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Annals of Plastic Surgery Jul 2024Minimizing resource use while optimizing patient outcomes has become an ever-growing component in modern healthcare, especially in the era of COVID-19. One essential...
PURPOSE
Minimizing resource use while optimizing patient outcomes has become an ever-growing component in modern healthcare, especially in the era of COVID-19. One essential component of this is deciding whether patients need hospital admission following elective procedures. The aim of this study is to investigate operative factors and patient outcomes when mastectomies with or without reconstruction are performed as ambulatory procedures versus planned inpatient admissions.
METHODS
Patient charts for those undergoing mastectomy with or without reconstruction were retrospectively analyzed ranging from March 2019 until February 2021. Factors such as demographic information, operative type, operating room time, cancer stage, total stay time in the medical environment, and postoperative complications were assessed and compared between the 2 groups.
RESULTS
A total of 89 patient charts were reviewed, 46 from before the COVID-19 pandemic and 43 from after the start of the pandemic. No differences were observed in demographic factors between the 2 groups. After surgical cases resumed a significant proportion, 79%, of mastectomies with or without reconstruction were performed in the ambulatory center, versus just 2% pre-COVID-19. Similarly, of all of these cases performed, only 19% resulted in hospital admission versus the previous rate of 100% (P < 0.00001). Together, these changes resulted in a significant reduction in length of stay of 39.77 ± 19.2 hours pre-COVID-19 versus 14.81 ± 18.4 hours afterward (P < 0.00001). Unfortunately, a higher number of patients who received surgery after the start of the pandemic elected to forego immediate reconstruction 49% versus 72% (P = 0.032). Most importantly, there were no observable differences found in 7-day readmission, reoperation, or emergency department visit between groups. There was also no difference in 30-day complication rate between groups.
CONCLUSIONS
Mastectomy with or without reconstruction can be safely performed in the ambulatory setting without additional risk of complications or negative patient factors. This divergence from traditional the protocol of inpatient overnight admission may contribute positively toward patient comfort, minimize the use of healthcare costs and resources, and allow for increased scheduling flexibility for patient and provider alike.
Topics: Humans; COVID-19; Mastectomy; Female; Retrospective Studies; Mammaplasty; Middle Aged; Ambulatory Surgical Procedures; Breast Neoplasms; Length of Stay; Adult; Pandemics; Aged; Postoperative Complications
PubMed: 38885164
DOI: 10.1097/SAP.0000000000003922 -
Annals of Plastic Surgery Jul 2024Acellular dermal matrices (ADMs) are frequently employed in immediate prosthesis-based breast reconstruction (iPBR) to provide structural support. Despite differences in... (Comparative Study)
Comparative Study
BACKGROUND
Acellular dermal matrices (ADMs) are frequently employed in immediate prosthesis-based breast reconstruction (iPBR) to provide structural support. Despite differences in ADM derivatives, few studies directly compare their outcomes in the setting of iPBR. We sought to conduct a large head-to-head study comparing 3 ADMs used across our institution.
METHODS
A multicenter retrospective review of patients undergoing iPBR with SurgiMend PRS (fetal bovine-derived; Integra Lifesciences, Princeton, NJ), AlloDerm (human-derived; LifeCell Corp, Bridgewater, NJ), or DermACELL (human-derived; Stryker Corp, Kalamazoo, MI) between January 2014 to July 2022 was performed. Primary outcomes included rates of unplanned explantation and total reconstructive failure. Secondary outcomes included 90-day postoperative complications and long-term rates of capsular contracture development.
