Feasibility of Breast-Conservation Therapy and Hypofractionated Radiation in the Setting of Prior Breast Augmentation

PurposeCosmetic outcomes and rate of implant loss are poorly characterized among patients with breast cancer with previous breast augmentation (BA) who undergo breast-conservation therapy (BCT). Here we determine capsular contracture and implant loss frequency after BCT among patients receiving contemporary whole-breast radiation therapy (RT).Methods and MaterialsPatients with breast cancer with a history of BA presenting to our institution from January 2006 to January 2017 who elected for BCT were included. Seventy-one breast cancers in 70 patients with a history of BA electing for BCT were retrospectively identified. Clinicopathologic, treatment, and outcome variables were examined. Whole-breast RT included conventional and hypofractionated schedules with and without a boost. Rates of implant loss and cosmetic outcomes among patients who did and did not develop a new/worse contracture based on physician assessment were compared.ResultsIn the study, 54.9% of patients received radiation using hypofractionated whole-breast tangents; 81.7% received a boost. In addition, 18 out of 71 cases (25.4%) developed a new/worse contracture after BCT with a mean follow-up of 1.9 years. Furthermore, 9 out of 71 cases (12.7%) were referred to a plastic surgeon for revisional surgery. There were no implant-loss cases. On univariate analysis, implant location, time from implant placement to diagnosis, RT type, RT boost, body mass index, and tumor size were not associated with new/worse contracture. Of 12 patients with existing contracture, only 2 developed worsening contracture. Physician assessment of cosmetic outcome after BCT was noted to be excellent or good for 87.4% of patients.ConclusionsBCT for breast cancer patients with prior history of BA has a low risk of implant loss. Hypofractionated RT does not adversely affect implant outcomes. Patients should be counseled regarding risk for capsular contracture, but the majority have good/excellent outcome; BA does not represent a contraindication to BCT.     

BROWSE: A multicentre comparison of nine year outcomes in acellular dermal matrix based and complete submuscular implant-based immediate breast reconstruction-aesthetics,capsular contracture and patient reported outcomes

Approximately 60% of implant-based breast reconstructions (IBBR) are performed with an acellular dermal matrix (ADM), for which, reliable, good quality long-term outcome data is limited. In a retrospective multicentre cohort study, we aimed to determine long-term aesthetic and quality of life outcomes of IBBR with ADM (Strattice?) compared to a submuscular technique.MethodsCapsular contracture (Baker III/IV capsule) was determined by clinical examination by an independent researcher. Quality of life was assessed using BREAST-Q and aesthetic outcome by photographic assessment from a breast surgeon, breast care nurse and lay person, blinded to reconstruction type.ResultsWe recruited 117 (51 bilateral) patients with ADM reconstructions, median follow-up 62 months (range 29–113) and 49 patients (16 bilateral) with submuscular reconstructions, median follow-up 76 months (range 38–111). 17 (10.1%) ADM reconstructions were Baker 3/4 compared to six (9.2%) submuscular (p = 0.85). Of the Baker 1/2 reconstructions six (3.6%) ADM and eight (13.6%) submuscular had previously undergone revision surgery to correct capsular contracture (p = 0.01). Combining both findings gave an estimated rate of capsular contracture of 13.6% in the ADM group and 21.2% in the submuscular (p = 0.14). A higher mean score for satisfaction with breasts was demonstrated when comparing ADM to submuscular (62 and 55, respectively; p = 0.01) but no significant difference in other BREAST-Q domains. The mean ‘general satisfaction’ score was higher in the ADM group for all three photograph assessors.ConclusionThis study provides evidence of improved aesthetic outcome and reduction in capsular contracture with ADM reconstruction when compared to submuscular, consistent over long-term follow-up.     

Reconstruction mammaire immédiate après mastectomie suivie de radiothérapie : facteurs de risque de complications

