Mastectomy Research Articles

The role of ct-DNA in breast cancer surveillance assessing treatment response and recurrence: A community center experience.

e13021 Background: Breast cancer is a heterogeneous disease and primarily classified on immunohistochemistry. Currently treatment is based on biopsy but studies have showed changes in subtype and acquired resistance in the original subtype due to cancer therapies. While biopsy is gold standard, recently liquid biopsy from serum containing circulating tumor DNA (ct-DNA) has emerged as a noninvasive technique of tumor surveillance. Methods: This is a retrospective study approved by the IRB at Monmouth Medical Center. Objectives were to identify use of ct-DNA level and highlight the trends over course of treatment. Subjects were identified by reviewing patient’s charts and included on criteria of age > 18 years and in whom ct-DNA level was followed up. 27 patients were identified and results were obtained by categorizing the patients and calculating the proportions. Results: A total of 27 patients were included. The mean age at diagnosis of cancer was 56.29 years (95% CI 51.19-61.39). Among 27 patients, 11 had left sided and 16 had right sided tumor. The pathology identified was Invasive ductal in 18, adenocarcinoma in 2, lobular in 4, poorly differentiated in 2 and mesenchymal in 1 of the patients. Hormonal subtypes identified were triple negative in 11, ER/PR+ve/Her 2-ve in 8, triple positive in 2, ER/PR-ve/Her 2+ve in 1 and ER+ve in 5 of the patients. Among 27, 8 of the patients had stage I, 15 had stage II, 3 had stage III and 1 had stage IV disease. During the course of treatment, 7 of patients had left, 10 had right and 7 had bilateral mastectomy due to BRCA mutation identified on genetic testing. 3 of the patients did not undergo surgery. ct-DNA levels were elevated 8.05 and 1.31 MTM/ml in 2 patients and subsequently became undetectable and decrease in tumor size was noticed from 6.1 cm to 1.1 cm and 1.8 cm to 9mm. ct-DNA levels remained undetectable the rest of 25 patients and patient’s remained gross tumor free on interval MRI imaging of the breasts. Conclusions: The ct-DNA levels have a great utility in establishing the correlation of treatment effect on tumor volume. All this information is vital for clinical decision making and appropriate management. Therefore, the application of liquid biopsy and ct-DNA analysis in breast cancer opens a window of opportunity that encompasses all possible disease situations: from early diagnosis, through the detection of minimal residual disease, the early detection of relapse, and the monitoring and treatment planning for advanced disease. A limitation of study was low sample size. [Table: see text]

Second primary breast cancer in young breast cancer survivors.

10503 Background: Prior data suggests that the risk of second primary breast cancer (SPBC) is higher among women diagnosed with primary breast cancer (BC) before age 40. There is evidence that risk differs by primary tumor characteristics, cancer treatments, and genetic predisposition. However, studies investigating risk of SPBC by clinical risk factors are often limited by low numbers of young women and lack of complete patient data, particularly regarding germline genetic risk. Methods: Using the Young Women’s BC Study (YWS), a prospective cohort of 1,302 women ≤40 years diagnosed with BC from 2006-2016, we sought to compare clinical and treatment characteristics among women who developed an SPBC vs. those who did not. The analytic cohort included women diagnosed with Stage 0-III BC who did not undergo bilateral mastectomy (N = 685). Demographics, genetic testing and results, clinical events, and treatment data were collected through self-report on baseline and follow-up surveys (every 6 months for 3 years, then annually). Detailed tumor and treatment information, confirmation of genetic testing results, and new and recurrent cancer events were obtained through regular and triggered medical record review. Univariate and multivariate Cox proportional hazards models were used to examine associations of age, race, genetic testing results, hormone receptor status, stage, and grade of primary tumor, and cancer treatments with SPBC. Participants were censored at the time of local recurrence, metastasis, death, or loss of follow-up. Results: At a median follow-up time of 9.9 years [inter-quartile range (IQR) = 6.6-12.0 y], 17 patients developed an SPBC (2.5%), in whom 3 occurred in the ipsilateral breast after lumpectomy as primary BC surgery. Median time from primary BC diagnosis to SPBC diagnosis was 4.2 years (IQR = 3.3-5.6 y). Compared to those who did not develop an SPBC, a greater percentage of women who developed an SPBC had in situ disease as their primary BC (24% v. 6%) and were of Ashkenazi descent (12% v. 5%). In the 577 women who had had genetic testing, 544 (94%) were non-carriers of pathogenic variants. Risk of SPBC was 2.2% (N = 12) in non-carriers and 9.1% (N = 3) in the 33 carriers. In Cox univariate analyses, carriers had a 4.1 times higher risk of SPBC compared to non-carriers (HR = 4.14, 95% confidence interval (CI) = 1.67-14.66, p = 0.03), and primary diagnosis with in situ BC was associated with a 5-fold increased risk of SPBC (HR = 5.02, 95% CI = 1.63-15.41, p = 0.005). Both factors remained strongly associated with SPBC when tested together in a multivariate model. Conclusions: This prospective study demonstrated a low risk of SPBC in the first 10 years after diagnosis of early BC in young women who are not germline pathogenic variant carriers. The finding that risk of SPBC was higher after in situ primary BC at a young age warrants further investigation. These findings have important implications for the treatment and follow-up care of young women with BC.

