Previous Lumpectomy Research Articles

Abstract P2-14-14: Effect Of Intra-operative And Post-operative Topical Tranexamic Acid On early post-operative complications In Patients Undergoing Axillary Lymph Node Dissection For Breast Cancer- A randomized controlled study

Abstract TITLE: Effect of intra-operative and post-operative topical tranexamic acid on early post-operative complications in patients undergoing axillary lymph node dissection for breast cancer. Authors: PACHIMATLA AKHIL GOUD1, ISHITHA LARAOIYA2, SIDDHANT KHARE3, R N NAGA SANTHOSH IRRINKI2, GURPREET SINGH4. Affiliation: 1. Junior Resident, Department of General Surgery, Post Graduate Institute of Medical Education & Research (P.G.I.M.E.R.), Chandigarh. 2. Assistant professor, Department of General Surgery, Post Graduate Institute of Medical Education & Research (P.G.I.M.E.R.), Chandigarh. 3. Associate professor, Department of General Surgery, Post Graduate Institute of Medical Education & Research (P.G.I.M.E.R.), Chandigarh. 4. Professor and Head (retired), Department of General Surgery, Post Graduate Institute of Medical Education & Research (P.G.I.M.E.R.), Chandigarh. BACKGROUND: Seroma formation after breast surgery has been a consistent problem with no established causes or risk factors. The role of topical tranexamic acid in reducing the incidence of seroma after axillary clearance in breast cancer is controversial. AIMS & OBJECTIVES: To study the effect of intra-operative and post-operative topical Tranexamic acid on the duration of drain and volume of seroma in patients undergoing axillary lymph node dissection (ALND) for breast cancer. MATERIALS AND METHODS: In this prospective, non-blinded, triple-arm randomized controlled trial conducted at the Department of General Surgery, PGIMER, 154 breast cancer patients were enrolled and studied from July 2020-July 2021. They were randomized into three groups. Group A (n=51) received a single dose of diluted topical tranexamic acid intra-operatively, Group B (n=52) received intra-operative dose and daily post-operative doses till day-5 through the suction drain placed intra-operatively, and Group C(n=51) did not receive any topical tranexamic acid. The study groups were primarily compared for the total drain duration and total drainage volume. Daily drain volume for the first five days, complications like seroma, wound infection and severity of surgical site infections using Southampton score, and adverse reactions of the drug were compared. RESULTS Out of the 154 patients, four have failed to maintain appropriate records and analysis was done with 150 patients. The mean age of the study population was 52.17±8.69 yrs, with a mean BMI of 26.20±4.14. The final analysis showed no significant difference in total drain volume across the three groups, but patients receiving multiple doses of topical tranexamic acid had the lowest total volume drained compared to patients receiving a single dose or no dose (1763ml Vs 1597 Vs 1773ml: p=0.269. There was no significant change in the duration of the post-operative drain (21.6 Vs 19.2 Vs 19.55 days: p=0.54). There was no statistically significant difference in complications between the groups. Seroma was seen in 6 vs 7 vs 4%(p=0.629) patients in groups A, B and C respectively. Wound site infection was noted in 11 vs 13 vs 10% of patients (p= 0.766). None of the patient characteristics like age, BMI, co-morbidities, previous lumpectomy, menopause, and length of history significantly correlated with seroma formation in the study population. CONCLUSION There was no significant reduction in drain volume or duration with either single or multiple doses of topical tranexamic acid after the axillary clearance for breast cancer. Even though not significant, an increasing trend in wound site infections was noted among the patients who received multiple doses of tranexamic acid was noted. Citation Format: AKHIL GOUD PACHIMATLA, R N NAGA SANTOSH IRRINKI, ISHITA LAROIYA, SIDDHANT KHARE. Effect Of Intra-operative And Post-operative Topical Tranexamic Acid On early post-operative complications In Patients Undergoing Axillary Lymph Node Dissection For Breast Cancer- A randomized controlled study. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-14-14.

Fat Grafting before Delayed Prophylactic Mastectomy and Immediate Implant Reconstruction for Patients at High Risk of Complications.

The majority of patients undergoing bilateral prophylactic mastectomy request immediate implant-based breast reconstruction. Some patients, especially those with prior radiotherapy, are at increased risk of early cutaneous complications and implant loss. The authors developed the technique of primary fat grafting before delayed prophylactic mastectomy to minimize early complications for selective high-risk patients. They have completed 21 cases in 14 patients, 10 of whom had previous lumpectomy and radiation treatment for breast cancer. A single session of fat grafting, with a median injection volume of 250 ml (interquartile range, 200 to 300 ml), was performed a median period of 19 weeks (interquartile range, 16 to 28 weeks) before prophylactic mastectomy. All cases were direct-to-implant reconstruction using textured silicone implants. The median implant volume was 410 ml (interquartile range, 318 to 450 ml). A minor early complication developed in 14 percent of cases (three of 21), with no early implant loss. At a median follow-up of 9 months (interquartile range, 5 to 27 months), the authors found no cases of implant loss and an excellent or good aesthetic outcome (score of 5 or 4) in 16 of 21 cases (76 percent). Fat grafting before prophylactic mastectomy is a novel strategy to minimize early complications and avoid implant loss in patients at high risk of postoperative complications. . Therapeutic, IV.