ObjectivesTo determine prospectively the factors associated with reconstruction failure (i.e. requiring expander removal) and capsular contracture in patients undergoing mastectomy and immediate two-stage breast reconstruction with a tissue expander and implant, and radiotherapy for breast cancer. This is a multi-institutional prospective nonrandomized trial.Patients and MethodsBetween 2/1998 and 9/2006, we prospectively evaluated 141 consecutive patients who received 141 implants after mastectomy and underwent chest wall radiotherapy (46 to 50 Gy in 23 to 25 fractions). Patients were evaluated after 24 to 36 months by two senior physicians (radiation oncologist and surgeon).ResultsMedical follow-up was 37 months. Baker 1 and 2 capsular contracture was observed in 67.5% of patients, Baker 3 and 4 in 32.5%. There were 32 reconstruction failures. In a univariate analysis, the following factors were associated with Baker 3 and 4 capsular contracture: surgeon, use of hormonotherapy and smoking, of which only one remained in the multivariate analysis: surgeon. In a univariate analysis, the following factors were associated with reconstruction failure: tumor size T3 or T4, smoking, pN+ axilla. Three factors remained associated with reconstruction failure in a multiple logistic regression: large tumors T3/T4, smoking and pN+ axilla.ConclusionsMastectomy, radiotherapy and immediate breast reconstruction with a tissue expander and implant should be considered when breast conserving surgery has been denied. Adequate patients can be easily selected by using three factors of favourable outcome.     

Direct to Implant Breast Reconstruction With Prepectoral Micropolyurethane Foam-Coated Implant: Analysis of Patient Satisfaction

BackgroundImmediate implant reconstruction after mastectomy with submuscular implant placement is widely used in order to avoid implant exposure, capsular contracture and poor aesthetic result. Postoperative complications can be reduced by maintain mastectomy flap thickness and asses flap vascularity with near infrared imaging. The prepectoral reconstruction with polyurethane implants has been utilized with encouraging results. Postoperative patient satisfaction was assessed with the BREAST-Q scores in patients who underwent prepectoral reconstruction with polyurethane implants. Additionally the impact of mastectomy flap thickness on breast reconstruction was investigated.Materials and MethodsThe Breast Q-scores of satisfaction with the breast, the postoperative outcome and physical well-being of the chest in 70 patients underwent immediate implant breast reconstructions with prepectoral polyurethane implant were retrospectively reviewed. The correlation between mastectomy flap thickness and satisfaction with breast was analyzed.ResultsAt 12-month follow-up the mean Q-score for satisfaction with breast was 71.73 (standard deviation: 13.31), and for physical well-being chest was 70.73 (standard deviation: 7.94). A positive linear correlation between mastectomy flap thickness and satisfaction with the breast was identified.ConclusionsThe postoperative Q-scores are encouraging in the use of polyurethane prepectoral implants in immediate breast reconstruction, especially in patients with “thick” mastectomy flaps.     

Survival after lumpectomy and mastectomy for early stage invasive breast cancer

BACKGROUND:

Randomized clinical trials (RCT) have demonstrated equivalent survival for breast‐conserving therapy with radiation (BCT) and mastectomy for early‐stage breast cancer. A large, population‐based series of women who underwent BCT or mastectomy was studied to observe whether outcomes of RCT were achieved in the general population, and whether survival differed by surgery type when stratified by age and hormone receptor (HR) status.

METHODS:

Information was obtained regarding all women diagnosed in the state of California with stage I or II breast cancer between 1990 and 2004, who were treated with either BCT or mastectomy and followed for vital status through December 2009. Cox proportional hazards modeling was used to compare overall survival (OS) and disease‐specific survival (DSS) between BCT and mastectomy groups. Analyses were stratified by age group (< 50 years and ≥ 50 years) and tumor HR status.

RESULTS:

A total of 112,154 women fulfilled eligibility criteria. Women undergoing BCT had improved OS and DSS compared with women with mastectomy (adjusted hazard ratio for OS entire cohort = 0.81, 95% confidence interval [CI] = 0.80‐0.83). The DSS benefit with BCT compared with mastectomy was greater among women age ≥ 50 with HR‐positive disease (hazard ratio = 0.86, 95% CI = 0.82‐0.91) than among women age < 50 with HR‐negative disease (hazard ratio = 0.88, 95% CI = 0.79‐0.98); however, this trend was seen among all subgroups analyzed.

CONCLUSIONS:

Among patients with early stage breast cancer, BCT was associated with improved DSS. These data provide confidence that BCT remains an effective alternative to mastectomy for early stage disease regardless of age or HR status. Cancer 2013. © 2012 American Cancer Society.     

