Paravertebral Blocks in Patients Undergoing Mastectomy with or without Immediate Reconstruction Provides Improved Pain Control and Decreased Postoperative Nausea and Vomiting

Background

Mastectomy is associated with postoperative nausea and pain. We evaluated whether paravertebral block (PVB) use altered opioid use, antiemetic use, and length of stay in patients undergoing mastectomy.

Methods

We performed a retrospective cohort analysis of all patients who underwent mastectomy with or without PVB from 2008 to 2010. Patient demographics, operative procedure, intraoperative medications, postoperative opioid and antiemetic use, and length of stay were reviewed. Statistical analysis included univariable and multivariable analysis.

Results

A total of 605 patients were identified, of whom 526 patients were evaluable. A total of 294 patients underwent mastectomy without PVB (132 bilateral), and 232 patients underwent mastectomy with PVB (148 bilateral). Immediate reconstruction was performed in 203 (39 %) patients. Need for any postoperative antiemetic was less frequent in the PVB group (39 vs. 57 %, p < 0.0001). Day of surgery opioid use was lower in the PVB group than the non-PVB group (mean ± SD 40.1 ± 15.2 vs. 47.6 ± 17.7 morphine equivalents, p < 0.0001). Decreased opioid use was seen in unilateral mastectomy without reconstruction and bilateral mastectomy with and without immediate reconstruction. The proportion of patients discharged within 36 h of surgery was significantly higher in the PVB group (55 vs. 42 %, p = 0.0031). On multivariable analysis controlling for year of surgery, patient age and surgeon, PVB use affected antiemetic use and opioid use but not hospital length of stay.

Conclusions

PVB results in decreased opioid use and decreased need for postoperative antiemetic medication in patients undergoing mastectomy. The greatest benefit is seen in patients undergoing bilateral mastectomy with immediate breast reconstruction.     

Use of Prophylactic Postoperative Antibiotics During Surgical Drain Presence Following Mastectomy

Background

National guidelines recommend one dose of perioperative antibiotics for breast surgery and discourage postoperative continuation. However, reported skin and soft tissue infection (SSI) rates after mastectomy range from 1–26 %, higher than expected for clean cases. Utility of routine or selective postoperative antibiotic use for duration of drain presence following mastectomy remains uncertain.

Methods

This study included all female patients who underwent mastectomy without reconstruction at our institution between 2005 and 2012. SSI was defined using CDC criteria or clinical diagnosis of cellulitis. Information on risk factors for infection (age, body mass index [BMI], smoking status, diabetes, steroid use), prior breast cancer treatment, drain duration, and antibiotic use was abstracted from medical records. Multivariable logistic regression was used to assess the association between postoperative antibiotic use and the occurrence of SSI, adjusting for concurrent risk factors.

Results

Among 480 patients undergoing mastectomy without reconstruction, 425 had sufficient documentation for analysis. Of these, 268 were prescribed antibiotics (63 %) at hospital discharge. An overall SSI rate of 7.3 % was observed, with 14 % of patients without postoperative antibiotics developing SSI compared with 3.4 % with antibiotics (p < 0.0001). Factors independently associated with SSI were smoking and advancing age. Diabetes, steroid use, BMI, prior breast surgery, neoadjuvant chemotherapy, prior radiation, concomitant axillary surgery, and drain duration were not associated with increased SSI rates.

Conclusions

SSI rates among patients who did and did not receive postoperative antibiotics after mastectomy were significantly different, particularly among smokers and women of advanced age. These patient subgroups may warrant special consideration for postoperative antibiotics.     

Breast Cancer Mastectomy Trends Between 2006 and 2010: Association with Magnetic Resonance Imaging, Immediate Breast Reconstruction, and Hospital Volume

Purpose

Analysis of mastectomy rates in breast cancer patients diagnosed between 2006 and 2010 in Germany with focus on impact of breast magnetic resonance imaging (MRI), immediate breast reconstruction (IBR) rates, and hospital volume as possible influencing factors of mastectomy rates.

