Patient-Reported Outcomes in Patients Undergoing Lumpectomy With and Without Defect Closure

BACKGROUND

The effect of lumpectomy defect repair (a level 1 oncoplastic technique) on patient-reported breast satisfaction among patients undergoing lumpectomy has not yet been investigated.

METHODS

Patients undergoing lumpectomy at our institution between 2018 and 2020 with or without repair of their lumpectomy defect during index operation, comprised our study population. The BREAST-Q quality-of-life questionnaire was administered preoperatively, and at 6 months, 1 year, and 2 years postoperatively. Satisfaction and quality-of-life domains were compared between those who did and did not have closure of their lumpectomy defect, and compared with surgeon-reported outcomes.

RESULTS

A total of 487 patients met eligibility criteria, 206 (42%) had their partial mastectomy defect repaired by glandular displacement. Median breast volume, as calculated from the mammogram, was smaller in patients undergoing defect closure (826 cm3 vs. 895 cm3, p = 0.006). There were no statistically significant differences in satisfaction with breasts (SABTR), physical well-being of the chest (PWB-CHEST), or psychosocial well-being (PsychWB) scores between the two cohorts at any time point. While patients undergoing defect closure had significantly higher sexual well-being (SexWB) scores compared with no closure (66 vs. 59, p = 0.021), there were no predictors of improvement in SexWB scores over time on multivariable analysis. Patients' self-reported scores positively correlated with physician-reported outcomes.

CONCLUSIONS

Despite a larger lumpectomy-to-breast volume ratio among patients undergoing defect repair, satisfaction was equivalent among those whose defects were or were not repaired at 2 years postsurgery. Defect repair was associated with clinically relevant improvement in patient-reported sexual well-being.

Modified oncoplastic lift, lymphatic excision, and reconstruction: Introduction of a novel technique in oncoplastic breast surgery with simple surgical principles

INTRODUCTION

Oncoplastic surgery is an important component of the management of breast cancer. As prognosis has improved, the need for proficient techniques to achieve disease eradication while maintaining cosmesis for naturally appearing breasts has gained importance. This study describes an easy-to-learn modified oncoplastic technique for patients undergoing breast-conserving treatment.

DESCRIPTION OF THE TECHNIQUE

Tumor resection is performed through different peri-areolar, inframammary, or radial incisions. To reduce the size of the surgical defect created after tissue resection, an internal purse-string is performed parallel to the chest wall or base of the wound with subsequent staggering in three or more layers as needed, while maintaining the parallel orientation of the needle. This is followed by the creation and overlapping of internal breast tissue flaps that are rearranged to decrease the dead space with the aim of improving cosmesis. The redundant skin is removed for the skin envelope to maintain shape. The wound is closed in layers. We also describe steps in performing sentinel lymph node and tumor extraction through the same periareolar, inframammary, or radial incisions for tumors located in outer quadrants. Following closure, contour and projection of the breast were maintained without indentation or loss of projection, with a symmetrical appearance to the contralateral side.

CONCLUSION

This simplified oncoplastic (MOLLER) technique can be easily learned and used by surgeons who treat cancer patients and have limited oncoplastic training. It uses basic known surgical principles to decrease the size of the defect created while minimizing the need for larger incisions/pedicles.

Breast Tissue Reconstruction Using Polycaprolactone Ball Scaffolds in a Partial Mastectomy Pig Model

BACKGROUND

Breast cancer patients suffer from lowered quality of life (QoL) after surgery. Breast conservancy surgery (BCS) such as partial mastectomy is being practiced and studied as an alternative to solve this problem. This study confirmed breast tissue reconstruction in a pig model by fabricating a 3-dimensional (3D) printed Polycaprolactone spherical scaffold (PCL ball) to fit the tissue resected after partial mastectomy.

METHODS

A 3D printed Polycaprolactone spherical scaffold with a structure that can help adipose tissue regeneration was produced using computer-aided design (CAD). A physical property test was conducted for optimization. In order to enhance biocompatibility, collagen coating was applied and a comparative study was conducted for 3 months in a partial mastectomy pig model.

