Feasibility of breast conserving surgery in multifocal breast cancers

Background

Multifocal breast cancers (MFBCs) present a challenge to surgeons. Although its feasibility is still controversial, breast-conserving surgery (BCS) is not contraindicated for MFBCs. The investigators retrospectively evaluated the feasibility of BCS and reviewed histopathologic findings in patients with MFBC.

Methods

A total of 222 patients with MFBC who were treated with either BCS (119 patients) or mastectomy (103 patients) at a single institution between January 2002 and December 2011 were retrospectively evaluated.

Results

The median follow-up time was 55 months (range, 10 to 102 months). Lymphovascular invasion and lymph node involvement were significantly less frequent in the BCS group (48.8% vs 62.2% for lymphovascular invasion, P = .04; 52.1% vs 71.8% for lymph node involvement, P = .002). There were no differences in local recurrence rates between the 2 groups. The overall survival rates were 92% in the BCS group and 72% in the mastectomy group (P = .000).

Conclusions

BCS is a feasible and safe procedure for the removal of multifocal tumors. Extended lymphovascular invasion is associated with mortality in patients who undergo mastectomy.     

Factors which affect the use of lumpectomy and mastectomy in an underinsured,safety net hospital population

Background

This study was performed to evaluate variables that affect the use of mastectomy and lumpectomy in an underinsured population.

Methods

A retrospective review of all patients who underwent breast cancer operations from July 2001 to February 2011 at a safety net hospital was performed. Univariate and multivariate analyses were performed to identify variables, which were associated with the type of operation.

Results

Of the 412 patients, 81% of the patients were underinsured or uninsured. Most patients (58%) presented with clinical stage 2A/B disease. Mastectomy was performed in 37% of patients and lumpectomy in 63%. In multivariate analysis, clinical tumor size (P = .035) and pathologic stage (P = .003) remained associated with mastectomy, while use of preoperative chemotherapy (P = .004) and type of surgeon (P = .001) was associated with lumpectomy.

Conclusions

Most patients underwent lumpectomy despite later stage at presentation. Preoperative chemotherapy was associated with increased likelihood of lumpectomy.     

Factors associated with decision to pursue mastectomy and breast reconstruction for treatment of ductal carcinoma in situ of the breast

Background

Factors influencing the treatment of ductal carcinoma in situ with mastectomy and reconstruction are poorly understood.

Methods

A retrospective cohort study of 196 patients presenting to one institution was performed.

Results

Forty-seven patients (24.0%) were treated with mastectomy, while 149 (76.0%) underwent breast-conserving surgery. Of the mastectomy patients, 28 (59.6%) elected for reconstruction. On bivariate analysis, patients who opted for mastectomy were younger than those treated with breast-conserving surgery (median age, 51.8 vs 56.5 years; P = .017) and had higher grade tumors (50.0% vs 34.6% grade 3, P = .009). Among patients treated with mastectomy, those who opted for reconstruction were younger than those forgoing reconstruction (49.4 vs 56.9 years, P = .024). Race, ductal carcinoma in situ tumor size, and histologic subtype were not associated with the decision to pursue mastectomy or reconstruction (P > .05 for all).

Conclusions

In patients with ductal carcinoma in situ, the decision to pursue mastectomy and reconstruction appears to be driven by younger patient age and higher tumor grade.     

Comparison of Patient Characteristics and Outcomes of Contralateral Prophylactic Mastectomy and Unilateral Total Mastectomy in Breast Cancer Patients

Background

There has been an increasing trend toward contralateral prophylactic mastectomy (CPM) in the management of breast cancer (BCa). This study??s objective was to compare clinicopathologic characteristics of BCa patients who elected CPM to those who elected unilateral total mastectomy (UTM) and to determine whether CPM improved survival.

Methods

Comparison was performed on 355 patients with stage 0?CIII BCa matched by age and stage who underwent mastectomy from 1995 to 2008: 177 patients had CPM; 178 patients had UTM. Clinicopathological characteristics and survival outcomes were analyzed.

