Bilateral Breast Surgery Research Articles

Paravertebral versus Pectoralis-II (Interpectoral and Pectoserratus) Nerve Blocks for Postoperative Analgesia after Nonmastectomy Breast Surgery: A Randomized, Controlled, Observer-masked Noninferiority Trial.

Pectoralis-II and paravertebral nerve blocks are both used to treat pain after breast surgery. Most previous studies involving mastectomy identified little difference of significance between the two approaches. Whether this is also accurate for nonmastectomy procedures remains unknown. Participants undergoing uni- or bilateral nonmastectomy breast surgery anticipated to have at least moderate postoperative pain were randomized to a pectoralis-II or paravertebral block (90 mg ropivacaine per side for both). Surgeons and recovery room staff were masked to treatment group assignment, and participants were not informed of their treatment group. Injectate for pectoralis-II blocks was ropivacaine 0.3% (30 ml) per side. Injectate for paravertebral blocks was ropivacaine 0.5% (9 ml in each of two levels) per side. This study hypothesized that pectoralis-II blocks would have noninferior analgesia (numeric rating scale) and noninferior cumulative opioid consumption within the operating and recovery rooms combined (dual primary outcomes). The study was adequately powered with n = 100, but the target enrollment was raised to n = 150 to account for higher-than-anticipated variability. The trial was ended prematurely with 119 (79%) of the original target of 150 participants enrolled due to (masked) surgeon preference. Within the recovery room, pain scores were higher in participants with pectoralis-II (n = 60) than paravertebral blocks (n = 59): median [interquartile range], 3.3 [2.3, 4.8] versus 1.3 [0, 3.6] (95% CI, 0.5 to 2.6; P < 0.001). Similarly, intravenous morphine equivalents were higher in the pectoralis-II group: 17.5 [12.5, 21.9] versus 10.0 mg [10, 20] (95% CI, 0.1 to 7.5; P = 0.004). No block-related adverse events were identified in either group. After nonmastectomy breast surgery, two-level paravertebral blocks provided superior analgesia and opioid sparing compared with pectoralis-II blocks. This is a contrary finding to the majority of studies in patients having mastectomy, in which little significant difference was identified between the two types of blocks.

Tension Reduction With Force Modulating Tissue Bridges Reduces Wounds in Breast Surgery.

Tension on healing wounds increases the risk of dehiscence and poor or pathologic scar formation. Force modulating tissue bridges (FMTBs) represent a new class of wound closure and support devices designed to offload tension on healing wounds to improve wound healing and scar outcomes. The study was undertaken to assess the efficacy of FMTBs to reduce the risk of wound healing complications in elective breast surgery. One hundred twenty-two consecutive patients undergoing bilateral aesthetic breast surgery underwent intraoperative placement of FMTBs on the vertical limb closure site. A matched case-control cohort of 121 consecutive patients was established for comparison. Wounds were considered significant if larger than 3 mm in diameter. The primary outcome of breast wounds >3 mm was reported with a relative risk, and all outcomes were framed with number needed to treat. The control and intervention cohorts had similar demographics, comorbidities, type of operation, and incision pattern utilized. Within the FMTB group, 96.7% (n = 118) patients completed treatment per protocol. Significant wounds occurred in 1.7% (n = 2) of patients in the tissue bridge vs 15.2% (n = 19) in controls on a per patient/per protocol basis (89% reduction, P < .001). Statistically significant improvements were maintained on sensitivity analyses with intention to treat, even when minor wounds were included. There were no complications noted related to FMTBs. FMTBs are safe and highly effective at reducing the risk of wound formation in elective breast surgery. Results are consistent with sensitivity analyses based on clinical and methodological factors. Further research will assess long-term scar outcomes.

Patient and procedure characteristics associated with postoperative pain after prophylactic versus therapeutic ambulatory bilateral breast surgery.