Abstract P6-03-09: Internal mammary lymph node biopsy during free flap breast reconstruction: Accurate oncologic staging leads to change in adjuvant therapies

Abstract Introduction: Accurate breast cancer staging, including nodal status, is essential for optimal management of adjuvant therapies leading to improved disease-specific and overall survival. Lymphatic drainage of the breast is known to involve both axillary and internal mammary (IM) lymph node basins. While IM nodal metastases represent advanced cancer stage, sampling is not routinely advocated due to relative lack of accessibility and the assumption that IM node positivity rarely alters adjuvant therapies. The current study analyzes the incidence of IM nodal metastases sampled during routine IM vessel exposure for free flap breast reconstruction and changes in adjuvant treatment. Methods: A retrospective analysis of patients with positive IM lymph node biopsies at the time of free flap breast reconstruction following mastectomy between September 2008 and December 2015 was performed. Patients undergoing reconstruction following prophylactic mastectomy and reconstruction where IM vessels were not exposed were excluded. Prevalence of neoadjuvant therapies and previous lumpectomy with axillary lymph node (LN) sampling were recorded. Tumor size, location, and axillary LN status were obtained from final pathologic analysis. Prognostic factors and proliferative index (Ki-67) for the primary breast lesion were utilized to determine oncologic subtype. Change in adjuvant therapies (chemotherapy or external beam radiation) based solely on IM LN positivity was calculated. Results: During the study period, 2057 patients fit study criteria. Twenty eight (1.3%) patients were found to have IM LN metastases and comprised the study population. Mean age of patients with positive IM metastases was 49 years with pre-reconstruction chemotherapy or radiation administered in 50% or 54% of cases, respectively. Five (18%) patients had previously undergone lumpectomy with axillary sampling prior to mastectomy and reconstruction for cancer recurrence. Mean tumor size was 3.1 cm (range 0.4 to 10 cm) with tumor location evenly distributed among all four quadrants. Although statistical significance between subtypes was not identified, luminal B (42.9 percent) was the most common subtype present. Ten (36%) patients had isolated IM lymph node metastases with negative axillary nodal disease. Patients with both axillary and internal mammary disease had larger lesions (4.4 cm vs. 2.5 cm), increased prevalence of pre-reconstruction chemotherapy (65 percent vs. 20 percent) and radiation (71 percent vs. 20 percent). Multivariate analysis did not identify any significant independent factors associated with isolated IM lymph node metastases. Ultimately, 17 (63%) patients had a change in their adjuvant therapy (additional chemotherapy or IM radiation therapy) based on positive IM LN disease. Conclusion: Despite the low overall incidence of IM LN metastases, IM LN biopsy at the time of free flap breast reconstruction is recommended. In 36% of cases, nodal metastases were isolated to the IM nodes. Interestingly, a significant percentage (18%) of patients had previously undergone lumpectomy and axillary sampling. Identification of IM metastases significantly influenced adjuvant therapies in a majority of cases. Citation Format: Ochoa O, Pisano S, Chrysopoulo M, Ledoux P, Arishita G, Nastala C. Internal mammary lymph node biopsy during free flap breast reconstruction: Accurate oncologic staging leads to change in adjuvant therapies [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-03-09.

Expanding the Criteria for Nipple-Sparing Mastectomy in Patients With Poor Prognostic Features

BackgroundIn this study we aimed to review the outcomes of nipple-sparing mastectomy (NSM) in the setting of expanded criteria: previous breast surgery/irradiation, neoadjuvant chemotherapy (NAC), post-NSM irradiation, and to assess conversion to acceptable criteria after NAC. Patients and MethodsIn this single-institution institutional review board-approved retrospective review, we identified patients who underwent NSM after previous breast intervention or NAC from January 2010 to February 2017. Clinicopathologic features, previous breast surgeries, response rate, complications, and recurrences were recorded. ResultsSixty-three patients underwent 106 NSMs. Among 63 patients, 39 (61.9%) received NAC, 30 (47.6%) previous lumpectomy, 4 (6.3%) with cosmetic implants, 4 (6.3%) with mastopexy, 5 (7.9%) with previous radiation therapy, and 21 (33%) underwent post-NSM radiation therapy. Transient epidermolysis occurred in 24 patients (38.1%), with 16 patients (66.6%) having complete flap recovery and nipple loss in 8 patients (12.6%). All 10 patients with central disease on pre-NAC imaging converted to acceptable criteria, with 9 having successful NSM. At mean 67.2-month follow-up, 56 patients (88.9%) were disease-free, 5 (7.9%) experienced a systemic recurrence, and 2 (3.2%) a local recurrence. ConclusionNSM is oncologically acceptable in this patient cohort. Patients with large central tumors who undergo NAC should be reconsidered after completion of chemotherapy because many might convert to successful nipple-areolar preservation.

