Breast reconstruction after surgery for breast cancer

Implant infection after prepectoral breast reconstruction treated with negative pressure wound therapy and photobiomodulation: a case report

Prepectoral breast reconstruction is a relatively new surgical technique that allows placement of the implant directly over the pectoralis major. It has benefits in terms of patient wellbeing, operative time, postoperative pain and recovery. However, in cases of infection, implant removal is often required and the patient is left with a flat chest. To the authors' knowledge, this is the first case of breast implant infection after breast reconstruction, successfully treated with a combination of both negative pressure wound therapy (NPWT) and photobiomodulation (PBM). A 32-year-old female patient with a BRCA2 mutation had undergone bilateral risk-reducing, nipple-sparing mastectomy for in situ ductal breast carcinoma followed by a prepectoral reconstruction. On the left side, the patient presented with dehiscence of 2.5cm with implant exposure 90 days after surgery. After an initial conservative approach, the patient's condition worsened, and she developed a larger dehiscence and a red breast. She was treated with implant removal. PBM of the cavity and the application of VeraFlo Therapy (3M, US) with a polyurethane-foam filling in the residual cavity were adopted. Pseudomonas aeruginosa was isolated and appropriate antibiotic therapy was started. Every 48-72 hours, she returned to the operating room for a washout, PBM, microbiological swabs, foam exchange and continuing NPWT. After 21 days of this approach and two consecutive negative swabs, the patient underwent breast reconstruction with a subpectoral expander. After six months, a definitive implant of the same size as the contralateral one was positioned. The cosmetic result was good and patient satisfaction was high. The combination of NPWT and PBM may represent a good solution in case of breast implant infection after prepectoral reconstruction with benefits in terms of surgical outcome, patient satisfaction and postoperative quality of life.

Assessment of Appearance-related Questions About Breast Reconstruction Generated by Chat Generative Pre-trained Transformer

Background

Previous studies have explored the ability of artificial intelligence (AI) tools based on large language models, such as Chat Generative Pre-Trained Transformer (ChatGPT), to answer patient questions about breast reconstruction. In this study, we assessed the quality of questions generated by ChatGPT for breast reconstruction patients to ask their providers.

Methods

ChatGPT was prompted to generate appearance-related questions representative of what patients might ask during breast reconstruction consultations. As a benchmark, a comparison group of questions from credible online sources was compiled. Blinded to the source, surgeons assessed the quality of questions in terms of their acceptability, contribution to the informed consent process, and contribution to the shared decision-making process. Surgeons were also asked to report their agreement on whether questions were generated by an AI tool.

Results

Experienced reconstructive surgeons rated ChatGPT-generated questions about appearance-related outcomes of breast reconstruction as acceptable (15 of 16), likely to positively contribute to the informed consent process (15 of 16), and likely to positively contribute to the shared decision-making process (16 of 16). These ratings were comparable to those for benchmark questions. Surgeons did not readily recognize questions as being AI-generated. Differences in surgeon assessments were most pronounced regarding the perceived potential for the questions to contribute to the informed consent process.

Conclusions

The quality of ChatGPT-generated questions related to appearance concerns is comparable to that of questions sourced from reputable online websites. Patients may benefit from discussion with their providers about best practices for using AI tools in preparation for consultations.

Implantation of engineered adipocytes suppresses tumor progression in cancer models

Tumors exhibit an increased ability to obtain and metabolize nutrients. Here, we implant engineered adipocytes that outcompete tumors for nutrients and show that they can substantially reduce cancer progression, a technology termed adipose manipulation transplantation (AMT). Adipocytes engineered to use increased amounts of glucose and fatty acids by upregulating UCP1 were placed alongside cancer cells or xenografts, leading to significant cancer suppression. Transplanting modulated adipose organoids in pancreatic or breast cancer genetic mouse models suppressed their growth and decreased angiogenesis and hypoxia. Co-culturing patient-derived engineered adipocytes with tumor organoids from dissected human breast cancers significantly suppressed cancer progression and proliferation. In addition, cancer growth was impaired by inducing engineered adipose organoids to outcompete tumors using tetracycline or placing them in an integrated cell-scaffold delivery platform and implanting them next to the tumor. Finally, we show that upregulating UPP1 in adipose organoids can outcompete a uridine-dependent pancreatic ductal adenocarcinoma for uridine and suppress its growth, demonstrating the potential customization of AMT.

Patient Perspectives of "Failure" in Breast Reconstruction: A Systematic Review of Qualitative Literature: Points de vue des patients sur les «échecs» de la reconstruction mammaire: Revue systématique des publications sur l'aspect qualitatif

Introduction: The concept of failure in breast reconstruction can occur when negative outcomes dominate the patient experience. The primary objective of this review was to identify experiences of failure in breast reconstruction from the patient's perspective in the qualitative literature. Methods: MEDLINE, Embase, Psychinfo, Emcare, and CINAHL were searched on July 31, 2023 using terms related to breast reconstruction and qualitative research. Thematic analysis was performed on direct quotations from included studies. Confidence in the Evidence from Reviews of Qualitative (CERQual) Research was used to assess confidence of the final findings. Results: Forty-two studies were identified. The following themes were identified in breast reconstruction failure: (1) failure occurs when expectations of restoring the original breast are not met with reconstruction, (2) failure occurs when unexpected outcomes were associated with the reconstruction, and (3) healthcare providers negatively impact the experience of breast reconstruction failure through lack of transparency when educating patients on expected results and poor relational support in the post-operative period. The evidence supporting themes 1-3 scored high confidence with CERQual. Conclusion: Breast reconstruction failure from the patient perspective arises from the limitations and adverse outcomes of the surgery. They may also arise even when the procedure was deemed "successful" from the surgeon's perspective. Dissatisfaction with result is increased by procedural complications. Healthcare providers can aggravate the perception of failure through inadequate patient education. Incorporating these perceptions of failure into discussions with patients can aid in their decision making.

Meta-analysis and systematic review of long-term oncological safety of immediate breast reconstruction in patients with locally advanced breast cancer

BACKGROUND

Immediate breast reconstruction (IBR) in locally advanced breast cancer (LABC) (stage 3A and above) is widely debated, both in terms of delay of adjuvant therapy and oncological safety. This study aims to systematically review and evaluate the long-term oncological safety of IBR in patients with LABC undergoing mastectomy.

METHODS

Search conducted using Medline, Embase, PubMed and Google Scholar between 1 and 24 December 2023 involving patients with LABC who underwent mastectomy with or without IBR were included. The meta-analysis included studies comparing IBR with mastectomy alone in patients with LABC with the primary outcomes of 5-year overall survival, disease-free survival and local and distant recurrence rates.

RESULTS

A total of 19,907 patients were included spanning 10 papers. Of these, 89.1% underwent mastectomy alone, while 10.9% underwent IBR (51.2% autologous and 48.8% implant-based reconstruction). The 5-year overall survival rate was higher in IBR compared to mastectomy alone (IBR n = 2038/2491 81.8%, vs. Mx only n = 7468/10,124 73.7%, RR 1.10 [95% CI 1.07-1.12], P < 0.001). No significant difference found in 5-year disease-free survival (IBR n = 510/689 74.0% vs. Mx only n = 1339/1924 69.6%, RR 1.06 [95% CI 0.98-1.15], P = 0.17), 5-year local recurrence groups (IBR n = 52/646 8.0% vs. Mx only n = 122/1708 7.1%, RR 0.80 [95% CI 0.46-1.38], P = 0.42), or 5-year distant recurrence rates (IBR n = 117/594 19.6% vs. Mx only n = 211/882 23.9%, P = 0.11).

CONCLUSION

IBR in LABC may be associated with improved overall 5-year survival rates without affecting disease-free survival or recurrence rates. Therefore, IBR may be a safe option in the treatment of LABC when considering optimal oncological outcomes.

Recent Advancements of Nanomedicine in Breast Cancer Surgery

Breast cancer surgery plays a pivotal role in the multidisciplinary approaches. Surgical techniques and objectives are gradually shifting from tumor complete resection towards prolonging survival, improving cosmetic outcomes, and restoring the social and psychological well-being of patients. However, surgical treatment still faces challenges such as inadequate sensitivity in sentinel lymph node localization, the need to improve intraoperative tumor boundary localization imaging, postoperative scar healing, and the risk of recurrence, necessitating other adjunct measures for improvement. To address these challenges, specificity-optimized nanomedicines have been introduced into the surgical therapeutic landscape of breast cancer. In particular, this review involves starting with an overview of breast structure and the composition of the tumor microenvironment and then introducing the guiding principle and foundation for the design of nanomedicine. Moreover, we will take the order process of breast cancer surgery diagnosis and treatment as the starting point, and adaptively propose the roles and advantages of nanomedicine in addressing the corresponding issues. Furthermore, we also involved the prospects of utilizing advanced technological approaches. Overall, this review seeks to uncover the sophisticated design and strategies of nanomedicine from a clinical standpoint, address the challenges faced in surgical treatment, and provide insights into this subject matter.

