Mastectomy In Breast Cancer Patients Research Articles

Dosimetric Influence of Normalization Points on Post Mastectomy Chest Wall Teletherapy

Background: Many advanced radiotherapy techniques had been employed in breast cancer teletherapy, purposely to significantly reduce dose to organs at risk (heart and lungs) with marginal or no compromise in planning target volume (PTV). Majority of used techniques yielded rewarding results in developed countries where facilities, manpower and skills are available. In Nigeria, significant number of post mastectomy breast cancer patients received chest wall irradiation using manual hand planning, therefore, the dose distributions to target volume and organs at risk (OAR) were uncertain. Sokoto centre being the first in the country to use treatment planning system (TPS) focused on identifying planning skills (normalization points) with good 95% dose coverage to PTV, and minimizing dose to OAR. Methods: Eighteen post mastectomy patients (ten rights and eight lefts chest walls) were simulated via computed tomography scan (CT-scan) in supine position with breast board and fudicial markers to demarcate tumour bed borders. Planning target volume (PTV chest walls) and OAR were contoured from the acquired CT images and bi-tangential portals were applied. The energy used from Elekta précised Linac was 6 MV, and dose of 50Gy in 25# was prescribed to each patient. The Upper 1/3rd normalization point (UNP), Lower 1/3rd (LNP) and Inter-field (INP) were sequentially applied as dose normalization points on each planning CT image, dose to PTV and OAR were evaluated using Clarkson and pencil beam calculation algorithms. Statistical analysis was conducted using SPSS Software to study dose distributions of the normalization points. Results: Patients simulated were between the ages of 29-56yrs with mean age of 42yrs. The mean percentage doses from normalization points on left chest walls ranged between 81.7-107.7% to PTV, 13.3-17.8% to the lung and 5.5-6.8% to the heart, the reported hot spots were between 110.7 to 141.5%. Similarly, the mean doses from normalization points on the right chest walls ranged between 81.5-108.8% for PTV, 17.8-23.5% to the lung and 2.7-3.7% to the heart, with hot spots of 108.8-137.9%. The statistical differences using independent-t- test for the normalization points on both left and right chest walls shows p-value < 5%. Conclusion: The three normalization points influenced dose distribution to PTV and OAR differently. The UNP and LNP showed a desired dosimetry with marginal compromise in 95% PTV coverage compared to INP.

259 (PB-083) Poster - Cytokine identification in seroma fluid after mastectomy in breast cancer patients – first results of SerMa pilot study subgroup

Introduction: Postoperative seroma formation is one of the most common and serious complications after breast cancer surgery. It frequently appears after simple or radical mastectomies. Data from our recently published pilot study on immunological processes in seroma formation, showed a specific immune response of CD3+/CD4+ T helper (Th) cells. A significant increase of Th2 and Th17 was observed in both, seroma fluid and peripheral blood of the same patients while no increase was found in healthy controls.

39 (PB-039) Poster - Oncologic outcome of Immediate Breast Reconstruction after mastectomy in breast cancer patients: A Systematic reviews and Meta-Analysis

Background: We performed a comprehensive systematic review of the literature and a meta-analysis of the oncologic outcome of immediate breast reconstruction (IBR) after mastectomy and mastectomy only. The aim of this study was to analyse the impact of IBR on the prognosis of patients with breast cancer.

A Comparison of Wound Complications and Post-operative Factors Following the Use of Hydrodissection for Mastectomy in Breast Cancer Patients

Introduction: Mastectomy with axillary clearance remains the hallmark of breast cancer treatment. The conventional use of electrocautery has been associated with the risk of post-operative complications. Hydrodissection may reduce surgery time and produce fewer wound complications with less post-operative pain. The aim of this study was to compare these 2 modalities. Materials & Methods: This prospective randomised control trial was performed with breast cancer patients in Hospital Selayang, Malaysia, between 1 June 2019 to 1 September 2020. The patients were randomised into conventional and hydrodissection groups. The outcomes of interest were post-operative wound complications and other post-operative factors. A chi-square test and independent Student t-test were used to compare the 2 groups. Result: A total of 94 patients were recruited. There was a significant reduction in post-operative seroma in the hydrodissection group compared to the conventional group (40.4 vs 19.1, p<0.05). The surgery in the hydrodissection group was also shorter (114.09 vs 100.15, p<0.05), and there was less 24-hour post-operative pain (3.28 vs 2.13, p<0.05). However, no significant association was observed with other post-operative wound complications (i.e. flap necrosis, surgical site infection and hematoma) or other post-operative factors (i.e. estimated blood loss, mean volume of drain and duration of drain). It was also demonstrated that the hydrodissection technique lowers the risk of developing seroma 3-fold (odds ratio=0.349, p<0.05). Conclusion: The use of hydrodissection with liposuction cannula reduced the rate of post-operative seroma and provided a shorter operative duration and better post-operative pain control.

