Immediately Reconstructed Research Articles

Immediate Breast Reconstruction After Neoadjuvant Chemotherapy: Factors Associated With Surgical Selection and Complications.

Breast reconstruction has become an integral component of breast cancer treatment, especially for patients who are unable to undergo breast-conserving surgery after neoadjuvant chemotherapy (NAC). We analyzed factors influencing the type of immediate reconstruction surgery after NAC, as well as the complication rates for each surgery type. The study included patients with breast cancer who underwent mastectomy following NAC from 2010 to 2021. Clinicopathological characteristics, unplanned reoperation rates, and the duration of postoperative hospitalization were analyzed in patients undergoing autologous tissue reconstruction (ATR, n = 127), implant-based reconstruction (IBR, n = 60), and combined autologous tissue and implant reconstruction (n = 60). A total of 1651 patients who received NAC before mastectomy were enrolled. Among them, 247 (15.0%) patients underwent immediate reconstruction (IR), whereas 1404 underwent mastectomy only. Patients in the IR group were younger (P < 0.001), had lower body mass index (P < 0.001), and exhibited earlier clinical (P = 0.003) and nodal (P < 0.001) stage than those in the non-IR group. Patients in the ATR group were older (P < 0.001) and had higher body mass index (P = 0.007), larger tumor size (P = 0.024), and more frequent childbearing history (P = 0.011) than those in the other groups. Complications resulting in unplanned reoperations were more frequent in the IBR group (P = 0.039). The duration of postoperative hospitalization was longest after ATR (P = 0.008). Age and clinical tumor/nodal stage at presentation are associated with IR for patients undergoing mastectomy after NAC. For patients undergoing IR after NAC, ATR may be safer and more suitable than IBR.

Patient-Reported Outcome Measures for Patients Who Have Clinical T4 Breast Cancer Treated via Mastectomy with and Without Reconstruction.

Patients with clinical T4M0 breast cancer are recommended to undergo neoadjuvant chemotherapy, modified radical mastectomy, and postmastectomy radiotherapy. This study determined whether BREAST-Q scores differ by decision to pursue reconstruction or timing of reconstruction. This retrospective, single-institutional study analyzed cT4 breast cancer patients from 2014 to 2021 without evidence of distant metastatic disease undergoing mastectomy with or without reconstruction. As routine care, BREAST-Q was administered preoperatively, then 6 months, 1 year, and 2 years postoperatively. Satisfaction and quality-of-life domains were compared between mastectomy with no reconstruction (NR), immediate reconstruction (IR), and delayed reconstruction (DR) groups. Of the 144 patients eligible for this study, 71 (49%) had NR, 36 (25%) had DR, and 37 (26%) had IR. The patients undergoing reconstruction were younger and more likely to elect contralateral prophylactic mastectomy. Timing of reconstruction was not associated with significant differences in satisfaction with breasts (SATBR) at any time point. For the patients who had DR, breast satisfaction increased over time after reconstructive surgery. Physical well-being of the chest (PWB-CHEST) did not significantly differ among IR, DR, and NR at any time point. The patients who underwent DR experienced improvement in PWB-CHEST scores from preoperative scores. The patients with IR and NR experienced PWB-CHEST decline over time. Psychosocial well-being (PSWB) did not differ significantly across time or by subgroup. The patients with T4 breast cancer who elected reconstruction did not differ in patient-reported outcomes based on timing of reconstruction. In the DR cohort, SATBR significantly improved after reconstructive surgery. These data can help inform breast reconstructive decision-making for patients facing the choice among DR, IR, and NR.

Psychosocial and sexual well-being in breast cancer survivors undergoing immediate breast reconstruction: The mediating role of breast satisfaction.

This study aimed to explore (1) the levels of quality of life (psychosocial, physical and sexual well-being) and breast satisfaction in breast cancer patients (BCP) after immediate reconstruction (IR), considering surgery reason and surgical technique, and (2) the explanatory and predictive capacity of psychosocial well-being on breast satisfaction, and of both on sexual well-being. This prospective study included 36 BCP who underwent IR between June 2006 and December 2014. Highest levels of quality of life were found in psychosocial well-being and sexual well-being, with no statistically significant differences by surgery reason or surgical technique in any quality of life indicator or breast satisfaction. Psychosocial, physical well-being and breast satisfaction explained 56.16% of the variance in sexual well-being, where 44.67% was attributed to psychosocial well-being. In addition, breast satisfaction statistically significantly mediated the relationship between psychosocial and sexual well-being, independently of physical well-being. Our findings highlight the importance of IR in reducing psychological morbidity and preserving the quality of life and breast satisfaction. Furthermore, this research indicated that psychosocial well-being should be considered a useful personal resource for improving the sexual well-being of BCP undergoing IR both through its direct effect and the mediated effect of breast satisfaction.

