Abstract P5-16-06: Prepectoral versus retropectoral implant-based breast reconstruction - The surgical and radiotherapeutical perspective

Background: Subpectoral implant positioning has been the standard of care in breast reconstruction despite involving disadvantages owing to the detachment of the pectoralis major muscle such as disruption of the muscle function, animation deformities and prolonged postoperative pain. Refined ablative techniques as well as dermal matrices and synthetic mesh products have led to the reintroduction of subcutaneous implant-based breast reconstruction possibly avoiding the negative sequelae of pectoralis disinsertion.

Objective: The primary objective of this study was to compare procedure-related complication rates following prepectoral versus retropectoral implant-based breast reconstruction. Furthermore the effect of the implant position on the quality of post-mastectomy radiation therapy (PMRT) was analysed.

Methods: All patients who underwent an implant-based breast reconstruction after mastectomy at the Department of Obstetrics and Gynecology of the University Clinic of Vienna within the years 1.1.2013 to 31.12.2017 were included in the study. A retrospective chart review of the patients was conducted assessing parameters regarding the mastectomy, the reconstruction, complications following the reconstructive procedure, patient-associated risk factors and radiation treatment plans. Complication rates were analysed one week, one month and one year after the implant-based reconstructive operation.

Results: In total 57 patients (94 breasts) were reconstructed following a prepectoral implant-placement approach, 95 patients (149 breasts) were reconstructed with implants in a retropectoral position. The two patient cohorts did not differ significantly in the occurrence of complications including the following dehiscence, infection, seroma, secondary bleeding, necrosis, fistula, capsular contracture and rippling. No significant differences regarding reinterventions and reoperations including seroma drainage, secondary suture and reoperation following secondary hemorrhage and necrosis could be detected between the two study populations. The two surgical procedures were not associated with a different rate of implant loss.

12 (2 in the cohort of patients with prepectorally placed implants and 10 in the subgroup of patients with subpectorally positioned implants) out of 152 patients needed PMRT for oncological safety. Prepectoral versus retropectoral implant positioning did not affect breast Dmean or D90, heart Dmax or V5 or lung V20 across treatment plans.

Conclusion: The study demonstrated no inferior outcome regarding the occurrence of complications, reinterventions, reoperations and implant loss of prepectoral implant-based breast reconstruction compared to retropectoral implant positioning. Therefore, subcutaneous implant placement permits reconstruction of the breast with comparable procedure-related complication rates while avoiding disadvantages associated with the detachment of the pectoral muscle.

Regarding the radiation perspective both prepectoral and retropectoral implant positioning allow for optimal coverage of the chest wall with acceptable doses to the heart and lung.

Citation Format: Deutschmann C, Gschwantler-Kaulich D, Dorffner G, Singer C, Leser C, Kauer-Dorner D. Prepectoral versus retropectoral implant-based breast reconstruction - The surgical and radiotherapeutical perspective [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-06.

[Shift Work among Men and Women on the Threshold to Higher Working Age - Working Conditions and Health Status]

Background: The number of older employees in shift and night work has increased significantly in recent years. Furthermore, the proportion of women in shift and night work has increased markedly. This is due to the aging workforce and the expansion of shift work in the tertiary sector. Previous research shows that shift work is often associated with health risks. Against this background, the aim of the present study is to examine the situation of working men and women on the threshold to higher working age with regard to the relationship between shift work and physical health. Methods: We employed data from the study "lidA - leben in der Arbeit" German Cohort Study on Work, Age and Health, a survey of the German baby boom cohorts born in 1959 and 1965 (n=5 637). Linear regression models are used to study the effect of shift work - with and without night work - and of further work exposures on the baby boomers' physical health status. The models control for sleep and health-related behaviour and are stratified by gender. Among women, also the scope of work was taken into account. Results: The results show that male shift workers are burdened by their on average lower occupational status and by physical exposure; female shift workers additionally suffer from high personal effort and low rewards and female part-time shift workers also from overcommitment. Conclusion: Working conditions of shift workers are strongly characterised by work stress. In order to preserve aging shift workers' work ability, some organisational measures seem necessary. In this context, occupational safety and health management as well as opportunities for recovery and encouraging leadership should be considered.

