Role of lipomodelling in improving aesthetic outcomes in patients undergoing immediate and delayed reconstructive breast surgery

Aims

The objective of this article is to report our findings regarding large-volume fat transfer in patients who have undergone autologous breast reconstruction with the latissimus dorsi (LD) flap and/or implant-based reconstruction with subsequent lipomodelling for symmetrisation.

Methods

We retrospectively collected data on all patients who have undergone lipomodelling from October 2008 to October 2011. Fat was harvested using a low-negative pressure syringe method and centrifuged at 3000 r.p.m. for 3 min. The purified fat was injected in 1 mL increments into multilayered microtunnels, starting from deeper layers and moving to superficial layers in the subcutaneous tissue. Patient satisfaction was assessed using validated Picker questions in a face-to-face consultation during follow-up visits, and the results were documented in the case notes.

Results

Thirty-one patients underwent lipomodelling following autologous breast reconstruction using the LD flap and implant-based reconstruction. Three patients in the study group had bilateral lipomodelling, and one patient required 3 lipomodelling sessions. Seven patients required 2 sessions, and 21 patients required a single session to achieve bilateral symmetry. The mean volume of fat that was harvested was 396 mL, and the mean injected volume of fat was 247 mL. Four patients (1 breast cancer recurrence, 2 patients with fat necrosis and 1 patient with oil cysts) developed postoperative complications. Twenty-nine patients (93%) were satisfied with the postoperative cosmetic outcome.

Conclusion

Lipomodelling offers an additional tool to refine breast reconstructive surgery. This study demonstrates that large volumes of fat can be injected for sculpture optimisation and for reshaping reconstructed breasts with improved softness and a natural feel.     

Autologous fat transfer after breast cancer surgery: An exact-matching study on the long-term oncological safety

IntroductionAutologous fat transfer (AFT) is widely adopted for breast reconstruction, but its long-term oncologic safety is still not clearly established. The aim of the present study was to compare the 10-year loco-regional recurrence (LRR)-free and distant metastases (DM)-free survival probabilities in AFT vs. control patients, also evaluating the impact of AFT in different intrinsic molecular subtypes of breast cancer.Materials and methods464 AFT patients were exactly matched with a cohort of 3100 control patients treated between 2007 and 2017. A multivariate survival analysis was performed accounting for all variables related to LRR and DM, including adjuvant/neoadjuvant treatments. End-points were analyzed both overall and in each molecular subtype.ResultsLRR occurred in 6.4% of AFT and in 5.0% of control patients (p = 0.42), while DM were observed respectively in 7.7% and 5.4% of cases (p = 0.20). AFT showed no effect on the 10-year LRR-free survival probability (adjusted HR 0.87, 95%CI 0.43–1.76, p = 0.69) or the 10-year DM-free survival probability (adjusted HR 0.82, 95%CI 0.43–1.57, p = 0.55). Luminal A patients treated by AFT showed a decreased LRR-free survival probability (HR 2.38, 95%CI 0.91–6.17, Log-Rank p = 0.07), which was significantly lower than controls after 80 months (Log-Rank p = 0.02). No differences in the 10-year event-free survival probability were found in Luminal B, HER2-positive or triple-negative patients.ConclusionAFT does not increase breast cancer recurrence, with the possible exception of late LRRs for Luminal A patients, but further clinical and preclinical data are required to better clarify this data. The use of AFT should not be discouraged.     