We investigated whether age, body mass index (BMI), and tissue expander placement were related to postoperative opioid requirement for patients undergoing therapeutic versus prophylactic breast surgery. Postoperative opioid consumption was evaluated for patients who underwent bilateral mastectomy with immediate implant-based reconstruction at a freestanding ambulatory cancer surgery center between 2016 and 2021. Ordinal regression tested whether surgical indication was associated with increased postoperative opioid requirements after adjusting for age, BMI, and tissue expander placement. Of 2447 patients, 6% underwent prophylactic surgeries. Therapeutic mastectomy patients had lower postoperative opioid requirement (OR = 0.67; 95% CI: 0.50-0.91; p = 0.030), but this was not significant after adjusting for covariates (OR = 0.75; 95% CI: 0.53-1.07; p = 0.2). Opioid use increased with higher BMI (OR = 1.06; 95% CI: 1.05-1.08;p < 0.001) and decreased with age (OR = 0.97; 95% CI: 0.96-0.98; p < 0.001) with therapeutic mastectomy patients being older (median 46 vs. 39). The subpectoral tissue expander group had nearly double the postoperative opioid requirement compared to prepectoral placement (OR = 1.86; 95% CI: 1.55-2.23; p < 0.001). Increased postoperative opioid requirement in women undergoing prophylactic procedures is best explained by age. Mastectomy patients should be counseled similarly about postoperative pain irrespective of indication. A larger prophylactic mastectomy sample is required to provide more precise estimates.

Satisfaction of Patients Who Received Breast-Conserving Surgery Using the Suture Scaffold Technique: A Single-Institution, Cross-Sectional Study.

Optimal cosmetic results after breast-conserving surgery (BCS) improve patient satisfaction. The suture scaffold technique (SST) is a breast reconstruction technique that all breast surgeons can perform without any extensive training in plastic surgery. We aimed to investigate patient satisfaction after BCS and compare blood loss and operative duration between the SST, breast glandular flap technique (BGFT), and no oncoplastic technique (NOT). This was a prospective, single-center, cross-sectional study. All patients who underwent BCS from August 2017 to September 2019 in our institution were included, with the exception of those with cT3 tumors or those who underwent nipple excision or bilateral breast surgery. The BREAST-Q™ was used to survey the patients, and the raw sum scale scores of the BREAST-Q™ were converted into BREAST-Q scores. Overall, we identified 421 eligible patients. The NOT was used in 47 (11.1%) patients, the BGFT was used in 231 (54.8%) patients, and the SST was used in 143 (33.9%) patients. In the univariable model, the BGFT and the SST had higher BREAST-Q scores than the NOT, while in the multivariable model, the SST had significantly higher BREAST-Q scores than the NOT (ß = +7.7, 95% confidence interval [CI] 0.9-13.7; p = 0.01). Blood loss was significantly less with the SST compared with the BGFT (ß = -4.4, 95% CI -7.3 to -1.4), and there was no difference in operative duration between the methods. Patient satisfaction with the SST was higher than with the NOT and was similar to the BGFT. The SST is an oncoplastic technique that all breast surgeons can perform and which requires comparable blood loss and operative duration in the NOT.

Abstract P3-18-13: A cross-sectional study to investigate association between oncoplastic techniques and patient satisfaction who received breast-conserving surgery

Abstract Background The suture scaffold technique (SST) is one of the oncoplastic techniques used for breast-conserving surgery (BCS), first reported in 2010. There is no report about the cosmetic outcome of SST, so we investigated SST patient satisfaction compared with other techniques. Method We started using the SST in August 2017. The SST requires the construction of scaffolds by using non-absorbable strings in the defect during BCS. The strings are pulled together and tied as close as possible without dimpling the skin from the superior to the inferior direction and medial to the defect's lateral direction. After approval by our institutional ethics committee in September 2020, we started a patient survey using the BREAST-QTM-BCT module (postoperative) version 2.0. We included the patients who received BCS from August 2017 to September 2019, except for cT3, patients who received nipple excision or bilateral breast surgery at our institution. The raw sum scale scores of BREAST-QTM were converted into one score that ranges from 0 (worst) to 100 (best). A score of 4 points is considered to be of minimal importance in breast reconstructive surgery. We utilized a multivariable linear regression model to identify the clinical factors associated with the score. The confounding variables included age, density of the breast, nipple-tumor distance, size of the tumor, location of the tumor, number of lymph nodes dissected, blood loss, and operative duration. Result We identified 437 eligible patients during the study period. Among them, 49 (11.7%) patients received no oncoplastic technique (NOT), 237 (56.8%) patients received mobilization technique of breast tissue (MTB), and 151 (36.2%) patients received SST. SST patients had a higher score than NOT and MTB patients in univariable analysis. In a multivariable model, SST patients had a significantly higher score than NOT (+7.1, 95%CI=0.5-13.0, p=0.03) and an equivalent score to MTB (+1.9, 95%CI=-1.9-5.8, p=0.32) patients. In addition, smaller tumors (+0.13; 95%CI=0.01-0.25) and cases with longer nipple-tumor distance (+1.1; 95%CI=0.24-1.9) showed significantly higher score. Conclusion Among patients who received BCS, the SST patients had higher satisfaction than NOT and equivalent satisfaction to MTB. Additional studies are needed to determine the indications and the limitations of this technique. Table. Multivariate logistic regression analyses for estimating the variables that may affect Rasch score who underwent BCS. Multivariate logistic regression analyses for estimating the variables that may affect Rasch score.Rasch score95% CIp-valueOncoplastic techniqueNOT (49)0 (Reference)BMT (237)5.1-0.7~11.10.08SST (151)7.10.88-13.40.02NTD (cm)1.10.2-1.90.01Size of the tumor (mm)-0.13-0.25~-0.010.02 Citation Format: Reiko Mitsueda, Anri Gen, Yoshitaka Fujiki, Naomi Gondo, Mutsumi Sato, Junko Kawano, Koichi Kuninaka, Shuichi Kanemitsu, Megumi Teraoka, Yoshito Matsuyama, Shinichi Baba, Sugako Nomoto, Robert Sloan, Yoshiaki Rai, Yoshiaki Sagara, Yasuaki Sagara. A cross-sectional study to investigate association between oncoplastic techniques and patient satisfaction who received breast-conserving surgery [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-18-13.