RESULTS

In order to identify adipose tissue and fibroglandular tissue, which mainly constitute breast tissue, the degree of adipose tissue and collagen regeneration was confirmed in a pig model after 3 months. As a result, it was confirmed that a lot of adipose tissue was regenerated in the PCL ball, whereas more collagen was regenerated in the collagen-coated Polycaprolactone spherical scaffold (PCL-COL ball). In addition, as a result of confirming the expression levels of TNF-a and IL-6, it was confirmed that PCL ball showed higher levels than PCL-COL ball.

CONCLUSION

Through this study, we were able to confirm the regeneration of adipose tissue through a 3-dimensional structure in a pig model. Studies were conducted on medium and large-sized animal models for the final purpose of clinical use and reconstruction of human breast tissue, and the possibility was confirmed.

Modern Approaches to Oncoplastic Surgical Treatment

Partial breast reconstruction using oncoplastic techniques is performed at the time of lumpectomy and includes volume replacement techniques such as flaps and volume displacement techniques such as reduction and mastopexy. These techniques are used to preserve breast shape, contour, size, symmetry, inframammary fold position, and position of the nipple-areolar complex. Newer techniques such as auto-augmentation flaps and perforator flaps continue to broaden options and newer radiation therapy protocols will hopefully reduce side effects. Options for the oncoplastic approach now include higher risk patients as there is a larger repository of data on the safety and efficacy of this technique.

Single Versus Dual Surgeon Approaches to Oncoplastic Surgery: A Comparison of Outcomes

INTRODUCTION

Oncoplastic surgery (OPS) is traditionally performed using a dual surgeon (DS) approach that involves both a breast surgeon and a plastic surgeon. It is also performed using a single surgeon (SS) approach with a surgeon trained in both breast surgical oncology and plastic surgery. We sought to determine if outcomes differed between SS versus DS OPS approaches.

METHODS

A retrospective chart review was conducted of all OPS performed in a single health system over a 6-y period by either an SS or a DS approach. Primary outcomes were rates of positive margins and the overall complication rate; secondary outcomes were loco-regional recurrence, disease-free survival, and overall survival.

RESULTS

A total of 217 patients were identified; 117 were SS cases and 100 were DS cases. Baseline preoperative patient characteristics were similar between the two groups as there was no difference in mean Charlson Comorbidity Index scores (P = 0.07). There was no difference in tumor stage (P = 0.09) or nodal status (P = 0.31). Rates of positive margins were not significantly different (10.9% (SS) versus 9% (DS); P = 0.81), nor were rates of complications (11.1% (SS) versus 15% (DS); P = 0.42). Rates of locoregional recurrence were also not significantly different (1.7% (SS) versus 0% (DS); P = 0.5). Disease-free survival and overall survival were not significantly different at 1-y, 3-y, and 5-y time points (P = 0.20 and P = 0.23, respectively) although follow-up time was not sufficient for definitive analysis regarding survival.

CONCLUSIONS

Both SS and DS approaches to OPS have similar outcomes with regards to positive margin rates and surgical complication rates and are comparably safe.

Prognosis stratification and postoperative radiation therapy utilization in adenoid cystic carcinoma of the breast

PURPOSE

Adenoid cystic carcinoma of the breast (ACCB) is a rare malignancy with a favorable prognosis. Little information exists regarding the impact of postoperative radiation therapy (RT) on survival outcome in patients with ACCB. This study aimed to evaluate the clinical significance of postoperative RT in ACCB.

METHODS

Data of patients with ACCB were extracted from the Surveillance, Epidemiology, and End Results database (2000-2019). Univariate and multivariable Cox regression analyses were performed to identify prognostic factors. In addition, a nomogram model was constructed and internally validated for discrimination and calibration. The value of postoperative RT was respectively accessed in each risk subgroup according to nomogram-deduced individualized score.