Role of sentinel lymph node biopsy in assessing the cancer spread to axilla in early breast cancer

Background:Sentinel lymph node (SLN) biopsy is a minimally invasive alternative to axillary lymph node dissection as a way to stage breast cancer in clinically node-negative patients. Objective of the study was to determine the safety and reliability of sentinel lymph node biopsy without axillary lymph node dissection (ALND) in early breast cancer patients.Methods: This prospective study was conducted in patients with operable breast cancer in a single surgical unit of our hospital. Patients with T1-T3 breast cancer with clinically negative axilla and patients with previous lumpectomy were included. All the patients had undergone complete axillary lymph node dissection after sentinel lymph node biopsy. All the specimens were sent separately for paraffin section histopathology.Results:Mean age of 35 female patients included was 54 years. SLN was identified in 94.29% cases and it could not be identified in 2 cases. SLN (96.97%) was most commonly identified at level I. Mean numbers of sentinel node and axillary node were 1.52 and 16.11 respectively. Study of SLN biopsy with methylene blue dye for staging the axilla was done with 81.25% sensitivity and 100% specificity. Positive predictive value was 100% and was able to negatively predict the axilla in 86.36% with an overall accuracy of staging of 96.97% and false negative rate of 18.75%.Conclusions:Sentinel lymph node biopsy without axillary lymph node dissection in sentinel lymph node negative breast cancers appears to be a safe and reliable procedure for determining the nodal status and ensuring the loco-regional control.

Arthrographis Kalrae Masquerading as a Pulmonary Nodule After Breast Irradiation

SESSION TITLE: Student/Resident Case Report Poster - Chest Infections II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: The genus Arthrographis is a mold usually isolated from soil and decaying vegetation. The genus is consisted of 5 species. It is an extremely rare cause of human disease and usually affects immunocompromised hosts. There have been only 11 reported cases in the literature since first described in 1976. Their role in human disease is still not completely clear. To our knowledge, this is the first reported case of solitary pulmonary nodule due to A kalrae infection. CASE PRESENTATION: An 80 year old past smoker female was referred to pulmonary clinic for evaluation of enlarging right upper lobe (RUL) ground glass opacity (GGO). She had a past history of breast cancer and underwent left sided lumpectomy with axillary dissection and radiation therapy in 2007. She had a chest CT in 2012 for evaluation of chronic cough and was noted to have a 1.1cm GGO in the RUL. In 2015, her breast cancer recurred at the previous lumpectomy site and during further evaluation the GGO was noted to have increased to 2.4cm. She underwent local resection. CT guided lung biopsy was non diagnostic. In the clinic, she complained of chronic cough but denied any fever, night sweats, weight loss, sputum production or shortness of breath. Physical exam and laboratory evaluation was unremarkable. A PET-CT showed 2.4cm hypermetabolic RUL GGO. She underwent navigational bronchoscopy with biopsy. The biopsies revealed reactive bronchial cells but no malignant cells. Initial cultures were negative. Fungal culture came back positive for Arthrographis kalrae. DISCUSSION: A kalrae is the most commonly isolated species from clinical specimens. They have been described to cause keratitis,opthalmitis, sinusitis, meningitis, cerebral vasculitis, endocarditis, mycetoma of the hand, onychomycosis, endocarditis and lung abscess. The route of entry is either the respiratory tract or direct inoculation into the skin and subcutaneous tissue. Specific risk factors or this rare fungalinfection are yet to be identified. Radiation therapy to the chest is suspected to be a risk factor for pulmonary infection with this organism. Terbinafine seems to be the best anti-fungal agentavailable. The azoles are also effective. Amphotericin seems to have some effect but the echinocandins are ineffective. CONCLUSIONS: Arthrographis kalrae is an unusual human pathogen and rarely considered in the differential diagnosis. With the ever growing number of immunosuppressant medications, whether this organism will become a potential threat is uncertain. The role of the organism in pathogenesis is human disease also needs further elucidation. Reference #1: Biser S. A, Perry H. D, Donnenfeld E. D, Doshi S. J. & Chaturvedi V. (2004). Arthrographis keratitis mimicking acanthamoeba keratitis. Cornea 23, 314-317. DISCLOSURE: The following authors have nothing to disclose: Biplab Saha, Himani Sharma, Kristin Fless, Paul Yodice, Fariborz Rezai, Nirav Mistry, Vagram Ovnanian No Product/Research Disclosure Information

Risk Factor Analysis for Mastectomy Skin Flap Necrosis: Implications for Intraoperative Vascular Analysis.