Fluence map analyzer reduces low dose volume in locally advanced post mastectomy breast cancer patients

Multi-leaf collimator dose leakage in intensity-modulated radiotherapy (IMRT) plans causes higher low dose volume which increases the long-term risks of radiotherapy. We have developed Fluence Map Analyzer (FMA) program that suggests the ideal field geometry to reduce low dose volume in locally advanced breast cancer IMRT plans. In this comparative experimental study, FMA has been applied to standard IMRT plans (STD-IMRT) of randomly selected 15 left and 15 right-sided locally advanced breast cancer patients. All patients underwent a modified radical mastectomy. The chest wall, IMN, axillary, and supraclavicular lymph nodes are included in planning target volume (PTV). The heart, lungs, contralateral breast, and medulla spinalis were delineated as organs at risk (OARs). Two sets of plans, namely STD-IMRT and FMA-IMRT, were generated for each patient. The dosimetric analysis was performed using dose-volume histogram (DVH) and standard evaluation parameters of PTV and OARs. No differences could be observed among the two techniques for PTV coverage. However, FMA-IMRT plans achieved significantly lower V5 volumes and mean doses of the heart, lungs, contralateral breast, and body contours. FMA-IMRT used a smaller number of sub-fields and fewer monitor units (MU). FMA automizes the field geometry determination process for locally advanced breast cancer IMRT planning while reducing low dose volume significantly.

Free nipple grafting is a Good technique in enhancing Aesthetics of Breast Cancer Surgery

Background: Mastectomy in breast cancer patients still has significant negative psychological impact. Therefore, restoring body image is fundamental to the quality of these women’s lives and breast reconstruction has become an important tool. The nipple-areola complex (NAC) is the central focus of the breast that enhances its aesthetic appearances. NAC preservation is commonly achieved via lipodermal pedicles (nipple-sparing mastectomy) or dermo-glandular pedicle (breast reduction). However, NAC preservation may not be achievable for a variety of reasons; either oncological or technical.

The Implication of Mastectomy Flap Fixation in Decreasing the Incidence of Seroma on Breast Cancer Patient

Highlight: Modification of radical mastectomy with flap fixation treatment in seroma production in breast cancer patients was analyzed.The number of seromas from the drain removal time in patients undergoing modified radical mastectomy with flap fixation was reduced. Abstract: Seroma is the most common complication after mastectomy procedure. This study was conducted to analyse the treatment of flap fixation in seroma production after modified radical mastectomy in breast cancer patients. An interventional prospective clinical study in 35 female patients with breast cancer who underwent modified radical mastectomy with flap fixation in the period August-December 2018 and 35 patients without flap fixation through historical data of patient who underwent modified radical mastectomy in the period 2016-2017 at RSUD Dr. Soetomo Surabaya. Data of characteristic patients will be presented descriptively and analyzed statistically using the appropriate test. The result of the statistical test using Chi Square with a 95% significance level obtained a value of p = 0.000 (p <0.05), it was said statistically that there was a significant relationship between the treatment of flap fixation and the time of releasing drain in this study. The treatment of flap fixation will reduce drainage time by <10 days. The results of the odds ratio (OR) obtained OR = 16 and CI: 95% (4.094 – 62.528) which means that the treatment of flap fixation will reduce the releasing time of the drain 16 times more effectively than not performing flap fixation. Correlation between the treatment of flap fixation and the time of releasing drain was considered to be moderately positive (Contingency Coefficient Chi Square = 0.476). There was a significant reduction in the number of seroma assessed from the time of releasing drain faster in patients who underwent modified radical mastectomy with flap fixation.