Serratus anterior plane versus paravertebral nerve blocks for postoperative analgesia after non-mastectomy breast surgery: a randomized controlled non-inferiority trial

BackgroundParavertebral and serratus plane blocks are both used to treat pain following breast surgery. However, it remains unknown if the newer serratus block provides comparable analgesia to the decades-old paravertebral...

Erector spinae plane versus paravertebral nerve blocks for postoperative analgesia after breast surgery: a randomized clinical trial

BackgroundParavertebral nerve blocks (PVBs) are frequently used to treat pain during and following breast surgery, but have various undesirable risks such as pneumothorax. The erector spinae plane block (ESPB) also...

50 Shades of Red: The Predictive Value of Closed Suction Drains for the Detection of Postoperative Bleeding in Breast Surgery.

While closed suction drains (CSDs) are still frequently employed in clinical practice, the supporting evidence is limited with some studies demonstrating a failure of routine CSD use in preventing hematoma or seroma. Nonetheless, CSD quantity and quality fluid assessment is still appreciated by clinicians to detect postoperative bleeding. This study investigates the value of routine CSD use, in breast surgery, to predict postoperative bleeding. A retrospective, intra-individual analysis, of CSD fluid volumes between the hematoma side and the unaffected contralateral breast, was undertaken in patients (n = 20) with unilateral postoperative bleeding following bilateral breast surgery (2003-2018). Statistical analysis was undertaken to establish a minimum cutoff fluid volume that might assist in the detection of postoperative bleeding. To determine the usefulness of quality assessment of CSD fluid output by visual inspection, surgeons (n = 56) prospectively matched six eligible hemoglobin concentrations corresponding to pre-filled CSDs. Statistical analysis did not yield a clinically reliable cutoff fluid volume indicating postoperative bleeding. All six eligible hemoglobin concentrations were completely successfully matched to pre-filled CSDs by 30.4% (17/56) of surgeons. This study questions the significance of routine CSD use to assist in the decision-making process to return to the theater and address postoperative bleeding. Quantity as well as quality analysis of CSD fluid output failed the reliability and diagnostic validity tests. Hemoglobin measurements in drain fluid specimens via blood gas analysis might contribute to the detection of postoperative bleeding. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Trapezius Port Placement in Patients with Breast Cancer: Long-Term Follow-up and Quality-of-Life Assessment

PurposeTo evaluate the long-term results of and patient satisfaction with trapezius ports in breast cancer patients, as an alternative to chest ports. Patients and MethodsThis retrospective study included all patients who underwent trapezius port placement from December 2007 to January 2017. Seventy female patients with breast cancer, with a mean age of 54 ± 9.9 years (range, 29–76 years), were included. Indications for trapezius implantation were bilateral breast surgery or unilateral breast surgery and contralateral breast involvement. Sixty-eight of 70 patients had long-term follow-up. A retrospective, questionnaire-based survey was conducted to assess satisfaction and the trapezius port’s effect on the daily life of the patient. ResultsAll implantations were technically successful. Total catheter service time for 68 patients was 65,952 days (2 patients were lost to follow-up). Mean catheter service time was 969.8 days (range 7–3,458 days; median 570 days; 95% confidence interval, 739–1199; standard deviation, 947.7). No immediate procedural complications occurred. Port complications developed in 4 patients (5.9%); port infection developed in 2 patients (0.03/1,000 days); skin dehiscence developed in 1 patient (0.02/1,000 days); and port malfunction developed in 1 patient (0.02/1,000 days). The overall infection rate was 2.9% (2/68). All patients (n = 44) or a close relative (n = 17) who were interviewed with a phone call reported satisfaction regarding their ports. ConclusionsTrapezius ports offer a safe and feasible option to patients with breast cancer who need an alternative site to chest ports. It is also associated with high overall patient satisfaction.