Effect of Breast Conservation Therapy vs Mastectomy on Overall Survival and Breast Cancer-Specific Survival Among Men With Stage I-II Breast Cancer: Analysis of SEER, 2000-2018

BackgroundMale breast cancer is a rare malignant tumor, and outcomes of breast conservation therapy (BCT) are currently lacking.MethodThe retrospective, population-based cohort study included 1369 stage I-II (T1–2 N0–1 M0) male breast cancer patients from the SEER database (2000-2018). The patients were grouped in two groups: BCT group and mastectomy group, according to surgical and radiation therapy. Kaplan-Meier method and univariable Cox proportional hazard analysis were used to compare overall survival (OS) and breast cancer-specific survival (BCSS) between two treatment groups. Propensity score matching (PSM) was performed to balance the confounding factors.ResultsOf the 1369 men, 97 (7%) patients received BCT, 1272 (93%) received mastectomy alone. The 5- and 10-year OS rates were 92.3% and 80.7% for BCT group compared with 80.4% and 61.4% for mastectomy group. The 5- and 10-year BCSS rates were 96.5% and 93.9% for patients undergoing BCT, as compared with 93.1% and 84.4% for patients undergoing mastectomy. Compared with mastectomy group, BCT group showed improved OS (hazard ratio [HR], 0.294; 95% CI 0.138-0.623, P = .002) and BCSS (hazard ratio [HR], 0.182; 95% CI 0.040-0.820, P = .027). Of the 791 patients with T1 stage, BCT showed insignificant association with OS (hazard ratio [HR], 0.555; 95% CI 0.207-1.488, P = .242) and BCSS (hazard ratio [HR], 1.217; 95% CI 0.171-8.675, P = .844).ConclusionThe results of this cohort study suggest that BCT is at least equivalent to mastectomy in male breast cancer patients. The underlying mechanism of this association needs further research.     

中国乳腺癌保乳治疗的前瞻性多中心研究

目的 探讨早期乳腺癌保乳治疗的可行性,以及我国开展保乳综合治疗的模式。方法 中国医学科学院中国协和医科大学肿瘤医院等全国共10家三级甲等医院协作,进行早期乳腺癌保乳治疗与切除乳房治疗的大样本前瞻性多中心对照研究。结果 完成保乳手术872例,占符合保乳治疗条件乳腺癌患者的19．5％,占同期全部可手术乳腺癌患者的9．0％。保乳治疗组复发9例（1．0％）,远处转移11例（1．3％）,死亡1例（0．1％）;切除乳房组复发18例（0．5％）,远处转移49例（1．4％）,死亡4例（0．1％）。两组术后局部复发率、远处转移率与死亡率差异无统计学意义（P均〉0．05）。保乳治疗乳房美容效果评估优、良者术后6个月占89．7％,术后1年占91．1％,术后2年占86．6％。结论 保乳治疗在中国是可行的,对早期乳腺癌患者的生存率、复发率无负面影响,提高了患者的生活质量。保乳治疗必须严格把握手术适应证,需要多学科的有机配合,综合治疗是保乳治疗成功的保证。     

Twenty-five year results of the national cancer institute randomized breast conservation trial

Breast conservation therapy (BCT) consisting of lumpectomy and postoperative radiation has become an accepted alternative to mastectomy (MRM) for the treatment of early stage breast cancer. We currently report the 25 year outcomes of a single institution, prospective, randomized clinical trial at the National Cancer Institute. 237 women with pathologically confirmed invasive breast tumors 5 cm or less were accrued between 1979 and 1987 and randomized to receive either BCT or MRM. Overall survival was the primary endpoint. Patients with node positive disease were included and treated with doxorubicin and cyclophosphamide. Both arms received axillary dissection. BCT patients had radiation to the whole breast followed by a boost. At a median follow-up of 25.7 years, overall survival was 43.8% for the MRM group and 37.9% for BCT (P = 0.38). Although the cumulative incidence of a disease-free survival event was higher in BCT patients (29.0% MRM vs. 56.4% BCT, P = 0.0017), the additional treatment failures were primarily isolated ipsilateral breast tumor recurrences (IBTR's) requiring salvage mastectomy. 22.3% of BCT patients experienced an IBTR. Distant disease and second cancers were similar in both arms. After 25 years, long term survival between BCT and MRM continues to be similar in patients treated for early stage breast cancer. Patients receiving BCT may be at risk for additional treatment-related morbidity, which may occur as a late event. Further studies are required to delineate patients at higher risk for these events, and prolonged follow up should be encouraged after treatment for all women.     

