Effective breast reconstruction in female veterans

Background

Despite increasing female veteran numbers, literature regarding reconstruction after breast cancer is lacking. The purpose of this study was to examine breast reconstruction referral rates and reconstruction outcomes at a tertiary Veterans Affairs hospital.

Methods

Female breast cancer patients (1997-2008) were identified. Demographics, tumor stage, oncologic therapies, reconstructive timings and procedures, and complications were noted.

Results

Eighty-two women underwent mastectomy (46%) or breast conservation (43%). The referral rates to plastic surgery were 61% (mastectomy) and 32% (overall). Reconstruction rates were 42% (mastectomy) and 22% (overall). Sixty-nine percent were suitable candidates and chose immediate (67%) or delayed (33%) reconstruction, with implant-based (44%), autologous (39%), or autologous plus implants (17%). There were complications (28%) but no mortalities. Comorbidities were not correlated with outcomes.

Conclusions

Breast reconstruction can be effectively delivered within the Veterans Affairs system. It is essential that sufficient Veterans Affairs resources be deployed to address the increasing reconstructive needs of female veterans.     

Outcome of oncoplastic breast surgery in 90 prospective patients

Background

Oncoplastic breast surgery refers to a wide range of techniques with a parallel goal of safely removing all malignant breast tissue while achieving the best possible esthetic outcome. We report the results of our oncoplastic breast operations from 2005 to 2007.

Methods

Ninety selected breast cancer patients were treated with a variety of oncoplastic operations. The patients were prospectively monitored. Radiotherapy and systemic adjuvant treatment were given according to national guidelines.

Results

Fifteen patients had an immediate surgical complication, of which 8 required a reoperation. Eleven patients had an inadequate surgical margin and required a completion mastectomy. During a median follow-up of 26 months no local or regional recurrences were noticed. Three patients developed distant metastases.

Conclusions

Oncoplastic breast surgery offers tools for breast conservation in patients otherwise destined for mastectomy or poor esthetic outcome. Despite the high proportion of patients in this series with large-volume ductal carcinoma in situ (DCIS) or extensive intraductal component, the use of oncoplastic techniques achieved negative margins with acceptable cosmetic results in the majority (84%) of patients.     

Factors associated with improved outcome after surgery in metastatic breast cancer patients

Background

Recent studies suggest local surgical therapy improves survival in metastatic breast cancer (MBC). We evaluate the difference in outcome in patients with MBC after mastectomy versus breast conservation (BCT) and factors that influence outcome.

Methods

In a retrospective review of our prospective database, we identified patients who presented with MBC (1990 to 2007). Patient surgery type and clinicopathologic factors were reviewed. We compared OS between pts dependent on surgery and clinicopathologic factors.

Results

Of the 566 patients with MBC, 154 (27%) underwent removal of the primary tumor. Surgery was associated with an improved OS (33%) versus no surgery (20%) (P = 0.0015). Of those undergoing local therapy; mastectomy was associated with a 37% OS vs BCT with a 20% OS (P = 0.04).

Conclusions

Our study confirms that removal of the primary tumor in MBC is associated with improved overall survival. It appears that mastectomy is associated with a significantly improved overall survival.     

Factors affecting post-operative complications following skin sparing mastectomy with immediate breast reconstruction

Skin sparing mastectomy (SSM) followed by immediate breast reconstruction (IBR) is not only oncologically safe but provides also significant benefits both cosmetically and functionally. The superiority of this technique can only be fully established, however, by developing a framework for minimising complications. The present study seeks to elucidate the key factors affecting outcome.

Methods

Data for all skin sparing mastectomies with immediate autologous and implant based reconstructions, performed in a three year period (2006-2008) was retrospectively collated. Complications were classified into major and minor. Patients were excluded who had flap loss due to vascular complications.

Results

The total number analysed was 151. 17.2% had major complications, 23% had minor and 61% had no complications. The Wise and the “tennis” incision had significantly higher rates of wound dehiscence when compared with the periareolar incision (p = 0.025, p = 0.098). There was no significant difference between diathermy or blade dissection techniques, or the use of subcutaneous adrenaline infiltration. Increasing BMI was associated with increased skin flap necrosis and wound dehiscence, and an excised breast mass of greater than 750 g and a sternal notch to nipple length of greater than 26 cm are associated as well with increased flap-related complications (p = 0.0002, p = 0.0049).