RESULTS

A total of 689 eligible patients were included in the analysis. Partial mastectomy was associated with an increased risk of death compared with partial mastectomy plus postoperative RT (P = 0.020), but total mastectomy with or without postoperative RT was comparable (P = 0.624). Then, in-depth analysis was performed for patients receiving breast-conserving therapy (n = 485, the training set vs. the testing set = 340 vs. 145). Age at diagnosis, histological grade, and T stage were identified as prognostic factors for overall survival (OS) (All P < 0.05). A nomogram was constructed to provide predictive accuracy toward individual OS rates of ACCB and to divide patients into different risk subgroups. Notably, compared with non-RT, postoperative RT significantly improved OS in the high-risk subgroup (P = 0.006 for the training set, and P = 0.013 for the overall population) but not in the low-risk subgroup (P = 0.807 for the training set, and P = 0.293 for the overall population), suggesting that these patients may be able to exempt from postoperative RT.

CONCLUSION

A robust and effective nomogram was developed to predict prognosis and assist in treatment decisions in patients with ACCB undergoing partial mastectomy.

Useful vertical latissimus dorsi flap for partial breast reconstruction in every tumor location

Background

We conducted a prospective cohort study to evaluate effective techniques for breast reconstruction after partial mastectomy due to breast cancer. Determining the method of reconstruction is often difficult as it depends on the location of the cancer and the amount of tissue excised.. Here, we present a new technique, using the vertical latissimus dorsi (LD) flap, that can be used in all partial mastectomies and can almost conceal scarring. We also compared these results to those of the mini LD flap.

Methods

We analyzed the data of a total of 50 and 47 patients, who underwent breast reconstruction with the mini LD flap and the vertical LD flap, respectively. Immediately after tumor excision, breast reconstruction was initiated. The skin flap for vertical LD was designed in a planarian shape, such that it may be hidden as much as possible and minimize bulging during closure, and the LD muscle flap was designed with a sufficient distance in the inferior direction.

Results

Our finding showed that the vertical LD flap group required significantly less total operation time than the mini LD flap group. While the mini-LD flap resulted in a scar that was difficult to conceal, the donor site scar of the vertical LD flap could not be seen easily, and no scar was visible on the back.

Conclusions

The vertical LD flap is useful for partial breast reconstruction, in all breast regions requires a rather small volume of the flap. Moreover, recovery was relatively fast with high patient satisfaction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01741-6.

The PROCEM study protocol: Added value of preoperative contrast-enhanced mammography in staging of malignant breast lesions - a prospective randomized multicenter study

BACKGROUND

Correct preoperative estimation of the malignant extent is crucial for optimal planning of breast cancer surgery. The sensitivity of mammography is lower in dense breasts, and additional imaging techniques are sometimes warranted. Contrast-enhanced mammography (CEM) has shown similar sensitivity and in some cases better specificity, than magnetic resonance imaging (MRI) in small, observational studies. CEM may be more cost-effective than MRI, and may provide better identification of the tumor extent, however, no randomized trials have been performed to date to investigate the added value of CEM. In a feasibility study, we found that the treatment was changed in 10/47 (21%) cases after additional CEM. The purpose of the present study is to evaluate the added value of CEM in preoperative staging of breast cancer in a randomized study.

METHOD

This prospective randomized study will include 440 patients with strongly suspected or established diagnosis of breast malignancy, based on assessment with mammography, ultrasound and core biopsy/cytology, and for whom primary surgery is planned. Patients will be randomized 1:1 using a web-based randomization tool to additional investigation with CEM or no further imaging. The CEM findings will be taken into consideration, which may lead to changes in primary treatment, which is the primary endpoint of this study. Secondary endpoints include rate of reoperation and number of avoidable mastectomies, as well as a cost-benefit analysis of additional CEM. Patient-reported health-related quality of life will be investigated at 1 year with the validated Breast-Q™ questionnaire. The rate of local recurrence or new cancer ipsi- or contralaterally within 5 years will be assessed from medical records and pathology reports.

