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.     

单侧乳腺癌行预防性对侧乳房切除术的研究进展

为了能够防止对侧乳腺癌的发生从而避免产生相关的治疗和死亡,越来越多的单侧乳腺癌患者接受了预防性对侧乳房切除术(CPM),CPM在高风险人群中已经被认为能够获益,比如对于绝经前的 BRCA1/2基因突变携带者。目前针对 BCRA基因突变接受CPM已经达成了共识,尚无法证明CPM在其他人群中的生存获益,...     

Technical considerations for prophylactic mastectomy in patients at high risk for breast cancer

A study of 5 patients and 10 mastectomy specimens was performed to identify the extent of surgery necessary to completely remove all breast tissue in patients having prophylactic mastectomies. A standard total mastectomy performed for breast cancer was shown to frequently leave breast tissue within the superficial pectoralis major muscle and the lower skin flap. Frozen section analysis of margins was found to be essential to clear the axillary extension of the breast and lower skin flap in particular. The value of more extensive surgery to remove all glandular elements of the breast in the high-risk patient remains to be demonstrated.     

Prospective study of intraoperative mammary ductoscopy in patients undergoing partial mastectomy for breast cancer

BACKGROUND: The purpose of this study was to critically evaluate the added benefit of intraoperative mammary ductoscopy on margin assessment and identification of occult intraductal pathology in patients undergoing therapeutic partial mastectomy for in-situ and invasive breast carcinoma. METHODS: Eligible patients underwent intraoperative mammary ductoscopy before partial mastectomy. In patients where an intraductal abnormality was identified and the mammary ductoscope was not within the partial mastectomy cavity, an additional ductoscopy-directed margin of tissue was analyzed. RESULTS: Nineteen of 30 (63%) patients yielded nipple aspirate fluid and were able to undergo mammary ductoscopy; an intraductal abnormality was identified in 15 of 19 (79%) patients. Only 1 patient had an occult infiltrating carcinoma, which was outside of the resection cavity and identified by ductoscopy. CONCLUSIONS: Although mammary ductoscopy can identify intraductal abnormalities during partial mastectomy in a significant number of patients, many of these findings may be either benign or within the standard field of resection, thus adding no benefit to the patient.     

Contralateral prophylactic mastectomy: A narrative review of the evidence and acceptability

The uptake of contralateral prophylactic mastectomy (CPM) has increased steadily over the last twenty years in women of all age groups and breast cancer stages. Since contralateral breast cancer is relatively rare and the breast cancer guidelines only recommend CPM in a small subset of patients with breast cancer, the drivers of this trend are unknown. This review aims to evaluate the evidence for and acceptability of CPM, data on patient rationales for choosing CPM, and some of the factors that might impact patient preferences. Based on the evidence, future recommendations will be provided. First, data on contralateral breast cancer risk and CPM rates and trends are addressed. After that, the evidence is structured around four main patient rationales for CPM formulated as questions that patients might ask their surgeon: Will CPM reduce mortality risk? Will CPM reduce the risk of contralateral breast cancer? Can I avoid future screening with CPM? Will I have better breast symmetry after CPM? Also, three different guidelines regarding CPM will be reviewed. Studies indicate a large gap between patient preferences for radical risk reduction with CPM and the current approaches recommended by important guidelines. We suggest a strategy including shared decision-making to enhance surgeons’ communication with patients about contralateral breast cancer and treatment options, to empower patients in order to optimize the use of CPM incorporating accurate risk assessment and individual patient preferences.     

盐酸羟考酮在乳腺癌改良根治手术后急性疼痛治疗中的应用

目的探讨盐酸羟考酮用于乳腺癌改良根治手术后急性疼痛治疗的安全有效剂量。方法选择择期全麻下行乳腺癌改良根治手术女性患者100例,年龄29~69岁,BMI30kg/m2、ASA分级Ⅰ或Ⅱ级。采用随机数字表法,将其均分为两组:低剂量盐酸羟考酮组(OL组)和高剂量盐酸羟考酮组(OH组)。手术结束前30 min,OL组和OH组分别静注盐酸羟考酮注射液0.03和0.09mg/kg。术毕缝皮时停用麻醉药。疗效指标:于拔除喉罩后5min、0.5、2、4、8、12、24h行静态和动态VAS评分。记录手术后24h内补救镇痛药物使用情况及不良事件的发生情况。结果拔除喉罩后8和12hOH组静态和动态VAS评分明显低于OL组(P0.05)。两组术后镇痛满意率差异无统计学意义。两组PONV、头晕、瘙痒、排尿困难、窦性心动过缓等术后不良事件和追加镇痛药的发生率差异无统计学意义。结论 0.09mg/kg盐酸羟考酮可以安全有效地减轻乳腺癌改良根治手术后患者的急性疼痛。     

Lymphatic mapping improves staging and reduces morbidity in women undergoing total mastectomy for breast carcinoma

