Radiation therapy management in BRCA1/2 carriers diagnosed with early breast cancer: An international cohort study.

Out-of-pocket (OOP) costs and healthcare utilization remain unknown for women facing breast conservation and mastectomy. Women aged 18-64 who underwent upfront breast cancer surgery were identified from the IBM MarketScan Commercial Claims Database (2014-2017). Surgical groups included lumpectomy+radiation; unilateral mastectomy + /-reconstruction, and bilateral mastectomy + /-reconstruction. Cumulative OOP payments were assessed at 12-month intervals over 4 years postoperatively and adjusted to 2017 USD$. Multivariable regression identified factors associated with increased OOP costs. Overall, 23,159 underwent lumpectomy with radiation (60%), unilateral mastectomy with (15%) and without (6%) reconstruction, and bilateral mastectomy with (17%) and without (2.6%) reconstruction. Women undergoing bilateral mastectomy+reconstruction were younger than other surgical groups (median age 49 vs. 50-55). In the first year after diagnosis, 1.24 million outpatient visits occurred, 27% of enrollees had inpatient admissions, 23% visited an E.R., and median OOP costs were $5669 (range $0 to $132 125). Cumulative costs were significantly higher in women < 45 yo and for those with greater comorbidities. Median OOP costs declined over time (0-12 months: $3661 vs 48 months: $486). OOP costs were 12% higher (8.9%-15.1%) with mastectomy+reconstruction than lumpectomy+radiation ($6529 vs $5333). Out-of-pocket costs and healthcare utilization differ between equally effective surgical treatment options; mastectomy + reconstruction is costlier for patients than breast conservation.

Women harboring pathogenic variant (PV) in the BRCA1 or BRCA2 genes (= BRCA) have an elevated lifetime risk for breast cancer (BC). One of the main options for active BC risk reduction is bilateral risk-reducing mastectomy (RRM). Understanding the factors influencing that decision is important for genetic-counselling and risk mitigation strategy planning. A structured questionnaire was circulated to BRCA carriers, members of the Good Genes NGO in Israel. Data on RRM uptake and timing, factors previously reported to be associated with decision to undergo RRM (e.g., psychosocial, family history, counselling/health-system factors) were obtained. Comparison between carriers who elected to undergo RRM with those who opted for early detection schemes were performed using logistic regression and chi square statistical analyses. Of cancer free women (n = 391), 272 (69.6%) elected to adhere to the recommended surveillance scheme and 119 (30.4%) elected to undergo RRM. The major reasons for electing RRM over surveillance were active BC risk reduction (4.96 ± 0.23), fear of developing BC (4.86 ± 0.50), and having at least one relative with BC diagnosed under age 45 years. Support group discussions emerged as a stronger determinant of RRM uptake than primary care physician or religious guidance. In conclusion, among healthy Israeli BRCA carriers the decision to undergo RRM was influenced by a complex interplay of factors-active BC risk reduction, fear of cancer diagnosis in the context of having one relative with early onset BC and support group discussions were the major drivers of RRM in Israeli BRCA1 carriers.

Factors influencing surgical decision-making in breast cancer: A multicenter study in Japan.

Risk-reducing mastectomy is an established preventive strategy for carriers of pathogenic germline mutations. In patients with severe cardiomyopathy, general anaesthesia may represent a prohibitive risk. Awake regional anaesthesia may offer a feasible alternative in selected high-risk patients. A 51-year-old woman with a pathogenic ATM mutation and severe hypertrophic cardiomyopathy (NYHA III-IV, ASA IV) underwent bilateral nipple-sparing risk-reducing mastectomy under awake thoracic regional anaesthesia using bilateral erector spinae plane and intertransverse process blocks with conscious sedation. Immediate prepectoral reconstruction with lightweight polyurethane-coated implants was performed. The procedure was completed without complications, recovery was uneventful, and the patient was discharged on postoperative day 1. Awake regional anaesthesia enabled maintenance of spontaneous ventilation and haemodynamic stability, while flap-preserving surgical technique and low-impact reconstruction supported uncomplicated recovery. Tailored perioperative strategies may allow safe completion of risk-reducing breast surgery in carefully selected patients otherwise considered unsuitable for conventional anaesthetic approaches.