Nipple margin assessment at the time of nipple-sparing mastectomy.

Documenting negative margins at the nipple-areolar complex (NAC) during nipple-sparing mastectomy (NSM) remains the standard, but how to achieve this and how to manage a positive margin is debated. We sought to review nipple margin assessments at our institution and to analyze the risk factors of a positive margin and rate of local recurrence. Patients who underwent NSM between 2012 and 2018 were reviewed and divided into 3 groups based on indication - cancer, contralateral prophylactic mastectomy (CPM) and bilateral prophylactic mastectomy (BPM). Nipple-sparing mastectomies were performed on 337 patients; 72% for cancer, 20% for CPMs and 8% for BPMs. Nipple margin assessments were performed in 87.8% of patients; 10 patients (3.4%) had a positive margin, 7 of whom underwent NAC excision and 3 were managed with observation. As indications for NSM increase, assessment of nipple margin provides valuable information to manage the NAC in patients with cancer. The routine use of nipple margin biopsies in patients undergoing CPM and BPM may no longer be required, as rates of occult malignant disease are low with no positive biopsies. Further studies with larger sample sizes are needed.

(005) A Systematic Review of Preventative BRCA Surgeries and Sexual Function Outcomes

Abstract Introduction BRCA 1 and 2 genes increase a patient’s risk for developing cancer of breast and ovarian origin. There are two methods of preventative care offered to BRCA-positive patients: prophylactic surgery or high risk screening for cancer accompanied by endocrine therapy. Preventative surgeries for BRCA-positive patients – bilateral salpingo-oophorectomy (BSO) and mastectomy - have been linked to decreased sexual function and dyspareunia. A patient’s decision whether or not to undergo preventive surgery as opposed to high risk screening (with or without hormone therapy) is heavily reliant on the advice received from their health care providers. The association of risk-reducing mastectomy and BSO with quality of life, including postoperative dyspareunia, should be taken into account when conducting shared decision-making with patients. Objective The objective of this systematic review is to assemble and analyze findings related to patient reported sexual function after these surgeries, to see if and how either surgery affects sexual dysfunction from patient baseline, and to compare the effects the two surgical procedures have on sexual function and whether these effects can be mitigated with hormone replacement therapy. Methods A literature review using Pubmed, Embase and MEDLINE databases from inception through January 25, 2022 was conducted. Included in the literature search were any form of observational study, clinical trial or article type. Conference abstracts were also included. To be included, studies had to meet an a priori list of Medical Subject Headings (MeSH) terms “BRCA” AND “sexual dysfunction” OR “dyspareunia”. Results The search yielded 13 results, of which seven reported sufficient data for systematic review. Participant numbers ranged from 15 to 804. Sexual dysfunction and dyspareunia were measured via both validated and investigator-generated surveys, three studies used the Female Sexual Function Index (2 BSO, 1 breast) and 2 of the studies used the Sexual Activity Questionnaire (both BSO). All of the studies, no matter the survey metric, found there to be significant sexual dysfunction with either BSO or mastectomy post surgery. All but one of the studies found that hormone replacement therapy was not show a significant improvement in sexual function, and all of the studies reported that sexual function post op could not reach baseline level with therapy. Menopausal status was not a significant moderator. No studies found preventative screenings to have an effect on sexual dysfunction or dyspareunia, and future studies could look into this group as a possible study control. Conclusions To our knowledge this is the first systematic review to incorporate the effects of both risk reducing mastectomies and BSO on sexual function among BRCA patients. The data can help decision making for BRCA positive patients and clinicians choosing between surgeries and high risk screening. Patients should be properly informed and counseled about dyspareunia before deciding to undergo irreversible procedures, and as part of shared decision making on which prevention approach is the best fit for their goals and preferences. Disclosure No