DISCUSSION

The aim of this trial is to explore the added value of CEM in preoperative staging of breast cancer. The results obtained from this study will contribute to our knowledge on CEM as an additional imaging method to standard investigation with digital mammography and ultrasound. The findings may also provide additional information on which patient groups would benefit from CEM, and on the economic aspects of CEM in standard preoperative practice.

TRIAL REGISTRATION

This trial is registered at clinicaltrials.gov , registration no: NCT04437602 , date of registration: June 18, 2020.

Prognostic factors for residual occult disease in shave margins during partial mastectomy

PURPOSE

Shave margins have been shown to decrease positive final margins in partial mastectomy. We investigated prognostic factors associated with residual disease in shave margins.

METHODS

Patients with invasive breast carcinoma and ductal carcinoma in situ (DCIS) who had circumferential shave margins excised during lumpectomy were abstracted from a retrospective database from 2015 to 2018. We defined residual occult disease (ROD) as either (1) residual disease in a shave margin when the initial lumpectomy specimen had negative margins or (2) residual disease in a shave margin that did not correspond with the positive lumpectomy margin. We identified the frequency of ROD and conducted logistic regression analysis to identify associated prognostic factors.

RESULTS

166 Patients (139 invasive carcinoma, 27 DCIS) were included with median follow-up of 28 months (9-50 months). Residual occult disease existed in 34 (24.5%) with invasive carcinoma and 8 (29.6%) with DCIS. In univariate analyses of the invasive group, invasive lobular carcinoma and a positive initial, non-corresponding lumpectomy margin were predictive of ROD (OR 3.63, p = 0.04, OR 3.48, p = 0.003 respectively). In multivariate analysis, a positive lumpectomy margin remained significant, p = 0.007. No variables were associated with ROD in DCIS.

CONCLUSION

Residual occult disease was shown to be a frequent event in this analysis of lumpectomy with circumferential shave margins. Having a positive initial lumpectomy margin was predictive of ROD in a non-corresponding margin. Surgeons should consider not being selective in their shave margins or margin of re-excision if shave margins were not obtained in their initial surgery.

Thirty-day postoperative morbidity in patients with breast cancer following neoadjuvant chemotherapy

BACKGROUND

Early post-operative complications for patients having partial and total mastectomies after neoadjuvant chemotherapy have not been well defined. The objective was to compare post-operative complication rates among patients treated with partial mastectomy (PM), unilateral mastectomy (UM), and bilateral mastectomy (BM) after NAC.

STUDY DESIGN

398 patients with breast cancer who had NAC from 2008 to 2016 were identified from a prospectively maintained database. The primary outcome measure was 30-day post-operative morbidity.

RESULTS

125 patients (31.4%) underwent PM, 107 patients (26.9%) UM, and 166 (41.7%) BM. There was no significant difference among the 3 groups with respect to histology (ductal: 96.0% PM, 88.8% UM, 92.6% BM, p = 0.161). Groups were similar with respect to estrogen receptor positivity (overall 58.8%, p = 0.331) and triple negative biomarker status (overall 23.9%, p = 0.559). The PM group had a higher rate of HER2 positive disease (n = 58, 47.5%, p = 0.012). Patients who underwent PM had a lower clinical T Stage at presentation (p=<0.001), fewer axillary lymph node dissections (n = 32, 25.6%, p=<0.001), and a higher rate of pathologic complete response (n = 48, 38.4%, p = 0.037) compared with patients who underwent mastectomies. Overall, 52 patients (13.1%) had a complication within the 30 day post-operative period. 30-day complication rates were significantly higher in the BM group compared to the PM group: 6.4% (n = 8) for PM, 12.2% (n = 13) for UM, and 18.7% (n = 31) for BM, (p = 0.008). 30-day readmission rates were significantly higher in the BM group compared to the PM group (overall 4.5%; 0.8% PM, 2.8% UM, 8.4% BM, p = 0.004).