Quality of life after autologous fat transfer additional to prosthetic breast reconstruction in women after breast surgery: A systematic review

BackgroundBreast cancer is the most frequent form of cancer among women worldwide. Reconstructive surgery may improve the quality of life (QoL), after mastectomy. Various techniques are used to reconstruct the female breast; however, few is known about its specific post-surgery influence represented in patient-reported outcomes.ObjectiveThis systematic review assesses the difference in patient-reported QoL between prosthetic reconstruction alone, and prosthetic reconstruction with additional autologous fat transfer (AFT).Data sourcesA literature search was performed in PubMed, Embase, Cochrane and CINAHL online databases from inception to February 11th, 2020.Study selectionInclusion and exclusion criteria were used to assess the eligibility of the retrieved articles. The only eligible studies were cohort studies.Data collection and analysisRelevant data for the research question was extracted from the articles and systematically documented. Results not contributing to answering the objective were intentionally left out. No meta-analysis was realized.ResultsThis systematic review resulted in the inclusion of only six relevant studies, all cohort studies, consisting of 1437 unique patients. These studies evaluated the quality of life of patients by means of the validated BREAST-Q questionnaire. Outcomes varied for which reason no definite answer could be provided to whether additional AFT results in a higher QoL.ConclusionsIt is unclear whether additional AFT after prosthetic surgery leads to a higher QoL when compared to sole prosthetic reconstruction or not. Additional studies, assessing the QoL of patients who received additional AFT, are required to draw solid conclusions.Level of evidenceLevel III; systematic literature review of cohort studies.     

Breast reconstructive surgery in medically underserved women with breast cancer

BACKGROUND:

Breast reconstructive surgery can improve mastectomy patients' emotional relationships and social functioning, but it may be underutilized in low‐income, medically underserved women. This study assessed the impact of patient‐physician communication on rates of breast reconstructive surgery in low‐income breast cancer (BC) women receiving mastectomy.

METHODS:

A cross‐sectional, California statewide survey was conducted of women with income less than 200% of the Federal Poverty Level and receiving BC treatment through the Medicaid Breast and Cervical Cancer Treatment Program. A subset of 327 women with nonmetastatic disease who underwent mastectomy was identified. Logistic regression was used for data analysis. The chief dependent variable was receipt of or planned breast reconstructive surgery by patient report at 6 months after diagnosis; chief independent variables were physician interactive information giving and patient perceived self‐efficacy in interacting with physicians.

RESULTS:

Greater physician information giving about BC and its treatment and greater patient perceived self‐efficacy positively predicted breast reconstructive surgery (OR = 1.12, P = .04; OR = 1.03, P = .01, respectively). The observed negative effects of language barriers and less acculturation among Latinas and lower education at the bivariate level were mitigated in multivariate modeling with the addition of the patient‐physician communication and self‐efficacy variables.

CONCLUSIONS:

Empowering aspects of patient‐physician communication and self‐efficacy may overcome the negative effects of language barriers and less acculturation for Latinas, as well as of lower education generally, on receipt of or planned breast reconstructive surgery among low‐income women with BC. Intervening with these aspects of communication could result in breast reconstructive surgery rates more consistent with the general population and in improved quality of life among this disadvantaged group. Cancer 2009. © 2009 American Cancer Society.     

自体脂肪移植在乳腺癌术后乳房重建中肿瘤学安全性的Meta分析

目的评价乳腺癌术后乳房重建患者行自体脂肪移植的肿瘤学安全性。 方法检索PubMed、Embase、Cochrane、中国知网、万方及维普数据库,收集截止至2018年5月所有已发表的队列研究,由2位评价员独立完成文献筛选和数据提取,并运用改良纽卡斯尔-渥太华量表(NOS)系统评价文献质量。采用比值比(OR)及95%置信区间(CI)为效应量,使用RevMan 5.3软件进行Meta分析。 结果最终纳入符合标准的文献13篇,总样本量8 466例患者,其中乳房重建过程应用脂肪移植者(AFG组)1 963例,未应用脂肪移植者(NFG组)6 503例。NOS评价结果显示,所有纳入文献质量均较高(评分为6～9分)。Meta分析显示：AFG组总复发病例数为88例(4.5%,88/1 963),NFG组总复发病例数为455例(7.0%,455/6 503),AFG组乳腺癌复发率明显低于NFG组(OR＝0.73,95%CI：0.57～0.95,P＝0.02);脂肪移植对乳腺癌的局部复发率、区域复发率及远处复发率均无显著影响(OR＝1.06,95%CI：0.60～1.88,P＝0.84;OR＝0.89,95%CI：0.32～2.48,P＝0.83;OR＝0.36,95%CI：0.10～1.28,P＝0.11)。亚组分析显示：在DCIS或浸润性癌患者中,脂肪移植对乳腺癌复发率无显著影响(OR＝1.16,95%CI：0.05～26.91,P＝0.93;OR＝0.68,95%CI：0.40～1.16,P＝0.16);在行保留乳房术或乳房全切手术的患者中,脂肪移植对乳腺癌复发率亦无显著影响(OR＝0.36,95%CI：0.08～1.66,P＝0.19;OR＝0.64,95%CI：0.33～1.26,P＝0.19)。 结论基于1965年1月至2018年5月相关临床队列研究的综合分析,自体脂肪移植是安全的,且其乳腺癌复发风险较低。     