Quality of life after immediate breast reconstruction and skin-sparing mastectomy – A comparison with patients undergoing breast conserving surgery

Background

Historically breast cancer surgery was associated with significant psychosocial morbidity and suboptimal cosmetic outcome. Recent emphasis on women’s quality of life following breast cancer treatment has drawn attention to the importance of aesthetic outcome and potential benefits of immediate breast reconstruction (IBR). Our primary aim was to assess patient’s quality of life after IBR, compared to a matched group undergoing breast conservation. We also investigated the oncological safety and morbidity associated with immediate reconstruction.

Methods

A prospectively collected database of all breast cancer patients who underwent IBR at a tertiary referral breast unit was reviewed. Patients were reviewed clinically, and administered two validated quality of life questionnaires, at least one year after completing their treatment.

Results

255 patients underwent IBR following mastectomy over a 55 month period. Reconstruction with ipsilateral latissimus dorsi flap was most commonly performed (88%). After mean follow-up of 36 months, IBR patients’ quality of life was comparable to a group of age-matched women (n = 160) who underwent breast conserving surgery (p = 0.89). No patient experienced local recurrence (0%), distant metastases developed in 4.8% and disease related mortality was 2.2%. Post-operative morbidities included wound infection (11.8%), chronic pain (2.0%), capsular contracture (11%; 36% of whom had radiotherapy) and fat necrosis (14.1%). No patient experienced flap loss.

Conclusions

IBR is a highly acceptable form of treatment for women requiring mastectomy. With high rates of patient satisfaction, low associated morbidity, and proven oncological safety, it is an appropriate recommendation for all women requiring mastectomy.     

T1-2N0M0 Triple-Negative Breast Cancer Treated With Breast-Conserving Therapy Has Better Survival Compared to Mastectomy: A SEER Population-Based Retrospective Analysis

BackgroundFor early-stage breast cancer, the two current mainstay treatments are breast-conserving therapy (BCT; lumpectomy followed by radiotherapy [RT] and BCT) and mastectomy. Generally, triple-negative breast cancer (TNBC) is more aggressive compared to hormone receptor–positive breast cancer. We sought to investigate the effect of BCT compared to mastectomy on overall survival (OS) and breast cancer–specific survival (BCSS) in T1-2N0M0 TNBC.Patients and MethodsA population-based retrospective analysis was performed using the Surveillance, Epidemiology, and End Results (SEER) database. Patients included in the analysis were divided into 3 groups according to surgical modality and RT: BCT, mastectomy alone, and mastectomy with RT. The survival end points were OS and BCSS, and survival analysis was performed by the Kaplan-Meier method and the log-rank test among treatment types.ResultsA total of 14,910 female subjects with T1-2N0M0 TNBC diagnosed between 2010 and 2014 were included. A total of 7381 patients had BCT; 6967 had mastectomy alone, and 562 had mastectomy with RT. Patients treated with BCT had better OS (log-rank P < .05) and BCSS (log-rank P < .05) than those receiving mastectomy with or without RT. The 5-year OS was 88.6% for BCT, 83.0% for mastectomy alone, and 79.6% for mastectomy with RT. The 5-year BCSS was 94.3% for BCT, 93.3% for mastectomy alone, and 83.7% for mastectomy with RT.ConclusionIn patients with T1-2N0M0 TNBC, BCT was associated with superior OS and BCSS compared to mastectomy with or without RT. After mastectomy, there was no evidence of survival benefit of RT.     

Immediate breast reconstruction after mastectomy for cancer.

AIMS: The oncological, surgical and cosmetic results, patient satisfaction and psychological morbidity of immediate breast reconstruction following mastectomy for breast cancer were evaluated. METHODS: From 1980 to 1994, 79 immediate breast reconstructions were performed in Malm?. From 1985 immediate breast reconstruction was performed in 21% of mastectomies among patients 相似文献   

The impact of neoadjuvant systemic therapy on breast conservation rates in patients with HER2-positive breast cancer: Surgical results from a phase II randomized controlled trial