Results

Women who underwent preoperative MRI were twice as likely to have CPM (40.9 vs. 19.7%, P?P?=?0.001; 64.3 vs. 41.4%, P?P?=?0.04, respectively). CPM patients elected nipple preservation (26 vs. 5.2%, P?P?P?=?0.01). CPM identified occult BCa in 11 patients (6.6%), and three UTM patients (1.7%) developed contralateral BCa. With median follow-up of 61?months, by univariable/multivariable analyses, CPM did not improve overall, disease-free, or distant metastases-free survival.

Conclusion

Factors that may influence choice of CPM included preoperative MRI, history of prior breast biopsies, immediate reconstruction, nipple preservation, family history, and BRCA status. Those who chose CPM did not have improved survival.     

Influence of preoperative magnetic resonance imaging on the surgical management of breast cancer patients

Background

Magnetic resonance imaging (MRI) is gaining popularity in the preoperative management of breast cancer patients. However, the role of this modality remains controversial. We aimed to study the impact of preoperative MRI (pMRI) on the surgical management of breast cancer patients.

Methods

This retrospective study included 766 subjects with breast cancer treated operatively at the specialized academic center.

Results

Between those who underwent pMRI (MRI group, n = 307) and those who did not (no-MRI group, n = 458), there were no significant differences (P = .254) in the proportions of either total mastectomies (20.5% vs 17.2%, respectively) or segmental mastectomies (79.5% vs 82.8%). Patients in the MRI group were significantly more likely (P = .002) to undergo contralateral surgery (11.7% vs 5.5%). Similar results were obtained in multivariate analysis adjusting for age, with the proportions of contralateral breast operations significantly higher in the MRI group (Odds Ratio = 2.25, P = .007). pMRI had no significant effect (P = .54) on the proportion of total re-excisions (7.5% vs 8.7%) or the type of re-excision (total vs segmental mastectomy) between the groups.

Conclusions

pMRI does not have a significant impact on the type of operative intervention on the ipsilateral breast but is associated with an increase in contralateral operations. Similarly, pMRI does not change the proportion of re-excisions or the type of the re-excision performed. This study demonstrates that pMRI has little impact on the surgical management of breast cancer, and its value as a routine adjunct in the preoperative work-up of recently diagnosed breast cancer patients needs to be re-examined.     

Psychological Predictors (Personal Recourses) of Quality of Life for Heart Transplant Recipients

Background

Heart transplantation (HTx) has a significant impact on all areas of the operation, adjustment, and quality of life (QOL) in patients after heart transplantation. In the process of healing and coping with the new situation, it is important to have personal resources.

Aim

The main objectives of this study were to assess subjective QOL of patients after HTx and to determine the relationship between personal resources and QOL in this group of patients.

Material and Methods

The study included 121 patients who received a heart transplant. A standardized instrument used to measure the quality of life was the World Health Organization (WHO) QOL Brief Questionnaire. The personal resources and deficits were determined using the following research techniques: Antonovsky's Sense of Coherence (SOC), coping strategies for stress (Brief-COPE), Generalized Self Efficacy Scale (GSES), and Life Orientation Test (LOT-R). The data were analyzed statistically.

Results

The patients gained an average level of QOL (13.75). The results indicate a positive relationship between the QOL in all its domains and personal resources: a sense of coherence (r = 0.65; P < .05), optimism (r = 0.55; P < .05), self-efficacy (r = 0.58; P < .05), and strategies for coping (active coping [r = 0.41; P < .05], planning [r = 0.42; P < .05; P < .05], and positive revaluing [r = 0.40; P < .05]). The regression model explained 56% of the predictors of QOL in patients after HTx.

Applications

It is necessary to strengthen personal resources in this group of patients as well as to detect early and treat symptoms of depression and to cope with stress.     

Reliable assessment of general surgeons' non-technical skills based on video-recordings of patient simulated scenarios

Background

Nontechnical skills are essential for safe and efficient surgery. The aim of this study was to evaluate the reliability of an assessment tool for surgeons' nontechnical skills, Non-Technical Skills for Surgeons dk (NOTSSdk), and the effect of rater training.

Methods

A 1-day course was conducted for 15 general surgeons in which they rated surgeons' nontechnical skills in 9 video recordings of scenarios simulating real intraoperative situations. Data were gathered from 2 sessions separated by a 4-hour training session.

Results

Interrater reliability was high for both pretraining ratings (Cronbach's α = .97) and posttraining ratings (Cronbach's α = .98). There was no statistically significant development in assessment skills. The D study showed that 2 untrained raters or 1 trained rater was needed to obtain generalizability coefficients >.80.