Clinical Evaluation of Hyaluronic Acid Sponge with Zinc versus Placebo for Scar Reduction after Breast Surgery.

Background:Scar formation is a major source of dissatisfaction among patients and surgeons. Individually, hyaluronan, or hyaluronic acid (HA), and zinc have been shown to reduce scarring. The authors evaluated the safety and efficacy of an HA sponge with zinc compared with placebo when applied to bilateral breast surgery scars; specifically, they evaluated whether the use of this product modulates inflammation and immediate scarring in treated patients after bilateral breast surgery.Methods:This double-blind, randomized, prospective study was approved by the local institutional review board. Bilateral breast surgery patients with right and left incision lines were randomly assigned to receive HA sponge with zinc or placebo within 2 to 4 days after their procedure. Participants were followed up at 6 weeks, 12 weeks, and 1 year and evaluated at 12 weeks. Three blinded evaluators reviewed photographs of the incision lines and assessed the scars using a visual analog scale, new scale, and a patient satisfaction survey.Results:Nineteen bilateral breast surgery patients were enrolled in the study. Statistical analysis was performed on 14 patients who completed the follow-up. The mean visual analog scale score was lower for the side receiving the HA sponge with zinc (2.6) than for the side receiving placebo (3.0), indicating a better outcome (t test; P = 0.08). The HA sponge with zinc was found to have significant positive findings on a patient satisfaction survey (P = 0.01).Conclusions:This is a preliminary study that shows zinc hyaluronan was associated with high patient satisfaction in achieving a better scar after bilateral breast surgery, irrespective of skin color. It seems to be safe and effective for early scars.

English

BACKGROUND: Temporomandibular joint (TMJ) ankylosis is associated with partial or complete restriction of mouth opening and poses a significant problem to the anesthesiologist making the airway management very challenging. Alternative methods of securing the airway should be kept ready because conventional laryngoscopy and intubation are impossible. Thoracic epidural anesthesia (TEA) is one of the options to avoid general anesthesia in this case. We aimed to manage a case of bilateral modified radical mastectomy with TMJ ankylosis solely under thoracic epidural anesthesia. METHODOLOGY: Female patient of 32 years of age, with bilateral TMJ ankylosis with no mouth opening was posted for bilateral breast surgery. Thoracic epidural was instituted at T4-T5 interspace and 18G epidural catheters was secured. Alternative airway management strategies were included in our plan if thoracic epidural fails. OBSERVATION: Adequate preparation of the patient, counseling about anesthetic plan of management, placement of epidural catheter by an experienced anesthesiologist helped in the successful management of this case. CONCLUSION: Regional anesthesia techniques are safer alternatives to provide intraoperative anesthesia with difficult airway for bilateral breast surgeries.

Abstract P3-09-12: Effects of acupuncture on rehabilitation after breast cancer surgery - Preliminary results

Abstract Background: The increased incidence of breast cancer and successful treatment result in greater survival of these patients and consequently a greater number of survivors. These patients may have chronic condition of pain in the shoulder and upper limb, including cervical and thoracic spine. This paper seeks, through acupuncture, a new approach in the rehabilitation of these patients. Method: This study was conducted in the Gynecological Department of São Paulo Federal University. The study included women who underwent surgical treatment of breast cancer, radical or conservative, and present pain in the region of the shoulder and upper limb, including cervical and thoracic spine after three months of surgery. Patients older than 18 years and pain level ≥ 3 on the Visual Analog Scale (VAS). We excluded patients with bilateral breast surgery, metastatic disease, vascular disorders and tactile sensitivity, with diabetes mellitus type I and II uncompensated and education level less than four years. The patients were randomly divided into two groups, with 15 patients per group who were treated weekly for 10 weeks, one group treated with kinesiotherapy standard, pre-defined, based on stretching the neck muscles, scapular exercises and upper limb strength lasting 30 minutes and the other group was performed the same protocol described above kinesiotherapy followed by another 30 minutes of Acupuncture using pre-defined points. Acupuncture points used were as follows: CV 3, SP 9, ST 36, KD 7, LV 3 - edema and treat gynecological disorders; VB 21, LI 15, TH 14, LU 5, LI 4, ST 38 and UB 60 - treat pain and difficulty of movement in the upper limb. Patients were evaluated at baseline, after five weeks and at the end of 10 weeks. We used the Visual Analog Scale (VAS) for pain intensity ratings and the DASH questionnaire (Disabilities of the Arm, Shoulder and Hand Questionnaire) assessing functional capacity in diseases of the upper limb, measuring the skills to do certain activities as well as the symptoms. Results: The ANOVA test was used for statistical analysis of pain relief by VAS scale in both groups. Both groups had significant improvement with p&amp;gt; 0.001 and no difference between groups, with p = 0.756. The same analysis of variance was used in the DASH questionnaire, with similar results, both groups improved significantly with p&amp;gt; 0.001 and no difference between groups with p = 0.200. In multiple comparisons all reviews are different from each other showing a gradual improvement. Conclusion: We found that both types of treatment (kinesiotherapy or kinesiotherapy and acupuncture) are effective, and the evolution of the two groups was the same with a gradual improvement. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-09-12.