BackgroundNeoadjuvant systemic therapy (NST) induces tumor shrinkage and boosts the chance of breast-conserving thearpy (BCT) in patients with breast cancer. However, only a few trials have evaluated the effect of NST in conversion from BCT ineligibility to BCT eligibility in HER2-positive breast cancer.MethodsWe conducted the surgical sub-study of a phase II randomized trial, which compared standard neoadjuvant treatment or an experimental treatment modified according to the interim Ki-67 evaluation in women with stage II or III HER2-positive breast cancer. The treating surgeons assessed eligibility for BCT before and after NST. We evaluated the change in BCT eligibility following NST. We also analyzed the type of surgery performed and the success rate of BCT.ResultsTwo hundred six patients were included in this study. Of these, 44.0% were considered BCT candidates at baseline, while 69.8% were deemed eligible for BCT after NST (P < 0.001). Among non-BCT candidates at baseline, 46% successfully converted to BCT candidates. Of 139 patients deemed eligible for BCT following NST, 84.2% attempted BCT, and successful BCT, defined as tumor-free at all surgical margins, was achieved in 96.8% of patients. Different treatment arms did not affect the rate of post-NST BCT eligibility (70.0% vs 69.7%).ConclusionsThis study demonstrated that NST resulted in an absolute increase of 25.8% in the rate of BCT eligibility in HER2-positive breast cancer. About a half of non-BCT candidates converted to BCT candidates. BCT was successful in most patients who attempted BCT. There were still patients who chose mastectomy even though they were deemed eligible for BCT. Patients considered BCT-ineligible due to large tumor size most likely converted to BCT-eligible with NST. On the other hand, NST had less impact on the surgical indication of patients with multicentric disease or probable poor cosmetic outcome.     

ASTRO Radiation Therapy Summary of the ASCO-ASTRO-SSO Guideline on Management of Hereditary Breast Cancer

PurposeTo develop a summary of recommendations regarding locoregional management of patients with breast cancer and germline mutations in breast cancer susceptibility genes based on the American Society of Clinical Oncology/American Society for Radiation Oncology/Society of Surgical Oncology Guideline on Management of Hereditary Breast Cancer.MethodsThe American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology convened an expert panel to develop recommendations based on a systematic review of the literature and a formal consensus process. A total of 58 articles met the eligibility criteria and formed the evidentiary basis for the locoregional therapy recommendations. Additionally, 6 randomized controlled trials of systemic therapy also met eligibility criteria.ResultsA joint evidence-based guideline was developed by a multidisciplinary panel, which has been separately published. From this guideline, the radiation-oncologist authors of the panel extracted pertinent surgical and radiation-specific recommendations of findings that are hereby presented.ConclusionsPatients with newly diagnosed breast cancer and BRCA1/2 mutations may be considered for breast conserving therapy (BCT), expecting similar rates of local control of the index cancer as noncarriers. The significant risk of contralateral breast cancer in these women (especially younger women), coupled with the higher risk of new cancers in the ipsilateral breast, warrant discussion of bilateral mastectomy. For women with mutations in BRCA1/2 or moderate-penetrance genes who are eligible for mastectomy, nipple-sparing mastectomy is a reasonable approach. There is no evidence of increased toxicity or contralateral breast cancer events from radiation exposure in BRCA1/2 carriers. Patients with mutations in moderate-risk genes should be offered BCT as one choice after appropriate counseling. Radiation therapy should not be withheld in ATM carriers if BCT is planned. For patients with germline TP53 mutations, mastectomy is advised and radiation therapy is contraindicated except for those with a significant risk of locoregional recurrence.     

Factors Influencing Cosmetic Outcome in Breast Conservation

With more than 1 million new cases each year, female breast cancer is the second most common cancer in the world and the most common cancer among women. Breast cancer involves a multimodality treatment and a co-ordinated approach from various specialties. Breast-conserving therapy (BCT) is increasingly being integrated into the management of breast cancer. The obvious advantages of BCT are equivalent local and distant control rates as compared with mastectomy and the preservation of the breast. However, the key to a successful BCT is achieving a cosmetic outcome that is acceptable to the patient and the physician. Cosmesis in breast cancer is the end result of a range of factors that fall under the broad heads of surgery, radiotherapy, chemotherapy and hormonal treatment. All of these modalities can play a role in compromising breast cosmesis. This overview discusses the factors that are critical in affecting the final cosmetic outcome in patients with BCT.     