Mastectomy with immediate breast reconstruction after neoadjuvant chemotherapy and radiation therapy. A new option for patients with operable invasive breast cancer. Results of a 20 years single institution study

Purpose

To evaluate the feasability of immediate breast reconstruction (IBR) following mastectomy after neoadjuvant chemotherapy (NACT) and radiation therapy (RT) for operable invasive breast cancer (OIBC), in terms of incidence of local complications, locoregional control and survival.

Patients and methods

From 1990 to 2008, 210 patients were treated by NACT, RT and mastectomy with IBR for OIBC. One hundred and seven patients underwent a latissimus dorsi flap with implant (LDI), 56 patients a transverse rectus abdominis musculocutaneous (TRAM) flap, 25 an autologous latissimus dorsi flap (ALD) and 22, a retropectoral implant (RI) reconstruction.

Results

Forty-six (21.9%) early events were recorded: 20 necrosis, 9 surgical site infections and 6 haematomas, requiring further surgery in 23 patients. More necrosis were observed with TRAM flap reconstructions (p = 0.000004), requiring more surgical revision than LD reconstructions. Seromas represented 42% of early complications in LD reconstructions. Fifty-five patients presented with late complications (26.2%) with mainly implant complications (capsular contracture, infection, dislocation, deflation) (23.6%), requiring reintervention in 14 cases. There were more delayed surgical revisions in RI reconstructions (p = 0.0005). The 5 years overall and disease-free survival rates were respectively 86.7% and 75.6%. Sixty-four patients presented at least one recurrence (30.5%) with 5 local, 9 locoregional and 54 distant relapses.

Conclusion

This therapeutic sequence does not seem to increase the IBR morbidity nor alter disease-free and overall survival.     

Focally positive margins in breast conserving surgery: Predictors,residual disease,and local recurrence

Background

Re-excision after breast conserving surgery (BCS) for invasive breast cancer (IBC) can be omitted for focally positive margins in the Netherlands, but this guideline is not routinely followed. Focally positive and extensively positive margins have rarely been studied separately and compared to negative margins regarding clinicopathological predictors, residual disease incidence, and local recurrence.

乳腺癌保乳手术切缘与瘤体距离对切缘状态及美容效果的影响

目的分析乳腺癌保乳手术切缘与瘤体距离对切缘状态及术后美容效果的影响。方法116例乳腺癌行保乳手术治疗患者的一般资料、手术方法,根据切缘与瘤体距离不同分为A组(瘤距1 cm)和B组(瘤距2 cm),A组63例,B组53例,比较两组患者的切缘阳性率、术后美容效果,随访2⁵年,观察患者的近期复发率及生存质量的差异。结果 A组患者术中切缘阳性率为3.2%,B组患者为1.9%,但差异无统计学意义(P>0.05)。A组患者美容效果优良率为73.0%,B组患者为43.4%,差异有统计学意义(P<0.05)。术后2年,A组患者心理、精神维度及总分高于B组患者,差异均有统计学意义(P<0.05),术后随访25年,观察患者的近期复发率及生存质量的差异。结果 A组患者术中切缘阳性率为3.2%,B组患者为1.9%,但差异无统计学意义(P>0.05)。A组患者美容效果优良率为73.0%,B组患者为43.4%,差异有统计学意义(P<0.05)。术后2年,A组患者心理、精神维度及总分高于B组患者,差异均有统计学意义(P<0.05),术后随访2⁵年,A组患者2年复发率和5年复发率分别为4.8%和5.7%,B组患者分别为3.8%和7.4%,差异无统计学意义(P>0.05)。结论在确保切缘阴性的基础上,切缘与瘤缘距离为1 cm能够在保证术后高生存率及低复发率的基础上,提供良好的美容效果,改善患者术后生存质量,是较为理想的瘤距选择。     