The Use of Intercostal Nerve Blocks for Implant-Based Breast Surgery

Sir: Postoperative pain following breast surgery has been a significant problem and the subject of extensive research for its prevention and management.1 Over the past two decades, there has been considerable interest in the use of intercostal nerve blocks for the management of pain following breast surgery. However, most studies have focused on oncologic breast surgery,2,3 except for Cooter et al., who showed the use of nerve blocks for breast augmentation procedures.4 A recent meta-analysis by Tahiri et al.5 compared several studies and showed that, in general, the use of intercostal nerve blocks has led to significantly improved postoperative parameters (e.g., analgesic consumption, reduced amounts of nausea and vomiting) and has led to increased patient satisfaction and reduced length of hospital stay. We demonstrate the use of intercostal nerve blocks in 57 consecutive patients undergoing bilateral implant-based breast surgery. After institutional review board approval, data were gathered for all patients undergoing breast surgery with the use of intercostal nerve blocks. Informed consent was obtained from the patients. All blocks and breast procedures were performed by a board-certified anesthesiologist and board-certified plastic and reconstructive surgeon, respectively. After positioning the patient, 2 to 4mg of intravenous midazolam was administered for sedation. Blocks were administered using a 25-gauge ⅝- to 1½-inch needle at the anterolateral chest wall at the midaxillary line, at each level from T2 to T9 bilaterally. Each intercostal nerve was infiltrated with 2ml of a solution containing 0.25% bupivacaine with 1:200,000 epinephrine. A total of 78mg of bupivacaine was administered, and no aspiration of blood or air was noted. Monitored anesthesia care was provided for the duration of the procedure. Fifty-seven patients underwent implant-based nononcologic breast procedures consisting mainly of bilateral augmentation mammaplasty (n = 42), followed by bilateral implant exchange with capsulectomy (n = 11), bilateral augmentation mammaplasty with mastopexy (n = 2), bilateral implant removal with capsulectomy (n = 1), or bilateral augmentation mammaplasty with blepharoplasty (n = 1). All patients were women, with a mean age of 35 years. Mean operative time was 74 minutes and mean time from the conclusion of the operation to discharge was 116 minutes. None of the patients was converted to general anesthesia. There were no complications related to the intercostal nerve blocks or surgery. Intraoperative and postoperative drug use was tabulated (Table 1). All patients received fentanyl and midazolam intraoperatively, and antiemetics. Postoperatively, only 44 percent of patients received intravenous fentanyl, 14 percent received acetaminophen-oxycodone, and 12 percent of patients received antiemetics.Table 1: Intraoperative and Postoperative Drug UseImplant-based nononcologic breast surgery can be safely performed with the use of intercostal nerve blocks without the need for conversion to general anesthesia. The lack of general anesthesia also leads to decreased consumption of postoperative narcotics and antiemetics. Although a limitation of this study is that there was no postdischarge survey of patients’ use of narcotics, all patients were given a prescription for 30 tablets of acetaminophen-oxycodone (325mg/5mg). No refills were requested. DISCLOSURE None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.

Preoperative MRI: Did randomized trials conclude the debate?