Conclusion

Factors such as Wise pattern and tennis racquet incision, BMI and breast mass and sternal notch to nipple length adversely affect skin sparing mastectomy flap morbidity. These factors should be factored in to patient selection and operative planning especially for obese and large breasted women undergoing skin sparing mastectomy with immediate breast reconstruction.     

Scientific Presentation Award: The impact of magnetic resonance imaging on surgical treatment of invasive breast cancer

Background

The purpose of this study was to examine the relationship between magnetic resonance imaging (MRI) and surgical treatment of invasive breast cancer (IBC).

Method

The IBC patients treated from January 2003-June 2008 were reviewed by a single institution.

Results

A total of 814 patients were treated, out of which 562 (69%) underwent breast conservation therapy (BCT), 151 (19%) chose mastectomy alone (M), and 101 (12%) chose mastectomy with reconstruction (M+ R). The mean age was comparatively low in M + R patients (P ≤ 0.001). The mean tumor size was the lowest in BCT patients (P ≤ 0.001). MRI use increased with no significant difference in type of surgery as noted by year. In multivariate analysis, type of surgery was significantly associated with tumor size, multifocality, age, and MRI use. The factors associated with MRI performance were: multifocality, younger age, tumor size, lobular histology, body mass index, and genetic testing.

Conclusions

The use of MRI in IBC patients has increased over the past 5 years, without any observable impact on surgical treatment. Similar factors are associated with mastectomy and MRI performance.     

Immediate conservative breast surgery reconstruction with perforator flaps: new challenges in the era of partial mastectomy reconstruction?

Introduction

Although the use of local flaps in conservative breast surgery (CBS) reconstruction is a reliable technique, little information has been available regarding outcome following the use of perforator flaps. The purpose of this study is to analyze the feasibility, surgical planning and outcome following CBS reconstruction with intercostal artery perforator (ICAP) flap.

Patients/methods

Thirteen patients underwent CBS reconstructions with an ICAP flap. These ?aps were raised from adjacent tissue located on the lateral and thoracic region and based on perforators originating from the costal and muscular segment of the intercostal vessels. The technique was indicated in patients with small/moderate volume breasts.

Results

Mean time of follow-up was 32 months. Flap complications were evaluated and information on patient satisfaction were collected. 61.5 percent had tumors located in the lower-outer quadrants and 69.2 percent had tumors measuring 2 cm or less (T1). Complications occurred in 3 patients (23%), including wound dehiscence in 2 patients and fat necrosis in one. All cases were treated by conservative approach with a good result. No ?ap loss or wound infection were reported. 90 percent were either satisfied or very satisfied with their result.

Conclusion

The ICAP flap is a reliable technique for immediate CBS reconstruction. The technique is advantageous because it does not require the use of muscle transfer, with minimum donor site morbidity. Success depends on patient selection, coordinated planning with the oncological surgeon and careful intra-operative management.     

Are mastectomy rates a reasonable quality measure of breast cancer surgery?

Background

Quality measures of breast cancer clinical management adopted by the National Quality Forum do not address the quality of surgical performance. We evaluated mastectomy rate as one potential quality indicator.

Methods

We reviewed the surgical management of small (stage T1; ≤2 cm) invasive breast tumors in patients treated from April 2003 through April 2007 at our institution. For patients undergoing mastectomy, factors leading to the selection of mastectomy were analyzed.

Results

We identified 496 patients with invasive breast cancer: 433 did not undergo neoadjuvant chemotherapy, and 319 of these had pathologic tumors ≤2 cm in size. Of these, 55 (17.2%) underwent initial mastectomy. Medical contraindications to breast conservation were identified in 42 of 319 (13.2%) patients, whereas the selection of mastectomy was attributed to patient choice in 13 of 319 (4.1%) patients.

Conclusions

Medical contraindications to breast-conserving therapy were much more common than patient choice as the indication for mastectomy. Institution- or surgeon-specific mastectomy rates are unlikely to reflect the complexity of decision making in the surgical management of patients with breast cancer.     

Sealants after axillary lymph node dissection for breast cancer: good intentions but bad results

Background

This study was conducted to evaluate the effect of 2 surgical sealants on postsurgical drainage and lymphocele formation after axillary surgery for breast cancer.