The Evolution of Implant-Based Breast Reconstruction: Innovations, Trends, and Future Directions

Background/Objectives: Implant-based breast reconstruction has been essential since the 1960s, offering a faster and less invasive alternative to autologous reconstruction. Recent innovations-including direct-to-implant (DTI) reconstruction, advancements in surgical planes, synthetic meshes, and nipple-areolar complex (NAC) neurotization-have improved patient outcomes. This review explores these developments, analyzing their impact on breast reconstruction over the past two decades. Methods: A comprehensive literature review was conducted using PubMed, Google Scholar, and Cochrane Library databases, focusing on peer-reviewed studies published up to 2024. Articles were selected based on relevance, quality, and documentation of clinical outcomes and patient satisfaction. Results: Findings indicate that DTI reconstruction reduces the need for multiple surgeries, especially in cases with sufficient mastectomy flap quality. Prepectoral placement showed benefits in postoperative comfort and recovery speed compared to subpectoral placement, but had specific risks, such as implant rippling. Synthetic meshes improved implant support and reduced complication rates, while neurotization has shown potential in restoring sensation to the nipple-areolar complex (NAC), addressing quality-of-life concerns. Conclusions: Innovations like DTI, prepectoral techniques, and adjunctive mesh and neurotization strategies are advancing patient outcomes. Future research should refine these methods, aiming to expand applicability and further improve aesthetic and sensory outcomes for breast cancer survivors.

Hug Flap and Hamdi Hammock: Two Innovative Techniques for Enhancing Aesthetic Outcomes in Deep Inferior Epigastric Artery Perforator Breast Reconstruction

Background

Achieving optimal aesthetic outcomes in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction remains a challenge, often necessitating additional procedures for refinement. This study presents two innovative techniques (the hug flap and Hamdi hammock) aimed at enhancing breast projection and inframammary fold (IMF) definition in DIEP flap reconstruction.

Methods

The hug flap technique uses de-epithelialized caudal mastectomy skin to augment breast projection, whereas the Hamdi hammock uses a percutaneous purse-string suture to define the IMF. A retrospective review of 782 patients who underwent DIEP flap breast reconstruction between 2007 and 2023 was conducted.

Results

The hug flap group required significantly less additional fat grafting compared to other techniques (11% versus 27% and 22%). No total flap losses occurred in the hug flap group, and fat necrosis rates were low. The Hamdi hammock was used in 405 patients with a mean of two lipofilling sessions. Complications were minor and no stitches required removal.

Conclusions

The hug flap and Hamdi hammock techniques offer effective and safe methods for enhancing breast projection and IMF definition in DIEP flap reconstruction. These techniques may reduce the need for additional procedures and improve aesthetic outcomes.

National Trends and In-Hospital Outcomes for Immediate Implant-Based Versus Autologous-Based Breast Reconstruction: A Propensity Score-Matched Analysis

BACKGROUND

Breast reconstruction consists primarily of two methods: autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR). Each of these methods has its advantages and disadvantages. The current study used the National Inpatient Sample (NIS), the largest inpatient database in the United States, to explore the trends, complications, and disparities in the use of IBR and ABR.

METHODS

The current study used the NIS database from 2016 to 2020, including the International Classification of Diseases, 10th version (ICD-10) codes. A propensity score-matching (1:1) analysis was used to match the IBR and ABR groups.

RESULTS

The percentage of breast reconstruction increased from 58.8% in 2016 to 63.4% by 2020. The trend of ABR was upward, and the trend of IBR was downward. In addition, the ABR group had significantly higher rates of cardiovascular complications (odds ratio [OR], 1.29), respiratory complications (OR, 4.26), vascular complications requiring surgery (OR, 7.82), blood transfusions (OR, 3.44), vasopressor need (OR, 1.409), and acute kidney injury (OR, 1.68). However, the ABR group had significantly lower rates of wound infection (OR, 0.430), wound dehiscence (OR, 0.213), wound seroma (OR, 0.602), and sepsis (OR, 0.252). A significant disparity was found in using ABR for different subgroups based on age, hospital teaching status, racial background, socioeconomic status, and hospital bed size.

CONCLUSION

The current study showed an upward trend in the utilization of ABR and a downward trend for IBR. Although ABR had a higher rate of pulmonary, cardiovascular, vascular, and bleeding complications, it had a lower rate of wound-related complications.

Effects of Nanofat in Plastic and Reconstructive Surgery: A Systematic Review

BACKGROUND

Since nanofat was first introduced by Tonnard in 2013, numerous studies have reported positive findings with its use; however, concerns exist regarding its effects and mechanisms, and the various methods used to generate nanofat also remain unclear. The authors conducted a systematic review to evaluate the efficacy of nanofat grafting alone in plastic and reconstructive surgery.

METHODS

The MEDLINE, Embase, Cochrane Central, Web of Science, and Scopus databases were searched for studies related to the use of nanofat grafting alone in plastic and reconstructive surgery. Outcomes of interest were all clinical results in humans or animals.

RESULTS

Twelve studies were included. No meta-analysis was conducted due to the clinical heterogeneity of the studies. In general, included studies had a low level of evidence. Six studies ( n = 253 patients) showed significant improvements in scar characteristics based on Patient and Observer Scar Assessment Scale, FACE-Q scale, physician assessment, patient satisfaction, and Vancouver Scar Scale scores. Four studies described the benefits of nanofat in skin rejuvenation (wrinkles, fine rhytides, pigmentation, and discoloration) through photographs, questionnaires, and indentation indices. Histologic evaluation illustrated overall increases in skin thickness, collagen, and elastic fibers. Three experimental studies showed the beneficial effects of nanofat on fat grafting, diabetic wound healing, and hair growth, with compelling histological evidence. No severe complication was reported.

CONCLUSIONS

Nanofat grafting shows potential benefits in scar and antiaging treatments, with conclusive histological evidence. Clinical studies of fat grafting, wound healing, and hair growth should be conducted, based on the results of this systematic review. Nanofat grafting could be a practical and safe procedure.

Risk Factors for Unplanned Reoperation during the Expansion Phase in Two-Stage Breast Reconstruction in the Dutch Breast Implant Registry

BACKGROUND

The majority of postmastectomy breast reconstructions (PMBRs) are currently performed in two stages using a tissue expander (TE). However, complications during the expansion phase occur regularly, leading to unplanned reoperations and/or reconstruction failure. This study aimed to identify risk factors for unplanned reoperation after TE placement, assessed the time until unplanned and planned reoperation, and investigated indications for unplanned reoperation.

METHODS

Patient- and surgery-related characteristics of patients who underwent two-stage PMBR between 2017 and 2021 were collected from the Dutch Breast Implant Registry (DBIR). Unplanned reoperation was defined as TE explantation followed by either no replacement or replacement with the same or a different TE. Covariate-adjusted characteristics associated with unplanned reoperation were determined using backward stepwise selection and multivariable logistic regression analyses.

RESULTS

In total, 2529 patients (mean age, 50.2 years) were included. Unplanned reoperation occurred in 19.4% of all registered TEs ( n = 3190). Independent factors associated with unplanned reoperation were body mass index (BMI) greater than or equal to 25 kg/m 2 (adjusted OR [aOR], 1.63, 99% CI, 1.20 to 2.57 for BMI of 25 to 29.9 kg/m 2 ; aOR, 2.57, 99% CI, 1.74 to 3.78 for BMI ≥30 kg/m 2 ), low institutional volume (aOR, 1.51; 99% CI, 1.06 to 2.18), no drains (aOR, 2.06; 99% CI, 1.15 to 3.60), subcutaneous TE placement (aOR, 5.71; 99% CI, 3.59 to 9.10), and partial pectoralis major muscle coverage (aOR, 1.35; 99% CI, 1.02 to 1.79). Age younger than 40 years (aOR, 0.49; 99% CI, 0.32 to 0.74) and delayed PMBR (aOR, 0.35; 99% CI, 0.19 to 0.60) reduced the risk of unplanned reoperation. Median time until reoperation was 97 days for unplanned and 213 days for planned reoperation. Deep wound infections were most often registered as indication for unplanned reoperation (34.4%).

CONCLUSION

This study identified several risk factors for unplanned reoperation that may be used to reduce complications in expander-based PMBR.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Locally advanced breast cancer patients should be cautious about the immediate breast reconstruction after mastectomy: a pooling analysis of safety and efficacy

BACKGROUND

The purpose of this study was to compare safety and efficacy outcomes between immediate breast reconstruction (IBR) and mastectomy alone in locally advanced breast cancer patients.

METHODS

We conducted a comprehensive literature search of PUBMED, EMBASE, and Cochrane databases. The primary outcomes evaluated were overall survival, disease-free survival, and local recurrence. The secondary outcome was the incidence of surgical complications. All data were analyzed using Review Manager 5.3.

RESULTS

Sixteen studies, involving 15,364 participants were included in this meta-analysis. Pooled data demonstrated that patients underwent IBR were more likely to experience surgical complications than those underwent mastectomy alone (HR: 3.96, 95%CI [1.07,14.67], p = 0.04). No significant difference was found in overall survival (HR: 0.94, 95%CI [0.73,1.20], p = 0.62), disease-free survival (HR: 1.03, 95%CI [0.83,1.27], p = 0.81), or breast cancer specific survival (HR: 0.93, 95%CI [0.71,1.21], p = 0.57) between IBR group and Non-IBR group.