Impact of local surgical treatment on survival in young women with T1 breast cancer: long-term results of a population-based cohort

The aim of this study was to analyze the effect of the type of local surgical treatment on survival in young women aged less than 40 years with T1 breast cancer. We analyzed data from 3,512 patients aged ≤40 years old who were diagnosed with T1 breast cancer from the Korean Breast Cancer Registry database between January 1988 and December 2006 and underwent either breast-conserving therapy (BCT) or mastectomy. The overall survival (OS) and breast-cancer-specific survival (BCSS) were compared between BCT and mastectomy. Of the 3,512 patients analyzed, 1,951 (55.6 %) underwent BCT, and 1,561 (44.4 %) underwent mastectomy. The median follow-up period was 111.0 (79.0–131.5) months. Overall, the 10-year OS rates for BCT and mastectomy were 95 and 92.1 %, respectively (p = 00004), and the 10-year BCSS rates for BCT and mastectomy patients were 96.9 and 94.9 %, respectively (p = 0.12). In node-negative patients, no significant difference was observed in either the OS (adjusted hazard ratio [HR] 1.072; 95 % CI, 0.750–1.5332, p = 0.704) or BCSS (adjusted HR 0.988; 95 % CI, 0.620–1.574, p = 0.960) rate between the BCT and mastectomy groups. In node-positive patients, no significant difference was observed in the OS (adjusted HR 1.634; 95 % CI, 0.982–2.272, p = 0.59) and BCSS (adjusted HR 1.410; 95 % CI, 0.755–2.633, p = 0.281) rates between the BCT and mastectomy groups. In this large, population-based analysis of young women with T1 breast cancer, the OS and BCSS were not different between BCT and mastectomy.     

Surgical management of BRCA-mutation carriers: A single institution experience

IntroductionThe optimal surgical management of BRCA-mutation carriers remains a subject of debate. To evaluate the appropriateness of breast cancer (BC) treatment, the oncological outcomes of BRCA-mutation carriers treated either with breast-conserving therapy (BCT) or mastectomy were compared. Additionally, the role of bilateral salpingo-oophorectomy (BSO) and potential independent predictive factors for BC treatment were analyzed.Materials and methodsWe retrospectively reviewed all the consecutive patients with a pathogenic germline mutation in the BRCA1/2 genes tested at our Institution between July 2008 and October 2018. Primary end-points were disease-free survival (DFS), distant disease-free survival (DDFS), and overall survival (OS).ResultsThe characteristics and outcomes of 124 BRCA-associated BC patients were analyzed. Overall, 69 (55.7%) and 55 (44.3%) patients underwent BCT and mastectomy, respectively; 72 (58.1%) patients underwent BSO. After a median interval of 13.3 months, 24 patients underwent mastectomy after primary BCT. There was no significant difference in terms of DFS, DDFS, and OS between patients treated with BCT or mastectomy (p = 0.39,p = 0.27,p = 0.265, respectively). Patients treated with BSO had significantly better DDFS and OS compared to ovarian conservation (p = 0.033,p = 0.040, respectively). Three independent predictive factors for BCT were identified: age ≤41 years, genetic testing performed post-operatively, and breast tumors ≤21 mm.ConclusionsOur data suggest that BRCA-mutation carriers treated with BCT present similar oncological outcomes compared to mastectomy. Ovarian preservation decreases survival. Young BRCA-mutated patients with small BCs may not need up-front mastectomy, and BSO might be performed when ovarian cancer risk epidemiologically rises and potential reproductive desire is fulfilled.     

Cost-utility analysis of four common surgical treatment pathways for breast cancer

BackgroundThe aim was to evaluate the cost-utility of four common surgical treatment pathways for breast cancer: mastectomy, breast-conserving therapy (BCT), implant breast reconstruction (BR) and autologous-BR.MethodsPatient-level healthcare consumption data and results of a large quality of life (QoL) study from five Dutch hospitals were combined. The cost-effectiveness was assessed in terms of incremental costs and quality adjusted life years (QALYs) over a 10-year follow-up period. Costs were assessed from a healthcare provider perspective.ResultsBCT resulted in comparable QoL with lower costs compared to implant-BR and autologous-BR and showed better QoL with higher costs than mastectomy (€17,246/QALY). QoL outcomes and costs of especially autologous-BR were affected by the relatively high occurrence of complications. If reconstruction following mastectomy was performed, implant-BR was more cost-effective than autologous-BR.ConclusionThe occurrence of complications had a substantial effect on costs and QoL outcomes of different surgical pathways for breast cancer. When this was taken into account, BCT was most the cost-effective treatment. Even with higher costs and a higher risk of complications, implant-BR and autologous-BR remained cost-effective over mastectomy. This pleas for adapting surgical pathways to individual patient preferences in the trade-off between the risks of complications and expected outcomes.     

