Bilateral Skin-sparing Mastectomy Research Articles

Quality of Life after Bilateral and Contralateral Prophylactic Mastectomy with Implant Reconstruction

Background: Prophylactic mastectomy is an effective approach to breast cancer risk reduction in patients at high risk. Further studies using standardized measures for quality of life are needed to better understand the effect of prophylactic mastectomy on individual patients and, thereby, allow for better patient counseling and selection. Methods: In this prospective study patients undergoing bilateral mastectomy were asked to complete the BREAST-Q questionnaire before and 1 year after surgery. All patients underwent bilateral mastectomy with implant-based breast reconstruction. Patient- and surgery-related information was collected in a database. Results: In total, 48 patients underwent bilateral skin-sparing mastectomy. Of these, 29 (60.4%) suffered from breast cancer. A 2-stage reconstruction with intermediate expander implantation was conducted in 19 (39.6%) patients. All patients completed the BREAST-Q questionnaire. The domain “psychosocial well-being” was significantly improved from a mean score of 74.98 preoperatively to a postoperative score of 81.56 (p = 0.021). In contrast, the domain “physical well-being” dropped –8.38 points on average to a postoperative score of 74.96 (p < 0.001). Interestingly, patients with the lowest preoperative score in the domain “satisfaction with breast” showed the greatest increase after surgery (50.31 vs. 67.25, p < 0.001). On the contrary, patients with the highest preoperative values experienced the strongest decrease in satisfaction (91.60 vs. 75.27, p = 0.012). Conclusion: Implant-based prophylactic mastectomy leads to good quality-of-life results in patients at high risk for breast cancer. Especially, patients with a low preoperative satisfaction with their breasts have a significantly higher chance of experiencing substantial improvements in their quality of life.

Initial clinical experience of postmastectomy intensity modulated proton therapy in patients with breast expanders with metallic ports

PurposeThe feasibility of proton postmastectomy radiation therapy in patients reconstructed with expanders has not been previously reported, limiting treatment options. We analyzed the dosimetric impact of the metallic port contained within expanders on intensity modulated proton therapy (IMPT) and report our techniques and quality control for treating patients in this setting. Methods and materialsTwelve patients with the same expander model underwent 2-field IMPT as part of a prospective registry. All planning dosimetry was checked with an in-house graphic processing unit--based Monte Carlo simulation. Proton ranges through the expander were validated using a sample implant. Dosimetric impact of setup metallic port position uncertainty was evaluated. Pre- and posttreatment photographs were obtained and acute toxicity was graded using the Common Terminology Criteria for Adverse Events, version 4.0. ResultsNine patients had bilateral skin-sparing mastectomy with bilateral tissue expander reconstruction, and 3 patients had unilateral skin-sparing mastectomy and reconstruction. The left side was treated in 10 patients and the right side in 2. Target coverage and normal tissue dose uncertainties resulting from the expander were small and clinically acceptable. The maximum physician-assessed acute radiation dermatitis was grade 3 in 1 patient, grade 2 in 5 patients, and grade 1 in 6 patients. ConclusionsPostmastectomy IMPT in breast cancer patients with expanders is feasible and associated with favorable clinical target volume coverage and normal tissue sparing, even when taking into account treatment uncertainties; therefore, these patients should be eligible to participate in clinical trials studying the potential role of proton therapy in breast cancer. We caution, however, that institutions should carry out similar analyses of the physical properties and dosimetric impact of the particular expanders used in their practice before considering IMPT.