Breast cancer remains a worldwide big killer also in countries with a long tradition of screening mammography [1]. Multifocal and multicentric nature of breast cancer has been widely demonstrated with a rate of ipsilateral additional cancers on histology up to 60% [2,3]. The annual risk for metachronous contralateral cancer in women with a previous history of breast cancer is 0.4–0.6% [4]. Breast conserving treatment, if compared with mastectomy, does not reduce survival rate even though it implies a higher incidence of ipsilateral recurrence with an annual rate of 0.5–1.0% [5,6]. Moreover, when conserving surgery is used, positive or close margins at final histology require re-excision up to 20–40% of cases. Bilateral contrast-enhanced breast MRI has been demonstrated to outperform mammography and ultrasonography in evaluating index tumor size as well as in detecting additional ipsilateral and contralateral cancers, showing otherwise undetected multifocal/multicentric disease in up to 20% of cases [7] and an incremental detection rate for contralateral cancers of about 4% [8]. In this scenario, preoperative breast MRI has been advocated for improving surgical planning by a reduction in re-excision rate, reducing in-breast cancer recurrences, and providing a screening tool for clinically unaffected contralateral breasts. While MRI has been demonstrated to prompt more extensive surgery in a not negligible proportion of women, its impact on clinical outcomes has not yet been demonstrated. Plana et al. [9] reported a 12.8% correct change (i.e., histologically confirmed) in surgical management versus a 6.3% inappropriate wider surgery (due to false positives MRI findings) while a 3% conversion to bilateral breast surgery (appropriate in 2.6%), confirming previous meta-analyses [7,8]. Thus, we would face a balanced result for the contralateral breast: about 3–4% of MRI-detected contralateral cancers versus 2–3% cumulative rate of expected contralateral cancers in the first 4–5 years. Conversely, we would have a 11–12% of MRI-induced

Persistent pain, sensory disturbances and functional impairment after adjuvant chemotherapy for breast cancer

Abstract Background Persistent pain after breast cancer treatment (PPBCT) is a considerable clinical problem affecting between 25 and 60% of breast cancer survivors [1]. Several risk factors have been proposed, among them nerve damage caused by adjuvant treatment [2]. Taxanes used in adjuvant therapy for breast cancer are neurotoxic, and thereby being a potential risk factor for PPBCT and sensory disturbances. However, the long term influence of taxanes on PPBCT is not well documented. Thus, the aim of this study was therefore to compare a nationwide cohort treated with cyclophosphamide and epirubicin + docetaxel (CE + T) versus a nationwide cohort treated with cyclophosphamide, epirubicin and fluoruracil (CEF), in order to assess differences in reporting of PPBCT, sensory disturbances in surgical area, symmetric peripheral sensory disturbances, and functional impairment. Methods A comparative nationwide cross-sectional questionnaire study on two cohorts treated with CEF respectively CE + T, based on the Danish Breast Cancer Cooperative Groups database. Inclusion criteria were identical i both cohorts: women treated with adjuvant chemotherapy for primary breast cancer, age 18–69 years, without recurrence. Exclusion criteria: bilateral or previous breast surgery, including reconstructive surgery. The same questionnaire [1] was used for both cohorts and contained detailed questions regarding pain intensity and frequency and sensory disturbances in the breast area, side of chest, axilla and arm, bilateral peripheral sensory disturbances in the hands and feet, and questions regarding daily activities. Results 1241 patients treated with CEF in 2005-2006 and 1652 patients treated with CE + T in 2007–2008 were included. 664 (54%) with CEF and 861 (53%) patients with CE+T reported PPBCT. In the multivariate analysis including available risk factors, CE + T did not increase risk of PPBCT, adjusted OR 0.95 (95%C10.81–1.11), p = 0.52, compared to CEF. Patients treated with CE + T had a lower risk of sensory disturbances in the area of surgery compared with CEF, adjusted OR 0.75 (95%C1 0.62–0.90), p = 0.002. More CE+T patients reported peripheral sensory disturbances in the hands, adjusted OR 1.56 (95%C11.27–1.92), p &lt; 0.0001, and in the feet, adjusted OR 2.0 (95%C1 1.66–2.42), p &lt; 0.0001, compared to CEF. There was no difference in functional impairment (p = 0.62). Conclusion Docetaxcel as adjuvant treatment for breast cancer does not increase the risk of PPBCT, sensory disturbances in the surgical area or functional impairment, but increase the risk for peripheral sensory disturbances.