CONCLUSIONS

Our study demonstrates that IBR after mastectomy does not affect the overall survival and disease-free survival of locally advanced breast cancer patients. However, IBR brings with it a nonnegligible higher risk of complications and needs to be fully evaluated and carefully decided.

The impact of the new ESTRO-ACROP target volume delineation guidelines for postmastectomy radiotherapy after implant-based breast reconstruction on breast complications

The European Society for Radiotherapy and Oncology-Advisory Committee in Radiation Oncology Practice (ESTRO-ACROP) updated a new target volume delineation guideline for postmastectomy radiotherapy (PMRT) after implant-based reconstruction. This study aimed to evaluate the impact on breast complications with the new guideline compared to the conventional guidelines. In total, 308 patients who underwent PMRT after tissue expander or permanent implant insertion from 2016 to 2021 were included; 184 received PMRT by the new ESTRO-ACROP target delineation (ESTRO-T), and 124 by conventional target delineation (CONV-T). The endpoints were major breast complications (infection, necrosis, dehiscence, capsular contracture, animation deformity, and rupture) requiring re-operation or re-hospitalization and any grade ≥2 breast complications. With a median follow-up of 36.4 months, the cumulative incidence rates of major breast complications at 1, 2, and 3 years were 6.6%, 10.3%, and 12.6% in the ESTRO-T group, and 9.7%, 15.4%, and 16.3% in the CONV-T group; it did not show a significant difference between the groups (p = 0.56). In multivariable analyses, target delineation is not associated with the major complications (sHR = 0.87; p = 0.77). There was no significant difference in any breast complications (3-year incidence, 18.9% vs. 23.3%, respectively; p = 0.56). Symptomatic RT-induced pneumonitis was developed in six (3.2%) and three (2.4%) patients, respectively. One local recurrence occurred in the ESTRO-T group, which was within the ESTRO-target volume. The new ESTRO-ACROP target volume guideline did not demonstrate significant differences in major or any breast complications, although it showed a tendency of reduced complication risks. As the dosimetric benefits of normal organs and comparable oncologic outcomes have been reported, further analyses with long-term follow-up are necessary to evaluate whether it could be connected to better clinical outcomes.

Three-dimensional Simulation on Patient-reported Outcomes Following Oncoplastic and Reconstructive Surgery of the Breast: A Randomized Trial

Background

Three-dimensional (3D) imaging using computer simulations is an evolving technology. There is a lack of strong data on the use of this technology for oncoplastic (OP) and reconstructive surgery.

Methods

A prospective, randomized, single-center trial including breast cancer patients undergoing OP or mastectomy with immediate breast reconstruction with implant (IBR) enrolled from November 2019 to October 2021 at the Hospital Nossa Senhora das Graças, Breast Unit in Curitiba, Brazil. Both patients undergoing OP and those in the IBR group were randomized to undergo 3D imaging and simulation of postoperative results (intervention group) or 3D imaging without simulation (control group). All patients were invited to complete a patient-reported outcome (BREAST-Q) expectations module and breast reconstruction or reduction/mastopexy module before and 6 months after surgery.

Results

A total of 96 patients were enrolled. Sixty-nine patients (45 OP and 24 IBR) completed the pre- and postoperative questionnaires and were randomized for the simulation. Women in the OP group had higher expectations for breast appearance when clothed than those in the IBR implant group (93.4 ± 16.3 versus 82.9 ± 26.5; P = 0.03). The intervention group was more satisfied with information than the control group (P = 0.021). Both patients who underwent OP and IBR believed that the 3D simulation helped them understand the surgical process (86.6% and 75%, respectively).

Conclusions

Preoperative 3D simulation significantly improved patient's satisfaction with information and did not decrease postoperative satisfaction with the outcomes. The incorporation of preoperative 3D simulation may be a valuable tool in breast reconstruction.

Surgical and Patient-Reported Outcomes After Mastectomy and Implant-Based Prepectoral Reconstruction Using TIGR® Synthetic Mesh

Background Single-stage direct-to-implant (DTI) breast reconstruction after mastectomy has gained popularity over the last decade, thanks to the wide use of biological matrices and synthetic meshes. Despite their high cost, there is no evidence of superior outcome from the biological matrices compared to the synthetic meshes. In this study, we aimed to evaluate our experience with TIGR, a synthetic, long-term absorbable mesh, in mastectomy and immediate breast reconstruction (MIBR) with a focus on patient-reported outcomes (PROMs). Methods This was a single-trust prospective quality improvement study conducted between 2017 and 2019. The main objectives were complication rates including infection, implant loss, and other surgical complications in patients undergoing TIGR mesh-assisted MIBR in the prepectoral plane for either cancer or risk reduction. PROMs were measured using the validated European Organisation for Research and Treatment of Cancer (EORTC) breast questionnaire module. Clinical evaluations were conducted at one week, three weeks, and 12 months postoperatively. All patients provided written consent, and the audit was registered with the Quality Improvement Department of the organization. Results One hundred and twelve meshes were used in 93 patients with a mean age of 49 (24-75) years and a body mass index (BMI) of 23.4 (19.1-29.6). During the follow-up period, complications occurred in 26 patients (28%), including infection in four (4.3%), complete skin flap necrosis in one (1%), partial flap necrosis in three (3.2%), and implant loss in four (4.3%) patients. PROM data from 41 individuals indicated a moderate overall quality of life (82.7%), with high functional domain scores with relatively lower emotional functioning scores. Symptom domains generally scored poorly except for body image and sexual functioning. Conclusion Mastectomy and immediate prepectoral breast reconstruction using TIGR mesh is safe with low major complication rates. It is associated with high functional and quality of life scores but low scores in symptom domains which could be multifactorial. However, limitations due to study type and follow-up duration suggest caution in generalizing findings.

Multimodality Imaging of Postmastectomy Breast Reconstruction Techniques, Complications, and Tumor Recurrence

For women undergoing mastectomy, breast reconstruction can be performed by using implants or autologous tissue flaps. Mastectomy options include skin- and nipple-sparing techniques. Implant-based reconstruction can be performed with saline or silicone implants. Various autologous pedicled or free tissue flap reconstruction methods based on different tissue donor sites are available. The aesthetic outcomes of implant- and flap-based reconstructions can be improved with oncoplastic surgery, including autologous fat graft placement and nipple-areolar complex reconstruction. The authors provide an update on recent advances in implant reconstruction techniques and contemporary expanded options for autologous tissue flap reconstruction as it relates to imaging modalities. As breast cancer screening is not routinely performed in this clinical setting, tumor recurrence after mastectomy and reconstruction is often detected by palpation at physical examination. Most local recurrences occur within the skin and subcutaneous tissue. Diagnostic breast imaging continues to have a critical role in confirmation of disease recurrence. Knowledge of the spectrum of benign and abnormal imaging appearances in the reconstructed breast is important for postoperative evaluation of patients, including recognition of early and late postsurgical complications and breast cancer recurrence. The authors provide an overview of multimodality imaging of the postmastectomy reconstructed breast, as well as an update on screening guidelines and recommendations for this unique patient population. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Information needs in breast reconstruction after mastectomy: a qualitative analysis of free-text responses from 2077 women

BACKGROUND

For many, breast reconstruction following mastectomy (BR) forms an integral part of breast cancer survivorship. For those considering BR, provision of information is essential to allow informed decisions. Using free-text responses from a survey of breast cancer survivors, this study aims to understand current gaps in information regarding BR.

METHOD

At the end of an online survey assessing BR experiences, participants were asked the open-ended question: "Thinking about women who may experience BR in the future, is there anything you think needs to change so that they have a better experience?". Responses were analysed to identify common themes.

RESULTS

3384 people completed the survey with 2,077 (61%) responding to the open-ended question. Three themes were identified: (1) content of information, (2) managing expectations, and (3) information sources, each associated with multiple subthemes. Information wanted in theme (1) covered a range of topics including BR options, risks, recovery and 'going flat.' Information on BR's psychological impact was also needed, with comments indicating many were not prepared for this. Theme (2) stressed the importance of realistic information about BR outcomes and processes to reduce discrepancies between expectations and experiences. In theme (3), peer insights and photos were important sources of realistic information.

CONCLUSION

Multiple gaps exist in BR-related information available to women. BR information needs to be comprehensive, realistic, and provided at the right time to allow informed decision-making. Developing strategies to strengthen existing information provision as well as new resources to fill information gaps might enhance BR experiences.

Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016-2019

INTRODUCTION

Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States.

METHODS

Using the National Inpatient Sample, 2016-2019, the International Classification of Disease , Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling.

RESULTS

A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Δ = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Δ = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR ( P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay ( P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242).

CONCLUSIONS

As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility.

"All about the value?" Decisional needs of breast reconstruction for breast cancer patients in the Chinese context: A mixed-methods study

OBJECTIVE

To explore breast cancer (BC) patients' participation in breast reconstruction (BR) decision-making and specific decisional needs, especially the manifestations and causes of decisional conflicts, in China.

METHODS

A mixed-methods study was conducted using triangulation of data from interviews and a questionnaire survey with health care professionals (HCPs) and BC patients with BR decision-making experience at 5 Beijing centers. The Ottawa Decision Support Framework guided (ODSF) the qualitative and quantitative data analyses.