Virtual breast oncoplastic surgery simulator (VBOSS): A novel training tool in breast surgery

Virtual simulators have been employed for the teaching of breast surgery. However, there remains no virtual simulator for the training of oncoplastic breast conserving surgery. This is the first known report of virtual simulator for oncoplastic breast conserving surgery training, to the best of our knowledge.     

Chest wall resection for locally recurrent breast cancer: indications, technique, and results.

A series of 100 patients with locally advanced carcinoma of the breast was analyzed for chest wall recurrence alone after primary treatment. Five patients were found to have had chest wall recurrence alone and were treated with en bloc chest wall resection. This group of patients was analyzed for the pathophysiology of recurrence including characteristics of the primary tumor, location of the chest wall recurrence, and overall local salvage and survival after chest wall recurrence. In this series, local recurrence after radical chest wall resection was 20%. The incidence of systemic recurrence after chest wall resection was 60%. The mean survival for the entire group was 17 months after chest wall recurrence and radical resection. The main surgical objectives, including relief from painful, inflammatory, and bleeding complications, were achieved in all patients after chest wall resection. Although patients with isolated chest wall recurrence included a highly selected group, chest wall resection with myocutaneous reconstruction may provide long-term disease-free survival for these patients.     

乳腺癌保留乳房手术中放射治疗有效性和安全性的Meta分析

目的评价乳腺癌保留乳房手术中放射治疗的有效性和安全性。 方法用计算机检索中国知网、维普、万方、PubMed、Cochrane、Web of Science和Embase数据库,检索时限为建库至2018年12月20日,收集有关乳腺癌保留乳房手术中放射治疗有效性和安全性的临床试验研究。由2名研究者独立按照纳入及排除标准进行文献筛选、资料提取、方法学质量评价后,采用RevMan 5.3软件对纳入研究进行Meta分析。 结果共纳入12项研究,包括8项随机对照研究(RCT)和4项非RCT,共6 277例患者。与术后放射治疗者比较,术中放射治疗患者的局部复发率更高(RR＝2.78,95%CI: 1.25～6.19,P＝0.01),切口愈合时间更长[均数差(MD)＝5.92,95%CI: 5.46～6.37,P<0.01],但在远处转移率和OS率方面与术后放射治疗者比较,差异均无统计学意义(RR＝0.92,95%CI: 0.62～1.37,P＝0.68;RR＝1.01,95%CI: 1.00～1.01,P＝0.26)。术中放射治疗患者的美容优良率高于术后放射治疗(RR＝1.17,95%CI: 1.05～1.31,P<0.01)。术中放射治疗患者的脂肪液化率和渗出率与术后放射治疗患者比较,差异均无统计学意义(RR＝2.18,95%CI: 0.71～6.72,P＝0.18;RR＝1.55,95%CI: 0.36～6.68,P＝0.56)。 结论术中放射治疗在远处转移率、总生存率及不良反应方面与术后放射治疗相似,且有更好的美容效果,但其局部复发率可能更高,应选择复发风险较低的患者。     

早期乳腺癌保乳术后调强放疗

现行早期乳腺癌保乳术后的常规切线野放射治疗技术存在靶区内剂量不均匀的缺陷.国内外多位研究者将调强放疗(IMRT)应用于保乳术后患者,以期在提高靶区剂量均匀性、降低危及器官受量及改善美容效果方面体现出一定优势.     