Breast Radiation Correlates with Side of Parathyroid Adenoma

Prior head and neck irradiation is a known risk factor for hyperparathyroidism. It is not clear whether irradiation for breast cancer, which may expose the neck to radiation, is also a risk factor for hyperparathyroidism. The present study analyzes the association between the side of radiation to the chest following breast surgery and the side of subsequent parathyroid adenoma development. We analyzed a prospective database of 1,428 consecutive patients who underwent parathyroidectomy at our institution between November 2000 and August 2010. Patients who had previously undergone breast surgery were identified. Patients with multigland disease were excluded. Patients with bilateral breast surgery were counted as having had two separate procedures; one on each side. Patients who had radiation therapy following breast surgery (RadRx) were compared to those who had breast surgery without radiation treatment (No RadRx). A total of 146 breast procedures were performed in 121 patients. Forty procedures were in the RadRx group versus 106 cases in the No RadRx group. Patients with radiation therapy were older (68 ± 1.8 years versus 63 ± 1.2 years; P = 0.02) and had higher preoperative calcium levels (11.3 ± 0.1 mg/dl versus 10.9 ± 0.1 mg/dl; P = 0.001). However, there was no significant difference in either parathyroid hormone (PTH) level or gland weight. The latency period between breast irradiation and parathyroid surgery was 8 ± 0.9 years. Interestingly, the side of radiation therapy was associated with the side of the parathyroid adenoma in 76% of cases, compared to only 44% in those who had breast surgery without radiation exposure (P = 0.0004). The present study demonstrates that, similar to prior head and neck radiation, prior breast irradiation correlates with the development of parathyroid disease. Specifically, there is a strong correlation between the side of the radiation therapy and the side of a subsequent parathyroid adenoma. Breast irradiation should therefore be considered a risk factor for the development of parathyroid adenomas.

P4-14-01: Weight-Adjusted Change of Unilateral Arm Volumes for Quantification of Lymphedema after Bilateral Breast Surgery.

Abstract Background: Accurate quantification of breast cancer-related lymphedema (BCRL) is important for early detection and successful management. Arm volume changes after unilateral breast surgery can be calculated through relative volume change (RVC) of the affected arm using the contralateral arm as a control (Ancukiewicz et al Int J Radiat Oncol Biol Phys 79(5):1436–43 2011). However there currently exists no accurate method for quantifying arm volume changes in patients after bilateral breast surgery. As the number of women undergoing bilateral mastectomies continues to increase, it is critical to develop a method to quantify arm volume changes in this population for detection of lymphedema. Our aim was to develop a weight-adjusted formula for unilateral arm volume changes independent of the contralateral arm for application in the setting of bilateral breast surgery. Materials and Methods: We analyzed longitudinal measurements of arm volumes in 141 unilaterally affected patients undergoing screening for BCRL with a perometer at our institution (71 with left affected and 70 with right affected arms). Each patient had a baseline measurement prior to surgery and at least one post-surgical measurement. Median time of follow-up was 27.5 months and median standard deviation of longitudinal weight changes within patients during follow-up was 3%. Results: Unilateral arm volume changes of the unaffected arm were correlated with weight changes at the last follow-up point (Kendall's tau=.58 and P&amp;lt;.0001). Estimates of slope and intercept for median regression line between percent weight change and percent arm volume change evaluated for the unaffected arm at last follow-up are, respectively, .90 [95% CI] and .009 [95% CI]. Thus, percent weight change and percent arm volume change in the unaffected arm have an approximately linear relationship, such that the weight adjusted change (WAC) of affected unilateral arm volumes can be calculated according to the formula WAC=(A2*W1)/(W2*A1) — 1, where A1 is pre-surgical baseline arm volume on the affected side and A2 is post-surgical arm volume on the affected side, and W1, W2 are the patient's weights at these time points. Weight-adjusted change showed a strong correlation with RVC (RVC=(A2*U1)/(U2*A1) — 1), where A1, A2 are arm volumes on the side of the affected breast, and U1, U2 are volumes on the contralateral side at these time points (Kendall's tau=.41, P&amp;lt;.0001). Discussion: Unilateral arm volume changes can be quantified by adjusting for weight changes. We propose the weight-adjusted change (WAC) formula to calculate unilateral arm volume changes for detection and monitoring of BCRL in patients who undergo bilateral breast surgery. The validity of such a formula needs to be assessed in conjunction with clinically reported lymphedema. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-14-01.