Free nipple-areola grafting (FNAG) is the most common approach for nipple-areola complex (NAC) reconstruction in transgender patients and is often performed in conjunction with double incision mastectomy for chest masculinization. Unwanted consequences of FNAG include graft failure, hypopigmentation as well as circular scarring around the areola. We developed a novel technique for NAC reconstruction using nipple punch grafts in conjunction with 3D areola tattooing (NPAT). Patient demographics and postoperative complications were reviewed. To compare aesthetic outcomes of NPAT with FNAG, postoperative images of both groups were distributed among public raters using the crowdsourcing platform Amazon MTurk. Raters were asked to rank the aesthetic appearance of each NAC on a 1-7 Likert scale. Eighteen patients (mean age 30 ± 10.74, mean BMI 27 ± 7.36) underwent double incision mastectomy together with NPAT for NAC reconstruction. Mean follow-up was 100 days after surgery. Postoperative complications such as graft loss, partial graft necrosis, hypertrophic/distended scarring were not observed. One patient demonstrated a loss of graft projection, and one patient developed partial graft depigmentation. Across the full sample of 895 public raters, NPAT received significantly higher aesthetic ratings than FNAG (NPAT 5.0 ± 1.5 vs FNAG 4.5 ± 1.8, p < 0.001), a pattern that persisted across different genders and age groups. The NPAT technique is a simple and effective approach to NAC reconstruction in transgender patients, combining the advantages of traditional FNAG and 3D tattooing. Our findings suggest that NPAT may provide an aesthetically superior NAC and potentially reduce complications associated with traditional FNAG.

Radiation therapy complicates implant-based breast reconstruction by inducing fibrosis, vascular compromise, and capsular contracture, often resulting in significant breast asymmetry. Reoperation on irradiated implant pockets carries a high risk of wound-healing complications and implant loss, limiting reconstructive options. We present a case demonstrating a contralateral reconstructive strategy to address radiation-induced asymmetry without revising the irradiated breast. A woman with a history of bilateral mastectomy and implant-based reconstruction developed severe asymmetry following postmastectomy radiation to the left breast. Given the patient's preference for the irradiated breast position and the risks of operating on irradiated tissue, revision was performed on the nonirradiated side using a narrow, ultra-high-profile implant wrapped in acellular dermal matrix that was positioned cephalad. This approach restored symmetry when surgical intervention of the irradiated breast was not advised, and nonsurgical treatment of the contracted breast was not preferred. This technique avoids the morbidity associated with operating on irradiated tissue and represents a safe, reproducible treatment option for select patients.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign proliferative lesion of the breast stroma, most often encountered in premenopausal women as a small unilateral nodule. Occurrence in children and adolescents is exceedingly rare, particularly in the setting of diffuse involvement causing bilateral macromastia. Here, we present the largest documented instance of PASH (in size and weight) in an 11-year-old premenarchal female patient with rapidly progressive, symptomatic bilateral, diffuse breast enlargement, ultimately requiring bilateral subtotal mastectomy with free nipple grafting. Bilateral tumors measured 39.1 cm and 29.2 cm, with resection weights of 10.2 kg and 5.2 kg. In addition, we reviewed all published literature on school-aged children with PASH (ages 6-12, n = 12) and compared them with nine large adult series (n ≈ 1072). Pediatric lesions showed significantly higher rates of bilaterality (50% vs <1%), diffuse/macromastic growth (58% vs <1%), larger mean size (18.3 cm vs 4-5 cm), and greater need for mastectomy (42% vs 1.5%). Our observations from clinical presentations in the literature and our from patient demonstrate that pediatric PASH has the potential to present as rapid, massive bilateral breast enlargement, suggesting that pediatric PASH is not merely a smaller form of the adult disease but a distinct clinical entity requiring age-appropriate management.