P193 A MYXOMA IN THE LEFT ATRIUM ADHERENT TO THE INTERATRIAL SEPTUM

Abstract A 73–year–old woman came to our observation to perform a routine echocardiographic examination. The patient had arterial hypertension, dyslipidemia, hypothyroidism, and paroxysmal atrial fibrillation. She underwent a bilateral mastectomy for breast cancer about 5 years ago, and she was undergoing chemotherapy and radiation therapy for a stage IV lung adenocarcinoma. The clinical evaluation was normal, as was the electrocardiogram. The transthoracic echocardiographic evaluation showed the presence of a rounded formation with variable echogenicity, with an irregular surface (4 x 3 cm), adherent to the interatrial septum at the level of the fossa ovalis, which did not hinder the excursion of the mitral valve. No other significant cardiac abnormalities were detected.Transesophageal echocardiography confirmed the presence of atrial mass adhered to the oval fossa (panels A, B). of coarsely rounded shape, and variable echogenicity, in the absence of interference with the movement of the valve leaflets and of anomalies of the interatrial septum (panel C). Coronary angiography showed right–dominant coronary circulation (panel D) and mild stenosis of the mid–left anterior descending artery. Abundant arterial perfusion of the atrial mass, with several vessels originating from the circumflex artery, was also evident at the coronary angiography (panels E, F). The patient underwent cardiac surgery; the surgical exeresis of the left atrial mass was performed through right mini–thoracotomy (panels I and L). Because the neo–formation was adherent not only to the atrial septum but also to the left atrial roof, to obtain a radical excision, a large portion of the atrial wall and the septum were removed and totally reconstructed with the pericardium. The main artery supplied the mass–related vascular network was ligated. The postoperative course was uneventful, and the patient was discharged at home on day six. The pre–discharge echocardiography and the cardiac magnetic resonance ( panels G, H) showed the absence of any residual mass in the left atrium that appears anatomically reshaped, no shunt at the level of the interatrial septum, and preserved ventricular function of both ventricles. Histological analysis confirmed the diagnosis of atrial myxoma. At the six–month follow–up the patient was asymptomatic and the echocardiography was superimposable to discharge.

Incidence of Cancer and Role of Sentinel Lymph Node Biopsy in BRCA Mutation Carriers Undergoing Prophylactic Mastectomies.

Breast surveillance in patients with BRCA mutations include mammography (MMG) and MRI. Patients may elect to undergo risk-reducing bilateral prophylactic mastectomies (BPM). Sentinel lymph node biopsies (SLNB) are frequently performed and associated with increased morbidity. This study sought to determine the correlation between preoperative imaging and the final pathology and evaluate the role of SLNB in these high-risk patients. A prospective database identified BRCA patients who underwent BPM between 2006 and 2022. Imaging, pathology, and operative reports were reviewed. 170 patients with BRCA 1/2 mutations were identified. 162 (95.3%) had imaging within one year of BPM. Of these, 28 (17.3%) patients had a MMG/ultrasound, 53 (32.7%) had an MRI, and 81 (50%) had both; 21/162 (13.0%) patients had abnormal imaging. Bilateral SLNB were performed in 31 (18.2%) patients, of which 7 had abnormal imaging; unilateral SLNB were performed in 4 (2.4%) patients, of which 3 had abnormal imaging. 11/170 (6.4%) patients had a malignancy and only one (9%) of these patients had imaging abnormalities. 1/170 (0.6%) patient had an invasive carcinoma requiring an axillary lymph node dissection (ALND), and 10/170 (5.9%) patients had ductal carcinoma in situ (DCIS). 25/170 (14.7%) had ADH/ALH. Only 7/170 (4.1%) patients had imaging abnormalities and abnormal pathology. All SLNB and ALND performed demonstrated no metastatic disease. There is a high rate of discordance between preoperative imaging prior to surgery in BRCA patients undergoing prophylactic mastectomies and final pathology. This study does not support routine SLNB at the time of BPM.