Skin flap necrosis after mastectomy can be a devastating complication significantly affecting patient outcomes. Routine vascular analysis (fluorescein or laser angiography) of mastectomy skin flaps in all patients has been advocated but is of questionable cost-effectiveness. The purpose of this study was to identify the incidence and causative risk factors for mastectomy skin flap necrosis and thereby calculate the fiscal reality of intraoperative vascular screening. This is an institutional review board-approved retrospective study of all patients from 2007 to 2013 who underwent mastectomy related to breast cancer. Skin flap necrosis was defined as major if it necessitated return to the operating room. Data analysis was done for determination of causative factors of necrosis, including age, body mass index, smoking, previous irradiation, coronary artery disease, chronic obstructive pulmonary disorder, hypertension, gastroesophageal reflux disease, hyperlipidemia, obstructive sleep apnea, asthma, diabetes, thyroid disease, history of lumpectomy, and breast reduction or augmentation. During this time, intraoperative vascular screening was not done. Five hundred eighty-one patients underwent 616 mastectomies with a total of 34 necrotic events (5.5%)-16 major and 18 minor. Analyses via Student t tests, univariate analyses, χ testing, and logistic regression showed that history of smoking was the only patient factor associated with postoperative necrosis (P = 0.008). More frequently represented in the necrosis group, but without statistical significance, are previous lumpectomy (P = 0.069) and immediate reconstruction (P = 0.078).For the entire study period, the actual cost to the hospital for major necrotic events was $7,123.10 or $445.19 for each of the 16 major necrotic events and $209.50 for all 34 necrotic events. Per-patient cost-effective screening would need to be less than $11.54 for all patients, $100.33 for highest risk patients (smokers), and $21.65 for highest risk patients (smokers, previous lumpectomy, and immediate reconstruction). Vascular screening other than clinical judgment of all patients is not cost effective. However, intraoperative vascular evaluation of high-risk patients is recommended before reconstruction and/or closure. These financial data that incorporate true costs and revenue can guide the use of newer, more expensive technology such as laser angiography and can be extrapolated to other institutions.

Compatibility of StratticeTM Matrix for Breast Reconstruction with Radiation Therapy

Introduction: StratticeTM is a porcine acellular dermal matrix used in breast reconstruction. It acts as a hammock for breast implants and to define the infra mammary fold. Method: All patients who underwent StratticeTM based reconstruction from 2010-15 under the care of one breast surgeon were included in this study. The StratticeTM matrix was used to create the sub pectoral pouch in which the implant was placed. Patients were divided into 2 Groups based on radiation therapy to the breast either before or after surgery (Group A) and those who received no radiation at any stage (Group B). Data regarding indication for surgery, size of implant, follow up time and significant complications were collected and analyzed using Windows Excel. Statistical analysis was performed using Chi-Squared test to compare the complications between the 2 Groups. A subgroup analysis was performed based on either breast surgery with skin sparing mastectomy and immediate reconstruction (SSM and IR), delayed reconstruction (DR) or re-do reconstruction (RR). Results: There were 76 cases with average age of 52 years (33-79). There were 30 cases in Group A and 46 in Group B. In Group A, 14 patients had IR, 15 DR and 1 RR. 3 patients had previous lumpectomy and radiation treatment for breast cancer followed by SSM and IR. In Group B, 25 had IR, 20 had DR and 1 had IR. The average size of implant used was 422 gms (195-765 gms). Follow up time was 27 months (1-62). In Group A there were 2 cases of infection, 1 case of capsule contracture and 2 wound breakdowns. 5 mastectomy flaps failed to stretch due to poor skin compliance secondary to radiation to the chest wall. There was 1 case of bottoming out of the implant in this Group requiring RR. In Group B, there was 1 case of extrusion requiring RR and 1 case of flap necrosis. Group A had more complications and implant loss than Group B and this was found to be statistically significant (p<0.0007). Conclusion: StratticeTM based breast reconstruction post radiotherapy carries higher risk of complications and abandoning due to non-compliant skin. This elevated risk should be emphasized to the patients and autologous flaps should be considered in these cases.

A novel approach to achieve breast symmetry in a single-stage procedure

Preservation of the skin envelope and the inframammary fold is the main factor in achieving breast symmetry in unilateral reconstruction. Skin sparing mastectomy (SSM) type-IV followed by immediate autologous reconstruction and contralateral symmetrization permits realizing this goal in large, ptotic breasted patients, and tumor superficially located in the inferior quadrants. If the tumor is superficially located in the superior or inferior quadrants with a previous lumpectomy or quadrantectomy scar in the superior quadrants, modified radical mastectomy and a staged procedure are recommended to avoid poor cosmetic results. Two patients who underwent immediate autologous reconstruction following SSM type-V with contralateral symmetrization in a one-stage procedure are presented.

Abstract P4-14-01: Incidence rate of nipple areolar complex ischemia after nipple sparing mastectomy. Analysis of the American Society of Breast Surgeons Nipple Sparing Mastectomy Registry.