A growing number of young breast cancer survivors are seeking information about surgical options after bilateral mastectomy. This study explores the factors influencing decision-making and interactions with the cancer care system among young breast cancer survivors who went "flat," or pursued aesthetic flat closure (AFC) post-bilateral mastectomy. Eighteen breast cancer survivors in the United States diagnosed before the age of 45 who had aesthetic flat closure completed semi-structured interviews. Verbatim transcripts were analyzed using Interpretative Phenomenological Analysis. Eighteen survivors (average age 39years) completed interviews lasting between 54 and 88min. Eight themes about factors that influenced decision-making were identified: centering self or romantic partners' perspectives; emphasizing body functionality, faster recovery, and fewer surgeries; viewing flat as the safest, healthiest, and most natural option; negatively experiencing breasts; questioning the purpose of breasts; benefiting from transgender liberation; serving as a role model; and treatment information gathering and self-advocacy. Regarding medical system interactions, the data revealed themes of assuming reconstruction; infantilizing survivors; dehumanizing survivors; gender-affirming surgeries advancing surgeons' skill sets; and supporting, communicating, and collaborating. Young survivors, who opt to go flat, prioritized functionality, faster recovery, and freedom of bodily autonomy and gender expression over societal beauty standards when making post-mastectomy surgical decisions. Survivors frequently had to advocate for AFC as a treatment option. These findings highlight the need for providers to present a range of affirming and accessible post-mastectomy treatment options. To improve young survivors' cancer care, providers can promote bodily autonomy and include AFC when presenting treatment options.

Postmastectomy breast reconstruction (PMBR) improves patients' quality of life, but patients often lack reliable, individualized information about complication risk. Machine learning (ML) can analyze complex clinical data to generate personalized risk estimates, facilitating shared decision-making. To develop and validate ML models trained on both structured data and manually abstracted variables from unstructured clinical notes to predict major complications after PMBR. This prognostic study used retrospective data from female patients aged 18 years or older who underwent unilateral or bilateral therapeutic mastectomy with immediate or delayed implant-based or autologous reconstruction at 2 academic centers in the US from 2012 to 2022. Demographic, treatment, and surgical variables were extracted from electronic health records with a 1-year postoperative follow-up period. Extreme gradient boosting (XGBoost) and random forest models were trained on 80% of the cohort (329 individuals) and tested on 20% of the cohort (82 individuals). Patients with bilateral prophylactic mastectomy, distant metastases, mixed autologous and implant-based reconstruction, or less than 12 months of follow-up were excluded. Of more than 4000 eligible patients, a random sample of 411 underwent manual health record review for variable abstraction. Data were analyzed from September through November 2024. PMBR. Outcomes of interest were major complications, defined as unplanned reoperations or rehospitalizations within 1 year of reconstruction. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC). The sample included 411 female patients (667 breasts) receiving implant-based (290 individuals [70.6%]) or autologous (121 individuals [29.4%]) PMBR, with a median (IQR) age of 51.3 (44.0-58.3) years. The overall major complication rate was 25.8% (106 individuals). The XGBoost model outperformed the random forest model, achieving an AUROC of 0.83 (95% CI, 0.72-0.94) and an AUPRC of 0.62 (95% CI, 0.55-0.69; baseline: 0.26) on the test set, compared with 0.74 (95% CI, 0.66-0.82) and 0.56 (95% CI, 0.50-0.62), respectively, for the random forest model. Top predictors of major complications included smoking, adjuvant radiotherapy, body mass index, age, and diabetes. Model performance remained consistent across reconstructive modalities. In this prognostic study of PMBR outcomes, an internally validated ML model trained on both structured and unstructured clinical data was used to predict 1-year major complications. Such models support personalized risk assessment, inform decision-making, and provide a foundation for future externally validated and prospectively tested decision-support tools.