RESULTS

A total of 82.53% of Chinese BC patients would consider BR. Seven themes captured patients' BR decisional needs per the ODSF: inadequate support/resources (100%, 58.82%) and knowledge (75%, 52.94%) were most frequently cited. Health beliefs (unclear values) reflected Chinese characteristics. Patients had inadequate knowledge (M=19.99/50, SD=8.67) but positive BR attitudes (M=59.48/95, SD=10.45).

CONCLUSIONS

BR decisions for Chinese BC patients are complex and often accompanied by decisional conflicts. Inadequate knowledge and inadequate support and resources contribute to these conflicts, emphasizing the need for culturally tailored information and support to promote SDM.

PRACTICE IMPLICATIONS

HCPs need specialized training in SDM to guide patients in decision-making. It is essential to provide relevant resources and support that are culturally and clinically appropriate for Chinese patients.

Microcirculatory changes in the skin after postmastectomy radiotherapy in women with breast cancer

Postmastectomy radiotherapy (PMRT) increases the risk for complications after breast reconstruction. The pathophysiological mechanism underlying this increased risk is not completely understood. The aim of this study was to examine if there is a relationship between PMRT and microvascular perfusion in the skin directly after, and at 2 and 6 months after PMRT and to assess if there is impaired responsiveness to a topically applied vasodilator (Methyl nicotinate-MN) after PMRT. Skin microvascular responses after PMRT were measured on two sites in the irradiated chest wall of 22 women before, immediately after, and at 2 and 6 months after unilateral PMRT with the contralateral breast as a control. A significant increase in basal skin perfusion was observed in the irradiated chest wall immediately after RT (p < 0.0001). At 2 and 6 months after RT, there was no longer a difference in basal skin perfusion compared to the contralateral breast and compared to baseline. Similarly, the blood flow response in the skin after application of MN was stronger immediately after RT compared to before RT (p < 0.0001), but there was no difference at later time points. These results indicate that the increased risk for complications after surgical procedures are not directly related to changes in skin perfusion and microvascular responsiveness observed after postmastectomy RT.

DIEP Flap for Head and Neck Reconstruction: An Underutilized Option!

Background  The deep inferior epigastric artery perforator (DIEP) flap is a workhorse flap for breast reconstruction. Its use for head and neck (HN) reconstruction is rare. Abdomen provides a donor site abundant in skin and subcutaneous tissue, amenable to primary closure; sizeable, robust, and consistent perforators and a long, sizeable pedicle for comfortable microvascular anastomosis. Its offers all the donor variables needed for HN reconstruction in abundance. Methods  It is a quasiexperimental design study. DIEP flap use for HN reconstruction in our series was opportunistic, that is, when donor site matched the defect. Cases that had very thick thighs and lesser bulk in abdomen and cases that had very thin thighs but much more bulk in abdomen were considered for reconstruction using DIEP flap. Results  The DIEP flap was done in 11 cases for HN reconstruction. There were two re-explorations during postoperative period: one flap loss and another had partial necrosis. Conclusion  Abdomen is an excellent donor site option for HN reconstruction in selected cases, especially when harvested as a perforator flap.

Key factors in the decision-making process for mastectomy alone or breast reconstruction: A qualitative analysis

Breast cancer is the most common cancer to affect New Zealand women. Women diagnosed face several decisions regarding surgical treatment, including whether to undergo lumpectomy, mastectomy, or breast reconstruction. Reconstructive surgery adds an additional layer of complexity, with several reconstructive options, each associated with differing surgical and recovery times. Furthermore, surgical decisions are often made under time-pressure and significant diagnostic distress, therefore provision of good information to support decision-making is crucial to adequately inform women of their options. We interviewed 24 women who had undergone breast surgery within the preceding 12 months to assess the key factors leading to their decision to opt for their chosen surgical procedure. Interviews revealed that decision-making was complex and involved multiple factors. Women were ultimately confronted with assessing feminine identity versus survival. Whether opting for breast reconstruction or not, women were fearful of what surgery would involve and how their reconstructed breast or mastectomy scar might look following surgery. Shared decision-making between patient and clinician can mitigate this fear and provide women with a sense of autonomy over their health decisions. Provision of visual depictions of surgical outcomes was not routinely provided to those interviewed but was expressed as important to help women manage surgical expectations. Therefore our findings support the multi-modal presentation of diagnostic and treatment information to support decision-making. Likewise, women reported feeling unsupported in their decision not to undergo breast reconstruction, suggesting a need to develop resources to provide women with positive discussions about 'going flat'.

Imaging findings after a total reconstructed breast with autologous fat transfer: what the radiologist needs to know

Autologous fat transfer (AFT) is an upcoming technique for total breast reconstruction. Consequently, radiological imaging of women with an AFT reconstructed breast will increase in the coming years, yet radiological experience and evidence after AFT is limited.

The surgical procedure of AFT and follow-up with imaging modalities including mammography (MG), ultrasound (US), and MRI in patients with a total breast reconstruction with AFT are summarized to illustrate the radiological normal and suspicious findings for malignancy.

Imaging after a total breast reconstruction with AFT appears to be based mostly on benign imaging findings with an overall low biopsy rate. As higher volumes are injected in this technique, the risk for the onset of fat necrosis increases. Imaging findings most often are related to fat necrosis after AFT. On MG, fat necrosis can mostly be seen as oil cysts. The occurrence of a breast seroma after total breast reconstruction with AFT is an unfavourable outcome and may require special treatment. Fat deposition in the pectoral muscle is a previously unknown, but benign entity. Although fat necrosis is a benign entity, it can mimic breast cancer (recurrence).

In symptomatic women after total breast reconstruction with AFT, MG and US can be considered as first diagnostic modalities. Breast MRI can be used as a problem-solving tool during later stage. Future studies should investigate the most optimal follow-up strategy, including different imaging modalities, in patients treated with AFT for total breast reconstruction.

COVID-associated complications after reconstructive breast surgery: a retrospective cohort study

PURPOSE

The COVID pandemic significantly influenced reconstructive breast surgery regimens. Many surgeries were cancelled or postponed. COVID entails not only respiratory, but also coagulative symptoms. It, therefore, potentially increases the risk of postoperative complications. The incidence of perioperative COVID infection and its influence on postoperative recovery after reconstructive breast surgery is still unknown.

METHODS

This dual center retrospective cohort study included patients that underwent reconstructive breast surgery between March 2020 and July 2021. Post-mastectomy autologous or implant-based breast reconstruction (ABR; IBR), as well as post-lumpectomy oncoplastic partial breast reconstruction (PBR) were eligible. Patient data were extracted from electronic medical records. Data regarding COVID-19 infection was collected through a questionnaire. The primary outcome was complication rate.

RESULTS

The ABR, IBR and PBR groups consisted of 113 (12 COVID-positive), 41 (2 COVID-positive) and 113 (10 COVID-positive) patients. In the ABR and PBR groups, postoperative complications occurred significantly more often in patients with perioperative COVID-infection. Especially impaired wound healing occurred significantly more often in the ABR and PBR breasts, but also at the donor site of ABR patients with perioperative COVID.

CONCLUSION

Perioperative COVID-infection increases susceptibility to complicated wound healing after reconstructive breast surgery. A possible explanation lies in the dysregulation of haemostasis by the virus, and its direct effects on microvasculature. A hypercoagulable state results. We recommend to postpone elective breast surgery for 4-6 weeks after COVID-19 infection. Also, precautionary measures remain important to minimize the risk of perioperative COVID-19 infection.

Prognosis of post-neoadjuvant therapy patients who underwent immediate breast reconstruction: a SEER-based, propensity-matched study

OBJECTIVE

The application of immediate breast reconstruction (IBR) for post-neoadjuvant therapy (NAT) patients was controversial. The aim of this study was to investigate the long-term survival outcomes of IBR for these patients.

METHODS

Data between January 2010 and November 2017 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was performed to reduce the influence of confounding factors between the mastectomy alone group (MA) and the mastectomy with IBR group (IBR). The rates of 5 year breast cancer-specific survival (BCSS) were compared by Kaplan-Meier curves with log-rank test.

RESULTS

The IBR was associated with improved 5-year BCSS in the IBR group before PSM (88.5 vs. 79.1%, P < 0.001). The proportion of IBR increased from 21.5% in 2010 to 28.2% in 2017. After PSM, a total of 9,610 patients were enrolled for survival analysis (4,805 in each group). In the complete response (CR) group, the 5-year BCSS rates did not differ (93.4 vs. 95.6%, P = 0.16). In the non-CR group, the 5-year BCSS rate was higher in patients who received IBR (82.5% 79.4%, P = 0.034).

CONCLUSION

In general, the application of IBR among post-NAT patients has steadily increased from 2010 to 2017. In the CR group, survival outcomes of post-NAT patients who received IBR were similar to those who received mastectomy alone. In the non-CR group, IBR was associated with potential survival benefits. More studies are expected to validate our findings.