RESULTS
A total of 738 patients (1228 breasts) underwent iPBR during the study period; 405 patients received DermACELL (54.9%), 231 received AlloDerm (31.3%), and 102 received SurgiMend PRS (13.8%). Rates of short-term complications, total reconstruction failure, reoperation within 90 days, capsular contracture, and unplanned explantation were comparable. These findings remained true upon multivariate analysis accounting for baseline differences between cohorts, whereby ADM type was not an independent predictor of any outcome of interest. Conversely, factors such as body mass index, diabetes mellitus, smoking history, neoadjuvant and adjuvant chemotherapy, adjuvant radiation, skin-sparing mastectomy, Wise pattern and periareolar incisions, use of tissue expanders, and a subpectoral plane of insertion were significant predictors of postoperative complications.
CONCLUSION
Low rates of complications support the equivalency of fetal bovine and human-derived ADMs in iPBR. Patient characteristics and operative approach are likely more predictive of postoperative outcomes than ADM derivative alone.
Topics: Humans; Female; Retrospective Studies; Acellular Dermis; Middle Aged; Adult; Collagen; Breast Neoplasms; Postoperative Complications; Breast Implants; Breast Implantation; Mammaplasty; Mastectomy; Treatment Outcome
PubMed: 38885163
DOI: 10.1097/SAP.0000000000003990 -
Annals of Plastic Surgery Jul 2024This study aims to investigate the patient-reported outcomes (PROs) and complications of distinct implant-based breast reconstruction modality for patients with...
OBJECTIVE
This study aims to investigate the patient-reported outcomes (PROs) and complications of distinct implant-based breast reconstruction modality for patients with postmastectomy radiation therapy (PMRT).
METHODS
A retrospective review was conducted on breast cancer patients with stage II-III disease who performed implant-based breast reconstruction following with PMRT between September 2016 and April 2022. The patients were categorized into two matched groups: (1) patients receiving prepectoral breast reconstruction (PBR) or (2) subpectoral breast reconstruction (SBR) followed by PMRT. Following reconstruction, the patients were further compared for PMRT with the tissue expander (PMRT-TE) versus PMRT with permanent implant (PMRT-PI). PROs were measured with BREAST-Q questionnaire. Early and late complications were recorded and analyzed.
RESULTS
A total of 55 eligible patients were recruited. Patients who underwent PBR reported significantly higher satisfaction with breasts scores (P = 0.003) compared with the SBR group. The PMRT-TE group had higher satisfaction with breasts (P = 0.001) but lower physical well-being (P = 0.029) scores compared with PMRT-PI group. Moreover, patients in SBR cohort had a higher risk of capsular contracture (Baker grade III or IV) (20.5% vs 6.3%) and implant dislocation (48.7% vs 12.5%) than patients in PBR cohort. Patients in PMRT-PI group had a slightly higher rate of capsular contracture (Baker grade III or IV) than PMRT-TE group (20.8% vs 12.9%).
CONCLUSIONS
PBR was associated with lower rates of late complications, especially for implant dislocation, and higher satisfaction with breasts scores compared to SBR. In addition, compared to PMRT-TE with PMRT-PI, patients in PMRT-TE cohort reported superior PROs of satisfaction with breasts.
Topics: Humans; Female; Patient Reported Outcome Measures; Retrospective Studies; Middle Aged; Breast Neoplasms; Mastectomy; Breast Implantation; Postoperative Complications; Breast Implants; Adult; Radiotherapy, Adjuvant; Patient Satisfaction; Mammaplasty
PubMed: 38885161
DOI: 10.1097/SAP.0000000000003974 -
Annals of Surgery Open : Perspectives... Mar 2024To investigate the possible association between breast implant illness (BII) and mast cell activation syndrome (MCAS), which often manifests increased mast cells (MCs)...
OBJECTIVE
To investigate the possible association between breast implant illness (BII) and mast cell activation syndrome (MCAS), which often manifests increased mast cells (MCs) in assorted tissues and may explain BII symptoms.
BACKGROUND
Mechanisms by which implants cause BII symptoms remain unclear, but BII and MCAS symptom profiles heavily overlap, warranting investigation of potential linkage.