Methods

This was a prospective, randomized study. Seventy-seven consecutive patients with breast cancer were included and randomized into a control group (18F vacuum drain) and 2 study groups (18F vacuum drain plus COSEAL or BioGlue).

Results

The 3 groups were matched. Neither postsurgical drainage nor time to drain removal was affected by the use of either of the 2 sealants. Although no statistically significant difference in lymphocele formation and wound infection was noted, complications caused by intense foreign-body reaction that led to surgical intervention occurred in both study groups.

Comments

The use of surgical sealants is not recommended after axillary lymph node dissection for breast cancer. Complications of their use may lead to reoperation.     

Geographic proximity to treatment for early stage breast cancer and likelihood of mastectomy

Purpose

Women with early stage breast cancer who live far from a radiation therapy facility may be more likely to opt for mastectomy over breast conserving surgery (BCS). The geographic dimensions of this relationship deserve further scrutiny.

Methods

For over 100,000 breast cancer patients in 10 states who received either mastectomy or BCS, a newly-developed software tool was used to calculate the shortest travel distance to the location of surgery and to the nearest radiation treatment center. The likelihood of receipt of mastectomy was modeled as a function of these distance measures and other demographic variables using multilevel logistic regression.

Results

Women traveling over 75 km for treatment are about 1.4 times more likely to receive a mastectomy than those traveling under 15 km.

Conclusions

Geographic barriers to optimal breast cancer treatment remain a valid concern, though most women traveling long distances to receive mastectomies are doing so after bypassing local options.     

Breast self-examination: defining a cohort still in need

Background

The value of breast self-examination (BSE) to detect early breast cancer is controversial.

Methods

Within an institutional review board-approved prospective study, 147 high-risk women were enrolled from 2004 to 2007. Yearly clinical examination, BSE teaching, and mammography were performed simultaneously followed by interval breast magnetic resonance imaging (MRI). Women underwent additional BSE teaching at 6 months. Women reporting a mass on BSE underwent clinical evaluation.

Results

Fourteen breast cancers were detected in 12 women. BSE detected 6/14 breast cancers versus 6/14 detected by MRI and 2/14 by mammography. Of 24 masses detected by BSE, 6/24 were malignant. The sensitivity, specificity, and predictive value of BSE to detect breast cancer were 58.3%, 87.4%, and 29.2%, respectively. The sensitivity, specificity, and predictive value of a Breast Image Reporting and Data System (BI-RADS) score of ≥4 on MRI were 66.7%, 88.9%, and 34.8%, respectively.

Conclusions

BSE detects new breast cancers in high-risk women undergoing screening mammogram, CBE, and yearly breast MRI.     

Gastric malignancies in breast cancer survivors: Pathology and outcomes

Background

As the number of breast cancer survivors increases, the appearance of second malignancies and unusual metastatic patterns likely also is increasing. In particular, we and others have observed gastric malignancies in breast cancer survivors.

Methods

We reviewed 3 regional hospital system tumor databases, comprising 19,049 analytic breast cancer cases, to determine the number, types, and outcomes of subsequent gastric malignancies.

Results

Twenty-eight patients developed subsequent gastric malignancies, representing .15% of breast cancer survivors; 82% of patients had gastric symptoms. Overall survival for the cohort was 39%. Twenty-four patients (86%) had gastric primaries and 13 died of their second cancers. Four patients had gastric metastases; all had lobular histology in both their primary tumors and metastatic lesions. Five patients had gastrointestinal stromal tumors; all patients underwent resection and currently are alive.

Conclusion

Gastric symptoms in breast cancer survivors may represent malignant lesions, often second primaries. All gastric metastases in our series were of lobular histology.     

Surgical treatment in Paget's disease of the breast

Background

The aim of this study was to evaluate the outcomes of surgical treatment of Paget's disease of the breast, with special emphasis on magnetic resonance imaging (MRI) and sentinel node biopsy (SNB).

Methods

The study included 58 consecutive patients with Paget's disease treated from 1995 to 2006.