Mesh versus acellular dermal matrix in immediate implant-based breast reconstruction - A prospective randomized trial

BACKGROUND

Comparative studies on the use of meshes and acellular dermal matrices (ADM) in implant-based breast reconstruction (IBBR) have not yet been performed.

METHODS

This prospective, randomized, controlled, multicenter pilot study was performed at four Austrian breast cancer centers. Fifty patients with oncologic or prophylactic indication for mastectomy and IBBR were randomized to immediate IBBR with either an ADM (Protexa(®)) or a titanized mesh (TiLOOP(®) Bra). Complications, failed reconstruction, cosmetic outcome, patients' quality of life and the thickness of the overlying tissue were recorded immediately postoperatively and 3 and 6 months after surgery.

RESULTS

48 patients participated in the study (Protexa(®) group: 23; TiLOOP(®) Bra group: 25 patients). The overall complication rate was 31.25% with similar rates in both groups (Protexa(®) group: 9 versus TiLOOP(®) Bra group: 6; p = 0.188). There was a higher incidence of severe complications leading to failed reconstructions with implant loss in the Protexa(®) group than in the TiLOOP(®) Bra group (7 versus 2; p < 0.0001). An inverted T-incision technique led to significantly more complications and reconstructive failure with Protexa(®) (p = 0.037, p = 0.012, respectively). There were no significant differences in patients' satisfaction with cosmetic results (p = 0.632), but surgeons and external specialists graded significantly better outcomes with TiLOOP(®) Bra (p = 0.034, p = 0.032).

CONCLUSION

This pilot study showed use of TiLOOP(®) Bra or Protexa(®) in IBBR is feasible leading to good cosmetic outcomes and high patient satisfaction. To validate the higher failure rates in the Protexa(®) group, data from a larger trial are required. NCT02562170.

The "egg-egg" syndrome: occupational respiratory allergy to airborne egg proteins with consecutive ingestive egg allergy in the bakery and confectionery industry

Allergies to various inhalative allergens are a serious problem in the bakery and confectionery industry. Sensitization to wheat flour and enzymes such as alpha-amylase are a frequent cause of occupational asthma. Airborne egg allergens have been reported as another cause of respiratory allergy. We examined bakery and confectionery workers with respiratory symptoms due to egg aerosols. Skin tests (SPT), scratch tests (ST), nasal provocation tests (NPT) and serological examinations (IgE) were performed. Lung function was assessed by spirometry, and continuous registration of aerosols and particulates as well as gravimetric sampling was done at the workplace. Four bakery and two confectionery workers intensively exposed to airborne egg proteins suffered from conjunctivitis and rhinitis, four also from asthma. Subsequently, three of these four workers reported symptoms after ingestion of food that contained egg. SPT with commercial egg white and egg yolk extracts were negative in four cases. Only two employees had clearly positive SPT to commercial egg allergens and reacted also to wheat flour extracts. Scratch tests with native egg proteins were positive in four employees. Specific IgE to egg white and egg yolk were positive (CAP > or = 2) in three and in four cases, respectively, whereas they were negative in two cases. Elevated levels of specific IgE to lysozyme were detected in four employees. Two workers were sensitized to lysozyme but not to other egg proteins. The clinical relevance of egg sensitization was confirmed by continuous air sampling and by correlating the onset of the respiratory symptoms which were reflected by a significant decline (> or = 30%) of the forced one second capacity (FEV1) in two workers. Sieving of egg white powder and an inadequate spray station for liquid eggs were identified as sources of excessive allergen exposure. Bakery and confectionery workers exposed to airborne egg proteins are at risk of developing occupational asthma and subsequent nutritive egg allergy. To our knowledge, these are the first cases of inhalative egg allergy and subsequent nutritive egg allergy reported in the literature, which we refer to as the "egg-egg syndrome" in analogy to the already known "bird-egg" and "egg-bird" syndromes.