About mother Yulia Savinovskikh, deprived of adopted children because of desire to change sex (tragic legal consequences of imperfections of psychiatric classifications)

In the article the case of Yulia Savinovskikh from whose family two adoptive juvenile children who have lived within several years with trustees and their own children and received during this time the effective help in therapy of the chronic diseases have been withdrawn, is analyzed. The surgery fact (a bilateral mastectomy) for the purpose of the further sex change which was carried out in Yu. Savinovskikh after approval of her husband and relatives, has formed the basis for withdrawal of children. Justification of the judgment was the instruction on the fact that the transsexualizm belongs to the category of mental disorders in the presence of which the person cant adopt the child or accept him under guardianship. The described case has highlighted aspect, relevant for modern psychiatry, the actual legal equating of behavioural disorders and deviations, to mental with distribution of rights deprivation of such persons.

Omitting Foley Catheter Use in Mastectomy Patients With or Without Immediate Reconstruction.

Foley catheter placement is often advised in surgeries anticipated to exceed 3 hours; however, this time cutoff does not take into account the type of surgery. Complications from Foley catheter placement include urinary tract infections and genitourinary trauma that may be costly to healthcare systems. Our objective was to determine whether mastectomy with or without reconstruction can be done without Foley use, without an increase in urinary retention risk. One hundred eighty-seven patients who underwent unilateral or bilateral mastectomies with or without reconstruction in 2020 and 2021 were reviewed. Chart review included intraoperative fluids given, estimated blood loss, lymph node dissection, and duration of procedure. After excluding patients with case duration under 180 minutes, 145 remained. Ninety-four patients did not have a Foley and 51 patients had an intraoperative Foley. None of the patients without a Foley experienced postoperative urinary retention, including 3 patients who also underwent lymphatic microsurgical preventive healing approach. Eighty-six percent of patients were discharged on the day of surgery. Patients with or without a Foley did not differ significantly in terms of race, rate of axillary lymph node dissection, body mass index, rate of same-day discharge, presence of hypertension or diabetes, estimated blood loss, or age. Patients undergoing unilateral and bilateral mastectomies with or without reconstruction or lymphatic microsurgical preventive healing approach may avoid Foley catheter placement without increased risk of urinary retention, even if the case is anticipated to exceed 3 hours. Advantages include elimination of catheter-associated urinary tract infections and their associated hospital costs, as well as avoiding genitourinary trauma.

A Decade of Nipple-Sparing Mastectomy: Lessons Learned in 3035 Immediate Implant-Based Breast Reconstructions.

Nipple-sparing mastectomy is commonly performed for breast cancer treatment or prevention. The authors present one of the largest breast reconstruction series in the literature. A single-institution retrospective review was conducted from 2007 to 2019. The authors' query identified 3035 implant-based breast reconstructions after nipple-sparing mastectomy, including 2043 direct-to-implant and 992 tissue expander-to-implant reconstructions. The overall major complication rate was 9.15%, and the nipple necrosis rate was 1.20%. Therapeutic mastectomy was associated with higher overall complications and explantations compared with prophylactic mastectomy ( P < 0.01). In comparisons of unilateral and bilateral procedures, bilateral mastectomy had an increased risk for complications (OR, 1.46; 95% CI, 0.997 to 2.145; P = 0.05). Tissue-expander reconstructions had higher rates of nipple necrosis (1.9% versus 0.88%; P = 0.015), infection (4.2% versus 2.8%; P = 0.04), and explantation (5.1% versus 3.5%; P = 0.04) compared with direct-to-implant reconstruction. When assessing plane of reconstruction, the authors found similar rates of complications between subpectoral dual-plane and prepectoral reconstruction. There was no difference in complications between reconstruction with acellular dermal matrix or mesh compared with total or partial muscle coverage without acellular dermal matrix/mesh (OR, 0.749; 95% CI, 0.404 to 1.391; P = 0.361). Multivariable regression analysis revealed preoperative radiotherapy (OR, 2.465; 95% CI, 1.579 to 3.848; P < 0.001), smoking (OR, 2.53; 95% CI, 1.581 to 4.054; P < 0.001), and a periareolar incision (OR, 3.657; 95% CI, 2.276 to 5.875; P < 0.001) to be the strongest predictors of complications and nipple necrosis ( P < 0.05). Nipple-sparing mastectomy and immediate breast reconstruction has a low rate of complications. In this series, radiation therapy, smoking, and incision choice predicted overall complications and nipple necrosis, whereas direct-to-implant reconstruction and acellular dermal matrix or mesh did not increase risk. Therapeutic, III.