Results

Twenty-five patients had ductal carcinoma in situ, and 31 had invasive carcinoma. MRI was performed in 14 patients, with positive findings in 7 patients, 5 of whom had negative findings on conventional imaging. The overall mastectomy rate was 76%. Eighteen patients underwent SNB, and 26 patients underwent full or partial axillary clearance. Fourteen patients had no axillary surgery. One patient had local recurrence after breast conservation, and another had axillary recurrence after negative results on SNB. Six patients had distant metastases. Four patients died of breast cancer.

Conclusions

Paget's disease is frequently associated with peripheral or multicentric cancer. MRI may be helpful when considering breast conservation or omitting axillary nodal staging.     

George Peters Award: How does breast-specific gamma imaging affect the management of patients with newly diagnosed breast cancer?

Background

We sought to determine the number of patients with known breast cancer who were found to have an additional, mammographically occult lesion detected on breast-specific gamma imaging (BSGI).

Methods

An institutional review board-approved review of all patients who underwent BSGI at Beth Israel Medical Center from 2006 to 2008 was performed.

Results

A total of 82 patients underwent BSGI for newly diagnosed breast cancer. Of these, 18 had an additional abnormality, and 17 were biopsied. There were 4 cases of invasive ductal carcinoma, 1 invasive lobular carcinoma, 1 ductal carcinoma in situ, 1 lobular carcinoma in situ, 2 papillomas, and 8 benign biopsies. One patient proceeded directly to mastectomy and an area of ductal carcinoma in situ was found, corresponding to the BSGI.

Conclusions

In our study group, 22% of patients had a surgical change in management based on BSGI findings. BSGI detected additional carcinoma in 9%. BSGI plays an important role in the clinical management of patients with known breast cancer.     

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.     

Breast reconstruction and radiation therapy: A Canadian perspective

BACKGROUND:

When and how best to perform breast reconstruction in the setting of radiation therapy is a much debated topic.

OBJECTIVE:

To investigate the approaches that Canadian plastic surgeons are taking to breast reconstruction in patients who require or may require radiation therapy.

METHODS:

In April 2009, a survey invitation was sent to Canadian plastic surgeons via e-mail. Survey responses were collected over a two-month period.

RESULTS:

Of the 307 invitees, 90 surgeons responded, of whom 76 met the inclusion criteria. Most surgeons (66%) do not perform immediate reconstruction in patients who require postmastectomy radiation. Most respondents (64%) perform immediate reconstructions for patients whose need for radiation is uncertain at the time of mastectomy. Expander and implants is their preferred option, followed by free transverse rectus abdominis myocutaneous (TRAM) flap. Thirty-five per cent use the delayed immediate technique in these cases. Twenty-one per cent are unfamiliar with the delayed-immediate technique. For delayed reconstruction of the irradiated patient, the pedicled TRAM is the most common choice.

CONCLUSIONS:

The reconstructive options are increasing for patients who may need postmastectomy radiation. The use of the delayed immediate technique could increase as physicians gain more knowledge of the technique.     

Bacteriologic features of surgical site infections following breast surgery

Background

Perioperative antibiotic prophylaxis to prevent surgical site infections (SSIs) after breast surgery is common practice. Breast SSIs were investigated to determine bacterial isolates, resistance patterns, and the appropriateness of cefazolin, the authors' institution's current regimen for perioperative antibiotic prophylaxis.

Methods

A retrospective review of 53 patients with culture-positive breast SSIs between June 1997 and August 2008 identified patient characteristics, bacterial isolates, and microbial resistance patterns.

Results

Among the 53 patients with positive cultures, 42% (n = 22) had undergone mastectomy, and 34% (n = 18) had undergone lumpectomy. Sixty-three bacterial isolates were identified, with 15% of SSIs being polymicrobial. Of the isolates, 49% (n = 31) were gram-negative bacteria. There was only 1 case of methicillin-resistant Staphylococcus aureus. Eight of 63 (13%) gram-negative isolates were cefazolin resistant.

Conclusions

Gram-negative SSIs constituted half of the SSIs in this breast surgery cohort. Of all breast isolates, 17.5% were resistant to cefazolin. On the basis of these findings, antibiotic prophylaxis regimens alternative to cefazolin should be considered.     

Immediate breast reconstruction after mastectomy: what are the long-term prospects?

INTRODUCTION

Immediate breast reconstruction after mastectomy has known psychological and financial advantages but it is difficult to compare the outcome of various methods of reconstruction. Re-operation rates are an objective measure of surgical intervention required to attain and maintain acceptable cosmesis.