Abstract P1-24-07: Management trends and outcomes assessment for inflammatory breast cancer

Abstract Introduction:Inflammatory breast cancer (IBC) is a rare and aggressive malignancy with a 5-year relapse free survival (RFS) previously reported to be approximately 40%. Standard treatment is tri-modality therapy consisting of neoadjuvant chemotherapy, surgery, and post-mastectomy radiation therapy. Certain systemic therapy recommendations for IBC are based on historical standards (such as use of anthracyclines for HER2+ breast cancer) that may no longer be favored in the real-world setting. Similarly, modified radical mastectomy without reconstruction has traditionally been the operation of choice for patients with IBC due to fears of margin positivity, risk of local recurrence, and the need for timely radiation. Studies have shown that reconstruction in breast cancer patients is associated with improved quality of life. Recognizing this benefit, the role of reconstruction in the setting of IBC is evolving. The purpose of this study is to characterize response to modern neoadjuvant chemotherapy, utilization of reconstruction, and survival outcomes for patients with IBC treated at our institution.Methods:A review of the Cleveland Clinic tumor registry was performed to identify patients with IBC between 2006-2019 who completed all 3 treatment modalities. Patient demographics, disease characteristics, treatment details, recurrence details, and date of last follow-up/death were recorded. Estimates of local and distal recurrence and RFS were created using Kaplan-Meier estimates. Results:A total of 68 patients with IBC were identified. Median duration of follow-up was 1.83 years (0.85-6.82) and median age was 55. Cases included 19 ER-/HER2-, 17 ER-/HER2+, 21 ER+/HER2-, and 11 ER+/HER2+. Pathologic complete response (pCR) was achieved in 27.9% of all patients with results by subtype as follows: ER-/HER2- 21.6%, ER-/HER2+ 41.2%, ER+/HER2- 19.0% and ER+/HER2+ 18.2%. The most common chemotherapy received by patients was AC-Taxol (52.9%). For HER2+ patients, 50% received AC-Taxol and 50% received non-anthracycline based chemotherapy. RFS was similar for ER+/HER2-, ER+/HER2+ and ER-/HER2+ patients, while ER-/HER2- patients had numerically worse RFS (58-65% vs 28% at 5 years) although this was not statistically significant (p=0.06). RFS was significantly better in patients who achieved pCR compared to those who had partial or no response to chemotherapy, regardless of biologic subtype (p=0.038).17 patients (24.3%) had immediate reconstruction (IR), 7 (10.0%) had delayed reconstruction (DR, &amp;gt;1 year after initial treatment) and46 patients (65.7%) had no reconstruction (NR). The 5 year RFS for IR and NR was similar (52% vs 47%, respectively, p=0.5) although surgical complication rates were higher in the IR group (35.3% vs 6.3%, respectively, p= 0.012).Conclusion:With modern approach to treatment, patients with ER+/HER2+ breast cancer have encouraging survival outcomes compared to historical standards. Patients with ER-/HER2- IBC continue to have poor outcomes and are a group of patients in need of better systemic therapy options. In this cohort, patients who underwent IR did not see an appreciable difference in RFS compared to their non-reconstructed counterparts. Patients should have consultation with plastic surgery as initial surgical management is being discussed if reconstruction is desired. These data may be helpful in counseling patients on anticipated complications of surgery with reconstruction. Citation Format: Jennifer Tran, Stephanie Valente, Chao Tu, Megan Kruse. Management trends and outcomes assessment for inflammatory breast cancer [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 P1-24-07.

Reconstruction in Women with T4 Breast Cancer after Neoadjuvant Chemotherapy: When Is It Safe?