CONCLUSION

Bilateral mastectomy is associated with higher rates of 30-day morbidity and re-admissions compared to partial mastectomy, but not unilateral mastectomy in patients who received neoadjuvant chemotherapy.

Breast reconstruction after breast conservation therapy for breast cancer

Conservative breast surgery followed by irradiation, often referred to as Breast conserving therapy (BCT), has replaced modified radical mastectomy for the treatment of early stage invasive breast cancer and ductal carcinoma in situ (DCIS). About 10% to 40% of the patients treated with BCT have poor cosmetic outcome results. Small tumours in large breasts can be successfully treated by lumpectomy and radiotherapy, with good cosmetic outcome. However when the tumour breast ratio is higher, the cosmetic outcome can be very disappointing. A surgical conflict arises between optimal oncologic resection and the desire to spare as much tissue as possible to minimize the risk of deformities. In case of a small defect lipofilling can be performed. This technique transplants fat grafts from a donor site to the defect in the breast. In case of larger defects there is the option of oncoplastic surgery. Oncoplastic techniques combine the optimal oncological resection with an adequate reconstruction for optimal cosmetic outcome. Oncoplastic techniques allow the breast surgeon to perform a tumour resection with adequate margins and the plastic surgeon will reconstruct the defect during the same procedure for optimal cosmetic outcome. The use of oncoplastic techniques to reconstruct defects of partial mastectomies (BCT) can be immediate, delayed or immediate delayed. Current breast cancer treatment leads to long-term surivival. It it there for important not only to survive but also life. Therefore the quality of life and good cosmetic outcome is mandatory after breast cancer treatment. Oncoplastic surgery is based on two techniques: volume displacement and volume replacement. The volume displacement techniques use (dermo)glandular flaps of the breast to fill the resection defect. Volume displacement techniques ideally work when the tumour resection can be incorporated in a breast reduction pattern. A similar technique is used on the contralateral breast to match size and shape. The volume replacement techniques use autologous non-breast tissues to compensate the volume loss after tumour resection. Volume replacement techniques are used when a large resection volume is needed in a small breast. Depending on the location and size of the defect many different flaps can be used for partial breast reconstruction.

Reoperations after primary breast conserving surgery in women with invasive breast cancer in Catalonia, Spain: a retrospective study

BACKGROUND

Although complete tumor resection is accepted as the best means to reduce recurrence, reoperations after lumpectomy are a common problem in breast cancer. The aim of this study was to assess the reoperation rates after primary breast conserving surgery in invasive breast cancer cases diagnosed in Catalonia, Spain, between 2005 and 2011 and to identify variations based on patient and tumour characteristics.

METHODS

Women with invasive incident breast cancer identified from the Patient's Hospital Discharge Database [174.0-174.9 codes of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) as the primary diagnosis] and receiving primary breast conserving surgery were included in the study and were followed up to 3 and 12 months by collecting information about repeat breast cancer surgery.

RESULTS

Reoperation rates after primary breast conserving surgery decreased from 13.0 % in 2005 to 11.7 % in 2011 at 3 months and from 14.2 % in 2005 to 12.9 % in 2011 at 12 months' follow-up. While breast conservation reoperations saw a slight, non-significant increase in the same period (from 5.7 to 7.3 % at 3 months, and from 6.0 to 7.5 % at 12 months), there was a significant decrease in radical reoperation (from 7.3 to 4.4 % at 3 months and from 8.2 to 5.4 % at 12 months). Overall, additional breast surgeries decreased among younger women.

CONCLUSIONS

Despite the rise of breast conserving surgery, reoperation rates following initial lumpectomy in Catalonia decreased by 10 % at 3 and 12 months' follow-up, remaining low and almost unchanged. Ultimately, there was also a significant decrease in mastectomies.

Surgical margin reporting in breast conserving surgery: Does compliance with guidelines affect re-excision and mastectomy rates?