1722P Prevalence and predictors of breast reconstruction following mastectomy in breast cancer patients treated in a public center in Mexico

Breast reconstruction (BR) has psychosocial and sexual well-being benefits in breast cancer (BC) patients that undergo mastectomy. However, this practice remains infrequent in many low- and middle-income countries as it is not usually covered by public health insurance schemes. This study aims to determine the prevalence and main predictors of BR among BC patients treated in a public center in Mexico.

Preoperative diagnosis of BRCA1/2 mutation impacts decision-making for risk-reducing mastectomy in breast cancer patients

Decision to undergo risk-reducing mastectomy (RRM) needs to consider several factors, including patient’s preference, surgeon’s preference, family history, and genetic predisposition. The aim of this study was to examine whether preoperative diagnosis of BRCA1/2 mutation status could influence surgical decision-making in newly diagnosed breast cancer patients. We retrospectively reviewed ipsilateral breast cancer patients with BRCA1/2 mutation who underwent primary surgery between January 2008 and November 2019 at a single institution in Korea. Of 344 eligible patients, 140 (40.7%) patients were aware of their mutation status ‘prior to surgery’, while 204 (59.3%) did not. Contralateral RRM rate was significantly higher in the group with BRCA1/2 mutation status identified ‘prior to surgery’ compared to the group with mutation status identified ‘after surgery’ [45.0% (63/140) vs. 2.0% (4/204)] (p < 0.001). Reduced turnaround time of BRCA1/2 testing (p < 0.001) and the use of neoadjuvant chemotherapy (p < 0.001) were associated with BRCA1/2 mutation status identified prior to surgery. Although not statistically significant, higher incidence of developing contralateral breast cancer for BRCA1/2 mutation carriers who underwent ipsilateral surgery-only compared to those who underwent contralateral RRM was observed [12.1% (95% CI: 7.7–17.7%)] (p = 0.1618). Preoperative diagnosis of BRCA1/2 mutation could impact surgical decision-making for breast cancer patients to undergo risk-reducing surgery at the time of initial surgery.

Application of a new serratus anterior plane block in modified radical mastectomy under ultrasound guidance: A prospective, randomized controlled trial

Study objectivesPost-operative pain is a significant concern following modified radical mastectomy in breast cancer patients. The serratus anterior plane block has recently been described as an effective technique for post-operative analgesia of modified radical mastectomy. The purpose of this study was to evaluate the analgesic efficacy and safety of a new serratus anterior plane (SAP) block for post-operative pain of mastectomy. DesignA randomized controlled trial. SettingSingle university teaching hospital, from October 2019 to April 2020. PatientsEighty-seven female breast cancer patients aged 30–81 years scheduled for unilateral modified radical mastectomy. InterventionsParticipants were randomly allocated to receive either general anesthesia plus SAP block (SAP block group, n = 43) or general anesthesia alone (Control group, n = 44). A single injection of 20 ml of 0.5% ropivacaine was administered into fascial plane between the pectoralis major and the serratus anterior in SAP block group. In the Control group, no block intervention was applied. MeasurementsThe primary outcome measure of the study was the VAS pain scores at different time-points (1, 6, 12, 24, 48 h) after modified radical mastectomy whereas the secondary outcome measures were the consumption of opioid analgesics. Main resultsBreast cancer patients in SAP block group had lower VAS pain scores compared with the Control group during the early post-operative period (1 h and 6 h after modified radical mastectomy), both at rest and with movement. In addition, the consumption of propofol was similar in two groups (P = 0.406), and the consumption of sufentanil and remifentanil in SAP block group were significantly lower than that of Control group (P = 0.000 and P = 0.000, respectively). ConclusionsSAP block significantly attenuated post-operative pain and decreased opioids consumption in breast cancer patients undergoing modified radical mastectomy. Trial registrationThis trial is registered in the Chinese Clinical Trial Registry (ChiCTR1900026989).