Multimodality Scar Management Program

This trial was undertaken to assess the efficacy of a multimodality management regime used for the prevention of hypertrophic scars. It follows previous research and experience (A.D. Widgerow et al, Aesthetic Plast Surg, 24(3):227-234, 2000) with a similar program but with the addition of active agents with specific effects against prolonged inflammation and enhanced hydrative capacity. The modalities specifically targeted are tension on the scar, hydration of the scar, collagen maturation, and controlled inflammation. Tape was impregnated with a combination of agents providing an occlusive dressing aimed at combatting exaggerated scarring. Patients who had undergone surgery were stratified into four groups: Group 1, 60 patients/60 scars following simple skin excisions, 30 treated scars, 30 untreated scars; Group 2, 20 patients/40 scars, each patient with two excisions, one treated, one untreated; Group 3, 10 patients/20 scars following bilateral breast surgery, one side treated with tape alone, one side treated with tape and gel; Group 4, 30 patients with varying cosmetic procedures/50 scars, all treated and compared with historical outcomes for hypertrophic scarring. Thus, 170 scars were assessed in 120 patients. Results were assessed at 1, 2, and 6 months using a combination of accepted scar assessment techniques. By amalgamating the Vancouver, Manchester, and morphologic table systems together with Patient and Observer Scar Assessment analyses, a comprehensive assessment of scar outcomes was undertaken and comparisons were made with control groups. Treated groups showed improvement outcomes in all variations of assessment. Patient and observer assessments correlated well, and morphologic appearances of the scars following the final assessment at 6 months showed statistically significant positive scar outcomes in the treatment groups. The multimodality approach to scar control showed significant benefits in the patient groups tested in this series.

Subcutaneous Venous Port Implantation in Patients with Bilateral Breast Surgery

The purpose of this study was to evaluate the long-term follow-up results of subcutaneous venous ports implanted in patients with bilateral mastectomies. We retrospectively reviewed the hospital charts and the electronic database of 17 patients with bilateral mastectomies whom had venous port implantation in our interventional radiology suit. A total of 17 ports were implanted to the paramedian (n = 3) and anterolateral (standard; n = 12) chest wall, on the trapezius muscle (n = 1), and to the antecubital fossa (n = 1). The mean age was 48.29 years (range: 35-60 years). The mean time interval from time of surgery to port implantation was 34 months (range: 1-84 months). The mean follow-up time was 15 months (range: 7-39 months). Follow-up parameters and classification of the complications was defined according to the SIR guidelines. No procedure-related complication occurred. A single case of mild late infection was noted and the infection rate was 0.19/1000 catheter days. Infusion chemotherapy administration was still going on in eight patients. Two patients died during the follow-up and four patients were lost after 6 months. Port removal was performed in three patients at follow-up because of the end of treatment. One trapezius port and one paramedian port weres among the removed ports without any problem. Although we have a limited number of patients, port placement to the anterior chest wall, either paramedian or anterolateral, on the trapezius muscle or to the antecubital fossa depending on the extent of the bilateral breast surgeries that can be performed with low complication rates by a careful patient and anatomical location selection by involving the patients in the decision-making process. We believe that patient education and knowledge of possible complications have high importance in follow-up.

Laparoscopic oophorectomy combined with breast surgery for breast cancer patients

Background Prophylactic oophorectomy is effective for risk-reduction for both breast and ovarian cancer in patients with hereditary breast/ovarian cancer syndromes. Oophorectomy in a woman with breast cancer might also be done as a diagnostic or therapeutic procedure for ovarian pathology discovered during pre-operative work-up. We carried out a study of breast cancer patients who underwent the combined procedure of bilateral laparoscopic oophorectomy and breast surgery to determine the short-term outcome.Methods From November 2000 until April 2004, 14 breast cancer patients had breast surgery and bilateral laparoscopic oophorectomy in the same operating room session. The files of these women were analyzed retrospectively.Results The mean age of the 14 women was 50.7 years (range 39-61). Six women had known BRCA1 or BRCA2 mutations, 3 women had suspected ovarian pathology, 2 had a family history of ovarian cancer and 3 others had a family history suggestive of hereditary breast cancer syndrome but no known mutation. There were no ovarian malignancies on histological examination of the resected ovaries. The mean operating time was 160 minutes (SD ± 60, range 40-240), the mean hospital stay was 2.7 days (SD ± 1.9, range 1-7), and the time from date of surgery to date of 1st chemotherapy was 25.4 days (SD ± 6.7, range 22-37) or 3.6 weeks (SD ± 0.95). There were no post-operative complications.Conclusions Combining laparoscopic oophorectomy with oncologic breast surgery is a reasonable treatment option that extends operating time and does not increase the complication rate. Time to discharge seems to be determined only by the breast component of the surgery. The time to start of chemotherapy did not extend beyond 6 weeks in our series. This approach should be considered for any breast cancer patient undergoing breast surgery who might require oophorectomy as well.