Successful Breast Reconstruction Despite Dislodgement of Tissue Expander Magnetic Ports

Structural failure of breast tissue expanders (TE) has previously been reported (port dislodgement,1-3 reversal of port magnetic polarity,4 and excessive heating of the magnetic port5), but in each case the surgeon has chosen to remove the failed tissue expander, thereby interrupting the reconstructive sequence and subjecting the patient to an additional, unanticipated anesthetic event. A 46-year-old woman underwent preoperative chemotherapy, bilateral skin-sparing mastectomy, immediate reconstruction with bilateral sub-pectoral Natrelle 600 mL 133MX-14 TE (Allergan, Dublin, Ireland) in November 2014. This was followed by postoperative radiation to the left axilla and chest wall. She then developed symptoms concerning for brain metastases, and 3-Tesla magnetic resonance imaging (3T MRI) was attempted, but as the table was being advanced towards the magnet, she felt the acute onset of pain in her bilateral breasts. She was immediately withdrawn from the MRI, and the test was aborted. She reported discomfort in her chest for approximately 72 hours, although physical exam did not reveal any changes (eg, burns, deformation of breast mounds). Her neurologic symptoms resolved, and her oncologists opted to not pursue further …

Breast amyloidosis: a case report

Amyloidosis is an uncommon disorder characterized by extracellular deposition of abnormal proteins. Breast involvement has rarely been reported and can clinically be misdiagnosed as breast cancer. A 60-year-old woman presented with a 3-mm diameter mass in the right breast close to a silicon implant positioned 20 years before. A core biopsy, performed to rule out breast cancer, showed amyloid deposit. Further exams confirmed a systemic amyloid light chain amyloidosis. After few months the mass increased causing breast volume and shape distortion. Since breast cancer may be the cause of amyloid deposits or be hidden by it, the patient underwent a bilateral skin sparing mastectomy and expander and fat grafting breast reconstruction. The resection specimens showed amyloid deposits only, no evidence of cancer. At 2 years follow-up, no breast amyloidosis recurrence was shown. Breast amyloidosis is rare but can occur in a plastic surgeon’s practice. It is mandatory to rule out a comitant breast cancer or systemic amyloidosis.

Abstract P2-13-04: Clinical outcome and patient satisfaction with the use of bovine-derived acellular dermal matrix (SurgiMendTM) in implant-based immediate reconstruction following skin sparing mastectomy: A prospective observational study

Abstract The advent of acellular dermal matrix devices (ADMs) has facilitated immediate breast reconstruction (IBR) with mammary implants following skin sparing mastectomy (SSM) for breast cancer treatment or risk reduction. This is a prospective observational single institution study of 118 consecutive patients undergoing a total of 164 SSM and IBR procedures using an implant and bovine-derived ADM (SurgiMend) for breast cancer or risk reduction purposes during 2012-2014. The primary endpoint was the explantation rate and secondary endpoints included patient quality of life, patient satisfaction, objective assessment of aesthetic outcome, surgical complications, recurrence and mortality. The mean age of the patients was 50.1 years (median age of 48, range of 27-78). Median follow up time was 21 months (mean of 21.4 months, range of 2-40 months). 46 patients had a bilateral SSM and IBR, 5 of whom had bilateral breast cancer and 3 for risk reduction due to a significant genetic mutation. The remaining 37 patients had unilateral breast cancer and a contralateral risk reducing mastectomy. 27 (37.5%) of the 72 patients who had unilateral SSM underwent contralateral adjustment procedures to optimise symmetry, including 9 augmentation mammoplasty, 12 mastopexy and 4 reduction mammaplasty procedures and 2 combined augmentation-mastopexies. 61 patients (51.7%) received chemotherapy, 5 of whom had primary systemic therapy prior to surgery. 32 (27.1%) patients received radiotherapy (10 patients had prior radiotherapy and 22 patients had post mastectomy radiation: PMR). Those with ER positive disease received hormonal therapy. Those with Her2 positivity received Herceptin +/- Pertuzumab. Over the study period, 2 implants had to be removed resulting in an explantation rate of 1.2%. Overall, wound complications were observed in 6 (3.7%) cases. There were 2 cases of local recurrence (1.7%), one distant recurrence (0.8%) and one patient died of metastatic breast cancer (0.8%). Overall survival was 99.2% and locoregional disease free survival (LRFS) was 98.3%. One patient (0.8%) developed a mild inflammatory reaction secondary to the underlying mesh. Wound complications were observed in 3 other patients (2 haematomas and wound dehiscence/persistent seroma requiring implant replacement). Patient satisfaction with the procedure was very high. The mean Breast Q Score was 85 and mean overall patient satisfaction was 9 out of a possible 10. The mean objective assessment score was 8.9 out of a possible 10 and the mean subjective capsular contracture severity score was 2.9 out of 10. In patients undergoing reoperations, the incorporation rate of the mesh was found to be very high almost approaching 95%. SurgiMendTM is an effective adjunct to IBR using implants following SSM for breast cancer or risk reduction, with a very low rate of implant loss and a high level of patient satisfaction. Furthermore, this ADM seems to incorporate readily and is associated with a very low incidence of inflammatory reactions. Neither prior radiotherapy nor PMR radiation represents a contraindication to its use. Citation Format: Wazir U, Kasem A, Headon H, Choy C, Manson A, Heeney J, Mead O, Mokbel K. Clinical outcome and patient satisfaction with the use of bovine-derived acellular dermal matrix (SurgiMendTM) in implant-based immediate reconstruction following skin sparing mastectomy: A prospective observational study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-04.