[Rehabilitation of cystic fibrosis in adulthood]

By the example of 2 adult patients with cystic fibrosis (CF) problems of pulmonary manifestation of CF and its complications are discussed. In both patients disease manifested late. Life expectancy of CF-patients has markedly increased over the last decades. In the adult distinct complications appear more often such as exacerbation of bronchitis due to pseudomonas aeruginosa, colonisation of air ways by Burkholderia cepacia or by atypical mycobacteria, development of allergic bronchopulmonary aspergillosis, bronchiectases and spontaneous pneumothorax. Today, even in adults with chronic bronchitis of unknown origin the possibility of CF has to be considered. Optimized treatment under clinical conditions, in combination with a physical training program and a diet rich in calories will ameliorate subjective physical performance as well as objective pulmonary function and work capacity. Regular rehabilitation programs contribute to better compliance. In patients with CF direct transition from pediatric to pneumologic/internistic treatment for adults is mandatory in order to optimize expectancy and quality of life.

Pulmonary oedema and hypotension induced by hydrochlorothiazide

We present the case of a patient with acute onset of dyspnoea after a long-distance flight. Pulmonary embolism was suspected, but could be excluded by perfusion scintigraphy. The electrocardiogram and chest X-ray were compatible with acute myocardial infarction and pulmonary oedema, but the slightness of the elevation of pulmonary capillary wedge pressure allowed cardiogenic pulmonary oedema to be excluded. The clinical picture was then interpreted as pneumonia with sepsis and hypotension. The rapid and full clinical recovery within 48 h, together with the close temporal relationship of ingestion of hydrochlorothiazide and the onset of symptoms, allowed the diagnosis of drug-induced pulmonary oedema and anaphylactoid hypotension.

Specific serum immunopatterns in clinical phases of allergic bronchopulmonary aspergillosis

Immunoblotting, radioallergosorbent test (RAST), and enzyme-linked immunosorbent assay (ELISA) were performed to determine specific IgE and IgG responses to Aspergillus fumigatus (Af) allergens (IgE-Af; IgG-Af). Serology results were compared in patients with allergic bronchopulmonary aspergillosis (ABPA) (n = 43), patients with Aspergillus fumigatus-associated asthma (Af-asthma) (n = 26), and healthy individuals (n = 3). In patients with different clinical phases of ABPA, three specific immunopatterns were found by immunoblotting. It is proposed to classify ABPA into the active, intermediate, and remission phase with respect to the specific immunoresponse to Af-allergens and asthma symptoms. First, the active phase of ABPA is characterized by a fully developed specific immunoresponse to Af-allergens and severe asthma. Second, the intermediate phase includes patients with elevated specific immunologic findings without asthma symptoms. Third, the remission phase is characterized by a weak specific immunoresponse to Af-allergens after a long-term asymptomatic period. No correlation occurred between specific immunopatterns and irreversible brochopulmonary lesions. The IgE-Af RAST and IgG-Af ELISA titers of patients with ABPA in the active and intermediate phase were significantly higher compared with patients with ABPA in remission phase and with patients with Af-asthma. In particular, the demonstration of positive IgG-Af ELISA titer generally allows the serologic discrimination of patients with asthma and ABPA from patients with Af-asthma in clinical practice. The present study revealed that immunoblots of most patients with Af-asthma were negative. Immunoblotting demonstrated an IgG reactivity exclusively to low molecular weight (MW) Af-allergens in 8 out of 26 patients with Af-asthma and in the three healthy individuals, and this IgG response may reflect naturally occurring antibodies.