Lymphatic mapping (LM) and sentinel lymph node biopsy (SLNB) have become widely accepted in the setting of breast conservation surgery. We hypothesized that LM can be extended to women undergoing total mastectomy, being technically feasible, yielding highly accurate and sensitive results, improving axillary staging, and reducing postoperative morbidity. Between 1995 and 2003, 99 women (mean age 59 years, range 34-87) underwent 100 mastectomies with LM using blue dye alone. Fifty-nine operations (60%) were followed by a completion axillary lymph node dissection (ALND). Ninety per cent of patients had invasive carcinoma; 10 per cent had in situ carcinoma. Mean tumor size was 2.5 cm (range 0.3-8 cm). One hundred fifty-nine sentinel nodes (SNs) (mean 1.65, range 1-5) were successfully identified in 96 (96%) axillae. Twenty-five (25%) sentinel nodes revealed nodal metastases. Five of 25 (20%) SNs had micrometasteses. Three patients had a false-negative SN, yielding a sensitivity of 91 per cent. The accuracy of LM was 97 per cent. No patient who underwent SLNB alone developed lymphedema, axillary seroma formation, infection, or restricted arm movement. This was contrasted with patients undergoing ALND, where 10 (16%) developed lymphedema and 2 (3%) developed an infection. Ten (25%) patients developed axillary paresthesias after SNB compared with 47 (78%) patients after ALND (P < 0.0001). LM in the setting of mastectomy is accurate and sensitive. This technique improves axillary staging and decreases morbidity. Patients who are not candidates for breast conservation should be offered LM and SLNB at the time of mastectomy.     

Contralateral prophylactic mastectomy in an Asian population: A single institution review

BackgroundContralateral prophylactic mastectomy (CPM) removes the non-diseased breast in women who have unilateral breast cancer. This reduces the incidence of contralateral breast cancer, and potentially improves survival in high risk patients. Such surgical risk-reduction strategy is increasingly being adopted in the United States, despite a decreasing incidence of contralateral breast cancer. The use of CPM in an Asian population is yet unknown. We present the first Asian report on CPM rates and trends in Singapore, the country with the highest incidence of breast cancer in Asia.MethodsA retrospective review of all patients who had breast cancer surgery from 2001 to 2010 at the largest healthcare system in Singapore was performed. Patient demographics and tumour characteristics were analysed with regards to type of surgery performed. Factors associated with CPM were identified.ResultsFrom 2001 to 2010, a total of 5130 patients underwent oncological breast surgery. A decreasing trend of mastectomies (82.7%–70.8%), an upward trend of breast conserving surgery (BCS) (17.3%–29.2%) and an increasing trend in CPM (0.46%–1.25%) is observed. Patients who opted for CPM are likely to be younger (48.4 ± 9.4 years), married (60%), parous (56.7%), with no family history of breast/ovarian cancer (66.7%), and diagnosed at an earlier stage. The rate of synchronous occult breast malignancy was found to be 10% (n = 30), and these were in patients who were of a low cancer-risk profile.ConclusionsThis retrospective study reflects an increasing incidence of breast cancer in Singapore, with a decrease in mastectomies, and an increase in BCS and CPM rates, similar to Western data. Similar to Western populations, the Asian woman who opts for CPM is likely to be young and have an earlier stage of breast cancer. In contrast, the Asian woman is likely to have no family history of breast or ovarian cancers. Commonly cited reasons for increased CPM rates such as the increased availability of genetic counselling and pre-operative MRI evaluation, along with wide use of reconstruction, do not feature as dominant factors in our population, suggesting that the Asian patients may have different considerations when electing for CPM.     

The safety and efficacy of prophylactic ondansetron in patients undergoing modified radical mastectomy

The purpose of our study was to determine the lowest concentration of ropivacaine that offers pain relief for the initiation of labor epidural analgesia. Women in active labor were enrolled in this prospective, randomized, double-blinded study to receive either ropivacaine 0.20% (Group I), ropivacaine 0.15% (Group II), or ropivacaine 0.10% (Group III). After placement of the epidural catheter, 13 mL of the study medication was administered. Fifteen minutes later, the adequacy of analgesia was assessed. If the woman reported that her degree of analgesia was not adequate, an additional 5 mL of the study medication was given, the degree of pain relief was reassessed 15 min later, and the study was concluded. A sequential study design was used to assess the success rates. We found that 26 of 28 (93%) women in Group I had adequate analgesia, compared with only 18 of 28 (64%) in Group II (P = 0.014) and 4 of 12 (33%) in Group III (P = 0.003). We conclude that ropivacaine 0.20% offers adequate analgesia significantly more often than either ropivacaine 0.15% or ropivacaine 0.10%. If one selects ropivacaine as the sole local anesthetic for the initiation of labor epidural analgesia, the minimal concentration should be 0.20%. IMPLICATIONS: The lowest effective concentration of ropivacaine for the initiation of labor epidural analgesia has not been determined. We found that ropivacaine 0.20% offers adequate analgesia significantly more often than either ropivacaine 0.15% or ropivacaine 0.10%. If one selects ropivacaine as the sole local anesthetic for the initiation of labor epidural analgesia, the minimal concentration should be 0.20%.     

直肠癌预防性回肠造口患者的营养教育

目的 探讨直肠癌预防性回肠造口患者基于自我效能理论的营养教育效果。方法 将66例直肠癌拟行预防性回肠造口患者按收治时间分为对照组(n=33)和干预组(n=33)。对照组实施常规健康教育,干预组实施基于自我效能理论的营养教育。比较两组干预前,出院后1、3个月的BMI、实验室相关营养指标、患者主观整体营养状况评估(PG-SGA)得分及造口自我效能。结果 干预后不同时间点干预组BMI和实验室相关营养指标显著高于对照组,营养状况得分、造口自我效能总分显著优于对照组(P<0.05,P<0.01)。结论 基于自我效能理论的营养教育有利于改善直肠癌预防性回肠造口患者的营养状况,提升其造口自我效能水平。