Conclusions

The high pretraining interrater reliability indicates that videos were easy to rate and Non-Technical Skills for Surgeons dk easy to use. This implies that Non-Technical Skills for Surgeons dk (NOTSSdk) could be an important tool in surgical training, potentially improving safety and quality for surgical patients.     

Contralateral prophylactic mastectomy in breast cancer patients who test negative for BRCA mutations

Background

Determination of BRCA1 and 2 mutation carrier status is important. Although BRCA carriers are offered bilateral mastectomy and oophorectomy, most who test negative decline. Some women choose contralateral prophylactic mastectomy (CPM) at the time of their breast cancer diagnosis despite testing negative.

Methods

A total of 110 women with breast cancer received genetic testing before surgical treatment. Patient demographics, tumor characteristics, surgical treatment, and magnetic resonance imaging use were recorded.

Results

Results revealed BRCA1/2 mutation in 33%, variant of unknown significance in 6%, and no mutation in 61% of women. In BRCA-negative women, 37% chose CPM. Marital status was significant for CPM (P = .03). Race, age, stage of presentation, and biomarker status were not associated with choice of CPM. Ninety-six percent of CPM recipients underwent breast reconstruction. Magnetic resonance imaging use did not affect CPM rates (P = .99).

Conclusions

Increased rates of CPM have been observed. In our study married women were more likely to choose CPM. We recommend genetic genotyping before surgery. These findings warrant further investigation.     

Effects of statins on ischemia–reperfusion complications in breast free flaps

Background

Administration of statins or other cardiovascular medications (CVMs) could potentially protect against the development of ischemia–reperfusion (I/R) injury in free flap reconstruction. The aim of this study was to examine whether the use of statins and other CVMs decreased the rate of I/R injury in autologous free flap breast reconstruction.

Methods

Retrospective chart review was performed on women who had undergone mastectomy and autologous free flap breast reconstruction between 2004 and 2010. Patient characteristics, use of statin and/or CVMs, and I/R–related complications were ascertained. Multivariable logistic regression was used to identify associations between independent risk factors and specific complications.

Results

There were 702 free flap breast reconstructions included in this study; 45 performed in patients on statins, 70 in patients on CVMs, and 38 in patients on both. Overall complication rate in patients on statins and patients on CVMs was significantly higher than those not on any medication (46.7% versus 31.5%, P = 0.037 and 45.7% versus 31.5%, P = 0.017, respectively). When I/R complications were pooled, there were no significant differences between patients not on any medications and those on statins (P = 0.26), CVMs (P = 0.18), and both (P = 0.83.)

Conclusions

Although there may be theoretical pharmacologic benefits of statins and/or CVMs to reduce the incidence of IR injury in autologous free flap breast reconstruction, the results of this study showed no clear advantages when these drugs were used.     

Symptomatic rectocele: what are the indications for repair?

Background

The surgical indications for symptomatic rectocele are undefined, and surgery has high recurrence rates. We implemented magnetic resonance imaging defecography (MRID) to determine if utilizing strict inclusion criteria for rectocele repair improves outcomes.

Methods

Patients with obstructive defecation syndrome (ODS) who underwent dynamic MRID were evaluated. Indications for surgical repair were defecation requiring manual assistance and the following MRID results: anterior defect >2 cm, incomplete evacuation, and the absence of perineal descent. Primary outcomes were the change in quality of life (QOL) scores and recurrence.

Results

From 2006 to 2013, 143 patients who presented with ODS underwent MRID. Seventeen patients met the criteria for repair. Recurrence was low (5.8%) with a median follow-up of 23 months, QOL scores improved from 57.3 to 76.5 (P = .041).

Conclusions

A minority of patients (12%) with ODS met the above criteria for rectocele repair. Patients who underwent repair had a significant improvement in QOL and low recurrence rate.     

Regional recurrence in the era of sentinel lymph node biopsy

Background

The incidence of all-location regional recurrence after sentinel lymph node biopsy is not well documented. This study attempts to identify risk factors.

Methods

A prospectively maintained database was queried to identify patients with a regional recurrence of breast cancer after a first operation for invasive unilateral breast cancer. Patients with regional recurrence were compared with those alive and disease free at 5 years.