Despite limited evidence regarding its safety, immediate reconstruction (IR) is increasingly offered to women with T4 breast cancer. We compared outcomes after IR, delayed reconstruction (DR), and no reconstruction (NR) in patients treated with neoadjuvant chemotherapy (NAC) and postmastectomy radiation therapy (PMRT) for T4 disease. We retrospectively identified consecutive women with T4 tumors treated with trimodality therapy from January 2007 through December 2019. Clinicopathologic characteristics, complications requiring reoperation, time to PMRT, and recurrence patterns were compared. The cumulative incidence of local recurrence (LR) was estimated using Kaplan-Meier methods. Of the 269 women identified, the median (IQR) age was 52 (45-62) years; 164 women (61%) had T4d disease. Forty-five women (17%) had IR, 41 (15%) had DR, and 183 (68%) had NR. IR was independently associated with T4a-c disease (odds ratio [OR], 5.75; 95% CI, 2.57-12.87; p < 0.001) and younger age (OR 0.91; 95% CI, 0.86-0.94; p<0.001). The risk of complications after IR was 22% overall and 46% in T4d patients (6/13), compared with 4.4% overall for NR and 7.3% for DR (p < 0.001). IR was associated with >8-week interval to PMRT (p < 0.001). At a median (range) follow-up of 4.2 (0.2-13) years, the median time to first recurrence was 18 months and was similar between groups (p= 0.13). The cumulative incidence of LR was 16% for T4d disease and 2.2% for T4a-c disease (p < 0.001). After IR, women with T4 tumors, particularly T4d disease, experienced delayed initiation of adjuvant treatment and substantial morbidity, suggesting that an interval of >18 months between mastectomy and reconstruction is advisable.

Does chemotherapy or radiotherapy affect the postoperative complication in breast cancer patients who underwent immediate breast reconstruction with tissue expander?

BackgroundImmediate breast reconstruction with tissue expander in breast cancer patients who were expected to receive adjuvant therapy, such as chemotherapy or radiotherapy, has been a topic of debate. Postoperative complications from tissue expander procedures can delay the timing of adjuvant treatment and subsequently increase the probability of recurrence. The purpose of this study was to identify the impact of chemotherapy and radiotherapy on postoperative complications in patients who underwent immediate reconstruction (IR) using tissue expander.MethodsWe conducted a retrospective study of 1081 breast cancer patients who underwent mastectomy and IR using tissue expander insertion between 2012 and 2017 in Samsung Medical Center. The patients were divided into two groups based on complications (complication group vs. no complication group). Complication group was regarded to have surgical removal or conservative treatment based on clinical findings such as infection, capsular contracture, seroma, hematoma, rupture, malposition, tissue viability, or cosmetic problem. The complication group had 59 patients (5.5%) and the no complication group had 1022 patients (94.5%).ResultsIn univariate analysis, adjuvant radiotherapy and adjuvant chemotherapy were significantly associated with postoperative complications. In multivariate analysis, however, only higher pathologic N stage was significantly associated with postoperative complications (p < 0.001). Chemotherapy (p = 0.775) or radiotherapy (p = 0.825) were not risk factors for postoperative complications.ConclusionsIR with tissue expander after mastectomy may be a treatment option even when the patients are expected to receive adjuvant chemotherapy or radiotherapy. These results will aid patients who are concerned about the complications of IR caused by chemotherapy or radiotherapy determine whether or not to have IR.Trial registrationPatients were selected and registered retrospectively, and medical records were evaluated.

Patients' satisfaction with the reconstructive options provided to them measured 18 months after mastectomy surgery for breast cancer.

Mastectomy patients' satisfaction with reconstructive options has not been examined. A national study measured 18-month satisfaction with reconstructive options and collected case-mix and reconstructive offer and uptake data on breast cancer patients having mastectomy with or without immediate reconstruction (IR) in England between January 2008 and March 2009. Multivariable logistic regression examined the relationship between satisfaction, age, IR offer and uptake, and clinical suitability. Of 4796 patients, 1889 were not offered IR, 1489 declined an offer and 1418 underwent it. Women not offered IR were more likely older, obese or smokers and had higher ASA grades, ECOG scores, tumour burdens and adjuvant chemotherapy and radiotherapy likelihoods (9% of lowest suitability group offered IR; 81% in highest suitability group). 83.7% were satisfied with their reconstructive options, varying significantly by IR offer and uptake (76.1% for those not offered IR; 85.8% for those who declined IR; 91.7% following IR). Older women and women deemed more suitable for IR were more often satisfied (p-values <0.001). Satisfaction varied by offer and uptake status, age and suitability score. Clinicians should target equity for women deemed unsuitable by exploring their needs and desired outcomes, standardising operative fitness assessments and utilising shared decision-making aids.