Methods

Data of a voluntary monitored benchmarking project were used to evaluate mastectomy trends across time in an unselected cohort of breast cancer patients. We used univariate and multivariate logistic regression analysis to identify predictive factors of mastectomy.

Results

A total of 142.863 cases were included into the analysis. There was an overall decrease of 5.9 % (95 % confidence interval 5.1–6.7) in mastectomy trend from 36.5 % in 2006 to 30.6 % in 2010 (P < 0.0001). Known predictive factors were confirmed. Breast MRI (odds ratio 1.42, 95 % confidence interval 1.36–1.47) and small hospitals (<150 cases per year) seem to favor mastectomy. IBR was not associated with mastectomy rates.

Conclusions

Mastectomy rates in comparable health systems differ. Performance of preoperative breast MRI and hospital volume seem to be independent influencing factors for mastectomy rates.     

Impact of Breast Reconstruction on the Decision to Undergo Contralateral Prophylactic Mastectomy

Background

In the last decade, there has been increasing use of contralateral prophylactic mastectomy (CPM) in patients with unilateral breast cancer and ductal carcinoma-in-situ (DCIS) undergoing mastectomy. Although many factors have been proposed to explain this trend, the impact of breast reconstruction on CPM has not been studied.

Methods

A retrospective review of patients with unilateral invasive breast cancer or DCIS from Surveillance, Epidemiology, and End Results registry data (2004–2008) was conducted. Characteristics of patients undergoing CPM and reconstruction were evaluated.

Results

A total of 102,674 patients diagnosed with DCIS or stage I to III infiltrating breast cancer underwent mastectomy for their primary lesion. Of these, 16,197 patients (16 %) underwent a CPM. A significantly higher proportion of women undergoing CPM had reconstruction performed (46 %) than those patients not undergoing CPM (15 %) (p < 0.001). Of the 20,760 patients (20 %) who underwent reconstruction, 7410 (36 %) had implant reconstruction, 7705 (37 %) tissue reconstruction, and 1941 (9 %) combined tissue/implant reconstruction; there were no data for 3,702 (18 %). There was an increasing trend of patients undergoing reconstruction from 2004 (n = 3390, 16.3 %) to 2008 (n = 5406, 26 %) (p < 0.001). On multivariable analysis, significant variables predicting CPM included age <45 years, stage I disease (odds ratio [OR] 1.44, 95 % confidence interval [CI] 1.35–1.54), lobular histology (OR 1.15, 95 % CI 1.11–1.20), and undergoing breast reconstruction (OR 3.58, 95 % CI 3.41–3.75).

Conclusions

Besides age, undergoing reconstructive surgery is the factor most strongly associated with CPM. This suggests that apart from risk reduction, the availability of and/or patient willingness to undergo breast reconstruction may influence the decision to undergo CPM.     

Single Dual-Trained Surgeon for Breast Care Leads to Higher Reconstruction Rates After Mastectomy

Background

Breast reconstruction improves the quality of life for mastectomy patients but is underutilized in the United States. This study investigated reconstruction rates for a dual-trained oncologic plastic surgeon to explore how provider-based factors influence reconstruction.

Methods

We evaluated consecutive mastectomy patients treated at the University of California, San Diego Medical Center between 2009 and 2012. We identified mastectomy patients based on Current Procedural Terminology codes and evaluated them for patient- and disease-specific variables. We evaluated reconstruction rates for the traditional team model of collaborating plastic and oncologic surgeons versus a single surgeon, dual trained in surgical breast oncology and plastic surgery. A multivariate regression analysis was then used to identify the significant predictors of reconstruction.

Results

Mastectomy was performed in 344 patients. The surgeon group was a significant predictor of postmastectomy reconstruction (p < 0.05). The traditional team of oncologic and plastic surgeons reconstructed 93 (63.3 %) of 147 mastectomy patients, whereas the single dual-trained surgeon reconstructed 140 (71.1 %) of 197 mastectomy patients. Race and insurance status did not influence the receipt of reconstruction in our single-surgeon model, however, patients of older age [odds ratio (OR) 0.93, confidence interval (CI) 0.89–0.98, p < 0.01], higher body mass index (OR 0.89, CI 0.82–0.97, p < 0.01), or more advanced disease (p < 0.01) were less likely to undergo reconstruction.