Results

Twenty-one of 1,060 patients (2%) experienced a regional recurrence. Most patients (95%) underwent sentinel lymph node biopsy as their axillary staging. Those with regional recurrences had larger tumors (P < .001), higher stage disease (P < .001), more estrogen receptor– and triple-negative breast cancers (P < .001), and more positive lymph nodes (P = .007). Mastectomy (P = .001) and receipt of neoadjuvant and/or chemotherapy (P < .001) were more common among those with regional recurrences.

Conclusions

Regional recurrence of breast cancer occurs infrequently. Risk factors include high-risk cancers, higher stage at presentation, nodal involvement, and need for therapies reflecting higher risk biology.     

Evaluation of Functional Status,Pulmonary Capacity,Body Composition,and Quality of Life of End-Stage Liver Disease Patients Who are Candidates for Liver Surgery

Introduction

Muscular weakness in combination with malnutrition can induce a global motor impairment and physical inactivity, adversely impairing the daily living activities and quality of life of end-stage liver disease patients who are candidates for liver transplantation.

Objectives

To evaluate functional status, pulmonary capacity, body composition and quality of life in end-stage liver disease patients who are candidates for liver transplantation; to verify if there is a correlation between the functional variables of the individuals tested through the 6-minute walk test (6MWT) and covariables: pulmonary function test (PFP), quality of life and body composition.

Methods

This study was carried out at the Liver Transplantation Unit of the State University of Campinas (UNICAMP). We included 46 patients with end-stage liver disease who underwent the following evaluations: medical history, quality of life questionnaire “Short Form 36” (SF-36), surface electromyography (sEMG) of the diaphragm and rectus abdominis muscles, body composition assessment by electrical vioimpedance (BIA), 6MWT and PFP.

Results

Univariate analysis and Pearson's correlation found correlations between distance walked on 6MWT and QOL (P = .006 and P = .02) and TBW (P = .5 and P = .02). Pearson's correlation were found between respiratory variables of 6MWT, QOL, and PFP.

Conclusion

The functional status may be correlated to body composition, quality of life and pulmonary capacity of patients with liver disease, candidates for transplantation.     

Illness Uncertainty and Quality of Life of Patients with Small Renal Tumors Undergoing Watchful Waiting: A 2-year Prospective Study

Background

Few studies have examined factors associated with the quality of life (QOL) of patients with renal tumors. Illness uncertainty may influence QOL.

Objective

To prospectively examine the influence of uncertainty on general and cancer-specific QOL and distress in patients undergoing watchful waiting (WW) for a renal mass.

Design, setting, and participants

In 2006–2010, 264 patients were enrolled in a prospective WW registry. The decision for WW was based on patient, tumor, and renal function characteristics at the discretion of the urologist and medical oncologist in the context of the physician–patient interaction. Participants had suspected clinical stage T1–T2 disease, were aged ≥18 yr, and spoke and read English. The first 100 patients enrolled in the registry participated in this study.

Outcome measurements and statistical analysis

Patients completed questionnaires on demographics, illness uncertainty (Mishel Uncertainty in Illness Scale), general QOL (Medical Outcomes Study 36-item short-form survey), cancer-specific QOL (Cancer Rehabilitation Evaluation System–Short Form), and distress (Impact of Events Scale) at enrollment and at 6, 12, and 24 mo. Age, gender, ethnicity, tumor size, estimated glomerular filtration rate, comorbidities, and assessment time point were controlled for in the models.

Results and limitations

Among the sample, 27 patients had biopsies, and 17 patients had proven renal cell carcinoma. Growth rate was an average of 0.17 cm/yr (standard deviation: 0.35). Mean age was 72.5 yr, 55% of the patients were male, and 84% of the patients were Caucasian. Greater illness uncertainty was associated with poorer general QOL scores in the physical domain (p = 0.008); worse cancer-related QOL in physical (p = 0.001), psychosocial (p < 0.001), and medical (p = 0.034) domains; and higher distress (p < 0.001).

Conclusions

This study is among the first to prospectively examine the QOL of patients with renal tumors undergoing WW and the psychosocial factors that influence QOL. Illness uncertainty predicted general QOL, cancer-specific QOL, and distress. These factors could be targeted in psychosocial interventions to improve the QOL of patients on WW.     