159P The impact of the extent of the type of primary breast cancer (BC) surgery from the analysis of historical Italian trials

Breast-conserving surgery (BCS) is the treatment of choice for women with early-stage BC. Several studies indicated a better outcome in patients undergoing BCS plus radiotherapy (RT) in comparison with mastectomy (MAST) +/- RT (PMID:33950173, 27344114). Indeed, in comparison with MAST, BCS reduces the extent of surgery, but the addition of radiotherapy (RT) makes it hard to understand whether the differences in outcome may be attributed to the extent of the surgery only. We performed a competing risks re-analysis in terms of dynamics and crude cumulative incidence (CCI), of distant recurrence free survival (DRFS) from two historical randomized clinical trials which of the Istituto Nazionale dei Tumori of Milan: the “Milan 1” trial (n = 701; 1973-1980, PMID:7015141) which compared MAST with BCS plus RT (BCS+RT) and the “Milan 3” trial (n = 567; 1987-1989, PMID: 8387637) which adopted the same surgical conservative approach with (BCS +RT) or without (BCS -RT) RT. Clinical features such as primary tumour size, axillary lymph node status (N) and menopausal status were considered. Concerning distant recurrence (DR) dynamics in Milan 1 trial, evidence of a different intensity of cause-specific hazard was found among subgroups related to surgery and lymph-node status (test of interaction effect: P=0.005), though with similar multi-peaked hazard patterns. Indeed, we observed that a MAST-related worse outcome is present in women with positive N (N+). Analysis of CCI reveals that, for the subgroup of N+ patients in Milan 3 trial, removal of RT from BCS (BCS -RT) results in 30% higher incidence of DR, comparable to the difference between MAST N+ and BCS+RT N+ patients in the Milan 1 trial. In this re-analysis of historical randomized clinical trials, we report that the worse outcome of MAST in comparison with BCS may be mainly attributed to higher extensive surgery and that the effect of the extent of the surgery without RT is mostly confined to patients with N+ BC. The effect of RT, as assessed by the re-analysis of Milan 3 trial, is likely related to a combined effect of the control of local recurrences, and the potential systemic effect of RT.

Can the size of chest wall recurrence after mastectomy in breast cancer patients predict the presence of systemic metastasis?

One of the manifestations of recurrence after mastectomy is the presentation of chest wall lesion. However, it is unclear if the size of the chest wall recurrence (CWR) is related to the presence of simultaneous systemic metastasis in these patients. We aimed to determine if the size of the CWR could affect the outcome in these patients. Stage I-III breast cancer patients who underwent mastectomy and developed invasive ipsilateral CWR were included. Patients with bilateral mastectomy were excluded. Demographic, radiologic and pathological data were analysed between patients with CWR and simultaneous systemic metastasis versus those with isolated CWR. Of the 1,619 patients treated with mastectomy, 214 (13.2%) patients developed recurrences. 57/214 (26.6%) patients had invasive ipsilateral CWR. 48 patients were analysed after exclusion of patients with missing data. Mean age at diagnosis of first cancer and at recurrence were 55.2 years (32-84 years) and 58.5 years (34-85 years) respectively. 26/48 (54.2%) had CWR with simultaneous systemic metastasis. Mean CWR size was 30.7 mm (6-121 mm) and 21.4 mm (5.3-90 mm) for the patients with simultaneous systemic metastasis and those without respectively (P=0.441). Grade (P=0.0008) and nodal status (P=0.0009) at primary diagnosis, grade (P=0.0011) and progesterone receptor (PR) status (P=0.0487) at recurrence were statistically significant for systemic metastasis in patients with CWR. Biologic factors such as grade of primary and recurrent cancer, PR status of recurrent cancer and nodal status at primary diagnosis, instead of CWR size, were associated with simultaneous systemic metastasis in patients with CWR.