A prospective randomized clinical trial to assess antibiotic pocket irrigation on tissue expander breast reconstruction

Bacterial infection is the most common complication following staged post-mastectomy breast reconstruction initiated with a tissue expander (TE). To limit bacterial infection, antibiotic irrigation of the surgical site is commonly performed despite little high-quality data to support this practice. We performed a prospective randomized control trial to compare the impact of saline irrigation alone to a triple antibiotic irrigation regimen (1 g cefazolin, 80 mg gentamicin, and 50,000 units of bacitracin in 500 mL of saline) for breast implant surgery. The microbiome in breasts with cancer (n = 16) was compared to those without (n = 16), as all patients (n = 16) had unilateral cancers but bilateral mastectomies (n = 32). Biologic and prosthetic specimens procured both at the time of mastectomy and during TE removal months later were analyzed for longitudinal comparison. Outcomes included clinical infection, bacterial abundance, and relative microbiome composition. No patient in either group suffered a reconstructive failure or developed an infection. Triple antibiotic irrigation administered at the time of immediate TE reconstruction did not reduce bacterial abundance or impact microbial diversity relative to saline irrigation at the time of planned exchange. Implanted prosthetic material adopted the microbial composition of the surrounding host tissue. In cancer-naïve breasts, relative to saline, antibiotic irrigation increased bacterial abundance on periprosthetic capsules (P = 0.03) and acellular dermal matrices (P = 0.04) and altered the microbiota on both. These data show that, relative to saline only, the use of triple antibiotic irrigation in TE breast reconstruction does impact the bacterial abundance and diversity of certain biomaterials from cancer-naïve breasts. IMPORTANCE The lifetime risk of breast cancer is ~13% in women and is treated with a mastectomy in ~50% of cases. The majority are reconstructed, usually starting with a tissue expander to help restore the volume for a subsequent permanent breast implant or the women's own tissues. The biopsychosocial benefits of breast reconstruction, though, can be tempered by a high complication rate of at least 7% but over 30% in some women. Bacterial infection is the most common complication, and can lead to treatment delays, patient physical and emotional distress and escalating health care cost. To limit this risk, plastic surgeons have tried a variety of strategies to limit bacterial infection including irrigating the pocket created after removing the breast implant with antibiotic solutions, but good-quality data are scarce. Herein, we study the value of antibiotics in pocket irrigation using a robust randomized clinical trial design and molecular microbiology approaches.

How breast cancer therapies impact body image - real-world data from a prospective cohort study collecting patient-reported outcomes

BACKGROUND

In breast cancer patients body image (BI) is a crucial aspect of quality of life (QoL). This study examined the postoperative impact of different surgical approaches on long-term BI analyzing real-world data to guide pre- and postoperative patient care and preserve QoL.

METHODS

EORTC QLQ-BR23 BI scores were collected electronically in 325 breast cancer patients within routine clinical care for a duration of 41.5 months (11/17/2016 - 4/30/2020) at predefined time points preoperatively and repeatedly up to two years after breast-conserving surgery (BCS) (n = 212), mastectomy alone (M) (n = 27) or mastectomy with immediate breast reconstruction (MIBR) (n = 86). Higher scores indicated better BI. A linear mixed regression model was used to analyze the impact of BCS, M and MIBR, as well as non-surgical therapies on BI at treatment initiation and over time.

RESULTS

BI scores deteriorated by 5 points (95%-confidence interval (CI) -8.94 to -1.57, p≈0.005) immediately after BCS, by 7 points (95%-CI -12.13 to -1.80, p≈0.008) after MIBR and by 19 points (95%-CI -27.34 to -10.34, p < 0.001) after M. The change over time after BCS (+ 0.10 points per week, 95%-CI -0.17 to 0.38), MIBR (-0.07 points per week, 95%-CI -0.35 to 0.20) and M (+ 0.14 points per week, 95%-CI -0.19 to 0.48) were not statistically significant (each p > 0.05). At treatment initiation chemotherapy was associated with a 22-point decline (95%-CI -25.39 to -17.87, p < 0.001) in BI score, while radiotherapy was associated with a 5-point increase (95%-CI 1.74 to 9.02, p≈0.004). However, over time chemotherapy was associated with a score recovery (+ 0.28 points per week, 95%-CI 0.19 to 0.37, p < 0.001), whereas for radiotherapy a trend towards BI deterioration was observed (-0.11 points per week, 95%-CI -0.23 to 0.02, p≈0.101).

CONCLUSIONS

Breast cancer surgery negatively affects BI. BCS and MIBR presumably harm BI less than M in the early postoperative period. Our data suggests BI to be deteriorating in the long term after MIBR while improving after BCS or M. Radiotherapy seems to have an additional negative long-term impact on BI. These findings should be confirmed in further studies to enable evidence-based patient information as part of preoperative shared decision-making and postoperative patient care.

Body-Shaping Membrane to Regenerate Breast Fat by Elastic Structural Holding

Tissue regeneration requires structural holding and movement support using tissue-type-specific aids such as bone casts, skin bandages, and joint protectors. Currently, an unmet need exists in aiding breast fat regeneration as the breast moves following continuous body motion by exposing the breast fat to dynamic stresses. Here, the concept of elastic structural holding is applied to develop a shape-fitting moldable membrane for breast fat regeneration ("adipoconductive") after surgical defects are made. The membrane has the following key characteristics: (a) It contains a panel of honeycomb structures, thereby efficiently handling motion stress through the entire membrane; (b) a strut is added into each honeycomb in a direction perpendicular to gravity, thereby suppressing the deformation and stress concentration upon lying and standing; and (c) thermo-responsive moldable elastomers are used to support structural holding by suppressing large deviations of movement that occur sporadically. The elastomer became moldable upon a temperature shift above T_m. The structure can then be fixed as the temperature decreases. As a result, the membrane promotes adipogenesis by activating mechanotransduction in a fat miniature model with pre-adipocyte spheroids under continuous shaking in vitro and in a subcutaneous implant placed on the motion-prone back areas of rodents in vivo.

The Effect of Adjuvant Radiotherapy on One- and Two-Stage Prosthetic Breast Reconstruction and on Autologous Reconstruction: A Multicenter Italian Study among 18 Senonetwork Breast Centres

Purpose

In modern breast cancer treatment, a growing role has been observed for breast reconstruction together with an increase in clinical indications for postmastectomy radiotherapy (PMRT). Choosing the optimum type of reconstructive technique is a clinical challenge. We therefore conducted a national multicenter study to analyze the impact of PMRT on breast reconstruction.

Methods

We conducted a retrospective case-control multicenter study on women undergoing breast reconstruction. Data were collected from 18 Italian Breast Centres and stored in a cumulative database which included the following: autologous reconstruction, direct-to-implant (DTI), and tissue expander/immediate (TE/I). For all patients, we described complications and surgical endpoints to complications such as reconstruction failure, explant, change in type of reconstruction, and reintervention.

Results

From 2001 to April 2020, 3116 patients were evaluated. The risk for any complication was significantly increased in patients receiving PMRT (aOR, 1.73; 95% CI, 1.33-2.24; p < 0.001). PMRT was associated with a significant increase in the risk of capsular contracture in the DTI and TE/I groups (aOR, 2.24; 95% CI, 1.57-3.20; p < 0.001). Comparing type of procedures, the risk of failure (aOR, 1.82; 95% CI, 1.06-3.12, p=0.030), explant (aOR, 3.34; 95% CI, 3.85-7.83, p < 0.001), and severe complications (aOR, 2.54; 95% CI, 1.88-3.43, p < 0.001) were significantly higher in the group undergoing DTI reconstruction as compared to TE/I reconstruction.

Conclusion

Our study confirms that autologous reconstruction is the procedure least impacted by PMRT, while DTI appears to be the most impacted by PMRT, when compared with TE/I which shows a lower rate of explant and reconstruction failure. The trial is registered with NCT04783818, and the date of registration is 1 March, 2021, retrospectively registered.

Selective Estrogen receptor degraders (SERDs) for the treatment of breast cancer: An overview

Discovery of SERDs has changed the direction of anticancer research, as more than 70% of breast cancer cases are estrogen receptor positive (ER+). Therapies such as selective estrogen receptor modulators (SERM) and aromatase inhibitors (AI's) have been effective, but due to endocrine resistance, SERDs are now considered essential therapeutics for the treatment of ER+ breast cancer. The present review deliberates the pathophysiology of SERDs from the literature covering various molecules in clinical trials. Estrogen receptors active sites distinguishing characteristics and interactions with currently available FDA-approved drugs have also been discussed. Designing strategy of previously reported SERDs, their SAR analysis, in silico, and the biological efficacy have also been summarized along with appropriate examples.

Effect of Total Breast Reconstruction With Autologous Fat Transfer Using an Expansion Device vs Implants on Quality of Life Among Patients With Breast Cancer: A Randomized Clinical Trial

Importance

There is a need for a new, less invasive breast reconstruction option for patients who undergo mastectomy in their breast cancer treatment.

Objective

To investigate quality of life (QoL) among patients undergoing a new breast reconstruction technique, autologous fat transfer (AFT), compared with that among patients undergoing implant-based reconstruction (IBR).