Abstract Objectives: The American Society of Breast Surgeons (ASBS) Nipple Sparing Mastectomy Registry (NSMR) is a prospective, non- randomized, IRB approved multi-center registry. The ASBS NSMR has been designed to facilitate compilation of information on metrics utilized, techniques utilized, aesthetic outcomes, as well as oncologic outcomes for the nipple sparing mastectomy. The NSMR will be ongoing for 10 years with an initial N of 1000. Patient selection entails all patients undergoing a NSM at the participating institutions who have agreed to participate. We evaluated the incidence rate of nipple or nipple areolar complex ischemia after a nipple sparing mastectomy. Method: The first 173 patients entered into the ASBS NSMR (2011–2012) were analyzed for incidence rate of ischemia of the nipple or nipple areolar complex (NAC). Ischemia is defined as epidermolysis (partial thickness necrosis) or full thickness necrosis. Metrics analyzed included: postoperative NAC status, indication for surgery, patient characteristics, incision utilized, sub areolar and flap dissection technique, as well as cosmetic outcomes. Results: (Thirty-five) surgeons entered 265 NSMs on 173 patients into the ASBS NSM Registry. Indications included invasive carcinoma, DCIS, and prophylaxis. Incisions utilized included radial +/− peri -areolar extension, infra mammary fold, peri- areolar ellipse/ hemi batwing, previous lumpectomy site, and previous mastopexy incisions. Sub areolar and flap dissection technique included sharp +/− tumescent injection, electrocautery, or plasma blade. Reconstruction type included tissue expander, immediate implant, or autologous flap. Median follow-up was 5 months (range 1–16 months). The nipple or NAC in 33 (12%) of 265 mastectomies experienced some degree of ischemia. Out of a total of 265 mastectomies 3 (1%) required surgical debridement, 1 (0.3%) required surgical excision, and 29 (11%) experienced epidermolysis with full recovery (17 topical treatment and 12 no treatment). No correlation in incision type, method of dissection, utilization of separate axillary incision for SLNBx/AXLND, size or location of tumor, type of reconstruction, initial fill volume if tissue expanders utilized, previous breast surgery, previous radiation therapy, previous chemotherapy, smoking history, cup size, degree of ptosis, or indication for surgery was found in NACs undergoing ischemia versus those that did not. Cosmetic outcome assessed by the surgeon as well as patient satisfaction did not vary from the population that did not experience nipple/NAC ischemia. Cosmetic results were rated consistently as good or excellent. Conclusion: We report a 12% incidence rate of nipple or nipple areolar complex ischemia ranging from epidermolysis to full thickness necrosis: 3 (1%) requiring surgical debridement, 1 (0.3%) requiring excision, and 29 (11%) exhibiting epidermolysis with full recovery. Surgical debridement or excision was rarely necessary. Epidermolysis was found to resolve with no bearing on perceived cosmetic outcome. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-01.

Ten-year follow-up of skin-sparing mastectomy followed by immediate breast reconstruction

The oncological safety of skin-sparing mastectomy (SSM) followed by immediate breast reconstruction (IBR) is debated owing to a presumed compromise in the completeness of mastectomy. Current evidence is poor as it is based mostly on short-term follow-up data from highly selected patients. A prospectively maintained institutional database was searched to identify patients who underwent SSM and IBR between 1995 and 2000. A retrospective review of medical records was carried out, including only patients with ductal carcinoma in situ and invasive breast cancer. During this time all patients treated with mastectomy were offered IBR regardless of tumour stage. Follow-up data from 253 consecutive patients with IBR were reviewed. Patients with incomplete follow-up data and those undergoing SSM for recurrent disease following previous lumpectomy were disregarded, leaving 207 for analysis. Offering IBR to all women requiring mastectomy resulted in a large proportion of patients with advanced disease. During a median follow-up of 119 months, 17 (8·2 per cent) locoregional, six (2·9 per cent) local and 22 (10·6 per cent) distant recurrences were detected; the overall recurrence rate was 39 (18·8 per cent). Overall recurrence rate was associated with axillary lymph node metastasis (P = 0·009), higher stage (P < 0·001) and higher tumour grade (P = 0·031). The breast cancer-specific survival rate was 90·8 per cent (19 of 207 women died from recurrence). Based on these long-term follow-up data, SSM combined with IBR is an oncologically safe treatment option regardless of tumour stage.

A Comparison of Surgical Complications Between Immediate Breast Reconstruction and Mastectomy: The Impact on Delivery of Chemotherapy—An Analysis of 391 Procedures

To compare the postoperative complications after immediate breast reconstruction (IBR) versus mastectomy alone and to examine the impact on the delivery of chemotherapy. In this prospective series, there were 391 consecutive women who underwent mastectomy (243 mastectomy alone and 148 mastectomy and IBR). The outcome measures were complications (within 3 months after surgery) and time to adjuvant chemotherapy. Compared to the IBR group, patients in the mastectomy alone group were significantly older (P < 0.0001), smokers (P = 0.007) and less likely to have had previous radiation or lumpectomy (P < 0.0001). Overall, the complication rate was significantly greater in the IBR group than mastectomy alone (27.0% vs. 15.6%, P = 0.009). Univariate analyses revealed that mastectomy with IBR [odds ratio (OR) = 2, 95% confidence interval (CI) 1.21-2.30]; bilateral procedure (OR = 1.84, 95% CI 1.07-3.16); previous radiotherapy (OR = 2.4, 95% CI 1.29-4.47); and previous lumpectomy (OR = 1.84, 95% CI 1.11-3.03) were significant predictors of increased complications. With multivariable analysis, none of these variables were significantly associated with increased complications. 106 patients received adjuvant chemotherapy; median time from mastectomy to chemotherapy was 6.8 (0.71-15) weeks in the mastectomy alone group (n = 96) compared to 8.5 (6.3-11) weeks in the IBR group (n = 10) (P = 0.01). Although the incidence of overall and major postoperative complications was higher after IBR than mastectomy alone, there were no significant relationships in the multivariable analysis. IBR was associated with a modest increase in time to chemotherapy that was statistically but not clinically significant.