Conclusions

A single dual-trained surgeon for breast care influences reconstruction rates. A dual-trained surgeon increases the likelihood of reconstruction and obtains rates higher than previously reported. This may reflect the comprehensive care provided by a multidisciplinary-trained professional. A single surgeon providing care in oncology and reconstruction represents a comprehensive approach to breast care and demonstrates a relationship between provider practice and breast reconstruction.     

Effect of Delayed Autologous Breast Reconstruction on Breast Cancer Recurrence and Survival

Background

The goal of the present study was to evaluate the impact of delayed autologous breast reconstruction on disease relapse in breast cancer patients treated with mastectomy.

Material and methods

The study was based on 503 consecutive patients younger than 70 years of age who underwent mastectomy between January 2000 and December 2003. Overall, 391 (78 %) received mastectomy alone and 112 (22 %) underwent a delayed breast reconstruction. The median time from mastectomy to delayed breast reconstruction was 34 months. The median duration of follow-up was 102 months.

Results

There were no locoregional recurrences (LRR) in patients who underwent delayed reconstruction (0.0 %); 21 LRR developed in patients treated with mastectomy only (5.4 %), P = 0.011. Distant metastases occurred less frequently in the reconstruction group (12.5 %) than in the patients who underwent mastectomy alone (21.5 %); P = 0.0343. The 8-year breast cancer specific survival in the reconstruction group was 98.2 and 85.7 % for the mastectomy only group, P = 0.000.

Conclusions

Delayed autologous breast reconstruction does not appear to adversely influence disease progression when compared to patients treated with mastectomy only.     

Impact of Availability of Immediate Breast Reconstruction on Bilateral Mastectomy Rates for Breast Cancer across the United States: Data from the Nationwide Inpatient Sample

Background

Availability of immediate breast reconstruction (IBR) varies among institutions, yet the impact of IBR availability on the rates of bilateral mastectomy (BM) versus unilateral mastectomy (UM) for breast cancer is unknown.

Methods

From the 2002 to 2010 Nationwide Inpatient Sample, we identified women with breast cancer undergoing UM or BM with and without IBR using ICD-9 codes. Hospitals were classified as performing IBR if at least one hospitalization included both mastectomy and reconstruction and then by IBR volume. Statistical comparisons utilized Chi square tests, tests for trend, and multivariable logistic regression.

Results

We identified 130,420 women undergoing UM (76.9 %) or BM (23.1 %) for breast cancer. Of 6,579 hospitals, 3,358 (51.0 %) performed no IBRs, while in the remaining 3,221 hospitals, 1 to 638 IBRs were performed per year. Large, teaching, urban, and Northeastern hospitals were more likely to have higher IBR volumes. BM rates were significantly higher in patients treated at those hospitals with higher IBR volumes, from 33.1 % at hospitals performing ≥24 IBRs per year to 9.0 % at hospitals without IBR (p < 0.001). Upon adjusted analysis, patients who elected BM were more likely to be seen at hospitals performing ≥24 IBRs per year (odds ratio 1.69 vs. UM, p < 0.001).

Conclusions

In this analysis of national data, BM rates were higher in hospitals where IBR was available, suggesting a significant influence of institutional factors on treatment options for breast cancer patients. Efforts are needed to ensure patients have access to IBR when desired and to better understand the reasons for hospital variation in BM rates.     

Freestyle facial perforator flaps—a safe reconstructive option for moderate-sized facial defects

Background

Perforators are a constant anatomical finding in the facial area and any known flap can in theory be based on the first perforator located at the flap rotation axis.

Methods

A case series of single stage reconstruction of moderate sized facial defects using 21 perforator based local flaps in 19 patients from 2008–2013.

Results

A sufficient perforator was located in every case and the flap rotated along its axis (76 %) or advanced (24 %). Reconstruction was successfully achieved with a high self reported patient satisfaction. Two minor complications occurred early on in the series and corrective procedures were performed in four patients.