METHODS
We retrospectively analyzed 20 implant patients who underwent explantation and total capsulectomy; 15 self-reported preoperatively they had BII (subject group); 5 felt they did not [control group 1 (CG1)]. Five prophylactic mastectomy patients constituted control group 2 (CG2). Subjects and CG1 patients completed BII symptom questionnaires preoperatively and multiple points postoperatively. With CD117 staining, average and maximum mast cell counts (MCCs) in resected tissues were determined.
RESULTS
Mean BII symptom score 2 weeks postexplantation was reduced by 77% ( < 0.0001), and 85% by 9 months. Analysis suggested BII in CG1 patients, too, who improved similarly. Among CG2 patients, healthy breast tissue showed mean and maximum MCCs of 5.0/hpf and 6.9/hpf. Mean and maximum MCCs in capsules in BII patients were 11.7/hpf and 16.3/hpf, and 7.6/hpf and 13.3/hpf in CG1 patients. All intergroup comparisons were significantly different ( < 0.0001).
CONCLUSIONS
MCCs in peri-implant capsules in BII patients are increased; some implanted patients appear to have unrecognized BII. Given that neoantigenic/xenobiotic exposures commonly trigger dysfunctional MCs in MCAS to heighten aberrant mediator expression driving inflammatory and other issues, further investigation of whether BII represents an implant-driven escalation of preexisting MCAS and whether an MCAS diagnosis flags risk for BII seems warranted.
PubMed: 38883946
DOI: 10.1097/AS9.0000000000000398 -
Cureus May 2024To describe the histopathological pattern of different breast lesions among tissue specimens sent to our laboratory.
OBJECTIVE
To describe the histopathological pattern of different breast lesions among tissue specimens sent to our laboratory.
METHOD
A record-based study using a retrospective review of 255 histologically diagnosed breast biopsy reports in the histopathology department of authors from December 2016 to November 2021 was conducted. The specimens were collected from core biopsy, lumpectomy, and mastectomy. All data obtained were analyzed using the Statistical Package for the Social Sciences (SPSS) version 28 (IBM SPSS Statistics, Armonk, NY). Then, the findings were presented using text, tables, and charts.
RESULT
A total of 255 breast lesions were analyzed in this study. Most of the cases were benign (58.8%), followed by inflammatory lesions (21.6%), and malignant (19.6%). Fibroadenoma was the most prevalent benign lesion (36.7%), and most of the patients (70.9%) were in the age group of 20-39 years old. The most common inflammatory lesion was granulomatous mastitis (56.4%), and most of the cases were diagnosed in the age group of 30-39 years old. Invasive ductal carcinoma (IDC) was the most encountered histological type of carcinoma (62%). Of the malignant cases, 52% were diagnosed before the age of 50 years. Among these 50 cases, grade 2 was the most prevalent one (46%).
CONCLUSION
Benign breast lesions are more common than malignant breast lesions, and fibroadenoma is the most common benign subtype. Granulomatous mastitis is the most prevalent inflammatory breast lesion. About two-thirds of malignant cases are non-Arab. Invasive ductal carcinoma with no special type (NST) is the most common malignant subtype.
PubMed: 38883142
DOI: 10.7759/cureus.60408 -
Cureus May 2024Secretory breast carcinoma (SBC) is an extremely rare entity of breast cancer, which can affect all age groups. The diagnosis is based on the characteristic microscopic...
Secretory breast carcinoma (SBC) is an extremely rare entity of breast cancer, which can affect all age groups. The diagnosis is based on the characteristic microscopic appearance, and despite the triple negativity or low hormone receptor positivity, SBC is generally characterized by a favorable prognosis. Due to the rarity of the disease, no clear consensus on optimal treatment is available. Nevertheless, conservative surgery or mastectomy is the main therapeutic option. The efficacy of chemotherapy, radiotherapy, and hormone therapy in this pathology has not been rigorously explored. We report the case of a 65-year-old woman with SBC treated with surgery and adjuvant radiotherapy, with a review of the literature.