BRCA carriers face high risks of developing both breast and ovarian/fallopian tube cancers (hereafter referred to as ovarian). Among BRCA carriers with ovarian cancer, it is not clear whether the risk of breast cancer is sufficiently high that risk-reducing mastectomy should be offered. This study aimed to assess the risk of breast cancer BRCA carriers after a diagnosis of ovarian cancer. We included women with a pathogenic/likely pathogenic variant in BRCA1 or BRCA2, a diagnosis of ovarian cancer, and no other cancer history and no risk-reducing bilateral mastectomy. Women were followed for incident breast cancer from the date of ovarian cancer diagnosis or the date of baseline questionnaire, whichever came last. The 5-, 10-, and 15-year cumulative risks of breast cancer were compared for women with ovarian cancer and an age-matched set of control women without ovarian cancer. A total of 960 participants with ovarian cancer were identified (814 BRCA1 and 146 BRCA2 carriers). After a mean follow-up of 4.9 years, 41 women (4.3%) developed breast cancer, at a mean age at diagnosis of 57.5 years (range, 39-74). Actuarial cumulative breast cancer risks after ovarian cancer were 4.4%, 8.9%, and 11.5% at 5, 10, and 15 years, respectively. Only three breast cancer-related deaths occurred. Among 741 age-matched BRCA carriers without ovarian cancer, actuarial cumulative risks of breast cancer were 20.9%, 38.6%, and 47.2% at 5, 10, and 15 years, respectively. The hazard ratio for breast cancer, after an ovarian cancer diagnosis, compared with no ovarian cancer, was 0.18 ([95% CI, 0.12 to 0.27]; P < .0001). After ovarian cancer, BRCA carriers have a relatively low risk of breast cancer. Risk-reducing mastectomy should not be recommended routinely, but might be considered for long-term survivors. Magnetic resonance imaging surveillance and/or mammography is a realistic alternative.

The Effect of Preoperative Psychological Well-Being on Postoperative Pain and Physiological Parameters in Women Undergoing Mastectomy.

Neurofibromatosis type 1 (NF1) is an autosomal dominant RASopathy associated with increased risk of early-onset breast cancer, particularly triple-negative breast cancer (TNBC). We report a woman in her early 40s with NF1 who presented for elective cosmetic breast surgery and was incidentally found to have a suspicious right breast lesion on screening mammogram. Biopsy confirmed high-grade ductal carcinoma in situ (DCIS) with invasive ductal carcinoma, immunohistochemically triple-negative. Staging investigations revealed no nodal or distant disease. She underwent bilateral mastectomy with right sentinel lymph node biopsy (SLNB), followed by adjuvant docetaxel–cyclophosphamide chemotherapy. Radiotherapy was avoided given the elevated risk of radiation-induced sarcoma (RIS) in NF1. Postoperative reconstruction was staged and ultimately successful. At more than 3 years of follow-up, she remains disease-free with satisfactory cosmetic outcomes. This case highlights the importance of vigilant breast surveillance in NF1, challenges in balancing oncologic control with treatment-related risks, and the need for individualised multidisciplinary care.

Nipple preservation rates of robot-assisted nipple-sparing mastectomy for breast cancer patients with different tumor-to-nipple distance categories.