PURPOSE

Margin status is important in guiding decisions to re-excise following breast-conserving surgery (BCS) for breast cancer. The College of American Pathologists (CAP) developed guidelines to standardize pathology reporting; however, compliance with margin documentation guidelines has been shown to vary. The aim of this retrospective study was to determine whether compliance with CAP guidelines affects re-excision and mastectomy rates.

METHODS

We identified 1423 patients diagnosed with breast cancer between 1998 and 2006 who underwent BCS with negative margins. CAP compliance was categorized as maximal, minimal, or non-compliant. Statistical analyses were performed comparing the frequency of re-excision and mastectomy after initial BCS according to CAP margin reporting guideline compliance. Data were adjusted for provider facility by including a clustering variable within the regression model.

RESULTS

Patients with non-compliant margin reporting were 1.7 times more likely to undergo re-excision and/or mastectomy than those with maximally compliant reporting. Level of compliance was most strongly associated with the frequency of mastectomy; non-compliant margin reporting was associated with a 2.5-fold increase in mastectomy rates compared to maximally compliant reporting. The results did not substantially change when the analyses accounted for clustering at the provider facility level.

CONCLUSIONS

Our findings suggest that compliance with CAP guidelines in pathology reporting may be associated with variation in re-excision and mastectomy rates following BCS.

[Breastfeeding after breast surgery: patient information]

OBJECTIVES

Partial mastectomy, augmentation and reduction mammaplasty are often operated on women who are not yet bothered by breastfeeding. The objectives of this study were to evaluate the information given to patients before surgery, and describe difficulties that mothers confront when starting breastfeeding in order to create a reference document about breastfeeding to inform patients who will undergo such surgery in the future.

MATERIAL AND METHODS

We led one first study to evaluate the surgeons' practice in the Reunion Island and a second retrospective and descriptive study upon patients.

RESULTS

We encountered the fact that few patients in childbearing age ask for information about breastfeeding before undergoing surgery, but surgeons do not systematically give such information either, even less before partial mastectomy. The impact of surgery on breastfeeding depends on the type of intervention and the surgical technique. Even though breastfeeding is possible, the mean period of breastfeeding after surgery is shorter and the most frequent difficulty encountered is lactation insufficiency, even more after reduction mammaplasty, periareolar incision, and nipple hypoesthesia after surgery.

DISCUSSION AND CONCLUSION

The information document that we tried to establish concerning breastfeeding after partial mastectomy, augmentation and reduction mammaplasty, may compensate patients' lack of information and sums up all the complications described in our study and in the literature.

Current aspects of therapeutic reduction mammaplasty for immediate early breast cancer management: An update

Breast-conservation surgery (BCS) is established as a safe surgical treatment for most patients with early breast cancer. Recently, advances in oncoplastic techniques are capable of preserving the breast form and quality of life. Although most BCS defects can be managed with primary closure, the aesthetic outcome may be unpredictable. Among technical options, therapeutic reduction mammaplasty (TRM) remains a useful procedure since the BCS defect can be repaired and the preoperative appearance can be improved, resulting in more proportional breasts. As a consequence of rich breast tissue vascularization, the greater part of reduction techniques have based their planning on preserving the pedicle of the nipple-areola complex after tumor removal. Reliable circulation and improvement of a conical shape to the breast are commonly described in TRM reconstructions. With an immediate approach, the surgical process is smooth since both procedures can be carried out in one operative setting. Additionally, it permits wider excision of the tumor, with a superior mean volume of the specimen and potentially reduces the incidence of margin involvement. Regardless of the fact that there is no consensus concerning the best TRM technique, the criteria is determined by the surgeon’s experience, the extent/location of glandular tissue resection and the size of the defect in relation to the size of the remaining breast. The main advantages of the technique utilized should include reproducibility, low interference with the oncological treatment and long-term results. The success of the procedure depends on patient selection, coordinated planning and careful intra-operative management.