PubMed: 38883124
DOI: 10.7759/cureus.60430 -
Health Services Research Jun 2024To systematically review Medicaid policies state-by-state for gender-affirming surgery coverage.
OBJECTIVE
To systematically review Medicaid policies state-by-state for gender-affirming surgery coverage.
DATA SOURCES AND STUDY SETTING
Primary data were collected for each US state utilizing the LexisNexis legal database, state legislature publications, and Medicaid manuals.
STUDY DESIGN
A cross-sectional study evaluating Medicaid coverage for numerous gender-affirming surgeries.
DATA COLLECTION/EXTRACTION METHODS
We previously reported on state health policies that protect gender-affirming care under Medicaid coverage. Building upon our prior work, we systematically assessed the 27 states with protective policies to determine coverage for each type of gender-affirming surgery. We analyzed Medicaid coverage for gender-affirming surgeries in four domains: chest, genital, craniofacial and neck reconstruction, and miscellaneous procedures. Medicaid coverage for each type of surgery was categorized as explicitly covered, explicitly noncovered, or not described.
PRINCIPAL FINDINGS
Among the 27 states with protective Medicaid policies, 17 states (63.0%) provided explicit coverage for at least one gender-affirming chest procedure and at least one gender-affirming genital procedure, while only eight states (29.6%) provided explicit coverage for at least one craniofacial and neck procedure (p = 0.04). Coverage for specific surgical procedures within these three anatomical domains varied. The most common explicitly covered procedures were breast reduction/mastectomy and hysterectomy (n = 17, 63.0%). The most common explicitly noncovered surgery was reversal surgery (n = 12, 44.4%). Several states did not describe the specific surgical procedures covered; thus, final coverage rates are indeterminate.
CONCLUSIONS
In 2022, 52.9% of states had health policies that protected gender-affirming care under Medicaid; however, coverage for various gender-affirming surgical procedures remains both variable and occasionally unspecified. When specified, craniofacial and neck reconstruction is the least covered anatomical area compared with chest and genital reconstruction.
PubMed: 38881495
DOI: 10.1111/1475-6773.14338 -
Gan To Kagaku Ryoho. Cancer &... May 2024Pulmonary lymphangitis carcinomatosis is generally characterized by resistance to chemotherapy and is associated with a poor prognosis. Herein, we present a case of...
Pulmonary lymphangitis carcinomatosis is generally characterized by resistance to chemotherapy and is associated with a poor prognosis. Herein, we present a case of pulmonary lymphangitic carcinomatosis from recurrent breast cancer that responded well to trastuzumab deruxtecan(T-DXd). The patient was a 40-year-old woman with hormone receptor-positive, HER2-positive breast cancer. At the age of 31, she had undergone a left mastectomy with axillary lymph node dissection. She received adjuvant chemotherapy(5-fluorouracil-epirubicin-cyclophosphamide, docetaxel, and trastuzumab)followed by endocrine therapy(tamoxifen and LH-RHa). Three years after the surgery, pulmonary and bone metastases were detected and she was treated with trastuzumab, pertuzumab, and capecitabine. Liver metastases were detected, and she was treated with trastuzumab emtansine. Nine years after surgery, the patient developed dyspnea and was diagnosed with lymphangitis carcinomatosis. After initiating T-DXd, dyspnea rapidly improved, and ground glass opacity on CT scan disappeared. She responded well to the treatment, with prolonged, stable disease for 1 year and 2 months. Thus, T-DXd may be effective against pulmonary lymphangitis carcinomatosis, which is generally characterized by resistance to chemotherapy.