Design, Setting, and Participants

The BREAST trial was a randomized clinical trial conducted between November 2, 2015, and October 31, 2021, performed in 7 hospitals across the Netherlands. Follow-up was 12 months. Referrals could be obtained from general practitioners and all departments from participating or nonparticipating hospitals. The patients with breast cancer who had undergone mastectomy and were seeking breast reconstruction were screened for eligibility (radiotherapy history and physique) by participating plastic surgeons. Patients receiving postmastectomy radiotherapy were excluded.

Interventions

Breast reconstruction with AFT plus expansion or 2-phased IBR. Randomization was done in a 1:1 ratio.

Main Outcomes and Measures

The statistical analysis was performed per protocol. The predefined primary outcome was QoL at 12 months after final surgery. This was measured by the BREAST-Q questionnaire, a validated breast reconstruction surgery questionnaire. Questions on the BREAST-Q questionnaire are scored from 0 to 100, with a higher score indicating greater satisfaction or better QoL (depending on the scale). Secondary outcomes were breast volume and the safety and efficacy of the techniques.

Results

A total of 193 female patients (mean [SD] age, 49.2 [10.6] years) 18 years or older who desired breast reconstruction were included, of whom 91 patients in the AFT group (mean [SD] age, 49.3 [10.3] years) and 80 in the IBR group (mean age, 49.1 [11.0] years) received the allocated intervention. In total, 64 women in the AFT group and 68 women in the IBR group completed follow-up. In the IBR group, 18 patients dropped out mainly due to their aversion to implant use while in the AFT group 6 patients ended their treatment prematurely because of the burden (that is, the treatment being too heavy or tiring). The BREAST-Q scores were higher in the AFT group in all 5 domains and significantly higher in 3: satisfaction with breasts (difference, 9.9; P = .002), physical well-being: chest (difference; 7.6; P = .007), and satisfaction with outcome (difference, 7.6; P = .04). Linear mixed-effects regression analysis showed that QoL change over time was dependent on the treatment group in favor of AFT. The mean (SD) breast volume achieved differed between the groups (AFT: 300.3 [111.4] mL; IBR: 384.1 [86.6] mL). No differences in oncological serious adverse events were found.

Conclusions and Relevance

This randomized clinical trial found higher QoL and an increase in QoL scores over time in the AFT group compared with the IBR group. No evidence was found that AFT was unsafe. This is encouraging news since it provides a third, less invasive reconstruction option for patients with breast cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT02339779.

Current perspectives on cell-assisted lipotransfer for breast cancer patients after radiotherapy

BACKGROUND

Cell-assisted lipotransfer (CAL), a technique of autologous adipose transplantation enriched with adipose-derived stem cells (ADSCs), has the potential to improve cosmetic outcomes at irradiated sites. However, many concerns have been raised about the possibility of ADSCs increasing oncological risk in cancer patients. With the increasing demand for CAL reconstruction, there is an urgent need to determine whether CAL treatment could compromise oncological safety after radiotherapy, as well as to evaluate its efficacy in guiding clinical decisions.

METHODS

A PRISMA-compliant systematic review of the safety and efficacy of CAL in breast cancer patients after radiotherapy was conducted. The PubMed, Ovid, Cochrane Library, and ClinicalTrials.gov databases were comprehensively searched from inception to 31 December 2021.

RESULTS

The search initially yielded 1185 unique studies. Ultimately, seven studies were eligible. Based on the limited outcome evidence, CAL did not increase recurrence risk in breast cancer patients but presented aesthetic improvement and higher volumetric persistence in a long-term follow-up. Although breast reconstruction with CAL also had oncological safety after radiotherapy, these patients needed more adipose tissue and had relatively lower fat graft retention than the non-irradiated patients (P < 0.05).

CONCLUSIONS

CAL has oncological safety and does not increase recurrence risk in irradiated patients. Since CAL doubles the amount of adipose required without significantly improving volumetric persistence, clinical decisions for irradiated patients should be made more cautiously to account for the potential costs and aesthetic outcomes. There is limited evidence at present; thus, higher-quality, evidence-based studies are required to establish a consensus on breast reconstruction with CAL after radiotherapy.

Implantation of engineered adipocytes that outcompete tumors for resources suppresses cancer progression

Tumors acquire an increased ability to obtain and metabolize nutrients. Here, we engineered and implanted adipocytes to outcompete tumors for nutrients and show that they can substantially reduce cancer progression. Growing cells or xenografts from several cancers (breast, colon, pancreas, prostate) alongside engineered human adipocytes or adipose organoids significantly suppresses cancer progression and reduces hypoxia and angiogenesis. Transplanting modulated adipocyte organoids in pancreatic or breast cancer mouse models nearby or distal from the tumor significantly suppresses its growth. To further showcase therapeutic potential, we demonstrate that co-culturing tumor organoids derived from human breast cancers with engineered patient-derived adipocytes significantly reduces cancer growth. Combined, our results introduce a novel cancer therapeutic approach, termed adipose modulation transplantation (AMT), that can be utilized for a broad range of cancers.

Survival Nomogram for Patients With Locally Advanced Breast Cancer Undergoing Immediate Breast Reconstruction: A SEER Population-Based Study

INTRODUCTION/BACKGROUND

This study aimed to construct a nomogram to provide prognostic references for patients with locally advanced breast cancer (LABC) to receive immediate breast reconstruction (IBR).

MATERIALS AND METHODS

All data were obtained from the Surveillance, Epidemiology and End Results (SEER) database. Univariate Cox regression, least absolute shrinkage and selection operator (LASSO) and best subset regression (BSR), separately followed by backward stepwise multivariable Cox, were used to construct the nomogram. Risk stratification was established after validation.

RESULTS

A total of 6,285 patients were enrolled to generate the training group (n = 3,466) and the test group (n = 2,819) by geographical split. Age, marital status, grade, T staging, N staging, radiotherapy, chemotherapy, estrogen receptor status (ER), progesterone receptor status (PR) and human epidermal growth factor receptor type 2 status (HER2) were used to fit the nomogram. The overall Harrell's concordance index (C-index) was 0.772 in the training group and 0.762 in the test group. The area under the receiver operator characteristic curves (AUC) at 3-year and 5-year were respectively 0.824 and 0.720 in the training group, 0.792 and 0.733 in the test group. The calibration curves showed great consistency in both groups. A dynamic nomogram (https://dcpanfromsh.shinyapps.io/NomforLABCafterIBR/) was developed.

CONCLUSION

A nomogram was developed and validated that predicts prognosis more accurately than the AJCC 7th stage and can be used as a reference for decision-making in LABC patients receiving IBR.

Injectable anti-cancer drug loaded silk-based hydrogel for the prevention of cancer recurrence and post-lumpectomy tissue regeneration aiding triple-negative breast cancer therapy

A single system capable of delivering anticancer drugs and growth factors by a minimally invasive approach is in demand for effective treatment of triple-negative breast cancer (TNBC) after lumpectomy. Here, we showcase one such holistic system for TNBC therapy and its assessment via 3D in vitro lumpectomy model, a first of its kind. Firstly, Bombyx mori silk fibroin (BMSF) and Antheraea assamensis silk fibroin (AASF) blended hydrogels were prepared and biophysically characterized. Secondly, a 3D in vitro lumpectomy model was developed using MDA-MB-231 cell line to assess the efficacy of localized delivery of doxorubicin (dox) using injectable hydrogel system in terminating remaining breast cancer after lumpectomy. Additionally, we have also evaluated the adipose tissue regeneration in the lumpectomy region by delivering dexamethasone (dex) using injectable hydrogels. Rheological studies showed that the BMSF/AASF blended hydrogels exhibit viscoelasticity and injectability conducive for minimally invasive application. The developed hydrogels by virtue of its slow and sustained release of dox exerted cytotoxicity towards MDA-MB-231 cells assessed through in vitro studies. Further, dex loaded hydrogel supported adipogenic differentiation of adipose tissue derived stem cells (ADSCs), while the secreted factors were found to aid in vascularization and macrophage polarization. This was confirmed through in vitro angiogenic tube formation assay and macrophage polarization study respectively. The corroborated results vouch for potential application of this injectable hydrogels for localized anticancer drug delivery and aiding in breast reconstruction, post lumpectomy.

Breast cancer recurrence after immediate and delayed postmastectomy breast reconstruction-A systematic review and meta-analysis

BACKGROUND

Oncological safety of different types and timings of PMBR after breast cancer remains controversial. Lack of stratified risk assessment in literature makes current clinical and shared decision-making complex. This is the first systematic review and meta-analysis to evaluate differences in oncological outcomes after immediate versus delayed postmastectomy breast reconstruction (PMBR) for autologous and implant-based PMBR separately.

METHODS

A systematic literature search was performed in MEDLINE, Cochrane Library, and Embase. The Cochrane Collaboration Handbook and Meta-analysis Of Observational Studies in Epidemiology checklist were followed for data abstraction. Variability in point estimates attributable to heterogeneity was assessed using I2 -statistic. (Loco)regional breast cancer recurrence rates, distant metastasis rates, and overall breast cancer recurrence rates were pooled in generalized linear mixed models using random effects.