Sentinel node biopsy in patients with breast cancer and previous breast surgery

Aim The aim of this study was to establish the efficacy and safety of sentinel lymph node biopsy for lymph node staging in patients with breast cancer and prior breast surgery, considering its extension, localization and time since the previous surgical procedure. Materials and methods A sentinel lymph node biopsy was performed in 38 patients with early breast cancer and previous breast surgery: recent excisional biopsy in 22 patients (Group I), previous lumpectomy or mammoplasty in 16, including one case of cancer treated with breast-conserving surgery (tumor recurrence). Lymphoscintigraphy was performed after periareolar injection, also sometimes adding an injection near to the surgical scar. After removing the sentinel node, axillary lymph node dissection was performed when the lymph node was positive (and not localized). Results The efficacy of the scintigraphic localization of the sentinel node was 92.1% of the patients, with 15.8% of extra-axillary drainages. Axillary intraoperative detection was 81.6%. The identification rate after recent excisional biopsy or previous surgery was similar (81.8 vs 81.2%). However, extra-axillary sentinel nodes were more frequent in Group II (9.1 vs 25%). Having a localization of previous surgical procedures in upper outer quadrant caused drainages outside of the axilla more frequently (27.2 vs 11.1%). Axillary detection rate was similar to other quadrants (81.8 vs 81.5%). The rate of breast cancer-related events was 5.2% (2/38), without axillary recurrences (mean follow-up: 3 years). Conclusion Sentinel lymph node biopsy in patients with previous but not extensive breast surgery is safe. Extra-axillary drainages are more common when the previous surgical area was wide, especially in the upper-outer quadrant.

Biopsia de ganglio centinela en pacientes con cáncer de mama y cirugía mamaria previa

Aim The aim of this study was to establish the efficacy and safety of sentinel lymph node biopsy for lymph node staging in patients with breast cancer and prior breast surgery, considering its extension, localization and time since the previous surgical procedure. Material and methods A sentinel lymph node biopsy was performed in 38 patients with early breast cancer and previous breast surgery: recent excisional biopsy in 22 patients (Group I), previous lumpectomy or mammoplasty in 16, including one case of cancer treated with breast-conserving surgery (tumor recurrence). Lymphoscintigraphy was performed after periareolar injection, also sometimes adding an injection near to the surgical scar. After removing the sentinel node, axillary lymph node dissection was performed when the lymph node was positive (and not localized). Results The efficacy of the scintigraphic localization of the sentinel node was 92.1% of the patients, with 15.8% of extra-axillary drainages. Axillary intraoperative detection was 81.6%. The identification rate after recent excisional biopsy or previous surgery was similar (81.8 vs 81.2%). However, extra-axillary sentinel nodes were more frequent in Group II (9.1 vs 25%). Having a localization of previous surgical procedures in upper outer quadrant caused drainages outside of the axilla more frequently (27.2 vs 11.1%). Axillary detection rate was similar to other quadrants (81.8 vs 81.5%). The rate of breast cancer-related events was 5.2% (2/38), without axillary recurrences (mean follow-up: 3 years). Conclusion Sentinel lymph node biopsy in patients with previous but not extensive breast surgery is safe. Extra-axillary drainages are more common when the previous surgical area was wide, especially in the upper-outer quadrant.

Postmastectomy Breast Reconstruction After Previous Lumpectomy and Radiation Therapy

Lumpectomy and radiation therapy (breast conservation therapy [BCT]) are common treatments for early-stage breast cancer. However, many of these patients will require a subsequent salvage mastectomy and reconstruction after a locoregional recurrence. This study examines whether prior BCT leads to higher rates of complications and dissatisfaction with subsequent mastectomy and breast reconstruction. All women undergoing initial breast reconstruction at an academic institution were identified (1999-2006). Women who had undergone prior BCT were compared with women without prior BCT. A questionnaire adapted from the Michigan Breast Reconstruction Outcomes Survey was administered. Rates of complications, as well as general and aesthetic satisfaction, were compared between the 2 groups. Multiple logistic regression was used to analyze the effects of prior BCT, age, comorbidities, reconstruction type, and time between radiation and reconstruction. Overall, 532 women underwent 802 reconstructions, of whom 113 women (137 reconstructions) had prior BCT. Prior BCT did not correlate with higher complication rates (odds ratio [OR] = 1.09, P = 0.690), or lower general or aesthetic satisfaction (OR = 0.84, P = 0.559; OR = 0.91, P = 0.723, respectively); however, there was an increased rate of mastectomy skin flap loss (12.4% vs. 6.8%, P = 0.024). Increasing age was the most significant risk factor for complications and dissatisfaction. Radiation in the setting of BCT did not increase overall rates of complications or dissatisfaction with subsequent breast reconstruction in our patient population. These patients, however, had a higher incidence of mastectomy skin flap loss. These findings are important for preoperative counseling and intraoperative planning in patients with prior lumpectomy and radiation.