Text mining and word embedding for classification of decision making variables in breast cancer surgery

IntroductionDecision making in surgical oncology of the breast has increased its complexity over the last twenty years.This Delphi survey investigates the opinion of an expert panel about the decision making process in surgical procedures on the breast for oncological purposes.MethodsTwenty-seven experts were invited to partake into a Delphi Survey. At the first round they have been asked to provide a list of features involved in the decision making process (patient's characteristics; disease characteristics; surgical techniques, outcomes) and comment on it. Using text-mining techniques we extracted a list of mono-bi-trigrams potentially representative of decision drivers. A technique of “natural language processing” called Word2vec was used to validate changes to texts using synonyms and plesionyms. Word2Vec was also used to test the semantic relevance of n-grams within a corpus of knowledge made up of books edited by panel members. The final list of variables extracted was submitted to the judgement of the panel for final validation at the second round of the Delphi using closed ended questions.Results52 features out of 59 have been approved by the panel. The overall consensus was 87.1%ConclusionsText mining and natural language processing allowed the extraction of a number of decision drivers and outcomes as part of the decision making process in surgical oncology on the breast. This result was obtained transforming narrative texts into structured data. The high level of consensus among experts provided validation to this process.     

Resection margins and local recurrences in breast cancer: Comparison between conventional and oncoplastic breast conserving surgery

BackgroundThis retrospective cohort study aims to compare surgical margins, reoperations and local recurrences after conventional or oncoplastic breast conservation surgery (BCS). Furthermore, we aim to investigate differences between various oncoplastic techniques.Material and methodsWe reviewed 1800 consecutive patients with primary invasive breast cancer (N = 1707) or ductal carcinoma in situ (N = 93) who underwent BCS at Helsinki University Hospital between 2010 and 2012.ResultsConventional BCS was performed in 1189 (66.1%) patients, oncoplastic BCS in 611 (33.9%). Various oncoplastic techniques were used. Patients with oncoplastic BCS had more often multifocal (p < 0.001), larger (p < 0.001), palpable tumours (p < 0.001) with larger resection specimens (p < 0.001). The amount of resected tissue varied substantially depending on the oncoplastic technique. Patients treated with oncoplastic BCS were younger (p < 0.001) and their tumours were more aggressive according to histological grade (p < 0.001), T-stage (p < 0.001), Ki-67 (p < 0.001) and lymph node status (p < 0.001).There was no difference, however, in surgical margins (p = 0.578) or reoperation rates (p = 0.430) between the groups. A total of 152 (8.4%) patients were reoperated because of insufficient margins, 96 (8.1%) in the conventional, 56 (9.2%) in the oncoplastic BCS group.The median follow-up time was 75 (2–94) months. There was no difference in local recurrence-free survival between the conventional and oncoplastic BCS groups (log-rank test, p = 0.172).ConclusionsOncoplastic BCS was used for larger, multifocal and more aggressive tumours. Nevertheless, no difference in reoperation rate or local recurrences were found. Oncoplastic BCS is as safe as conventional BCS enabling breast conserving for patients who otherwise were candidates for mastectomy.     

Variability in breast cancer surgery training across Europe: An ESSO-EUSOMA international survey