RESULTS

Fifty-five studies, evaluating 14,217 patients, were included. When comparing immediate versus delayed autologous PMBR, weighted average proportions were: 0.03 (95% confidence interval [CI], 0.02-0.03) versus 0.02 (95% CI, 0.01-0.04), respectively, for local recurrences, 0.02 (95% CI, 0.01-0.03) versus 0.02 (95% CI, 0.01-0.03) for regional recurrences, and 0.04 (95% CI, 0.03-0.06) versus 0.01 (95% CI, 0.00-0.03) for locoregional recurrences. No statistically significant differences in weighted average proportions for local, regional and locoregional recurrence rates were observed between immediate and delayed autologous PMBR. Data did not allow comparing weighted average proportions of distant metastases and total breast cancer recurrences after autologous PMBR, and of all outcome measures after implant-based PMBR.

CONCLUSIONS

Delayed autologous PMBR leads to similar (loco)regional breast cancer recurrence rates compared to immediate autologous PMBR. This study highlights the paucity of strong evidence on breast cancer recurrence after specific types and timings of PMBR.

LAY SUMMERY

Oncologic safety of different types and timings of postmastectomy breast reconstruction (PMBR) remains controversial. Lack of stratified risk assessment in literature makes clinical and shared decision-making complex. This meta-analysis showed that delayed autologous PMBR leads to similar (loco)regional recurrence rates as immediate autologous PMBR. Data did not allow comparing weighted average proportions of distant metastases and total breast cancer recurrence after autologous PMBR, and of all outcome measures after implant-based PMBR. Based on current evidence, oncological concerns do not seem a valid reason to withhold patients from certain reconstructive timings or techniques, and patients should equally be offered all reconstructive options they technically qualify for.

Five decades of progress in surgical oncology: Breast

Surgery remains the single most effective treatment for breast cancer but coincident with a deeper understanding of tumor biology and advances in multidisciplinary care (encompassing breast imaging, systemic adjuvant therapy, radiotherapy, and genomics) continues to de-escalate, supported by strong level I data. We have moved from mastectomy to breast conservation, and from routine axillary dissection to sentinel lymph node biopsy to selective omission of axillary node staging altogether. We have further de-escalated through consensus over margin width in breast conservation, through improvements in neoadjuvant therapy, and by demonstrating no benefit for upfront surgery in patients with stage IV disease. For patients with ipsilateral breast tumor recurrence, reconservation surgery and reirradiation are promising. Cell cycle and immune checkpoint inhibitors, when added to conventional systemic therapy, have now moved beyond stage IV disease to phase III trials in the adjuvant and neoadjuvant settings, promising even further de-escalation of surgery. Finally, with genomic profiling we are moving away from the primacy of axillary node status for prognostication and into a new era allowing prediction of response to therapy.

Citation Analysis in Breast Reconstruction Publications Between 2000 and 2010

Introduction and Purpose: Breast reconstruction is an active area of plastic surgery research. Citation analysis allows for quantitative analysis of publications, with more citations presumed to indicate greater influence. We performed citation analysis to evaluate the most cited papers on breast reconstruction between 2000 to 2010 to identify contemporary research trends. Methods: The SCI-EXPANDED database was used to identify the 50 most cited papers. Data points included authorship, publication year, publication journal, study design, level of evidence, number of surgeons/institutions, center of surgery, primary outcome assessed, implant/flap/acellular dermal matrix/fat graft, acellular dermal matrix brand and use with implants/flaps, fat graft use with implants/flaps, unilateral/bilateral, one-/two-stage, immediate/delayed, number of patients/procedures, complications. Descriptive analysis of trends was performed based on results. Results: 20% of papers were published in 2006, 16% in 2007 and 12% in both 2004/2009. 66% were published in Plastic and Reconstructive Surgery. The majority were retrospective or case series, and of Level III or IV evidence. The one Level I study was a prospective multicenter trial. 21 and 7 papers discussed procedures by single/multiple surgeons, respectively. Results from single/multiple centers were discussed in 18 and 6 papers, respectively. 30 papers discussed implant-based reconstruction, 22 papers flap-based (19 microsurgical), 15 papers acellular dermal matrix, and five papers fat grafting. The primary focus in the majority was complications or outcomes. Conclusion: Our analysis demonstrates continually evolving techniques in breast reconstruction. However, there is notable lack of high quality evidence to guide surgical decision-making in the face of increasing surgical options.

Breaking Barriers to Breast Reconstruction among Socioeconomically Disadvantaged Patients at a Large Safety-net Hospital

Socioeconomic disparities remain prevalent among those who undergo breast reconstruction. At our institution, patients must meet certain criteria to become eligible for breast reconstruction. The purpose of this study was to determine the impact of socioeconomic factors on breast reconstruction eligibility, enrollment, choice, and completion at our large safety-net institution.

Additive manufactured macroporous chambers facilitate large volume soft tissue regeneration from adipose-derived extracellular matrix

Breast tissue engineering is a promising alternative intervention for breast reconstruction. Due to their low immunogenicity and well-preserved adipogenic microenvironment, decellularized adipose tissue (DAT) can potentially regenerate adipose tissue in vivo. However, the volume of adipose tissue regenerated from DAT can hardly satisfy the demand for breast reconstruction. Tissue engineering chamber (TEC) is an effective technique for generation of large adipose tissue volumes. However, TEC applications necessitate reoperation to remove non-degradable plastic chambers and harvest autologous tissue flaps, which prolongs the operation time and causes potential damage to donor sites. We improved the TEC strategy by combining bioresorbable polycaprolactone (PCL) chambers and decellularized adipose tissues (DAT). A miniaturized porous PCL chamber was fabricated based on scaling differences between human and rabbit chests, and basic fibroblast growth factor (bFGF)-loaded DAT successfully prepared. In rabbit models, a highly vascularized adipose tissue that nearly filled up the PCL chamber (5 mL) was generated de novo from 0.5 mL bFGF-loaded DAT. The newly formed tissue had significantly high expressions of adipogenic genes, compared to the endogenous adipose tissue. The concept described here can be exploited for breast tissue engineering. STATEMENT OF SIGNIFICANCE: Decellularized adipose tissue (DAT), which provides infiltrated cells adipogenic microenvironment, can potentially regenerate adipose tissue in vivo. Nevertheless, the volume of regenerated adipose tissue is insufficient to repair large sized tissue defect. Tissue engineering chamber (TEC) could provide a protective space for in situ regeneration of large volume tissue. Herein, a new strategy by combining biodegradable polycaprolactone chambers and basic fibroblast growth factor-loaded decellularized adipose tissue is proposed. In rabbit model, newly formed adipose tissue regenerated from DAT successfully filled the dome shaped chamber with ten folds higher volume than DAT, which is proportionally similar to women breast. This work highlighted the importance of adipogenic microenvironment and protective space for adipose tissue regeneration.

Short-Term Surgical Complications of Skin-Sparing Mastectomy and Direct-to-Implant Immediate Breast Reconstruction in Women Concurrently Treated with Adjuvant Radiotherapy for Breast Cancer

Background  Postmastectomy radiotherapy (PMRT) is allegedly associated with a higher risk of complications of combined nipple-sparing or skin-sparing mastectomy and subpectoral direct-to-implant immediate breast reconstruction ([N]SSM/SDTI-IBR). For this reason, this combination is usually advised against or, even, refused in women who need to undergo PMRT. Because this advice has never been justified, we assessed the short-term complications that may potentially be associated with PMRT after [N]SSM/SDTI-IBR. Methods  We compared the complications requiring reintervention and implant loss occurring after 273 [N]SSM/SDTI-IBR that were exposed to PMRT within the first 16 postoperative weeks (interventional group) to those occurring in 739 similarly operated breasts that were not (control group). Additionally, we compared the fraction of complications requiring reintervention occurring after the onset of radiotherapy in the interventional group to that occurring after a comparable postoperative period in the control group. Results  The fraction of breasts requiring unscheduled surgical reinterventions for complications and the loss of implants did not differ significantly between both groups but significantly more reinterventions were needed among the controls ( p  = 0.00). The fraction of events after the onset of radiotherapy in the interventional group was higher than the fraction of events after 6.2 weeks in the control group, but not significantly so. Conclusion  We found no prove for the alleged increase of short-term complications of adjuvant radiotherapy. Therefore, we advise that these should not be considered valid arguments to advice against [N]SSM/SDTI-IBR.

Disparities in Access to Postmastectomy Breast Reconstruction: Does Living in a Specific ZIP Code Determine the Patient's Reconstructive Journey?

BACKGROUND

Postmastectomy breast reconstruction (BR) has been shown to provide long-term quality of life and psychosocial benefits. Despite the policies initiated to improve access to BR, its delivery continues to be inequitable, suggesting that barriers to access have not been fully identified and/or addressed. The purpose of this study was to assess the influence of geographic location, socioeconomic status, and race in access to immediate BR (IBR).

METHODS

An institutional review board-approved observational study was conducted. All patients who underwent breast cancer surgery from 2014 to 2019 were queried from our institutional Breast Cancer Registry. A geographical analysis was conducted using demographic characteristics and patient's ZIP codes. Euclidean distance from patient home ZIP code to UPMC Magee Women's Hospital was calculated, and χ2, Student t test, Mann-Whitney, and Kruskal-Wallis tests was used to evaluate differences between groups, as appropriate. Statistical significance was set at P < 0.05.