Abstract #1397393: A Case of HPA Axis Recovery in the Setting of Immune Checkpoint Inhibitor-induced Hypophysitis

Immune checkpoint inhibitor-related hyophysitis resulting in the loss of anterior pituitary hormones is well described in the literature. Patients with hypophysitis frequently develop secondary adrenal insufficiency, which is usually permanent. We present an unusual case of a patient who had recovery of her hypothalamic pituitary adrenal (HPA) axis. A 32-year-old woman was diagnosed with locally advanced estrogen, progesterone, and human epidermal growth factor 2 receptor negative breast cancer. She received neoadjuvant chemotherapy with pembrolizumab and then underwent a bilateral mastectomy. While on pembrolizumab the patient’s thyroid and cortisol axis were monitored every month. She endorsed increasing fatigue after eight months of pembrolizumab therapy. Her workup showed morning ACTH level was 6.6 (reference range 7.2-63 pg/mL), and her cortisol level was 2.2 (6.7-22.6 mcg/dL), which was confirmed on repeat testing. A diagnosis of secondary adrenal insufficiency was made, and the patient was started on hydrocortisone 10mg at 8 am and 5 mg at 2 pm. Her pituitary hormonal profile was otherwise normal. An MRI brain was not done as the patient denied any symptoms of headache or visual changes. The pembrolizumab was held and the patient had repeat HPA axis testing. She was asked to hold her hydrocortisone 24 hours prior to the assessment of her pituitary adrenal axis. This was conducted every month. After four months of hydrocortisone replacement, her cortisol axis recovered as her labs showed an ACTH of 47.2 and cortisol of 17.4 (6.7-22.6 mcg/dL). The patient was asked to discontinue hydrocortisone and counseled to report if she had any symptoms of adrenal insufficiency. The patient continued to feel well off hydrocortisone therapy with no symptoms of adrenal insufficiency. Her ACTH and cortisol levels remained normal. Recovery from secondary adrenal insufficiency associated with immune checkpoint inhibitor related hypophysitis is rarely seen. This case suggests that certain individuals may recover, potentially those who are younger or do not completely lose ACTH secretion. Repeated pituitary hormone testing for the first six months after the development of hypophysitis may identify more patients with HPA axis recovery and lead to less long-term use of steroids.

D120. Prospective Cohort Study Evaluating Chest Reinnervation in Gender Affirming Double Incision Mastectomy with Free Nipple Grafting

D120. Prospective Cohort Study Evaluating Chest Reinnervation in Gender Affirming Double Incision Mastectomy with Free Nipple Grafting

D22. Effects of Exogenous Testosterone on Scarring in Gender-affirming Chest Surgery

PURPOSE: Chest masculinization surgery (CMS) can lead to hypertrophic scarring with reduced quality-of-life and need for revision. Given our clinical observations and prior animal studies suggesting testosterone(T) has negative effects on wound healing, we hypothesized T is associated with worse scarring after CMS. METHODS: 152 patients undergoing either double incision mastectomy or keyhole/circumareolar mastectomy were enrolled in an IRB-approved prospective registry at JHU from 2017-2022. Data regarding patient demographics, hormone regimen, scarring co-morbidities, procedural details and complications were collected. Scars were assessed by four blinded clinicians using Manchester Scar Scale and SCARS-scale using photos taken at early, mid, and late post-op timepoints. T-tests and Pearson correlations were used to look for association between scarring and T dose/level. RESULTS: 66% of patients were white and 90% were on T. MSS contour and SCAR palpability were positively correlated with increasing weekly dose of T (r=0.2/p=0.034 and r=0.234/p=0.013,respectively). Patients with high preop T-level (>500ng/dl) and high weekly T-dose (>50ng/dl) had a higher mean score on SCAR palpability subscale and SCAR overall impression subscale compared to patients in low preop T (<500ng/dl) and low weekly T-dose (<50ng/dl) group (p=0.038,p=0.047). CONCLUSION: Exogenous testosterone appears to be correlated with hypertrophic scarring after CMS. Current T-dosing regimens focus largely on subjective patient response and may lead to supratherapeutic doses. Recent trends towards continuation of hormones throughout perioperative period may warrant further evaluation of risks and benefits.