Conclusions

The random facial perforator flap seems to be a good and reliable option for the reconstruction of facial subunits, especially the periorbital, nasal and periocular area with a minimal morbidity and a pleasing result in a one stage outpatient setting. Level of Evidence: Level IV, therapeutic study     

A Systematic Review of Complications of Implant-based Breast Reconstruction with Prereconstruction and Postreconstruction Radiotherapy

Purpose

To conduct a systematic review of the literature to assess outcomes data on complications associated with implant-based breast reconstruction performed before or after chest wall radiation to assist in guiding the decision-making process for reconstruction of the irradiated breast.

Methods

Studies from a PubMed search that met predetermined inclusion criteria were identified and included. Complications of interest were low- and high-grade capsular contractures, minor and major complications, reconstruction failure rates, and reconstruction completion rates. Pooled complication rates were calculated.

Results

A total of 26 articles were included in the study after screening 1,006 publications, with 14 studies presenting data on prereconstruction radiation and 23 studies presenting data on postreconstruction radiation. Complication rates evaluated in patients exposed to radiation before or after implant reconstruction were not significantly different. Reconstruction failure rates were similar at 19 and 20 % for pre- and postreconstruction radiation patients, respectively. Completion rates were similar at 83 and 80 % for pre- and postreconstruction radiation patients, respectively.

Conclusions

Review of the current literature suggests similar overall success and failure rates with radiotherapy provided both before and after reconstruction. Failure rates in both groups of patients are clinically significant when considering implant reconstruction in the setting of radiation.     

Same-Day Thyroidectomy: A Review of Practice Patterns and Outcomes for 1,168 Procedures in New York State

Background

There has been a shift of procedures from the inpatient to the outpatient setting. Same-day thyroidectomy (SDT) has been reported in high-volume single-institution series, but few studies have evaluated its widespread use.

Methods

Patients undergoing thyroidectomy for benign and malignant thyroid disease were abstracted from the 2004 New York State inpatient (SID) and ambulatory surgery (SASD) databases. SDTs were discharged on the same day as their surgery. Patient and provider (surgeon and hospital volume) characteristics were associated with outcomes, including probability of SDT versus hospital admission and 30-day rehospitalization, by bivariate and multivariate analyses.

Results

A total of 6,762 thyroidectomies were identified; 17% (1,168) were SDTs. Patients undergoing SDT compared to thyroidectomy with admission were more often white (80 vs. 65%, P < 0.001), with private insurance (80 vs. 70%, P < 0.001) and fewer comorbidities (96 vs. 89% with Charlson scores of none/low, P < 0.001). SDT was performed more often by high-volume surgeons (48 vs. 31%, P < 0.001) and at high-volume hospitals (61 vs. 35%, P < 0.001). Rehospitalization rates of 1.4 and 2.4% were observed for SDT and inpatient thyroidectomy, respectively (P = NS). In multivariate analysis, thyroidectomy by a high-volume surgeon was associated with a higher chance of same-day discharge (odds ratio = 2.3, P < 0.001).

Conclusion

Nearly 20% of thyroidectomy patients undergo SDT in New York State. They have different demographic and clinical characteristics than patients undergoing thyroidectomy who are admitted. There seem to be a few high-volume surgeons and centers with extensive SDT experience. More research is needed to explore optimized patient triage and patterns of referral to centers of excellence.     

Variation in the Utilization of Reconstruction Following Mastectomy in Elderly Women

Background

Regardless of their age, women who choose to undergo postmastectomy reconstruction report improved quality of life as a result. However, actual use of reconstruction decreases with increasing age. Whereas this may reflect patient preference and clinical factors, it may also represent age-based disparity.

Methods

Women aged 65 years or older who underwent mastectomy for DCIS/stage I/II breast cancer (2000–2005) were identified in the SEER-Medicare database. Overall and institutional rates of reconstruction were calculated. Characteristics of hospitals with higher and lower rates of reconstruction were compared. Pseudo-R² statistics utilizing a patient-level logistic regression model estimated the relative contribution of institution and patient characteristics.