A Protocol for Resection and Immediate Reconstruction of Pediatric Mandibles Using Microvascular Free Fibula Flaps

The use of a vascularized free fibula graft (FFF) for the reconstruction of a mandible in a child with a mandibular tumor is infrequent. The purpose of this study is to report our protocol for resection of mandibular jaw tumors and immediate reconstruction using FFF in pediatric patients. This was a retrospective case series of children with a mandibular tumor, which was resected and immediately reconstructed with FFF. All patients were treated via the same staged protocol: 1) presurgical digital planning, 2) surgical intervention (resection and immediate reconstruction), 3) postoperative care in the pediatric intensive unit, and 4) prosthodontic dental rehabilitation. Outcomes were complications and recurrence. Medical records were reviewed to document demographic information, tumor details, surgical interventions, postoperative course, and prosthodontic rehabilitation. Fifteen patients (10 males, average age of 13.7years) met inclusion criteria. Ten patients had mandibular ameloblastoma. All patients were treated by a dedicated pediatric team and followed the same protocol. The average tumor size was 4.87 × 3.22×2.03cm. Most fibulas (n=12) had one osteotomy to reestablish mandibular continuity and create appropriate contour. The most common microvascular anastomosis was with a facial artery (n=13) and the external jugular vein (n=9). At an average follow-up of 15.5months, there were only 3 minor donor site complications. Eight implants were placed without complications. No tumors recurred. The results of this study suggest that pediatric mandibular tumors can be successfully treated using a specific protocol involving resection and immediate reconstruction using FFF with minimal complications and without recurrence.

Comparison of complications according to incision types in nipple-sparing mastectomy and immediate reconstruction

BackgroundNipple-sparing mastectomy (NSM), followed by immediate reconstruction (IR) of the breast, has become a preferred surgical procedure with good cosmesis results and patient satisfaction. However, nipple-areolar complex (NAC) ischemia and necrosis remain major problems after NSM and IR. MethodsWe retrospectively analyzed patients who underwent NSM and IR at Gangnam Severance Hospital from January 2009 to June 2018. We compared the patient characteristics and complication rate among three different incisions (inframammary fold [IMF], radial, periareolar). Additionally, we identified the risk factors of NAC necrosis. ResultsData from 290 eligible breasts in 275 patients were analyzed. Patients with IMF incision had relatively lower breast weights. The overall complication rate was the highest with periareolar incision and the lowest with IMF incision (42.6% vs. 18.8%, p < 0.001). The rate of NAC ischemia or necrosis was significantly different among the three incisions (9.7%, 17.0%, and 31.1% in IMF, radial, and periareolar, respectively; p < 0.001). Moreover, surgical treatments were more frequently needed in patients with periareolar incision. Periareolar incision, short distance from the tumor to the nipple base, and large breast weight were independent risk factors of NAC ischemia or necrosis in multivariable analysis. ConclusionsCompared with IMF incision, periareolar incision was associated with higher incidences of surgical complications and NAC necrosis. Careful consideration is needed when planning NSM in patients with a large breast volume or a tumor close to the nipple.

Level of surgical reapproach in reference women’s health unit

Globally, breast carcinoma is the most commonly diagnosed cancer and the main cause of death by cancer among women. Its treatment requires a multidisciplinary approach, involving radiotherapists, oncologists and surgeons. Despite the advancements in therapy, surgery still plays an essential role in the treatment. A postoperative complication rate is expected, which ranges according to the type and extension of the procedure. The quality of surgical approach is mirrored by the measurement of direct results, such as morbidity and mortality of the patient. There are some indicators of quality that are usually used to assess a service, such as rate of complications, time of hospitalization, patient’s satisfaction and rate of reoperation. Objective: To assess the surgical reapproach rates in a reference women’s health unit – Hospital Pérola Byington (CRSM), comparing them with the data observed in a literature review from major global institutions. Methods: Literature review of retrospective studies carried out in major institutions and data from CRSM. Results: The main complications that lead to surgical reapproach include bleeding, infection, seroma, problems in the injury, matters related to reconstruction and others. From the CRSM database, of a total of 8,806 analyzed patients, about 48.2% were submitted to conserving surgery (CS), and 51.8%, to mastectomy (MASTE). The rate of reoperation in CRSM in the past 8 years is 1.82%. By confronting these data with the data review of ACS-NSQIP, we identified that patients submitted to MASTE with immediate reconstruction (IR) were more prone to undergoing a reoperation due to complications (6.8%) in comparison to patients who underwent MASTE without IR (2.8%) or CS with or without pedicular rotation (2.4% and 0.7%, respectively); the general rate of reoperation was 4.2%. Conclusion: Even though the rate is low, considering the high number of surgeries carried out in the service, it is necessary to maintain the complication rates to a minimum. The possible causes for the significantly reduced volume of reapproaches in CRSM should be considered: The imaging team is prepared, allowing a more accurate location of tumor beds, for example, the department of non-palpable lesions (NPL), which is responsible for mammotome clip and needling. This allows the signaling of a tumor bed, before and/or after being submitted to neoadjuvant chemotherapy (NEO CT); number of MASTE being higher to the number of CS, therefore, with fewer chances of residual tumor in the tumor bed. Usually, patients arrive to our unit at an advanced tumor clinical stage, therefore, with indication for MASTE; presence of pathologists in the surgical unit available at the time of the procedure, therefore, intraoperative freezing, which allows to increase margins in the same surgical period, preventing reapproaches; Multidisciplinary team, including NEO CT. Integrated care protocols can significantly reduce the rates of postoperative complications.