Paraneoplastic Neurologic Syndromes with ANNA-2/anti-Ri: a Contrasting Story of Two Cases (P5-5.026)

Paraneoplastic Neurologic Syndromes with ANNA-2/anti-Ri: a Contrasting Story of Two Cases (P5-5.026)

Mastopexy Strategies for Ptotic Breasts in Patients Choosing Autologous Reconstruction Following Prophylactic Mastectomy.

Autologous breast reconstruction is a reliable solution for many patients after mastectomy. While this technique represents a standardized approach in many patients, patients with ptotic breasts may require a combination of procedures to achieve an aesthetically pleasing result. We reviewed the mastectomy and free-flap breast reconstruction procedures performed at our institution from 2018 to 2022 in patients with ptotic breasts. The technique used to address the ptosis was put in focus as we present the four strategies used by our reconstructive surgeons. We performed two different one-stage and two different two-stage procedures. The difference between the two-stage procedures was the way the nipple areola complex was treated (inferior dermal pedicle or free skin graft). The difference between the one-stage procedures was the time of execution of the mastopexy/breast reduction (before or after the mastectomy and autologous breast reconstruction). The one-stage procedure was performed with a free NAC in three patients and with a pedicled NAC in five patients. The two-stage procedure was performed in seven patients, with six of them undergoing mastopexy before and one patient undergoing mastopexy after the bilateral mastectomy and autologous reconstruction. No flap loss or total loss of the nipple areola complex occurred. Partial NAC loss was observed in five breasts in the single-stage group without any occurrence in the double-stage group. While both one- and two-stage procedures were performed in a safe fashion with satisfactory results at our institution, larger trials are required to determine which procedure may yield the best possible outcomes. These outcomes should also include oncological safety and patient-reported outcomes.

Emotion regulation and choice of bilateral mastectomy for the treatment of unilateral breast cancer.

There has been steadily increasing use of bilateral mastectomy (BMX) in the treatment of primary breast cancer (BC). In this study, we utilized functional magnetic resonance imaging (fMRI) to examine the influence of emotion regulation on the decision of newly diagnosed BC patients to choose BMX rather than non-BMX treatments. We recruited 123 women with unilateral BC, 61 of whom received BMX and 62 of whom received non-BMX treatments, and 39 healthy controls. While participants were in the fMRI scanner, we showed them BC-related and non-BC-negative images. In one condition, they were instructed to watch the images naturally. In another, they were instructed to regulate their negative emotion. We compared the fMRI signal during these conditions throughout the brain. With non-BC-negative images as the baseline, BC patients showed greater self-reported reactivity and neural reactivity to BC-related images in brain regions associated with self-reflection than did controls. Among the BC patients, the BMX group showed weaker activation in prefrontal emotion regulation brain regions during emotion regulation than did the non-BMX group. BC patients are understandably emotionally hyper-reactive to BC-related stimuli and those who ultimately received BMX experience more difficulty in regulating BC-related negative emotion than non-BMX BC patients. These findings offer neuropsychological evidence that difficulty in managing anxiety related to the possibility of cancer recurrence is a factor in surgical treatment decision-making and may be an intervention target with the goal of strengthening the management of cancer-related anxiety by nonsurgical means. NCT03050463.

Bilateral risk-reducing mastectomy and reconstruction-A 12-year review of methodological trends and outcomes at a tertiary referral centre.