THE RELATIONSHIP BETWEEN ARM EXERCISES AND THE INCIDENCE OF LYMPHEDEMA IN POST-MASTECTOMY BREAST CANCER PATIENTS IN RSUPH ADAM MALIK MEDAN

Breast cancer is a malignant neoplasm, an abnormal growth of breast tissue that does not see the surrounding tissue, grows infiltrative and destructive, and can metastasize. Every breast cancer patient experiences side effects from various treatment treatments. This is because the therapy that each patient gets varies and also that cancer patients have different genetic backgrounds and different environments. Mastectomy in breast cancer patients can cause many patients to suffer from decreased joint mobility, lymphedema, and limitation in daily activities. These complaints can be overcome with arm exercises. Arm exercises are done to improve circulation and muscle strength and to prevent joint stiffness, preventing lymphedema from occurring. The purpose of this study was to determine the effect of arm exercises on lymphedema prevention. The research design was a quasi-experimental study with a sample size of 64 respondents. The results of the study were p value = 0.001. It is hoped that this study can be used as an education for post-mastectomy patients to improve lymph flow so that lymph flow obstruction does not occur.

Frequency of Contralateral Prophylactic Mastectomy in Breast Cancer Patients with a Negative BRCA1 and BRCA2 Rapid Genetic Test Result.

There is an increasing desire for contralateral prophylactic mastectomy (CPM) among patients with unilateral breast cancer. It is unknown if risk assessment and genetic testing at the time of diagnosis will aid women in their surgical choice. We report on the uptake and predictors of CPM in women receiving a negative genetic test result for BRCA1 and BRCA2 mutations before surgery. Women diagnosed with breast cancer between June 2013 and May 2018 were recruited from four academic health sciences centers in Toronto, Canada. Genetic counseling (risk assessment) and genetic testing was performed prior to surgery. Women were asked about their surgical preference before surgery. At 1year post-surgery we asked what surgery was completed. This study reports on women who received a negative BRCA1/BRCA2 result. A total of 766 women with a mean age of 46 years (range 21-82) were included in the analysis. Before genetic counseling and testing, 37% of the women were undecided or leaning towards CPM; however, after receiving a negative BRCA test, 15% of the women opted for CPM. Thirty percent of women whose mother died of breast cancer elected for CPM, compared with 15% of women whose mother did not die of breast cancer (p=0.03). Women receiving a risk assessment and negative BRCA1/BRCA2 genetic test result before surgery use this information to guide their surgical decision. Uptake of CPM for women who were planning on CPM before genetic testing decreases after receiving a negative BRCA1/BRCA2 genetic test result.

Multi-injection paravertebral block with low volume local anesthetic for anesthesia in radical mastectomy - randomized controlled trial.

Paravertebral block (PVB) is generally used in breast cancer surgery in combination with general anesthesia. Only multi-injection PVB can decrease the volume of local anesthetic (LA) while maintaining the efficacy of the block. The use of small LA volumes in PVB prevents its undesirable distribution from the injection site. The objective of this study was to examine the effect of multi-injection paravertebral block for anesthesia in radical mastectomy in breast cancer patients. The study analyzed 130 cases of anesthesia in radical mastectomy. The patients were randomized to two groups: Group 1 (n = 65) received general anesthesia (GA), and Group 2 (n = 65) received PVB (Th1 to Th6) with GA. In Group 2, 0.75% ropivacaine solution at 1.5 to 3.0 mL per level was used. Serum cortisol levels were measured. The post-operative acute pain perception was measured using a 100-point visual analogue scale (VAS). Fentanyl consumption in Group 1 was 70% higher than in Group 2 (P < 0.05). No increase in intra-operative cortisol levels was seen; 2 hours after surgery, cortisol levels were 3.3 times and 2.7 times higher than the baseline in Group 1 and Group 2, respectively (P < 0.05). VAS scores in Group 2 were lower at 2, 6, 12, and 48 hours after surgery (P < 0.05). Supplementation of GA with multilevel PVB decreased the intra-operative fentanyl consumption. In radical mastectomy, the intra-operative cortisol levels do not increase. The highest VAS pain scores are seen within the first 24 hours after mastectomy.