A Case in Point

Together with my wife, we read this article on the cost that might be saved by not performing group and save prior to elective breast cancer surgery. She had just had elective breast cancer surgery. She was having completion left mastectomy and right mastectomy following previous lumpectomy with sentinel node biopsy (November 2007) and subsequent level 2 left axillary clearance surgery (December 2007) for a grade 3 left breast cancer 1.5 cm with one micrometastasis and one metastasis confirmed in the axilla. ER and PR were both strongly positive, Herceptin negative. She completed 4 cycles of Epirubicin and 2.5 cycles of 4 scheduled of CMF complicated by Mycobacterium chelonae infection of her Hickmann line causing a severe atypical pneumonia. She was on a 3-month course of clarithromycin following on initial clarithromycin/ciprofloxacin/meripenem/ linezolid by infusion which brought rapid improvement in condition, as species were resistant to all except clarithromycin. Her tumour had arisen in an area of previous irradiation fields for Hodgkin' lymphoma treated in her early 20s (she had 4 relapses). She had been under follow-up in the local MR breast scanning screening programme started for long-term Hodgkin' survivors but sadly her lesion was not identified and she found the lump herself. At 6 h postoperatively, she had severe sudden haemorrhage with blood pressure dropping to 60/? and tachycardia of 120 requiring return to theatre. She was transfused with two units of irradiated blood of her own blood group (as previously grouped and saved) and had a further unit of irradiated universal donor blood. She had only recently found out re TA-GvHD from Lymphoma Matters (quarterly newsletter from the Lymphoma Association, Issue 74, Summer 2008) and also having come across the NHS leaflet Information for patients needing irradiated blood. (Blood for Hodgkin' disease patients is irradiated to prevent the life-long risk of graft versus host disease.) We were grateful for the rapidity of response of her surgical team and the availability of blood, otherwise her outcome may not have been so good. We would disagree with the assertion that money can be saved by not doing group and save for patients for elective breast cancer surgery as potentially losing the life (or having a significant hypotensive complication) of a comparatively young patient for lack of transfused blood would easily involve the clinicians/hospital involved in expensive litigation!

Is the routine use of sentinel lymph node biopsy for ductal carcinoma in situ necessary?

791 Background: Because of the incidence of lymphatic metastases in ductal carcinoma in situ (DCIS) has been small and its significance has been undefined. There were some controversies regarding the need for lymph node evaluation as part of the treatment for patients with DCIS. We reviewed our cases with DCIS to determine the node positive rate and evaluate the recurrence pattern in DCIS patients according to surgical modalities. And then we identified the value of sentinel lymph node biopsy for DCIS. Methods: Between Oct. 1994 and Nov. 2004, 371(9.9%) of 3729 patients with breast cancer were pure DCIS in Samsung Medical Center. We reviewed medical records retrospectively. Results: Median age was 46(21–80) year-old. Mastectomy and breast conservation surgery were performed 180(48.5%) and 191(51.5%) cases respectively. 108(29.1%) cases underwent sentinel lymph node biopsy. 27cases followed routine axillary dissection after sentinel lymph node biopsy during learning period. Only 1 case was found the metastases in sentinel lymph node. We underwent routine axillary dissection in 139(37.5%) cases and found axillary metastases in 3 cases. Remained 124(33.4) had been no axillary treatment. There were 10cases of local recurrences and 3 cases of contra-lateral breast cancer during follow-up periods. But, there were no distant metastases and lymphatic recurrence. Median follow-up were 27.9(1.1–115.2) months. Conclusions: No lymphatic recurrence was identified in whom local recurrence cases with previous lumpectomy only. There was a little value of sentinel lymph node biopsy for DCIS. We suggest that the routine use of sentinel lymph node biopsy for DCIS may be unnecessary. No significant financial relationships to disclose.

Mastectomy by inverted drip incision and immediate reconstruction: data from 510 cases.

Immediate reconstruction of the breast can be performed in selected cases after mastectomy for breast cancer or after prophylactic mastectomy in patients with a high risk of developing breast cancer. Despite the frequency with which these procedures are performed, data from large series of subpectoral implantation of silicone prostheses in combination with a skin-saving approach are lacking. In this retrospective study, data on complications and late surgical interventions in 356 patients who underwent 510 mastectomies with an inverted drip incision and immediate reconstruction (MIDIIR) were analyzed to determine potential prognostic factors of early complications. In 82% of the MIDIIRs, the postoperative course was uneventful. In 18%, the complications were infection (32 cases), necrosis of the skin flap (29 cases), bleeding (31 cases), and protrusion of the prosthesis (20 cases), resulting in surgery in 9, 12, 15, and 20 cases, respectively. At the end of the follow-up period, 30 (6%) prostheses were definitively removed. Age, size of the prostheses, radiotherapy, previous lumpectomy, and indication for mastectomy were not significant factors for the prognosis of early complications. With the right technique and indications, MIDIIR is a very safe procedure and should be one of the surgical treatments that can be offered in the overall management of patients with, or at high risk for, breast cancer.