Results

A total of 19,234 patients at 716 institutions were examined. Overall, 6 % of elderly patients received reconstruction after mastectomy. Institutional rates ranged from zero to >40 %. Whereas 53 % of institutions performed no reconstruction on elderly patients, 5.6 % performed reconstructions on more than 20 %. Although patient characteristics (%ΔR² = 70 %), and especially age (%ΔR² = 34 %), were the primary determinants of reconstruction, institutional characteristics also explained some of the variation (%ΔR² = 16 %). This suggests that in addition to appropriate factors, including clinical characteristics and patient preferences, the use of reconstruction among older women also is influenced by the institution at which they receive care.

Conclusions

Variation in the likelihood of reconstruction by institution and the association with structural characteristics suggests unequal access to this critical component of breast cancer care. Increased awareness of a potential age disparity is an important first step to improve access for elderly women who are candidates and desire reconstruction.     

Use of Preoperative Paravertebral Block Decreases Length of Stay in Patients Undergoing Mastectomy Plus Immediate Reconstruction

Background

A prior study in patients undergoing breast surgery with and without the use of paravertebral blocks (PVB) found no significant difference in patient length of stay (LOS). However, patients undergoing bilateral procedures and those undergoing immediate reconstructions were excluded. We sought to determine if the use of PVB in patients undergoing unilateral or bilateral mastectomy plus immediate reconstruction decreases patient LOS.

Methods

We undertook a retrospective review of patients who had mastectomies with immediate reconstructions with and without the use of preoperative PVB. Outcomes including LOS, postoperative nausea and vomiting, and time to oral narcotics were compared between groups.

Results

Mean LOS for the PVB group was 42 h. This was significantly less than the mean LOS of 47 h for the nonblock group (p = .0015). The significantly lower LOS for the PVB group was true for patients undergoing bilateral procedures (p = .045), unilateral procedures (p = .0031), tissue expander placement (p = .0114), and immediate implant placement (p = .037). Mean time to conversion to oral narcotics was significantly shorter in the PVB group (15 h) compared with the nonblock group (20 h) (p < .001). The incidence of postoperative nausea in the PVB group (42.8 %) was also significantly less than in the nonblock group (54.7 %) (p = .031).

Conclusions

The routine use of preoperative PVB in patients undergoing mastectomy plus immediate reconstruction significantly decreased patient LOS. In addition to improved pain control from the block itself, quicker conversion to oral narcotics because of less postoperative nausea likely contributed to a decreased LOS.     

Increasing Mastectomy Rates—The Effect of Environmental Factors on the Choice for Mastectomy: A Comparative Analysis Between Canada and the United States

Purpose

Unilateral mastectomy (UM) and contralateral prophylactic mastectomy (CPM) for early-stage breast cancer (ESBC) have been increasing. Numerous etiological factors for this rise have been suggested, including increasing use of magnetic resonance imaging (MRI) and reconstruction, surgeon’s preference, and patient’s choice. We conducted a qualitative study to explore what role the surgeon and their practice environment play in the increasing rates.

Methods

Semi-structured interviews were conducted with general surgeons to explore their current approach to treating ESBC and their experience with women requesting mastectomy. Purposive sampling identified surgeons across Ontario, Canada, and the United States (US). Constant comparative analysis identified key concepts.

Results

Data saturation was achieved after 45 interviews. ‘The effect of external factors on rising mastectomy rates’ was the dominant theme. All surgeons described increasing mastectomy rates over the last 5 years, and all surgeons discussed breast-conserving therapy (BCT) and UM as equivalent options. However, US surgeons discussed reconstruction early in the consultation process, reflecting legislative requirements. In contrast, Ontario surgeons discussed reconstruction only when a patient was considering mastectomy. Ontario surgeons often recommended BCT, whereas US surgeons rarely made a direct recommendation regarding the extent of surgery. Neither US nor Canadian surgeons recommended the use of UM + CPM in average-risk ESBC, and all surgeons described women initiating this request. MRI use and access to immediate breast reconstruction also impacted the choice for mastectomy.