RESULTS

Overall, 5835 patients underwent breast cancer surgery. A total of 56.7% underwent lumpectomy or segmental mastectomy, and 43.3% underwent modified, total, or radical mastectomy. From the latter group, 33.5% patients pursued BR at the time of mastectomy: 28.6% autologous, 48.1% implant-based, 19.4% a combination of autologous and implant-based, and 3.9% unspecified reconstruction. Rates of IBR varied among races: White or European (34.1%), Black or African American (27.7%), and other races (17.8%), P = 0.022. However, no difference was found between type of BR among races (P = 0.38). Moreover, patients who underwent IBR were significantly younger than those who did not pursue reconstruction (P < 0.0001). Patients who underwent reconstruction resided in ZIP codes that had approximately US $2000 more annual income, a higher percentage of White population (8% vs 11% non-White) and lower percentage of Black or African American population (1.8% vs 2.9%) than the patients who did not undergo reconstruction.

CONCLUSIONS

While the use of postmastectomy BR has been steadily rising in the United States, racial and socioeconomic status disparities persist. Further efforts are needed to reduce this gap and expand the benefits of IBR to the entire population without distinction.

Uptake of breast reconstruction following mastectomy: a Gold Coast experience

BACKGROUND

The breast reconstruction (BR) rate for women undergoing mastectomy for breast cancer management is 18% in Australia. The Australian Access to Breast Reconstruction Collaborative Group recommends that all women should have access to BR. This study presents BR uptake and outcomes from a breast surgical unit.

METHODS

A retrospective observational study identified women who had curative mastectomy for breast cancer between 1 January 2016 and 31 December 2021. Patient factors and surgical complications were compared between BR and no BR (NBR) patients.

RESULTS

Out of 929 women who had a curative mastectomy, 34% underwent reconstruction. Of this, 89% were immediate, and 11% were delayed. Reconstruction increased from 27% (2016) to 35% (2021). During this time, 588 women had a discussion for BR documented at their initial consultation, 58 after initial surgery and 283 were not documented. The rate of discussion prior to mastectomy increased from 38% to 74%. Women who had BR were more likely to be younger, premenopausal and less likely to be diabetic. Complications requiring return to theatre were higher in reconstructed women (13% vs. 7%). Overall, infected seroma, cellulitis requiring intravenous antibiotics and haematoma requiring drainage were comparable between both groups.

CONCLUSION

Our unit achieved a reconstruction rate of 34%, which is higher than national and international averages. Open discussion of reconstruction is crucial for women to make an informed decision. Further prospective studies exploring barriers to timely reconstruction will improve uptake of BR surgery and allow prioritization of BR services in Australia.

Patient-reported outcomes following bilateral prophylactic mastectomy and immediate breast reconstruction: comparing implant-based with autologous breast reconstruction

Background

Since the number of breast cancer genetic gene testing is increasing, more women opt for bilateral prophylactic mastectomy (BPM) followed by breast reconstruction. However, little is known about the differences in Quality of Life (QoL) after various reconstructive surgeries in this population. In this study, the long-term breast-related, body-related, and health-related QoL between immediate implant-based breast reconstruction (IBBR) and autologous breast reconstruction (ABR) were compared, in women who underwent BPM.

Methods

In this cross-sectional study, women who underwent postmastectomy breast reconstruction between January 2015 and December 2018 were invited for an online questionnaire, in which the BREAST-Q, the BODY-Q and the SF-36 were included. Women who underwent BPM and immediate breast reconstruction were included for analysis. Multivariable linear regression analysis was performed to adjust mean differences in patient-reported outcomes between IBBR and ABR for potential confounders.

Results

Of the included women (n = 47), 33 underwent ABR and 14 women underwent IBBR following BPM. BREAST-Q scores were in favor of the ABR group before and after adjustment, with statistically significance on Satisfaction with breasts (mean difference 15.8, p = 0.019) and Physical well-being (mean difference 13.5, p = 0.033). None of the mean differences in BODY-Q and SF-36 scores between groups, before and after adjustment, were statistically significant.

Conclusion

This study suggests that there is a higher satisfaction with breasts and better physical well-being in women who underwent immediate ABR compared to those who underwent immediate IBBR after BPM. However, these data should be interpreted carefully as a result of selection bias and a small sample size.

Level of Evidence: Level III, risk study.

Predictors of delayed breast reconstruction in the Netherlands: a 5-year follow-up study in stage I-III breast cancer patients

PURPOSE

Delayed breast reconstruction (DBR) is a valid option for postmastectomy breast cancer patients who have a desire for breast reconstruction but are not considered suitable for immediate breast reconstruction (IBR). The objective of this study was to investigate the clinical practice and predictors of the use of DBR in the Netherlands.

METHODS

Stage I-III breast cancer patients diagnosed from January to March 2012 and treated with mastectomy were selected from the Netherlands Cancer Registry. Routinely collected patient, tumor, treatment and hospital characteristics were complemented with data about DBR up to 2018. Multivariable logistic regression analyses were performed to identify factors independently associated with postmastectomy DBR. Factors associated with time to DBR were identified through Cox regression analyses.

RESULTS

Of all patients who underwent mastectomy (n = 1,415), 10.2% underwent DBR. DBR patients more often received autologous reconstruction compared to IBR patients (37.5% vs 6.2%, p < 0.001). Age below 50 years (age < 35 OR 15.55, age 35-49 OR 4.18) and neoadjuvant and adjuvant chemotherapy (OR 2.59 and OR 2.83, respectively) were significantly associated with DBR. Mean time to DBR was 2.4 years [range 1-6 years]. Time to DBR was significantly associated with age < 35 years (HR 2.22), and a high hospital volume (HR 1.87).

DISCUSSION

The use of DBR after mastectomy could not be fully explained by age below 50 years, chemotherapy, and hospital volume. Treatment with radiotherapy and adjuvant chemotherapy increased time to DBR. More information about patient preferences is needed to understand the use and timing of reconstruction.

"Struggling to Accept the New Breast as Part of My Body" - The Challenge of Immediate Breast Reconstruction in Women With Breast Cancer

BACKGROUND

Women have difficulties in making decisions and experiences an unexpectedly long recovery period after immediate breast reconstruction. There are still many limitations in understanding the overall changes in life experienced by women with breast cancer before and after immediate breast reconstruction.

OBJECTIVE

This study aimed to explore the challenges experienced by women with breast cancer undergoing immediate breast reconstruction and how they coped with these problems.

METHODS

Strauss and Corbin's grounded theory design was used. In-depth face-to-face individual interviews were undertaken with 11 women with breast cancer from 4 hospitals in Korea. Data collection and analysis were conducted simultaneously, using the constant comparative method.

RESULTS

The core category was "struggling to accept the new breast as part of my body." "Decision making regarding immediate breast reconstruction" was the initial step, followed by "facing the changed breasts after surgery." The challenge of "living with the new breasts" slowly merged into "making up my mind to accept my breasts with gratitude."

CONCLUSION

Women with breast cancer undergoing immediate breast reconstruction struggled to accept the new breast as part of their body, and some reached a measure of closure and acceptance with gratitude.

IMPLICATION FOR PRACTICE

Nurses can apply findings by recognizing the experiences, perceptions, and needs of women; providing patients with sufficient information on the whole process; and offering continuous supportive care to facilitate the coping process. In addition, nurses should consider a variety of approaches that help women to integrate their changed bodies into their self-concept and self-image and restore a sense of normality.

Long-term oncologic safety of immediate reconstructive surgery in patients with invasive breast cancer: a retrospective matched-cohort study

Objective

Immediate reconstruction (IR) is a safe and effective surgical treatment for patients with breast cancer. We aimed to assess the prognosis, aesthetic outcomes, and patient satisfaction of IR compared with breast conservation surgery (BCS) and total mastectomy (TM).

Methods

This retrospective matched-cohort study was conducted between May 2005 and December 2014. We established two cohorts according to the tumor (T) size of breast cancer. In the T≤3cm group, cases (IR) and controls (BCS or TM) were matched for age, pathological tumor size, and pathologic nodal status in a 1:1:1 ratio. In the T>3cm group, cases (IR) and controls (TM) were matched with the same factors and ratio. The primary outcome was the 5-year disease-free survival (DFS). The secondary outcome was patient satisfaction and quality of life.

Results

A total of 12,678 breast cancer patients were assessed for eligibility, of which 587 were included (T≤3 cm group: 155 IR vs 155 BCS vs 155 TM; T>3cm group: 61 IR vs 61 TM). In the T≤3 cm cohort, patients who underwent IR had no difference compared with those who underwent BCS or TM regarding the 5-year DFS (P=0.539); however, an improved aesthetic satisfaction, psychosocial, and sexual well-being were achieved in the IR group (P<0.001). In the T>3 cm cohort, the IR group had a worse median 5-year DFS (P=0.044), especially for Her2+ or triple-negative breast carcinoma (TNBC) subtypes compared with the TM group.

Conclusions

IR improves aesthetic satisfaction, psychosocial, and sexual well-being for breast cancer patients with T≤3 cm. For patients with T > 3 cm invasive breast cancer, TM is superior to IR as it predicts a better 5-year DFS.