Repeat high-dose external beam irradiation for in-breast tumor recurrence after previous lumpectomy and whole breast irradiation

Purpose: To determine whether excision of an in-breast tumor recurrence (IBTR) plus 5000 cGy in 25 fractions to the new operative area is both tolerated and effective as treatment for an IBTR after previous lumpectomy and whole breast irradiation. Methods and Materials: Thirty-nine women with an IBTR after lumpectomy and breast irradiation for invasive carcinoma ( n = 31) or ductal carcinoma in situ ( n = 8) were treated with excision of the IBTR and radiotherapy (RT), 5000 cGy in 25 fractions, to the operative area using electrons of appropriate energy. The interval from completion of the first course of RT to diagnosis of the IBTR ranged from 16 to 291 months (median 63). Results: The repeat course of RT to the new operative area was well tolerated in all patients, and no late sequelae occurred other than skin pigmentation changes. Eight patients, including 2 with suspicious bone scans at the time of IBTR, developed distant metastases, and 7 died 21–71 months (median 48) after retreatment. One patient was alive with distant metastases at 27 months after retreatment. Four of the 8 patients who developed distant metastases also had a second IBTR, and 3 died with persistent disease in the breast. An additional 4 patients, for a total of 8, had a second IBTR. Three were alive and free of disease after mastectomy, and 1 was alive and free of disease after mastectomy and additional RT for chest wall recurrence. An additional patient developed recurrence in the axilla 9 months after reirradiation and was treated with surgery; she died free of disease at 63 months. One patient underwent mastectomy for suspected persistent disease 2 months after completion of repeat RT; no evidence of recurrent tumor was found in the removed breast. Thus, 30 women (76.9%) had an intact breast free of tumor at death or at last follow-up 1–180 months (median 51.5) after reirradiation. Using the Kaplan-Meier life table analysis, the estimated overall and disease-free 5-year survival rate for the 39 patients was 77.9% and 68.5%, respectively. Conclusion: For select patients with an IBTR after lumpectomy and breast irradiation, excision of the IBTR followed by repeat external beam RT to the operative area may be an acceptable alternative to mastectomy.

Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications.

A retrospective review was performed of one surgeon's experience with 40 consecutive patients who had undergone two-stage saline-filled implant breast reconstruction and radiation during the period from 1990 through 1997. A randomly selected group of 40 other two-stage saline-filled implant breast reconstructions from the same surgeon and time period served as controls. This review was undertaken because of the absence of specific information on the outcome of staged saline implant reconstructions in the radiated breast. Previously published reports on silicone gel implants and radiation have been contradictory. At the same time, the criteria for the use of radiation in the treatment of breast cancer have been expanded and the numbers of reconstruction patients who have been radiated are increasing dramatically. For example, in a 1985 report on immediate breast reconstruction, only 1 of 185 patients over a 6-year period underwent adjuvant radiation therapy, whereas in this review, there were 40 radiated breasts with saline-filled implants, 19 of which received adjuvant radiation therapy during their expansion. The study parameters included patient age, breast cup size, implant size, length of follow-up, number of procedures, coincident flap operations, Baker classification, complications, opposite breast procedures, pathologic stage, indications for and details about the radiation, and outcomes. The use of radiation in this review of reconstructed breasts can logically be divided into four groups: previous lumpectomy and radiation (n = 7), mastectomy and radiation before reconstruction (n = 9), mastectomy and adjuvant radiation during reconstruction/expansion (n = 19), and radiation after reconstruction (n = 5). The largest and most rapidly growing group of patients is of those receiving postmastectomy adjuvant radiation therapy. A total of 47.5 percent (19 of 40) of radiated breasts with saline implants ultimately needed the addition of, or replacement by, a flap. Ten percent of a control group with nonradiated saline implant reconstructions also had flaps, none as replacements. Fifty percent or more of both the radiated and control groups had contralateral surgery. Complications were far more common in the radiated group; for example, there were 32.5 percent capsular contractures compared with none in the control group. The control nonradiated implant-only group and the flap plus implant radiated group did well cosmetically. The radiated implant-only group was judged the worst. The increasing use of radiation after mastectomy has important implications for breast reconstruction. The possibility for radiation should be thoroughly investigated and anticipated preoperatively before immediate breast reconstruction. Patients with invasive disease, particularly with large tumors or palpable axillary lymph nodes, are especially likely to be encouraged to undergo postmastectomy radiation therapy. The indications for adjuvant radiation therapy have included four or more positive axillary lymph nodes, tumors 4 cm (or more) in diameter, and tumors at or near the margin of resection. More recently, some centers are recommending adjuvant radiation therapy for patients with as few as one positive lymph node or even in situ carcinoma close to the resection margin. The use of latissimus dorsi flaps after radiation has proven to be an excellent solution to postradiation tissue contracture, which can occur during breast expander reconstruction. The use of the latissimus flap electively with skin-sparing mastectomy preradiation is probably unwise, unless postmastectomy radiation is unlikely. Skin-sparing mastectomy with a latissimus flap thus should be preserved for patients unlikely to undergo adjuvant radiation therapy. Purely autologous reconstruction such as a TRAM flap is another option for these patients, either before or after radiation therapy.