Topics: Humans; Female; Adult; Breast Neoplasms; Lymphangitis; Trastuzumab; Lung Neoplasms; Recurrence; Antineoplastic Combined Chemotherapy Protocols; Antineoplastic Agents, Immunological; Immunoconjugates; Camptothecin
PubMed: 38881071
DOI: No ID Found -
The Journal of Infection Jun 2024Implant-based reconstructions are increasingly utilized following mastectomy in the prevention and treatment of breast cancer. However, these implants are associated... (Review)
Review
Implant-based reconstructions are increasingly utilized following mastectomy in the prevention and treatment of breast cancer. However, these implants are associated with a high rate of infection, which is a major complication that can lead to implant removal, delay in adjuvant radiation and chemotherapy, and increase in health care costs. Early clinical signs and symptoms of infection, such as erythema, warmth, and tenderness, are challenging to discern from expected postsurgical responses. Furthermore, when atypical features are present or the patient's condition does not improve on adequate antimicrobials, the clinician should be prompted to consider an alternative noninfectious etiology. Herein we highlight the key elements of the preventive, diagnostic, and multidisciplinary therapeutic approach to salvaging the infected breast implant; review several infectious disease mimickers; and provide many pearls of wisdom that the practicing clinician must be familiar with and be able to manage in an effective and successful manner.
PubMed: 38879134
DOI: 10.1016/j.jinf.2024.106197 -
Precision dose prediction for breast cancer patients undergoing IMRT: The Swin-UMamba-Channel Model.Computerized Medical Imaging and... Jun 2024Radiation therapy is one of the crucial treatment modalities for cancer. An excellent radiation therapy plan relies heavily on an outstanding dose distribution map,...
BACKGROUND
Radiation therapy is one of the crucial treatment modalities for cancer. An excellent radiation therapy plan relies heavily on an outstanding dose distribution map, which is traditionally generated through repeated trials and adjustments by experienced physicists. However, this process is both time-consuming and labor-intensive, and it comes with a degree of subjectivity. Now, with the powerful capabilities of deep learning, we are able to predict dose distribution maps more accurately, effectively overcoming these challenges.
METHODS
In this study, we propose a novel Swin-UMamba-Channel prediction model specifically designed for predicting the dose distribution of patients with left breast cancer undergoing radiotherapy after total mastectomy. This model integrates anatomical position information of organs and ray angle information, significantly enhancing prediction accuracy. Through iterative training of the generator (Swin-UMamba) and discriminator, the model can generate images that closely match the actual dose, assisting physicists in quickly creating DVH curves and shortening the treatment planning cycle. Our model exhibits excellent performance in terms of prediction accuracy, computational efficiency, and practicality, and its effectiveness has been further verified through comparative experiments with similar networks.
RESULTS
The results of the study indicate that our model can accurately predict the clinical dose of breast cancer patients undergoing intensity-modulated radiation therapy (IMRT). The predicted dose range is from 0 to 50 Gy, and compared with actual data, it shows a high accuracy with an average Dice similarity coefficient of 0.86. Specifically, the average dose change rate for the planning target volume ranges from 0.28 % to 1.515 %, while the average dose change rates for the right and left lungs are 2.113 % and 0.508 %, respectively. Notably, due to their small sizes, the heart and spinal cord exhibit relatively higher average dose change rates, reaching 3.208 % and 1.490 %, respectively. In comparison with similar dose studies, our model demonstrates superior performance. Additionally, our model possesses fewer parameters, lower computational complexity, and shorter processing time, further enhancing its practicality and efficiency. These findings provide strong evidence for the accuracy and reliability of our model in predicting doses, offering significant technical support for IMRT in breast cancer patients.
CONCLUSION
This study presents a novel Swin-UMamba-Channel dose prediction model, and its results demonstrate its precise prediction of clinical doses for the target area of left breast cancer patients undergoing total mastectomy and IMRT. These remarkable achievements provide valuable reference data for subsequent plan optimization and quality control, paving a new path for the application of deep learning in the field of radiation therapy.
PubMed: 38878631
DOI: 10.1016/j.compmedimag.2024.102409