A PROSPECTIVE STUDY TO EVALUATE CARDIAC FUNCTIONS IN POSTMASTECTOMY LEFT-SIDED BREAST CANCER PATIENTS RECEIVING DOXORUBICIN BASED CHEMOTHERAPY AND CHEST WALL IRRADIATION

This prospective single institution study was carried out with 55 patients to evaluate the cardiac functions in left sided post mastectomy breast cancer patients who received Doxorubicin based chemotherapy with chest wall irradiation. Our study reported only 18% cardiotoxicity in contrast to about 30% in similar studies. There was a decline in the left ventricular ejection fraction after chemotherapy. Radiation did not affect left ventricular function much. The right ventricular systolic dysfunction observed in our study, as depicted by the value of TAPSE decreased after chemotherapy and then after radiation. Neither age nor the use of Taxanes following Doxorubicin administration factored much. The mean cumulative dose of Doxorubicin was confined to 360 mg/m2. Radiation induced cardiac dysfunction was mainly confined to the changes in the dimensions of the ventricles and left atrium volume. Decreased cardiotoxicity observed was probably due to short follow up of 6 months.

ASO Author Reflections: Contralateral Prophylactic Mastectomy in Breast Cancer Patients with CHEK2 Gene Mutations.

ASO Author Reflections: Contralateral Prophylactic Mastectomy in Breast Cancer Patients with CHEK2 Gene Mutations.

Factors contributing to persistent rates of contralateral prophylactic mastectomy in breast cancer patients: Examination of 1051 mastectomies across a single health system.

The American Society of Breast Surgeons (ASBrS) outlined definitive guidelines for contralateral prophylactic mastectomy (CPM) in 2016. Despite this, rates of CPM have remained steady. The objective of this study was to identify factors contributing to persistent over-delivery of CPM. Breast cancer patients across 8 hospitals in a single healthcare system from 2014 to 2018 were retrospectively reviewed. The patients were divided according to whether they received nonindicated CPMs versus other mastectomy types.Nonindicated CPM were those procedures not meeting ASBrS consensus guidelines for recommended patients. CPM rate was calculated for each year in the study period. Patient, disease, provider, and system level factors were obtained. Bivariate analysis was used to identify variables for inclusion in a backward multivariable model. A total of 1,051 patients were analyzed. Nonindicated CPM rates by year remained steady throughout the time period (P=.391). In multivariable regression, patient, disease, and provider level factors were associated with odds of undergoing CPM. Every unit increase in age was associated with a 4% reduction in odds of undergoing CPM (CI 0.941-0.986). Stage 3 breast cancer compared to stage 1 had 53% lower odds of CPM (CI 0.288-0.757). Implant-based breast reconstruction had 2.9-fold higher odds of CPM compared to no reconstruction (CI 1.476-5.551). No system level factors were statistically significant. CPM rates have not notably decreased since the ASBrS consensus statement with certain patient and provider factors impacting persistent overuse of CPM. These results inform oncologic and reconstructive providers of factors contributing to continued use of a nonindicated procedure.

Patterns of supraclavicular area failure after mastectomy in breast cancer patients: implications for target volume delineation.

PurposeTo characterize the pattern of post-mastectomy supraclavicular lymph node (LN) metastases in patients with breast cancer (BC) and to provide insights for individualized clinical target volume delineation for radiotherapy.MethodsWe retrospectively analyzed 88 patients with BC who developed post-mastectomy regional LN metastases. The affected regional LNs were categorized as the ipsilateral medial supraclavicular LN area (IMSC-LN), ipsilateral lateral supraclavicular LN area (ILSC-LN), ipsilateral infraclavicular LN area (IIC-LN), and ≥2 groups in the ipsilateral clavicular LN area (MMIC-LN). Clinical characteristics were included in a multivariate analysis to identify risk factors for clavicular LN metastases.ResultsThe ILSC-LNs (68.2%) were the most common metastatic site. IMSC-LN metastases showed a significant association with estrogen-receptor (ER) negative status, left-sided BC, and positive axillary LNs. Tumor size ≥2.4 cm and Her2 type were predictors of ILSC-LN metastases. Additionally, tumor size ≥2.4 cm, and level I ipsilateral axillary metastases were associated with MMIC-LN metastasis.ConclusionILSC-LN was the most frequently affected group of supraclavicular lymph nodes. ER-negative status, left-sided BC, tumor size, and positive ipsilateral axillary LNs are potentially associated with the pattern of supraclavicular LN metastatic involvement.

Contralateral Risk-Reducing Mastectomy in Breast Cancer Patients Who Undergo Multigene Panel Testing.