PATIENTS AND METHODS

A series of 95 patients (110 immediate reconstructions) was analysed for number of re-operations required within 5 years of initial surgery, magnitude of procedures, ‘survival’ of the reconstruction and effect of radiotherapy.

RESULTS

Although more intervention was seen in patients with implant-based reconstruction and the time-course over which autologous and implant-based reconstructions fail is different these did not reach statistical significance. Radiotherapy has a significant effect on failure of implant-based reconstruction.

CONCLUSIONS

Long-term, large studies of immediate reconstruction are required to assess adequately the impact of type of reconstruction on re-operation rates. The National Mastectomy and Breast Reconstruction Audit is ideally placed to provide answers to remaining questions about longevity of immediate breast reconstruction and the effect that late failure has on patient satisfaction.     

The effect of magnetic resonance imaging in the workup of breast cancer

Background

Breast magnetic resonance imaging (MRI) is becoming an often-utilized examination in the preoperative planning for breast cancer. However, it is not yet accepted as a routine examination for all breast cancer patients due to the lack of data regarding whether breast MRI has any effect on recurrence or survival.

Methods

The charts of 76 patients referred by their surgeons for breast MRI during breast cancer workup were reviewed to determine if the breast MRI changed the preoperative clinical staging, the operative plan, or prompted additional testing.

Results

Thirty-eight of 76 patients (50%) received follow-up imaging and 22/76 (29%) received additional biopsies. The breast MRI upstaged the cancer in 14/76 patients (18%). There was a change in the surgical plan in 19 of 76 (25%) patients, all of whom received more extensive surgery than previously planned.

Conclusion

Breast MRI contributed significantly to the workup and management of breast cancer at our institution, suggesting a higher stage in 18% of the patients and changing the surgical plan in 25% of the patients.     

Delayed two-stage breast reconstruction with implants: The authors�� recent experience

BACKGROUND:

Presently, breast cancer detection is delayed in Poland and, thus, the only other option for patients is amputation and breast reconstruction (immediate or delayed). Reconstructive methods are based on using the patient’s own tissue (pedicled or free myocutaneous flaps) or implants (a tissue expander, which is later exchanged for a prosthesis or an expandable implant).

OBJECTIVE:

To evaluate the aesthetic results of a delayed two-stage breast reconstruction with the use of implants (expander and prosthesis) in patients who have previously undergone cancer-related mastectomy.

METHODS:

From 2006 to 2009, 54 patients (34 to 65 years of age) underwent reconstruction at least one year after their mastectomy and adjuvant chemotherapy; three women also received x-ray therapy. All women underwent a two-stage treatment with a tissue expander, which was later exchanged for a prosthesis.

RESULTS:

Outcomes of the surgery (evaluated by the physician and the patient at least six months after all stages of reconstruction) were found to be very good in 42 patients and good in 12 patients. After amputation and x-ray therapy in two cases, a fistula developed, which necessitated implant removal.

CONCLUSIONS:

After amputation, breast reconstruction with implants (expander and prosthesis) provides good aesthetic results. The method is mildly burdening to the patient and does not cause severe scarring. Symmetrization of the second breast is often recommended; however, the cost is not covered by the national health system. In principle, earlier x-ray therapy disqualifies the application of implants. Dividing reconstruction into two stages (expander and prosthesis) allows for possible correction of prosthesis placement.     

Clinicopathologic characteristics and prognosis of young patients with breast cancer

Background

The aim was to describe the clinicopathological features and prognosis of young patients with breast cancer.

Patients and Methods

We reviewed the records of 1478 consecutive patients aged ≤50 years with first diagnosis of invasive breast cancer referred to surgery from January 1999 to March 2005. A total of 174 patients were aged <35 years (group I) and 1304 were aged 35-50 years (group II).

Results

Compared with patients of group II, patients of group I had a higher percentage of tumors classified as estrogen receptors (ER) negative, progesterone receptors (PR) negative, with a Ki-67 labeling index ≥20% of the cells. The 5-year survival of group I was 78.3% as compared with 84.2% for group II (P = 0.006).

Conclusion

Compared with patients aged between 35 and 50 years, patients aged <35 years have a greater chance of having an endocrine-unresponsive tumor and a significantly poor prognosis.