Immediate Reconstruction of Segmental Mandibular Defects with Non-Vascularized Bone Grafts

Purpose There is long-standing evidence that a segmental mandibular defect greater than 6cm needs to be reconstructed with a vascularized graft, which significantly increases patient morbidity. We challenge this notion. In this study, we determined maximum defect size that can be predictably reconstructed with nonvascularized bone grafts immediately after resection. Methods A retrospective chart review of 34 patients that had mandibular resections for benign pathologies that were immediately reconstructed with particulate marrow grafts were reviewed. The same senior surgeon at a university medical center oversaw all cases. Cohort demographic and descriptive data were obtained, resection size was determined, and statistics were calculated. Results The patient cohort had a mean age of 49 years (standard deviation [SD] = 12.2), and consisted of 16 males and 18 females. Mean follow-up time was 18 months. Diagnoses included 15 (44%) cases of osteomyelitis, 13 (38%) ameloblastomas, 5 (15%) ossifying fibromas, and 1 (3%) histiocytoma. Average resection size of all cases was 8.7 cm (SD = 4.1). Average resection size of successful grafts was 8.1 cm (SD = 3.2). Graft failures measured 12.1 cm (SD = 2.8). When comparing graft success versus failure there is statistical significance (P Conclusions Taken together, these data demonstrate that segmental mandibular resections for benign pathology can be predictably reconstructed using non-vascular grafts up to 8.1Â ± 3.1cm. The morbidity and time of surgery of particulate marrow grafts is significantly less compared with free-flap reconstruction. Furthermore, the course of treatment in these patients is significantly decreased. This facilitates expedited convalescent care and an earlier return to normal form and function.

Does response to neo-adjuvant chemotherapy impact breast reconstruction?

Neo-adjuvant chemotherapy (NAC) is administered in breast cancer treatment for downstaging of disease. Here, we determined the impact of response to NAC on breast reconstruction uptake. A prospective NAC and mastectomy database with or without reconstruction were reviewed with IRB approval. Univariable analyses were conducted using Kruskal-Wallis or Fisher's exact tests. Multivariable logistic regression was used to adjust for potential confounders. We identified 271 patients with unilateral breast cancer receiving NAC and either unilateral or bilateral mastectomy from 9/2013 to 5/2016. Seventy patients (25.8%) had a pCR to NAC. One hundred and seventy-five patients (64.6%) had immediate reconstruction (IR), and 96 had no IR. On univariable analysis, younger age (P < .001), lower T-stage at presentation (P<.001), bilateral versus unilateral mastectomy (P<.001) and HR-negative tumor subtype (P=.006) were significantly associated with higher IR rates. On multivariable analysis, pCR (P=.792) and tumor subtype (P=0.061) were not significantly associated with IR; T-stage was significantly associated with IR (P < .001), such that patients with T4 tumors at presentation had lower odds of IR (OR 0.10, 95% CI 0.02-0.50), even when accounting for response to NAC. One hundred and seventy-three patients (63.8%) received adjuvant radiation therapy; this was associated with lower IR frequency (P=.048) but was not associated with reconstruction type (tissue expander versus autologous, P=1.0) among 175 patients who had IR. In patients who have mastectomy after NAC, IR is influenced by age, T-stage at presentation, and choice of bilateral mastectomy, but not by response to NAC. A subset of patients who are young, with earlier T-stage and pCR, is more likely to proceed with bilateral mastectomy.