Bilateral Thoracodorsal Neuromas: A Cause of Persistent Breast Pain after Bilateral Latissimus Dorsi Breast Reconstruction.

Bilateral Thoracodorsal Neuromas: A Cause of Persistent Breast Pain after Bilateral Latissimus Dorsi Breast Reconstruction.

Transverse Upper Gracilis Flap with Implant In Postmastectomy Breast Reconstruction: a Case Report

Autologous flaps can be used in combination with prosthesis in postmastectomy breast reconstruction. The deep inferior epigastric perforator (DIEP) flap is considered the preferred choice among autologous tissue transfer techniques. However, in patients with a peculiar figure (moderately large breasts and large thighs with flat stomach), who cannot use their abdominal tissue, the transverse upper gracilis (TUG) flap with implant is investigated as a further option for breast reconstruction. This report presents a patient who underwent the TUG flap plus implant reconstruction. A bilateral skin-sparing mastectomy was performed removing 340 g for each breast. The volume of the TUG flaps was 225 g (left) and 250 g (right). Preoperative volumes were restored by placing under the TUG muscle a round textured implant. No complications occurred during the postoperative period both in the recipient and donor site and the outcomes of the procedure were good. In cases where the use of the DIEP flap is not possible because of past laparotomies or inadequate abdominal volume, the TUG flap plus implant may be considered as a valid alternative.

Traditional electrosurgery and a low thermal injury dissection device yield different outcomes following bilateral skin-sparing mastectomy: a case report

IntroductionAlthough a skin- and nipple-sparing mastectomy technique offers distinct cosmetic and reconstructive advantages over traditional methods, partial skin flap and nipple necrosis remain a significant source of post-operative morbidity. Prior work has suggested that collateral thermal damage resulting from electrocautery use during skin flap development is a potential source of this complication. This report describes the case of a smoker with recurrent ductal carcinoma in situ (DCIS) who experienced significant unilateral skin necrosis following bilateral skin-sparing mastectomy while participating in a clinical trial examining mastectomy outcomes with two different surgical devices. This unexpected complication has implications for the choice of dissection devices in procedures requiring skin flap preservation.Case presentationThe patient was a 61-year-old Caucasian woman who was a smoker with recurrent DCIS of her right breast. As part of the clinical trial, each breast was randomized to either the standard of care treatment group (a scalpel and a traditional electrosurgical device) or treatment with a novel, low thermal injury dissection device, allowing for a direct, internally controlled comparison of surgical outcomes. Post-operative follow-up at six days was unremarkable for both operative sites. At 16 days post-surgery, the patient presented with a significant wound necrosis in the mastectomy site randomized to the control study group. Following debridement and closure, this site progressively healed over 10 weeks. The contralateral mastectomy, randomized to the alternative device, healed normally.ConclusionWe hypothesize that thermal damage to the subcutaneous microvasculature during flap dissection may have contributed to this complication and that the use of a low thermal injury dissection device may be advantageous in select patients undergoing skin- and nipple-sparing mastectomy.