Breast conserving surgery versus mastectomy: the influence of comorbidities on choice of surgical operation in the Department of Defense health care system

Background

Studies on the effect of comorbidities on breast cancer operation have been limited and inconsistent. This study investigated whether pre-existing comorbidities influenced breast cancer surgical operation in an equal access health care system.

Methods

This study was based on linked Department of Defense cancer registry and medical claims data. The study subjects were patients diagnosed with stage I to III breast cancer during 2001 to 2007. Logistic regression was used to determine if comorbidity was associated with operation type and time between diagnosis and operation.

Results

Breast cancer patients with comorbidities were more likely to receive mastectomy (odds ratio [OR] = 1.27; 95% confidence interval [CI], 1.14 to 1.42) than breast conserving surgery plus radiation. Patients with comorbidities were also more likely to delay having operation than those without comorbidities (OR = 1.27; 95% CI, 1.14 to 1.41).

Conclusions

In an equal access health care system, comorbidity was associated with having a mastectomy and with a delay in undergoing operation.     

Contralateral Prophylactic Mastectomy Provides No Survival Benefit in Young Women with Estrogen Receptor-Negative Breast Cancer

Background

Several studies have shown that contralateral prophylactic mastectomy (CPM) provides a disease-free and overall survival (OS) benefit in young women with estrogen receptor (ER)-negative breast cancer. We utilized the National Cancer Data Base to evaluate CPM’s survival benefit for young women with early -stage breast cancer in the years that ER status was available.

Methods

We selected 14,627 women ≤45 years of age with American Joint Committee on Cancer stage I–II breast cancer who underwent unilateral mastectomy or CPM from 2004 to 2006. Five-year OS was compared between those who had unilateral mastectomy and CPM using the Kaplan–Meier method and Cox regression analysis.

Results

A total of 10,289 (70.3 %) women underwent unilateral mastectomy and 4,338 (29.7 %) women underwent CPM. Median follow up was 6.1 years. After adjusting for patient age, race, insurance status, co-morbidities, year of diagnosis, ER status, tumor size, nodal status, grade, histology, facility type, facility location, use of adjuvant radiation and chemohormonal therapy, there was no difference in OS in women <45 years of age who underwent CPM compared towith those who underwent unilateral mastectomy (hazard ratio [HR] = 0.93; p = 0.39). In addition, Tthere was no improvement in OS in women <45 years of age with T1N0 tumors who underwent CPM versus unilateral mastectomy (HR = 0.85; p = 0.37) after adjusting for the aforementioned factors. Among women ≤45 years of age with ER-negative tumors who underwent CPM, there was no improvement in OS compared with women who underwent unilateral mastectomy (HR = 1.12; p = 0.32) after adjusting for the same aforementioned factors.

Conclusions

CPM provides no survival benefit to young patients with early-stage breast cancer, and no benefit to ER-negative patients. Future studies with longer follow-up are required in this cohort of patients.     

Pain and its effects on physical activity and quality of life before operation in patients undergoing elective inguinal and ventral hernia repair

Background

Pain is the most common symptom associated with hernias. The aim was to assess the frequency of pain and its effects on physical activity and quality of life in patients with inguinal and ventral hernias.

Methods

All patients undergoing elective inguinal or ventral hernia repair over a 16-month period were asked to complete a questionnaire including a 4-point Verbal Rating Scale, Visual Analog Scale, and Brief Pain Inventory (BPI) to assess pain severity and interference.

Results

One hundred twenty-four patients (72 inguinal, 52 ventral) completed the questionnaire and 75% registered pain on the BPI. There was good correlation between scoring systems (correlation coefficient >.8). Ventral hernia patients had more pain (P = .037), interference with mood (P = .027), sleep (P = .004), relation with other people (P = .019), and enjoyment of life (P = .029) than their inguinal hernia counterparts.

Conclusions

The BPI is an easy and effective way of assessing pain and its impact on physical activity and quality of life in patients with an inguinal or ventral hernia with most experiencing mild to moderate chronic pain and disability.     

Review of risk factors for the development of contralateral breast cancer

Background

Women treated for breast cancer have an increased risk for developing metachronous contralateral breast cancer (CBC). Patient perception of this risk is often overestimated and has been found to contribute to the decision to undergo contralateral prophylactic mastectomy. An individual's risk is dependent on both patient and tumor characteristics. This review examines and summarizes the current literature on the factors that affect CBC risk.