Crowdsourcing the perception of foregoing nipple-areola complex reconstruction during double incision mastectomy top surgery

Tranexamic acid (TXA) has been increasingly acknowledged as a beneficial pharmacological agent in plastic surgery. However, despite its proven efficacy and safety, there is limited research on its intravenous application in gender-affirming mastectomy, particularly regarding its effect on drain duration, drain output, and length of hospital stay. In this retrospective single-center study, patients who underwent double incision mastectomy with free nipple grafts were categorized into two cohorts: one group receiving TXA and a control group without TXA utilization (TXA vs no-TXA). Demographic characteristics, surgical data, and complication rates were analyzed and compared. A total of 75 patients were included, with 34 procedures performed without the administration of TXA and 41 patients receiving TXA. The median age of the study population was 24 years (range 18-57). Postoperative bleeding requiring surgical revision was significantly less frequent in the TXA group (p = 0.038). Total drain output (p = 0.048), drain duration (p < 0.001) and length of hospital stay (p = 0.008) were significantly reduced in the TXA group. No thromboembolic events or seizures were observed. This study demonstrated that intravenously administered TXA significantly reduces the incidence of postoperative hematoma, length of hospital stay, drain duration, and output after gender-affirming mastectomy. Based on these findings, we would recommend the use of TXA in double incision mastectomy with free nipple grafts to minimize the occurrence of seroma formation and major bleeding-related complications. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Although endocrine prevention has proven to be successful in reducing estrogen receptor (ER)-positive breast cancer, there is still no pharmacologic strategy for preventing ER-negative and BRCA1-associated disease. The study by Moyer and colleagues demonstrated that RXR agonists, particularly IRX4204, delay tumor onset in BRCA1-deficient and triple-negative mouse models, suggesting a potential preventive role through immunomodulation. Yet the translational road ahead is complex, limited by biological uncertainty, sociocultural barriers, and safety concerns. A rational next step may be to carefully design window-of-opportunity trials in BRCA1 carriers undergoing risk-reducing bilateral mastectomy to assess biomarker modulation and tolerability. See related article by Moyer et al., p. 161.

Mastectomy pain blocks: A comparison of preoperative versus intraoperative pectoralis nerve blocks: Mastectomy pectoralis nerve blocks comparison.

As the data on BRCA1/2-associated breast and ovarian cancer prevalence after prophylactic surgery has not been exhaustively investigated yet, we aimed to evaluate the cancer prevalence in a single center cohort of BRCA1 and BRCA2 carriers after conducting prophylactic mastectomy, as well as prophylactic bilateral salpingo-oophorectomy (PBSO) respectively. We included 875 women that were tested positive for a germline variant in the BRCA1/BRCA2 gene (gPV) between 2002 and 2022 at the Center of Hereditary Breast and Ovarian Cancer of the Technical University Munich Germany. Mean follow up was 7.2 years (range 0-44 years; 95% CI: 6.70 to 7.70). We differentiated breast and/or ovarian cancer diseased (n = 643) and non-diseased BRCA1/2 carriers (n = 232). Our analysis confirmed the effectiveness of prophylactic surgeries in genetically predisposed women with a gPV in the BRCA1/2 gene. We observed no breast cancer after prophylactic bilateral mastectomy, 2 contralateral breast cancer diseases after contralateral prophylactic mastectomy and 1 extraovarian serous adenocarcinoma after PBSO. Within the entire study collective, a total of 293 have undergone PBSO, with 6 women having an incidental finding of ovarian cancer and STIC respectively (=2.0%; 1.7% gBRCA1 and 0.3% gBRCA2). Our data suggests that, particularly regarding ipsilateral secondary cancer (ISC), higher oncological safety can be achieved through mastectomy rather than breast-conserving surgery (BCS). In the group of patients who had a second breast cancer and were treated with BCS during their first cancer, 18.3% showed an ISC. Within the patients who were first treated with a mastectomy, only 4.3% showed an ISC. Prophylactic surgeries demonstrate high oncological effectiveness in gPV BRCA1/2 carriers. In particular, mastectomy may provide greater protection against ISC compared with BCS. Further studies will have to be conducted to compare ipsilateral cancer prevalence after breast-sparing surgery and mastectomy.

Goldilocks breast reconstruction for bilateral mastectomy: ‘Just right’ for women with high BMI