Oral and masticatory rehabilitation using osseointegrated dental implants after resective treatment of multicystic ameloblastoma in the lower jaw with a fibula graft

Ameloblastoma is an aggressive odontogenic tumor which typically occurs between third and fourth decade of life that often needs resective approach. Immediate reconstruction may show better results. The treatment of multicystic ameloblastoma in the mandible being a rare case that occurred in the late second decade of life, which was surgically removed along with the affected teeth with safety margins, and the region was immediately reconstructed using a vascularized graft, removed from the fibula. Its integration, in combination with osseointegrated dental implants and fixed implant-supported prostheses, restored chewing function and esthetics. After 6 years from fibular graft and 24 months of dental implants, an excellent outcome was observed, with oral health and normal functions properly restored, and the immediate reconstruction of the mandible in resective cases, associated with oral rehabilitation with dental implants, may be considered a suitable treatment option.

Immediate Reconstruction of Failed Implants in the Esthetic Zone Using a Flapless Technique and Autogenous Composite Tuberosity Graft

We describe a technique for immediate reconstruction of bone after removal of failed dental implants in the esthetic region to optimize the esthetic outcome of retreatment. We conducted a study of 16 consecutive patients in whom the bony defect resulting from implant removal was immediately reconstructed with a combined autogenous bone and soft tissue graft harvested from the maxillary tuberosity. After a healing period of 3months, implants were inserted. At 1year after placement of the definitive restoration, no implants had been lost, the peri-implant tissues were healthy, the aesthetics scored with the pink esthetic score were favorable, and the patients were satisfied. With this technique, it appears that immediate reconstruction of the hard and soft tissue components with a combined bone-soft tissue graft after removal of an implant is a feasible treatment option, from the perspective of both patients and professionals. It expedites rehabilitation, reduces morbidity, and results in a favorable esthetic outcome.

Comparison of Wound Complications After Immediate, Delayed, and Secondary Breast Reconstruction Procedures

Few data are available concerning surgical site infection (SSI) and noninfectious wound complications (NIWCs) after delayed (DR) and secondary reconstruction (SR) compared with immediate reconstruction (IR) procedures in the breast. To compare the incidence of SSI and NIWCs after implant and autologous IR, DR, and SR breast procedures after mastectomy. This retrospective cohort study included women aged 18 to 64 years undergoing mastectomy from January 1, 2004, through December 31, 2011. Data were abstracted from a commercial insurer claims database in 12 states and analyzed from January 1, 2015, through February 7, 2017. Reconstruction within 7 days of mastectomy was considered immediate. Reconstruction more than 7 days after mastectomy was considered delayed if the mastectomy did not include IR or secondary if the mastectomy included IR. International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for SSI and NIWCs. Mastectomy was performed in 17 293 women (mean [SD] age, 50.4 [8.5] years); 61.4% of women had IR or DR. Among patients undergoing implant reconstruction, the incidence of SSI was 8.9% (685 of 7655 women) for IR, 5.7% (21 of 369) for DR, and 3.2% (167 of 5150) for SR. Similar results were found for NIWCs. In contrast, the incidence of SSI was similar after autologous IR (9.8% [177 of 1799]), DR (13.9% [19 of 137]), and SR (11.6% [11 of 95]) procedures. Compared with women without an SSI after implant IR, women with an SSI after implant IR were significantly more likely to have another SSI (47 of 412 [11.4%] vs 131 of 4791 [2.7%]) and an NIWC (24 of 412 [5.8%] vs 120 of 4791 [2.5%]) after SR. The incidence of SSI (24 of 379 [6.3%] vs 152 of 5286 [2.9%]) and NIWC (22 of 379 [5.8%] vs 129 of 5286 [2.4%]) after implant SR was higher in women who had received adjuvant radiotherapy. Wound complications after IR were associated with significantly more breast surgical procedures (mean of 1.92 procedures [range, 0-9] after implant IR and 1.11 [range, 0-6] after autologous IR) compared with women who did not have a complication (mean of 1.37 procedures [range, 0-8] after implant IR and 0.87 [range, 0-6] after autologous IR). The incidence of SSI and NIWCs was slightly higher for implant IR compared with delayed or secondary implant reconstruction. Women who had an SSI or NIWC after implant IR had a higher risk for subsequent complications after SR and more breast operations. The risk for complications should be carefully balanced with the psychosocial and technical benefits of IR. Select high-risk patients may benefit from consideration of delayed rather than immediate implant reconstruction to decrease breast complications after mastectomy.