BackgroundAt present there is a lack of standardization of training in breast cancer surgery across Europe. The aim of this survey was to assess current practice in Europe regarding training in breast cancer (BC) surgery.Material and methodsGeneral surgeons, surgical oncologists, gynecologist, and plastic surgeons in Europe were invited to participate in this bespoke survey including 19 questions.ResultsThe survey was sent to 3.000 surgical oncologists across Europe. A total of 671 physicians (387 general surgeons, 152 gynecologists, 126 surgical oncologist, 31 plastic surgeons) answered the survey (23% response rate). Four hundred and sixty-eight physicians devoted between 50% −100% of their job to treating breast cancer. 45% worked in a community/University hospital within a dedicated Breast Unit.Specific additional breast surgery training was not universal: 20% had undertaken an accredited breast fellowship, 30% in a Breast Unit as a trainee, 21% had done additional courses, masters or diploma and 8% had not done any additional training. The majority (61%) of respondents worked in Units treating >150 BC cases per year, while 26% of the responders treat >120 new primary cases per year, and 23% less than 50 new cases a year. Multivariate analysis showed that breast surgeons working in a Breast Unit and treating more than 50 cases/year significantly performed oncoplastic procedures.ConclusionThere is a great variability in breast cancer surgery training in Europe. It is imperative to develop quality standards for breast cancer surgery training to ensure that patients get standardized and certified surgical management regardless of the country in which they are treated.     

Long-term results of breast conserving surgery for stages I and II breast cancer: experiences at Osaka Medical Center for Cancer and Cardiovascular Diseases

PURPOSE: The purpose of this study is to summarize the long-term results of breast conserving surgery (BCS) for Japanese patients with stage I and II breast cancer at a single institute and to identify risk factors for local recurrence after BCS. PATIENTS AND METHODS: Between October 1986 and June 2000, 979 women underwent BCS with or without radiation therapy (RT). Overall survival, disease free survival and local recurrence rates were calculated by the Kaplan-Meier method. Risk factors for local recurrence were examined by multivariate analysis using the Cox proportional regression model. RESULTS: The 10-year overall survival rates were 90.9% for the surgery and radiation therapy (RT group) and 89.3% for the surgery only group with a median follow-up time of 46 months. The 10-year disease free survival rates were 85.1% in the RT group and 69.2% in the surgery only group (p=0.0001). The positive margin rate was 14.1% (138/979). The 10-year overall survival rate of the patients with positive margins was 87.9%, compared with 90.8% for patients with negative margins (N.S.). The cumulative incidence of local recurrence at 10 years was significantly lower in the RT group (7.2% ) than in the surgery only group (27.5% ) (p<0.0001). Multivariate analysis showed that positive margins and lack of post-operative irradiation or adjuvant endocrine therapy were risk factors for non-inflammatory local recurrence. CONCLUSIONS: Our study indicates that BCS can be performed for Japanese women with early breast cancer. The margin status and post-operative irradiation had no influence on overall survival while but were significantly related to local recurrence.     

Comparison of surgical and oncological outcomes between oncoplastic breast-conserving surgery versus conventional breast-conserving surgery for treatment of breast cancer: A systematic review and meta-analysis of 31 studies

AimsTo evaluate comparative outcomes of oncoplastic breast conserving surgery (OBCS) versus conventional breast conserving surgery (BCS) for breast cancer treatment.MethodsA systematic search of multiple electronic data sources was conducted, and all eligible studies comparing OBCS and BCS were included. Characteristics of the tumour includes preoperative size of tumour on imaging and the weight of the specimen after resection. While positive margins rate, re-excision rate, completion mastectomy rate and loco-regional recurrence were considered as oncological outcome parameters. Post-operative complications include surgical site infection (SSI), seroma, haematoma and skin/nipple necrosis.ResultsThirty-one studies reporting a total number of 115011 patients who underwent OBCS (n = 11978) or BCS (n = 103033) were included. OBCS group showed lower risk of positive margins rate [OR 0.76, P = 0.05], re-excision rate [OR 0.72, P = 0.02], and loco-regional recurrence [OR 0.62, P = 0.03] compared to BCS group. There was no significant difference between the two groups regarding post-operative complications.ConclusionAlthough there is a lack of level 1 evidence, the available studies clearly demonstrate superior or at least equivalent outcomes when comparing OBCS with conventional BCS. The benefits of OBCS include dealing with larger tumours, wider surgical margins and better aesthetic results for patients.