First case of invasive breast cancer following prophylactic bilateral skin sparing mastectomy in a BRCA1 mutation carrier

correspondence: Corresponding author. Fax: +088 75 580 22. (van Hillegersberg, R.)

Bilateral ductal carcinoma in situ of the breast after radiation therapy for Ewing’s sarcoma of the vertebra in a young woman: Report of a case

Thoracic radiation in the early years of life is a known risk factor for breast cancer later in life. A 21-year-old woman who had received thoracic radiation therapy for Ewing's sarcoma of the vertebra 9 years earlier was referred to our hospital for investigation of a palpable mass in her left breast. Ultrasonography and excisional biopsy showed ductal carcinoma in situ (DCIS) of the left breast, with no detectable pathology in the right breast except that it was more hypoplastic than the left breast. Considering the known risk factors for invasive breast cancer in both breasts, we performed bilateral skin-sparing mastectomy with immediate breast reconstruction using subpectoral implants. The final histopathological diagnosis was bilateral DCIS.

Contralateral Prophylactic Mastectomy and Prophylactic Salphingo-Oophorectomy in a BRCA1-Positive Breast Cancer Patient: A Case Report

Risk-reducing surgery is known as the most powerful preventive strategy for BRCA mutation carriers. This current case report represents the first documentation of the contralateral prophylactic mastectomy (CPM) and bilateral salphingooophorectomy (BSO) in a carrier of BRCA mutation in Korea. The patient was a 39-year-old woman who was seen in at a genetic counseling clinic for discussing of risk-reducing strategies for the breast and ovarian cancer. She presented at the age of 38 year with a 1.5 cm sized, grade 3, and ER/PR/HER2 negative infiltrating ductal carcinoma of the right breast. She was treated with wide local excision of the right breast and sentinel lymph node biopsy of the axilla. She was then treated with CAF (Cyclophosphamide+Doxorubicin+5-Fluorouracil) chemotherapy and radiation therapy. She was initially counseled at the time of surgery due to the family history of her mother, who suffered with breast cancer at the age of 58. After the completion of chemotherapy, we received the genetic test results and it was positive for the BRCA1 mutation (3746_ 3747insA). After a long discussion of cancer surveillance and risk-reducing options, she decided to undergo ipsilateral mastectomy and CPM and BSO. Before surgery, psychiatric consultation was done and questionnaires evaluating her depression, anxiety, body image, quality of life, and psychological distress were filled out. After discussion with the plastic surgeon, she decided to undergo delayed reconstruction of the breast. We performed endoscopic bilateral skin-sparing mastectomy and a laparoscopic bilateral salphingo-oophorectomy. There was no complication after surgery and the pathologic examination revealed no evidence of cancer in both breasts and ovaries. We think that CPM and BSO are feasible risk-reducing options for the breast cancer patients with the BRCA mutation in Korea.

A case of bilateral breast cancer with Peutz–Jeghers syndrome

We report the case of a 30-year old woman, who was diagnosed with Peutz–Jeghers Syndrome (PJS) at the age of 12 when she presented with small intestinal intussusception. Her supervising physician referred her for complete gastrointestinal and extraintestinal malignancy screening in keeping with PJS management guidelines. Screening mammography revealed extensive bilateral microcalcifications, proven to be high grade ductal carcinoma in situ (DCIS) by stereotactic core biopsy. She opted for bilateral skin-sparing mastectomy, with immediate latissimus dorsi flap reconstruction.