Conclusions

Use of MRI, access to reconstruction, and legislative requirements regarding information disclosure, appeared to influence the surgical consultation process and the patient’s request for CPM.     

Imaging the urologic patient: the utility of intravenous pyelogram in the CT scan era

Purpose

An opportunity exists to evaluate the quality of care in patients undergoing intravenous pyelogram (IVP) imaging and to define the role of IVP in the computed tomography scan era.

Methods

Medical records were reviewed for patient demographics, inpatient versus outpatient setting, indication for IVP, physician/specialty who ordered IVP, and the need for subsequent imaging within a 30-day period in patients who underwent IVP from October 2007 to December 2011. Chi-square test was used to compare the number of additional radiologic examinations ordered within 30 days of the initial IVP across the different specialties ordering IVPs.

Results

Six hundred and eighty patients underwent IVP imaging during the study period. The primary reason to order an IVP was the evaluation of urolithiasis/flank pain (50 %), followed by urologic evaluation after surgery (23 %). Three hundred and twenty-five patients (48 %) subsequently had an additional 547 radiologic studies within 30 days of the IVP to further evaluate their condition. Of the 325 patients undergoing additional imaging studies, 36 % had differing or additional diagnostic information noted that could change medical decision-making.

Conclusions

Inferior imaging of the urologic patient by IVP leads to the acquisition of additional imaging studies to render a diagnosis. IVP has a limited clinical role, and thus, its use should be strictly limited to highly select cases.     

International Rates of Breast Reconstruction After Prophylactic Mastectomy in BRCA1 and BRCA2 Mutation Carriers

Background

Breast reconstruction is an option for women with BRCA1 or BRCA2 mutations who elect to undergo prophylactic mastectomy to prevent breast cancer. We report on the uptake of breast reconstruction after prophylactic mastectomy in women with BRCA mutations from eight countries.

Methods

Women with a BRCA1 or BRCA2 mutation were questioned regarding their cancer preventive practices. Information was recorded on prophylactic mastectomy and breast reconstruction.

Results

A total of 1,635 women with a BRCA1 or BRCA2 mutation who elected to undergo prophylactic mastectomy from eight countries were included. A total of 1,137 women (69.5 %) had breast reconstruction after prophylactic mastectomy. A total of 58.7 % of women over the age of 45 years at the time of prophylactic mastectomy had breast reconstruction compared to 77.6 % of women 35 years of age or younger [odds ratio (OR) 0.36, 95 % confidence interval (CI) 0.26–0.50, p < 0.001]. In addition, 62.9 % of women with a breast cancer diagnosis (contralateral prophylactic mastectomy) had breast reconstruction after prophylactic mastectomy compared to 79.7 % of women without a previous breast cancer diagnosis (OR 0.48, 95 % CI 0.38–0.61, p < 0.001). A total of 66.9 % of women from Canada had breast reconstruction after mastectomy compared to 71.9 % of American women (OR 0.75, 95 % CI 0.59–0.96, p = 0.02).

Conclusions

The majority of women elect for breast reconstruction after prophylactic mastectomy. However, younger women and those without a previous diagnosis of breast cancer are more likely to have breast reconstruction than older women or those with a previous diagnosis of cancer.     

A Comparison of Clinical and Pathologic Assessments for the Prediction of Occult Nipple Involvement in Nipple-Sparing Mastectomies

Background

Nipple-sparing mastectomy (NSM) for both risk reduction and cancer is increasing. In the cancer setting, most studies suggest the use of both clinical and intraoperative biopsy criteria in patient selection. This study examines the use of both biopsy and clinical criteria in women undergoing total nipple-removing mastectomy.

Methods

The study consisted of 58 patients undergoing total mastectomy without nipple sparing. Biopsies of the subareola tissue (SA), proximal nipple (NC) contents and radial sections of the residual nipple (NR) were examined microscopically. Tumor size and distance from the nipple were also noted.