Paget's disease of the nipple as local recurrence after breast-conservation treatment for early-stage breast cancer

Breast conservation treatment (BCT) for early-stage breast cancer is associated with survival rates comparable with mastectomy but has the risk of ipsilateral breast tumor recurrence, including Paget's disease of the nipple. A small number of cases of Paget's disease presenting as local recurrence following BCT for breast cancer have been previously reported. Between 1977 and 2002, 2181 women with early-stage breast cancer were treated with BCT at the Hospital of the University of Pennsylvania. In this cohort, there were 183 local treatment failures, 4 of which were cases of Paget's disease (2.2%), which are reported herein. These local recurrences developed 1.8, 3.8, 7.3, and 9.7 years after diagnosis of the patients' primary tumors. Three of the 4 primary cancers were invasive ductal carcinomas, with an associated intraductal component, and 1 was ductal carcinoma in situ. All 4 patients were successfully given salvage therapy consisting of mastectomy with or without tamoxifen, with follow-up times of 20.9, 10.6, 3.1, and 3.8 years. Paget's disease as local recurrence after BCT is uncommon and can be treated with salvage therapy if detected early.     

Surgical management of breast cancer: today and tomorrow

The surgeon continues to play a key role in the initial local/regional management of breast cancer. Breast conserving therapy (BCT) utilizing segmental mastectomy has been developed as an alternative to total mastectomy to improve cosmetic and psychosocial outcomes while retaining oncologic benefits. Developments in the surgical treatment of breast cancer have changed the way breast cancer is diagnosed and treated, and will likely continue to evolve in the future. This review highlights aspects of breast cancer treatment in which the surgical approach has evolved or is evolving, and comments on how the surgeon may participate in breast cancer care in the future.     

背阔肌皮瓣修复在乳腺癌保乳手术中的应用

目的 探讨采用背阔肌皮瓣修复乳腺癌部分乳房切除术后较大范围缺损的治疗和美容效果.方法 24例乳腺癌患者的肿瘤最大径为3.0～5.5 cr,平均3.5 cm.均行保留乳房的病灶广泛切除,所有患者均在术中冰冻切片确定切缘达阴性后,即刻采用背阔肌皮瓣修复局部缺损,术后给予全乳放射治疗±辅助化疗±内分泌治疗.结果 全组24例患者背阔肌皮瓣全部成活,背部及乳房皮肤无坏死.术后中位随访23个月,患者均无病生存.全乳放射治疗对转移的背阔肌皮瓣末见明显影响,乳房外观优良率为79.2%,患者主观评价满意度为96.0%.结论 采用转移的背阔肌皮瓣修复部分乳房切除术后的较大缺损可获得满意的治疗效果和美容效果,对存在导管内癌、新辅助化疗后、乳房中央区(乳头乳晕区)及较大肿瘤(＞3 cm)等保乳手术相对或绝对禁忌的患者可行保乳手术,扩大了保乳手术的适应证.

Abstract：

Objective Breast conserving surgery (BCS) is one of standard treatment approaches in early breast cancer.Although most defect after BCS can be repaired, the cosmetic outcomes are unsatisfactory in the patients with poor tumor/breast ratio.Oncoplastic surgery (OPS) has emerged as a new approach for providing adequate tumor resection without compromise of aesthetic outcomes in BCS.Our purpose is to explore the cosmetic outcomes of applying latissimus dorsi (LD) muscle flap to reshape severe breast conservation deformities in breast cancer.Methods Totally 24 cases of breast cancer were studied.The tumor size was 3.0-5.5 cm ( median 3.5 cm).All the cases underwent BCS and achieved negative margin by frozen sections examination.Then LD flap reshaping were performed.All the patients received whole breast radiotherapy ± chemotherapy ± endocrine therapy.Results All the LD flaps were alive without skin necrosis.After a median 23-month follow-up, all the cases were disease-free surviving.The whole breast radiotherapy had no significant effect on the LD flaps.The rate of good cosmetic results was 79.2%.The subjective satisfactory rate of the patients was 96%.Conclusions Both satisfactory aesthetic outcome and good treatment effect were obtained using LD flap to reshape severe breast conservation deformity.OPS offers tools for breast conservation in patients otherwise destined for mastectomy or poor aesthetic outcome, such as large tumor/breast ratio, nipple-areola complex tumor, ductal carcinoma in situ,neoadjuvant chemotherapy cases and so on.