast cancer survivors carrying a BRCA1/2 mutation. The semistructured interview probed FCR level and impact, the role FCR played in the decision to have a prophylactic bilateral mastectomy and/or salpingo-oophorectomy, the effect that surgery had on FCR, and the relevance of offering a psychological intervention targeting FCR to this population.
RESULTS
Findings indicated that FCR was a significant issue in these women, even though a majority had undergone a prophylactic surgery. Patients strongly affirmed the need to develop and provide access to FCR interventions that are specifically adapted to the needs of this group.
DISCUSSION
These results suggest that, although being the most effective medical option to reduce the actual risk of local recurrence (or second breast cancer), prophylactic surgery only partially reduces FCR. A psychological intervention targeting specifically FCR would be an appropriate complement to preventive surgery.
PubMed: 38192174
DOI: 10.1002/cam4.6889