Data Sources

English-language publications with the keyword “contralateral breast cancer” were identified through a MEDLINE literature search.

Conclusions

The global incidence of CBC is decreasing, a trend that is attributed to more effective adjuvant therapies. Patients with BRCA germ-line mutations demonstrate the highest risk for CBC. In the absence of known genetic mutations, patients with strong family histories who are diagnosed at young ages (<35 years) with estrogen receptor–negative index tumors appear to have a higher incidence of CBC.     

The evaluation of national time trends,quality of care,and factors affecting the use of minimally invasive breast biopsy and open biopsy for diagnosis of breast lesions

Background

Minimally invasive breast biopsy is a recommended biopsy method for suspicious lesions. This study examines national trends and factors associated with the use of open breast biopsy (OBB).

Methods

The national inpatient sample database was used to examine trends and factors associated with the use of OBB. Factors associated with OBB were evaluated using chi-square test for univariate analysis and logistic regression for multivariate analysis.

Results

OBB rate was 34%. Patients below 50 years of age had OBB rates of 47%, while those above 50 had OBB rates of 29.1% (P < .001). Higher OBB rates were observed in Asian (39.8%) and Hispanic (40.6%) women compared with white women (34.1%, P < .001). Private insurance patients were more likely to have OBB compared with Medicaid/Medicare patients (40.9% vs 30.6%, P < .001). About 1.2% of women who underwent OBB required multiple biopsies for diagnosis compared with .5% for minimally invasive breast biopsy (P < .001).

Conclusions

OBB is still performed in one third of women despite higher morbidity and less accuracy. Factors associated with higher OBB rate included younger age; Asian ethnicity; private insurance; small, rural, and nonteaching hospitals.     

Neoadjuvant therapy and breast cancer surgery: a closer look at postoperative complications

Background

Neoadjuvant therapy is important in the treatment of advanced breast cancer.

Methods

Postoperative complications in neoadjuvant patients were analyzed.

Results

One hundred forty patients underwent 148 breast cancer surgeries after neoadjuvant therapy: 28% breast-conserving therapy procedures, 36% mastectomies, 28% mastectomies with immediate reconstruction, and 8% mastectomies with delayed reconstruction. Forty-seven patients (34%) suffered 59 complications: 18% of those undergoing breast-conserving therapy, 30% of those undergoing mastectomy, 44% of those undergoing mastectomy with immediate reconstruction, and 67% of those undergoing mastectomy with delayed reconstruction. Major complications occurred in 18% of patients. Skin loss occurred in 6% of patients. One patient had partial nipple necrosis. Three patients suffered implant loss. One patient had deep inferior epigastric artery perforator flap loss. Eleven hematomas and 5 infectious complications required reoperation.

Conclusions

Surgery after neoadjuvant therapy is safe, but careful counseling is warranted given that 18% of patients experienced major complications. Complications rates are higher with reconstruction, but feared complications of skin, nipple, implant, or flap loss were infrequent.     

Surgical,oncologic, and cosmetic differences between oncoplastic and nononcoplastic breast conserving surgery in breast cancer patients

Background

There is a lack of information regarding the safety, complication rate, and cosmetic outcome of oncoplastic breast conserving surgery. The purpose of this study is to evaluate and compare oncoplastic and nononcoplastic procedures.

Methods

A retrospective review was conducted of patients treated with oncoplastic or nononcoplastic lumpectomies. Immediate and long-term complication rates and cosmetic satisfaction were compared.

Results

Of the 142 surgeries, 58 were oncoplastic lumpectomies (40.8%). Oncoplastic patients were younger than nononcoplastic patients (60.9 vs 65.2 years, P = .043). Immediate complications were similar with the exception of nonhealing wounds (oncoplastic = 8.6% vs nononcoplastic = 1.2%, P = .042). Cosmetic complaints were similar, but fat necrosis was more common in the oncoplastic group (25.9% vs 9.5%, P = .009). Time to radiation and number of future biopsies were similar between the groups.

Conclusion

Oncoplastic lumpectomy is a safe alternative to standard lumpectomy for selected breast cancer patients.