Determinants of short and long term outcomes in patients undergoing immediate breast reconstruction following neoadjuvant chemotherapy

We evaluated oncologic outcomes and complications of skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) with immediate reconstruction (IR) after neoadjuvant chemotherapy (NAC) in patients with early-stage and locally advanced breast cancer (BC). BC patients from 2000 to 2014 treated with NAC followed by SSM/NSM and IR were reviewed. Patient demographics, tumor characteristics, NAC response, complications, and recurrence were analyzed. Two hundred sixty-nine patients with 280 BCs were treated with NAC followed by SSM (94%) or NSM (6%) with IR. Median age was 47 (26-72) years with a median follow-up of 45 months. Pathologic complete response (pCR) was noted in 49 (17.5%) cases. Overall 30-day complication rate was 13.2%. Variables associated with complications included BMI (P < 0.0001), tobacco use (P = 0.015), and adjuvant radiation (P = 0.025). Local-regional recurrence was 3.2% and metastatic recurrence was 13.2%. Variables predicting recurrence risk were pre-NAC tumor size (P < 0.001), residual tumor size (P = 0.002), Grade III (P = 0.002), HER-2 negative (P = 0.025), pre-NAC nodal disease (P = 0.05), and lack of pCR (P = 0.045). Following NAC, risk factors for complications in patients undergoing SSM/NSM with IR are high BMI, smoking, and adjuvant XRT. SSM/NSM following NAC is associated with excellent local control. These data support expanding the indications for NSM/SSM to include patients receiving NAC.

Aesthetic Outcome after Nipple Sparing Mastectomy for Cancer Patient Egyptian Pattern

Background: Recent advances in breast reconstruction and the introduction of oncoplastic techniques have resulted in significant improvement in quality of life and psychological well-being of most patients. Nipple sparing mastectomy is a surgical technique that removes breast tissue while preserving the native skin envelope, infra-mammary fold and the NAC, which allows immediately reconstructed breasts to have an excellent cosmetic outcome. Aim: Our primary end point was for objective assessment of aesthetic outcome after NSM via more accurate new method and subsiding bias in that assessment and the secondary end point was for evaluating the influence of incision choice and recommending which incision is the best for each patient putting in mind cup size, degree of ptosis and body mass index of Egyptian patients. Methods: Starting January 2013 to November 2015, 74 patients with breast cancer underwent NSM with immediate reconstruction using LD flap with or without implant augmentation. Results: Incisions used are elliptical (37.8%), lateral (27%), peri-areolar (21.6%) and infra-mammary (13.5%). In 81.1% of the patients, the procedure was performed using extended LD flaps only, while in the remaining 18.9% the flaps were augmented using implant insertion. Axillary dissection was done in 68.9% of patients and SLN in 24.3% of patients. Overall aesthetic results were done by patient self-assessment, assessment by the surgeon, assessment by professional plastic breast surgeon and assessment by onco-plastic surgeon, and this was followed by statistical analysis of the agreement between the plastic surgeon and the onco-plastic surgeon. Conclusion: NSM is safe, feasible and offers adequate oncologic results along with excellent cosmetic outcome. Choice of incision and reconstruction should be tailored to suit each patient. Breast cancer patients can benefit from sound resection and enjoy a sense of wholeness.

Assessing long-term complications in patients undergoing immediate postmastectomy breast reconstruction and adjuvant radiation

PurposeThe purpose of this article is to report the long-term rate and timing of complications associated with postmastectomy radiation therapy (PMRT) following immediate breast reconstruction in a large patient population. Methods and materialsWe identified and reviewed the charts of all patients with stages I through IIIC breast cancer who underwent mastectomy with immediate reconstruction followed by subsequent radiation therapy between November 1997 and May 2010. We aimed to assess the rate of major complications, defined as events requiring a separate and distinct procedure. Statistical analysis between variables was evaluated using Fisher exact test and Pearson χ2 Elder et al. (2005) test. ResultsIn total, 134 patients met inclusion criteria for having adequate long-term follow-up and documentation. The median follow-up for all patients was 77.4 months (range, 6-185 months). The overall major complication rate was found to be 44%. Nine patients (6.7%) experienced complications for which a secondary procedure could not be performed to retain a reconstructed breast. The average time between initiation of PMRT and the first major complication was 13.5 months, with 68.3% of first major complications occurring within 1 year of PMRT initiation and 81.7% within 2 years. The difference in incidence of major complications for patients undergoing immediate tissue expander/implant reconstruction followed by PMRT was not statistically different when compared with that for patients with immediate autologous tissue reconstruction followed by PMRT (47.3% vs 30.4%, P = .168). ConclusionsThe risk of first major complications and reconstruction loss in patients undergoing PMRT on immediately reconstructed breasts is greatest within 1 year of beginning radiation therapy and decreases significantly with time. Immediate autologous tissue reconstruction followed by PMRT can be performed with reasonable complication rates.