An increasing number of breast cancer patients are undergoing expanded genetic testing and are being identified as germline mutation carriers. We sought to determine rates of contralateral risk-reducing mastectomy (CRRM) in patients with various germline mutations. All women ≥ 18years of age with unilateral breast cancer who underwent multigene panel testing between January 1, 2014 and August 1, 2019 at our academic institution were identified. Demographic, tumor, and treatment variables were identified from the medical record. Multivariable analyses were performed to compare factors associated with performance of CRRM. We identified 1613 patients, of whom 28.1% had a pathogenic variant and 40.1% had variants of uncertain significance (VUS). Overall, 420 patients (26.0%) underwent a CRRM. On multivariable analysis, factors associated with CRRM included age < 50years (OR 3.8, 95% CI 3.0, 5.0), race (OR 0.5, 95% CI 0.3, 0.7 and OR 0.4, 95% CI 0.2, 0.7 for Black and Asian women, respectively, versus White women), and the presence of any germline mutation or VUS (OR 13.2, 95% CI 8.7, 20.2 for BRCA1/2; OR 3.9, 95% CI 2.7, 5.8 for non-BRCA germline mutation; and OR 1.8, 95% CI 1.3, 2.6 for VUS). In breast cancer patients who undergo multigene panel testing, a sizeable number of women with pathogenic non-BRCA germline findings are opting for CRRM. Given that the risk of contralateral breast cancer in women with most pathogenic mutations other than BRCA1/2 remains poorly characterized, these data have implications for risk counseling and for ascertaining the true risks of contralateral breast cancer in this population.

Psychosocial impact of mastectomy on female breast cancer patients presenting at an academic radiotherapy oncology centre in Ghana

AbstractIntroduction:Mastectomy is a treatment option for patients diagnosed with breast cancer. There is very limited research into the psychosocial impact of mastectomy on female breast cancer patients, especially in the sub-Saharan African setting which has unique cultural norms. The study aimed at assessing the psychosocial impact of mastectomy on female breast cancer patients attending a radiotherapy/oncology centre in Ghana.Methods:A cross-sectional design was used to undertake this study. A total of 80 female mastectomy breast cancer patients participated in this study. A semi-structured questionnaire was used for data collection over a 5-month period, January to May 2018. The data collected were analysed with Statistical Package for Social Science (SPSS) version 22.Results:Most of the participants were adversely affected psychologically and emotionally by mastectomy. In particular, many (56·7%) agreed that they felt less feminine, and 71% reported they experienced psychological distress as a result of their mastectomy, while 63% of them reported loss of self-confidence. A large proportion of them (51, 63·8%) agreed that their lifestyles had changed following mastectomy, while 58% of them admitted that they felt treated as outcasts by society, and 75% resorted to the use of breast prostheses to reduce attention.Conclusion:The study revealed that mastectomy for breast cancer patients had a negative impact on their psychological, emotional and social well-being. The availability of affordable breast prostheses, involvement of clinical psychologists in the care of post-mastectomy women, provision of emotional, psychological and even financial support could alleviate the psychosocial impact of affected women.

Tumor-to-nipple Distance Should Not Preclude Nipple-sparing Mastectomy in Breast Cancer Patients. Personal Experience and Literature Review.

A retrospective study was performed in 246 breast cancer patients to define whether tumor-to-nipple distance (TND) assessment by breast MRI may select patients eligible to nipple-sparing mastectomy (NSM) as compared to permanent section assessment of retroareolar margin. Pre- and post-operative parameters including imaging data, histology of the primary tumor, biologic prognostic factors, and adjuvant regimens were retrieved; patients with close/positive retroareolar margins underwent nipple or NAC excision. The primary endpoint was loco-regional recurrence (LRR). Patients with TND ≤2 cm had a significantly higher rate of invasive ductal carcinoma (p<0.003) and excision margins less than 2 mm (p<0.000). Eleven retroareolar specimens were positive at definitive pathology; final re-excision specimen examination showed residual disease in seven patients (63.6%). At a median follow-up of 31 to 33 months, no NAC recurrence did occur; disease-free survival was more than 96%, and LRR was homogeneously distributed among TND subgroups. Therapeutic NSM is a safe procedure independently of TND assessed at preoperative breast MRI. Permanent section assessment of retroareolar tissue is more accurate and cost-effective than frozen section. Furthermore, delayed nipple and/or NAC excision did not impair local disease control.