Results

Using clinical criteria alone, the false negative rate was 53.8 % and a false positive rate of 44.4 %. When adding subareola and nipple core biopsies to clinical criteria the false negative rate fell to 7.7 % but the false positive rate remained at 44.4 %. When using only SA and NC biopsies to predict occult nipple involvement, the false negative rate was 11.8 %. In 4 cases the NC was positive while the SA was negative for cancer and in 6 cases the SA was positive and NC negative. In 2 cases both the NC and SA biopsies were negative while the NR was positive.

Conclusions

This study supports a more limited role in the use of clinical criteria for evaluating patients for NSM. This maximizes the number of patients who are candidates for NSM with minimal risk of nipple involvement. It was also noted that intraoperative biopsies are not totally reliable in predicting occult nipple involvement.     

Areola and Nipple-Areola-Sparing Mastectomy for Breast Cancer Treatment and Risk Reduction: Report of an Initial Experience in a Community Hospital Setting

Background

The use of areola-sparing (AS) or nipple-areola-sparing (NAS) mastectomy for the treatment or risk reduction of breast cancer has been the subject of increasing dialogue in the surgical literature over the past decade. We report the initial experience of a large community hospital with AS and NAS mastectomies for both breast cancer treatment and risk reduction.

Methods

A retrospective chart review was performed of patients undergoing either AS or NAS mastectomies from November 2004 through September 2009. Data collected included patient sex, age, family history, cancer type and stage, operative surgical details, complications, adjuvant therapies, and follow-up.

Results

Forty-three patients underwent 60 AS and NAS mastectomies. Forty-two patients were female and one was male. The average age was 48.7 years (range, 28–76 years). Forty mastectomies were for breast cancer treatment, and 20 were prophylactic mastectomies. The types of cancers treated were as follows: invasive ductal (n = 19), invasive lobular (n = 5), ductal carcinoma-in situ (n = 15), and malignant phyllodes (n = 1). Forty-seven mastectomies (78.3%) were performed by inframammary incisions. All patients underwent immediate reconstruction with either tissue expanders or permanent implants. There was a 5.0% incidence of full-thickness skin, areola, or nipple tissue loss. The average follow-up of the series was 18.5 months (range, 6–62 months). One patient developed Paget’s disease of the areola 34 months after an AS mastectomy (recurrence rate, 2.3%). There were no other instances of local recurrence.

Conclusions

AS and NAS mastectomies can be safely performed in the community hospital setting with low complication rates and good short-term results.     

Use of MRI in Preoperative Planning for Women with Newly Diagnosed DCIS: Risk or Benefit?

Background

The role of magnetic resonance imaging (MRI) in preoperative planning for women diagnosed with breast cancer remains controversial. The risks and benefits in women with newly diagnosed ductal carcinoma in situ (DCIS) are largely unknown.

Patients and Methods

Retrospective chart review comparing women treated for DCIS who did and did not undergo MRI for preoperative planning. End points included number of additional biopsies prompted by MRI, surgical reexcision rates, weight of excisions, mastectomy rates, and conversion to mastectomy after attempted breast conservation.

Results

218 patients met study criteria. Sixty-four patients did not undergo preoperative MRI, and 154 patients did. There was no statistically significant difference (P = not significant, NS) in reexcision rates between the 34.1 % (42/123) of women who did and 20/51 (39.2 %) women who did not undergo MRI. Despite use of preoperative MRI, 11/123 women (8.9 %) were converted to mastectomy due to positive margins compared with 4/51 (7.8 %) in the women who did not undergo MRI (P = NS). In women undergoing MRI, average weight of excision at definitive surgery was 49.5 g, while in women who did not undergo MRI, average weight of excision at definitive surgery was 48.7 g.

Conclusions

Our data show that MRI does not significantly decrease reexcision rates or conversion to mastectomy after attempted breast-conservation surgery. Based on our findings, we do not believe preoperative MRI adds benefit to the care of this patient population. Prospective trials are necessary to further investigate the risks and benefits of preoperative MRI in women with DCIS.