Staged Reconstruction Brachytherapy Has Lower Overall Cost in Recurrent Soft Tissue Sarcoma

Recurrent soft tissue sarcoma (STS) of the extremity can be effectively treated with adjuvant brachytherapy (AB). Prior studies have shown a reduction in wound complications with the use of staged reconstruction (SR) and negative pressure wound therapy (NPWT) when treating STS with wide local excision (WLE) followed by high dose rate AB. Compared to immediate reconstruction (IR) techniques, SR may have higher expected costs due to hospitalization during treatment, wound-vac expenses, and the need for additional procedures and reconstruction. The purpose of this study is to determine whether the benefits of SR translate into lower cost and toxicity. Records of 145 STS patients treated with AB between 1999 and 2015 were reviewed from an IRB approved institutional database. Patients with recurrent STS of the extremity treated with resection followed by AB at our institution were identified. Hospital charges accrued at our institution were reviewed for patients with a minimum of 12 months of follow up. AB was delivered with Ir-192 to 3200-4500cGy BID in 8-10 fractions. Median follow-up was 31 months. The cohort of 22 patients (12 SR, 10 IR) included those with lower extremity disease (64%), FNCLCC grade 3 (64%), and previously irradiated (77%). The patient and tumor characteristics were relatively well balanced between SR and IR. When compared to IR, the SR cohort had a higher percentage of wound vac use (75% vs. 0%, P<0.001), reconstruction as mode of final closure (83% vs. 20%, P = 0.003), and longer initial hospital stay (10 vs. 3 days, P = 0.002). On MVA, SR independently predicted for lower rates of chronic pain (>1 year: 8% vs. 50%, OR 0.09 95% CI 0.01-0.7, P = 0.022) and chronic edema (>30 days: 60% vs. 17%, OR 0.2 95% CI 0.4-0.9, P = 0.038). The cost of initial hospital stay favors IR ($79k vs. $96k, P = NS). The charges accrued after initial hospitalization became significant during months 12 to 18 months ($9k vs. $68k, P = 0.046) following WLE. At 18 months, the total hospital days were no longer different between SR and IR, both of which had an average of 11 days, because IR had a higher hospitalization rate after initial WLE. Local control (LC) favors SR at 18 months (85% vs. 42%, P = 0.034). Two-thirds of local recurrences (LR) occurred during months 6 to 12, predicting for a difference in cost during this time period ($90K vs. $16k, P = 0.003). After exclusion of patients with LR, there was no difference in cost between SR and IR. On MVA, predictors of cost at initial treatment was hospital stay (∼$4.5k per hospital day, P<0.001). At 18 months, SR independently predicted for decrease in cost ∼$175k (95% CI $69k-$286k, P = 0.005). In our single institution experience of recurrent STS, SR may have higher initial costs during WLE and reconstruction. However, at 18 months SR had lower toxicity and local recurrence rates compared to IR, which translated to lower total costs for the patient.

National trends and regional variation in immediate breast reconstruction rates.

Previous studies have identified variation in immediate reconstruction (IR) rates following mastectomy for breast cancer across English regions during a period of service reorganization, a national audit and changing guidelines. This study analysed current variations in regional rates of IR in England. Patient-level data from Hospital Episode Statistics were used to define a cohort of women who underwent primary mastectomy for invasive or in situ breast carcinoma in English National Health Service (NHS) hospitals between April 2000 and March 2014. A time series of IR rates was calculated nationally and within regions in 28 cancer networks. Regional IR rates before and after the national audit were compared, using logistic regression to adjust for patient demographics, tumour type, co-morbidity and year of mastectomy. Between 2000 and 2014, a total of 167 343 women had a mastectomy. The national IR rate was stable at around 10 per cent until 2005; it then increased to 23·3 per cent by 2013-2014. Preaudit (before January 2008), adjusted cancer network-level IR rates ranged from 4·3 to 22·6 per cent. Postaudit (after April 2009) adjusted IR rates ranged from 13·1 to 36·7 per cent, with 20 networks having IR rates between 15 and 24 per cent. The degree of change was not greatest amongst those that started with the lowest IR rates, with four networks with the largest absolute increase also starting with relatively high IR rates. The national IR rate increased throughout the study period. Substantial regional variation remains, although considerable time has elapsed since a period of service reorganization, guideline revision and a national audit.