Bilateral risk-reducing mastectomy (BRRM) involves removal of healthy breast tissue to substantially decrease the risk of developing breast cancer in individuals with greater susceptibility due to a strong family history or genetic mutation. This retrospective study evaluates cases of BRRM and associated reconstruction performed at a tertiary centre, with emphasis on mastectomy and reconstructive trends. A retrospective review of all BRRM cases performed between January 2010 and May 2022 was conducted, with two separate cohorts corresponding to the earlier (group 1) and later (group 2) portion of the time-period. Data collected included demographics, genetic test results, family history of breast/ovarian cancer, co-morbidities, mastectomy type, reconstruction type, surgical histopathology findings and post-operative complications. A total of 82 patients (group 1 = 41, group 2 = 41) underwent BRRM. The proportion of nipple-sparing mastectomy increased from 14.6% to 56.1% between the two time periods with a reduction in skin-sparing mastectomies from 75.6% to 20.3% (p<0.001). Of the 80 patients who opted to undergo reconstruction, there was a significant decrease in combined flap-implant reconstructions (19.51% to 0%, p<0.01). Importantly, for implant-only reconstruction, there were significant increases in prepectoral approaches (p = 0.0267) and use of acellular dermal matrix (ADM) (48.15% to 90.63%, p<0.001). This study documents recent increases in nipple-sparing techniques for BRRM compared to more traditional skin-sparing methods. Concurrently, reconstruction following RRM has become predominantly implant-based without a flap, coinciding with more widespread usage of ADM. This is consistent with national trends towards fewer complex autologous procedures.

Visual Perception of Breast Free Flap Size Is Influenced by Radiation Changes of Surrounding Tissue.

Microsurgical reconstruction for bilateral mastectomy defects after unilateral radiation often results in asymmetry, despite both flap tissues never being radiated. Photos of 16 patients who received prior radiation to one breast and underwent bilateral abdominal free flap reconstruction were taken postoperatively. Layperson and expert assessment were attained via online crowdsourcing and a panel of attending surgeons and senior residents. Stratification by interflap weight differences was done for subanalysis. A total of 399 laypersons responded, with the majority (57.3%) reporting that the radiated breast appeared smaller than the nonradiated breast. When the photos were stratified by interflap weight differences, the photos with the radiated side flap weight over 3% more than nonradiated side were significantly more likely to be perceived by laypersons as the same size (odds ratio [OR] = 2.7; p < 0.001) and of similar aesthetic (OR = 1.9; p < 0.001) when compared with photos with same-sized flaps. Of the expert responses (n = 16), the radiated side was perceived as smaller 72.3% of the time and the nonradiated side appeared more aesthetic 52.7% of the time. Contrary to layperson responses, the experts tend to report the radiated side as smaller despite varying flap weight. Interestingly, expert raters were significantly more likely to rate the flaps of equal aesthetics when the radiated side has a flap larger by 3% or more (OR = 3.6; p < 0.001). Higher aesthetic scores were noted when larger flaps were inset to the radiated envelope by both laypersons and experts, suggesting potential technical refinement in reconstructive outcomes.

Primary Cutaneous Apocrine Adenocarcinoma of the Axilla in Klinefelter’s Syndrome: A Case Report

Background: Primary Cutaneous Apocrine Adenocarcinoma (PCAA) is a rare cutaneous malignancy that arises from areas rich in apocrine glands, particularly the axilla. There are less than 200 cases described in the literature. However, none has been reported in patients with Klinefelter syndrome, who are known to have an increased risk of breast cancer, Case Presentation: We present a 66-year-old man with a significant family history of breast cancer who developed a right axillary mass initially thought to be hidradenitis suppurativa. On physical examination, he had bilateral gynecomastia. Laboratory workup was significant for hyper-gonadotrophic hypogonadism. Mammography showed bilateral gynecomastia with no radiologic evidence of malignancy in the breast, while magnetic resonance imaging of the breast revealed two suspicious masses seen in the right breast. Excision biopsy of the right axillary mass revealed a high-grade invasive adenocarcinoma involving the dermis and subcutis; the cells had prominent nucleoli vesicular chromatin pattern and voluminous eosinophilic cytoplasm consistent with primary cutaneous apocrine adenocarcinoma. Immunohistochemistry was positive for GATA-3, GCDFP-15, E-cadherin, ER Positive, PR negative, HER 2 by IHC 3 +, and androgen receptor-positive 100 %. Positron emission tomography showed mildly hypermetabolic asymmetric gynecomastia, right greater than left, but no abnormal hypermetabolic activity to suggest malignancy. Karyotype confirmed 47 XXY chromosomes which on. The patient underwent bilateral mastectomy due to his preference; excised breast tissue was negative for malignancy. Conclusion: We presented the first case report of PCAA of axillary in Klinefelter syndrome. Awareness of this association and differentiation from breast carcinoma should be undertaken.